Practice Management

HCAHPS is a national, standardized survey of hospital patients created to publicly report patients’ perspective of hospital care. The survey asks a random sample of recently discharged patients about important aspects of their hospital experience. The HCAHPS results posted on Medicare’s Hospital Compare website (www.hospitalcompare.hhs.gov) allow consumers to make fair and objective comparisons of hospitals and individual hospitals to state and national benchmarks.

Contributed by HMX user Dr. Patrick Torcson, MD, MMM, FACP, SFHM, chair of SHM’s Performance and Standards Committee.

HCAHPS is a national, standardized survey of hospital patients created to publicly report patients’ perspective of hospital care. The survey asks a random sample of recently discharged patients about important aspects of their hospital experience. The HCAHPS results posted on Medicare’s Hospital Compare website (www.hospitalcompare.hhs.gov) allow consumers to make fair and objective comparisons of hospitals and individual hospitals to state and national benchmarks.

Contributed by HMX user Dr. Patrick Torcson, MD, MMM, FACP, SFHM, chair of SHM’s Performance and Standards Committee.

HCAHPS is a national, standardized survey of hospital patients created to publicly report patients’ perspective of hospital care. The survey asks a random sample of recently discharged patients about important aspects of their hospital experience. The HCAHPS results posted on Medicare’s Hospital Compare website (www.hospitalcompare.hhs.gov) allow consumers to make fair and objective comparisons of hospitals and individual hospitals to state and national benchmarks.

Contributed by HMX user Dr. Patrick Torcson, MD, MMM, FACP, SFHM, chair of SHM’s Performance and Standards Committee.

On Nov. 1, 2012, the Centers for Medicare & Medicaid Services (CMS) released the final regulation implementing increased Medicaid payments for specified primary-care services to 100% of Medicare levels in 2013 and 2014.

Covered Medicaid services include evaluation and management codes between 99201 and 99499 when used by physicians with a specialty designation of family medicine, general internal medicine, or pediatric medicine. CMS also finalized a policy to qualify services provided by subspecialists related to the designated primary-care specialists board-certified by the American Board of Medical Specialties, American Osteopathic Association, and the American Board of Physician Specialties. Advanced-practice clinicians also qualify for the increased payment when services are furnished under a physician’s personal supervision.

In commenting on the proposed rule, SHM stated that hospitalists should qualify for purposes of the increased payment because they are an important part of the “team” of clinicians required to treat many common conditions within the Medicaid population, and that hospitalists often provide the first contact and facilitate an entry point into the comprehensive care network.

CMS agreed.

The codes included in the pay increase will be limited to traditional primary care but also will include hospital observation and consultation for inpatient services provided by nonadmitting physicians, ED services, and critical-care services.

Hospitalists will qualify for the enhanced payment, but it remains somewhat unclear how individual states will handle the increase. State Medicaid agencies could pay physicians based on their self-attestation alone or in conjunction with any other provider enrollment requirements that currently exist in the state. Further, inclusion of a code does not require a state to pay for the service if it is not already covered under the state’s Medicaid program. All other state coverage and payment policy rules related to the services also remain in effect.

Timing of the pay increase also remains unclear. The statute requires that states make higher payments for services provided on or after Jan. 1, 2013, but for many physicians, the higher payment might be longer in coming despite being retroactive to the January deadline. States must submit a State Plan Amendment (SPA) to reflect the fee schedule rate increases by March 31, 2013, and CMS may then take up to 90 days to review and approve the SPA. Therefore, it could be six months or longer before eligible physicians and practitioners receive any of the payment increase.

States will receive an estimated $5.8 billion in 2013 and $6.1 billion in 2014 in federal funds to meet this two-year requirement, unless Congress acts to extend or fund the provision permanently. In response to an SHM suggestion on the potential to extend the increase, CMS will be collecting relevant data on the impact of the pay increase on Medicaid patients.

Even with the remaining uncertainty and timing issues, this is a change in payment policy that presents an important shift in the valuation of primary-care services, including some services provided by hospitalists. Medicaid services are notoriously undervalued, and this increase to providers will certainly have a positive impact on the accessibility of care for patients.

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

On Nov. 1, 2012, the Centers for Medicare & Medicaid Services (CMS) released the final regulation implementing increased Medicaid payments for specified primary-care services to 100% of Medicare levels in 2013 and 2014.

Covered Medicaid services include evaluation and management codes between 99201 and 99499 when used by physicians with a specialty designation of family medicine, general internal medicine, or pediatric medicine. CMS also finalized a policy to qualify services provided by subspecialists related to the designated primary-care specialists board-certified by the American Board of Medical Specialties, American Osteopathic Association, and the American Board of Physician Specialties. Advanced-practice clinicians also qualify for the increased payment when services are furnished under a physician’s personal supervision.

In commenting on the proposed rule, SHM stated that hospitalists should qualify for purposes of the increased payment because they are an important part of the “team” of clinicians required to treat many common conditions within the Medicaid population, and that hospitalists often provide the first contact and facilitate an entry point into the comprehensive care network.

CMS agreed.

The codes included in the pay increase will be limited to traditional primary care but also will include hospital observation and consultation for inpatient services provided by nonadmitting physicians, ED services, and critical-care services.

Hospitalists will qualify for the enhanced payment, but it remains somewhat unclear how individual states will handle the increase. State Medicaid agencies could pay physicians based on their self-attestation alone or in conjunction with any other provider enrollment requirements that currently exist in the state. Further, inclusion of a code does not require a state to pay for the service if it is not already covered under the state’s Medicaid program. All other state coverage and payment policy rules related to the services also remain in effect.

Timing of the pay increase also remains unclear. The statute requires that states make higher payments for services provided on or after Jan. 1, 2013, but for many physicians, the higher payment might be longer in coming despite being retroactive to the January deadline. States must submit a State Plan Amendment (SPA) to reflect the fee schedule rate increases by March 31, 2013, and CMS may then take up to 90 days to review and approve the SPA. Therefore, it could be six months or longer before eligible physicians and practitioners receive any of the payment increase.

States will receive an estimated $5.8 billion in 2013 and $6.1 billion in 2014 in federal funds to meet this two-year requirement, unless Congress acts to extend or fund the provision permanently. In response to an SHM suggestion on the potential to extend the increase, CMS will be collecting relevant data on the impact of the pay increase on Medicaid patients.

Even with the remaining uncertainty and timing issues, this is a change in payment policy that presents an important shift in the valuation of primary-care services, including some services provided by hospitalists. Medicaid services are notoriously undervalued, and this increase to providers will certainly have a positive impact on the accessibility of care for patients.

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

On Nov. 1, 2012, the Centers for Medicare & Medicaid Services (CMS) released the final regulation implementing increased Medicaid payments for specified primary-care services to 100% of Medicare levels in 2013 and 2014.

Covered Medicaid services include evaluation and management codes between 99201 and 99499 when used by physicians with a specialty designation of family medicine, general internal medicine, or pediatric medicine. CMS also finalized a policy to qualify services provided by subspecialists related to the designated primary-care specialists board-certified by the American Board of Medical Specialties, American Osteopathic Association, and the American Board of Physician Specialties. Advanced-practice clinicians also qualify for the increased payment when services are furnished under a physician’s personal supervision.

In commenting on the proposed rule, SHM stated that hospitalists should qualify for purposes of the increased payment because they are an important part of the “team” of clinicians required to treat many common conditions within the Medicaid population, and that hospitalists often provide the first contact and facilitate an entry point into the comprehensive care network.

CMS agreed.

The codes included in the pay increase will be limited to traditional primary care but also will include hospital observation and consultation for inpatient services provided by nonadmitting physicians, ED services, and critical-care services.

Hospitalists will qualify for the enhanced payment, but it remains somewhat unclear how individual states will handle the increase. State Medicaid agencies could pay physicians based on their self-attestation alone or in conjunction with any other provider enrollment requirements that currently exist in the state. Further, inclusion of a code does not require a state to pay for the service if it is not already covered under the state’s Medicaid program. All other state coverage and payment policy rules related to the services also remain in effect.

Timing of the pay increase also remains unclear. The statute requires that states make higher payments for services provided on or after Jan. 1, 2013, but for many physicians, the higher payment might be longer in coming despite being retroactive to the January deadline. States must submit a State Plan Amendment (SPA) to reflect the fee schedule rate increases by March 31, 2013, and CMS may then take up to 90 days to review and approve the SPA. Therefore, it could be six months or longer before eligible physicians and practitioners receive any of the payment increase.

States will receive an estimated $5.8 billion in 2013 and $6.1 billion in 2014 in federal funds to meet this two-year requirement, unless Congress acts to extend or fund the provision permanently. In response to an SHM suggestion on the potential to extend the increase, CMS will be collecting relevant data on the impact of the pay increase on Medicaid patients.

Even with the remaining uncertainty and timing issues, this is a change in payment policy that presents an important shift in the valuation of primary-care services, including some services provided by hospitalists. Medicaid services are notoriously undervalued, and this increase to providers will certainly have a positive impact on the accessibility of care for patients.

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

John Nelson, MD, MHM

Ben was just accepted to med school!!! Hopefully, more acceptances will be forthcoming. We are very proud of Ben for all his hard work. Another doctor in the family.

I was delighted to find the above message from an old friend in my inbox. It got me thinking: Will Ben become a hospitalist? Will he join his dad’s hospitalist group? Will his dad encourage him to pursue a hospitalist career or something else?

Early Hospitalist Practice

The author of that email was Ben’s dad, Chuck Wilson. Chuck is the reason I’m a hospitalist. He was a year ahead of me in residency, and while still a resident, he somehow connected with a really busy family physician in town who was looking for someone to manage his hospital patients. Not one to be bound by convention, Chuck agreed to what was at the time a nearly unheard-of arrangement. He finished residency, joined the staff of the community hospital across town from our residency, and began caring for the family physician’s hospital patients. Within days, he was fielding calls from other doctors asking him to do the same for them. Within weeks of arriving, he had begun accepting essentially all unassigned medical admissions from the ED. This was in the 1980s; Chuck was among the nation’s first real hospitalists.

I don’t think Chuck spent any time worrying about how his practice was so different from the traditional internists and family physicians in the community. He was confident he was providing a valuable service to his patients and the medical community. The rapid growth in his patient census was an indicator he was on to something, and soon he and I began talking. He was looking for a partner.

In November of my third year of residency, I decided I would put off my endocrinology fellowship for a year or two and join Chuck in his new practice. From our conversations, I anticipated that I would care for exactly the kinds of patients that filled nearly all of my time as a resident. I wouldn’t need to learn the new skills in ambulatory medicine, and wouldn’t need to make the long-term commitment expected to join a traditional primary-care practice. And I would earn a competitive compensation and have a flexible lifestyle. I soon realized that hospitalist practice provided me with all of these advantages, so more than two decades later, I still haven’t gotten around to completing the application for an endocrine fellowship.

A Loose Arrangement

For the first few years, Chuck and I didn’t bother to have any sort of legal agreement with each other. We shook hands and agreed to a “reap what you till” form of compensation, which meant we didn’t have to work exactly the same amount, and never had disagreements about how practice revenue was divided between us.

Because of Chuck’s influence, we had miniscule overhead expenses, most likely less than 10% of revenue. We each bought our own malpractice insurance, paid our biller a percent of collections, and rented a pager. That was about it for overhead.

We had no rigid scheduling algorithm, the only requirement being that at least one of us needed to be working every day. Both of us worked most weekdays, but we took time off whenever it suited us. Our scheduling meetings were usually held when we bumped into one another while rounding and went something like this:

“You OK if I take five days off starting tomorrow?”

“Sure. That’s fine.”

Meeting adjourned.

For years, we had no official name for our practice. This became a bigger issue when our group had grown to four doctors, so we defaulted to referring to the group by the first letter of the last name of each doctor, in order of tenure: The WNKL Group. A more formal name was to follow a few years later when the group was even larger, but I’ve taken delight in hearing that WNKL has persisted in some places and documents around the hospital years later, even though N, K, and L left the group long ago.

In the first few years, we never thought about developing clinical protocols or measuring our efficiency or clinical effectiveness. Chuck was confident that compared to the traditional primary-care model, we were providing higher-quality care at a lower cost. But I wasn’t so sure. After a few years, we began seeing hospital data showing that our cost per case tended to be lower, and what little data we could get regarding our quality of care suggested that it was about the same, and in some cases might be better.

A principal reason the practice has survived more than 25 years is that other than a small “tax” during their first 18 months (mainly to cover the cost of recruiting them), new doctors were regarded as equals in the business. Chuck and subsequent doctors never tried to gain an advantage over newer doctors by trying to claim a greater share of the practice’s revenue or decision-making authority.

Chuck is still in the same group he founded. In 2000, I was lured away by the chance to start a new group and live in a place that both my wife and I love. He and I have enjoyed watching our field grow up, and we take satisfaction in our roles in its evolution.

Lessons Learned

The hospitalist model of practice didn’t have a single inventor or place of origin, and anyone involved in starting a practice in the 1980s or before should be proud to have invented their practice when no blueprint existed. Creative thinking and openness to a new way of doing things were critical in developing the first hospitalist practices. They also are useful traits in trying to improve modern hospitalist practices or other segments of our healthcare system.

Like many new developments in medicine, the economic effects of our practice—lower hospital cost per case—became apparent, especially to Chuck, before data regarding quality surfaced. I wish we had gotten more serious early on about capturing whatever quality data might have been available—clearly less than what is available today—and those in new healthcare endeavors today should try to measure quality at the outset. Unlike the 1980s, the current marketplace will help ensure that happens.

Coda

There is one other really cool thing about Chuck’s email at the beginning of this column: those three exclamation points! Chuck is typically laconic and understated, and not given to such displays of emotion, but there are few things that generate more enthusiasm than a parent sharing news of a child’s success.

So, Ben, as you start med school next year, I wish you the best. You can be sure I’ll be asking for updates about your progress. The most important thing is that you find a life and career that engages you to do good work for others and provides satisfaction. And whatever you choose to do after med school, I know you’ll continue to make your parents proud.

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 course co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

John Nelson, MD, MHM

Ben was just accepted to med school!!! Hopefully, more acceptances will be forthcoming. We are very proud of Ben for all his hard work. Another doctor in the family.

I was delighted to find the above message from an old friend in my inbox. It got me thinking: Will Ben become a hospitalist? Will he join his dad’s hospitalist group? Will his dad encourage him to pursue a hospitalist career or something else?

Early Hospitalist Practice

The author of that email was Ben’s dad, Chuck Wilson. Chuck is the reason I’m a hospitalist. He was a year ahead of me in residency, and while still a resident, he somehow connected with a really busy family physician in town who was looking for someone to manage his hospital patients. Not one to be bound by convention, Chuck agreed to what was at the time a nearly unheard-of arrangement. He finished residency, joined the staff of the community hospital across town from our residency, and began caring for the family physician’s hospital patients. Within days, he was fielding calls from other doctors asking him to do the same for them. Within weeks of arriving, he had begun accepting essentially all unassigned medical admissions from the ED. This was in the 1980s; Chuck was among the nation’s first real hospitalists.

I don’t think Chuck spent any time worrying about how his practice was so different from the traditional internists and family physicians in the community. He was confident he was providing a valuable service to his patients and the medical community. The rapid growth in his patient census was an indicator he was on to something, and soon he and I began talking. He was looking for a partner.

In November of my third year of residency, I decided I would put off my endocrinology fellowship for a year or two and join Chuck in his new practice. From our conversations, I anticipated that I would care for exactly the kinds of patients that filled nearly all of my time as a resident. I wouldn’t need to learn the new skills in ambulatory medicine, and wouldn’t need to make the long-term commitment expected to join a traditional primary-care practice. And I would earn a competitive compensation and have a flexible lifestyle. I soon realized that hospitalist practice provided me with all of these advantages, so more than two decades later, I still haven’t gotten around to completing the application for an endocrine fellowship.

A Loose Arrangement

For the first few years, Chuck and I didn’t bother to have any sort of legal agreement with each other. We shook hands and agreed to a “reap what you till” form of compensation, which meant we didn’t have to work exactly the same amount, and never had disagreements about how practice revenue was divided between us.

Because of Chuck’s influence, we had miniscule overhead expenses, most likely less than 10% of revenue. We each bought our own malpractice insurance, paid our biller a percent of collections, and rented a pager. That was about it for overhead.

We had no rigid scheduling algorithm, the only requirement being that at least one of us needed to be working every day. Both of us worked most weekdays, but we took time off whenever it suited us. Our scheduling meetings were usually held when we bumped into one another while rounding and went something like this:

“You OK if I take five days off starting tomorrow?”

“Sure. That’s fine.”

Meeting adjourned.

For years, we had no official name for our practice. This became a bigger issue when our group had grown to four doctors, so we defaulted to referring to the group by the first letter of the last name of each doctor, in order of tenure: The WNKL Group. A more formal name was to follow a few years later when the group was even larger, but I’ve taken delight in hearing that WNKL has persisted in some places and documents around the hospital years later, even though N, K, and L left the group long ago.

In the first few years, we never thought about developing clinical protocols or measuring our efficiency or clinical effectiveness. Chuck was confident that compared to the traditional primary-care model, we were providing higher-quality care at a lower cost. But I wasn’t so sure. After a few years, we began seeing hospital data showing that our cost per case tended to be lower, and what little data we could get regarding our quality of care suggested that it was about the same, and in some cases might be better.

A principal reason the practice has survived more than 25 years is that other than a small “tax” during their first 18 months (mainly to cover the cost of recruiting them), new doctors were regarded as equals in the business. Chuck and subsequent doctors never tried to gain an advantage over newer doctors by trying to claim a greater share of the practice’s revenue or decision-making authority.

Chuck is still in the same group he founded. In 2000, I was lured away by the chance to start a new group and live in a place that both my wife and I love. He and I have enjoyed watching our field grow up, and we take satisfaction in our roles in its evolution.

Lessons Learned

The hospitalist model of practice didn’t have a single inventor or place of origin, and anyone involved in starting a practice in the 1980s or before should be proud to have invented their practice when no blueprint existed. Creative thinking and openness to a new way of doing things were critical in developing the first hospitalist practices. They also are useful traits in trying to improve modern hospitalist practices or other segments of our healthcare system.

Like many new developments in medicine, the economic effects of our practice—lower hospital cost per case—became apparent, especially to Chuck, before data regarding quality surfaced. I wish we had gotten more serious early on about capturing whatever quality data might have been available—clearly less than what is available today—and those in new healthcare endeavors today should try to measure quality at the outset. Unlike the 1980s, the current marketplace will help ensure that happens.

Coda

There is one other really cool thing about Chuck’s email at the beginning of this column: those three exclamation points! Chuck is typically laconic and understated, and not given to such displays of emotion, but there are few things that generate more enthusiasm than a parent sharing news of a child’s success.

So, Ben, as you start med school next year, I wish you the best. You can be sure I’ll be asking for updates about your progress. The most important thing is that you find a life and career that engages you to do good work for others and provides satisfaction. And whatever you choose to do after med school, I know you’ll continue to make your parents proud.

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 course co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

John Nelson, MD, MHM

Ben was just accepted to med school!!! Hopefully, more acceptances will be forthcoming. We are very proud of Ben for all his hard work. Another doctor in the family.

I was delighted to find the above message from an old friend in my inbox. It got me thinking: Will Ben become a hospitalist? Will he join his dad’s hospitalist group? Will his dad encourage him to pursue a hospitalist career or something else?

Early Hospitalist Practice

The author of that email was Ben’s dad, Chuck Wilson. Chuck is the reason I’m a hospitalist. He was a year ahead of me in residency, and while still a resident, he somehow connected with a really busy family physician in town who was looking for someone to manage his hospital patients. Not one to be bound by convention, Chuck agreed to what was at the time a nearly unheard-of arrangement. He finished residency, joined the staff of the community hospital across town from our residency, and began caring for the family physician’s hospital patients. Within days, he was fielding calls from other doctors asking him to do the same for them. Within weeks of arriving, he had begun accepting essentially all unassigned medical admissions from the ED. This was in the 1980s; Chuck was among the nation’s first real hospitalists.

I don’t think Chuck spent any time worrying about how his practice was so different from the traditional internists and family physicians in the community. He was confident he was providing a valuable service to his patients and the medical community. The rapid growth in his patient census was an indicator he was on to something, and soon he and I began talking. He was looking for a partner.

In November of my third year of residency, I decided I would put off my endocrinology fellowship for a year or two and join Chuck in his new practice. From our conversations, I anticipated that I would care for exactly the kinds of patients that filled nearly all of my time as a resident. I wouldn’t need to learn the new skills in ambulatory medicine, and wouldn’t need to make the long-term commitment expected to join a traditional primary-care practice. And I would earn a competitive compensation and have a flexible lifestyle. I soon realized that hospitalist practice provided me with all of these advantages, so more than two decades later, I still haven’t gotten around to completing the application for an endocrine fellowship.

A Loose Arrangement

For the first few years, Chuck and I didn’t bother to have any sort of legal agreement with each other. We shook hands and agreed to a “reap what you till” form of compensation, which meant we didn’t have to work exactly the same amount, and never had disagreements about how practice revenue was divided between us.

Because of Chuck’s influence, we had miniscule overhead expenses, most likely less than 10% of revenue. We each bought our own malpractice insurance, paid our biller a percent of collections, and rented a pager. That was about it for overhead.

We had no rigid scheduling algorithm, the only requirement being that at least one of us needed to be working every day. Both of us worked most weekdays, but we took time off whenever it suited us. Our scheduling meetings were usually held when we bumped into one another while rounding and went something like this:

“You OK if I take five days off starting tomorrow?”

“Sure. That’s fine.”

Meeting adjourned.

For years, we had no official name for our practice. This became a bigger issue when our group had grown to four doctors, so we defaulted to referring to the group by the first letter of the last name of each doctor, in order of tenure: The WNKL Group. A more formal name was to follow a few years later when the group was even larger, but I’ve taken delight in hearing that WNKL has persisted in some places and documents around the hospital years later, even though N, K, and L left the group long ago.

In the first few years, we never thought about developing clinical protocols or measuring our efficiency or clinical effectiveness. Chuck was confident that compared to the traditional primary-care model, we were providing higher-quality care at a lower cost. But I wasn’t so sure. After a few years, we began seeing hospital data showing that our cost per case tended to be lower, and what little data we could get regarding our quality of care suggested that it was about the same, and in some cases might be better.

A principal reason the practice has survived more than 25 years is that other than a small “tax” during their first 18 months (mainly to cover the cost of recruiting them), new doctors were regarded as equals in the business. Chuck and subsequent doctors never tried to gain an advantage over newer doctors by trying to claim a greater share of the practice’s revenue or decision-making authority.

Chuck is still in the same group he founded. In 2000, I was lured away by the chance to start a new group and live in a place that both my wife and I love. He and I have enjoyed watching our field grow up, and we take satisfaction in our roles in its evolution.

Lessons Learned

The hospitalist model of practice didn’t have a single inventor or place of origin, and anyone involved in starting a practice in the 1980s or before should be proud to have invented their practice when no blueprint existed. Creative thinking and openness to a new way of doing things were critical in developing the first hospitalist practices. They also are useful traits in trying to improve modern hospitalist practices or other segments of our healthcare system.

Like many new developments in medicine, the economic effects of our practice—lower hospital cost per case—became apparent, especially to Chuck, before data regarding quality surfaced. I wish we had gotten more serious early on about capturing whatever quality data might have been available—clearly less than what is available today—and those in new healthcare endeavors today should try to measure quality at the outset. Unlike the 1980s, the current marketplace will help ensure that happens.

Coda

There is one other really cool thing about Chuck’s email at the beginning of this column: those three exclamation points! Chuck is typically laconic and understated, and not given to such displays of emotion, but there are few things that generate more enthusiasm than a parent sharing news of a child’s success.

So, Ben, as you start med school next year, I wish you the best. You can be sure I’ll be asking for updates about your progress. The most important thing is that you find a life and career that engages you to do good work for others and provides satisfaction. And whatever you choose to do after med school, I know you’ll continue to make your parents proud.

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 course co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

Patient Transfers

Hospitalist billing depends on several factors. Know your role and avoid common mistakes Patient transfers can occur for many reasons: advanced technological services required, health insurance coverage, or a change in the level of care, to name a few. Patient care that is provided in the acute-care setting does not always terminate with discharge to home. Frequently, hospitalists are involved in patient transfers to another location to receive additional services: intrafacility (a different unit or related facility within the same physical plant) or interfacility (geographically separate facilities). The hospitalist must identify his or her role in the transfer and the patient’s new environment.

Physician billing in the transferred setting depends upon several factors:¹

• Shared or merged medical record;
• The attending of record in each setting;
• The requirements for care rendered by the hospitalist in each setting; and
• Service dates.

Intrafacility Initial Service

Let’s examine a common example: A hospitalist serves as the “attending of record” in an inpatient hospital where acute care is required for an 83-year-old female with hypertension and diabetes who sustained a left hip fracture. The hospitalist plans to discharge the patient to the rehabilitation unit. After transfer, the rehabilitation physician becomes the attending of record, and the hospitalist might be asked to provide ongoing care for the patient’s hypertension and diabetes.

What should the hospitalist report for the initial post-transfer service? The typical options to consider are:²

• Inpatient consultation (99251-99255);
• Initial hospital care (99221-99223); and
• Subsequent hospital care (99231-99233).

Report a consultation only if the rehab attending requests an opinion or advice for an unrelated, new condition instead of previously treated conditions, and the requesting physician’s intent is for opinion or advice on management options rather than the a priori intent for the hospitalist to assume the patient’s medical care. If these requirements are met, the hospitalist may report an inpatient consultation code (99251-99255). Alternatively, if the intent or need represents a continuity of medical care provided during the acute episode of care, report the most appropriate subsequent hospital care code (99231-99233) for the hospitalist’s initial rehab visit and all follow-up services.

Initial hospital care (99221-99223) codes can only be reported for Medicare beneficiaries in place of consultation codes (99251-99255), as Medicare ceased to reimburse consultation codes.³ Most other payors who do not recognize consultation services only allow one initial hospital care code per hospitalization, reserved for the attending of record.

Interfacility Initial Service

Hospitalist groups provide patient care and coverage in many different types of facilities. Confusion often arises when the “attending of record” during acute care and the “subacute” setting (e.g. long-term acute-care hospital) are two different hospitalists from the same group practice. The hospitalist receiving the patient in the transfer facility may decide to report subsequent hospital care (99231-99233), because the group has been providing ongoing care to this patient. In this scenario, the hospitalist group could be losing revenue if an admission service (99221-99223) was not reported.

An initial hospital care service (99221-99223) is permitted when the transfer is between:

• Different hospitals;
• Different facilities under common ownership which do not have merged records; or
• Between the acute-care hospital and a PPS (prospective payment system)-exempt unit within the same hospital when there are no merged records (e.g. Medicare Part A-covered inpatient care in psychiatric, rehabilitation, critical access, and long-term care hospitals).⁴

In all other transfer circumstances not meeting the elements noted above, the physician should bill only the appropriate level of subsequent hospital care (99231-99233) for the date of transfer.¹ Do not equate “merged records” to commonly accessible charts via an electronic medical record system or an electronic storage system. If the medical record for the patient’s acute stay is “closed” and the patient is given a separate medical record and registration for the stay in the transferred facility, consider the transfer stay as a separate admission.

Billing Two Services on Day of Transfer

Whether the transfer is classified as intrafacility or interfacility, an individual hospitalist or two separate hospitalists from the same group practice may provide the acute-care discharge and the transfer admission. A hospital discharge day management service (99238-99239) and an initial hospital care service (99221-99223) can only be reported if they do not occur on the same day.¹ Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician; if more than one evaluation and management (face to face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported.⁵

The Exception

CMS will allow a single hospitalist or two hospitalists from the same group practice to report a discharge day management service on the same day as an admission service. When they are billed by the same physician or group with the same date of service, contractors are instructed to pay the hospital discharge day management code (99238-99239) in addition to a nursing facility admission code (99304-99306).⁶

Conversely, if the patient is admitted to a hospital (99221-99223) following a nursing facility discharge (99315-99316) on the same date by the same physician/group, insurers will only reimburse the initial hospital care code. Payment for the initial hospital care service includes all work performed by the physician/group in all sites of service on that date.

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

References available online at the-hospitalist.org

ICD-10 Update

On Sept. 5, 2012, the Centers for Medicare & Medicaid Services (CMS) published the final rule for Administration Simplification, which included a compliance date change for the International Classification of Diseases, 10th Edition (ICD-10-CM and ICD-10-PCS), Medical Data Code Sets:⁷

“According to a recent survey conducted by the CMS, up to one-quarter of healthcare providers believe they will not be ready for an October 1, 2013, compliance date. While the survey found no significant differences among practice settings regarding the likelihood of achieving compliance before the deadline, based on recent industry feedback we believe that larger healthcare plans and providers generally are more prepared than smaller entities. The uncertainty about provider readiness is confirmed in another recent readiness survey in which nearly 50 percent of the 2,140 provider respondents did not know when they would complete their impact assessment of the ICD-10 transition. By delaying the compliance date of ICD-10 from October 1, 2013, to October 1, 2014, we are allowing more time for covered entities to prepare for the transition to ICD-10 and to conduct thorough testing. By allowing more time to prepare, covered entities may be able to avoid costly obstacles that would otherwise emerge while in production.”⁷

Although providers have gained a year to adopt ICD-10, this should not deter progress toward the 2014 goal, with hopefulness that additional rulings will be made to further stall full implementation.

Patient Transfers

Hospitalist billing depends on several factors. Know your role and avoid common mistakes Patient transfers can occur for many reasons: advanced technological services required, health insurance coverage, or a change in the level of care, to name a few. Patient care that is provided in the acute-care setting does not always terminate with discharge to home. Frequently, hospitalists are involved in patient transfers to another location to receive additional services: intrafacility (a different unit or related facility within the same physical plant) or interfacility (geographically separate facilities). The hospitalist must identify his or her role in the transfer and the patient’s new environment.

Physician billing in the transferred setting depends upon several factors:¹

• Shared or merged medical record;
• The attending of record in each setting;
• The requirements for care rendered by the hospitalist in each setting; and
• Service dates.

Intrafacility Initial Service

Let’s examine a common example: A hospitalist serves as the “attending of record” in an inpatient hospital where acute care is required for an 83-year-old female with hypertension and diabetes who sustained a left hip fracture. The hospitalist plans to discharge the patient to the rehabilitation unit. After transfer, the rehabilitation physician becomes the attending of record, and the hospitalist might be asked to provide ongoing care for the patient’s hypertension and diabetes.

What should the hospitalist report for the initial post-transfer service? The typical options to consider are:²

• Inpatient consultation (99251-99255);
• Initial hospital care (99221-99223); and
• Subsequent hospital care (99231-99233).

Report a consultation only if the rehab attending requests an opinion or advice for an unrelated, new condition instead of previously treated conditions, and the requesting physician’s intent is for opinion or advice on management options rather than the a priori intent for the hospitalist to assume the patient’s medical care. If these requirements are met, the hospitalist may report an inpatient consultation code (99251-99255). Alternatively, if the intent or need represents a continuity of medical care provided during the acute episode of care, report the most appropriate subsequent hospital care code (99231-99233) for the hospitalist’s initial rehab visit and all follow-up services.

Initial hospital care (99221-99223) codes can only be reported for Medicare beneficiaries in place of consultation codes (99251-99255), as Medicare ceased to reimburse consultation codes.³ Most other payors who do not recognize consultation services only allow one initial hospital care code per hospitalization, reserved for the attending of record.

Interfacility Initial Service

Hospitalist groups provide patient care and coverage in many different types of facilities. Confusion often arises when the “attending of record” during acute care and the “subacute” setting (e.g. long-term acute-care hospital) are two different hospitalists from the same group practice. The hospitalist receiving the patient in the transfer facility may decide to report subsequent hospital care (99231-99233), because the group has been providing ongoing care to this patient. In this scenario, the hospitalist group could be losing revenue if an admission service (99221-99223) was not reported.

An initial hospital care service (99221-99223) is permitted when the transfer is between:

• Different hospitals;
• Different facilities under common ownership which do not have merged records; or
• Between the acute-care hospital and a PPS (prospective payment system)-exempt unit within the same hospital when there are no merged records (e.g. Medicare Part A-covered inpatient care in psychiatric, rehabilitation, critical access, and long-term care hospitals).⁴

In all other transfer circumstances not meeting the elements noted above, the physician should bill only the appropriate level of subsequent hospital care (99231-99233) for the date of transfer.¹ Do not equate “merged records” to commonly accessible charts via an electronic medical record system or an electronic storage system. If the medical record for the patient’s acute stay is “closed” and the patient is given a separate medical record and registration for the stay in the transferred facility, consider the transfer stay as a separate admission.

Billing Two Services on Day of Transfer

Whether the transfer is classified as intrafacility or interfacility, an individual hospitalist or two separate hospitalists from the same group practice may provide the acute-care discharge and the transfer admission. A hospital discharge day management service (99238-99239) and an initial hospital care service (99221-99223) can only be reported if they do not occur on the same day.¹ Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician; if more than one evaluation and management (face to face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported.⁵

The Exception

CMS will allow a single hospitalist or two hospitalists from the same group practice to report a discharge day management service on the same day as an admission service. When they are billed by the same physician or group with the same date of service, contractors are instructed to pay the hospital discharge day management code (99238-99239) in addition to a nursing facility admission code (99304-99306).⁶

Conversely, if the patient is admitted to a hospital (99221-99223) following a nursing facility discharge (99315-99316) on the same date by the same physician/group, insurers will only reimburse the initial hospital care code. Payment for the initial hospital care service includes all work performed by the physician/group in all sites of service on that date.

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

References available online at the-hospitalist.org

ICD-10 Update

On Sept. 5, 2012, the Centers for Medicare & Medicaid Services (CMS) published the final rule for Administration Simplification, which included a compliance date change for the International Classification of Diseases, 10th Edition (ICD-10-CM and ICD-10-PCS), Medical Data Code Sets:⁷

“According to a recent survey conducted by the CMS, up to one-quarter of healthcare providers believe they will not be ready for an October 1, 2013, compliance date. While the survey found no significant differences among practice settings regarding the likelihood of achieving compliance before the deadline, based on recent industry feedback we believe that larger healthcare plans and providers generally are more prepared than smaller entities. The uncertainty about provider readiness is confirmed in another recent readiness survey in which nearly 50 percent of the 2,140 provider respondents did not know when they would complete their impact assessment of the ICD-10 transition. By delaying the compliance date of ICD-10 from October 1, 2013, to October 1, 2014, we are allowing more time for covered entities to prepare for the transition to ICD-10 and to conduct thorough testing. By allowing more time to prepare, covered entities may be able to avoid costly obstacles that would otherwise emerge while in production.”⁷

Although providers have gained a year to adopt ICD-10, this should not deter progress toward the 2014 goal, with hopefulness that additional rulings will be made to further stall full implementation.

Patient Transfers

Hospitalist billing depends on several factors. Know your role and avoid common mistakes Patient transfers can occur for many reasons: advanced technological services required, health insurance coverage, or a change in the level of care, to name a few. Patient care that is provided in the acute-care setting does not always terminate with discharge to home. Frequently, hospitalists are involved in patient transfers to another location to receive additional services: intrafacility (a different unit or related facility within the same physical plant) or interfacility (geographically separate facilities). The hospitalist must identify his or her role in the transfer and the patient’s new environment.

Physician billing in the transferred setting depends upon several factors:¹

• Shared or merged medical record;
• The attending of record in each setting;
• The requirements for care rendered by the hospitalist in each setting; and
• Service dates.

Intrafacility Initial Service

Let’s examine a common example: A hospitalist serves as the “attending of record” in an inpatient hospital where acute care is required for an 83-year-old female with hypertension and diabetes who sustained a left hip fracture. The hospitalist plans to discharge the patient to the rehabilitation unit. After transfer, the rehabilitation physician becomes the attending of record, and the hospitalist might be asked to provide ongoing care for the patient’s hypertension and diabetes.

What should the hospitalist report for the initial post-transfer service? The typical options to consider are:²

• Inpatient consultation (99251-99255);
• Initial hospital care (99221-99223); and
• Subsequent hospital care (99231-99233).

Report a consultation only if the rehab attending requests an opinion or advice for an unrelated, new condition instead of previously treated conditions, and the requesting physician’s intent is for opinion or advice on management options rather than the a priori intent for the hospitalist to assume the patient’s medical care. If these requirements are met, the hospitalist may report an inpatient consultation code (99251-99255). Alternatively, if the intent or need represents a continuity of medical care provided during the acute episode of care, report the most appropriate subsequent hospital care code (99231-99233) for the hospitalist’s initial rehab visit and all follow-up services.

Initial hospital care (99221-99223) codes can only be reported for Medicare beneficiaries in place of consultation codes (99251-99255), as Medicare ceased to reimburse consultation codes.³ Most other payors who do not recognize consultation services only allow one initial hospital care code per hospitalization, reserved for the attending of record.

Interfacility Initial Service

Hospitalist groups provide patient care and coverage in many different types of facilities. Confusion often arises when the “attending of record” during acute care and the “subacute” setting (e.g. long-term acute-care hospital) are two different hospitalists from the same group practice. The hospitalist receiving the patient in the transfer facility may decide to report subsequent hospital care (99231-99233), because the group has been providing ongoing care to this patient. In this scenario, the hospitalist group could be losing revenue if an admission service (99221-99223) was not reported.

An initial hospital care service (99221-99223) is permitted when the transfer is between:

• Different hospitals;
• Different facilities under common ownership which do not have merged records; or
• Between the acute-care hospital and a PPS (prospective payment system)-exempt unit within the same hospital when there are no merged records (e.g. Medicare Part A-covered inpatient care in psychiatric, rehabilitation, critical access, and long-term care hospitals).⁴

In all other transfer circumstances not meeting the elements noted above, the physician should bill only the appropriate level of subsequent hospital care (99231-99233) for the date of transfer.¹ Do not equate “merged records” to commonly accessible charts via an electronic medical record system or an electronic storage system. If the medical record for the patient’s acute stay is “closed” and the patient is given a separate medical record and registration for the stay in the transferred facility, consider the transfer stay as a separate admission.

Billing Two Services on Day of Transfer

Whether the transfer is classified as intrafacility or interfacility, an individual hospitalist or two separate hospitalists from the same group practice may provide the acute-care discharge and the transfer admission. A hospital discharge day management service (99238-99239) and an initial hospital care service (99221-99223) can only be reported if they do not occur on the same day.¹ Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician; if more than one evaluation and management (face to face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported.⁵

The Exception

CMS will allow a single hospitalist or two hospitalists from the same group practice to report a discharge day management service on the same day as an admission service. When they are billed by the same physician or group with the same date of service, contractors are instructed to pay the hospital discharge day management code (99238-99239) in addition to a nursing facility admission code (99304-99306).⁶

Conversely, if the patient is admitted to a hospital (99221-99223) following a nursing facility discharge (99315-99316) on the same date by the same physician/group, insurers will only reimburse the initial hospital care code. Payment for the initial hospital care service includes all work performed by the physician/group in all sites of service on that date.

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

References available online at the-hospitalist.org

ICD-10 Update

On Sept. 5, 2012, the Centers for Medicare & Medicaid Services (CMS) published the final rule for Administration Simplification, which included a compliance date change for the International Classification of Diseases, 10th Edition (ICD-10-CM and ICD-10-PCS), Medical Data Code Sets:⁷

“According to a recent survey conducted by the CMS, up to one-quarter of healthcare providers believe they will not be ready for an October 1, 2013, compliance date. While the survey found no significant differences among practice settings regarding the likelihood of achieving compliance before the deadline, based on recent industry feedback we believe that larger healthcare plans and providers generally are more prepared than smaller entities. The uncertainty about provider readiness is confirmed in another recent readiness survey in which nearly 50 percent of the 2,140 provider respondents did not know when they would complete their impact assessment of the ICD-10 transition. By delaying the compliance date of ICD-10 from October 1, 2013, to October 1, 2014, we are allowing more time for covered entities to prepare for the transition to ICD-10 and to conduct thorough testing. By allowing more time to prepare, covered entities may be able to avoid costly obstacles that would otherwise emerge while in production.”⁷

Although providers have gained a year to adopt ICD-10, this should not deter progress toward the 2014 goal, with hopefulness that additional rulings will be made to further stall full implementation.

Dr. Hospitalist

Position Paper Did Not Address Family Practice Physicians in ICU

I just finished reading “The Critical-Care Debate” article in The Hospitalist’s October issue. I was quite interested in getting further follow-up and comments regarding family practice physicians’ role in critical care. Now that some hospitalist programs are utilized as “intensivists,” what are SHM and the Society of Critical Care Medicine’s (SCCM) opinions of family practitioners who are hospitalists acting in this manner? The TH article says that internal-medicine programs are insufficient for preparing internists; what are SHM and SCCM’s positions and opinions of family practice physicians being utilized as intensivists?

—Ray Nowaczyk, DO

Dr. Hospitalist responds:

Boy, and we thought this issue was politically charged before you asked that question. From my reading of the position paper (J Hosp Med. 2012;7:359-364) cited in the article, the role of family practice physicians is only alluded to, and not addressed except by its absence. The main thrust of the paper focuses specifically on physicians trained in internal medicine (IM) and how they could become “qualified” to provide ICU care. A few items stand out:

1. The baseline assumption is that these would be IM-trained physicians, not family practice physicians.
2. The requirements to entry wouldinclude: a) completion of IM residency; b) three years’ clinical practice as a hospitalist; and c) enrollment in the ABIM Focused Practice in Hospital Medicine Maintenance of Certification process, which, by definition, requires board certification in internal medicine.

Judging by the vocal backlash from the American College of Chest Physicians (ACCP), I imagine that even getting consensus on the points above required some fairly heavy lifting. Addressing the issue of family practitioners in HM likely was not a topic they felt could gain traction

You are absolutely correct, though, in that plenty of family practitioners practice full time as adult hospitalists (and are doing a fine job). As the paper notes, it is estimated that 6% to 8% of all hospitalists are familypractice- trained. Unfortunately, there is very little objective documentation that will allow them to demonstrate their clinical quality other than direct clinical practice or observation. There is no formal “bridge” to cross for a family practice physician wanting to receive certification in hospital medicine; this currently can only happen through ABIM.

At the same time, I do not believe that the absence of formal certification disqualifies any family practitioner from practicing quality medicine in the hospital. In fact, in my market, there are some fantastic family practice hospitalists who have been in practice in a busy, urban, Level I hospital for more than 10 years. They clearly have the clinical experience and skills that would vastly outweigh those of almost any new graduate of an internal-medicine program. Can they prove it? Not today.

I think it’s a similar discussion with IM-trained hospitalists providing ICU care. I have colleagues who actively seek to accept and care for ICU patients when it comes time for admissions, and these physicians spend much more time in direct patient care in the ICU than even some of our intensivists. Can they prove their skills? Not today. However, as noted in the Leapfrog data, at this point, only 4% of ICUs have 24/7 dedicated intensivists, so who are we kidding? We need hospitalists to provide competent ICU care. Whether we provide a pathway for objective recognition or not, it is still going to happen. It sure would be nice if it happened in a sensible way with input from the stakeholders—just as was suggested in the position paper.

Here’s a little anecdote: Many years ago, there was an ortho PA (we’ll call him Jimmy John) in our hospital, but when you called his pager number, which he also gave out routinely to patients, the message said, “You’ve reached the pager of Doctor John.” He was no doctor. Well, one of us finally asked him about it, and he replied, with a straight face: “Oh, I used to be a vet.” OK.

The point is, we all need to recognize our own skills and limitations and be able to communicate those same skills and limitations to others, especially to patients, honestly. Since honesty has its limits, then independent objective measurement is a useful adjunct. Just look at your office walls.

Dr. Hospitalist

Position Paper Did Not Address Family Practice Physicians in ICU

I just finished reading “The Critical-Care Debate” article in The Hospitalist’s October issue. I was quite interested in getting further follow-up and comments regarding family practice physicians’ role in critical care. Now that some hospitalist programs are utilized as “intensivists,” what are SHM and the Society of Critical Care Medicine’s (SCCM) opinions of family practitioners who are hospitalists acting in this manner? The TH article says that internal-medicine programs are insufficient for preparing internists; what are SHM and SCCM’s positions and opinions of family practice physicians being utilized as intensivists?

—Ray Nowaczyk, DO

Dr. Hospitalist responds:

Boy, and we thought this issue was politically charged before you asked that question. From my reading of the position paper (J Hosp Med. 2012;7:359-364) cited in the article, the role of family practice physicians is only alluded to, and not addressed except by its absence. The main thrust of the paper focuses specifically on physicians trained in internal medicine (IM) and how they could become “qualified” to provide ICU care. A few items stand out:

1. The baseline assumption is that these would be IM-trained physicians, not family practice physicians.
2. The requirements to entry wouldinclude: a) completion of IM residency; b) three years’ clinical practice as a hospitalist; and c) enrollment in the ABIM Focused Practice in Hospital Medicine Maintenance of Certification process, which, by definition, requires board certification in internal medicine.

Judging by the vocal backlash from the American College of Chest Physicians (ACCP), I imagine that even getting consensus on the points above required some fairly heavy lifting. Addressing the issue of family practitioners in HM likely was not a topic they felt could gain traction

You are absolutely correct, though, in that plenty of family practitioners practice full time as adult hospitalists (and are doing a fine job). As the paper notes, it is estimated that 6% to 8% of all hospitalists are familypractice- trained. Unfortunately, there is very little objective documentation that will allow them to demonstrate their clinical quality other than direct clinical practice or observation. There is no formal “bridge” to cross for a family practice physician wanting to receive certification in hospital medicine; this currently can only happen through ABIM.

At the same time, I do not believe that the absence of formal certification disqualifies any family practitioner from practicing quality medicine in the hospital. In fact, in my market, there are some fantastic family practice hospitalists who have been in practice in a busy, urban, Level I hospital for more than 10 years. They clearly have the clinical experience and skills that would vastly outweigh those of almost any new graduate of an internal-medicine program. Can they prove it? Not today.

I think it’s a similar discussion with IM-trained hospitalists providing ICU care. I have colleagues who actively seek to accept and care for ICU patients when it comes time for admissions, and these physicians spend much more time in direct patient care in the ICU than even some of our intensivists. Can they prove their skills? Not today. However, as noted in the Leapfrog data, at this point, only 4% of ICUs have 24/7 dedicated intensivists, so who are we kidding? We need hospitalists to provide competent ICU care. Whether we provide a pathway for objective recognition or not, it is still going to happen. It sure would be nice if it happened in a sensible way with input from the stakeholders—just as was suggested in the position paper.

Here’s a little anecdote: Many years ago, there was an ortho PA (we’ll call him Jimmy John) in our hospital, but when you called his pager number, which he also gave out routinely to patients, the message said, “You’ve reached the pager of Doctor John.” He was no doctor. Well, one of us finally asked him about it, and he replied, with a straight face: “Oh, I used to be a vet.” OK.

The point is, we all need to recognize our own skills and limitations and be able to communicate those same skills and limitations to others, especially to patients, honestly. Since honesty has its limits, then independent objective measurement is a useful adjunct. Just look at your office walls.

Dr. Hospitalist

Position Paper Did Not Address Family Practice Physicians in ICU

I just finished reading “The Critical-Care Debate” article in The Hospitalist’s October issue. I was quite interested in getting further follow-up and comments regarding family practice physicians’ role in critical care. Now that some hospitalist programs are utilized as “intensivists,” what are SHM and the Society of Critical Care Medicine’s (SCCM) opinions of family practitioners who are hospitalists acting in this manner? The TH article says that internal-medicine programs are insufficient for preparing internists; what are SHM and SCCM’s positions and opinions of family practice physicians being utilized as intensivists?

—Ray Nowaczyk, DO

Dr. Hospitalist responds:

Boy, and we thought this issue was politically charged before you asked that question. From my reading of the position paper (J Hosp Med. 2012;7:359-364) cited in the article, the role of family practice physicians is only alluded to, and not addressed except by its absence. The main thrust of the paper focuses specifically on physicians trained in internal medicine (IM) and how they could become “qualified” to provide ICU care. A few items stand out:

1. The baseline assumption is that these would be IM-trained physicians, not family practice physicians.
2. The requirements to entry wouldinclude: a) completion of IM residency; b) three years’ clinical practice as a hospitalist; and c) enrollment in the ABIM Focused Practice in Hospital Medicine Maintenance of Certification process, which, by definition, requires board certification in internal medicine.

Judging by the vocal backlash from the American College of Chest Physicians (ACCP), I imagine that even getting consensus on the points above required some fairly heavy lifting. Addressing the issue of family practitioners in HM likely was not a topic they felt could gain traction

You are absolutely correct, though, in that plenty of family practitioners practice full time as adult hospitalists (and are doing a fine job). As the paper notes, it is estimated that 6% to 8% of all hospitalists are familypractice- trained. Unfortunately, there is very little objective documentation that will allow them to demonstrate their clinical quality other than direct clinical practice or observation. There is no formal “bridge” to cross for a family practice physician wanting to receive certification in hospital medicine; this currently can only happen through ABIM.

At the same time, I do not believe that the absence of formal certification disqualifies any family practitioner from practicing quality medicine in the hospital. In fact, in my market, there are some fantastic family practice hospitalists who have been in practice in a busy, urban, Level I hospital for more than 10 years. They clearly have the clinical experience and skills that would vastly outweigh those of almost any new graduate of an internal-medicine program. Can they prove it? Not today.

I think it’s a similar discussion with IM-trained hospitalists providing ICU care. I have colleagues who actively seek to accept and care for ICU patients when it comes time for admissions, and these physicians spend much more time in direct patient care in the ICU than even some of our intensivists. Can they prove their skills? Not today. However, as noted in the Leapfrog data, at this point, only 4% of ICUs have 24/7 dedicated intensivists, so who are we kidding? We need hospitalists to provide competent ICU care. Whether we provide a pathway for objective recognition or not, it is still going to happen. It sure would be nice if it happened in a sensible way with input from the stakeholders—just as was suggested in the position paper.

Here’s a little anecdote: Many years ago, there was an ortho PA (we’ll call him Jimmy John) in our hospital, but when you called his pager number, which he also gave out routinely to patients, the message said, “You’ve reached the pager of Doctor John.” He was no doctor. Well, one of us finally asked him about it, and he replied, with a straight face: “Oh, I used to be a vet.” OK.

The point is, we all need to recognize our own skills and limitations and be able to communicate those same skills and limitations to others, especially to patients, honestly. Since honesty has its limits, then independent objective measurement is a useful adjunct. Just look at your office walls.

An increasing number of hospitalists are pursuing part-time schedules to cater to lifestyle demands and personal desires. According to a 2010 survey conducted by the American Medical Group Management Association and Cejka Search, 21% of physicians in the U.S. are working part time, compared with only 13% in 2005.

Among those part-time physicians, the fastest-growing segments are men approaching retirement and women in the early to middle stages of their careers. Senior physicians who are tired of the commitment that comes with full-time employment increasingly are opting for part-time employment as a transition into retirement. Physicians with young children are seeking part-time employment to be more active in child-rearing.

The medical community generally has welcomed the opportunity to incorporate part-time physicians into hospital settings as a way to maintain female physicians, senior physicians, and physicians in specialties experiencing shortages. Physicians who are retained on a part-time basis should be cognizant of the following areas of the physician’s employment or independent contractor agreement:

• Independent contractor or employee status;
• Compensation;
• Benefits;
• Professional liability (malpractice) insurance; and
• Restrictive covenants.

Independent Contractor vs. Employee

Oftentimes, physicians assume that just because he or she is working part time, he or she is an independent contractor. That is an inaccurate assumption. The amount of time a physician works is not the determining factor as to whether someone is an employee or an independent contractor of the practice or hospital. Whether a physician is an employee or an independent contractor is a distinction with real consequences for tax purposes and protections under federal and state labor and employment laws.

Generally, labor and employment laws provide protections for employees, but these protections do not extend to independent contractors. With regard to taxes, if a hospitalist is an employee, the employer is required to withhold income, Social Security, and Medicare taxes, and pay unemployment tax on wages paid to the hospitalist. Conversely, if a hospitalist is an independent contractor, the practice or hospital will not withhold or pay taxes on payments to the hospitalist; rather, the individual hospitalist will be responsible for making those payments to the IRS and state tax authorities. It is imperative that the contract clearly indicates whether the hospitalist is an employee or an independent contractor, as well as the corresponding responsibilities of the parties.

Compensation and Benefits

Partial compensation for part-time work is logical, but determining a fair and competitive compensation package is not always as straightforward when it comes to part-timers. There are two general models that practices and hospitals use to determine compensation for hospitalists working part time. First, the physician may be paid a percentage of a full-time physician’s salary, based on the number of hours worked. Second, the physician may receive a per diem rate or an hourly rate. As with full-time physicians, there are various ways to formulate a part-time physician’s compensation, and the method used should be explicitly outlined in the physician’s employment or independent contractor agreement.

Benefit plans and arrangements (such as health, dental, vision, retirement plan, pension plan, disability coverage, life insurance, etc.) frequently are provided to employees and infrequently provided to independent contractors. Whether a physician who is working part time will receive benefits will vary from employer to employer. A threshold issue, however, is whether a part-time worker is even eligible to receive certain benefits. Many health, dental, and vision plans require employees to work a minimum of 30 hours a week on a regular basis, thus excluding part-time employees who work fewer hours. For retirement and pension plans, employees typically must work a minimum of 1,000 hours per year to be eligible to participate. Even if a hospitalist’s employment agreement provides that the hospitalist may receive benefits from the employer, the agreement may also provide that such a provision is subject to the terms and conditions of the particular benefit plans or arrangements.

Professional Liability (Malpractice) Insurance

While some practices or hospitals pay for a part-time physician’s malpractice insurance premiums, many shift some or all of these costs to the physician. Many insurance providers offer malpractice plans for physicians practicing part time, with reduced premiums and reduced coverage.

When negotiating a compensation package, payment for malpractice insurance should be considered. A physician also must be aware of what is excluded from coverage. For example, if a physician works part time with Hospital A and part time with Hospital B, and Hospital A provides malpractice coverage for the physician, it cannot be assumed that such coverage will cover the physician’s work with Hospital B. In this case, the physician may need a separate policy for work performed through Hospital B.

Restrictive Covenants

Although a physician might only be employed on a part-time basis, the employer might nevertheless want to protect itself by including restrictive covenants (i.e. noncompetition and nonsolicitation clauses) in the physician’s employment agreement. A part-time physician must be careful that the restrictive covenants do not jeopardize their other career objectives. For example, in the example described above with the physician working part time for both Hospital A and Hospital B, a noncompetition clause in the physician’s employment agreement with Hospital A could prohibit the physician from working at another hospital, including Hospital B.

Retaining part-time hospitalists is an increasingly attractive option for physician practices and hospitals, and part-time work is an increasingly attractive option for physicians. The items described above are just a few of the provisions that are unique to the part-time physician relationship that should be reflected in the physician’s employment or independent contractor agreement.

Steven M. Harris, Esq., is a nationally recognized healthcare attorney and a member of the law firm McDonald Hopkins LLC in Chicago. Write to him at [email protected].

An increasing number of hospitalists are pursuing part-time schedules to cater to lifestyle demands and personal desires. According to a 2010 survey conducted by the American Medical Group Management Association and Cejka Search, 21% of physicians in the U.S. are working part time, compared with only 13% in 2005.

Among those part-time physicians, the fastest-growing segments are men approaching retirement and women in the early to middle stages of their careers. Senior physicians who are tired of the commitment that comes with full-time employment increasingly are opting for part-time employment as a transition into retirement. Physicians with young children are seeking part-time employment to be more active in child-rearing.

The medical community generally has welcomed the opportunity to incorporate part-time physicians into hospital settings as a way to maintain female physicians, senior physicians, and physicians in specialties experiencing shortages. Physicians who are retained on a part-time basis should be cognizant of the following areas of the physician’s employment or independent contractor agreement:

• Independent contractor or employee status;
• Compensation;
• Benefits;
• Professional liability (malpractice) insurance; and
• Restrictive covenants.

Independent Contractor vs. Employee

Oftentimes, physicians assume that just because he or she is working part time, he or she is an independent contractor. That is an inaccurate assumption. The amount of time a physician works is not the determining factor as to whether someone is an employee or an independent contractor of the practice or hospital. Whether a physician is an employee or an independent contractor is a distinction with real consequences for tax purposes and protections under federal and state labor and employment laws.

Generally, labor and employment laws provide protections for employees, but these protections do not extend to independent contractors. With regard to taxes, if a hospitalist is an employee, the employer is required to withhold income, Social Security, and Medicare taxes, and pay unemployment tax on wages paid to the hospitalist. Conversely, if a hospitalist is an independent contractor, the practice or hospital will not withhold or pay taxes on payments to the hospitalist; rather, the individual hospitalist will be responsible for making those payments to the IRS and state tax authorities. It is imperative that the contract clearly indicates whether the hospitalist is an employee or an independent contractor, as well as the corresponding responsibilities of the parties.

Compensation and Benefits

Partial compensation for part-time work is logical, but determining a fair and competitive compensation package is not always as straightforward when it comes to part-timers. There are two general models that practices and hospitals use to determine compensation for hospitalists working part time. First, the physician may be paid a percentage of a full-time physician’s salary, based on the number of hours worked. Second, the physician may receive a per diem rate or an hourly rate. As with full-time physicians, there are various ways to formulate a part-time physician’s compensation, and the method used should be explicitly outlined in the physician’s employment or independent contractor agreement.

Benefit plans and arrangements (such as health, dental, vision, retirement plan, pension plan, disability coverage, life insurance, etc.) frequently are provided to employees and infrequently provided to independent contractors. Whether a physician who is working part time will receive benefits will vary from employer to employer. A threshold issue, however, is whether a part-time worker is even eligible to receive certain benefits. Many health, dental, and vision plans require employees to work a minimum of 30 hours a week on a regular basis, thus excluding part-time employees who work fewer hours. For retirement and pension plans, employees typically must work a minimum of 1,000 hours per year to be eligible to participate. Even if a hospitalist’s employment agreement provides that the hospitalist may receive benefits from the employer, the agreement may also provide that such a provision is subject to the terms and conditions of the particular benefit plans or arrangements.

Professional Liability (Malpractice) Insurance

While some practices or hospitals pay for a part-time physician’s malpractice insurance premiums, many shift some or all of these costs to the physician. Many insurance providers offer malpractice plans for physicians practicing part time, with reduced premiums and reduced coverage.

When negotiating a compensation package, payment for malpractice insurance should be considered. A physician also must be aware of what is excluded from coverage. For example, if a physician works part time with Hospital A and part time with Hospital B, and Hospital A provides malpractice coverage for the physician, it cannot be assumed that such coverage will cover the physician’s work with Hospital B. In this case, the physician may need a separate policy for work performed through Hospital B.

Restrictive Covenants

Although a physician might only be employed on a part-time basis, the employer might nevertheless want to protect itself by including restrictive covenants (i.e. noncompetition and nonsolicitation clauses) in the physician’s employment agreement. A part-time physician must be careful that the restrictive covenants do not jeopardize their other career objectives. For example, in the example described above with the physician working part time for both Hospital A and Hospital B, a noncompetition clause in the physician’s employment agreement with Hospital A could prohibit the physician from working at another hospital, including Hospital B.

Retaining part-time hospitalists is an increasingly attractive option for physician practices and hospitals, and part-time work is an increasingly attractive option for physicians. The items described above are just a few of the provisions that are unique to the part-time physician relationship that should be reflected in the physician’s employment or independent contractor agreement.

Steven M. Harris, Esq., is a nationally recognized healthcare attorney and a member of the law firm McDonald Hopkins LLC in Chicago. Write to him at [email protected].

An increasing number of hospitalists are pursuing part-time schedules to cater to lifestyle demands and personal desires. According to a 2010 survey conducted by the American Medical Group Management Association and Cejka Search, 21% of physicians in the U.S. are working part time, compared with only 13% in 2005.

Among those part-time physicians, the fastest-growing segments are men approaching retirement and women in the early to middle stages of their careers. Senior physicians who are tired of the commitment that comes with full-time employment increasingly are opting for part-time employment as a transition into retirement. Physicians with young children are seeking part-time employment to be more active in child-rearing.

The medical community generally has welcomed the opportunity to incorporate part-time physicians into hospital settings as a way to maintain female physicians, senior physicians, and physicians in specialties experiencing shortages. Physicians who are retained on a part-time basis should be cognizant of the following areas of the physician’s employment or independent contractor agreement:

• Independent contractor or employee status;
• Compensation;
• Benefits;
• Professional liability (malpractice) insurance; and
• Restrictive covenants.

Independent Contractor vs. Employee

Oftentimes, physicians assume that just because he or she is working part time, he or she is an independent contractor. That is an inaccurate assumption. The amount of time a physician works is not the determining factor as to whether someone is an employee or an independent contractor of the practice or hospital. Whether a physician is an employee or an independent contractor is a distinction with real consequences for tax purposes and protections under federal and state labor and employment laws.

Generally, labor and employment laws provide protections for employees, but these protections do not extend to independent contractors. With regard to taxes, if a hospitalist is an employee, the employer is required to withhold income, Social Security, and Medicare taxes, and pay unemployment tax on wages paid to the hospitalist. Conversely, if a hospitalist is an independent contractor, the practice or hospital will not withhold or pay taxes on payments to the hospitalist; rather, the individual hospitalist will be responsible for making those payments to the IRS and state tax authorities. It is imperative that the contract clearly indicates whether the hospitalist is an employee or an independent contractor, as well as the corresponding responsibilities of the parties.

Compensation and Benefits

Partial compensation for part-time work is logical, but determining a fair and competitive compensation package is not always as straightforward when it comes to part-timers. There are two general models that practices and hospitals use to determine compensation for hospitalists working part time. First, the physician may be paid a percentage of a full-time physician’s salary, based on the number of hours worked. Second, the physician may receive a per diem rate or an hourly rate. As with full-time physicians, there are various ways to formulate a part-time physician’s compensation, and the method used should be explicitly outlined in the physician’s employment or independent contractor agreement.

Benefit plans and arrangements (such as health, dental, vision, retirement plan, pension plan, disability coverage, life insurance, etc.) frequently are provided to employees and infrequently provided to independent contractors. Whether a physician who is working part time will receive benefits will vary from employer to employer. A threshold issue, however, is whether a part-time worker is even eligible to receive certain benefits. Many health, dental, and vision plans require employees to work a minimum of 30 hours a week on a regular basis, thus excluding part-time employees who work fewer hours. For retirement and pension plans, employees typically must work a minimum of 1,000 hours per year to be eligible to participate. Even if a hospitalist’s employment agreement provides that the hospitalist may receive benefits from the employer, the agreement may also provide that such a provision is subject to the terms and conditions of the particular benefit plans or arrangements.

Professional Liability (Malpractice) Insurance

While some practices or hospitals pay for a part-time physician’s malpractice insurance premiums, many shift some or all of these costs to the physician. Many insurance providers offer malpractice plans for physicians practicing part time, with reduced premiums and reduced coverage.

When negotiating a compensation package, payment for malpractice insurance should be considered. A physician also must be aware of what is excluded from coverage. For example, if a physician works part time with Hospital A and part time with Hospital B, and Hospital A provides malpractice coverage for the physician, it cannot be assumed that such coverage will cover the physician’s work with Hospital B. In this case, the physician may need a separate policy for work performed through Hospital B.

Restrictive Covenants

Although a physician might only be employed on a part-time basis, the employer might nevertheless want to protect itself by including restrictive covenants (i.e. noncompetition and nonsolicitation clauses) in the physician’s employment agreement. A part-time physician must be careful that the restrictive covenants do not jeopardize their other career objectives. For example, in the example described above with the physician working part time for both Hospital A and Hospital B, a noncompetition clause in the physician’s employment agreement with Hospital A could prohibit the physician from working at another hospital, including Hospital B.

Retaining part-time hospitalists is an increasingly attractive option for physician practices and hospitals, and part-time work is an increasingly attractive option for physicians. The items described above are just a few of the provisions that are unique to the part-time physician relationship that should be reflected in the physician’s employment or independent contractor agreement.

Steven M. Harris, Esq., is a nationally recognized healthcare attorney and a member of the law firm McDonald Hopkins LLC in Chicago. Write to him at [email protected].

Edward Ma, MD, wasn’t sure what he wanted to be when he grew up. As a biology student at the University of Pennsylvania in Philadelphia, he says friends “peer-pressured” him to choose a career in medicine. Once the decision was made and he began his training, he found out he was pretty good at the doctor thing.

“I realized that I like this,” he says. “I told myself, ‘I’m going to go for it.’”

Dr. Ma also realized he had a liking for business, and where better to study business than at Penn’s Wharton School of Business? He hasn’t completed an MBA, but he’s taken post-grad courses focused on healthcare management. And now he’s combining that knowledge with his experiences as a hospitalist and medical director to develop a consulting business.

“That sort of evolved because I sort of have a big mouth. When I see something wrong, or something that could be done better, I tend to vocalize it,” says Dr. Ma, medical director of hospitalist services at 168-bed Brandywine Hospital in Coatesville, Pa. “The biggest opportunity is to really help a hospitalist group realize its potential and its value.”

Dr. Ma joined Team Hospitalist in April 2012. Although his side business is evolving via “word of mouth,” he still spends the majority of his time in the hospital directing a six-member HM group and caring for hospitalized patients.

Question: What do you like most about caring for patients?

Answer: I like the acuity of the care. The acuity of the illness is pretty high for our patients, and you can see very quickly the impact hospitalists can have. A lot of outpatient medicine is preventive care, so usually you don’t have an immediate problem that needs to be fixed, whereas in HM, the patients are acutely ill and there’s an ability to get these patients better—and see a change in their medical condition in a day or two. There’s more immediate gratification in terms of the effort that we put in caring for a patient.

Q: What do you like least?

A: The paperwork. At my hospital, a lot of it is computerized. But there are tons of checklists, tons of quality measures that need to be addressed, which is good. Still, it ends up bogging down our ability to take care of the patient. For example, a patient comes in for pneumonia and you have to make sure that some of their chronic issues (e.g. diabetes) are addressed. Have they had their hemoglobin A1C checked in the last 60 days? Does it really matter right now when we’re taking care of the patient’s pneumonia that we have to address this? Smoking cessation, yes, it’s very important, and we need to address this, but is it really necessary that we do this at this point when a patient is really ill? I think there’s a lot of these government regulations that they want us to take care of sometimes in the acute setting, which sometimes feels awkward or not necessarily time-appropriate.

Q: You say your training as an internist prepared you for a seamless transition to a hospitalist job, but you also think IM training is “doing a disservice to medicine.” How so?

A: Don’t get me wrong, I love hospital medicine. But I think what we really need is more primary-care doctors. This is not just my commentary on hospital medicine, but all subspecialties. I know specifically speaking that we need more outpatient internists, outpatient family physicians. If there are many internists, they’re not going to have as much need for cardiology or GI, or a lot of other subspecialties. There’s enough of a population of internists that would satisfy the need for internists and obviously the need for subspecialties.

Q: What’s the biggest change in HM you’ve witnessed since you started 10 years ago?

A: Our acceptance as a field by the medical community. Other physicians have now come to be very accepting of our role as the primary caretakers of their hospitalized patients.

Q: Do you consider yourself to have an entrepreneurial spirit or are you more of a solutions-oriented physician?

A: I have more of the entrepreneurial spirit. I’ve been talking to a lot of hospitalists, and what I encourage them to do is completely counter to the current healthcare environment. I’ve been encouraging them to say, “Let’s get a bunch of us together and set up our own hospitalist practice and do it in a way that we can have a certain level of autonomy, but also do it in a way that we can collaborate with the hospital, work intimately with them, and get certain guarantees from them. And do it privately, so that we can maintain our autonomy.” I think that’s important because I see the difference between the private practices and the practices that are owned by a health system. People just care so much more when it’s their own practice.

Q: What are the biggest challenges you face as medical director?

A: Getting everyone to work as a team. Everyone has a different schedule, differing values, and priorities. It’s very important that we work as a team because when one person does something, it impacts what somebody else does.

Q: What’s the most important thing to know when starting an HM group or fixing a broken group?

A: For fixing a group, you have to look at the values of the group of doctors. What are the values? What are the objectives? What are the professional goals? What I’ve encountered in HM is a lot of people are just coming in to get a paycheck. They come in, they do their job, and they like to take care of patients. Don’t get me wrong about that, but they like the freedom and the high competition that’s provided by hospital medicine. Oftentimes they come in, they do their jobs very well, they take care of their patients, and then they’re out the door. They don’t really have an interest in building up that practice or building up something for the hospital. We as doctors are all part of a medical community, we’re part of a medical staff, and it’s very important for us to get involved.

Q: Last year, you became president of SHM’s Philadelphia Tri-State Region chapter. What are your goals?

A: I’ve always been involved with the chapter, but I saw it as a good opportunity to network and talk with more hospitalists. I wanted to get their viewpoints on things and bounce ideas. I’m a very vocal person, so when I hear a good idea, I like to spread it amongst other people. And if I see something that someone said was bad and I hear it from enough people, I like to bring it up and discuss with everybody.

Q: What’s the best part of being an SHM member?

A: Getting to interact with a lot of my colleagues. To see what struggles they’re going through, to see that their struggles are very similar to the struggles that my group is going through, that we’re all in the same boat, and that we need to collaborate a little more to make things work. Instead of each practice trying to reinvent the wheel, we can try to work together and build off each other.

Richard Quinn is a freelance writer in New Jersey.

Edward Ma, MD, wasn’t sure what he wanted to be when he grew up. As a biology student at the University of Pennsylvania in Philadelphia, he says friends “peer-pressured” him to choose a career in medicine. Once the decision was made and he began his training, he found out he was pretty good at the doctor thing.

“I realized that I like this,” he says. “I told myself, ‘I’m going to go for it.’”

Dr. Ma also realized he had a liking for business, and where better to study business than at Penn’s Wharton School of Business? He hasn’t completed an MBA, but he’s taken post-grad courses focused on healthcare management. And now he’s combining that knowledge with his experiences as a hospitalist and medical director to develop a consulting business.

“That sort of evolved because I sort of have a big mouth. When I see something wrong, or something that could be done better, I tend to vocalize it,” says Dr. Ma, medical director of hospitalist services at 168-bed Brandywine Hospital in Coatesville, Pa. “The biggest opportunity is to really help a hospitalist group realize its potential and its value.”

Dr. Ma joined Team Hospitalist in April 2012. Although his side business is evolving via “word of mouth,” he still spends the majority of his time in the hospital directing a six-member HM group and caring for hospitalized patients.

Question: What do you like most about caring for patients?

Answer: I like the acuity of the care. The acuity of the illness is pretty high for our patients, and you can see very quickly the impact hospitalists can have. A lot of outpatient medicine is preventive care, so usually you don’t have an immediate problem that needs to be fixed, whereas in HM, the patients are acutely ill and there’s an ability to get these patients better—and see a change in their medical condition in a day or two. There’s more immediate gratification in terms of the effort that we put in caring for a patient.

Q: What do you like least?

A: The paperwork. At my hospital, a lot of it is computerized. But there are tons of checklists, tons of quality measures that need to be addressed, which is good. Still, it ends up bogging down our ability to take care of the patient. For example, a patient comes in for pneumonia and you have to make sure that some of their chronic issues (e.g. diabetes) are addressed. Have they had their hemoglobin A1C checked in the last 60 days? Does it really matter right now when we’re taking care of the patient’s pneumonia that we have to address this? Smoking cessation, yes, it’s very important, and we need to address this, but is it really necessary that we do this at this point when a patient is really ill? I think there’s a lot of these government regulations that they want us to take care of sometimes in the acute setting, which sometimes feels awkward or not necessarily time-appropriate.

Q: You say your training as an internist prepared you for a seamless transition to a hospitalist job, but you also think IM training is “doing a disservice to medicine.” How so?

A: Don’t get me wrong, I love hospital medicine. But I think what we really need is more primary-care doctors. This is not just my commentary on hospital medicine, but all subspecialties. I know specifically speaking that we need more outpatient internists, outpatient family physicians. If there are many internists, they’re not going to have as much need for cardiology or GI, or a lot of other subspecialties. There’s enough of a population of internists that would satisfy the need for internists and obviously the need for subspecialties.

Q: What’s the biggest change in HM you’ve witnessed since you started 10 years ago?

A: Our acceptance as a field by the medical community. Other physicians have now come to be very accepting of our role as the primary caretakers of their hospitalized patients.

Q: Do you consider yourself to have an entrepreneurial spirit or are you more of a solutions-oriented physician?

A: I have more of the entrepreneurial spirit. I’ve been talking to a lot of hospitalists, and what I encourage them to do is completely counter to the current healthcare environment. I’ve been encouraging them to say, “Let’s get a bunch of us together and set up our own hospitalist practice and do it in a way that we can have a certain level of autonomy, but also do it in a way that we can collaborate with the hospital, work intimately with them, and get certain guarantees from them. And do it privately, so that we can maintain our autonomy.” I think that’s important because I see the difference between the private practices and the practices that are owned by a health system. People just care so much more when it’s their own practice.

Q: What are the biggest challenges you face as medical director?

A: Getting everyone to work as a team. Everyone has a different schedule, differing values, and priorities. It’s very important that we work as a team because when one person does something, it impacts what somebody else does.

Q: What’s the most important thing to know when starting an HM group or fixing a broken group?

A: For fixing a group, you have to look at the values of the group of doctors. What are the values? What are the objectives? What are the professional goals? What I’ve encountered in HM is a lot of people are just coming in to get a paycheck. They come in, they do their job, and they like to take care of patients. Don’t get me wrong about that, but they like the freedom and the high competition that’s provided by hospital medicine. Oftentimes they come in, they do their jobs very well, they take care of their patients, and then they’re out the door. They don’t really have an interest in building up that practice or building up something for the hospital. We as doctors are all part of a medical community, we’re part of a medical staff, and it’s very important for us to get involved.

Q: Last year, you became president of SHM’s Philadelphia Tri-State Region chapter. What are your goals?

A: I’ve always been involved with the chapter, but I saw it as a good opportunity to network and talk with more hospitalists. I wanted to get their viewpoints on things and bounce ideas. I’m a very vocal person, so when I hear a good idea, I like to spread it amongst other people. And if I see something that someone said was bad and I hear it from enough people, I like to bring it up and discuss with everybody.

Q: What’s the best part of being an SHM member?

A: Getting to interact with a lot of my colleagues. To see what struggles they’re going through, to see that their struggles are very similar to the struggles that my group is going through, that we’re all in the same boat, and that we need to collaborate a little more to make things work. Instead of each practice trying to reinvent the wheel, we can try to work together and build off each other.

Richard Quinn is a freelance writer in New Jersey.

Edward Ma, MD, wasn’t sure what he wanted to be when he grew up. As a biology student at the University of Pennsylvania in Philadelphia, he says friends “peer-pressured” him to choose a career in medicine. Once the decision was made and he began his training, he found out he was pretty good at the doctor thing.

“I realized that I like this,” he says. “I told myself, ‘I’m going to go for it.’”

Dr. Ma also realized he had a liking for business, and where better to study business than at Penn’s Wharton School of Business? He hasn’t completed an MBA, but he’s taken post-grad courses focused on healthcare management. And now he’s combining that knowledge with his experiences as a hospitalist and medical director to develop a consulting business.

“That sort of evolved because I sort of have a big mouth. When I see something wrong, or something that could be done better, I tend to vocalize it,” says Dr. Ma, medical director of hospitalist services at 168-bed Brandywine Hospital in Coatesville, Pa. “The biggest opportunity is to really help a hospitalist group realize its potential and its value.”

Dr. Ma joined Team Hospitalist in April 2012. Although his side business is evolving via “word of mouth,” he still spends the majority of his time in the hospital directing a six-member HM group and caring for hospitalized patients.

Question: What do you like most about caring for patients?

Answer: I like the acuity of the care. The acuity of the illness is pretty high for our patients, and you can see very quickly the impact hospitalists can have. A lot of outpatient medicine is preventive care, so usually you don’t have an immediate problem that needs to be fixed, whereas in HM, the patients are acutely ill and there’s an ability to get these patients better—and see a change in their medical condition in a day or two. There’s more immediate gratification in terms of the effort that we put in caring for a patient.

Q: What do you like least?

A: The paperwork. At my hospital, a lot of it is computerized. But there are tons of checklists, tons of quality measures that need to be addressed, which is good. Still, it ends up bogging down our ability to take care of the patient. For example, a patient comes in for pneumonia and you have to make sure that some of their chronic issues (e.g. diabetes) are addressed. Have they had their hemoglobin A1C checked in the last 60 days? Does it really matter right now when we’re taking care of the patient’s pneumonia that we have to address this? Smoking cessation, yes, it’s very important, and we need to address this, but is it really necessary that we do this at this point when a patient is really ill? I think there’s a lot of these government regulations that they want us to take care of sometimes in the acute setting, which sometimes feels awkward or not necessarily time-appropriate.

Q: You say your training as an internist prepared you for a seamless transition to a hospitalist job, but you also think IM training is “doing a disservice to medicine.” How so?

A: Don’t get me wrong, I love hospital medicine. But I think what we really need is more primary-care doctors. This is not just my commentary on hospital medicine, but all subspecialties. I know specifically speaking that we need more outpatient internists, outpatient family physicians. If there are many internists, they’re not going to have as much need for cardiology or GI, or a lot of other subspecialties. There’s enough of a population of internists that would satisfy the need for internists and obviously the need for subspecialties.

Q: What’s the biggest change in HM you’ve witnessed since you started 10 years ago?

A: Our acceptance as a field by the medical community. Other physicians have now come to be very accepting of our role as the primary caretakers of their hospitalized patients.

Q: Do you consider yourself to have an entrepreneurial spirit or are you more of a solutions-oriented physician?

A: I have more of the entrepreneurial spirit. I’ve been talking to a lot of hospitalists, and what I encourage them to do is completely counter to the current healthcare environment. I’ve been encouraging them to say, “Let’s get a bunch of us together and set up our own hospitalist practice and do it in a way that we can have a certain level of autonomy, but also do it in a way that we can collaborate with the hospital, work intimately with them, and get certain guarantees from them. And do it privately, so that we can maintain our autonomy.” I think that’s important because I see the difference between the private practices and the practices that are owned by a health system. People just care so much more when it’s their own practice.

Q: What are the biggest challenges you face as medical director?

A: Getting everyone to work as a team. Everyone has a different schedule, differing values, and priorities. It’s very important that we work as a team because when one person does something, it impacts what somebody else does.

Q: What’s the most important thing to know when starting an HM group or fixing a broken group?

A: For fixing a group, you have to look at the values of the group of doctors. What are the values? What are the objectives? What are the professional goals? What I’ve encountered in HM is a lot of people are just coming in to get a paycheck. They come in, they do their job, and they like to take care of patients. Don’t get me wrong about that, but they like the freedom and the high competition that’s provided by hospital medicine. Oftentimes they come in, they do their jobs very well, they take care of their patients, and then they’re out the door. They don’t really have an interest in building up that practice or building up something for the hospital. We as doctors are all part of a medical community, we’re part of a medical staff, and it’s very important for us to get involved.

Q: Last year, you became president of SHM’s Philadelphia Tri-State Region chapter. What are your goals?

A: I’ve always been involved with the chapter, but I saw it as a good opportunity to network and talk with more hospitalists. I wanted to get their viewpoints on things and bounce ideas. I’m a very vocal person, so when I hear a good idea, I like to spread it amongst other people. And if I see something that someone said was bad and I hear it from enough people, I like to bring it up and discuss with everybody.

Q: What’s the best part of being an SHM member?

A: Getting to interact with a lot of my colleagues. To see what struggles they’re going through, to see that their struggles are very similar to the struggles that my group is going through, that we’re all in the same boat, and that we need to collaborate a little more to make things work. Instead of each practice trying to reinvent the wheel, we can try to work together and build off each other.

Richard Quinn is a freelance writer in New Jersey.

Two recent studies have reached the same surprising conclusion: Adherence to national quality and performance guidelines does not translate into reduced readmissions rates.

Sula Mazimba, MD, MPH, and colleagues at Kettering Medical Center in Kettering, Ohio, focused on congestive heart failure (CHF) patients, documenting compliance with four core CHF performance measures at discharge and subsequent 30-day readmissions. Only one measure-assessment of left ventricular function-had a significant association with readmissions.

A second study published the same month looked at a wider range of diagnoses in a Medicare population at more than 2,000 hospitals nationwide. That study reached similar conclusions about the disconnect between hospitals that followed Hospital Compare process quality measures and their readmission rates.

Dr. Mazimba says hospitalists and other physicians involved in quality improvement (QI) should be more involved in defining quality measures that reflect quality of care for their patients.

“We should be looking for parameters that have a higher yield for outcomes, such as preventing readmissions,” he says, encouraging better symptom management before the CHF patient is hospitalized and enhanced coordination of care after discharge.

Alpesh Amin, MD, MBA, SFHM, professor and chair of the department of medicine and executive director of the hospitalist program at the University of California at Irvine, says the findings are important, but he adds that the core quality measures studied were never designed to address readmissions.

“The challenge is to find a way to connect the dots between the core measures and readmissions,” he says.

Learn more about the four "core" heart failure quality measures for hospitals by visiting the Resource Rooms on the SHM website, or check out this 80-page implementation guide, “Improving Heart Failure Care for Hospitalized Patients [PDF],” also available on SHM’s website.

Read The Hospitalist columnist Win Whitcomb’s take on readmissions penalty programs.

Two recent studies have reached the same surprising conclusion: Adherence to national quality and performance guidelines does not translate into reduced readmissions rates.

Sula Mazimba, MD, MPH, and colleagues at Kettering Medical Center in Kettering, Ohio, focused on congestive heart failure (CHF) patients, documenting compliance with four core CHF performance measures at discharge and subsequent 30-day readmissions. Only one measure-assessment of left ventricular function-had a significant association with readmissions.

A second study published the same month looked at a wider range of diagnoses in a Medicare population at more than 2,000 hospitals nationwide. That study reached similar conclusions about the disconnect between hospitals that followed Hospital Compare process quality measures and their readmission rates.

Dr. Mazimba says hospitalists and other physicians involved in quality improvement (QI) should be more involved in defining quality measures that reflect quality of care for their patients.

“We should be looking for parameters that have a higher yield for outcomes, such as preventing readmissions,” he says, encouraging better symptom management before the CHF patient is hospitalized and enhanced coordination of care after discharge.

Alpesh Amin, MD, MBA, SFHM, professor and chair of the department of medicine and executive director of the hospitalist program at the University of California at Irvine, says the findings are important, but he adds that the core quality measures studied were never designed to address readmissions.

“The challenge is to find a way to connect the dots between the core measures and readmissions,” he says.

Learn more about the four "core" heart failure quality measures for hospitals by visiting the Resource Rooms on the SHM website, or check out this 80-page implementation guide, “Improving Heart Failure Care for Hospitalized Patients [PDF],” also available on SHM’s website.

Read The Hospitalist columnist Win Whitcomb’s take on readmissions penalty programs.

Two recent studies have reached the same surprising conclusion: Adherence to national quality and performance guidelines does not translate into reduced readmissions rates.

Sula Mazimba, MD, MPH, and colleagues at Kettering Medical Center in Kettering, Ohio, focused on congestive heart failure (CHF) patients, documenting compliance with four core CHF performance measures at discharge and subsequent 30-day readmissions. Only one measure-assessment of left ventricular function-had a significant association with readmissions.

A second study published the same month looked at a wider range of diagnoses in a Medicare population at more than 2,000 hospitals nationwide. That study reached similar conclusions about the disconnect between hospitals that followed Hospital Compare process quality measures and their readmission rates.

Dr. Mazimba says hospitalists and other physicians involved in quality improvement (QI) should be more involved in defining quality measures that reflect quality of care for their patients.

“We should be looking for parameters that have a higher yield for outcomes, such as preventing readmissions,” he says, encouraging better symptom management before the CHF patient is hospitalized and enhanced coordination of care after discharge.

Alpesh Amin, MD, MBA, SFHM, professor and chair of the department of medicine and executive director of the hospitalist program at the University of California at Irvine, says the findings are important, but he adds that the core quality measures studied were never designed to address readmissions.

“The challenge is to find a way to connect the dots between the core measures and readmissions,” he says.

Learn more about the four "core" heart failure quality measures for hospitals by visiting the Resource Rooms on the SHM website, or check out this 80-page implementation guide, “Improving Heart Failure Care for Hospitalized Patients [PDF],” also available on SHM’s website.

Read The Hospitalist columnist Win Whitcomb’s take on readmissions penalty programs.

Listen to Robert Bessler, CEO of Sound Physicians, discuss the importance of locum agencies.

Listen to Brent Bormaster, of StaffCare, discuss expectations for filling an open hospitalist position and what to look for in a locum agency.

Listen to Robert Bessler, CEO of Sound Physicians, discuss the importance of locum agencies.

Listen to Brent Bormaster, of StaffCare, discuss expectations for filling an open hospitalist position and what to look for in a locum agency.

Listen to Robert Bessler, CEO of Sound Physicians, discuss the importance of locum agencies.

Listen to Brent Bormaster, of StaffCare, discuss expectations for filling an open hospitalist position and what to look for in a locum agency.

As efforts intensify to rein in the soaring cost of healthcare, greater attention is being paid to the cost-control potential of price transparency. Initially envisioned as a consumer-driven dynamic, price transparency beckons physicians to consider much more seriously the cost impacts of their diagnostic and treatment decisions.

Consumer-Driven Approach

The U.S. Department of Health and Human Services (HHS) regards price transparency as an important weapon in its armamentarium of “value-driven” approaches to drive down the cost of healthcare. By unleashing the energy of the savvy shopper and empowering consumers with the ability to compare the price and quality of healthcare services, they can make informed choices of their doctors and hospitals. In turn, HHS hopes to motivate the entire system to provide better care for less money.

That “empowered consumerism” principle is the guiding impetus for the Affordable Care Act’s state-regulated health insurance exchange apparatus, which, beginning in 2014, will present a side-by-side comparison of health plan choices, premium costs, and out-of-pocket copays in a way that is designed to help consumers shop for better-value health plans.

Some health plans are using price transparency to nudge consumers to choose lower-cost healthcare service options. Anthem BlueCross BlueShield, for example, has launched the Compass SmartShopper program (www.compasssmartshopper.com), which gives members in New Hampshire, Connecticut, and Indiana $50 to $200 if they get a diagnostic test or surgical procedure at a less expensive facility. Anthem notes that the cost for the same service can vary greatly. For example, hernia repairs range in price from $4,026 to $7,498, and colonoscopies range from $1,450 to $2,973.

New price transparency tools also are available (HealthCareBlueBook.com and FairHealthConsumer.org, for example) to help consumers who face high deductibles or out-of-pocket costs to find “fair prices” for surgeries, hospital stays, doctor visits, and medical tests—and shop accordingly.

Despite these developments, however, there is limited evidence that the “empowered consumerism” approach to price transparency will spur consumers to choose lower-cost providers. Some experts note that many consumers equate higher-cost providers with higher quality, and caution that healthcare cost-profiling initiatives might even have the perverse effect of deterring them from seeking these providers.¹ Cost measures, they argue, must be tied to quality information in order to neutralize the typical association of high costs with higher quality.¹

Provider-Driven Approach

There are healthcare price transparency initiatives that address the supply side of the healthcare cost equation. These initiatives seek to educate physicians about the ways in which their clinical decisions drive cost and affect what patients pay for care. Some believe that this approach has the potential to make a much bigger dent in cost containment than the empowered-consumerism approach.

“Ninety percent of healthcare cost comes from a physician’s pen, but a lot of that spending doesn’t help patients get better,” says Neel Shah, MD, a Harvard-affiliated OBGYN and executive director of Costs of Care (www.costsofcare.org), a nonprofit aimed at empowering both patients and their caregivers to deflate medical bills. The challenge, he adds, is making physicians aware of how their decisions can inflate costs unnecessarily, and giving them the training and tools they need to take appropriate action.

“Just as the patient-safety movement helped caregivers think about how to prevent unintended harm, a new movement is needed to educate doctors, nurses, and other caregivers about the cost and value of their decisions, so they can avoid waste and protect patients from unintended financial harms as well,” Dr. Shah says.

Costs of Care recently launched its Teaching Value Project, which employs Web-based video education modules to help medical students and residents learn to optimize both quality and cost in clinical decision-making.

“We’re also developing an iPhone app to put cost and quality information at physicians’ fingertips at the critical moment when medical decisions are made,” Dr. Shah adds. “Just being able to see the price variation—an ultrasound versus a CT scan, a generic versus a brand-name medication, or the cost of a marginally valuable test—can help drive physician ordering behavior.”

Hospitalist Impacts

Robert A. Bessler, MD, CEO of Tacoma, Wash.-based hospitalist management firm Sound Physicians, says his hospitalists spend about $2 million a year “with their pen or computerized physician order entry.” A quarter of the cost is pharmacy-related, and the “majority of the rest is from bed-days.”

Dr. Bessler

“The most expensive thing we do is make the decision to admit,” Dr. Bessler notes. “With hospitals switching from revenue centers to cost centers in a population health/ACO [accountable-care organization] environment, an increasingly important part of the hospitalist’s job will be asking

questions, such as, ‘Could this patient go to a nursing home tonight from the ER?’ and ‘Can my colleague in the post-acute environment take care of this patient, with the same effective outcome, if we provide more intense services in the nursing home, going forward?’”

Because most diagnostic testing is done on the front end of an inpatient’s stay, the hospitalist’s main contribution to cost control is to get that diagnosis right and use consults to answer specific questions, Dr. Bessler explains. “There is a direct correlation between the number of consults and the volume of procedures which lead to higher inpatient costs,” he adds.

As hospitals convert to value-based care models, and pressure increases on hospitalists to ramp up their analysis and sharing of cost data and resource utilization, not all physicians will find that conversion easy.

Just as the patient-safety movement helped caregivers think about how to prevent unintended harm, a new movement is needed to educate doctors, nurses, and other caregivers about the cost and value of their decisions.

—Neel Shah, MD, executive director, Costs of Care

“We are trained to take good care of our patients, not to be financial stewards of the healthcare system,” says SHM Public Policy Committee member Bradley Flansbaum, DO, MPH, SFHM. “Now, physicians are being asked to do both—to watch our resource use without looking like we’re selling out to payors. You’re putting physicians in a difficult position. Will they say to patients, ‘You can’t have this service’? When does being pragmatic stewards of resources become rationing?” he cautions.

Dr. Shah concedes that there is a perceived tension between “what’s best” for my patient and “what’s best” for society. “We, as a profession, haven’t given serious attention to how to navigate those tensions,” he says.

Dr. Flansbaum, a hospitalist at Lenox Hill Hospital in New York City, says it’s time to start down the transparency road.

“Otherwise, we will have a centralized body making these decisions for us,” he says.

Christopher Guadagnino is a freelance medical writer in Philadelphia.

Reference

1. Mehrotra A, Hussey PS, Milstein A, Hibbard JH. Consumers’ and providers’ responses to public cost reports, and how to raise the likelihood of achieving desired results. Health Affairs. 2012;31(4):843-850.

As efforts intensify to rein in the soaring cost of healthcare, greater attention is being paid to the cost-control potential of price transparency. Initially envisioned as a consumer-driven dynamic, price transparency beckons physicians to consider much more seriously the cost impacts of their diagnostic and treatment decisions.

Consumer-Driven Approach

The U.S. Department of Health and Human Services (HHS) regards price transparency as an important weapon in its armamentarium of “value-driven” approaches to drive down the cost of healthcare. By unleashing the energy of the savvy shopper and empowering consumers with the ability to compare the price and quality of healthcare services, they can make informed choices of their doctors and hospitals. In turn, HHS hopes to motivate the entire system to provide better care for less money.

That “empowered consumerism” principle is the guiding impetus for the Affordable Care Act’s state-regulated health insurance exchange apparatus, which, beginning in 2014, will present a side-by-side comparison of health plan choices, premium costs, and out-of-pocket copays in a way that is designed to help consumers shop for better-value health plans.

Some health plans are using price transparency to nudge consumers to choose lower-cost healthcare service options. Anthem BlueCross BlueShield, for example, has launched the Compass SmartShopper program (www.compasssmartshopper.com), which gives members in New Hampshire, Connecticut, and Indiana $50 to $200 if they get a diagnostic test or surgical procedure at a less expensive facility. Anthem notes that the cost for the same service can vary greatly. For example, hernia repairs range in price from $4,026 to $7,498, and colonoscopies range from $1,450 to $2,973.

New price transparency tools also are available (HealthCareBlueBook.com and FairHealthConsumer.org, for example) to help consumers who face high deductibles or out-of-pocket costs to find “fair prices” for surgeries, hospital stays, doctor visits, and medical tests—and shop accordingly.

Despite these developments, however, there is limited evidence that the “empowered consumerism” approach to price transparency will spur consumers to choose lower-cost providers. Some experts note that many consumers equate higher-cost providers with higher quality, and caution that healthcare cost-profiling initiatives might even have the perverse effect of deterring them from seeking these providers.¹ Cost measures, they argue, must be tied to quality information in order to neutralize the typical association of high costs with higher quality.¹

Provider-Driven Approach

There are healthcare price transparency initiatives that address the supply side of the healthcare cost equation. These initiatives seek to educate physicians about the ways in which their clinical decisions drive cost and affect what patients pay for care. Some believe that this approach has the potential to make a much bigger dent in cost containment than the empowered-consumerism approach.

“Ninety percent of healthcare cost comes from a physician’s pen, but a lot of that spending doesn’t help patients get better,” says Neel Shah, MD, a Harvard-affiliated OBGYN and executive director of Costs of Care (www.costsofcare.org), a nonprofit aimed at empowering both patients and their caregivers to deflate medical bills. The challenge, he adds, is making physicians aware of how their decisions can inflate costs unnecessarily, and giving them the training and tools they need to take appropriate action.

“Just as the patient-safety movement helped caregivers think about how to prevent unintended harm, a new movement is needed to educate doctors, nurses, and other caregivers about the cost and value of their decisions, so they can avoid waste and protect patients from unintended financial harms as well,” Dr. Shah says.

Costs of Care recently launched its Teaching Value Project, which employs Web-based video education modules to help medical students and residents learn to optimize both quality and cost in clinical decision-making.

“We’re also developing an iPhone app to put cost and quality information at physicians’ fingertips at the critical moment when medical decisions are made,” Dr. Shah adds. “Just being able to see the price variation—an ultrasound versus a CT scan, a generic versus a brand-name medication, or the cost of a marginally valuable test—can help drive physician ordering behavior.”

Hospitalist Impacts

Robert A. Bessler, MD, CEO of Tacoma, Wash.-based hospitalist management firm Sound Physicians, says his hospitalists spend about $2 million a year “with their pen or computerized physician order entry.” A quarter of the cost is pharmacy-related, and the “majority of the rest is from bed-days.”

Dr. Bessler

“The most expensive thing we do is make the decision to admit,” Dr. Bessler notes. “With hospitals switching from revenue centers to cost centers in a population health/ACO [accountable-care organization] environment, an increasingly important part of the hospitalist’s job will be asking

questions, such as, ‘Could this patient go to a nursing home tonight from the ER?’ and ‘Can my colleague in the post-acute environment take care of this patient, with the same effective outcome, if we provide more intense services in the nursing home, going forward?’”

Because most diagnostic testing is done on the front end of an inpatient’s stay, the hospitalist’s main contribution to cost control is to get that diagnosis right and use consults to answer specific questions, Dr. Bessler explains. “There is a direct correlation between the number of consults and the volume of procedures which lead to higher inpatient costs,” he adds.

As hospitals convert to value-based care models, and pressure increases on hospitalists to ramp up their analysis and sharing of cost data and resource utilization, not all physicians will find that conversion easy.

Just as the patient-safety movement helped caregivers think about how to prevent unintended harm, a new movement is needed to educate doctors, nurses, and other caregivers about the cost and value of their decisions.

—Neel Shah, MD, executive director, Costs of Care

“We are trained to take good care of our patients, not to be financial stewards of the healthcare system,” says SHM Public Policy Committee member Bradley Flansbaum, DO, MPH, SFHM. “Now, physicians are being asked to do both—to watch our resource use without looking like we’re selling out to payors. You’re putting physicians in a difficult position. Will they say to patients, ‘You can’t have this service’? When does being pragmatic stewards of resources become rationing?” he cautions.

Dr. Shah concedes that there is a perceived tension between “what’s best” for my patient and “what’s best” for society. “We, as a profession, haven’t given serious attention to how to navigate those tensions,” he says.

Dr. Flansbaum, a hospitalist at Lenox Hill Hospital in New York City, says it’s time to start down the transparency road.

“Otherwise, we will have a centralized body making these decisions for us,” he says.

Christopher Guadagnino is a freelance medical writer in Philadelphia.

Reference

1. Mehrotra A, Hussey PS, Milstein A, Hibbard JH. Consumers’ and providers’ responses to public cost reports, and how to raise the likelihood of achieving desired results. Health Affairs. 2012;31(4):843-850.

As efforts intensify to rein in the soaring cost of healthcare, greater attention is being paid to the cost-control potential of price transparency. Initially envisioned as a consumer-driven dynamic, price transparency beckons physicians to consider much more seriously the cost impacts of their diagnostic and treatment decisions.

Consumer-Driven Approach

The U.S. Department of Health and Human Services (HHS) regards price transparency as an important weapon in its armamentarium of “value-driven” approaches to drive down the cost of healthcare. By unleashing the energy of the savvy shopper and empowering consumers with the ability to compare the price and quality of healthcare services, they can make informed choices of their doctors and hospitals. In turn, HHS hopes to motivate the entire system to provide better care for less money.

That “empowered consumerism” principle is the guiding impetus for the Affordable Care Act’s state-regulated health insurance exchange apparatus, which, beginning in 2014, will present a side-by-side comparison of health plan choices, premium costs, and out-of-pocket copays in a way that is designed to help consumers shop for better-value health plans.

Some health plans are using price transparency to nudge consumers to choose lower-cost healthcare service options. Anthem BlueCross BlueShield, for example, has launched the Compass SmartShopper program (www.compasssmartshopper.com), which gives members in New Hampshire, Connecticut, and Indiana $50 to $200 if they get a diagnostic test or surgical procedure at a less expensive facility. Anthem notes that the cost for the same service can vary greatly. For example, hernia repairs range in price from $4,026 to $7,498, and colonoscopies range from $1,450 to $2,973.

New price transparency tools also are available (HealthCareBlueBook.com and FairHealthConsumer.org, for example) to help consumers who face high deductibles or out-of-pocket costs to find “fair prices” for surgeries, hospital stays, doctor visits, and medical tests—and shop accordingly.

Despite these developments, however, there is limited evidence that the “empowered consumerism” approach to price transparency will spur consumers to choose lower-cost providers. Some experts note that many consumers equate higher-cost providers with higher quality, and caution that healthcare cost-profiling initiatives might even have the perverse effect of deterring them from seeking these providers.¹ Cost measures, they argue, must be tied to quality information in order to neutralize the typical association of high costs with higher quality.¹

Provider-Driven Approach

There are healthcare price transparency initiatives that address the supply side of the healthcare cost equation. These initiatives seek to educate physicians about the ways in which their clinical decisions drive cost and affect what patients pay for care. Some believe that this approach has the potential to make a much bigger dent in cost containment than the empowered-consumerism approach.

“Ninety percent of healthcare cost comes from a physician’s pen, but a lot of that spending doesn’t help patients get better,” says Neel Shah, MD, a Harvard-affiliated OBGYN and executive director of Costs of Care (www.costsofcare.org), a nonprofit aimed at empowering both patients and their caregivers to deflate medical bills. The challenge, he adds, is making physicians aware of how their decisions can inflate costs unnecessarily, and giving them the training and tools they need to take appropriate action.

“Just as the patient-safety movement helped caregivers think about how to prevent unintended harm, a new movement is needed to educate doctors, nurses, and other caregivers about the cost and value of their decisions, so they can avoid waste and protect patients from unintended financial harms as well,” Dr. Shah says.

Costs of Care recently launched its Teaching Value Project, which employs Web-based video education modules to help medical students and residents learn to optimize both quality and cost in clinical decision-making.

“We’re also developing an iPhone app to put cost and quality information at physicians’ fingertips at the critical moment when medical decisions are made,” Dr. Shah adds. “Just being able to see the price variation—an ultrasound versus a CT scan, a generic versus a brand-name medication, or the cost of a marginally valuable test—can help drive physician ordering behavior.”

Hospitalist Impacts

Robert A. Bessler, MD, CEO of Tacoma, Wash.-based hospitalist management firm Sound Physicians, says his hospitalists spend about $2 million a year “with their pen or computerized physician order entry.” A quarter of the cost is pharmacy-related, and the “majority of the rest is from bed-days.”

Dr. Bessler

“The most expensive thing we do is make the decision to admit,” Dr. Bessler notes. “With hospitals switching from revenue centers to cost centers in a population health/ACO [accountable-care organization] environment, an increasingly important part of the hospitalist’s job will be asking

questions, such as, ‘Could this patient go to a nursing home tonight from the ER?’ and ‘Can my colleague in the post-acute environment take care of this patient, with the same effective outcome, if we provide more intense services in the nursing home, going forward?’”

Because most diagnostic testing is done on the front end of an inpatient’s stay, the hospitalist’s main contribution to cost control is to get that diagnosis right and use consults to answer specific questions, Dr. Bessler explains. “There is a direct correlation between the number of consults and the volume of procedures which lead to higher inpatient costs,” he adds.

As hospitals convert to value-based care models, and pressure increases on hospitalists to ramp up their analysis and sharing of cost data and resource utilization, not all physicians will find that conversion easy.

Just as the patient-safety movement helped caregivers think about how to prevent unintended harm, a new movement is needed to educate doctors, nurses, and other caregivers about the cost and value of their decisions.

—Neel Shah, MD, executive director, Costs of Care

“We are trained to take good care of our patients, not to be financial stewards of the healthcare system,” says SHM Public Policy Committee member Bradley Flansbaum, DO, MPH, SFHM. “Now, physicians are being asked to do both—to watch our resource use without looking like we’re selling out to payors. You’re putting physicians in a difficult position. Will they say to patients, ‘You can’t have this service’? When does being pragmatic stewards of resources become rationing?” he cautions.

Dr. Shah concedes that there is a perceived tension between “what’s best” for my patient and “what’s best” for society. “We, as a profession, haven’t given serious attention to how to navigate those tensions,” he says.

Dr. Flansbaum, a hospitalist at Lenox Hill Hospital in New York City, says it’s time to start down the transparency road.

“Otherwise, we will have a centralized body making these decisions for us,” he says.

Christopher Guadagnino is a freelance medical writer in Philadelphia.

Reference

1. Mehrotra A, Hussey PS, Milstein A, Hibbard JH. Consumers’ and providers’ responses to public cost reports, and how to raise the likelihood of achieving desired results. Health Affairs. 2012;31(4):843-850.