Public Policy

The “Billing and Coding Bandwagon” article in the May 2011 issue of The Hospitalist (p. 26) recently was brought to my attention and I have some concerns that the following statement gives a false impression of acceptable documentation: “When I first started working, I couldn’t believe that I could get audited and fined just because I didn’t add ‘10-point’ or ‘12-point’ to my note of ‘review of systems: negative,’” says hospitalist Amaka Nweke, MD, assistant director with Hospitalists Management Group (HMG) at Kenosha Medical Center in Kenosha, Wis. “I had a lot of frustration, because I had to repackage and re-present my notes in a manner that makes sense to Medicare but makes no sense to physicians.”

In fact, that would still not be considered acceptable documentation for services that require a complete review of systems (99222, 99223, 99219, 99220, 99235, and 99236). The documentation guidelines clearly state: “A complete ROS [review of systems] inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional body systems.” At least 10 organ systems must be reviewed. Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least 10 systems must be individually documented.

What Medicare is saying is the provider must have inquired about all 14 systems, not just 10 or 12. The term “point” means nothing in an ROS statement. “Systems” is the correct terminology, not “points.”

I am afraid the article is misleading and could be providing inappropriate documentation advice to hospitalists dealing with CMS and AMA guidelines.

The “Billing and Coding Bandwagon” article in the May 2011 issue of The Hospitalist (p. 26) recently was brought to my attention and I have some concerns that the following statement gives a false impression of acceptable documentation: “When I first started working, I couldn’t believe that I could get audited and fined just because I didn’t add ‘10-point’ or ‘12-point’ to my note of ‘review of systems: negative,’” says hospitalist Amaka Nweke, MD, assistant director with Hospitalists Management Group (HMG) at Kenosha Medical Center in Kenosha, Wis. “I had a lot of frustration, because I had to repackage and re-present my notes in a manner that makes sense to Medicare but makes no sense to physicians.”

In fact, that would still not be considered acceptable documentation for services that require a complete review of systems (99222, 99223, 99219, 99220, 99235, and 99236). The documentation guidelines clearly state: “A complete ROS [review of systems] inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional body systems.” At least 10 organ systems must be reviewed. Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least 10 systems must be individually documented.

What Medicare is saying is the provider must have inquired about all 14 systems, not just 10 or 12. The term “point” means nothing in an ROS statement. “Systems” is the correct terminology, not “points.”

I am afraid the article is misleading and could be providing inappropriate documentation advice to hospitalists dealing with CMS and AMA guidelines.

The “Billing and Coding Bandwagon” article in the May 2011 issue of The Hospitalist (p. 26) recently was brought to my attention and I have some concerns that the following statement gives a false impression of acceptable documentation: “When I first started working, I couldn’t believe that I could get audited and fined just because I didn’t add ‘10-point’ or ‘12-point’ to my note of ‘review of systems: negative,’” says hospitalist Amaka Nweke, MD, assistant director with Hospitalists Management Group (HMG) at Kenosha Medical Center in Kenosha, Wis. “I had a lot of frustration, because I had to repackage and re-present my notes in a manner that makes sense to Medicare but makes no sense to physicians.”

In fact, that would still not be considered acceptable documentation for services that require a complete review of systems (99222, 99223, 99219, 99220, 99235, and 99236). The documentation guidelines clearly state: “A complete ROS [review of systems] inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional body systems.” At least 10 organ systems must be reviewed. Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least 10 systems must be individually documented.

What Medicare is saying is the provider must have inquired about all 14 systems, not just 10 or 12. The term “point” means nothing in an ROS statement. “Systems” is the correct terminology, not “points.”

I am afraid the article is misleading and could be providing inappropriate documentation advice to hospitalists dealing with CMS and AMA guidelines.

Everything has a price, and we all have become accustomed to knowing how much something is going to cost before we buy it. Generally, we start with thinking about how much we are willing to pay, then finding what we need within the range of what we expect to pay. Whether it is shopping on Amazon.com, negotiating the price with a landscaper, or going out to eat, we get to weigh the options in advance of acquiring the goods or services. And, generally ahead of the purchase of big-ticket items, we get an itemized list of what is available.

I recently had to buy a car. Some of the many decisions that went into the purchase were whether to include some of the offered amenities, including:

• “Surround sound”;
• Seat heaters;
• Blind-spot indicator system;
• Premium floor mat package; and
• Built-in GPS.

My husband and I thought about the price of each of these line items relative to what we were going to “get out of it”—e.g., the value. Seat heaters in South Carolina? No, thanks. Surround sound? We had to flip a coin on that one. Safety features? Absolutely. Premium floor mat package? Only if they were guaranteed to be Fruit Roll-Ups-resistant.

Over the course of several negotiations, we picked and chose options that were highly likely to add value (safety, comfort, convenience) and omitted the rest. Then we settled on a total price, paid the negotiated price, and drove away fairly content.

Now, this doesn’t mean that we actually knew the cost of adding each of those amenities into our new car; would anyone actually be able to tell us exactly how much each of those features cost to innovate, create, and install? Probably not, but they might be able to give us a pretty good estimate, as well as an estimate of how much had been added in to ship it to the dealer, to pay the overhead for the dealership, and to pay the dealership staff (from the front desk to the CEO). And we could feel pretty certain that most buyers would be presented with similar prices, regardless of their personal characteristics.

So all in all, there was a reasonable amount of transparency around the cost and the price of the car and all of its amenities, as there would be in most industries. Except in health care.

A Ton of Money, for What?

There was a fascinating article in the March 4 edition of Time titled “Bitter Pill” that discussed the cost and the price of health-care services.¹ It certainly is a worthy topic, as the U.S. spends about 20% of our gross domestic product on health care, whereas most other developed countries spend half of that. In fact, according to the article, the U.S. spends more on health care annually ($2.8 trillion) than the top 10 countries combined—Japan, Germany, France, China, United Kingdom, Italy, Canada, Brazil, Spain, and Australia.

About $800 billion of our health care is paid out annually by the Centers for Medicare & Medicaid Services (CMS). CMS is an ongoing and substantial driver to the depth of the federal deficit. When Medicare was enacted in 1965, they expected the cost in 1990 to be about $12 billion per year, which was miscalculated by more than a factor of 10.

And the federal deficit, while insurmountably important, pales in comparison to the sobering statistic that 60% of personal bankruptcies are filed due to health-care bills.

Equally disappointing, the U.S. does not appear to get great value out of this exorbitant price tag, as our health-care outcomes certainly are not any better, and are sometimes worse, than other industrialized countries.

Elephants in the Room

The Time article talks extensively about the lack of transparency and drivers for cost in the industry. But there are two major, unreconciled questions the article fails to answer that are at the core of the issue:

1. Is health care in the U.S. a right or a luxury?
2. Can the U.S. health-care system be compassionate and restrictive at the same time?

You really don’t encounter the first question with any other industry. If I am hungry and do not have any money, I would not march into a restaurant and say, “I am hungry; therefore, you must feed me.” But we all feel like we can—and should—march into an emergency room and say, “I am sick; therefore, you must treat me,” no matter our financial situation. For all other industries, we rely on community resources, nonprofit agencies, and some state/federal funding to bridge gaps in basic necessities (food, housing, clothing, and transportation). And when those run short, people do without.

Car dealerships and Jiffy Lube do not have to follow any Emergency Medicine Treatment and Active Labor Act rules. If health care is a right, then we should not make individuals figure out how to get it, and we should not accept huge disparities in the provision of care based on personal characteristics.

My hospital, like most others in the U.S., is trying to figure out how to cut costs and do more with less. In a series of town-hall-style meetings, our leadership has been telling all of our hospital staff about planned cost-cutting and revenue-generating strategies. One of the tactics is to be more proactive and consistent with collecting copays in outpatient settings (before the delivery of any visit, test, or procedure) and to have parity with our local market on setting the price of those copays. But several employees were wrestling with the thought of collecting copays before the delivery of service. Some voiced a particular concern: “But what if they don’t have the money?” Again, not a conversation heard too often at car dealerships or Jiffy Lube.

The U.S. has a long way to go in reconciling these questions. Addressing them might be easier if there were more transparency in pricing. When you walk into Jiffy Lube, you are presented with all the things you might need for your car, based on make, model, and mileage; you get a listing of the cost of all the items, then you make decisions about what you do and do not need as you factor in what you are willing to spend. But when you go for your annual primary-care check-up, you are not presented a list of all the things you need (based on age, comorbidities, family history, etc.); you are not given a listing of the cost of those available services (check-up, eye exam, colonoscopy, pneumococcal vaccination); and rarely is there ever a discussion of what you are willing to spend. You just assume you need what is recommended, then get a bill later. There is almost no incentive for providers to discuss or present those prices to patients in advance. There is even less incentive to reduce the utilization of those offered services. And the price on the bill variably reflects the actual cost of the products/services provided.

In the hospital setting, the price of most products/services are based on the “chargemaster,” which is a fictional line listing of prices, which, according to the Time article, “gives them a big number to put in front of rich, uninsured patients” to make up for the losses in revenue from all other patients.

For the most part, health-care reform efforts have done little to address the two unanswered questions. And although reform efforts have triggered plenty of discussions about changing the rules on who pays for what and when, these efforts have done little to change the price or the cost of care, or make them more transparent.

The author of “Bitter Pill” makes an attempt to call out the “bad actors” in the industry, those who drive up the cost of health care—health-care leaders with generous salaries, pharmaceutical companies, device/product companies, trial lawyers, and profitable laboratory and radiology departments. But the article does not come close to capturing the other elephants in the room. Without confronting those issues, we will continue to fail to distinguish between the cost and the price, and any value within.

Reference

1. Brill S. Bitter pill: why medical bills are killing us. Time website. Available at: http://www.time.com/time/magazine/article/0,9171,2136864,00.html. Accessed March 26, 2013.

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

Everything has a price, and we all have become accustomed to knowing how much something is going to cost before we buy it. Generally, we start with thinking about how much we are willing to pay, then finding what we need within the range of what we expect to pay. Whether it is shopping on Amazon.com, negotiating the price with a landscaper, or going out to eat, we get to weigh the options in advance of acquiring the goods or services. And, generally ahead of the purchase of big-ticket items, we get an itemized list of what is available.

I recently had to buy a car. Some of the many decisions that went into the purchase were whether to include some of the offered amenities, including:

• “Surround sound”;
• Seat heaters;
• Blind-spot indicator system;
• Premium floor mat package; and
• Built-in GPS.

My husband and I thought about the price of each of these line items relative to what we were going to “get out of it”—e.g., the value. Seat heaters in South Carolina? No, thanks. Surround sound? We had to flip a coin on that one. Safety features? Absolutely. Premium floor mat package? Only if they were guaranteed to be Fruit Roll-Ups-resistant.

Over the course of several negotiations, we picked and chose options that were highly likely to add value (safety, comfort, convenience) and omitted the rest. Then we settled on a total price, paid the negotiated price, and drove away fairly content.

Now, this doesn’t mean that we actually knew the cost of adding each of those amenities into our new car; would anyone actually be able to tell us exactly how much each of those features cost to innovate, create, and install? Probably not, but they might be able to give us a pretty good estimate, as well as an estimate of how much had been added in to ship it to the dealer, to pay the overhead for the dealership, and to pay the dealership staff (from the front desk to the CEO). And we could feel pretty certain that most buyers would be presented with similar prices, regardless of their personal characteristics.

So all in all, there was a reasonable amount of transparency around the cost and the price of the car and all of its amenities, as there would be in most industries. Except in health care.

A Ton of Money, for What?

There was a fascinating article in the March 4 edition of Time titled “Bitter Pill” that discussed the cost and the price of health-care services.¹ It certainly is a worthy topic, as the U.S. spends about 20% of our gross domestic product on health care, whereas most other developed countries spend half of that. In fact, according to the article, the U.S. spends more on health care annually ($2.8 trillion) than the top 10 countries combined—Japan, Germany, France, China, United Kingdom, Italy, Canada, Brazil, Spain, and Australia.

About $800 billion of our health care is paid out annually by the Centers for Medicare & Medicaid Services (CMS). CMS is an ongoing and substantial driver to the depth of the federal deficit. When Medicare was enacted in 1965, they expected the cost in 1990 to be about $12 billion per year, which was miscalculated by more than a factor of 10.

And the federal deficit, while insurmountably important, pales in comparison to the sobering statistic that 60% of personal bankruptcies are filed due to health-care bills.

Equally disappointing, the U.S. does not appear to get great value out of this exorbitant price tag, as our health-care outcomes certainly are not any better, and are sometimes worse, than other industrialized countries.

Elephants in the Room

The Time article talks extensively about the lack of transparency and drivers for cost in the industry. But there are two major, unreconciled questions the article fails to answer that are at the core of the issue:

1. Is health care in the U.S. a right or a luxury?
2. Can the U.S. health-care system be compassionate and restrictive at the same time?

You really don’t encounter the first question with any other industry. If I am hungry and do not have any money, I would not march into a restaurant and say, “I am hungry; therefore, you must feed me.” But we all feel like we can—and should—march into an emergency room and say, “I am sick; therefore, you must treat me,” no matter our financial situation. For all other industries, we rely on community resources, nonprofit agencies, and some state/federal funding to bridge gaps in basic necessities (food, housing, clothing, and transportation). And when those run short, people do without.

Car dealerships and Jiffy Lube do not have to follow any Emergency Medicine Treatment and Active Labor Act rules. If health care is a right, then we should not make individuals figure out how to get it, and we should not accept huge disparities in the provision of care based on personal characteristics.

My hospital, like most others in the U.S., is trying to figure out how to cut costs and do more with less. In a series of town-hall-style meetings, our leadership has been telling all of our hospital staff about planned cost-cutting and revenue-generating strategies. One of the tactics is to be more proactive and consistent with collecting copays in outpatient settings (before the delivery of any visit, test, or procedure) and to have parity with our local market on setting the price of those copays. But several employees were wrestling with the thought of collecting copays before the delivery of service. Some voiced a particular concern: “But what if they don’t have the money?” Again, not a conversation heard too often at car dealerships or Jiffy Lube.

The U.S. has a long way to go in reconciling these questions. Addressing them might be easier if there were more transparency in pricing. When you walk into Jiffy Lube, you are presented with all the things you might need for your car, based on make, model, and mileage; you get a listing of the cost of all the items, then you make decisions about what you do and do not need as you factor in what you are willing to spend. But when you go for your annual primary-care check-up, you are not presented a list of all the things you need (based on age, comorbidities, family history, etc.); you are not given a listing of the cost of those available services (check-up, eye exam, colonoscopy, pneumococcal vaccination); and rarely is there ever a discussion of what you are willing to spend. You just assume you need what is recommended, then get a bill later. There is almost no incentive for providers to discuss or present those prices to patients in advance. There is even less incentive to reduce the utilization of those offered services. And the price on the bill variably reflects the actual cost of the products/services provided.

In the hospital setting, the price of most products/services are based on the “chargemaster,” which is a fictional line listing of prices, which, according to the Time article, “gives them a big number to put in front of rich, uninsured patients” to make up for the losses in revenue from all other patients.

For the most part, health-care reform efforts have done little to address the two unanswered questions. And although reform efforts have triggered plenty of discussions about changing the rules on who pays for what and when, these efforts have done little to change the price or the cost of care, or make them more transparent.

The author of “Bitter Pill” makes an attempt to call out the “bad actors” in the industry, those who drive up the cost of health care—health-care leaders with generous salaries, pharmaceutical companies, device/product companies, trial lawyers, and profitable laboratory and radiology departments. But the article does not come close to capturing the other elephants in the room. Without confronting those issues, we will continue to fail to distinguish between the cost and the price, and any value within.

Reference

1. Brill S. Bitter pill: why medical bills are killing us. Time website. Available at: http://www.time.com/time/magazine/article/0,9171,2136864,00.html. Accessed March 26, 2013.

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

Everything has a price, and we all have become accustomed to knowing how much something is going to cost before we buy it. Generally, we start with thinking about how much we are willing to pay, then finding what we need within the range of what we expect to pay. Whether it is shopping on Amazon.com, negotiating the price with a landscaper, or going out to eat, we get to weigh the options in advance of acquiring the goods or services. And, generally ahead of the purchase of big-ticket items, we get an itemized list of what is available.

I recently had to buy a car. Some of the many decisions that went into the purchase were whether to include some of the offered amenities, including:

• “Surround sound”;
• Seat heaters;
• Blind-spot indicator system;
• Premium floor mat package; and
• Built-in GPS.

My husband and I thought about the price of each of these line items relative to what we were going to “get out of it”—e.g., the value. Seat heaters in South Carolina? No, thanks. Surround sound? We had to flip a coin on that one. Safety features? Absolutely. Premium floor mat package? Only if they were guaranteed to be Fruit Roll-Ups-resistant.

Over the course of several negotiations, we picked and chose options that were highly likely to add value (safety, comfort, convenience) and omitted the rest. Then we settled on a total price, paid the negotiated price, and drove away fairly content.

Now, this doesn’t mean that we actually knew the cost of adding each of those amenities into our new car; would anyone actually be able to tell us exactly how much each of those features cost to innovate, create, and install? Probably not, but they might be able to give us a pretty good estimate, as well as an estimate of how much had been added in to ship it to the dealer, to pay the overhead for the dealership, and to pay the dealership staff (from the front desk to the CEO). And we could feel pretty certain that most buyers would be presented with similar prices, regardless of their personal characteristics.

So all in all, there was a reasonable amount of transparency around the cost and the price of the car and all of its amenities, as there would be in most industries. Except in health care.

A Ton of Money, for What?

There was a fascinating article in the March 4 edition of Time titled “Bitter Pill” that discussed the cost and the price of health-care services.¹ It certainly is a worthy topic, as the U.S. spends about 20% of our gross domestic product on health care, whereas most other developed countries spend half of that. In fact, according to the article, the U.S. spends more on health care annually ($2.8 trillion) than the top 10 countries combined—Japan, Germany, France, China, United Kingdom, Italy, Canada, Brazil, Spain, and Australia.

About $800 billion of our health care is paid out annually by the Centers for Medicare & Medicaid Services (CMS). CMS is an ongoing and substantial driver to the depth of the federal deficit. When Medicare was enacted in 1965, they expected the cost in 1990 to be about $12 billion per year, which was miscalculated by more than a factor of 10.

And the federal deficit, while insurmountably important, pales in comparison to the sobering statistic that 60% of personal bankruptcies are filed due to health-care bills.

Equally disappointing, the U.S. does not appear to get great value out of this exorbitant price tag, as our health-care outcomes certainly are not any better, and are sometimes worse, than other industrialized countries.

Elephants in the Room

The Time article talks extensively about the lack of transparency and drivers for cost in the industry. But there are two major, unreconciled questions the article fails to answer that are at the core of the issue:

1. Is health care in the U.S. a right or a luxury?
2. Can the U.S. health-care system be compassionate and restrictive at the same time?

You really don’t encounter the first question with any other industry. If I am hungry and do not have any money, I would not march into a restaurant and say, “I am hungry; therefore, you must feed me.” But we all feel like we can—and should—march into an emergency room and say, “I am sick; therefore, you must treat me,” no matter our financial situation. For all other industries, we rely on community resources, nonprofit agencies, and some state/federal funding to bridge gaps in basic necessities (food, housing, clothing, and transportation). And when those run short, people do without.

Car dealerships and Jiffy Lube do not have to follow any Emergency Medicine Treatment and Active Labor Act rules. If health care is a right, then we should not make individuals figure out how to get it, and we should not accept huge disparities in the provision of care based on personal characteristics.

My hospital, like most others in the U.S., is trying to figure out how to cut costs and do more with less. In a series of town-hall-style meetings, our leadership has been telling all of our hospital staff about planned cost-cutting and revenue-generating strategies. One of the tactics is to be more proactive and consistent with collecting copays in outpatient settings (before the delivery of any visit, test, or procedure) and to have parity with our local market on setting the price of those copays. But several employees were wrestling with the thought of collecting copays before the delivery of service. Some voiced a particular concern: “But what if they don’t have the money?” Again, not a conversation heard too often at car dealerships or Jiffy Lube.

The U.S. has a long way to go in reconciling these questions. Addressing them might be easier if there were more transparency in pricing. When you walk into Jiffy Lube, you are presented with all the things you might need for your car, based on make, model, and mileage; you get a listing of the cost of all the items, then you make decisions about what you do and do not need as you factor in what you are willing to spend. But when you go for your annual primary-care check-up, you are not presented a list of all the things you need (based on age, comorbidities, family history, etc.); you are not given a listing of the cost of those available services (check-up, eye exam, colonoscopy, pneumococcal vaccination); and rarely is there ever a discussion of what you are willing to spend. You just assume you need what is recommended, then get a bill later. There is almost no incentive for providers to discuss or present those prices to patients in advance. There is even less incentive to reduce the utilization of those offered services. And the price on the bill variably reflects the actual cost of the products/services provided.

In the hospital setting, the price of most products/services are based on the “chargemaster,” which is a fictional line listing of prices, which, according to the Time article, “gives them a big number to put in front of rich, uninsured patients” to make up for the losses in revenue from all other patients.

For the most part, health-care reform efforts have done little to address the two unanswered questions. And although reform efforts have triggered plenty of discussions about changing the rules on who pays for what and when, these efforts have done little to change the price or the cost of care, or make them more transparent.

The author of “Bitter Pill” makes an attempt to call out the “bad actors” in the industry, those who drive up the cost of health care—health-care leaders with generous salaries, pharmaceutical companies, device/product companies, trial lawyers, and profitable laboratory and radiology departments. But the article does not come close to capturing the other elephants in the room. Without confronting those issues, we will continue to fail to distinguish between the cost and the price, and any value within.

Reference

1. Brill S. Bitter pill: why medical bills are killing us. Time website. Available at: http://www.time.com/time/magazine/article/0,9171,2136864,00.html. Accessed March 26, 2013.

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

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

Comprehensive Service

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

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

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

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

Critical/Key Portion

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

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

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

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

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

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

EHR Considerations

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

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

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

Students

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

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

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

References

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

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

Comprehensive Service

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

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

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

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

Critical/Key Portion

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

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

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

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

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

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

EHR Considerations

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

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

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

Students

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

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

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

References

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

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

Comprehensive Service

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

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

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

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

Critical/Key Portion

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

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

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

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

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

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

EHR Considerations

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

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

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

Students

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

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

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

References

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

Rate of 30-day, all-cause hospital readmissions for the fourth quarter of 2012, per the Centers for Medicare & Medicaid Services (CMS). The figure had fluctuated between 18.5% and 19.5% the prior five years. The drop corresponds with the implementation of Medicare penalties for higher-than-expected readmission rates. Previous studies of readmissions, including the recent Dartmouth Atlas of Health Care report described in last month’s “Innovations” found little or no progress on reducing hospital readmissions.

Larry Beresford is a freelance writer in Oakland, Calif.

References

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

Rate of 30-day, all-cause hospital readmissions for the fourth quarter of 2012, per the Centers for Medicare & Medicaid Services (CMS). The figure had fluctuated between 18.5% and 19.5% the prior five years. The drop corresponds with the implementation of Medicare penalties for higher-than-expected readmission rates. Previous studies of readmissions, including the recent Dartmouth Atlas of Health Care report described in last month’s “Innovations” found little or no progress on reducing hospital readmissions.

Larry Beresford is a freelance writer in Oakland, Calif.

References

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

Rate of 30-day, all-cause hospital readmissions for the fourth quarter of 2012, per the Centers for Medicare & Medicaid Services (CMS). The figure had fluctuated between 18.5% and 19.5% the prior five years. The drop corresponds with the implementation of Medicare penalties for higher-than-expected readmission rates. Previous studies of readmissions, including the recent Dartmouth Atlas of Health Care report described in last month’s “Innovations” found little or no progress on reducing hospital readmissions.

Larry Beresford is a freelance writer in Oakland, Calif.

References

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

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

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

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

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

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

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

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

Purposeful, Team-Based Medicine

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

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

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

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

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

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

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

The ISSF contract contains such performance incentives.

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

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

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

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

Supply and Demand

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

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

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

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

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

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

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

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

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

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

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

Impact of Health-Care Reform

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

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

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

Larry Beresford is a freelance writer in Oakland, Calif.

References

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

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

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

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

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

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

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

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

Purposeful, Team-Based Medicine

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

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

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

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

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

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

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

The ISSF contract contains such performance incentives.

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

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

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

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

Supply and Demand

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

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

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

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

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

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

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

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

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

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

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

Impact of Health-Care Reform

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

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

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

Larry Beresford is a freelance writer in Oakland, Calif.

References

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

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

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

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

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

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

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

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

Purposeful, Team-Based Medicine

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

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

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

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

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

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

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

The ISSF contract contains such performance incentives.

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

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

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

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

Supply and Demand

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

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

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

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

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

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

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

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

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

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

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

Impact of Health-Care Reform

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

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

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

Larry Beresford is a freelance writer in Oakland, Calif.

References

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

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

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

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

Larry Beresford is a freelance writer in Oakland, Calif.

References

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

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

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

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

Larry Beresford is a freelance writer in Oakland, Calif.

References

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

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

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

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

Larry Beresford is a freelance writer in Oakland, Calif.

References

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

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

Are You Part of an ACO?

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

How ACOs Work

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

Main Flavors of ACOs

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

ACO Quality Measures and Hospitalists

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

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

Four Key Actions for Hospitalists

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

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

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

Mindset Change

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

Reference

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

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

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

Are You Part of an ACO?

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

How ACOs Work

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

Main Flavors of ACOs

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

ACO Quality Measures and Hospitalists

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

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

Four Key Actions for Hospitalists

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

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

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

Mindset Change

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

Reference

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

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

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

Are You Part of an ACO?

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

How ACOs Work

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

Main Flavors of ACOs

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

ACO Quality Measures and Hospitalists

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

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

Four Key Actions for Hospitalists

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

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

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

Mindset Change

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

Reference

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Larry Wellikson, MD, SFHM

Exceptional hospitalists

Dr. Cawley

Dr. Gottlieb

Dr. Wachter

Dr. Gorman

Dr. Conway

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

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

Chief Medical Officer of CMS

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

Resident Fellow at the American Enterprise Institute

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

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

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

Chairman of the American Board of Internal Medicine

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

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

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

CEO: Telemedicine for the ICU

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

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

CEO, Medical University of South Carolina (MUSC) Hospitals

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

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

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

Hospitalists Contribute at the Highest Level

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

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

Larry Wellikson, MD, SFHM

Exceptional hospitalists

Dr. Cawley

Dr. Gottlieb

Dr. Wachter

Dr. Gorman

Dr. Conway

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

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

Chief Medical Officer of CMS

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

Resident Fellow at the American Enterprise Institute

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

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

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

Chairman of the American Board of Internal Medicine

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

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

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

CEO: Telemedicine for the ICU

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

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

CEO, Medical University of South Carolina (MUSC) Hospitals

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

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

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

Hospitalists Contribute at the Highest Level

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

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

Larry Wellikson, MD, SFHM

Exceptional hospitalists

Dr. Cawley

Dr. Gottlieb

Dr. Wachter

Dr. Gorman

Dr. Conway

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

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

Chief Medical Officer of CMS

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

Resident Fellow at the American Enterprise Institute

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

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

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

Chairman of the American Board of Internal Medicine

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

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

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

CEO: Telemedicine for the ICU

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

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

CEO, Medical University of South Carolina (MUSC) Hospitals

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

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

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

Hospitalists Contribute at the Highest Level

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

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

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

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

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

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

Clostridium-Difficile-Associated Disease (CDAD)

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

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

click for large version

Methicillin-Resistant Staphylococcus Aureus (MRSA)

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

Central-Line-Associated Bloodstream Infection (CLABSI)

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

Catheter-Associated Urinary Tract Infection (CAUTI)

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

Surgical-Site Infection (SSI)

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

Ventilator-Associated Pneumonia (VAP)

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

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

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

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

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

The View from The Center

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

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

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

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

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

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

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

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

Clostridium-Difficile-Associated Disease (CDAD)

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

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

click for large version

Methicillin-Resistant Staphylococcus Aureus (MRSA)

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

Central-Line-Associated Bloodstream Infection (CLABSI)

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

Catheter-Associated Urinary Tract Infection (CAUTI)

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

Surgical-Site Infection (SSI)

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

Ventilator-Associated Pneumonia (VAP)

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

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

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

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

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

The View from The Center

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

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

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

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

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

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

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

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

Clostridium-Difficile-Associated Disease (CDAD)

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

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

click for large version

Methicillin-Resistant Staphylococcus Aureus (MRSA)

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

Central-Line-Associated Bloodstream Infection (CLABSI)

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

Catheter-Associated Urinary Tract Infection (CAUTI)

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

Surgical-Site Infection (SSI)

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

Ventilator-Associated Pneumonia (VAP)

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

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

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

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

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

The View from The Center

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

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

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

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