Practice Management

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

Comprehensive Service

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

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

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

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

Critical/Key Portion

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

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

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

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

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

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

EHR Considerations

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

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

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

Students

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

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

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

References

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

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

Comprehensive Service

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

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

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

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

Critical/Key Portion

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

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

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

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

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

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

EHR Considerations

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

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

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

Students

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

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

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

References

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

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

Comprehensive Service

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

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

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

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

Critical/Key Portion

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

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

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

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

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

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

EHR Considerations

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

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

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

Students

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

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

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

References

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

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

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

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

In November 2011, the board of directors of Lee Memorial Health System in Fort Myers, Fla., voted to close access at its four hospitals to any hospitalist who didn’t already practice there or wasn’t affiliated with private practices that contracted with the health system. According to a report in a local newspaper, the proliferation of competing hospitalist practices at Lee Memorial was contributing to high rates of patient and referring physician dissatisfaction and hospitalist turnover.¹ As a result, the board limited new hospitalists from entering practice in their facilities until they could develop “rules of engagement” for the existing hospitalists through new contracts and standards of practice.

The Lee Memorial example of multiple, competing hospitalist groups—and individuals practicing hospital medicine, also known as “lone wolf” hospitalists—causing havoc is atypical of the fledgling medical specialty, which has seen rapid growth the past two decades. Even so, veteran hospitalists confirm that nowadays, with nearly 40,000 hospitalists practicing in a majority of U.S. hospitals, it’s not uncommon to have multiple groups or individuals working under the same hospital roof. What is concerning to some in the specialty is how the competition can turn ugly, especially considering SHM espouses such virtues as teamwork, leadership, and quality improvement (QI).

Even so, situations arise when multiple HM groups under one roof don’t get along. Sometimes those groups or individual practitioners compete, head to head, for new admissions. Some hospitals have patient populations carved out by capitated medical groups or staff/group model HMOs. Some specialty groups, cardiology or orthopedics, for example, choose to contract hospitalist groups for their patients, setting up potential conflicts with new admissions. Other hospitals have “lone wolf” hospitalists, basically a practice of one.

No matter the dynamic, hospital administrators are frustrated with their inability to control competitive situations, especially when competing groups or individuals do not act in conjunction with their strategic goals.

Depending on hospital bylaws and state regulations, it might be difficult to exclude hospitalists from practicing in the hospital or to cut off competition. Some hospitals even welcome competition—as a prime virtue in its own right, a way to advance quality, or to guard against staffing shortages. The challenge, hospitalists and administrators say, is to encourage multiple groups to work amicably alongside each other, cooperating on the hospital’s larger mission and working toward its quality targets—and to make sure clinicians focus less on competition and more on patients (see “The Magic Bullet: Communication,”).

It forces us to make sure the services we provide are meeting the customer’s expectations. We can and do learn from each other.

—Lowell Palmer, MD, FHM, hospitalist, Southwest Washington Medical Center, Vancouver

Purposeful, Team-Based Medicine

Scott Nygaard, MD, Lee Memorial’s chief medical officer for physician services, announced on Aug. 29, 2012, that the health system was contracting with a newly formed medical group called Inpatient Specialists of Southwest Florida (ISSF), a partnership between Cape Coral, Fla.-based Hospitalist Group of Southwest Florida (HGSF) and national management company Cogent HMG based in Brentwood, Tenn. HGSF and Cogent HMG already had established practices in two of Lee’s four hospitals.

Other existing hospitalist groups are permitted to continue practicing in these hospitals, although only a contracted group will be able to recruit or add new physicians, Dr. Nygaard says.

“The bylaws did not allow us to formally close access for staff already in practice,” he said. Physicians have the option of joining ISSF, and eventually, he says, the other groups dwindled in numbers through attrition. As Lee Memorial’s sole provider of hospitalist care, ISSF’s long-term goal is to put HM on a similar footing with other hospital-based specialties, such as emergency medicine and anesthesiology.

As of late 2012, six hospitalist groups and more than 80 hospitalists practice at Lee Memorial hospitals; 40 of those hospitalists belong to ISSF. “The other groups were all offered an opportunity to discuss a contractual relationship with the system, but they declined,” Dr. Nygaard says.

The remaining groups had worked amicably alongside each other but in an atmosphere Dr. Nygaard likens to a flea market, with each group practicing its own separate business and business model.

A standardized approach conducive to achieving the hospital’s quality and performance targets was lacking, however. As a result, Lee Memorial implemented an HM standard of care within the system. It helped somewhat, Dr. Nygaard says, but it didn’t fix all of the competition problems.

“We have learned that variation is the enemy of quality, especially in the highly complex environment of an acute-care hospital, trying to generate the kinds of measurable results we are now being asked to provide,” he explains. “We need to be more organized, structured, and purposeful in an era of team-based medicine. You need committed, aligned partnerships offering appropriate incentives.”

The ISSF contract contains such performance incentives.

“The joint venture formalizes an informal, long-standing, collaborative relationship” between the two participating HM groups, says Joseph Daley, MD, co-founder and director of quality services for Hospitalist Group of Southwest Florida. “We bring substantial, local expertise to the table, and have been quality partners with both Lee Memorial and Cogent HMG.”

And, as of April, Lee Memorial spokesperson Mary Briggs reported patient satisfaction scores for hospitalists are improving. “We believe the changes put in place were the right ones,” she emailed The Hospitalist.

We have learned that variation is the enemy of quality, especially in the highly complex environment of an acute-care hospital, trying to generate the kinds of measurable results we are now being asked to provide. We need to be more organized, structured, and purposeful in an era of team-based medicine.

—Scott Nygaard, MD, chief medical officer for physician services, Lee Memorial Health System, Fort Myers, Fla.

Supply and Demand

Every local hospital environment is different, with HM group arrangements shaped to a large degree by supply and demand for physicians, says Brian Hazen, MD, chief of hospital medicine at Inova Fairfax Hospital in Falls Church, Va., one of five hospitals in the Inova system. Inova Fairfax employs the hospitalists in Dr. Hazen’s group but is also home to other groups, including a neurohospitalist service and about a half dozen solo practitioners. Dr. Hazen’s group receives administrative support from the hospital and primarily is assigned patients through the ED. Some of the private hospitalists don’t want to take ED call, he says, instead preferring to get referrals of insured patients from primary-care-physician groups.

“Here in the D.C. area, we’re reasonably well staffed by hospitalists, but we’re not fighting over patients. In fact, if it weren’t for the private physicians, we’d have trouble meeting current staffing needs,” Dr. Hazen says. “I have also seen competition in other hospital settings, but I haven’t been in a situation where the doctors were fighting over patients.”

The “lone wolf” hospitalists at Inova Fairfax work very hard, Dr. Hazen adds. “A lot of them have private practices, see patients in the hospital, and also take call. If one of them has to leave town on short notice, we can help them out. On the flip side, if we’re busy in the emergency department, we’ll call on them,” he says.

The ED receives instruction on which hospitalist group admits which patient, but sometimes referral mistakes are made.

“If we accidently admit a patient who should have gone to one of the private people, who depend on these admissions for their income, I let them choose whether we should continue to see that patient or do a transfer,” Dr. Hazen says. “For the most part, we all try to be nice people.”

In the current health-care environment, hospital administrators might be reluctant to erect barriers to multiple hospitalist practices under one roof for fear of restraining trade, just as they don’t stand in the way of primary-care physicians who want to follow their own patients into the hospital. It might be easier to enact equally enforced requirements for the credentialing and privileging of all hospitalists who want to practice at the hospital, spelling out expectations in such areas as following protocols. (In 2011, SHM issued a position paper on hospitalist credentialing that addressed the appropriate time to institute a credentialing category with privileging criteria for hospitalists, and how to preserve maximum flexibility within this process.)²

Hospitals can limit who they contract with, who gets administrative support—and how much—using financial and quality performance to shape contracting decisions. In many communities, that could serve as an excluder of multiple groups in the same building, but in other locales, the payor mix might be attractive enough for physicians to survive on billing alone, says Leslie Flores, MPH, of Nelson Flores Hospital Medicine Consultants. If the hospital isn’t providing financial support, it will have less influence over how that group does things.

Dr. Hazen says his employed hospitalist group at Inova Fairfax is represented on more than 20 hospital committees and quality initiatives in the hospital, and has demonstrated its alignment with the hospital’s goals. Recently, in response to the administration’s concerns about throughput, his group initiated geographic, multidisciplinary rounding.

“I can do this because I have elite physicians, and because I protect them from unreasonable expectations,” he says. “Everyone needs to understand that the hospital needs to survive, so the hospital has a right to expect certain things from its hospitalists, such as performance on length of stay, throughput, other core measures, and promptly answering pages. Everyone should understand that those are the rules. Being fair, honest, and transparent about expectations is not an unreasonable expectation.”

Competition among hospitalists should be on a professional basis, experts emphasize, and cooperation is in everyone’s best interests. But Lowell Palmer, MD, FHM, a hospitalist at Southwest Washington Medical Center in Vancouver, Wash., thinks competition can be a healthy thing for hospitalist groups.

“It forces us to make sure the services we provide are meeting the customer’s expectations,” says Dr. Palmer, who works with Cogent Physician Services, one of the three HM groups at Southwest Washington. “We can and do learn from each other.”

Impact of Health-Care Reform

Beware the transformation health-care reform is having on the dynamics of hospital-based practice and the competitive landscape facing more hospitalist groups, says Roger Heroux, MHA, PhD, CHE, consultant with Hospitalist Management Resources LLC. Reforms mean hospitalists are seeing an increased emphasis on coordinating with post-acute-care providers, improving care transitions, preventing readmissions, and meeting hospital targets for quality and patient safety.

Primary-care groups, accountable-care organizations (ACOs), and health plans could choose specific hospitalist practices they want to partner with to manage the care of their hospitalized members, but they will have clear performance expectations that those groups will need to meet, spelled out in benchmarks. Or, as some experts believe, they might opt to bring in their own hospitalist group.

“We’re spending our time working with existing hospitalist programs to help them be more efficient and effective, to manage risk, and to become aggressive about meeting the clinical benchmarks,” Heroux says. Hospitals, ACOs, and capitated groups can’t afford not to have a high-performing hospitalist program, so this will become a hallmark of survival for hospitalist programs as well. “In a highly managed environment, patients will be managed by a hospitalist group that is responsive to these expectations,” he says.

Larry Beresford is a freelance writer in Oakland, Calif.

References

1. Gluck F. Lee Memorial Health Systems’ hospitalists under new controls. Fort Myers News Press. Dec. 1, 2011.
2. Society of Hospital Medicine Position Statement on Hospitalist Credentialing and Medical Staff Privileges. SHM website. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Where_We_Stand&Template=/CM/HTMLDisplay.cfm&ContentID=28262. Accessed April 1, 2013.

In November 2011, the board of directors of Lee Memorial Health System in Fort Myers, Fla., voted to close access at its four hospitals to any hospitalist who didn’t already practice there or wasn’t affiliated with private practices that contracted with the health system. According to a report in a local newspaper, the proliferation of competing hospitalist practices at Lee Memorial was contributing to high rates of patient and referring physician dissatisfaction and hospitalist turnover.¹ As a result, the board limited new hospitalists from entering practice in their facilities until they could develop “rules of engagement” for the existing hospitalists through new contracts and standards of practice.

The Lee Memorial example of multiple, competing hospitalist groups—and individuals practicing hospital medicine, also known as “lone wolf” hospitalists—causing havoc is atypical of the fledgling medical specialty, which has seen rapid growth the past two decades. Even so, veteran hospitalists confirm that nowadays, with nearly 40,000 hospitalists practicing in a majority of U.S. hospitals, it’s not uncommon to have multiple groups or individuals working under the same hospital roof. What is concerning to some in the specialty is how the competition can turn ugly, especially considering SHM espouses such virtues as teamwork, leadership, and quality improvement (QI).

Even so, situations arise when multiple HM groups under one roof don’t get along. Sometimes those groups or individual practitioners compete, head to head, for new admissions. Some hospitals have patient populations carved out by capitated medical groups or staff/group model HMOs. Some specialty groups, cardiology or orthopedics, for example, choose to contract hospitalist groups for their patients, setting up potential conflicts with new admissions. Other hospitals have “lone wolf” hospitalists, basically a practice of one.

No matter the dynamic, hospital administrators are frustrated with their inability to control competitive situations, especially when competing groups or individuals do not act in conjunction with their strategic goals.

Depending on hospital bylaws and state regulations, it might be difficult to exclude hospitalists from practicing in the hospital or to cut off competition. Some hospitals even welcome competition—as a prime virtue in its own right, a way to advance quality, or to guard against staffing shortages. The challenge, hospitalists and administrators say, is to encourage multiple groups to work amicably alongside each other, cooperating on the hospital’s larger mission and working toward its quality targets—and to make sure clinicians focus less on competition and more on patients (see “The Magic Bullet: Communication,”).

It forces us to make sure the services we provide are meeting the customer’s expectations. We can and do learn from each other.

—Lowell Palmer, MD, FHM, hospitalist, Southwest Washington Medical Center, Vancouver

Purposeful, Team-Based Medicine

Scott Nygaard, MD, Lee Memorial’s chief medical officer for physician services, announced on Aug. 29, 2012, that the health system was contracting with a newly formed medical group called Inpatient Specialists of Southwest Florida (ISSF), a partnership between Cape Coral, Fla.-based Hospitalist Group of Southwest Florida (HGSF) and national management company Cogent HMG based in Brentwood, Tenn. HGSF and Cogent HMG already had established practices in two of Lee’s four hospitals.

Other existing hospitalist groups are permitted to continue practicing in these hospitals, although only a contracted group will be able to recruit or add new physicians, Dr. Nygaard says.

“The bylaws did not allow us to formally close access for staff already in practice,” he said. Physicians have the option of joining ISSF, and eventually, he says, the other groups dwindled in numbers through attrition. As Lee Memorial’s sole provider of hospitalist care, ISSF’s long-term goal is to put HM on a similar footing with other hospital-based specialties, such as emergency medicine and anesthesiology.

As of late 2012, six hospitalist groups and more than 80 hospitalists practice at Lee Memorial hospitals; 40 of those hospitalists belong to ISSF. “The other groups were all offered an opportunity to discuss a contractual relationship with the system, but they declined,” Dr. Nygaard says.

The remaining groups had worked amicably alongside each other but in an atmosphere Dr. Nygaard likens to a flea market, with each group practicing its own separate business and business model.

A standardized approach conducive to achieving the hospital’s quality and performance targets was lacking, however. As a result, Lee Memorial implemented an HM standard of care within the system. It helped somewhat, Dr. Nygaard says, but it didn’t fix all of the competition problems.

“We have learned that variation is the enemy of quality, especially in the highly complex environment of an acute-care hospital, trying to generate the kinds of measurable results we are now being asked to provide,” he explains. “We need to be more organized, structured, and purposeful in an era of team-based medicine. You need committed, aligned partnerships offering appropriate incentives.”

The ISSF contract contains such performance incentives.

“The joint venture formalizes an informal, long-standing, collaborative relationship” between the two participating HM groups, says Joseph Daley, MD, co-founder and director of quality services for Hospitalist Group of Southwest Florida. “We bring substantial, local expertise to the table, and have been quality partners with both Lee Memorial and Cogent HMG.”

And, as of April, Lee Memorial spokesperson Mary Briggs reported patient satisfaction scores for hospitalists are improving. “We believe the changes put in place were the right ones,” she emailed The Hospitalist.

We have learned that variation is the enemy of quality, especially in the highly complex environment of an acute-care hospital, trying to generate the kinds of measurable results we are now being asked to provide. We need to be more organized, structured, and purposeful in an era of team-based medicine.

—Scott Nygaard, MD, chief medical officer for physician services, Lee Memorial Health System, Fort Myers, Fla.

Supply and Demand

Every local hospital environment is different, with HM group arrangements shaped to a large degree by supply and demand for physicians, says Brian Hazen, MD, chief of hospital medicine at Inova Fairfax Hospital in Falls Church, Va., one of five hospitals in the Inova system. Inova Fairfax employs the hospitalists in Dr. Hazen’s group but is also home to other groups, including a neurohospitalist service and about a half dozen solo practitioners. Dr. Hazen’s group receives administrative support from the hospital and primarily is assigned patients through the ED. Some of the private hospitalists don’t want to take ED call, he says, instead preferring to get referrals of insured patients from primary-care-physician groups.

“Here in the D.C. area, we’re reasonably well staffed by hospitalists, but we’re not fighting over patients. In fact, if it weren’t for the private physicians, we’d have trouble meeting current staffing needs,” Dr. Hazen says. “I have also seen competition in other hospital settings, but I haven’t been in a situation where the doctors were fighting over patients.”

The “lone wolf” hospitalists at Inova Fairfax work very hard, Dr. Hazen adds. “A lot of them have private practices, see patients in the hospital, and also take call. If one of them has to leave town on short notice, we can help them out. On the flip side, if we’re busy in the emergency department, we’ll call on them,” he says.

The ED receives instruction on which hospitalist group admits which patient, but sometimes referral mistakes are made.

“If we accidently admit a patient who should have gone to one of the private people, who depend on these admissions for their income, I let them choose whether we should continue to see that patient or do a transfer,” Dr. Hazen says. “For the most part, we all try to be nice people.”

In the current health-care environment, hospital administrators might be reluctant to erect barriers to multiple hospitalist practices under one roof for fear of restraining trade, just as they don’t stand in the way of primary-care physicians who want to follow their own patients into the hospital. It might be easier to enact equally enforced requirements for the credentialing and privileging of all hospitalists who want to practice at the hospital, spelling out expectations in such areas as following protocols. (In 2011, SHM issued a position paper on hospitalist credentialing that addressed the appropriate time to institute a credentialing category with privileging criteria for hospitalists, and how to preserve maximum flexibility within this process.)²

Hospitals can limit who they contract with, who gets administrative support—and how much—using financial and quality performance to shape contracting decisions. In many communities, that could serve as an excluder of multiple groups in the same building, but in other locales, the payor mix might be attractive enough for physicians to survive on billing alone, says Leslie Flores, MPH, of Nelson Flores Hospital Medicine Consultants. If the hospital isn’t providing financial support, it will have less influence over how that group does things.

Dr. Hazen says his employed hospitalist group at Inova Fairfax is represented on more than 20 hospital committees and quality initiatives in the hospital, and has demonstrated its alignment with the hospital’s goals. Recently, in response to the administration’s concerns about throughput, his group initiated geographic, multidisciplinary rounding.

“I can do this because I have elite physicians, and because I protect them from unreasonable expectations,” he says. “Everyone needs to understand that the hospital needs to survive, so the hospital has a right to expect certain things from its hospitalists, such as performance on length of stay, throughput, other core measures, and promptly answering pages. Everyone should understand that those are the rules. Being fair, honest, and transparent about expectations is not an unreasonable expectation.”

Competition among hospitalists should be on a professional basis, experts emphasize, and cooperation is in everyone’s best interests. But Lowell Palmer, MD, FHM, a hospitalist at Southwest Washington Medical Center in Vancouver, Wash., thinks competition can be a healthy thing for hospitalist groups.

“It forces us to make sure the services we provide are meeting the customer’s expectations,” says Dr. Palmer, who works with Cogent Physician Services, one of the three HM groups at Southwest Washington. “We can and do learn from each other.”

Impact of Health-Care Reform

Beware the transformation health-care reform is having on the dynamics of hospital-based practice and the competitive landscape facing more hospitalist groups, says Roger Heroux, MHA, PhD, CHE, consultant with Hospitalist Management Resources LLC. Reforms mean hospitalists are seeing an increased emphasis on coordinating with post-acute-care providers, improving care transitions, preventing readmissions, and meeting hospital targets for quality and patient safety.

Primary-care groups, accountable-care organizations (ACOs), and health plans could choose specific hospitalist practices they want to partner with to manage the care of their hospitalized members, but they will have clear performance expectations that those groups will need to meet, spelled out in benchmarks. Or, as some experts believe, they might opt to bring in their own hospitalist group.

“We’re spending our time working with existing hospitalist programs to help them be more efficient and effective, to manage risk, and to become aggressive about meeting the clinical benchmarks,” Heroux says. Hospitals, ACOs, and capitated groups can’t afford not to have a high-performing hospitalist program, so this will become a hallmark of survival for hospitalist programs as well. “In a highly managed environment, patients will be managed by a hospitalist group that is responsive to these expectations,” he says.

Larry Beresford is a freelance writer in Oakland, Calif.

References

1. Gluck F. Lee Memorial Health Systems’ hospitalists under new controls. Fort Myers News Press. Dec. 1, 2011.
2. Society of Hospital Medicine Position Statement on Hospitalist Credentialing and Medical Staff Privileges. SHM website. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Where_We_Stand&Template=/CM/HTMLDisplay.cfm&ContentID=28262. Accessed April 1, 2013.

In November 2011, the board of directors of Lee Memorial Health System in Fort Myers, Fla., voted to close access at its four hospitals to any hospitalist who didn’t already practice there or wasn’t affiliated with private practices that contracted with the health system. According to a report in a local newspaper, the proliferation of competing hospitalist practices at Lee Memorial was contributing to high rates of patient and referring physician dissatisfaction and hospitalist turnover.¹ As a result, the board limited new hospitalists from entering practice in their facilities until they could develop “rules of engagement” for the existing hospitalists through new contracts and standards of practice.

The Lee Memorial example of multiple, competing hospitalist groups—and individuals practicing hospital medicine, also known as “lone wolf” hospitalists—causing havoc is atypical of the fledgling medical specialty, which has seen rapid growth the past two decades. Even so, veteran hospitalists confirm that nowadays, with nearly 40,000 hospitalists practicing in a majority of U.S. hospitals, it’s not uncommon to have multiple groups or individuals working under the same hospital roof. What is concerning to some in the specialty is how the competition can turn ugly, especially considering SHM espouses such virtues as teamwork, leadership, and quality improvement (QI).

Even so, situations arise when multiple HM groups under one roof don’t get along. Sometimes those groups or individual practitioners compete, head to head, for new admissions. Some hospitals have patient populations carved out by capitated medical groups or staff/group model HMOs. Some specialty groups, cardiology or orthopedics, for example, choose to contract hospitalist groups for their patients, setting up potential conflicts with new admissions. Other hospitals have “lone wolf” hospitalists, basically a practice of one.

No matter the dynamic, hospital administrators are frustrated with their inability to control competitive situations, especially when competing groups or individuals do not act in conjunction with their strategic goals.

Depending on hospital bylaws and state regulations, it might be difficult to exclude hospitalists from practicing in the hospital or to cut off competition. Some hospitals even welcome competition—as a prime virtue in its own right, a way to advance quality, or to guard against staffing shortages. The challenge, hospitalists and administrators say, is to encourage multiple groups to work amicably alongside each other, cooperating on the hospital’s larger mission and working toward its quality targets—and to make sure clinicians focus less on competition and more on patients (see “The Magic Bullet: Communication,”).

It forces us to make sure the services we provide are meeting the customer’s expectations. We can and do learn from each other.

—Lowell Palmer, MD, FHM, hospitalist, Southwest Washington Medical Center, Vancouver

Purposeful, Team-Based Medicine

Scott Nygaard, MD, Lee Memorial’s chief medical officer for physician services, announced on Aug. 29, 2012, that the health system was contracting with a newly formed medical group called Inpatient Specialists of Southwest Florida (ISSF), a partnership between Cape Coral, Fla.-based Hospitalist Group of Southwest Florida (HGSF) and national management company Cogent HMG based in Brentwood, Tenn. HGSF and Cogent HMG already had established practices in two of Lee’s four hospitals.

Other existing hospitalist groups are permitted to continue practicing in these hospitals, although only a contracted group will be able to recruit or add new physicians, Dr. Nygaard says.

“The bylaws did not allow us to formally close access for staff already in practice,” he said. Physicians have the option of joining ISSF, and eventually, he says, the other groups dwindled in numbers through attrition. As Lee Memorial’s sole provider of hospitalist care, ISSF’s long-term goal is to put HM on a similar footing with other hospital-based specialties, such as emergency medicine and anesthesiology.

As of late 2012, six hospitalist groups and more than 80 hospitalists practice at Lee Memorial hospitals; 40 of those hospitalists belong to ISSF. “The other groups were all offered an opportunity to discuss a contractual relationship with the system, but they declined,” Dr. Nygaard says.

The remaining groups had worked amicably alongside each other but in an atmosphere Dr. Nygaard likens to a flea market, with each group practicing its own separate business and business model.

A standardized approach conducive to achieving the hospital’s quality and performance targets was lacking, however. As a result, Lee Memorial implemented an HM standard of care within the system. It helped somewhat, Dr. Nygaard says, but it didn’t fix all of the competition problems.

“We have learned that variation is the enemy of quality, especially in the highly complex environment of an acute-care hospital, trying to generate the kinds of measurable results we are now being asked to provide,” he explains. “We need to be more organized, structured, and purposeful in an era of team-based medicine. You need committed, aligned partnerships offering appropriate incentives.”

The ISSF contract contains such performance incentives.

“The joint venture formalizes an informal, long-standing, collaborative relationship” between the two participating HM groups, says Joseph Daley, MD, co-founder and director of quality services for Hospitalist Group of Southwest Florida. “We bring substantial, local expertise to the table, and have been quality partners with both Lee Memorial and Cogent HMG.”

And, as of April, Lee Memorial spokesperson Mary Briggs reported patient satisfaction scores for hospitalists are improving. “We believe the changes put in place were the right ones,” she emailed The Hospitalist.

We have learned that variation is the enemy of quality, especially in the highly complex environment of an acute-care hospital, trying to generate the kinds of measurable results we are now being asked to provide. We need to be more organized, structured, and purposeful in an era of team-based medicine.

—Scott Nygaard, MD, chief medical officer for physician services, Lee Memorial Health System, Fort Myers, Fla.

Supply and Demand

Every local hospital environment is different, with HM group arrangements shaped to a large degree by supply and demand for physicians, says Brian Hazen, MD, chief of hospital medicine at Inova Fairfax Hospital in Falls Church, Va., one of five hospitals in the Inova system. Inova Fairfax employs the hospitalists in Dr. Hazen’s group but is also home to other groups, including a neurohospitalist service and about a half dozen solo practitioners. Dr. Hazen’s group receives administrative support from the hospital and primarily is assigned patients through the ED. Some of the private hospitalists don’t want to take ED call, he says, instead preferring to get referrals of insured patients from primary-care-physician groups.

“Here in the D.C. area, we’re reasonably well staffed by hospitalists, but we’re not fighting over patients. In fact, if it weren’t for the private physicians, we’d have trouble meeting current staffing needs,” Dr. Hazen says. “I have also seen competition in other hospital settings, but I haven’t been in a situation where the doctors were fighting over patients.”

The “lone wolf” hospitalists at Inova Fairfax work very hard, Dr. Hazen adds. “A lot of them have private practices, see patients in the hospital, and also take call. If one of them has to leave town on short notice, we can help them out. On the flip side, if we’re busy in the emergency department, we’ll call on them,” he says.

The ED receives instruction on which hospitalist group admits which patient, but sometimes referral mistakes are made.

“If we accidently admit a patient who should have gone to one of the private people, who depend on these admissions for their income, I let them choose whether we should continue to see that patient or do a transfer,” Dr. Hazen says. “For the most part, we all try to be nice people.”

In the current health-care environment, hospital administrators might be reluctant to erect barriers to multiple hospitalist practices under one roof for fear of restraining trade, just as they don’t stand in the way of primary-care physicians who want to follow their own patients into the hospital. It might be easier to enact equally enforced requirements for the credentialing and privileging of all hospitalists who want to practice at the hospital, spelling out expectations in such areas as following protocols. (In 2011, SHM issued a position paper on hospitalist credentialing that addressed the appropriate time to institute a credentialing category with privileging criteria for hospitalists, and how to preserve maximum flexibility within this process.)²

Hospitals can limit who they contract with, who gets administrative support—and how much—using financial and quality performance to shape contracting decisions. In many communities, that could serve as an excluder of multiple groups in the same building, but in other locales, the payor mix might be attractive enough for physicians to survive on billing alone, says Leslie Flores, MPH, of Nelson Flores Hospital Medicine Consultants. If the hospital isn’t providing financial support, it will have less influence over how that group does things.

Dr. Hazen says his employed hospitalist group at Inova Fairfax is represented on more than 20 hospital committees and quality initiatives in the hospital, and has demonstrated its alignment with the hospital’s goals. Recently, in response to the administration’s concerns about throughput, his group initiated geographic, multidisciplinary rounding.

“I can do this because I have elite physicians, and because I protect them from unreasonable expectations,” he says. “Everyone needs to understand that the hospital needs to survive, so the hospital has a right to expect certain things from its hospitalists, such as performance on length of stay, throughput, other core measures, and promptly answering pages. Everyone should understand that those are the rules. Being fair, honest, and transparent about expectations is not an unreasonable expectation.”

Competition among hospitalists should be on a professional basis, experts emphasize, and cooperation is in everyone’s best interests. But Lowell Palmer, MD, FHM, a hospitalist at Southwest Washington Medical Center in Vancouver, Wash., thinks competition can be a healthy thing for hospitalist groups.

“It forces us to make sure the services we provide are meeting the customer’s expectations,” says Dr. Palmer, who works with Cogent Physician Services, one of the three HM groups at Southwest Washington. “We can and do learn from each other.”

Impact of Health-Care Reform

Beware the transformation health-care reform is having on the dynamics of hospital-based practice and the competitive landscape facing more hospitalist groups, says Roger Heroux, MHA, PhD, CHE, consultant with Hospitalist Management Resources LLC. Reforms mean hospitalists are seeing an increased emphasis on coordinating with post-acute-care providers, improving care transitions, preventing readmissions, and meeting hospital targets for quality and patient safety.

Primary-care groups, accountable-care organizations (ACOs), and health plans could choose specific hospitalist practices they want to partner with to manage the care of their hospitalized members, but they will have clear performance expectations that those groups will need to meet, spelled out in benchmarks. Or, as some experts believe, they might opt to bring in their own hospitalist group.

“We’re spending our time working with existing hospitalist programs to help them be more efficient and effective, to manage risk, and to become aggressive about meeting the clinical benchmarks,” Heroux says. Hospitals, ACOs, and capitated groups can’t afford not to have a high-performing hospitalist program, so this will become a hallmark of survival for hospitalist programs as well. “In a highly managed environment, patients will be managed by a hospitalist group that is responsive to these expectations,” he says.

Larry Beresford is a freelance writer in Oakland, Calif.

References

1. Gluck F. Lee Memorial Health Systems’ hospitalists under new controls. Fort Myers News Press. Dec. 1, 2011.
2. Society of Hospital Medicine Position Statement on Hospitalist Credentialing and Medical Staff Privileges. SHM website. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Where_We_Stand&Template=/CM/HTMLDisplay.cfm&ContentID=28262. Accessed April 1, 2013.

New national legislation proposed in March would change Medicare billing rules to allow patients to more easily access Medicare’s institutional skilled nursing care benefit following a hospital discharge. Currently, patients can get the benefit only after a qualifying three-day hospital stay. If they don’t qualify, they often have to pay out of pocket for the subsequent skilled nursing facility placement.

The Improving Access to Medicare Coverage Act, introduced by Reps. Joe Courtney (D-Conn.) and Tom Latham (R-Iowa) and Sen. Sherrod Brown (D-Ohio), would allow the time patients spend inside the hospital on “observation status” to count toward their required three-day hospital stay. It also would establish a 90-day appeal period for those who have been denied this benefit.

SHM is one of a dozen endorsing organizations, joining the American Medical Association, American Medical Directors Association, and AARP. For more information, check out this month’s “Policy Corner”.

Larry Beresford is a freelance writer in Oakland, Calif.

References

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

New national legislation proposed in March would change Medicare billing rules to allow patients to more easily access Medicare’s institutional skilled nursing care benefit following a hospital discharge. Currently, patients can get the benefit only after a qualifying three-day hospital stay. If they don’t qualify, they often have to pay out of pocket for the subsequent skilled nursing facility placement.

The Improving Access to Medicare Coverage Act, introduced by Reps. Joe Courtney (D-Conn.) and Tom Latham (R-Iowa) and Sen. Sherrod Brown (D-Ohio), would allow the time patients spend inside the hospital on “observation status” to count toward their required three-day hospital stay. It also would establish a 90-day appeal period for those who have been denied this benefit.

SHM is one of a dozen endorsing organizations, joining the American Medical Association, American Medical Directors Association, and AARP. For more information, check out this month’s “Policy Corner”.

Larry Beresford is a freelance writer in Oakland, Calif.

References

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

New national legislation proposed in March would change Medicare billing rules to allow patients to more easily access Medicare’s institutional skilled nursing care benefit following a hospital discharge. Currently, patients can get the benefit only after a qualifying three-day hospital stay. If they don’t qualify, they often have to pay out of pocket for the subsequent skilled nursing facility placement.

The Improving Access to Medicare Coverage Act, introduced by Reps. Joe Courtney (D-Conn.) and Tom Latham (R-Iowa) and Sen. Sherrod Brown (D-Ohio), would allow the time patients spend inside the hospital on “observation status” to count toward their required three-day hospital stay. It also would establish a 90-day appeal period for those who have been denied this benefit.

SHM is one of a dozen endorsing organizations, joining the American Medical Association, American Medical Directors Association, and AARP. For more information, check out this month’s “Policy Corner”.

Larry Beresford is a freelance writer in Oakland, Calif.

References

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

In a poster presented at HM12, Kathryn Quinn, MPH, CPPS, FACHE, described how her quality team at the University of California at San Francisco (UCSF) developed a checklist to improve physician communication with patients, then taught it to the attending hospitalist faculty.¹ The project began with a list of 29 best practices for patient-physician interaction, as identified in medical literature. Hospitalists then voted for the elements they felt were most important to their practice, as well as those best able to be measured, and a top-10 list was created.

Quinn, the program manager for quality and safety in the division of hospital medicine at UCSF, says the communication best practices were “chosen by the people whose practices we are trying to change.”

The quality team presented the best practices in one-hour training sessions that included small-group role plays, explains co-investigator and UCSF hospitalist Diane Sliwka, MD. The training extended to outpatient physicians, medical specialists, and chief residents. Participants also were provided a laminated pocket card listing the interventions. They also received feedback from structured observations with patients on service.

Quinn says UCSF hospitalists have improved at knocking and asking permission to enter patient rooms, introducing themselves by name and role, and encouraging questions at the end of the interaction. They have been less successful at inquiring about the patient’s concerns early in the interview and at discussing duration of treatment and next steps.

“We learned that it takes more than just talk,” Quinn says. “Just telling physicians how to improve communication doesn’t mean it’s easy to do.”

Still to be determined is the project’s impact on patient satisfaction scores, although the hospitalists reported that they found the training and feedback helpful.

References

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

In a poster presented at HM12, Kathryn Quinn, MPH, CPPS, FACHE, described how her quality team at the University of California at San Francisco (UCSF) developed a checklist to improve physician communication with patients, then taught it to the attending hospitalist faculty.¹ The project began with a list of 29 best practices for patient-physician interaction, as identified in medical literature. Hospitalists then voted for the elements they felt were most important to their practice, as well as those best able to be measured, and a top-10 list was created.

Quinn, the program manager for quality and safety in the division of hospital medicine at UCSF, says the communication best practices were “chosen by the people whose practices we are trying to change.”

The quality team presented the best practices in one-hour training sessions that included small-group role plays, explains co-investigator and UCSF hospitalist Diane Sliwka, MD. The training extended to outpatient physicians, medical specialists, and chief residents. Participants also were provided a laminated pocket card listing the interventions. They also received feedback from structured observations with patients on service.

Quinn says UCSF hospitalists have improved at knocking and asking permission to enter patient rooms, introducing themselves by name and role, and encouraging questions at the end of the interaction. They have been less successful at inquiring about the patient’s concerns early in the interview and at discussing duration of treatment and next steps.

“We learned that it takes more than just talk,” Quinn says. “Just telling physicians how to improve communication doesn’t mean it’s easy to do.”

Still to be determined is the project’s impact on patient satisfaction scores, although the hospitalists reported that they found the training and feedback helpful.

References

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

In a poster presented at HM12, Kathryn Quinn, MPH, CPPS, FACHE, described how her quality team at the University of California at San Francisco (UCSF) developed a checklist to improve physician communication with patients, then taught it to the attending hospitalist faculty.¹ The project began with a list of 29 best practices for patient-physician interaction, as identified in medical literature. Hospitalists then voted for the elements they felt were most important to their practice, as well as those best able to be measured, and a top-10 list was created.

Quinn, the program manager for quality and safety in the division of hospital medicine at UCSF, says the communication best practices were “chosen by the people whose practices we are trying to change.”

The quality team presented the best practices in one-hour training sessions that included small-group role plays, explains co-investigator and UCSF hospitalist Diane Sliwka, MD. The training extended to outpatient physicians, medical specialists, and chief residents. Participants also were provided a laminated pocket card listing the interventions. They also received feedback from structured observations with patients on service.

Quinn says UCSF hospitalists have improved at knocking and asking permission to enter patient rooms, introducing themselves by name and role, and encouraging questions at the end of the interaction. They have been less successful at inquiring about the patient’s concerns early in the interview and at discussing duration of treatment and next steps.

“We learned that it takes more than just talk,” Quinn says. “Just telling physicians how to improve communication doesn’t mean it’s easy to do.”

Still to be determined is the project’s impact on patient satisfaction scores, although the hospitalists reported that they found the training and feedback helpful.

References

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

From informal polls I’ve recently conducted of hospitalists, many are not even aware they are part of an accountable-care organization (ACO). And if they are aware, they might not be engaging in meaningful dialogue with ACO leaders about their role in these organizations. But, in the long term, ACOs will need to bring hospitalists to the table in order to be successful.

Are You Part of an ACO?

David Muhlestein, who blogs for Health Affairs, tracks the growth of ACOs around the country. He states that, as of Jan. 31, there were 428 ACOs in the U.S. (see Figure 1).¹ In terms of numbers, Florida, Texas, and California lead the nation with 42, 33, and 46 ACOs, respectively. So it is likely that you are part of an ACO. If you are unsure, ask your chief medical officer or president of the medical staff.

How ACOs Work

All ACOs seek to manage a group, or population, of patients as efficiently as possible while maintaining or improving quality of care. For Medicare ACOs, the goal is to bring together hospitals and physicians in order to share savings derived from efficiencies in care. But before any savings can be shared, the Medicare ACO must demonstrate that it achieved high-quality care across four domains, totaling 33 individual quality measures. (see Table 1)

Main Flavors of ACOs

There are two types of ACOs: private ACOs and Medicare ACOs. Prior to Medicare ACOs, which were launched in January 2012, there were 150 private-sector ACOs, and this number continues to grow. Private ACOs represent a heterogeneous group in terms of reimbursement model. Some operate under shared savings programs; others use full or partial capitation, bundled payments, and/or other types of arrangements. But nearly all ACOs operate under the premise that the incentives used to make care more efficient and less costly can only be applied if measurable quality is maintained or improved. ACOs do not pay doctors or hospitals more unless high quality is demonstrated.

ACO Quality Measures and Hospitalists

Most of the 33 quality measures required by Medicare ACOs are based in ambulatory practice. These include measures related to blood pressure, immunizations, cancer, and fall-risk screening, and measures for diabetics, such as lipids and hemoglobin A1C. However, there are a few measures for which hospitalists should share in accountability, including:

• All-cause hospital readmission rate—risk-standardized;
• Ambulatory sensitive condition hospital admission rates (CHF, COPD); and
• Medication reconciliation after discharge from an inpatient facility.

Four Key Actions for Hospitalists

Hospitalists make a significant contribution to the quality and the financial performance of ACOs. In addition to the quality metrics cited above, hospitalists impact the inpatient portion of the overall population’s cost of care. Furthermore, hospitalists are vital partners in the care coordination required for an ACO to be successful.

Here are four actions I suggest taking in order for your hospitalist group to be effective as participants in an ACO:

1. Have a representative from your group participate in ACO committees that address hospital utilization and related matters, such as care coordination impacting pre- and post-hospital care.
2. Learn how to work with ACO case managers on care transitions, including post-discharge follow-up and information transfer.
3. Understand an ACO’s approach to engagement of and coordination with post-acute-care facilities. The ability of a post-acute facility, such a skilled nursing facility, to accept patients who have complex care needs, to manage changes in condition in the facility when appropriate, and to send complete information upon transfer to the hospital are important strategies for an ACO’s success.
4. Understand how an ACO reports quality and cost performance and how savings will be shared among participants.

Mindset Change

If hospitalists are part of the chain of ACO physicians and providers held accountable for the health of a population of patients, we must work more closely with the medical home/neighborhood, post-acute-care facilities, and home-care providers. The change in mindset will occur only if we have a set of tools to get the job done, such as case managers and information technology, and the appropriate incentives to support better care coordination. I encourage my fellow hospitalists to make things happen, instead of taking a passive role in this monumental transformation.

Reference

1. Muhlestein D. Continued growth of public and private accountable care organizations. Health Affairs website. Available at: http://healthaffairs.org/blog/2013/02/19/continued-growth-of-public-and-private-accountable-care-organizations. Accessed March 16, 2013.

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

From informal polls I’ve recently conducted of hospitalists, many are not even aware they are part of an accountable-care organization (ACO). And if they are aware, they might not be engaging in meaningful dialogue with ACO leaders about their role in these organizations. But, in the long term, ACOs will need to bring hospitalists to the table in order to be successful.

Are You Part of an ACO?

David Muhlestein, who blogs for Health Affairs, tracks the growth of ACOs around the country. He states that, as of Jan. 31, there were 428 ACOs in the U.S. (see Figure 1).¹ In terms of numbers, Florida, Texas, and California lead the nation with 42, 33, and 46 ACOs, respectively. So it is likely that you are part of an ACO. If you are unsure, ask your chief medical officer or president of the medical staff.

How ACOs Work

All ACOs seek to manage a group, or population, of patients as efficiently as possible while maintaining or improving quality of care. For Medicare ACOs, the goal is to bring together hospitals and physicians in order to share savings derived from efficiencies in care. But before any savings can be shared, the Medicare ACO must demonstrate that it achieved high-quality care across four domains, totaling 33 individual quality measures. (see Table 1)

Main Flavors of ACOs

There are two types of ACOs: private ACOs and Medicare ACOs. Prior to Medicare ACOs, which were launched in January 2012, there were 150 private-sector ACOs, and this number continues to grow. Private ACOs represent a heterogeneous group in terms of reimbursement model. Some operate under shared savings programs; others use full or partial capitation, bundled payments, and/or other types of arrangements. But nearly all ACOs operate under the premise that the incentives used to make care more efficient and less costly can only be applied if measurable quality is maintained or improved. ACOs do not pay doctors or hospitals more unless high quality is demonstrated.

ACO Quality Measures and Hospitalists

Most of the 33 quality measures required by Medicare ACOs are based in ambulatory practice. These include measures related to blood pressure, immunizations, cancer, and fall-risk screening, and measures for diabetics, such as lipids and hemoglobin A1C. However, there are a few measures for which hospitalists should share in accountability, including:

• All-cause hospital readmission rate—risk-standardized;
• Ambulatory sensitive condition hospital admission rates (CHF, COPD); and
• Medication reconciliation after discharge from an inpatient facility.

Four Key Actions for Hospitalists

Hospitalists make a significant contribution to the quality and the financial performance of ACOs. In addition to the quality metrics cited above, hospitalists impact the inpatient portion of the overall population’s cost of care. Furthermore, hospitalists are vital partners in the care coordination required for an ACO to be successful.

Here are four actions I suggest taking in order for your hospitalist group to be effective as participants in an ACO:

1. Have a representative from your group participate in ACO committees that address hospital utilization and related matters, such as care coordination impacting pre- and post-hospital care.
2. Learn how to work with ACO case managers on care transitions, including post-discharge follow-up and information transfer.
3. Understand an ACO’s approach to engagement of and coordination with post-acute-care facilities. The ability of a post-acute facility, such a skilled nursing facility, to accept patients who have complex care needs, to manage changes in condition in the facility when appropriate, and to send complete information upon transfer to the hospital are important strategies for an ACO’s success.
4. Understand how an ACO reports quality and cost performance and how savings will be shared among participants.

Mindset Change

If hospitalists are part of the chain of ACO physicians and providers held accountable for the health of a population of patients, we must work more closely with the medical home/neighborhood, post-acute-care facilities, and home-care providers. The change in mindset will occur only if we have a set of tools to get the job done, such as case managers and information technology, and the appropriate incentives to support better care coordination. I encourage my fellow hospitalists to make things happen, instead of taking a passive role in this monumental transformation.

Reference

1. Muhlestein D. Continued growth of public and private accountable care organizations. Health Affairs website. Available at: http://healthaffairs.org/blog/2013/02/19/continued-growth-of-public-and-private-accountable-care-organizations. Accessed March 16, 2013.

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

From informal polls I’ve recently conducted of hospitalists, many are not even aware they are part of an accountable-care organization (ACO). And if they are aware, they might not be engaging in meaningful dialogue with ACO leaders about their role in these organizations. But, in the long term, ACOs will need to bring hospitalists to the table in order to be successful.

Are You Part of an ACO?

David Muhlestein, who blogs for Health Affairs, tracks the growth of ACOs around the country. He states that, as of Jan. 31, there were 428 ACOs in the U.S. (see Figure 1).¹ In terms of numbers, Florida, Texas, and California lead the nation with 42, 33, and 46 ACOs, respectively. So it is likely that you are part of an ACO. If you are unsure, ask your chief medical officer or president of the medical staff.

How ACOs Work

All ACOs seek to manage a group, or population, of patients as efficiently as possible while maintaining or improving quality of care. For Medicare ACOs, the goal is to bring together hospitals and physicians in order to share savings derived from efficiencies in care. But before any savings can be shared, the Medicare ACO must demonstrate that it achieved high-quality care across four domains, totaling 33 individual quality measures. (see Table 1)

Main Flavors of ACOs

There are two types of ACOs: private ACOs and Medicare ACOs. Prior to Medicare ACOs, which were launched in January 2012, there were 150 private-sector ACOs, and this number continues to grow. Private ACOs represent a heterogeneous group in terms of reimbursement model. Some operate under shared savings programs; others use full or partial capitation, bundled payments, and/or other types of arrangements. But nearly all ACOs operate under the premise that the incentives used to make care more efficient and less costly can only be applied if measurable quality is maintained or improved. ACOs do not pay doctors or hospitals more unless high quality is demonstrated.

ACO Quality Measures and Hospitalists

Most of the 33 quality measures required by Medicare ACOs are based in ambulatory practice. These include measures related to blood pressure, immunizations, cancer, and fall-risk screening, and measures for diabetics, such as lipids and hemoglobin A1C. However, there are a few measures for which hospitalists should share in accountability, including:

• All-cause hospital readmission rate—risk-standardized;
• Ambulatory sensitive condition hospital admission rates (CHF, COPD); and
• Medication reconciliation after discharge from an inpatient facility.

Four Key Actions for Hospitalists

Hospitalists make a significant contribution to the quality and the financial performance of ACOs. In addition to the quality metrics cited above, hospitalists impact the inpatient portion of the overall population’s cost of care. Furthermore, hospitalists are vital partners in the care coordination required for an ACO to be successful.

Here are four actions I suggest taking in order for your hospitalist group to be effective as participants in an ACO:

1. Have a representative from your group participate in ACO committees that address hospital utilization and related matters, such as care coordination impacting pre- and post-hospital care.
2. Learn how to work with ACO case managers on care transitions, including post-discharge follow-up and information transfer.
3. Understand an ACO’s approach to engagement of and coordination with post-acute-care facilities. The ability of a post-acute facility, such a skilled nursing facility, to accept patients who have complex care needs, to manage changes in condition in the facility when appropriate, and to send complete information upon transfer to the hospital are important strategies for an ACO’s success.
4. Understand how an ACO reports quality and cost performance and how savings will be shared among participants.

Mindset Change

If hospitalists are part of the chain of ACO physicians and providers held accountable for the health of a population of patients, we must work more closely with the medical home/neighborhood, post-acute-care facilities, and home-care providers. The change in mindset will occur only if we have a set of tools to get the job done, such as case managers and information technology, and the appropriate incentives to support better care coordination. I encourage my fellow hospitalists to make things happen, instead of taking a passive role in this monumental transformation.

Reference

1. Muhlestein D. Continued growth of public and private accountable care organizations. Health Affairs website. Available at: http://healthaffairs.org/blog/2013/02/19/continued-growth-of-public-and-private-accountable-care-organizations. Accessed March 16, 2013.

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

Johnbuck Creamer, MD

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

Johnbuck Creamer, MD

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

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

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

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

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

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

References

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

Johnbuck Creamer, MD

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

Johnbuck Creamer, MD

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

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

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

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

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

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

References

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

Johnbuck Creamer, MD

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

Johnbuck Creamer, MD

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

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

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

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

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

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

References

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Other Workload Data

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

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

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

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

Perspective

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

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

What Can Be Done?

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

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

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

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

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

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

Reference

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

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

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

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

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

Other Workload Data

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

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

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

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

Perspective

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

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

What Can Be Done?

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

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

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

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

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

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

Reference

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

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

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

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

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

Other Workload Data

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

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

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

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

Perspective

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

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

What Can Be Done?

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

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

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

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

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

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

Reference

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

Dr. Wachter

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

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

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

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

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

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

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

Q: What’s the most realistic interpretation?

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

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

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

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

Richard Quinn is a freelance writer in New Jersey.

Dr. Wachter

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

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

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

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

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

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

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

Q: What’s the most realistic interpretation?

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

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

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

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

Richard Quinn is a freelance writer in New Jersey.

Dr. Wachter

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

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

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

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

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

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

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

Q: What’s the most realistic interpretation?

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

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

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

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

Richard Quinn is a freelance writer in New Jersey.