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Should hospitalists accept gifts from pharmaceutical, medical device, and biotech companies?
The pharmaceutical industry is big business, and its goal is to make money. If the industry can convince physicians to prescribe its medicines, then it makes more money.
Although pharmaceutical representatives brief physicians on new medications in an effort to encourage the use of their brand-name products, they also provide substantive information on the drugs that serves an educational purpose.
In the past, pharmaceutical companies—along with the medical device and biotechnology industries—showered physicians with expensive gifts, raising ethical questions about physicians’ obligation to the drug companies. Fair enough. These excessive practices were identified and curtailed—to my knowledge—some years ago.
Watchdog groups, however, have continued to call into question every suggestion of “being in the pay” of big pharma. Everything from a plastic pen to a piece of pizza is suspect. There is considerable concern that practicing clinicians are influenced by the smallest gesture, while many large medical institutions continue to accept pharmaceutical-company-funded research grants. If big-pharma investment in research does not corrupt institutions, why is it assumed that carrying a pharmaceutical pen has such a pernicious effect on clinicians?
As a corollary to this question, does anyone really want to discontinue these important research studies just because they are funded by industry dollars?
Listening to drug representatives—even being seen in the vicinity—raises the eyebrows of purists. Do we really want physicians completely divorced from all pharmaceutical company education and communication? Do we feel there is zero benefit to hearing about new medications from the company’s viewpoint?
If physicians completely shut out the representatives, it would be expected that pharmaceutical companies would direct their efforts elsewhere—most likely, to consumers. Is that a better and healthier scenario?
Clearly, there is potential for abuse in pharmaceutical gifts to physicians. The practice should be controlled and monitored. The suspicions raised by purist groups that physicians’ prescribing habits are unalterably biased after a five-minute pharmaceutical representative detail and a chicken sandwich is hyperbole. The voice of reason is silenced in the midst of the inquisition.
In the academic setting, fear of being accused of “bought bias” has physicians clearing their pockets of tainted pens and checking their desks for corrupting paraphernalia. The positive aspects of pharma-sponsored programs and medical lectures are lost for fear of appearing to be complicit with drug companies.
The Aristotelian Golden Mean is superior to extreme positions, and I submit that the best road is the center. Listen to what the drug company representatives have to say, just like you listen to a car salesman: You can learn from both—as long as you research the data and form your own opinion. TH
Dr. Brezina is a hospitalist at Durham Regional Hospital in North Carolina.
The pharmaceutical industry is big business, and its goal is to make money. If the industry can convince physicians to prescribe its medicines, then it makes more money.
Although pharmaceutical representatives brief physicians on new medications in an effort to encourage the use of their brand-name products, they also provide substantive information on the drugs that serves an educational purpose.
In the past, pharmaceutical companies—along with the medical device and biotechnology industries—showered physicians with expensive gifts, raising ethical questions about physicians’ obligation to the drug companies. Fair enough. These excessive practices were identified and curtailed—to my knowledge—some years ago.
Watchdog groups, however, have continued to call into question every suggestion of “being in the pay” of big pharma. Everything from a plastic pen to a piece of pizza is suspect. There is considerable concern that practicing clinicians are influenced by the smallest gesture, while many large medical institutions continue to accept pharmaceutical-company-funded research grants. If big-pharma investment in research does not corrupt institutions, why is it assumed that carrying a pharmaceutical pen has such a pernicious effect on clinicians?
As a corollary to this question, does anyone really want to discontinue these important research studies just because they are funded by industry dollars?
Listening to drug representatives—even being seen in the vicinity—raises the eyebrows of purists. Do we really want physicians completely divorced from all pharmaceutical company education and communication? Do we feel there is zero benefit to hearing about new medications from the company’s viewpoint?
If physicians completely shut out the representatives, it would be expected that pharmaceutical companies would direct their efforts elsewhere—most likely, to consumers. Is that a better and healthier scenario?
Clearly, there is potential for abuse in pharmaceutical gifts to physicians. The practice should be controlled and monitored. The suspicions raised by purist groups that physicians’ prescribing habits are unalterably biased after a five-minute pharmaceutical representative detail and a chicken sandwich is hyperbole. The voice of reason is silenced in the midst of the inquisition.
In the academic setting, fear of being accused of “bought bias” has physicians clearing their pockets of tainted pens and checking their desks for corrupting paraphernalia. The positive aspects of pharma-sponsored programs and medical lectures are lost for fear of appearing to be complicit with drug companies.
The Aristotelian Golden Mean is superior to extreme positions, and I submit that the best road is the center. Listen to what the drug company representatives have to say, just like you listen to a car salesman: You can learn from both—as long as you research the data and form your own opinion. TH
Dr. Brezina is a hospitalist at Durham Regional Hospital in North Carolina.
The pharmaceutical industry is big business, and its goal is to make money. If the industry can convince physicians to prescribe its medicines, then it makes more money.
Although pharmaceutical representatives brief physicians on new medications in an effort to encourage the use of their brand-name products, they also provide substantive information on the drugs that serves an educational purpose.
In the past, pharmaceutical companies—along with the medical device and biotechnology industries—showered physicians with expensive gifts, raising ethical questions about physicians’ obligation to the drug companies. Fair enough. These excessive practices were identified and curtailed—to my knowledge—some years ago.
Watchdog groups, however, have continued to call into question every suggestion of “being in the pay” of big pharma. Everything from a plastic pen to a piece of pizza is suspect. There is considerable concern that practicing clinicians are influenced by the smallest gesture, while many large medical institutions continue to accept pharmaceutical-company-funded research grants. If big-pharma investment in research does not corrupt institutions, why is it assumed that carrying a pharmaceutical pen has such a pernicious effect on clinicians?
As a corollary to this question, does anyone really want to discontinue these important research studies just because they are funded by industry dollars?
Listening to drug representatives—even being seen in the vicinity—raises the eyebrows of purists. Do we really want physicians completely divorced from all pharmaceutical company education and communication? Do we feel there is zero benefit to hearing about new medications from the company’s viewpoint?
If physicians completely shut out the representatives, it would be expected that pharmaceutical companies would direct their efforts elsewhere—most likely, to consumers. Is that a better and healthier scenario?
Clearly, there is potential for abuse in pharmaceutical gifts to physicians. The practice should be controlled and monitored. The suspicions raised by purist groups that physicians’ prescribing habits are unalterably biased after a five-minute pharmaceutical representative detail and a chicken sandwich is hyperbole. The voice of reason is silenced in the midst of the inquisition.
In the academic setting, fear of being accused of “bought bias” has physicians clearing their pockets of tainted pens and checking their desks for corrupting paraphernalia. The positive aspects of pharma-sponsored programs and medical lectures are lost for fear of appearing to be complicit with drug companies.
The Aristotelian Golden Mean is superior to extreme positions, and I submit that the best road is the center. Listen to what the drug company representatives have to say, just like you listen to a car salesman: You can learn from both—as long as you research the data and form your own opinion. TH
Dr. Brezina is a hospitalist at Durham Regional Hospital in North Carolina.
Volume Control, Part II
Last month I began looking at ways hospitalist practices can manage unpredictable increases in patient volume, also known as surge staffing. I provided my view of a “jeopardy” system and a patient volume cap for hospitalists. While both are potentially very effective, they have a high cost and in my view are imperfect solutions. This month I’ll examine some less common strategies to provide surge staffing. Although less popular, I think these options are more valuable.
Schedule More Providers
I’ve worked with a lot of practices and am struck by how patient volume for nearly all of them falls within a reasonably predictable range. While no one can predict with certainty which days will be unusually busy or slow, nearly all practices have a range of daily encounters that is roughly half to 1 1/2 of the mean. For example, if a practice has a mean of 60 billable encounters per day, it probably ranges from about 30 to 90 encounters on any given day. (The larger the practice, the more likely they are to conform to this range. Small practices, with average daily encounters fewer than 20, have a much wider range of daily volumes as a percent of the mean.)
Despite knowing that volumes will vary unpredictably, most practices provide the same fixed “dose” of provider staffing every day—that is, the single most common model for staffing and scheduling is to provide a fixed number of day-shift doctors (“rounders”) who work a fixed number of hours. For example, with an average of 60 billable encounters a day, a hospitalist group might decide to staff with four day-shift rounders working 12-hour shifts. This equates to a fixed 48 hours of daytime staffing. This is reasonable until the busy days arrive. Those four doctors will be much busier than average when there are 90 patients to see in a day, and will probably have a hard time seeing 22 or 23 patients each during their 12-hour shift. If such a busy day occurs more than a couple of times annually, then the practice should probably make some changes.
One approach to solving this type of staffing predicament is to add a fifth day-shift rounder. In other words, when making staffing decisions, consider giving more weight to the busiest days than the average day. This sounds fine until thinking about the practice budget. It will be pretty expensive to add doctors every day just so there are enough on duty when things get really busy. But if the hospitalists are willing to accept reduced compensation, then it might be financially reasonable to go ahead and add staff. This is easiest to do when the hospitalists are paid a significant (e.g. ≥50%) portion of their income based on their productivity, which will enable the hospitalists themselves to have a lot of say about when it is time to add staff. (Being paid on a nearly fixed annual salary means that it is the finance person who usually has the say about when it is time to add staff. And you can bet he’ll be making staffing decisions based on the average daily encounters, rather than the busy days.)
My own preference would be to do just that: Accept a reduction in compensation in return for protection against really busy and stressful days. I’m not suggesting others should agree with me, and in my experience, most don’t. (My own practice partners don’t agree with me on this one.) So I’m not really recommending it as a best practice, but I want to ensure that you don’t forget it is an option. And keep in mind you could adjust staffing by degrees; some settings might add a half-time physician or a nonphysician provider to try to find the sweet spot between having enough staff on duty every day to handle surges in volume and the cost of that staffing to the employer—or the hospitalists themselves.
Of course, if I were willing to reduce my compensation and average daily workload, then I would expect to be freed from the expectation that all rounding doctors work 12-hour shifts. Let’s turn our attention to the interplay between fixed day-shift durations and surge staffing.
Fixed-Shift Schedules Inhibit Surge Capacity
I think it usually is best to avoid fixed durations for day shifts. It might be necessary to require at least one daytime rounder to stay at least until a specified time (e.g. the arrival of the night-shift doctor), but in most cases it is reasonable for some rounders to leave when their work is done. They might need to continue responding to pages until the start of the night shift, but it usually isn’t necessary to have all rounders in the hospital until a predetermined end of the shift.
The problem is that when shifts have a fixed duration, the providers will focus on the start and stop time of their shift and might be unwilling to work beyond it. If instead there are no clearly fixed start and stop times for each day shift, then the hospitalists are likely to be willing to simply work longer on busy days, as long as they can work shorter on slow days. This is probably the most effective method of surge capacity, and it fits well with staffing each day with more providers than are required for the average patient volume.
Simply having the rounding doctors work longer on busy days must be done within reason. And there is a really wide range of opinion about what is reasonable. I think it is reasonable if a hospitalist works two or three hours longer than usual for three or four consecutive busy days, as long as the hospitalist is allowed to work less on days that are not very busy. But just what is a reasonable maximum daily amount of work for even one day is a topic that can lead to passionate debate. You’ll have to decide the details of what is and isn’t acceptable in your group.
Unit-Based Assignments
Aside from fixed-duration day shifts, unit-based assignment of hospitalists is the most common practice inhibiting surge capacity. Not long ago I worked with a practice that followed very strict unit-based assignments, which significantly inhibited “load-leveling,” and thus surge capacity. On any given day the patient volume for the whole practice might be very reasonable, but because it was never distributed evenly among the rounders, there was a very good chance that at least one doctor was drowning in work. And because of the strict approach, the other doctors didn’t come to the rescue.
I think the only reasonable approach is to deviate from such a strict unit-based assignment, at least a little. One rounder could be a utility doctor who doesn’t have her own unit and instead roams throughout the hospital, having been assigned patients based on the workload of each of her unit-based colleagues. TH
Dr. Nelson has been a practicing hospitalist since 1988 and is cofounder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants (www.nelsonflores.com) and codirector and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.
Last month I began looking at ways hospitalist practices can manage unpredictable increases in patient volume, also known as surge staffing. I provided my view of a “jeopardy” system and a patient volume cap for hospitalists. While both are potentially very effective, they have a high cost and in my view are imperfect solutions. This month I’ll examine some less common strategies to provide surge staffing. Although less popular, I think these options are more valuable.
Schedule More Providers
I’ve worked with a lot of practices and am struck by how patient volume for nearly all of them falls within a reasonably predictable range. While no one can predict with certainty which days will be unusually busy or slow, nearly all practices have a range of daily encounters that is roughly half to 1 1/2 of the mean. For example, if a practice has a mean of 60 billable encounters per day, it probably ranges from about 30 to 90 encounters on any given day. (The larger the practice, the more likely they are to conform to this range. Small practices, with average daily encounters fewer than 20, have a much wider range of daily volumes as a percent of the mean.)
Despite knowing that volumes will vary unpredictably, most practices provide the same fixed “dose” of provider staffing every day—that is, the single most common model for staffing and scheduling is to provide a fixed number of day-shift doctors (“rounders”) who work a fixed number of hours. For example, with an average of 60 billable encounters a day, a hospitalist group might decide to staff with four day-shift rounders working 12-hour shifts. This equates to a fixed 48 hours of daytime staffing. This is reasonable until the busy days arrive. Those four doctors will be much busier than average when there are 90 patients to see in a day, and will probably have a hard time seeing 22 or 23 patients each during their 12-hour shift. If such a busy day occurs more than a couple of times annually, then the practice should probably make some changes.
One approach to solving this type of staffing predicament is to add a fifth day-shift rounder. In other words, when making staffing decisions, consider giving more weight to the busiest days than the average day. This sounds fine until thinking about the practice budget. It will be pretty expensive to add doctors every day just so there are enough on duty when things get really busy. But if the hospitalists are willing to accept reduced compensation, then it might be financially reasonable to go ahead and add staff. This is easiest to do when the hospitalists are paid a significant (e.g. ≥50%) portion of their income based on their productivity, which will enable the hospitalists themselves to have a lot of say about when it is time to add staff. (Being paid on a nearly fixed annual salary means that it is the finance person who usually has the say about when it is time to add staff. And you can bet he’ll be making staffing decisions based on the average daily encounters, rather than the busy days.)
My own preference would be to do just that: Accept a reduction in compensation in return for protection against really busy and stressful days. I’m not suggesting others should agree with me, and in my experience, most don’t. (My own practice partners don’t agree with me on this one.) So I’m not really recommending it as a best practice, but I want to ensure that you don’t forget it is an option. And keep in mind you could adjust staffing by degrees; some settings might add a half-time physician or a nonphysician provider to try to find the sweet spot between having enough staff on duty every day to handle surges in volume and the cost of that staffing to the employer—or the hospitalists themselves.
Of course, if I were willing to reduce my compensation and average daily workload, then I would expect to be freed from the expectation that all rounding doctors work 12-hour shifts. Let’s turn our attention to the interplay between fixed day-shift durations and surge staffing.
Fixed-Shift Schedules Inhibit Surge Capacity
I think it usually is best to avoid fixed durations for day shifts. It might be necessary to require at least one daytime rounder to stay at least until a specified time (e.g. the arrival of the night-shift doctor), but in most cases it is reasonable for some rounders to leave when their work is done. They might need to continue responding to pages until the start of the night shift, but it usually isn’t necessary to have all rounders in the hospital until a predetermined end of the shift.
The problem is that when shifts have a fixed duration, the providers will focus on the start and stop time of their shift and might be unwilling to work beyond it. If instead there are no clearly fixed start and stop times for each day shift, then the hospitalists are likely to be willing to simply work longer on busy days, as long as they can work shorter on slow days. This is probably the most effective method of surge capacity, and it fits well with staffing each day with more providers than are required for the average patient volume.
Simply having the rounding doctors work longer on busy days must be done within reason. And there is a really wide range of opinion about what is reasonable. I think it is reasonable if a hospitalist works two or three hours longer than usual for three or four consecutive busy days, as long as the hospitalist is allowed to work less on days that are not very busy. But just what is a reasonable maximum daily amount of work for even one day is a topic that can lead to passionate debate. You’ll have to decide the details of what is and isn’t acceptable in your group.
Unit-Based Assignments
Aside from fixed-duration day shifts, unit-based assignment of hospitalists is the most common practice inhibiting surge capacity. Not long ago I worked with a practice that followed very strict unit-based assignments, which significantly inhibited “load-leveling,” and thus surge capacity. On any given day the patient volume for the whole practice might be very reasonable, but because it was never distributed evenly among the rounders, there was a very good chance that at least one doctor was drowning in work. And because of the strict approach, the other doctors didn’t come to the rescue.
I think the only reasonable approach is to deviate from such a strict unit-based assignment, at least a little. One rounder could be a utility doctor who doesn’t have her own unit and instead roams throughout the hospital, having been assigned patients based on the workload of each of her unit-based colleagues. TH
Dr. Nelson has been a practicing hospitalist since 1988 and is cofounder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants (www.nelsonflores.com) and codirector and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.
Last month I began looking at ways hospitalist practices can manage unpredictable increases in patient volume, also known as surge staffing. I provided my view of a “jeopardy” system and a patient volume cap for hospitalists. While both are potentially very effective, they have a high cost and in my view are imperfect solutions. This month I’ll examine some less common strategies to provide surge staffing. Although less popular, I think these options are more valuable.
Schedule More Providers
I’ve worked with a lot of practices and am struck by how patient volume for nearly all of them falls within a reasonably predictable range. While no one can predict with certainty which days will be unusually busy or slow, nearly all practices have a range of daily encounters that is roughly half to 1 1/2 of the mean. For example, if a practice has a mean of 60 billable encounters per day, it probably ranges from about 30 to 90 encounters on any given day. (The larger the practice, the more likely they are to conform to this range. Small practices, with average daily encounters fewer than 20, have a much wider range of daily volumes as a percent of the mean.)
Despite knowing that volumes will vary unpredictably, most practices provide the same fixed “dose” of provider staffing every day—that is, the single most common model for staffing and scheduling is to provide a fixed number of day-shift doctors (“rounders”) who work a fixed number of hours. For example, with an average of 60 billable encounters a day, a hospitalist group might decide to staff with four day-shift rounders working 12-hour shifts. This equates to a fixed 48 hours of daytime staffing. This is reasonable until the busy days arrive. Those four doctors will be much busier than average when there are 90 patients to see in a day, and will probably have a hard time seeing 22 or 23 patients each during their 12-hour shift. If such a busy day occurs more than a couple of times annually, then the practice should probably make some changes.
One approach to solving this type of staffing predicament is to add a fifth day-shift rounder. In other words, when making staffing decisions, consider giving more weight to the busiest days than the average day. This sounds fine until thinking about the practice budget. It will be pretty expensive to add doctors every day just so there are enough on duty when things get really busy. But if the hospitalists are willing to accept reduced compensation, then it might be financially reasonable to go ahead and add staff. This is easiest to do when the hospitalists are paid a significant (e.g. ≥50%) portion of their income based on their productivity, which will enable the hospitalists themselves to have a lot of say about when it is time to add staff. (Being paid on a nearly fixed annual salary means that it is the finance person who usually has the say about when it is time to add staff. And you can bet he’ll be making staffing decisions based on the average daily encounters, rather than the busy days.)
My own preference would be to do just that: Accept a reduction in compensation in return for protection against really busy and stressful days. I’m not suggesting others should agree with me, and in my experience, most don’t. (My own practice partners don’t agree with me on this one.) So I’m not really recommending it as a best practice, but I want to ensure that you don’t forget it is an option. And keep in mind you could adjust staffing by degrees; some settings might add a half-time physician or a nonphysician provider to try to find the sweet spot between having enough staff on duty every day to handle surges in volume and the cost of that staffing to the employer—or the hospitalists themselves.
Of course, if I were willing to reduce my compensation and average daily workload, then I would expect to be freed from the expectation that all rounding doctors work 12-hour shifts. Let’s turn our attention to the interplay between fixed day-shift durations and surge staffing.
Fixed-Shift Schedules Inhibit Surge Capacity
I think it usually is best to avoid fixed durations for day shifts. It might be necessary to require at least one daytime rounder to stay at least until a specified time (e.g. the arrival of the night-shift doctor), but in most cases it is reasonable for some rounders to leave when their work is done. They might need to continue responding to pages until the start of the night shift, but it usually isn’t necessary to have all rounders in the hospital until a predetermined end of the shift.
The problem is that when shifts have a fixed duration, the providers will focus on the start and stop time of their shift and might be unwilling to work beyond it. If instead there are no clearly fixed start and stop times for each day shift, then the hospitalists are likely to be willing to simply work longer on busy days, as long as they can work shorter on slow days. This is probably the most effective method of surge capacity, and it fits well with staffing each day with more providers than are required for the average patient volume.
Simply having the rounding doctors work longer on busy days must be done within reason. And there is a really wide range of opinion about what is reasonable. I think it is reasonable if a hospitalist works two or three hours longer than usual for three or four consecutive busy days, as long as the hospitalist is allowed to work less on days that are not very busy. But just what is a reasonable maximum daily amount of work for even one day is a topic that can lead to passionate debate. You’ll have to decide the details of what is and isn’t acceptable in your group.
Unit-Based Assignments
Aside from fixed-duration day shifts, unit-based assignment of hospitalists is the most common practice inhibiting surge capacity. Not long ago I worked with a practice that followed very strict unit-based assignments, which significantly inhibited “load-leveling,” and thus surge capacity. On any given day the patient volume for the whole practice might be very reasonable, but because it was never distributed evenly among the rounders, there was a very good chance that at least one doctor was drowning in work. And because of the strict approach, the other doctors didn’t come to the rescue.
I think the only reasonable approach is to deviate from such a strict unit-based assignment, at least a little. One rounder could be a utility doctor who doesn’t have her own unit and instead roams throughout the hospital, having been assigned patients based on the workload of each of her unit-based colleagues. TH
Dr. Nelson has been a practicing hospitalist since 1988 and is cofounder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants (www.nelsonflores.com) and codirector and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.
Playground Politics
Baseball, kick the can, Russian roulette—pick your game. Chances are good that it has worked its way into a metaphor to illustrate the infuriating, perplexing, and altogether frustrating inability of Congress to step up to the plate and pass a long-term fix to the broken sustainable growth rate (SGR) formula used to determine Medicare reimbursement rates.
On June 24, legislators avoided catastrophe by temporarily rescinding a 21.3% rate cut that went into effect June 1. The after-the-fact patch meant that some Medicare claims had to be reprocessed to recoup the full value, creating an administrative mess. The accompanying 2.2% rate increase expires Nov. 30. The reimbursement cut could reach nearly 30% next year unless Congress intervenes again.
“Obviously, there’s a lot of frustration around the issue, especially on the membership side,” says Ron Greeno, MD, FACP, SFHM, a member of SHM’s Public Policy and Leadership committees, and chief medical officer for Brentwood, Tenn.-based Cogent Healthcare. For hospitalists in many small private practices, he says, a major percentage of income comes from Medicare. “It’s a tremendous headache,” he says of the uncertainty. “It’s very hard to plan for. You’re trying to budget and you don’t know what the policy is going to be literally from week to week.”
The Blame Game
Despite the widespread sentiment among doctors that a permanent reimbursement rate fix should have been included in the healthcare reform legislation, skittishness over the price tag led legislators to drop it from the package. Based on last fall’s estimates, the total cost of a reform bill that scrapped the SGR would have ballooned by roughly $250 billion over 10 years, which would have threatened the bill’s passage.
But Congress has since been unable to pass a permanent fix as standalone legislation amid mounting concern over the national debt, and the price of inaction continues to rise. On April 30, the Congressional Budget Office (CBO) estimated that the cost of jettisoning the SGR formula and freezing rates at current levels had grown to $276 billion over 10 years.
Any serious consideration of lasting alternatives has now been pushed back to the lame-duck session, after the midterm elections. The can has been kicked down the road so many times, Dr. Greeno and others say, that most Congressional members have boot marks all over them. “So now you have a bigger problem at a more crucial time, when money is tighter than ever in a poor economy,” Dr. Greeno says. “And I just think it’s been a failure of our politicians.”
Other healthcare industry leaders have been just as critical. “Delaying the problem is not a solution,” said AMA President Cecil B. Wilson, MD, in a prepared statement after Congress passed the latest six-month reprieve in June. “It doesn’t solve the Medicare mess Congress has created with a long series of short-term Medicare patches over the last decade—including four to avert the 2010 cut alone.”
AMA-sponsored print ads have reminded legislators that delaying a fix until 2013 will again increase its cost, to $396 billion over 10 years. And the association’s June press release asserted that “Congress is playing a dangerous game of Russian roulette with seniors’ healthcare.”
Perhaps a game of “chicken” would be more apt.
Republicans have dared Democrats to spend the billions for a more lasting solution—in the absence of any cuts elsewhere in the healthcare delivery system—and be labeled as fiscally irresponsible. In turn, Democrats have dared Republicans to let the rate cut take effect and be labeled heartless as Medicare beneficiaries lose access to their healthcare providers.
Both parties blinked, resorting to almost unanimous short-term fixes that have allowed legislators to save face while putting off politically risky votes until after the November elections.
Lynne M. Allen, MN, ARNP, who works as a part-time hospitalist in hematology-oncology at 188-bed Kadlec Regional Medical Center in Richland, Wash., says she and other colleagues were initially hopeful that the Obama administration would make Congress work together to find a lasting solution. “There’s a sense of frustration because instead of that happening from our legislators, they’re playing a lot of games with the funding,” says Allen, a member of Team Hospitalist. “They’re not willing to step up to the plate, as they say, and make a decision that will allow us to go forward smoothly.”
The result, Allen says, has been a “roller-coaster ride” of uncertainty over reimbursements. Because Washington’s Tri-Cities region has a relatively high percentage of patients with private insurance, her hospital is somewhat cushioned from a precipitous drop in Medicare fees. But if CMS is ever forced to cut back on its rates, she fully expects private insurers to follow the same downward track.
Practical Concerns
Barbara Hartley, MD, a part-time hospitalist at 22-bed Benson Hospital in Benson, Ariz., says the town’s healthcare facility is somewhat protected from potential Medicare rate cuts through its official status as a Critical Access Hospital. Instead of being reimbursed through diagnosis-related group (DRG) codes, the rural hospital is repaid by Medicare for its total cost per day per patient.
The arrangement is a stable one at the moment, but not enough to dispel Dr. Hartley’s uneasy question: If the economy worsens, will Medicare be able to retain its commitment to rural hospitals? If not, the pain might be felt acutely in communities like Benson, where Dr. Hartley estimates that as much as 75% of the hospital’s in-patient business is through either Medicare or a Medicare Advantage plan.
Kirk Mathews, CEO of St. Louis-based Inpatient Management Inc. and a member of SHM’s Public Policy and Practice Management committees, says Medicare rate cuts also could significantly reduce the leverage of hospitalists during contract negotiations.
“Even if we’re employed by the hospital, but our professional fees that the hospital can recoup for our services are dramatically affected, it will affect how those future contracts go,” Mathews says. “We might be insulated temporarily by the strength of our current contract. But if the formula—however that works out—dramatically impacts the hospitalist reimbursement on the professional fee side, the hospital will feel that, and then hospitalists will eventually feel that as well.” In other words, it could strengthen the bargaining hand of the hospital at the expense of the hospitalist. “Therein lies the long-term threat,” he points out.
Independent Solution?
Some of the authority over physician payments might eventually be depoliticized via language in the reform legislation that empowers a new entity, the Independent Payment Advisory Board, to create policy on such critical monetary issues as reimbursement rates. Congress could still override the board’s policy decisions, but only if the Congressional alternative saves just as much money.
In the meantime, the money for a fix still has to come from somewhere, and no consensus has emerged. Advocates likewise refuse to coalesce around any single alternative. Some experts favor a new formula based on the Medicare economic index, which measures inflation in healthcare delivery costs. But the CBO estimates that per-beneficiary spending under such a formula would be 30% more by 2016 than under the current formula. Other proposals call for temporarily increasing rates, then reverting to annual GDP growth, plus a bit more to cover physician costs.
No matter how the crisis is resolved, experts say, doctors almost certainly will have to make do with less. “When healthcare reform is finally fully implemented, there are going to be less dollars to pay for more services. It’s inevitable,” Mathews says. “And whether it takes the form of SGR or some other form, I’m afraid physicians are going to have to get used to having less money in the pool of money that’s allocated to pay providers.”
It could be a whole new ballgame. TH
Bryn Nelson, PhD, is a freelance medical writer based in Seattle.
Baseball, kick the can, Russian roulette—pick your game. Chances are good that it has worked its way into a metaphor to illustrate the infuriating, perplexing, and altogether frustrating inability of Congress to step up to the plate and pass a long-term fix to the broken sustainable growth rate (SGR) formula used to determine Medicare reimbursement rates.
On June 24, legislators avoided catastrophe by temporarily rescinding a 21.3% rate cut that went into effect June 1. The after-the-fact patch meant that some Medicare claims had to be reprocessed to recoup the full value, creating an administrative mess. The accompanying 2.2% rate increase expires Nov. 30. The reimbursement cut could reach nearly 30% next year unless Congress intervenes again.
“Obviously, there’s a lot of frustration around the issue, especially on the membership side,” says Ron Greeno, MD, FACP, SFHM, a member of SHM’s Public Policy and Leadership committees, and chief medical officer for Brentwood, Tenn.-based Cogent Healthcare. For hospitalists in many small private practices, he says, a major percentage of income comes from Medicare. “It’s a tremendous headache,” he says of the uncertainty. “It’s very hard to plan for. You’re trying to budget and you don’t know what the policy is going to be literally from week to week.”
The Blame Game
Despite the widespread sentiment among doctors that a permanent reimbursement rate fix should have been included in the healthcare reform legislation, skittishness over the price tag led legislators to drop it from the package. Based on last fall’s estimates, the total cost of a reform bill that scrapped the SGR would have ballooned by roughly $250 billion over 10 years, which would have threatened the bill’s passage.
But Congress has since been unable to pass a permanent fix as standalone legislation amid mounting concern over the national debt, and the price of inaction continues to rise. On April 30, the Congressional Budget Office (CBO) estimated that the cost of jettisoning the SGR formula and freezing rates at current levels had grown to $276 billion over 10 years.
Any serious consideration of lasting alternatives has now been pushed back to the lame-duck session, after the midterm elections. The can has been kicked down the road so many times, Dr. Greeno and others say, that most Congressional members have boot marks all over them. “So now you have a bigger problem at a more crucial time, when money is tighter than ever in a poor economy,” Dr. Greeno says. “And I just think it’s been a failure of our politicians.”
Other healthcare industry leaders have been just as critical. “Delaying the problem is not a solution,” said AMA President Cecil B. Wilson, MD, in a prepared statement after Congress passed the latest six-month reprieve in June. “It doesn’t solve the Medicare mess Congress has created with a long series of short-term Medicare patches over the last decade—including four to avert the 2010 cut alone.”
AMA-sponsored print ads have reminded legislators that delaying a fix until 2013 will again increase its cost, to $396 billion over 10 years. And the association’s June press release asserted that “Congress is playing a dangerous game of Russian roulette with seniors’ healthcare.”
Perhaps a game of “chicken” would be more apt.
Republicans have dared Democrats to spend the billions for a more lasting solution—in the absence of any cuts elsewhere in the healthcare delivery system—and be labeled as fiscally irresponsible. In turn, Democrats have dared Republicans to let the rate cut take effect and be labeled heartless as Medicare beneficiaries lose access to their healthcare providers.
Both parties blinked, resorting to almost unanimous short-term fixes that have allowed legislators to save face while putting off politically risky votes until after the November elections.
Lynne M. Allen, MN, ARNP, who works as a part-time hospitalist in hematology-oncology at 188-bed Kadlec Regional Medical Center in Richland, Wash., says she and other colleagues were initially hopeful that the Obama administration would make Congress work together to find a lasting solution. “There’s a sense of frustration because instead of that happening from our legislators, they’re playing a lot of games with the funding,” says Allen, a member of Team Hospitalist. “They’re not willing to step up to the plate, as they say, and make a decision that will allow us to go forward smoothly.”
The result, Allen says, has been a “roller-coaster ride” of uncertainty over reimbursements. Because Washington’s Tri-Cities region has a relatively high percentage of patients with private insurance, her hospital is somewhat cushioned from a precipitous drop in Medicare fees. But if CMS is ever forced to cut back on its rates, she fully expects private insurers to follow the same downward track.
Practical Concerns
Barbara Hartley, MD, a part-time hospitalist at 22-bed Benson Hospital in Benson, Ariz., says the town’s healthcare facility is somewhat protected from potential Medicare rate cuts through its official status as a Critical Access Hospital. Instead of being reimbursed through diagnosis-related group (DRG) codes, the rural hospital is repaid by Medicare for its total cost per day per patient.
The arrangement is a stable one at the moment, but not enough to dispel Dr. Hartley’s uneasy question: If the economy worsens, will Medicare be able to retain its commitment to rural hospitals? If not, the pain might be felt acutely in communities like Benson, where Dr. Hartley estimates that as much as 75% of the hospital’s in-patient business is through either Medicare or a Medicare Advantage plan.
Kirk Mathews, CEO of St. Louis-based Inpatient Management Inc. and a member of SHM’s Public Policy and Practice Management committees, says Medicare rate cuts also could significantly reduce the leverage of hospitalists during contract negotiations.
“Even if we’re employed by the hospital, but our professional fees that the hospital can recoup for our services are dramatically affected, it will affect how those future contracts go,” Mathews says. “We might be insulated temporarily by the strength of our current contract. But if the formula—however that works out—dramatically impacts the hospitalist reimbursement on the professional fee side, the hospital will feel that, and then hospitalists will eventually feel that as well.” In other words, it could strengthen the bargaining hand of the hospital at the expense of the hospitalist. “Therein lies the long-term threat,” he points out.
Independent Solution?
Some of the authority over physician payments might eventually be depoliticized via language in the reform legislation that empowers a new entity, the Independent Payment Advisory Board, to create policy on such critical monetary issues as reimbursement rates. Congress could still override the board’s policy decisions, but only if the Congressional alternative saves just as much money.
In the meantime, the money for a fix still has to come from somewhere, and no consensus has emerged. Advocates likewise refuse to coalesce around any single alternative. Some experts favor a new formula based on the Medicare economic index, which measures inflation in healthcare delivery costs. But the CBO estimates that per-beneficiary spending under such a formula would be 30% more by 2016 than under the current formula. Other proposals call for temporarily increasing rates, then reverting to annual GDP growth, plus a bit more to cover physician costs.
No matter how the crisis is resolved, experts say, doctors almost certainly will have to make do with less. “When healthcare reform is finally fully implemented, there are going to be less dollars to pay for more services. It’s inevitable,” Mathews says. “And whether it takes the form of SGR or some other form, I’m afraid physicians are going to have to get used to having less money in the pool of money that’s allocated to pay providers.”
It could be a whole new ballgame. TH
Bryn Nelson, PhD, is a freelance medical writer based in Seattle.
Baseball, kick the can, Russian roulette—pick your game. Chances are good that it has worked its way into a metaphor to illustrate the infuriating, perplexing, and altogether frustrating inability of Congress to step up to the plate and pass a long-term fix to the broken sustainable growth rate (SGR) formula used to determine Medicare reimbursement rates.
On June 24, legislators avoided catastrophe by temporarily rescinding a 21.3% rate cut that went into effect June 1. The after-the-fact patch meant that some Medicare claims had to be reprocessed to recoup the full value, creating an administrative mess. The accompanying 2.2% rate increase expires Nov. 30. The reimbursement cut could reach nearly 30% next year unless Congress intervenes again.
“Obviously, there’s a lot of frustration around the issue, especially on the membership side,” says Ron Greeno, MD, FACP, SFHM, a member of SHM’s Public Policy and Leadership committees, and chief medical officer for Brentwood, Tenn.-based Cogent Healthcare. For hospitalists in many small private practices, he says, a major percentage of income comes from Medicare. “It’s a tremendous headache,” he says of the uncertainty. “It’s very hard to plan for. You’re trying to budget and you don’t know what the policy is going to be literally from week to week.”
The Blame Game
Despite the widespread sentiment among doctors that a permanent reimbursement rate fix should have been included in the healthcare reform legislation, skittishness over the price tag led legislators to drop it from the package. Based on last fall’s estimates, the total cost of a reform bill that scrapped the SGR would have ballooned by roughly $250 billion over 10 years, which would have threatened the bill’s passage.
But Congress has since been unable to pass a permanent fix as standalone legislation amid mounting concern over the national debt, and the price of inaction continues to rise. On April 30, the Congressional Budget Office (CBO) estimated that the cost of jettisoning the SGR formula and freezing rates at current levels had grown to $276 billion over 10 years.
Any serious consideration of lasting alternatives has now been pushed back to the lame-duck session, after the midterm elections. The can has been kicked down the road so many times, Dr. Greeno and others say, that most Congressional members have boot marks all over them. “So now you have a bigger problem at a more crucial time, when money is tighter than ever in a poor economy,” Dr. Greeno says. “And I just think it’s been a failure of our politicians.”
Other healthcare industry leaders have been just as critical. “Delaying the problem is not a solution,” said AMA President Cecil B. Wilson, MD, in a prepared statement after Congress passed the latest six-month reprieve in June. “It doesn’t solve the Medicare mess Congress has created with a long series of short-term Medicare patches over the last decade—including four to avert the 2010 cut alone.”
AMA-sponsored print ads have reminded legislators that delaying a fix until 2013 will again increase its cost, to $396 billion over 10 years. And the association’s June press release asserted that “Congress is playing a dangerous game of Russian roulette with seniors’ healthcare.”
Perhaps a game of “chicken” would be more apt.
Republicans have dared Democrats to spend the billions for a more lasting solution—in the absence of any cuts elsewhere in the healthcare delivery system—and be labeled as fiscally irresponsible. In turn, Democrats have dared Republicans to let the rate cut take effect and be labeled heartless as Medicare beneficiaries lose access to their healthcare providers.
Both parties blinked, resorting to almost unanimous short-term fixes that have allowed legislators to save face while putting off politically risky votes until after the November elections.
Lynne M. Allen, MN, ARNP, who works as a part-time hospitalist in hematology-oncology at 188-bed Kadlec Regional Medical Center in Richland, Wash., says she and other colleagues were initially hopeful that the Obama administration would make Congress work together to find a lasting solution. “There’s a sense of frustration because instead of that happening from our legislators, they’re playing a lot of games with the funding,” says Allen, a member of Team Hospitalist. “They’re not willing to step up to the plate, as they say, and make a decision that will allow us to go forward smoothly.”
The result, Allen says, has been a “roller-coaster ride” of uncertainty over reimbursements. Because Washington’s Tri-Cities region has a relatively high percentage of patients with private insurance, her hospital is somewhat cushioned from a precipitous drop in Medicare fees. But if CMS is ever forced to cut back on its rates, she fully expects private insurers to follow the same downward track.
Practical Concerns
Barbara Hartley, MD, a part-time hospitalist at 22-bed Benson Hospital in Benson, Ariz., says the town’s healthcare facility is somewhat protected from potential Medicare rate cuts through its official status as a Critical Access Hospital. Instead of being reimbursed through diagnosis-related group (DRG) codes, the rural hospital is repaid by Medicare for its total cost per day per patient.
The arrangement is a stable one at the moment, but not enough to dispel Dr. Hartley’s uneasy question: If the economy worsens, will Medicare be able to retain its commitment to rural hospitals? If not, the pain might be felt acutely in communities like Benson, where Dr. Hartley estimates that as much as 75% of the hospital’s in-patient business is through either Medicare or a Medicare Advantage plan.
Kirk Mathews, CEO of St. Louis-based Inpatient Management Inc. and a member of SHM’s Public Policy and Practice Management committees, says Medicare rate cuts also could significantly reduce the leverage of hospitalists during contract negotiations.
“Even if we’re employed by the hospital, but our professional fees that the hospital can recoup for our services are dramatically affected, it will affect how those future contracts go,” Mathews says. “We might be insulated temporarily by the strength of our current contract. But if the formula—however that works out—dramatically impacts the hospitalist reimbursement on the professional fee side, the hospital will feel that, and then hospitalists will eventually feel that as well.” In other words, it could strengthen the bargaining hand of the hospital at the expense of the hospitalist. “Therein lies the long-term threat,” he points out.
Independent Solution?
Some of the authority over physician payments might eventually be depoliticized via language in the reform legislation that empowers a new entity, the Independent Payment Advisory Board, to create policy on such critical monetary issues as reimbursement rates. Congress could still override the board’s policy decisions, but only if the Congressional alternative saves just as much money.
In the meantime, the money for a fix still has to come from somewhere, and no consensus has emerged. Advocates likewise refuse to coalesce around any single alternative. Some experts favor a new formula based on the Medicare economic index, which measures inflation in healthcare delivery costs. But the CBO estimates that per-beneficiary spending under such a formula would be 30% more by 2016 than under the current formula. Other proposals call for temporarily increasing rates, then reverting to annual GDP growth, plus a bit more to cover physician costs.
No matter how the crisis is resolved, experts say, doctors almost certainly will have to make do with less. “When healthcare reform is finally fully implemented, there are going to be less dollars to pay for more services. It’s inevitable,” Mathews says. “And whether it takes the form of SGR or some other form, I’m afraid physicians are going to have to get used to having less money in the pool of money that’s allocated to pay providers.”
It could be a whole new ballgame. TH
Bryn Nelson, PhD, is a freelance medical writer based in Seattle.
Productivity Capacity
The mark of any great society is balance—balance between the production realized today and the preservation of “production capacity” to ensure the same or greater production in the future. HM is not exempt from this fundamental tenet. What we do now in the way of advancing quality, efficiency, and patient safety will matter little if our contributions are not sustained by the generation that follows us.
It is tempting to think that the issue of how we train residents is germane only to universities, but the reality is that it affects us all. There are 126 “university” medical school programs, but there are 384 residency programs, most of which are within community-based hospitals. The result is that most hospitalists encounter resident physicians in some capacity, and all hospitalists will encounter the results of residency training when they welcome a new recruit to their ranks.
The education and socialization of our residents will define the character of the hospitalists of the future. But the “residency” in which most of us trained does not exist anymore: The duty-hours changes and additional training requirements have dramatically changed the landscape of residency training in the past 10 years, and another series of sea changes is underway. As with all things HM, we again have a choice: Be reactive, wait for the dust to clear, and then lament the results, or be proactive and see this change for what it is—an opportunity to improve healthcare quality now, and in the future.
The ACGME
HM felt the impact of the first wave of duty-hours restrictions beginning in 2003, as many training programs opted to employ hospitalists to provide the coverage that could no longer be maintained by residents working under tighter admission caps and duty-hour restrictions. In doing so, hospitalists have provided a valuable service in preserving the integrity of training environments and fidelity to the Accreditation Council for Graduate Medical Education (ACGME) regulations (more than 85% of training programs have hospitalists working in their systems). But the model of hospitalists working solely as “resident-extenders” is not sustainable.
First, hospitalists who work solely on nonteaching services are at great risk of burning out, especially if the distribution of patients has been manipulated such that the more interesting patients are funneled away from the hospitalist’s service to the teaching service. Second, there is a risk in perception: In models in which the hospitalist is solely the “overflow cap coverage” or the night-float physician (i.e., the resident-extender), residents come to see hospitalists as the “PGY-4, 5, 6 …” physicians—that is, the physician who becomes a resident for life. The result is a serious pipeline issue for us, as the most talented resident physicians are unlikely to forego subspecialty training for a career in HM if hospitalists are perceived as perpetual residents.
The solution is simple: The hospitalist’s role in training environments has to be more than merely solving admission cap or duty-hour issues. It is fine for hospitalists to operate nonteaching services, but the hospitalist also has to be a part of the fulfillment that comes with overseeing teaching services. Further, residents have to see the hospitalist career for what it actually is: Academic or not, HM is much more than merely clinical service. HM is about the value-added services of system interventions to improve quality and patient safety; it is about developing a career as a systems architect. Getting the best and brightest residents to choose HM as a career is contingent upon residents seeing hospitalists in the training environment who are happy and fulfilled in the execution of this career goal.
The hospitalist’s plight was helped substantially on June 23, when ACGME released for comment the revised Common Program Requirements (www.acgme.org). The duty-hours changes are unlikely to substantially alter hospitalists’ lives; the only significant change was a limitation on intern shift durations to fewer than 16 hours in a row (upper-level residents still operate under the 24+6 hour rule, with increased flexibility to stay longer by volition). But the interesting part of the new requirements is an augmented focus on teaching residents transitions-of-care skills, improving direct supervision of residents, and constructing educational systems that minimize handoffs.
There is no specialty that is as suited as HM for fulfilling these unique (and, as of yet, unmet) requirements. Transitions, quality, being present on the hospital wards … this is what we do. And requiring instruction in transitions and quality is an unprecedented leverage point for HM to advance the quality of future physicians. How great it would be to attend HM20 and realize that the attendees had already learned the “Quality 101” lessons (i.e., those we are currently teaching at our annual meeting) as part of their residency? Freed from the need to do basic quality sessions, the content of the annual meeting could escalate to even higher-level principles that would result in substantial and sustainable quality improvement (QI).
MedPAC and GME Funding
Simultaneous with the ACGME changes are changes at the Medicare Payment Advisory Committee (MedPAC), the advisory organization responsible for recommending changes in the distribution of Centers for Medicare and Medicaid Services (CMS) funds to support graduate medical education. CMS is the primary funding agent for residency training. Each hospital receives direct medical expenditures to cover a resident’s salary and benefits. Each hospital has a pre-set per-resident allotment, or PRA. This number varies by hospital, but the average is $100,000 per resident. CMS reimburses the hospital a percentage of this number based upon the percentage of hospital days occupied by Medicare patients (e.g., 35% Medicare days=$35,000 per resident).
The hospital also receives indirect medical expenditures, or IME. IME is not a distinct payment to the hospital, but rather an “inflator” of the clinical-care payments the hospital receives from CMS. IME is paid to the hospital under the presumption that a typical training facility incurs greater cost due to higher patient severity, a higher indigent care percentage, and has higher resource utilization due to residents’ excessive testing, etc. The final presumption is that support is needed for the educational infrastructure (i.e., supervision and teaching).
IME is not inconsequential to a hospital; depending upon the payor mix, a 200-bed hospital might have from $4 million to $8 million in annual IME payments. CMS’ total IME payments to hospitals is more than $6 billion a year. Each hospital’s IME revenue can be found at www.graham-center.org/online/graham/home/tools-resources/data-tables/dt001-gme-2007.html.
The game-changing event occurred in April, when MedPAC announced its intent to reassess the mechanisms of IME funding, with a vision of IME funding eventually being linked to a hospital’s training programs’ ability to demonstrate substantial improvement in quality and patient safety. And here is the leverage point that is a unique opportunity for hospitalists in the training environment. For many hospitalists, especially if employed directly by the hospital, there is little financial incentive to engaging on a teaching service. The ACGME caps limit the service size, and this in turn limits the possible RVUs. Up until now, asking the hospital to compensate for teaching time (i.e., EVUs) was a pipe dream. But the linking of IME funding to quality outcomes (and quality instruction to residents) could change all of that.
If you put the two together: ACGME calling for instruction in quality and transitions, plus MedPAC calling for payments linked to resident outcomes in quality and patient safety, you have one inescapable conclusion—the residency of the future will hinge upon having supervisors with the necessary expertise to ensure that residents participate in, and understand the principles of, patient safety and quality as a part of the residency curriculum. And the people who can ensure that goal are likely to be in a position to warrant compensation for doing so.
Who is better to do this than the hospitalist?
SHM’s Proactive Strategy
This is the opportune time for HM to advance its stature as a profession and to ensure its future via a pipeline of residents adequately training in quality and patient safety. But it is not enough to merely wish for this to happen. There are real barriers that have kept hospitalists from being more intimately involved in physician training, the first of which is age.
HM is a young specialty (the average hospitalist is 37; the average HM leader is 41), and its youth makes it hard to compete with older subspecialists/generalists who have more experience in education. But deficits in experience can be compensated by additional training.
The Academic Hospitalist Academy (AHA)—cosponsored by SHM, the Society of General Internal Medicine (SGIM), and the Association of Chiefs and Leaders of General Internal Medicine (ACLGIM)—is the key to the strategy of catching up quickly. The academy will convene this month outside of Atlanta, and it is very important that each training facility think about sending one of its hospitalists to receive the advanced training in education necessary to compensate for not having years of experience in medical education. Academy details are available at http://academichospitalist.org.
SHM’s initiatives on this front do not stop with the academy. Over the past three months, Kevin O’Leary, MD, and his Quality Improvement Education Committee have been furiously building a “Quality and Patient Safety” curriculum, with a target audience of new hospitalists and resident physicians. The vision is to create a Web-based, interactive curriculum that teaches resident physicians the basics of quality and patient safety, design projects with their colleagues (under the supervision of their hospitalist mentor), and track their data to see real-time results.
Unlike other curricula on the market, the SHM Quality Curriculum for residents will be dynamic, requiring participating institutions commit to SHM’s modus operandi of mentored implementation by sponsoring a hospitalist to receive the training necessary to put the curriculum in motion. To this end, SHM has collaborated with the Alliance for Internal Medicine (AIM) in co-sponsoring the Quality Academy, with a focus on how to teach quality and patient safety. Jen Meyers, MD, FHM, and Jeff Glasheen, MD, SFHM, will be leading the team responsible for the development of this Quality Training Course, which should emerge in the fall of 2011.
As this project proceeds, Paul Grant, MD, chair of the Early Career Hospitalist Committee, and Cheryl O’Malley, MD, chair of the Pipeline Committee, will provide counsel. Both of these groups will continue efforts to improve the process by which residents transition from residency to HM practice, and supporting young physicians with distance mentoring.
The SHM vision of our production capacity is simple: Bring in the best and brightest hospitalists who are interested in teaching quality and patient safety, train them in the fundamentals of medical education, provide them with an “off the net” curriculum for how to teach quality, then return them to their respective training environments to coach residents on the principles of quality.
Training programs that invest in this vision will reap the rewards of fidelity to the new ACGME requirements. Hospitals that support such a vision will receive assurances, should MedPAC’s recommendation come to fruition, that DME and IME funding is secure. Hospitalists investing in this vision will find a fulfilling career in quality education.
And all of us will find assurances that, for as good as things are right now for HM, the future will be even better. TH
Dr. Wiese is president of SHM.
The mark of any great society is balance—balance between the production realized today and the preservation of “production capacity” to ensure the same or greater production in the future. HM is not exempt from this fundamental tenet. What we do now in the way of advancing quality, efficiency, and patient safety will matter little if our contributions are not sustained by the generation that follows us.
It is tempting to think that the issue of how we train residents is germane only to universities, but the reality is that it affects us all. There are 126 “university” medical school programs, but there are 384 residency programs, most of which are within community-based hospitals. The result is that most hospitalists encounter resident physicians in some capacity, and all hospitalists will encounter the results of residency training when they welcome a new recruit to their ranks.
The education and socialization of our residents will define the character of the hospitalists of the future. But the “residency” in which most of us trained does not exist anymore: The duty-hours changes and additional training requirements have dramatically changed the landscape of residency training in the past 10 years, and another series of sea changes is underway. As with all things HM, we again have a choice: Be reactive, wait for the dust to clear, and then lament the results, or be proactive and see this change for what it is—an opportunity to improve healthcare quality now, and in the future.
The ACGME
HM felt the impact of the first wave of duty-hours restrictions beginning in 2003, as many training programs opted to employ hospitalists to provide the coverage that could no longer be maintained by residents working under tighter admission caps and duty-hour restrictions. In doing so, hospitalists have provided a valuable service in preserving the integrity of training environments and fidelity to the Accreditation Council for Graduate Medical Education (ACGME) regulations (more than 85% of training programs have hospitalists working in their systems). But the model of hospitalists working solely as “resident-extenders” is not sustainable.
First, hospitalists who work solely on nonteaching services are at great risk of burning out, especially if the distribution of patients has been manipulated such that the more interesting patients are funneled away from the hospitalist’s service to the teaching service. Second, there is a risk in perception: In models in which the hospitalist is solely the “overflow cap coverage” or the night-float physician (i.e., the resident-extender), residents come to see hospitalists as the “PGY-4, 5, 6 …” physicians—that is, the physician who becomes a resident for life. The result is a serious pipeline issue for us, as the most talented resident physicians are unlikely to forego subspecialty training for a career in HM if hospitalists are perceived as perpetual residents.
The solution is simple: The hospitalist’s role in training environments has to be more than merely solving admission cap or duty-hour issues. It is fine for hospitalists to operate nonteaching services, but the hospitalist also has to be a part of the fulfillment that comes with overseeing teaching services. Further, residents have to see the hospitalist career for what it actually is: Academic or not, HM is much more than merely clinical service. HM is about the value-added services of system interventions to improve quality and patient safety; it is about developing a career as a systems architect. Getting the best and brightest residents to choose HM as a career is contingent upon residents seeing hospitalists in the training environment who are happy and fulfilled in the execution of this career goal.
The hospitalist’s plight was helped substantially on June 23, when ACGME released for comment the revised Common Program Requirements (www.acgme.org). The duty-hours changes are unlikely to substantially alter hospitalists’ lives; the only significant change was a limitation on intern shift durations to fewer than 16 hours in a row (upper-level residents still operate under the 24+6 hour rule, with increased flexibility to stay longer by volition). But the interesting part of the new requirements is an augmented focus on teaching residents transitions-of-care skills, improving direct supervision of residents, and constructing educational systems that minimize handoffs.
There is no specialty that is as suited as HM for fulfilling these unique (and, as of yet, unmet) requirements. Transitions, quality, being present on the hospital wards … this is what we do. And requiring instruction in transitions and quality is an unprecedented leverage point for HM to advance the quality of future physicians. How great it would be to attend HM20 and realize that the attendees had already learned the “Quality 101” lessons (i.e., those we are currently teaching at our annual meeting) as part of their residency? Freed from the need to do basic quality sessions, the content of the annual meeting could escalate to even higher-level principles that would result in substantial and sustainable quality improvement (QI).
MedPAC and GME Funding
Simultaneous with the ACGME changes are changes at the Medicare Payment Advisory Committee (MedPAC), the advisory organization responsible for recommending changes in the distribution of Centers for Medicare and Medicaid Services (CMS) funds to support graduate medical education. CMS is the primary funding agent for residency training. Each hospital receives direct medical expenditures to cover a resident’s salary and benefits. Each hospital has a pre-set per-resident allotment, or PRA. This number varies by hospital, but the average is $100,000 per resident. CMS reimburses the hospital a percentage of this number based upon the percentage of hospital days occupied by Medicare patients (e.g., 35% Medicare days=$35,000 per resident).
The hospital also receives indirect medical expenditures, or IME. IME is not a distinct payment to the hospital, but rather an “inflator” of the clinical-care payments the hospital receives from CMS. IME is paid to the hospital under the presumption that a typical training facility incurs greater cost due to higher patient severity, a higher indigent care percentage, and has higher resource utilization due to residents’ excessive testing, etc. The final presumption is that support is needed for the educational infrastructure (i.e., supervision and teaching).
IME is not inconsequential to a hospital; depending upon the payor mix, a 200-bed hospital might have from $4 million to $8 million in annual IME payments. CMS’ total IME payments to hospitals is more than $6 billion a year. Each hospital’s IME revenue can be found at www.graham-center.org/online/graham/home/tools-resources/data-tables/dt001-gme-2007.html.
The game-changing event occurred in April, when MedPAC announced its intent to reassess the mechanisms of IME funding, with a vision of IME funding eventually being linked to a hospital’s training programs’ ability to demonstrate substantial improvement in quality and patient safety. And here is the leverage point that is a unique opportunity for hospitalists in the training environment. For many hospitalists, especially if employed directly by the hospital, there is little financial incentive to engaging on a teaching service. The ACGME caps limit the service size, and this in turn limits the possible RVUs. Up until now, asking the hospital to compensate for teaching time (i.e., EVUs) was a pipe dream. But the linking of IME funding to quality outcomes (and quality instruction to residents) could change all of that.
If you put the two together: ACGME calling for instruction in quality and transitions, plus MedPAC calling for payments linked to resident outcomes in quality and patient safety, you have one inescapable conclusion—the residency of the future will hinge upon having supervisors with the necessary expertise to ensure that residents participate in, and understand the principles of, patient safety and quality as a part of the residency curriculum. And the people who can ensure that goal are likely to be in a position to warrant compensation for doing so.
Who is better to do this than the hospitalist?
SHM’s Proactive Strategy
This is the opportune time for HM to advance its stature as a profession and to ensure its future via a pipeline of residents adequately training in quality and patient safety. But it is not enough to merely wish for this to happen. There are real barriers that have kept hospitalists from being more intimately involved in physician training, the first of which is age.
HM is a young specialty (the average hospitalist is 37; the average HM leader is 41), and its youth makes it hard to compete with older subspecialists/generalists who have more experience in education. But deficits in experience can be compensated by additional training.
The Academic Hospitalist Academy (AHA)—cosponsored by SHM, the Society of General Internal Medicine (SGIM), and the Association of Chiefs and Leaders of General Internal Medicine (ACLGIM)—is the key to the strategy of catching up quickly. The academy will convene this month outside of Atlanta, and it is very important that each training facility think about sending one of its hospitalists to receive the advanced training in education necessary to compensate for not having years of experience in medical education. Academy details are available at http://academichospitalist.org.
SHM’s initiatives on this front do not stop with the academy. Over the past three months, Kevin O’Leary, MD, and his Quality Improvement Education Committee have been furiously building a “Quality and Patient Safety” curriculum, with a target audience of new hospitalists and resident physicians. The vision is to create a Web-based, interactive curriculum that teaches resident physicians the basics of quality and patient safety, design projects with their colleagues (under the supervision of their hospitalist mentor), and track their data to see real-time results.
Unlike other curricula on the market, the SHM Quality Curriculum for residents will be dynamic, requiring participating institutions commit to SHM’s modus operandi of mentored implementation by sponsoring a hospitalist to receive the training necessary to put the curriculum in motion. To this end, SHM has collaborated with the Alliance for Internal Medicine (AIM) in co-sponsoring the Quality Academy, with a focus on how to teach quality and patient safety. Jen Meyers, MD, FHM, and Jeff Glasheen, MD, SFHM, will be leading the team responsible for the development of this Quality Training Course, which should emerge in the fall of 2011.
As this project proceeds, Paul Grant, MD, chair of the Early Career Hospitalist Committee, and Cheryl O’Malley, MD, chair of the Pipeline Committee, will provide counsel. Both of these groups will continue efforts to improve the process by which residents transition from residency to HM practice, and supporting young physicians with distance mentoring.
The SHM vision of our production capacity is simple: Bring in the best and brightest hospitalists who are interested in teaching quality and patient safety, train them in the fundamentals of medical education, provide them with an “off the net” curriculum for how to teach quality, then return them to their respective training environments to coach residents on the principles of quality.
Training programs that invest in this vision will reap the rewards of fidelity to the new ACGME requirements. Hospitals that support such a vision will receive assurances, should MedPAC’s recommendation come to fruition, that DME and IME funding is secure. Hospitalists investing in this vision will find a fulfilling career in quality education.
And all of us will find assurances that, for as good as things are right now for HM, the future will be even better. TH
Dr. Wiese is president of SHM.
The mark of any great society is balance—balance between the production realized today and the preservation of “production capacity” to ensure the same or greater production in the future. HM is not exempt from this fundamental tenet. What we do now in the way of advancing quality, efficiency, and patient safety will matter little if our contributions are not sustained by the generation that follows us.
It is tempting to think that the issue of how we train residents is germane only to universities, but the reality is that it affects us all. There are 126 “university” medical school programs, but there are 384 residency programs, most of which are within community-based hospitals. The result is that most hospitalists encounter resident physicians in some capacity, and all hospitalists will encounter the results of residency training when they welcome a new recruit to their ranks.
The education and socialization of our residents will define the character of the hospitalists of the future. But the “residency” in which most of us trained does not exist anymore: The duty-hours changes and additional training requirements have dramatically changed the landscape of residency training in the past 10 years, and another series of sea changes is underway. As with all things HM, we again have a choice: Be reactive, wait for the dust to clear, and then lament the results, or be proactive and see this change for what it is—an opportunity to improve healthcare quality now, and in the future.
The ACGME
HM felt the impact of the first wave of duty-hours restrictions beginning in 2003, as many training programs opted to employ hospitalists to provide the coverage that could no longer be maintained by residents working under tighter admission caps and duty-hour restrictions. In doing so, hospitalists have provided a valuable service in preserving the integrity of training environments and fidelity to the Accreditation Council for Graduate Medical Education (ACGME) regulations (more than 85% of training programs have hospitalists working in their systems). But the model of hospitalists working solely as “resident-extenders” is not sustainable.
First, hospitalists who work solely on nonteaching services are at great risk of burning out, especially if the distribution of patients has been manipulated such that the more interesting patients are funneled away from the hospitalist’s service to the teaching service. Second, there is a risk in perception: In models in which the hospitalist is solely the “overflow cap coverage” or the night-float physician (i.e., the resident-extender), residents come to see hospitalists as the “PGY-4, 5, 6 …” physicians—that is, the physician who becomes a resident for life. The result is a serious pipeline issue for us, as the most talented resident physicians are unlikely to forego subspecialty training for a career in HM if hospitalists are perceived as perpetual residents.
The solution is simple: The hospitalist’s role in training environments has to be more than merely solving admission cap or duty-hour issues. It is fine for hospitalists to operate nonteaching services, but the hospitalist also has to be a part of the fulfillment that comes with overseeing teaching services. Further, residents have to see the hospitalist career for what it actually is: Academic or not, HM is much more than merely clinical service. HM is about the value-added services of system interventions to improve quality and patient safety; it is about developing a career as a systems architect. Getting the best and brightest residents to choose HM as a career is contingent upon residents seeing hospitalists in the training environment who are happy and fulfilled in the execution of this career goal.
The hospitalist’s plight was helped substantially on June 23, when ACGME released for comment the revised Common Program Requirements (www.acgme.org). The duty-hours changes are unlikely to substantially alter hospitalists’ lives; the only significant change was a limitation on intern shift durations to fewer than 16 hours in a row (upper-level residents still operate under the 24+6 hour rule, with increased flexibility to stay longer by volition). But the interesting part of the new requirements is an augmented focus on teaching residents transitions-of-care skills, improving direct supervision of residents, and constructing educational systems that minimize handoffs.
There is no specialty that is as suited as HM for fulfilling these unique (and, as of yet, unmet) requirements. Transitions, quality, being present on the hospital wards … this is what we do. And requiring instruction in transitions and quality is an unprecedented leverage point for HM to advance the quality of future physicians. How great it would be to attend HM20 and realize that the attendees had already learned the “Quality 101” lessons (i.e., those we are currently teaching at our annual meeting) as part of their residency? Freed from the need to do basic quality sessions, the content of the annual meeting could escalate to even higher-level principles that would result in substantial and sustainable quality improvement (QI).
MedPAC and GME Funding
Simultaneous with the ACGME changes are changes at the Medicare Payment Advisory Committee (MedPAC), the advisory organization responsible for recommending changes in the distribution of Centers for Medicare and Medicaid Services (CMS) funds to support graduate medical education. CMS is the primary funding agent for residency training. Each hospital receives direct medical expenditures to cover a resident’s salary and benefits. Each hospital has a pre-set per-resident allotment, or PRA. This number varies by hospital, but the average is $100,000 per resident. CMS reimburses the hospital a percentage of this number based upon the percentage of hospital days occupied by Medicare patients (e.g., 35% Medicare days=$35,000 per resident).
The hospital also receives indirect medical expenditures, or IME. IME is not a distinct payment to the hospital, but rather an “inflator” of the clinical-care payments the hospital receives from CMS. IME is paid to the hospital under the presumption that a typical training facility incurs greater cost due to higher patient severity, a higher indigent care percentage, and has higher resource utilization due to residents’ excessive testing, etc. The final presumption is that support is needed for the educational infrastructure (i.e., supervision and teaching).
IME is not inconsequential to a hospital; depending upon the payor mix, a 200-bed hospital might have from $4 million to $8 million in annual IME payments. CMS’ total IME payments to hospitals is more than $6 billion a year. Each hospital’s IME revenue can be found at www.graham-center.org/online/graham/home/tools-resources/data-tables/dt001-gme-2007.html.
The game-changing event occurred in April, when MedPAC announced its intent to reassess the mechanisms of IME funding, with a vision of IME funding eventually being linked to a hospital’s training programs’ ability to demonstrate substantial improvement in quality and patient safety. And here is the leverage point that is a unique opportunity for hospitalists in the training environment. For many hospitalists, especially if employed directly by the hospital, there is little financial incentive to engaging on a teaching service. The ACGME caps limit the service size, and this in turn limits the possible RVUs. Up until now, asking the hospital to compensate for teaching time (i.e., EVUs) was a pipe dream. But the linking of IME funding to quality outcomes (and quality instruction to residents) could change all of that.
If you put the two together: ACGME calling for instruction in quality and transitions, plus MedPAC calling for payments linked to resident outcomes in quality and patient safety, you have one inescapable conclusion—the residency of the future will hinge upon having supervisors with the necessary expertise to ensure that residents participate in, and understand the principles of, patient safety and quality as a part of the residency curriculum. And the people who can ensure that goal are likely to be in a position to warrant compensation for doing so.
Who is better to do this than the hospitalist?
SHM’s Proactive Strategy
This is the opportune time for HM to advance its stature as a profession and to ensure its future via a pipeline of residents adequately training in quality and patient safety. But it is not enough to merely wish for this to happen. There are real barriers that have kept hospitalists from being more intimately involved in physician training, the first of which is age.
HM is a young specialty (the average hospitalist is 37; the average HM leader is 41), and its youth makes it hard to compete with older subspecialists/generalists who have more experience in education. But deficits in experience can be compensated by additional training.
The Academic Hospitalist Academy (AHA)—cosponsored by SHM, the Society of General Internal Medicine (SGIM), and the Association of Chiefs and Leaders of General Internal Medicine (ACLGIM)—is the key to the strategy of catching up quickly. The academy will convene this month outside of Atlanta, and it is very important that each training facility think about sending one of its hospitalists to receive the advanced training in education necessary to compensate for not having years of experience in medical education. Academy details are available at http://academichospitalist.org.
SHM’s initiatives on this front do not stop with the academy. Over the past three months, Kevin O’Leary, MD, and his Quality Improvement Education Committee have been furiously building a “Quality and Patient Safety” curriculum, with a target audience of new hospitalists and resident physicians. The vision is to create a Web-based, interactive curriculum that teaches resident physicians the basics of quality and patient safety, design projects with their colleagues (under the supervision of their hospitalist mentor), and track their data to see real-time results.
Unlike other curricula on the market, the SHM Quality Curriculum for residents will be dynamic, requiring participating institutions commit to SHM’s modus operandi of mentored implementation by sponsoring a hospitalist to receive the training necessary to put the curriculum in motion. To this end, SHM has collaborated with the Alliance for Internal Medicine (AIM) in co-sponsoring the Quality Academy, with a focus on how to teach quality and patient safety. Jen Meyers, MD, FHM, and Jeff Glasheen, MD, SFHM, will be leading the team responsible for the development of this Quality Training Course, which should emerge in the fall of 2011.
As this project proceeds, Paul Grant, MD, chair of the Early Career Hospitalist Committee, and Cheryl O’Malley, MD, chair of the Pipeline Committee, will provide counsel. Both of these groups will continue efforts to improve the process by which residents transition from residency to HM practice, and supporting young physicians with distance mentoring.
The SHM vision of our production capacity is simple: Bring in the best and brightest hospitalists who are interested in teaching quality and patient safety, train them in the fundamentals of medical education, provide them with an “off the net” curriculum for how to teach quality, then return them to their respective training environments to coach residents on the principles of quality.
Training programs that invest in this vision will reap the rewards of fidelity to the new ACGME requirements. Hospitals that support such a vision will receive assurances, should MedPAC’s recommendation come to fruition, that DME and IME funding is secure. Hospitalists investing in this vision will find a fulfilling career in quality education.
And all of us will find assurances that, for as good as things are right now for HM, the future will be even better. TH
Dr. Wiese is president of SHM.
The Devil & the Details
Act I: The Negotiation
(A barren academic office, dimly lit, the pall of difficult negotiations afloat, backlit like dust in the air. Seated, under a strangely intense incandescent bulb, a man, who looks eerily like a good-looking version of me, sits uncomfortably adjusting himself in his seat. His eyes constrict on his counterpart, a miserly sort peering out from behind wire-rim glasses and a shock of hair improbably combed over from ear to ear. The tension crests.)
GOOD-LOOKING ME
(Voice cracking)
I’ve come to ask for a raise for our hospitalist group.
MISER
(Adjusts his clip-on tie)
We just gave you a raise in 2004.
GOOD-LOOKING ME
(Smiles uncomfortably)
That was very gracious, sir, but I think the numbers support another.
MISER
(Incredulous look at his watch)
But your work RVUs are thousands below what I’d like to see.
GOOD-LOOKING ME
(Dabs bead of sweat away from chiseled chin)
That’s because you’ve set your benchmark thousands above a reasonable number.
MISER
(Voice flitting with child-like condescension)
But those are the numbers my finance guy gave me. It’s the benchmark.
(Blackout and end of Act I.)
Mutual Agreement
Tony Award-winning stuff for sure—and based on a true story! In fact, this scene no doubt plays out annually for those of you unfortunate enough to have to negotiate with hospital executives for programmatic support. To be fair, hospital administrators deserve to know that they are getting what they pay for. Thus, the concepts of a benchmark are reasonable. The problem lies in setting mutually-agreed-upon standards.
Act II: Disbelief and Confusion
GOOD-LOOKING ME
(Unsteadily hands document to Miser)
Sir, I’ve highlighted the national benchmarks for you to see. Column four of this 2007-2008 SHM survey clearly shows that the average academic hospitalist should make $168,800 and achieve 2,813 work RVUs. We achieve the latter benchmark but are severely underpaid.
MISER
(Produces a folded cocktail napkin from his shirt pocket)
But look at this: My executive-friends-at-other-medical-centers-who-overwork-and-underpay-their-hospitalists benchmark shows that you should be well over 4,500 work RVUs. And besides, the SHM numbers are skewed; it’s a survey of hospitalists done by a group that represents hospitalists. I don’t believe them.
GOOD-LOOKING ME
(Eyes averted, adopts a tone of trepidation)
But sir, with all due respect, don’t your numbers reflect a survey of hospital administrators who might have a bias toward more expected productivity? Which benchmark should we believe?
(Blackout and end of Act II.)
A New HM Benchmark Arises
It’s all about the benchmark you choose to believe. For years, the best source of data regarding hospitalist compensation and productivity was that published every other year by SHM. It is a fair, but unfounded, concern that these data might tilt toward the benefit of hospitalists. Likewise, the hospital administrator I work most closely with (who, for the record, reads this publication and IS NOT miserly, has a FULL HEAD of hair, and is, for innumerable reasons, a TRULY GREAT man) will produce benchmarks from organizations like the Association of American Medical Colleges (AAMC) or the University HealthSystems Consortium (UHC), all of which show surprisingly disparate numbers dripping with a similar tilt toward the medical center.
Thus, the importance of the 2010 SHM/MGMA report. The Medical Group Management Association (MGMA) consists of administrators and leaders of medical group practices. Since 1926, they’ve been providing accurate, independent data on physician practice metrics. For most hospital administrators, it is the benchmark. The problem is that in the past, MGMA has struggled to identify hospitalists; the MGMA data were always underpowered and, therefore, suspect.
Enter SHM and its large database of HM groups. What has resulted in the new survey rivals those old commercials in which a person walking with a piece of chocolate slams into another with a jar of peanut butter, resulting in the creation of the Reese’s Peanut Butter Cup (apologies to those readers under the age of 35).
Act III: No Raise; Children Go Hungry
GOOD-LOOKING ME
(Unsheathing haloed document from his portfolio)
Perhaps we could agree to use these new SHM/MGMA numbers as our benchmark. It includes data from more than 440 HM groups and 4,200 hospitalists. And it appears to be fair and balanced.
MISER
(Eyes alight, peering through a shroud of compromise)
MGMA, huh? Let’s take a look. Hmmm. Well. But wait—this says the average hospitalist makes $215,000! That’s outrageous.
GOOD-LOOKING ME
(Smugly retorts)
Yes, sir, we are severely underpaid.
MISER
(Reading; a weasel-like countenance overtakes his face)
Let me take a closer look at this. Aha! Here it is. You see, this only included community hospitalist practices. You will be getting no raise!
(Blackout and end of Act III.)
A Cautionary Tale
Alas, the miser is right. It’s not always what the data say but also what they don’t say.
The one snag with the new data is that it only included a handful of academic HM groups (only 1% of respondents). In fact, the survey actively instructed academic HM practices to not complete the survey. Rather, we academic types were instructed to await the MGMA survey of academic practices completed every fall to be reported early next year.
This is emblematic of the need to dig deep when interpreting these data. As tempting as it is to use a sound bite or two of these data to your advantage, the truth lies in the details. It’s easy to say that all hospitalists should make $215,000, see 2,229 encounters, and achieve 4,107 wRVUs annually.
However, just as there is no average hospitalist, there are no average numbers. There are just too many variables (e.g., practice ownership, geography, group size, night coverage, staffing model, compensation structure) to say definitively what an individual hospitalist should look like or achieve. Rather, these numbers should be used as a guide, adapted to each individual situation.
Act IV: See You This Spring
(Standing, Good-Looking Me shakes his foe’s shriveled claw of a hand while looking him intensely in the eye—a look that says, “I’ll see you this spring.” In his rival’s eyes, the Miser sees his future—a future that involves another meeting, more practice-appropriate data, and a dusting off of his checkbook.)
(Blackout and end of Act IV.) TH
Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.
Act I: The Negotiation
(A barren academic office, dimly lit, the pall of difficult negotiations afloat, backlit like dust in the air. Seated, under a strangely intense incandescent bulb, a man, who looks eerily like a good-looking version of me, sits uncomfortably adjusting himself in his seat. His eyes constrict on his counterpart, a miserly sort peering out from behind wire-rim glasses and a shock of hair improbably combed over from ear to ear. The tension crests.)
GOOD-LOOKING ME
(Voice cracking)
I’ve come to ask for a raise for our hospitalist group.
MISER
(Adjusts his clip-on tie)
We just gave you a raise in 2004.
GOOD-LOOKING ME
(Smiles uncomfortably)
That was very gracious, sir, but I think the numbers support another.
MISER
(Incredulous look at his watch)
But your work RVUs are thousands below what I’d like to see.
GOOD-LOOKING ME
(Dabs bead of sweat away from chiseled chin)
That’s because you’ve set your benchmark thousands above a reasonable number.
MISER
(Voice flitting with child-like condescension)
But those are the numbers my finance guy gave me. It’s the benchmark.
(Blackout and end of Act I.)
Mutual Agreement
Tony Award-winning stuff for sure—and based on a true story! In fact, this scene no doubt plays out annually for those of you unfortunate enough to have to negotiate with hospital executives for programmatic support. To be fair, hospital administrators deserve to know that they are getting what they pay for. Thus, the concepts of a benchmark are reasonable. The problem lies in setting mutually-agreed-upon standards.
Act II: Disbelief and Confusion
GOOD-LOOKING ME
(Unsteadily hands document to Miser)
Sir, I’ve highlighted the national benchmarks for you to see. Column four of this 2007-2008 SHM survey clearly shows that the average academic hospitalist should make $168,800 and achieve 2,813 work RVUs. We achieve the latter benchmark but are severely underpaid.
MISER
(Produces a folded cocktail napkin from his shirt pocket)
But look at this: My executive-friends-at-other-medical-centers-who-overwork-and-underpay-their-hospitalists benchmark shows that you should be well over 4,500 work RVUs. And besides, the SHM numbers are skewed; it’s a survey of hospitalists done by a group that represents hospitalists. I don’t believe them.
GOOD-LOOKING ME
(Eyes averted, adopts a tone of trepidation)
But sir, with all due respect, don’t your numbers reflect a survey of hospital administrators who might have a bias toward more expected productivity? Which benchmark should we believe?
(Blackout and end of Act II.)
A New HM Benchmark Arises
It’s all about the benchmark you choose to believe. For years, the best source of data regarding hospitalist compensation and productivity was that published every other year by SHM. It is a fair, but unfounded, concern that these data might tilt toward the benefit of hospitalists. Likewise, the hospital administrator I work most closely with (who, for the record, reads this publication and IS NOT miserly, has a FULL HEAD of hair, and is, for innumerable reasons, a TRULY GREAT man) will produce benchmarks from organizations like the Association of American Medical Colleges (AAMC) or the University HealthSystems Consortium (UHC), all of which show surprisingly disparate numbers dripping with a similar tilt toward the medical center.
Thus, the importance of the 2010 SHM/MGMA report. The Medical Group Management Association (MGMA) consists of administrators and leaders of medical group practices. Since 1926, they’ve been providing accurate, independent data on physician practice metrics. For most hospital administrators, it is the benchmark. The problem is that in the past, MGMA has struggled to identify hospitalists; the MGMA data were always underpowered and, therefore, suspect.
Enter SHM and its large database of HM groups. What has resulted in the new survey rivals those old commercials in which a person walking with a piece of chocolate slams into another with a jar of peanut butter, resulting in the creation of the Reese’s Peanut Butter Cup (apologies to those readers under the age of 35).
Act III: No Raise; Children Go Hungry
GOOD-LOOKING ME
(Unsheathing haloed document from his portfolio)
Perhaps we could agree to use these new SHM/MGMA numbers as our benchmark. It includes data from more than 440 HM groups and 4,200 hospitalists. And it appears to be fair and balanced.
MISER
(Eyes alight, peering through a shroud of compromise)
MGMA, huh? Let’s take a look. Hmmm. Well. But wait—this says the average hospitalist makes $215,000! That’s outrageous.
GOOD-LOOKING ME
(Smugly retorts)
Yes, sir, we are severely underpaid.
MISER
(Reading; a weasel-like countenance overtakes his face)
Let me take a closer look at this. Aha! Here it is. You see, this only included community hospitalist practices. You will be getting no raise!
(Blackout and end of Act III.)
A Cautionary Tale
Alas, the miser is right. It’s not always what the data say but also what they don’t say.
The one snag with the new data is that it only included a handful of academic HM groups (only 1% of respondents). In fact, the survey actively instructed academic HM practices to not complete the survey. Rather, we academic types were instructed to await the MGMA survey of academic practices completed every fall to be reported early next year.
This is emblematic of the need to dig deep when interpreting these data. As tempting as it is to use a sound bite or two of these data to your advantage, the truth lies in the details. It’s easy to say that all hospitalists should make $215,000, see 2,229 encounters, and achieve 4,107 wRVUs annually.
However, just as there is no average hospitalist, there are no average numbers. There are just too many variables (e.g., practice ownership, geography, group size, night coverage, staffing model, compensation structure) to say definitively what an individual hospitalist should look like or achieve. Rather, these numbers should be used as a guide, adapted to each individual situation.
Act IV: See You This Spring
(Standing, Good-Looking Me shakes his foe’s shriveled claw of a hand while looking him intensely in the eye—a look that says, “I’ll see you this spring.” In his rival’s eyes, the Miser sees his future—a future that involves another meeting, more practice-appropriate data, and a dusting off of his checkbook.)
(Blackout and end of Act IV.) TH
Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.
Act I: The Negotiation
(A barren academic office, dimly lit, the pall of difficult negotiations afloat, backlit like dust in the air. Seated, under a strangely intense incandescent bulb, a man, who looks eerily like a good-looking version of me, sits uncomfortably adjusting himself in his seat. His eyes constrict on his counterpart, a miserly sort peering out from behind wire-rim glasses and a shock of hair improbably combed over from ear to ear. The tension crests.)
GOOD-LOOKING ME
(Voice cracking)
I’ve come to ask for a raise for our hospitalist group.
MISER
(Adjusts his clip-on tie)
We just gave you a raise in 2004.
GOOD-LOOKING ME
(Smiles uncomfortably)
That was very gracious, sir, but I think the numbers support another.
MISER
(Incredulous look at his watch)
But your work RVUs are thousands below what I’d like to see.
GOOD-LOOKING ME
(Dabs bead of sweat away from chiseled chin)
That’s because you’ve set your benchmark thousands above a reasonable number.
MISER
(Voice flitting with child-like condescension)
But those are the numbers my finance guy gave me. It’s the benchmark.
(Blackout and end of Act I.)
Mutual Agreement
Tony Award-winning stuff for sure—and based on a true story! In fact, this scene no doubt plays out annually for those of you unfortunate enough to have to negotiate with hospital executives for programmatic support. To be fair, hospital administrators deserve to know that they are getting what they pay for. Thus, the concepts of a benchmark are reasonable. The problem lies in setting mutually-agreed-upon standards.
Act II: Disbelief and Confusion
GOOD-LOOKING ME
(Unsteadily hands document to Miser)
Sir, I’ve highlighted the national benchmarks for you to see. Column four of this 2007-2008 SHM survey clearly shows that the average academic hospitalist should make $168,800 and achieve 2,813 work RVUs. We achieve the latter benchmark but are severely underpaid.
MISER
(Produces a folded cocktail napkin from his shirt pocket)
But look at this: My executive-friends-at-other-medical-centers-who-overwork-and-underpay-their-hospitalists benchmark shows that you should be well over 4,500 work RVUs. And besides, the SHM numbers are skewed; it’s a survey of hospitalists done by a group that represents hospitalists. I don’t believe them.
GOOD-LOOKING ME
(Eyes averted, adopts a tone of trepidation)
But sir, with all due respect, don’t your numbers reflect a survey of hospital administrators who might have a bias toward more expected productivity? Which benchmark should we believe?
(Blackout and end of Act II.)
A New HM Benchmark Arises
It’s all about the benchmark you choose to believe. For years, the best source of data regarding hospitalist compensation and productivity was that published every other year by SHM. It is a fair, but unfounded, concern that these data might tilt toward the benefit of hospitalists. Likewise, the hospital administrator I work most closely with (who, for the record, reads this publication and IS NOT miserly, has a FULL HEAD of hair, and is, for innumerable reasons, a TRULY GREAT man) will produce benchmarks from organizations like the Association of American Medical Colleges (AAMC) or the University HealthSystems Consortium (UHC), all of which show surprisingly disparate numbers dripping with a similar tilt toward the medical center.
Thus, the importance of the 2010 SHM/MGMA report. The Medical Group Management Association (MGMA) consists of administrators and leaders of medical group practices. Since 1926, they’ve been providing accurate, independent data on physician practice metrics. For most hospital administrators, it is the benchmark. The problem is that in the past, MGMA has struggled to identify hospitalists; the MGMA data were always underpowered and, therefore, suspect.
Enter SHM and its large database of HM groups. What has resulted in the new survey rivals those old commercials in which a person walking with a piece of chocolate slams into another with a jar of peanut butter, resulting in the creation of the Reese’s Peanut Butter Cup (apologies to those readers under the age of 35).
Act III: No Raise; Children Go Hungry
GOOD-LOOKING ME
(Unsheathing haloed document from his portfolio)
Perhaps we could agree to use these new SHM/MGMA numbers as our benchmark. It includes data from more than 440 HM groups and 4,200 hospitalists. And it appears to be fair and balanced.
MISER
(Eyes alight, peering through a shroud of compromise)
MGMA, huh? Let’s take a look. Hmmm. Well. But wait—this says the average hospitalist makes $215,000! That’s outrageous.
GOOD-LOOKING ME
(Smugly retorts)
Yes, sir, we are severely underpaid.
MISER
(Reading; a weasel-like countenance overtakes his face)
Let me take a closer look at this. Aha! Here it is. You see, this only included community hospitalist practices. You will be getting no raise!
(Blackout and end of Act III.)
A Cautionary Tale
Alas, the miser is right. It’s not always what the data say but also what they don’t say.
The one snag with the new data is that it only included a handful of academic HM groups (only 1% of respondents). In fact, the survey actively instructed academic HM practices to not complete the survey. Rather, we academic types were instructed to await the MGMA survey of academic practices completed every fall to be reported early next year.
This is emblematic of the need to dig deep when interpreting these data. As tempting as it is to use a sound bite or two of these data to your advantage, the truth lies in the details. It’s easy to say that all hospitalists should make $215,000, see 2,229 encounters, and achieve 4,107 wRVUs annually.
However, just as there is no average hospitalist, there are no average numbers. There are just too many variables (e.g., practice ownership, geography, group size, night coverage, staffing model, compensation structure) to say definitively what an individual hospitalist should look like or achieve. Rather, these numbers should be used as a guide, adapted to each individual situation.
Act IV: See You This Spring
(Standing, Good-Looking Me shakes his foe’s shriveled claw of a hand while looking him intensely in the eye—a look that says, “I’ll see you this spring.” In his rival’s eyes, the Miser sees his future—a future that involves another meeting, more practice-appropriate data, and a dusting off of his checkbook.)
(Blackout and end of Act IV.) TH
Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.
Surge Protection
Unpredictable workloads and frequent interruptions are the things I regard as the most stressful components of work as a hospitalist. Your list might be very different, but I bet unpredictable workloads ranks at least in the top five of every hospitalist’s list.
I’ve discussed interruptions previously (see “Really, It’s Switch-Tasking,” p. 68, November 2008; “Technological Advance or Workplace Setback?” p. 69, December 2008), but this month and next will turn to unpredictable workloads. In other words, what are the strategies available to a hospitalist practice to provide surge capacity in response to such unpredictable increases in patient volume as an uptick in census or daily admissions 50% to 100% above normal? I’ll leave to others the topic of how hospitals respond to such disasters as terrorist attacks, earthquakes, etc.
The Bottom Line
Sadly, there is no magic bullet for the “surge” problem, and no way to protect on-duty hospitalists from the need to work harder when it gets busy. But we needn’t feel too sorry for ourselves; doctors in most other specialties who practice in the hospital face the same problem and tend to rely heavily on simply working harder and longer when it is unusually busy. Sometimes they couple the “work harder” mantra with other strategies, such as calling another doctor in to help.
Hospitalists have a duty to ensure high patient volume doesn’t lead to deterioration in the quality of patient care, but occasionally working longer days than average probably poses a low risk, and might be less risky than the additional handoffs usually associated with having a doctor on “jeopardy” to be called in when it’s busy. Routinely or frequently working unreasonably long days is another story.
The trick for HM programs is to build some surge capacity into the routine daily staffing 1) without exceeding a reasonable budget, while 2) ensuring that the hospitalists don’t simply become accustomed to light workloads as the only reasonable norm, which could lead to them becoming unwilling to accept higher, but still reasonable, workloads when needed. (More on these issues later.) First, I’ll go through what I see as the pros and cons of several approaches to addressing surges in patient volume. All are in use with variable frequency around the country.
“Jeopardy” System
In its most common form, a jeopardy system has an unscheduled doctor each day who must remain available on short notice by pager. When patient volume surges, the unscheduled doctor is paged to come in and help. In most cases, this doctor focuses primarily—or exclusively—on admitting patients for a few hours. So it is most common for this doctor to be called in late in the afternoon or early in the evening. The jeopardy doctor usually turns over all admitted patients to another hospitalist in the group for all subsequent care. In addition to providing surge capacity, the jeopardy doctor almost always is used to cover unexpected absences of scheduled doctors, including illness-related absences.
Sometimes this doctor is paid extra for each day or week spent being “available” on jeopardy duty (not to be confused with jury duty, though it can be equally difficult to get exempted from). Then again, it is not uncommon to have jeopardy duty included in base compensation. However, once a jeopardy doctor is actually called in to work, most practices pay additional compensation, often based on an hourly rate that usually is higher than the average compensation generated per hour for nonjeopardy work.
There are a number of reasonable ways to compensate the jeopardy doctor. You probably can get some good ideas by talking with others in your hospital who function in a similar capacity, such as cath-lab technicians who get called in on nights and weekends.
No definitive data are available to show how common the jeopardy system is, but my experience is that 30% to 50% of HM groups use some form of it. Its popularity is proof that it is a reasonable system, but I’m not convinced. I think it is in use by a lot of groups not because it is an optimal way to ensure surge capacity, but because it is easy to conceptualize and put in place, and because many hospitalists came from residency programs in which the system was standard.
The gaps between theoretical and realized benefits become evident once a practice implements a jeopardy system. For example, it might be really busy today, but Dr. Stravinsky doesn’t call in Dr. Copeland, who is on jeopardy, because next week their roles will be reversed and Dr. Stravinsky sure hopes he won’t be called in. No one wants to be the weak doctor who calls in the jeopardy doctor and spoils what was otherwise a day off.
I’ve worked with a lot of practices who say they have a jeopardy system in place, but when I ask for the last time the jeopardy doctor was called in, they say it has been more than a year, or in some cases never. So even if the policy manual says they have a jeopardy system, the doctors never activate it, so it provides no benefit.
Practices that do utilize the jeopardy doctor have their own problems, such as assigning that doctor’s admissions the next day. The jeopardy doctor might provide some relief today, but they essentially just delay the work of having to get to know all of those new patients until the morning, when everyone is very busy with rounds. So while there might be significant benefit in activating the jeopardy system today, it could just delay the problem of high workload until the next morning, which isn’t much of a net benefit for the practice.
A small number of practices call in the jeopardy doctor frequently, and sometimes have that doctor continue to round on admitted patients for the next few days. This usage might get the most value out of the system, but the practice should consider if it is more cost-effective, and less stressful for the doctors, if the system were reversed. For example, instead of having the doctor on jeopardy and called in as necessary, the doctor would report to work and be given the day off or let go early when it isn’t busy.
Despite my reservations, if you are convinced the jeopardy system is valuable and cost-effective, keep it in place. However, if your group is thinking about options to handle surge capacity, don’t be too quick to adopt a jeopardy system. It usually falls far short of a perfect solution.
Patient Volume Cap
Another way to address the problem of unpredictable increases in patient volume is to establish a patient volume (e.g., total census) cap for the whole hospitalist practice. Like the jeopardy system, this is an appealingly uncomplicated idea, and hospitalists who have finished residency within the last few years all worked with a cap.
Except for the rarest of exceptions, this is a poor idea and should be avoided if at all possible. I’ll leave for another time a discussion of all the political and financial costs of a cap system, but trust me on this one. It is best to avoid a cap.
Stay Tuned …
Next month, I’ll examine other strategies to provide surge capacity. I think they’re more valuable than the two I’ve mentioned here, but I need to warn you that they aren’t perfect and are more complicated to operationalize. TH
Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelson flores.com). He is course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.
Unpredictable workloads and frequent interruptions are the things I regard as the most stressful components of work as a hospitalist. Your list might be very different, but I bet unpredictable workloads ranks at least in the top five of every hospitalist’s list.
I’ve discussed interruptions previously (see “Really, It’s Switch-Tasking,” p. 68, November 2008; “Technological Advance or Workplace Setback?” p. 69, December 2008), but this month and next will turn to unpredictable workloads. In other words, what are the strategies available to a hospitalist practice to provide surge capacity in response to such unpredictable increases in patient volume as an uptick in census or daily admissions 50% to 100% above normal? I’ll leave to others the topic of how hospitals respond to such disasters as terrorist attacks, earthquakes, etc.
The Bottom Line
Sadly, there is no magic bullet for the “surge” problem, and no way to protect on-duty hospitalists from the need to work harder when it gets busy. But we needn’t feel too sorry for ourselves; doctors in most other specialties who practice in the hospital face the same problem and tend to rely heavily on simply working harder and longer when it is unusually busy. Sometimes they couple the “work harder” mantra with other strategies, such as calling another doctor in to help.
Hospitalists have a duty to ensure high patient volume doesn’t lead to deterioration in the quality of patient care, but occasionally working longer days than average probably poses a low risk, and might be less risky than the additional handoffs usually associated with having a doctor on “jeopardy” to be called in when it’s busy. Routinely or frequently working unreasonably long days is another story.
The trick for HM programs is to build some surge capacity into the routine daily staffing 1) without exceeding a reasonable budget, while 2) ensuring that the hospitalists don’t simply become accustomed to light workloads as the only reasonable norm, which could lead to them becoming unwilling to accept higher, but still reasonable, workloads when needed. (More on these issues later.) First, I’ll go through what I see as the pros and cons of several approaches to addressing surges in patient volume. All are in use with variable frequency around the country.
“Jeopardy” System
In its most common form, a jeopardy system has an unscheduled doctor each day who must remain available on short notice by pager. When patient volume surges, the unscheduled doctor is paged to come in and help. In most cases, this doctor focuses primarily—or exclusively—on admitting patients for a few hours. So it is most common for this doctor to be called in late in the afternoon or early in the evening. The jeopardy doctor usually turns over all admitted patients to another hospitalist in the group for all subsequent care. In addition to providing surge capacity, the jeopardy doctor almost always is used to cover unexpected absences of scheduled doctors, including illness-related absences.
Sometimes this doctor is paid extra for each day or week spent being “available” on jeopardy duty (not to be confused with jury duty, though it can be equally difficult to get exempted from). Then again, it is not uncommon to have jeopardy duty included in base compensation. However, once a jeopardy doctor is actually called in to work, most practices pay additional compensation, often based on an hourly rate that usually is higher than the average compensation generated per hour for nonjeopardy work.
There are a number of reasonable ways to compensate the jeopardy doctor. You probably can get some good ideas by talking with others in your hospital who function in a similar capacity, such as cath-lab technicians who get called in on nights and weekends.
No definitive data are available to show how common the jeopardy system is, but my experience is that 30% to 50% of HM groups use some form of it. Its popularity is proof that it is a reasonable system, but I’m not convinced. I think it is in use by a lot of groups not because it is an optimal way to ensure surge capacity, but because it is easy to conceptualize and put in place, and because many hospitalists came from residency programs in which the system was standard.
The gaps between theoretical and realized benefits become evident once a practice implements a jeopardy system. For example, it might be really busy today, but Dr. Stravinsky doesn’t call in Dr. Copeland, who is on jeopardy, because next week their roles will be reversed and Dr. Stravinsky sure hopes he won’t be called in. No one wants to be the weak doctor who calls in the jeopardy doctor and spoils what was otherwise a day off.
I’ve worked with a lot of practices who say they have a jeopardy system in place, but when I ask for the last time the jeopardy doctor was called in, they say it has been more than a year, or in some cases never. So even if the policy manual says they have a jeopardy system, the doctors never activate it, so it provides no benefit.
Practices that do utilize the jeopardy doctor have their own problems, such as assigning that doctor’s admissions the next day. The jeopardy doctor might provide some relief today, but they essentially just delay the work of having to get to know all of those new patients until the morning, when everyone is very busy with rounds. So while there might be significant benefit in activating the jeopardy system today, it could just delay the problem of high workload until the next morning, which isn’t much of a net benefit for the practice.
A small number of practices call in the jeopardy doctor frequently, and sometimes have that doctor continue to round on admitted patients for the next few days. This usage might get the most value out of the system, but the practice should consider if it is more cost-effective, and less stressful for the doctors, if the system were reversed. For example, instead of having the doctor on jeopardy and called in as necessary, the doctor would report to work and be given the day off or let go early when it isn’t busy.
Despite my reservations, if you are convinced the jeopardy system is valuable and cost-effective, keep it in place. However, if your group is thinking about options to handle surge capacity, don’t be too quick to adopt a jeopardy system. It usually falls far short of a perfect solution.
Patient Volume Cap
Another way to address the problem of unpredictable increases in patient volume is to establish a patient volume (e.g., total census) cap for the whole hospitalist practice. Like the jeopardy system, this is an appealingly uncomplicated idea, and hospitalists who have finished residency within the last few years all worked with a cap.
Except for the rarest of exceptions, this is a poor idea and should be avoided if at all possible. I’ll leave for another time a discussion of all the political and financial costs of a cap system, but trust me on this one. It is best to avoid a cap.
Stay Tuned …
Next month, I’ll examine other strategies to provide surge capacity. I think they’re more valuable than the two I’ve mentioned here, but I need to warn you that they aren’t perfect and are more complicated to operationalize. TH
Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelson flores.com). He is course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.
Unpredictable workloads and frequent interruptions are the things I regard as the most stressful components of work as a hospitalist. Your list might be very different, but I bet unpredictable workloads ranks at least in the top five of every hospitalist’s list.
I’ve discussed interruptions previously (see “Really, It’s Switch-Tasking,” p. 68, November 2008; “Technological Advance or Workplace Setback?” p. 69, December 2008), but this month and next will turn to unpredictable workloads. In other words, what are the strategies available to a hospitalist practice to provide surge capacity in response to such unpredictable increases in patient volume as an uptick in census or daily admissions 50% to 100% above normal? I’ll leave to others the topic of how hospitals respond to such disasters as terrorist attacks, earthquakes, etc.
The Bottom Line
Sadly, there is no magic bullet for the “surge” problem, and no way to protect on-duty hospitalists from the need to work harder when it gets busy. But we needn’t feel too sorry for ourselves; doctors in most other specialties who practice in the hospital face the same problem and tend to rely heavily on simply working harder and longer when it is unusually busy. Sometimes they couple the “work harder” mantra with other strategies, such as calling another doctor in to help.
Hospitalists have a duty to ensure high patient volume doesn’t lead to deterioration in the quality of patient care, but occasionally working longer days than average probably poses a low risk, and might be less risky than the additional handoffs usually associated with having a doctor on “jeopardy” to be called in when it’s busy. Routinely or frequently working unreasonably long days is another story.
The trick for HM programs is to build some surge capacity into the routine daily staffing 1) without exceeding a reasonable budget, while 2) ensuring that the hospitalists don’t simply become accustomed to light workloads as the only reasonable norm, which could lead to them becoming unwilling to accept higher, but still reasonable, workloads when needed. (More on these issues later.) First, I’ll go through what I see as the pros and cons of several approaches to addressing surges in patient volume. All are in use with variable frequency around the country.
“Jeopardy” System
In its most common form, a jeopardy system has an unscheduled doctor each day who must remain available on short notice by pager. When patient volume surges, the unscheduled doctor is paged to come in and help. In most cases, this doctor focuses primarily—or exclusively—on admitting patients for a few hours. So it is most common for this doctor to be called in late in the afternoon or early in the evening. The jeopardy doctor usually turns over all admitted patients to another hospitalist in the group for all subsequent care. In addition to providing surge capacity, the jeopardy doctor almost always is used to cover unexpected absences of scheduled doctors, including illness-related absences.
Sometimes this doctor is paid extra for each day or week spent being “available” on jeopardy duty (not to be confused with jury duty, though it can be equally difficult to get exempted from). Then again, it is not uncommon to have jeopardy duty included in base compensation. However, once a jeopardy doctor is actually called in to work, most practices pay additional compensation, often based on an hourly rate that usually is higher than the average compensation generated per hour for nonjeopardy work.
There are a number of reasonable ways to compensate the jeopardy doctor. You probably can get some good ideas by talking with others in your hospital who function in a similar capacity, such as cath-lab technicians who get called in on nights and weekends.
No definitive data are available to show how common the jeopardy system is, but my experience is that 30% to 50% of HM groups use some form of it. Its popularity is proof that it is a reasonable system, but I’m not convinced. I think it is in use by a lot of groups not because it is an optimal way to ensure surge capacity, but because it is easy to conceptualize and put in place, and because many hospitalists came from residency programs in which the system was standard.
The gaps between theoretical and realized benefits become evident once a practice implements a jeopardy system. For example, it might be really busy today, but Dr. Stravinsky doesn’t call in Dr. Copeland, who is on jeopardy, because next week their roles will be reversed and Dr. Stravinsky sure hopes he won’t be called in. No one wants to be the weak doctor who calls in the jeopardy doctor and spoils what was otherwise a day off.
I’ve worked with a lot of practices who say they have a jeopardy system in place, but when I ask for the last time the jeopardy doctor was called in, they say it has been more than a year, or in some cases never. So even if the policy manual says they have a jeopardy system, the doctors never activate it, so it provides no benefit.
Practices that do utilize the jeopardy doctor have their own problems, such as assigning that doctor’s admissions the next day. The jeopardy doctor might provide some relief today, but they essentially just delay the work of having to get to know all of those new patients until the morning, when everyone is very busy with rounds. So while there might be significant benefit in activating the jeopardy system today, it could just delay the problem of high workload until the next morning, which isn’t much of a net benefit for the practice.
A small number of practices call in the jeopardy doctor frequently, and sometimes have that doctor continue to round on admitted patients for the next few days. This usage might get the most value out of the system, but the practice should consider if it is more cost-effective, and less stressful for the doctors, if the system were reversed. For example, instead of having the doctor on jeopardy and called in as necessary, the doctor would report to work and be given the day off or let go early when it isn’t busy.
Despite my reservations, if you are convinced the jeopardy system is valuable and cost-effective, keep it in place. However, if your group is thinking about options to handle surge capacity, don’t be too quick to adopt a jeopardy system. It usually falls far short of a perfect solution.
Patient Volume Cap
Another way to address the problem of unpredictable increases in patient volume is to establish a patient volume (e.g., total census) cap for the whole hospitalist practice. Like the jeopardy system, this is an appealingly uncomplicated idea, and hospitalists who have finished residency within the last few years all worked with a cap.
Except for the rarest of exceptions, this is a poor idea and should be avoided if at all possible. I’ll leave for another time a discussion of all the political and financial costs of a cap system, but trust me on this one. It is best to avoid a cap.
Stay Tuned …
Next month, I’ll examine other strategies to provide surge capacity. I think they’re more valuable than the two I’ve mentioned here, but I need to warn you that they aren’t perfect and are more complicated to operationalize. TH
Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelson flores.com). He is course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.
ONLINE EXCLUSIVE: Audio interview with Troy Ahlstrom, MD, FHM, CFO of Hospitalists of Northern Michigan
SHM Practice Analysis Committee member Troy Ahlstrom, MD, FHM, discusses the new compensation and productivity report, and gives advice on how best to use benchmarking data in your practice.
SHM Practice Analysis Committee member Troy Ahlstrom, MD, FHM, discusses the new compensation and productivity report, and gives advice on how best to use benchmarking data in your practice.
SHM Practice Analysis Committee member Troy Ahlstrom, MD, FHM, discusses the new compensation and productivity report, and gives advice on how best to use benchmarking data in your practice.
The Coming Challenges—and Opportunities—of Value-Based Purchasing
The Coming Challenges—and Opportunities—of Value-Based Purchasing
The Patient Protection and Affordable Care Act was signed into law in March, furthering the federal government’s commitment to increasing the efficiency of the U.S. healthcare system by decreasing cost and improving quality. An expansion of the “value-based purchasing” model, this law mandates that ratings and reimbursements to physicians and hospitals be increasingly tied to measured quality of care.
In this system, a physician’s quality profile will be determined by a variety of factors, including reported quality data, severity-adjusted clinical outcome measures, patient-safety indicators, and hospital-acquired conditions (HACs). Since all of these are, to a large extent, documentation issues, physicians are now forced to pay close attention to how they identify and describe diagnoses and procedures.
Medicare will, in effect, attempt to determine: “Did the clinical team correctly identify and appropriately treat all relevant patient conditions—without causing any adverse conditions—and do so safely, efficiently, and with good outcomes?”
The patient chart must “tell the story” of the episode of care in the hospital. It must accurately describe all of the patient’s conditions and demonstrate the complexity of medical decision-making and establishment of risk. Upon discharge, this risk must “match up” with the diagnoses that are being coded and the Medicare Severity Diagnostic Related Group (MS-DRGs) being assigned. Often, the information is present in the chart but is inconsistent from provider to provider, or documented in a way that is misunderstood by hospital coders.
If successful in improving our documentation skills, the reward will be a higher rating and increased reimbursement.
Medicare also is ramping up its claims denial and recovery business to help “clean up” the system. This includes the national rollout of the Recovery Audit Contactor (RAC) initiative (see “Attention to Detail,” April 2010, p. 1), as well as the new Medicare administrative contractors (MACs). Both rely on accurate documentation. The RACs will penalize hospitals and physicians financially for documentation lacking in specificity and accuracy; the MACs will deny payment for claims erroneously submitted (technical errors) or lacking documentation of medical necessity.
What makes many physicians even more uncomfortable in this new environment is that Medicare is striving to better align the priorities and financial incentives of hospitals and physicians. Alliances between the two are strongly encouraged through such programs as the Acute Care Episode (ACE) Demonstration Project (the precursor to hospital-physician bundled payments), and the establishment of accountable care organizations (ACOs).
This emerging environment presents a unique set of challenges and opportunities to HM groups. Hospitalists are historically more aligned with hospital administrations, as compared with most other specialties. Hospitalists also are asked to participate in the care of an increasingly large percentage of patients across all specialties. This could well be an opportunity to be rewarded for embracing both of these trends.
Hospitalists are uniquely positioned to function as the documentation improvement clinical team leaders, working closely with other physicians across all specialties and the administration to fulfill all documentation requirements—and to be rewarded for doing so. Though hospitalists should have a general understanding of the language and rules of documentation, a system must be in place that helps them identify and capture all the pertinent aspects of the medical record without the need to become coders themselves. To this end, a clinical documentation improvement (CDI) program is critical.
But it might not be enough.
What is needed is a clinical integration program, an enhancement of traditional CDI. This approach requires participation from ED physicians, along with clinical integration specialists, to document accurately and completely from the start. The clinical integration specialist ensures that medical necessity for inpatient admission and patient risk is being addressed and established, conditions are appropriately identified as being present on admission (POA), and all diagnoses are properly recognized and documented thoroughly and accurately. Clinical integration through collaborative documentation then continues throughout the hospitalization, with diagnostic authority and oversight from the hospitalist, all the way through discharge.
Hospitalists should welcome and champion this type of program. As documentation becomes the key to survival, a complete medical record will stand up to any and all scrutiny by Medicare or others.
As for the negatives, there are none.
Andrew H. Dombro, MD, national medical director, and Paul Weygandt, MD, JD, vice president of physician services, J.A. Thomas & Associates, Atlanta
The Coming Challenges—and Opportunities—of Value-Based Purchasing
The Patient Protection and Affordable Care Act was signed into law in March, furthering the federal government’s commitment to increasing the efficiency of the U.S. healthcare system by decreasing cost and improving quality. An expansion of the “value-based purchasing” model, this law mandates that ratings and reimbursements to physicians and hospitals be increasingly tied to measured quality of care.
In this system, a physician’s quality profile will be determined by a variety of factors, including reported quality data, severity-adjusted clinical outcome measures, patient-safety indicators, and hospital-acquired conditions (HACs). Since all of these are, to a large extent, documentation issues, physicians are now forced to pay close attention to how they identify and describe diagnoses and procedures.
Medicare will, in effect, attempt to determine: “Did the clinical team correctly identify and appropriately treat all relevant patient conditions—without causing any adverse conditions—and do so safely, efficiently, and with good outcomes?”
The patient chart must “tell the story” of the episode of care in the hospital. It must accurately describe all of the patient’s conditions and demonstrate the complexity of medical decision-making and establishment of risk. Upon discharge, this risk must “match up” with the diagnoses that are being coded and the Medicare Severity Diagnostic Related Group (MS-DRGs) being assigned. Often, the information is present in the chart but is inconsistent from provider to provider, or documented in a way that is misunderstood by hospital coders.
If successful in improving our documentation skills, the reward will be a higher rating and increased reimbursement.
Medicare also is ramping up its claims denial and recovery business to help “clean up” the system. This includes the national rollout of the Recovery Audit Contactor (RAC) initiative (see “Attention to Detail,” April 2010, p. 1), as well as the new Medicare administrative contractors (MACs). Both rely on accurate documentation. The RACs will penalize hospitals and physicians financially for documentation lacking in specificity and accuracy; the MACs will deny payment for claims erroneously submitted (technical errors) or lacking documentation of medical necessity.
What makes many physicians even more uncomfortable in this new environment is that Medicare is striving to better align the priorities and financial incentives of hospitals and physicians. Alliances between the two are strongly encouraged through such programs as the Acute Care Episode (ACE) Demonstration Project (the precursor to hospital-physician bundled payments), and the establishment of accountable care organizations (ACOs).
This emerging environment presents a unique set of challenges and opportunities to HM groups. Hospitalists are historically more aligned with hospital administrations, as compared with most other specialties. Hospitalists also are asked to participate in the care of an increasingly large percentage of patients across all specialties. This could well be an opportunity to be rewarded for embracing both of these trends.
Hospitalists are uniquely positioned to function as the documentation improvement clinical team leaders, working closely with other physicians across all specialties and the administration to fulfill all documentation requirements—and to be rewarded for doing so. Though hospitalists should have a general understanding of the language and rules of documentation, a system must be in place that helps them identify and capture all the pertinent aspects of the medical record without the need to become coders themselves. To this end, a clinical documentation improvement (CDI) program is critical.
But it might not be enough.
What is needed is a clinical integration program, an enhancement of traditional CDI. This approach requires participation from ED physicians, along with clinical integration specialists, to document accurately and completely from the start. The clinical integration specialist ensures that medical necessity for inpatient admission and patient risk is being addressed and established, conditions are appropriately identified as being present on admission (POA), and all diagnoses are properly recognized and documented thoroughly and accurately. Clinical integration through collaborative documentation then continues throughout the hospitalization, with diagnostic authority and oversight from the hospitalist, all the way through discharge.
Hospitalists should welcome and champion this type of program. As documentation becomes the key to survival, a complete medical record will stand up to any and all scrutiny by Medicare or others.
As for the negatives, there are none.
Andrew H. Dombro, MD, national medical director, and Paul Weygandt, MD, JD, vice president of physician services, J.A. Thomas & Associates, Atlanta
The Coming Challenges—and Opportunities—of Value-Based Purchasing
The Patient Protection and Affordable Care Act was signed into law in March, furthering the federal government’s commitment to increasing the efficiency of the U.S. healthcare system by decreasing cost and improving quality. An expansion of the “value-based purchasing” model, this law mandates that ratings and reimbursements to physicians and hospitals be increasingly tied to measured quality of care.
In this system, a physician’s quality profile will be determined by a variety of factors, including reported quality data, severity-adjusted clinical outcome measures, patient-safety indicators, and hospital-acquired conditions (HACs). Since all of these are, to a large extent, documentation issues, physicians are now forced to pay close attention to how they identify and describe diagnoses and procedures.
Medicare will, in effect, attempt to determine: “Did the clinical team correctly identify and appropriately treat all relevant patient conditions—without causing any adverse conditions—and do so safely, efficiently, and with good outcomes?”
The patient chart must “tell the story” of the episode of care in the hospital. It must accurately describe all of the patient’s conditions and demonstrate the complexity of medical decision-making and establishment of risk. Upon discharge, this risk must “match up” with the diagnoses that are being coded and the Medicare Severity Diagnostic Related Group (MS-DRGs) being assigned. Often, the information is present in the chart but is inconsistent from provider to provider, or documented in a way that is misunderstood by hospital coders.
If successful in improving our documentation skills, the reward will be a higher rating and increased reimbursement.
Medicare also is ramping up its claims denial and recovery business to help “clean up” the system. This includes the national rollout of the Recovery Audit Contactor (RAC) initiative (see “Attention to Detail,” April 2010, p. 1), as well as the new Medicare administrative contractors (MACs). Both rely on accurate documentation. The RACs will penalize hospitals and physicians financially for documentation lacking in specificity and accuracy; the MACs will deny payment for claims erroneously submitted (technical errors) or lacking documentation of medical necessity.
What makes many physicians even more uncomfortable in this new environment is that Medicare is striving to better align the priorities and financial incentives of hospitals and physicians. Alliances between the two are strongly encouraged through such programs as the Acute Care Episode (ACE) Demonstration Project (the precursor to hospital-physician bundled payments), and the establishment of accountable care organizations (ACOs).
This emerging environment presents a unique set of challenges and opportunities to HM groups. Hospitalists are historically more aligned with hospital administrations, as compared with most other specialties. Hospitalists also are asked to participate in the care of an increasingly large percentage of patients across all specialties. This could well be an opportunity to be rewarded for embracing both of these trends.
Hospitalists are uniquely positioned to function as the documentation improvement clinical team leaders, working closely with other physicians across all specialties and the administration to fulfill all documentation requirements—and to be rewarded for doing so. Though hospitalists should have a general understanding of the language and rules of documentation, a system must be in place that helps them identify and capture all the pertinent aspects of the medical record without the need to become coders themselves. To this end, a clinical documentation improvement (CDI) program is critical.
But it might not be enough.
What is needed is a clinical integration program, an enhancement of traditional CDI. This approach requires participation from ED physicians, along with clinical integration specialists, to document accurately and completely from the start. The clinical integration specialist ensures that medical necessity for inpatient admission and patient risk is being addressed and established, conditions are appropriately identified as being present on admission (POA), and all diagnoses are properly recognized and documented thoroughly and accurately. Clinical integration through collaborative documentation then continues throughout the hospitalization, with diagnostic authority and oversight from the hospitalist, all the way through discharge.
Hospitalists should welcome and champion this type of program. As documentation becomes the key to survival, a complete medical record will stand up to any and all scrutiny by Medicare or others.
As for the negatives, there are none.
Andrew H. Dombro, MD, national medical director, and Paul Weygandt, MD, JD, vice president of physician services, J.A. Thomas & Associates, Atlanta
Financial Risk
When I started writing this, Congress hadn’t settled the issue of the 21% cut in Medicare reimbursement for services called for by the sustainable growth rate (SGR) formula. Fortunately, Congress stepped up and passed another extension with a 2.2% pay increase; however, the quick fix only lasts until November.
The process is all too routine: The deadline for these reimbursement cuts looms, Medicare instructs its fiscal intermediaries (the organizations that actually write the checks to providers) to hold claims rather than pay at the lower rate, and, within a few days of the deadline passing, Congress decides to pass an extension, which allows Medicare to continue paying the historical (higher) rate for the time being.
Imagine Medicare reimbursement rates dropping 21% overnight. I suspect it would be cataclysmic. But I hear remarkably little chatter about this possibility. In fact, while with 2,500 other hospitalists for several days at HM10 in April, I didn’t hear a single person bring up the SGR issue.
One reason there isn’t more handwringing about the looming, draconian cuts is that we’ve been there before. In fact, reimbursement cuts required by the SGR have come up every year since 2001. Each time, Congress has chosen not to implement the cuts; and in some years it has approved reimbursement increases instead. So most in healthcare circles basically have come to expect Congress to pass last-minute legislation to avoid the drastic cuts. (SHM and most other medical societies want a repeal of the flawed SGR formula. Visit SHM’s Legislative Action Center, http://capwiz.com/hospitalmedicine/home/, to write your legislators and urge repeal of the SGR. It only takes about two minutes, and you don’t even need to remember who your representatives are; you just need to know your ZIP code.)
Don’t Be Too Smug
There is another reason many hospitalists, and other doctors who are employed and salaried by a large entity like a hospital, might not be more concerned about proposed cuts: They probably think their own salaries will be unaffected by decreases in reimbursement from Medicare and other payors. My experience is that a lot of hospitalists are so unconcerned about payor reimbursement rates that they aren’t even aware of the threatened Medicare cuts.
Their thinking goes something like this: “I’m paid mostly via a fixed annual salary with a small productivity and quality incentive. None of this is connected to the payor mix or collection rates from the patients I see. So if the portion of uninsured patients I see goes up, my compensation is unaffected. Or if payors decrease their rates, my compensation is unaffected. So I don’t need to sweat the possibility of a 21% decrease in Medicare rates. The hospital will have to make up the difference, so my salary is unaffected, and it will be up to bean counters at the hospital to get the numbers to work out.”
In fact, this is true, in theory, for the majority of hospitalists. But I think it is a mistake to assume your salary is untouchable. If Medicare were to cut rates by 21%, you’d better run to your hospital CEO’s office right away, because a long line will form immediately. Every doctor who sees patients at your hospital will be in that line asking the CEO to provide some money to offset the Medicare cuts, and I doubt any hospital will be able to satisfy their doctors without spending so much money that the hospital goes bankrupt or out of business.
Even if you have a valid contract that calls for your compensation to be paid independent of the amount of professional fee collections, a dire shortage of money could lead a hospital to lay off hospitalists or cancel the contract (most contracts would allow the hospital to do this simply by giving a 90-day notice).
I suggest that no hospitalist feel too smug about how well their employment contract protects the group from broader market forces like reimbursement rates. I doubt we’ll ever see an overnight 21% reduction in Medicare rates, but over time, we could see ever-increasing pressure to limit the growth in our incomes.
I believe every hospitalist should spend at least a little time following broader financial issues like this one, and get involved in the political process to let your legislators know your thoughts. For the record, I think the financial underpinnings of our healthcare system are disastrously messed up and something has to be done. And I don’t think anyone’s salary, including mine, is untouchable. But I also believe the SGR is an ineffective way to make the system more financially sound. That said, you don’t need to agree with me; I only recommend that you have a reasonably informed opinion.
One approach might be for your HM group to appoint a “political” or “marketplace” watchdog. This person could be charged with following issues closely and reporting back to the whole group during regular meetings.
“Marketplace” Risk
Medicare rates are only one part of the complex financial ecosystem on which we depend. It is awfully common, and I think pretty reasonable, for hospitalists to have a contractual arrangement with hospitals. The majority of the time, the hospital has most—or all—of the risk for the financial performance of the practice. In fact, most prospective hospitalists, especially those seeking their first jobs out after residency, say one of the most attractive reasons for choosing work as a hospitalist is that many practices provide a salary that is nearly fixed. Any variable components to the salary, such as those based on production or quality, are typically very small.
A hospitalist might think, “I want a practice that pays a fixed salary so I don’t have to worry about any business and financial issues other than when to show up to work.” In fact, a lot of recruitment ads trumpet this very idea (i.e., “you handle the doctoring and get to enjoy the wonderful recreational opportunities and schools our locale provides, and we’ll worry about all the business issues”). That may sound nice, but I worry it is a little short-sighted.
Here is another point of view, which is only slightly more complicated. In most cases, you should try to negotiate a contract that insulates you from “payor risk” (e.g., changes in payor mix and rates paid by payors don’t flow through to your compensation). But you should think twice before asking your employer to assume all the risk for staffing and scheduling decisions, such as whether you get the work done with 10 hospitalists or 11, or whether you have an evening admitter (“swing”) shift. If the employer holds all the risk, then the hospitalists give up nearly all their autonomy to decide how hard they want to work and how they want to schedule themselves. This causes problems for many practices, and is the No. 1 reason I’m called in as a consultant. Contrary to being very risky and stressful, many hospitalists find it liberating to assume financial risk for their staffing and workload decisions.
You should realize that if your employer pays you a fixed compensation, then someone has to ensure that you do enough work to justify that compensation. This can mean that the employer “issues decrees” (i.e., “we won’t add another provide to the practice until we’ve averaged ‘X’ encounters per month for 6 months”). A hospitalist might see this as unreasonable, yet the group has limited recourse since the employer has already guaranteed the compensation.
If you’d rather have more autonomy in your staffing and workload, then you will need to connect your paycheck to these decisions. Although it might sound terribly risky, those who make the switch often say they wouldn’t have it any other way. Most importantly, it ensures hospitalists have much more say in big decisions. TH
Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is also course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.
When I started writing this, Congress hadn’t settled the issue of the 21% cut in Medicare reimbursement for services called for by the sustainable growth rate (SGR) formula. Fortunately, Congress stepped up and passed another extension with a 2.2% pay increase; however, the quick fix only lasts until November.
The process is all too routine: The deadline for these reimbursement cuts looms, Medicare instructs its fiscal intermediaries (the organizations that actually write the checks to providers) to hold claims rather than pay at the lower rate, and, within a few days of the deadline passing, Congress decides to pass an extension, which allows Medicare to continue paying the historical (higher) rate for the time being.
Imagine Medicare reimbursement rates dropping 21% overnight. I suspect it would be cataclysmic. But I hear remarkably little chatter about this possibility. In fact, while with 2,500 other hospitalists for several days at HM10 in April, I didn’t hear a single person bring up the SGR issue.
One reason there isn’t more handwringing about the looming, draconian cuts is that we’ve been there before. In fact, reimbursement cuts required by the SGR have come up every year since 2001. Each time, Congress has chosen not to implement the cuts; and in some years it has approved reimbursement increases instead. So most in healthcare circles basically have come to expect Congress to pass last-minute legislation to avoid the drastic cuts. (SHM and most other medical societies want a repeal of the flawed SGR formula. Visit SHM’s Legislative Action Center, http://capwiz.com/hospitalmedicine/home/, to write your legislators and urge repeal of the SGR. It only takes about two minutes, and you don’t even need to remember who your representatives are; you just need to know your ZIP code.)
Don’t Be Too Smug
There is another reason many hospitalists, and other doctors who are employed and salaried by a large entity like a hospital, might not be more concerned about proposed cuts: They probably think their own salaries will be unaffected by decreases in reimbursement from Medicare and other payors. My experience is that a lot of hospitalists are so unconcerned about payor reimbursement rates that they aren’t even aware of the threatened Medicare cuts.
Their thinking goes something like this: “I’m paid mostly via a fixed annual salary with a small productivity and quality incentive. None of this is connected to the payor mix or collection rates from the patients I see. So if the portion of uninsured patients I see goes up, my compensation is unaffected. Or if payors decrease their rates, my compensation is unaffected. So I don’t need to sweat the possibility of a 21% decrease in Medicare rates. The hospital will have to make up the difference, so my salary is unaffected, and it will be up to bean counters at the hospital to get the numbers to work out.”
In fact, this is true, in theory, for the majority of hospitalists. But I think it is a mistake to assume your salary is untouchable. If Medicare were to cut rates by 21%, you’d better run to your hospital CEO’s office right away, because a long line will form immediately. Every doctor who sees patients at your hospital will be in that line asking the CEO to provide some money to offset the Medicare cuts, and I doubt any hospital will be able to satisfy their doctors without spending so much money that the hospital goes bankrupt or out of business.
Even if you have a valid contract that calls for your compensation to be paid independent of the amount of professional fee collections, a dire shortage of money could lead a hospital to lay off hospitalists or cancel the contract (most contracts would allow the hospital to do this simply by giving a 90-day notice).
I suggest that no hospitalist feel too smug about how well their employment contract protects the group from broader market forces like reimbursement rates. I doubt we’ll ever see an overnight 21% reduction in Medicare rates, but over time, we could see ever-increasing pressure to limit the growth in our incomes.
I believe every hospitalist should spend at least a little time following broader financial issues like this one, and get involved in the political process to let your legislators know your thoughts. For the record, I think the financial underpinnings of our healthcare system are disastrously messed up and something has to be done. And I don’t think anyone’s salary, including mine, is untouchable. But I also believe the SGR is an ineffective way to make the system more financially sound. That said, you don’t need to agree with me; I only recommend that you have a reasonably informed opinion.
One approach might be for your HM group to appoint a “political” or “marketplace” watchdog. This person could be charged with following issues closely and reporting back to the whole group during regular meetings.
“Marketplace” Risk
Medicare rates are only one part of the complex financial ecosystem on which we depend. It is awfully common, and I think pretty reasonable, for hospitalists to have a contractual arrangement with hospitals. The majority of the time, the hospital has most—or all—of the risk for the financial performance of the practice. In fact, most prospective hospitalists, especially those seeking their first jobs out after residency, say one of the most attractive reasons for choosing work as a hospitalist is that many practices provide a salary that is nearly fixed. Any variable components to the salary, such as those based on production or quality, are typically very small.
A hospitalist might think, “I want a practice that pays a fixed salary so I don’t have to worry about any business and financial issues other than when to show up to work.” In fact, a lot of recruitment ads trumpet this very idea (i.e., “you handle the doctoring and get to enjoy the wonderful recreational opportunities and schools our locale provides, and we’ll worry about all the business issues”). That may sound nice, but I worry it is a little short-sighted.
Here is another point of view, which is only slightly more complicated. In most cases, you should try to negotiate a contract that insulates you from “payor risk” (e.g., changes in payor mix and rates paid by payors don’t flow through to your compensation). But you should think twice before asking your employer to assume all the risk for staffing and scheduling decisions, such as whether you get the work done with 10 hospitalists or 11, or whether you have an evening admitter (“swing”) shift. If the employer holds all the risk, then the hospitalists give up nearly all their autonomy to decide how hard they want to work and how they want to schedule themselves. This causes problems for many practices, and is the No. 1 reason I’m called in as a consultant. Contrary to being very risky and stressful, many hospitalists find it liberating to assume financial risk for their staffing and workload decisions.
You should realize that if your employer pays you a fixed compensation, then someone has to ensure that you do enough work to justify that compensation. This can mean that the employer “issues decrees” (i.e., “we won’t add another provide to the practice until we’ve averaged ‘X’ encounters per month for 6 months”). A hospitalist might see this as unreasonable, yet the group has limited recourse since the employer has already guaranteed the compensation.
If you’d rather have more autonomy in your staffing and workload, then you will need to connect your paycheck to these decisions. Although it might sound terribly risky, those who make the switch often say they wouldn’t have it any other way. Most importantly, it ensures hospitalists have much more say in big decisions. TH
Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is also course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.
When I started writing this, Congress hadn’t settled the issue of the 21% cut in Medicare reimbursement for services called for by the sustainable growth rate (SGR) formula. Fortunately, Congress stepped up and passed another extension with a 2.2% pay increase; however, the quick fix only lasts until November.
The process is all too routine: The deadline for these reimbursement cuts looms, Medicare instructs its fiscal intermediaries (the organizations that actually write the checks to providers) to hold claims rather than pay at the lower rate, and, within a few days of the deadline passing, Congress decides to pass an extension, which allows Medicare to continue paying the historical (higher) rate for the time being.
Imagine Medicare reimbursement rates dropping 21% overnight. I suspect it would be cataclysmic. But I hear remarkably little chatter about this possibility. In fact, while with 2,500 other hospitalists for several days at HM10 in April, I didn’t hear a single person bring up the SGR issue.
One reason there isn’t more handwringing about the looming, draconian cuts is that we’ve been there before. In fact, reimbursement cuts required by the SGR have come up every year since 2001. Each time, Congress has chosen not to implement the cuts; and in some years it has approved reimbursement increases instead. So most in healthcare circles basically have come to expect Congress to pass last-minute legislation to avoid the drastic cuts. (SHM and most other medical societies want a repeal of the flawed SGR formula. Visit SHM’s Legislative Action Center, http://capwiz.com/hospitalmedicine/home/, to write your legislators and urge repeal of the SGR. It only takes about two minutes, and you don’t even need to remember who your representatives are; you just need to know your ZIP code.)
Don’t Be Too Smug
There is another reason many hospitalists, and other doctors who are employed and salaried by a large entity like a hospital, might not be more concerned about proposed cuts: They probably think their own salaries will be unaffected by decreases in reimbursement from Medicare and other payors. My experience is that a lot of hospitalists are so unconcerned about payor reimbursement rates that they aren’t even aware of the threatened Medicare cuts.
Their thinking goes something like this: “I’m paid mostly via a fixed annual salary with a small productivity and quality incentive. None of this is connected to the payor mix or collection rates from the patients I see. So if the portion of uninsured patients I see goes up, my compensation is unaffected. Or if payors decrease their rates, my compensation is unaffected. So I don’t need to sweat the possibility of a 21% decrease in Medicare rates. The hospital will have to make up the difference, so my salary is unaffected, and it will be up to bean counters at the hospital to get the numbers to work out.”
In fact, this is true, in theory, for the majority of hospitalists. But I think it is a mistake to assume your salary is untouchable. If Medicare were to cut rates by 21%, you’d better run to your hospital CEO’s office right away, because a long line will form immediately. Every doctor who sees patients at your hospital will be in that line asking the CEO to provide some money to offset the Medicare cuts, and I doubt any hospital will be able to satisfy their doctors without spending so much money that the hospital goes bankrupt or out of business.
Even if you have a valid contract that calls for your compensation to be paid independent of the amount of professional fee collections, a dire shortage of money could lead a hospital to lay off hospitalists or cancel the contract (most contracts would allow the hospital to do this simply by giving a 90-day notice).
I suggest that no hospitalist feel too smug about how well their employment contract protects the group from broader market forces like reimbursement rates. I doubt we’ll ever see an overnight 21% reduction in Medicare rates, but over time, we could see ever-increasing pressure to limit the growth in our incomes.
I believe every hospitalist should spend at least a little time following broader financial issues like this one, and get involved in the political process to let your legislators know your thoughts. For the record, I think the financial underpinnings of our healthcare system are disastrously messed up and something has to be done. And I don’t think anyone’s salary, including mine, is untouchable. But I also believe the SGR is an ineffective way to make the system more financially sound. That said, you don’t need to agree with me; I only recommend that you have a reasonably informed opinion.
One approach might be for your HM group to appoint a “political” or “marketplace” watchdog. This person could be charged with following issues closely and reporting back to the whole group during regular meetings.
“Marketplace” Risk
Medicare rates are only one part of the complex financial ecosystem on which we depend. It is awfully common, and I think pretty reasonable, for hospitalists to have a contractual arrangement with hospitals. The majority of the time, the hospital has most—or all—of the risk for the financial performance of the practice. In fact, most prospective hospitalists, especially those seeking their first jobs out after residency, say one of the most attractive reasons for choosing work as a hospitalist is that many practices provide a salary that is nearly fixed. Any variable components to the salary, such as those based on production or quality, are typically very small.
A hospitalist might think, “I want a practice that pays a fixed salary so I don’t have to worry about any business and financial issues other than when to show up to work.” In fact, a lot of recruitment ads trumpet this very idea (i.e., “you handle the doctoring and get to enjoy the wonderful recreational opportunities and schools our locale provides, and we’ll worry about all the business issues”). That may sound nice, but I worry it is a little short-sighted.
Here is another point of view, which is only slightly more complicated. In most cases, you should try to negotiate a contract that insulates you from “payor risk” (e.g., changes in payor mix and rates paid by payors don’t flow through to your compensation). But you should think twice before asking your employer to assume all the risk for staffing and scheduling decisions, such as whether you get the work done with 10 hospitalists or 11, or whether you have an evening admitter (“swing”) shift. If the employer holds all the risk, then the hospitalists give up nearly all their autonomy to decide how hard they want to work and how they want to schedule themselves. This causes problems for many practices, and is the No. 1 reason I’m called in as a consultant. Contrary to being very risky and stressful, many hospitalists find it liberating to assume financial risk for their staffing and workload decisions.
You should realize that if your employer pays you a fixed compensation, then someone has to ensure that you do enough work to justify that compensation. This can mean that the employer “issues decrees” (i.e., “we won’t add another provide to the practice until we’ve averaged ‘X’ encounters per month for 6 months”). A hospitalist might see this as unreasonable, yet the group has limited recourse since the employer has already guaranteed the compensation.
If you’d rather have more autonomy in your staffing and workload, then you will need to connect your paycheck to these decisions. Although it might sound terribly risky, those who make the switch often say they wouldn’t have it any other way. Most importantly, it ensures hospitalists have much more say in big decisions. TH
Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is also course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.
Dr. Hospitalist
I have been asked to create a proposal for incentive-based reimbursements for our group. One of the more common areas cited in the literature is incentives for “good citizenship.” What exactly constitutes good citizenship and how is it tracked? Thanks.
Lou O’Boyle
Dr. Hospitalist responds:
Congratulations on your new responsibility! Most hospitalist programs in the U.S. have incentive-based compensation as part of their provider compensation plans. While some groups succeed with their incentive-based compensation plans, others fail at what the plan is intended to achieve. In addition to answering your question, I will discuss some keys to developing a successful plan.
From the nature of your question, it sounds as if you are a staff hospitalist or a group administrator who was tasked by the leader or the group to come up with the terms of an incentive-based plan. I am not aware of any guidelines on who is best suited to develop an incentive-based compensation plan, but, in general, I do think it is a mistake for group leaders to unilaterally mandate the terms the of the plan without input from its clinical providers. After all, it seems like common sense to speak with the people who you are trying to motivate before developing an incentive plan. Depending on the size of the group, I think most groups would do well to have a small, representative group of the frontline providers who would work with the leader to develop the plan.
First and foremost, the plan rules must be clear to all participants. Your question is an excellent example. “Good citizenship” probably means different things to different people. For some, it means attending all staff meetings, or active participation on hospital committees. For others, it represents high customer satisfaction or adherence to clinical guidelines. I am not aware of a universal definition for “good citizenship” when it comes to hospitalist incentive-based compensation plans.
After you have determined what you want your plan to motivate the staff to do, I urge you to define the plan rules as clearly as possible; write it down for all providers to see. If the plan rules are vague, opaque, or open to interpretation, participants might not be motivated to reach the goals, because they don’t really understand the plan rules. Even worse, participants might leave with the falsely held belief that someone is trying to mislead them.
Next, figure out a way to easily gather and display the data. Don’t underestimate the amount of work this involves. It is vitally important for everyone to understand who, when, where, and how the data will be gathered and displayed. Needless to say, the process of gathering and displaying the data must be done in a fashion that eliminates questions of validity.
At the core of any incentive-based compensation plan is the actual incentive. The process of determining the actual incentive can be fraught with controversy. I urge all working groups to proceed through this step with caution. What motivates people can vary widely. It is important for participants to view the incentives as sufficiently significant so that they are motivated to take the desired steps to achieve the goal. That said, if participants view the incentive as too large a component of total compensation, they might look for alternative employment with incentive plans they view as “safer” for their personal income.
Most incentive-based compensation plans are from 15% to 25% of total compensation. Again, this is not a fixed rule. Some groups choose incentives that are 5% to 10% of total compensation; others have incentives up to 40% of total compensation. The important takeaway here is to understand what is necessary to motivate your group.
Although most incentives are monetary, I encourage you to think beyond money as the only motivator in your plan. Some examples include time off from work; flat-screen televisions; or all-expenses-paid vacations.
Whether you choose money or nonmonetary items, it is important to be clear on when the payout will occur. Many groups pay the incentive annually. It might be the easy way to do it, but it also doesn’t mean a once-a-year payout is right for your group. The goal of the incentive is to change provider behavior. In order to accomplish this goal, participants must associate their behavior with the incentive-based reward. Paying the incentive-based reward at the right frequency (quarterly, every six months) might increase the chance this will occur. I don’t advise weekly incentives; not only is that process cumbersome, but the rewards also are likely to be small and potentially ineffective. The frequency of payout should be part of the planning discussions.
My last piece of advice is to take steps to help your providers succeed. In addition to telling your providers how to reach their incentives, show them how to succeed. This does not mean setting the bar low. Providers should have to work hard to reach their goals, and there is no reason why you shouldn’t give them the tools to help them succeed. TH
I have been asked to create a proposal for incentive-based reimbursements for our group. One of the more common areas cited in the literature is incentives for “good citizenship.” What exactly constitutes good citizenship and how is it tracked? Thanks.
Lou O’Boyle
Dr. Hospitalist responds:
Congratulations on your new responsibility! Most hospitalist programs in the U.S. have incentive-based compensation as part of their provider compensation plans. While some groups succeed with their incentive-based compensation plans, others fail at what the plan is intended to achieve. In addition to answering your question, I will discuss some keys to developing a successful plan.
From the nature of your question, it sounds as if you are a staff hospitalist or a group administrator who was tasked by the leader or the group to come up with the terms of an incentive-based plan. I am not aware of any guidelines on who is best suited to develop an incentive-based compensation plan, but, in general, I do think it is a mistake for group leaders to unilaterally mandate the terms the of the plan without input from its clinical providers. After all, it seems like common sense to speak with the people who you are trying to motivate before developing an incentive plan. Depending on the size of the group, I think most groups would do well to have a small, representative group of the frontline providers who would work with the leader to develop the plan.
First and foremost, the plan rules must be clear to all participants. Your question is an excellent example. “Good citizenship” probably means different things to different people. For some, it means attending all staff meetings, or active participation on hospital committees. For others, it represents high customer satisfaction or adherence to clinical guidelines. I am not aware of a universal definition for “good citizenship” when it comes to hospitalist incentive-based compensation plans.
After you have determined what you want your plan to motivate the staff to do, I urge you to define the plan rules as clearly as possible; write it down for all providers to see. If the plan rules are vague, opaque, or open to interpretation, participants might not be motivated to reach the goals, because they don’t really understand the plan rules. Even worse, participants might leave with the falsely held belief that someone is trying to mislead them.
Next, figure out a way to easily gather and display the data. Don’t underestimate the amount of work this involves. It is vitally important for everyone to understand who, when, where, and how the data will be gathered and displayed. Needless to say, the process of gathering and displaying the data must be done in a fashion that eliminates questions of validity.
At the core of any incentive-based compensation plan is the actual incentive. The process of determining the actual incentive can be fraught with controversy. I urge all working groups to proceed through this step with caution. What motivates people can vary widely. It is important for participants to view the incentives as sufficiently significant so that they are motivated to take the desired steps to achieve the goal. That said, if participants view the incentive as too large a component of total compensation, they might look for alternative employment with incentive plans they view as “safer” for their personal income.
Most incentive-based compensation plans are from 15% to 25% of total compensation. Again, this is not a fixed rule. Some groups choose incentives that are 5% to 10% of total compensation; others have incentives up to 40% of total compensation. The important takeaway here is to understand what is necessary to motivate your group.
Although most incentives are monetary, I encourage you to think beyond money as the only motivator in your plan. Some examples include time off from work; flat-screen televisions; or all-expenses-paid vacations.
Whether you choose money or nonmonetary items, it is important to be clear on when the payout will occur. Many groups pay the incentive annually. It might be the easy way to do it, but it also doesn’t mean a once-a-year payout is right for your group. The goal of the incentive is to change provider behavior. In order to accomplish this goal, participants must associate their behavior with the incentive-based reward. Paying the incentive-based reward at the right frequency (quarterly, every six months) might increase the chance this will occur. I don’t advise weekly incentives; not only is that process cumbersome, but the rewards also are likely to be small and potentially ineffective. The frequency of payout should be part of the planning discussions.
My last piece of advice is to take steps to help your providers succeed. In addition to telling your providers how to reach their incentives, show them how to succeed. This does not mean setting the bar low. Providers should have to work hard to reach their goals, and there is no reason why you shouldn’t give them the tools to help them succeed. TH
I have been asked to create a proposal for incentive-based reimbursements for our group. One of the more common areas cited in the literature is incentives for “good citizenship.” What exactly constitutes good citizenship and how is it tracked? Thanks.
Lou O’Boyle
Dr. Hospitalist responds:
Congratulations on your new responsibility! Most hospitalist programs in the U.S. have incentive-based compensation as part of their provider compensation plans. While some groups succeed with their incentive-based compensation plans, others fail at what the plan is intended to achieve. In addition to answering your question, I will discuss some keys to developing a successful plan.
From the nature of your question, it sounds as if you are a staff hospitalist or a group administrator who was tasked by the leader or the group to come up with the terms of an incentive-based plan. I am not aware of any guidelines on who is best suited to develop an incentive-based compensation plan, but, in general, I do think it is a mistake for group leaders to unilaterally mandate the terms the of the plan without input from its clinical providers. After all, it seems like common sense to speak with the people who you are trying to motivate before developing an incentive plan. Depending on the size of the group, I think most groups would do well to have a small, representative group of the frontline providers who would work with the leader to develop the plan.
First and foremost, the plan rules must be clear to all participants. Your question is an excellent example. “Good citizenship” probably means different things to different people. For some, it means attending all staff meetings, or active participation on hospital committees. For others, it represents high customer satisfaction or adherence to clinical guidelines. I am not aware of a universal definition for “good citizenship” when it comes to hospitalist incentive-based compensation plans.
After you have determined what you want your plan to motivate the staff to do, I urge you to define the plan rules as clearly as possible; write it down for all providers to see. If the plan rules are vague, opaque, or open to interpretation, participants might not be motivated to reach the goals, because they don’t really understand the plan rules. Even worse, participants might leave with the falsely held belief that someone is trying to mislead them.
Next, figure out a way to easily gather and display the data. Don’t underestimate the amount of work this involves. It is vitally important for everyone to understand who, when, where, and how the data will be gathered and displayed. Needless to say, the process of gathering and displaying the data must be done in a fashion that eliminates questions of validity.
At the core of any incentive-based compensation plan is the actual incentive. The process of determining the actual incentive can be fraught with controversy. I urge all working groups to proceed through this step with caution. What motivates people can vary widely. It is important for participants to view the incentives as sufficiently significant so that they are motivated to take the desired steps to achieve the goal. That said, if participants view the incentive as too large a component of total compensation, they might look for alternative employment with incentive plans they view as “safer” for their personal income.
Most incentive-based compensation plans are from 15% to 25% of total compensation. Again, this is not a fixed rule. Some groups choose incentives that are 5% to 10% of total compensation; others have incentives up to 40% of total compensation. The important takeaway here is to understand what is necessary to motivate your group.
Although most incentives are monetary, I encourage you to think beyond money as the only motivator in your plan. Some examples include time off from work; flat-screen televisions; or all-expenses-paid vacations.
Whether you choose money or nonmonetary items, it is important to be clear on when the payout will occur. Many groups pay the incentive annually. It might be the easy way to do it, but it also doesn’t mean a once-a-year payout is right for your group. The goal of the incentive is to change provider behavior. In order to accomplish this goal, participants must associate their behavior with the incentive-based reward. Paying the incentive-based reward at the right frequency (quarterly, every six months) might increase the chance this will occur. I don’t advise weekly incentives; not only is that process cumbersome, but the rewards also are likely to be small and potentially ineffective. The frequency of payout should be part of the planning discussions.
My last piece of advice is to take steps to help your providers succeed. In addition to telling your providers how to reach their incentives, show them how to succeed. This does not mean setting the bar low. Providers should have to work hard to reach their goals, and there is no reason why you shouldn’t give them the tools to help them succeed. TH