Ask Dr.

During a facility stay, a patient could be attended to by more than one hospitalist. For example, perhaps one hospitalist is the admitting physician, but the patient has a three-day stay and may be seen by three different hospitalists. Are there any guidelines as to which physician should be billed on the facility claim? Thank you for any remarks, suggestions, or references.

—Anonymous

Dr. Hospitalist responds:

Most of us can definitely relate to the concerns you have about properly billing during the patient’s hospital stay. By facility claim, I’m assuming you mean the physician’s bill for services rendered to a hospitalized patient. After querying the Centers for Medicare and Medicaid (CMS) website and discussing the question with several of our coding and billing gurus, as far as I can tell, there are no specific guidelines pertaining to which physician in a multiphysician group should bill. CMS guidelines are clear that you should only bill for the services you provide. CMS is very specific about allowing only one physician of the same specialty billing per day (reference the CMS Manual, Chapter 12, 30.6.9-Payment for Inpatient Hospital Visits).

In our very large group, we bill daily for the individual inpatient services we provide. That way, when the bill goes out, the clinician author is responsible for its validity and can support the level of care as documented.

Billing and coding is such an arduous process, I can’t imagine attempting it without an electronic interface. Most hospitalist groups have some form of electronic billing software that has integrated checks and balances to catch the common mistakes. Improper billing done by anyone in the group can expose the entire group to an audit. With ICD-10 now upon us, this becomes ever more important.

Good luck!

Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to drhospit@wiley.com.

During a facility stay, a patient could be attended to by more than one hospitalist. For example, perhaps one hospitalist is the admitting physician, but the patient has a three-day stay and may be seen by three different hospitalists. Are there any guidelines as to which physician should be billed on the facility claim? Thank you for any remarks, suggestions, or references.

—Anonymous

Dr. Hospitalist responds:

Most of us can definitely relate to the concerns you have about properly billing during the patient’s hospital stay. By facility claim, I’m assuming you mean the physician’s bill for services rendered to a hospitalized patient. After querying the Centers for Medicare and Medicaid (CMS) website and discussing the question with several of our coding and billing gurus, as far as I can tell, there are no specific guidelines pertaining to which physician in a multiphysician group should bill. CMS guidelines are clear that you should only bill for the services you provide. CMS is very specific about allowing only one physician of the same specialty billing per day (reference the CMS Manual, Chapter 12, 30.6.9-Payment for Inpatient Hospital Visits).

In our very large group, we bill daily for the individual inpatient services we provide. That way, when the bill goes out, the clinician author is responsible for its validity and can support the level of care as documented.

Billing and coding is such an arduous process, I can’t imagine attempting it without an electronic interface. Most hospitalist groups have some form of electronic billing software that has integrated checks and balances to catch the common mistakes. Improper billing done by anyone in the group can expose the entire group to an audit. With ICD-10 now upon us, this becomes ever more important.

Good luck!

Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to drhospit@wiley.com.

During a facility stay, a patient could be attended to by more than one hospitalist. For example, perhaps one hospitalist is the admitting physician, but the patient has a three-day stay and may be seen by three different hospitalists. Are there any guidelines as to which physician should be billed on the facility claim? Thank you for any remarks, suggestions, or references.

—Anonymous

Dr. Hospitalist responds:

Most of us can definitely relate to the concerns you have about properly billing during the patient’s hospital stay. By facility claim, I’m assuming you mean the physician’s bill for services rendered to a hospitalized patient. After querying the Centers for Medicare and Medicaid (CMS) website and discussing the question with several of our coding and billing gurus, as far as I can tell, there are no specific guidelines pertaining to which physician in a multiphysician group should bill. CMS guidelines are clear that you should only bill for the services you provide. CMS is very specific about allowing only one physician of the same specialty billing per day (reference the CMS Manual, Chapter 12, 30.6.9-Payment for Inpatient Hospital Visits).

In our very large group, we bill daily for the individual inpatient services we provide. That way, when the bill goes out, the clinician author is responsible for its validity and can support the level of care as documented.

Billing and coding is such an arduous process, I can’t imagine attempting it without an electronic interface. Most hospitalist groups have some form of electronic billing software that has integrated checks and balances to catch the common mistakes. Improper billing done by anyone in the group can expose the entire group to an audit. With ICD-10 now upon us, this becomes ever more important.

Good luck!

Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to drhospit@wiley.com.

I am a psychiatric nurse and am concerned about the new group of hospitalists who are taking over all the new ED patients:

1. Are signing off to the nursing staff or in the electronic health record (EHR); they do not speak with the attending psychiatrist;
2. Are not monitoring their own medications, including Coumadin or insulin (from what some other nurses have reported);
3. Require that, if we need to speak with one, we are to call the triage hospitalist, who typically says that they can’t do anything because they didn’t start the medication and they don’t know the patient.

Many of our patients are very ill, not only psychiatrically but also medically. We feel the hospital has placed us and the patients in jeopardy. Is this typical? Do other hospitalist groups manage their patients like the ones I have described?

–Sincerely,

Psych Nurse Caught in the Middle

Dr. Hospitalist responds:

Since you mention that the “new group” of hospitalists is caring for “all the new ED patients,” I’m assuming the patients are being assigned to the hospitalist group because they are unassigned and either don’t have a primary care physician (who would direct them to a specific hospitalist) or the group is the only one in the hospital and receives all patients admitted through the ED who require admission to a hospitalist service. After all, if either you or the PCP is dissatisfied with the group and there were other groups to choose from, you would simply call another group.

I’ll address your concerns individually:

Although signing off from a consult in the EHR is fairly common, especially in busy practices, the process is usually mutually agreed upon by the clinicians involved. If the attending psychiatrist would like a call from the hospitalists before they sign off, then he or she should make that known to the group.

On most occasions, the sign-off does not occur until the hospitalist/consultant feels the patient is stable and the clinicians involved can handle “basic medical issues.” There are many patients in the hospital on insulin, Coumadin, and anti-hypertensive medications; if the hospitalist followed all of them throughout their entire hospitalization, there would be no time for the new consults. It is customary to follow patients until they are stable (e.g. the blood sugars are not markedly fluctuating and there is good sliding scale coverage, or the PT/INR [prothrombin time/international normalized ratio] has been relatively unchanged for several days). To do otherwise might also alert the CMS auditors to check the “medical necessity” for the ongoing visits.

While most large hospitalist programs have a designated triage person who receives all the calls from the ED, the other providers, and the transfer service, that person can usually answer basic patient care questions. If the person is very busy, or if the problem is more complex and the original consultant is not available, there is always someone covering for that person or the consult service to answer questions, since this is a very common occurrence.

Consults are meant to answer a specific question or assist with complex medical management issues. In order for the arrangement to work, both parties have to agree to well-defined parameters, and, at some point, there should be mutually agreed upon closure.

If no such arrangement exists, I would discuss the issue with the hospitalist director.

I am a psychiatric nurse and am concerned about the new group of hospitalists who are taking over all the new ED patients:

1. Are signing off to the nursing staff or in the electronic health record (EHR); they do not speak with the attending psychiatrist;
2. Are not monitoring their own medications, including Coumadin or insulin (from what some other nurses have reported);
3. Require that, if we need to speak with one, we are to call the triage hospitalist, who typically says that they can’t do anything because they didn’t start the medication and they don’t know the patient.

Many of our patients are very ill, not only psychiatrically but also medically. We feel the hospital has placed us and the patients in jeopardy. Is this typical? Do other hospitalist groups manage their patients like the ones I have described?

–Sincerely,

Psych Nurse Caught in the Middle

Dr. Hospitalist responds:

Since you mention that the “new group” of hospitalists is caring for “all the new ED patients,” I’m assuming the patients are being assigned to the hospitalist group because they are unassigned and either don’t have a primary care physician (who would direct them to a specific hospitalist) or the group is the only one in the hospital and receives all patients admitted through the ED who require admission to a hospitalist service. After all, if either you or the PCP is dissatisfied with the group and there were other groups to choose from, you would simply call another group.

I’ll address your concerns individually:

Although signing off from a consult in the EHR is fairly common, especially in busy practices, the process is usually mutually agreed upon by the clinicians involved. If the attending psychiatrist would like a call from the hospitalists before they sign off, then he or she should make that known to the group.

On most occasions, the sign-off does not occur until the hospitalist/consultant feels the patient is stable and the clinicians involved can handle “basic medical issues.” There are many patients in the hospital on insulin, Coumadin, and anti-hypertensive medications; if the hospitalist followed all of them throughout their entire hospitalization, there would be no time for the new consults. It is customary to follow patients until they are stable (e.g. the blood sugars are not markedly fluctuating and there is good sliding scale coverage, or the PT/INR [prothrombin time/international normalized ratio] has been relatively unchanged for several days). To do otherwise might also alert the CMS auditors to check the “medical necessity” for the ongoing visits.

While most large hospitalist programs have a designated triage person who receives all the calls from the ED, the other providers, and the transfer service, that person can usually answer basic patient care questions. If the person is very busy, or if the problem is more complex and the original consultant is not available, there is always someone covering for that person or the consult service to answer questions, since this is a very common occurrence.

Consults are meant to answer a specific question or assist with complex medical management issues. In order for the arrangement to work, both parties have to agree to well-defined parameters, and, at some point, there should be mutually agreed upon closure.

If no such arrangement exists, I would discuss the issue with the hospitalist director.

I am a psychiatric nurse and am concerned about the new group of hospitalists who are taking over all the new ED patients:

1. Are signing off to the nursing staff or in the electronic health record (EHR); they do not speak with the attending psychiatrist;
2. Are not monitoring their own medications, including Coumadin or insulin (from what some other nurses have reported);
3. Require that, if we need to speak with one, we are to call the triage hospitalist, who typically says that they can’t do anything because they didn’t start the medication and they don’t know the patient.

Many of our patients are very ill, not only psychiatrically but also medically. We feel the hospital has placed us and the patients in jeopardy. Is this typical? Do other hospitalist groups manage their patients like the ones I have described?

–Sincerely,

Psych Nurse Caught in the Middle

Dr. Hospitalist responds:

Since you mention that the “new group” of hospitalists is caring for “all the new ED patients,” I’m assuming the patients are being assigned to the hospitalist group because they are unassigned and either don’t have a primary care physician (who would direct them to a specific hospitalist) or the group is the only one in the hospital and receives all patients admitted through the ED who require admission to a hospitalist service. After all, if either you or the PCP is dissatisfied with the group and there were other groups to choose from, you would simply call another group.

I’ll address your concerns individually:

Although signing off from a consult in the EHR is fairly common, especially in busy practices, the process is usually mutually agreed upon by the clinicians involved. If the attending psychiatrist would like a call from the hospitalists before they sign off, then he or she should make that known to the group.

On most occasions, the sign-off does not occur until the hospitalist/consultant feels the patient is stable and the clinicians involved can handle “basic medical issues.” There are many patients in the hospital on insulin, Coumadin, and anti-hypertensive medications; if the hospitalist followed all of them throughout their entire hospitalization, there would be no time for the new consults. It is customary to follow patients until they are stable (e.g. the blood sugars are not markedly fluctuating and there is good sliding scale coverage, or the PT/INR [prothrombin time/international normalized ratio] has been relatively unchanged for several days). To do otherwise might also alert the CMS auditors to check the “medical necessity” for the ongoing visits.

While most large hospitalist programs have a designated triage person who receives all the calls from the ED, the other providers, and the transfer service, that person can usually answer basic patient care questions. If the person is very busy, or if the problem is more complex and the original consultant is not available, there is always someone covering for that person or the consult service to answer questions, since this is a very common occurrence.

Consults are meant to answer a specific question or assist with complex medical management issues. In order for the arrangement to work, both parties have to agree to well-defined parameters, and, at some point, there should be mutually agreed upon closure.

If no such arrangement exists, I would discuss the issue with the hospitalist director.

Dr. Hospitalist

“Infusion Privileges” a Simple Answer to Complex Issue

I have a couple of questions based on the following scenario: hospital infusion center treating patients referred by physicians who are not members of hospital staff and don’t have hospital privileges. Since they are not credentialed at the hospital, they cannot give orders for infusion treatment for their patients. And they are not interested in applying for membership and hospital privileges. First, is it OK for the referring physicians to talk to our hospitalist of the day and give an infusion treatment order? Second, what CPT code would the hospitalist use for just writing an infusion treatment order—and can they bill the service?

—Glena Loyola

Dr. Hospitalist responds:

The alternate site infusion therapy market has exploded in the U.S. in the past 25 years. Most of this surge has been driven by increased emphasis on cost containment and the desires of patients to resume their usual lifestyles while recovering from illness. Most recent estimates show that these services represent approximately $9-$11 billion a year. Although the cost is substantial, it is far lower than the cost of inpatient treatment.

Many hospitals have infusion centers, both as revenue-generating ventures and to provide a service for their patients without admitting them to the hospital. Initially, most centers focused on oncologic medications; most now provide a variety of infusion services and therapies. Having clinical staff, prescribing physicians, and pharmacists under the same roof, or in the same healthcare system, should lead to better communication, which is key when administering these specialty drugs. The center at my hospital is of average size, and it seems there are at least one or two medical emergencies there every month. I can imagine the wasted time and lives lost in situations where a full cadre of emergency staff was not immediately available.

The processes and procedures developed by hospital administrators to allow physicians to administer these medications are highly variable. When the centers first came on the scene, most of the prescribing physicians were practicing oncologists and active members of the medical staff. While oncologists still make up the largest group utilizing these centers, rheumatologists, cardiologists, and endocrinologists also are active participants. As these clinicians have aged, and as the services, as well as the variety of infusions, have expanded, hospitals have needed alternate staffing models to keep up.

My CMO created specific “infusion privileges” for health system physicians working on alternate campuses. This privilege allows them to write for the medications but does not give them core privileges like most courtesy staff designations. There is no associated hospital call or ED coverage requirement, and no quality monitoring is needed with this “special” designation. We did consider having our hospitalist write the orders for these docs, but there were many reasons not to go that route—most importantly the logistics and our current HM program’s bandwidth.

The situation you describe, in which physicians call in and give infusion orders to another physician/hospitalist, is the one I believe is most fraught with problems. The potential for prescribing error is very high. Plus, the multiple downstream opportunities for the patient’s care to be compromised are myriad. Because the consequences of a medication error with many of these infusions can be catastrophic, most institutions (including ours) limit who can prescribe them to those specializing in that field. Many also require physicians to use computerized physician order entry, which has been shown to reduce medication errors, for these agents.

The billing requirements for infusion centers and prescribers are very complex and were last globally consolidated in May 2004. CMS annually updates using National Correct Coding Initiative Edits, with which most coders are familiar. The CPT code is tied to the infusion or type of infusion that is given and even incorporates the amount of time it takes to administer. Prior to 2004, the codes incorporated practice expense as well as malpractice relative value units (RVUs), but zero physician RVUs. Since then, a lot has changed. Although a physician can usually bill for services using E&M codes, most require face-to-face time to be allowable. If you would like to bill independently as a prescriber for your services, I recommend you sit down with your coders and decide if it’s feasible.

Dr. Hospitalist

“Infusion Privileges” a Simple Answer to Complex Issue

I have a couple of questions based on the following scenario: hospital infusion center treating patients referred by physicians who are not members of hospital staff and don’t have hospital privileges. Since they are not credentialed at the hospital, they cannot give orders for infusion treatment for their patients. And they are not interested in applying for membership and hospital privileges. First, is it OK for the referring physicians to talk to our hospitalist of the day and give an infusion treatment order? Second, what CPT code would the hospitalist use for just writing an infusion treatment order—and can they bill the service?

—Glena Loyola

Dr. Hospitalist responds:

The alternate site infusion therapy market has exploded in the U.S. in the past 25 years. Most of this surge has been driven by increased emphasis on cost containment and the desires of patients to resume their usual lifestyles while recovering from illness. Most recent estimates show that these services represent approximately $9-$11 billion a year. Although the cost is substantial, it is far lower than the cost of inpatient treatment.

Many hospitals have infusion centers, both as revenue-generating ventures and to provide a service for their patients without admitting them to the hospital. Initially, most centers focused on oncologic medications; most now provide a variety of infusion services and therapies. Having clinical staff, prescribing physicians, and pharmacists under the same roof, or in the same healthcare system, should lead to better communication, which is key when administering these specialty drugs. The center at my hospital is of average size, and it seems there are at least one or two medical emergencies there every month. I can imagine the wasted time and lives lost in situations where a full cadre of emergency staff was not immediately available.

The processes and procedures developed by hospital administrators to allow physicians to administer these medications are highly variable. When the centers first came on the scene, most of the prescribing physicians were practicing oncologists and active members of the medical staff. While oncologists still make up the largest group utilizing these centers, rheumatologists, cardiologists, and endocrinologists also are active participants. As these clinicians have aged, and as the services, as well as the variety of infusions, have expanded, hospitals have needed alternate staffing models to keep up.

My CMO created specific “infusion privileges” for health system physicians working on alternate campuses. This privilege allows them to write for the medications but does not give them core privileges like most courtesy staff designations. There is no associated hospital call or ED coverage requirement, and no quality monitoring is needed with this “special” designation. We did consider having our hospitalist write the orders for these docs, but there were many reasons not to go that route—most importantly the logistics and our current HM program’s bandwidth.

The situation you describe, in which physicians call in and give infusion orders to another physician/hospitalist, is the one I believe is most fraught with problems. The potential for prescribing error is very high. Plus, the multiple downstream opportunities for the patient’s care to be compromised are myriad. Because the consequences of a medication error with many of these infusions can be catastrophic, most institutions (including ours) limit who can prescribe them to those specializing in that field. Many also require physicians to use computerized physician order entry, which has been shown to reduce medication errors, for these agents.

The billing requirements for infusion centers and prescribers are very complex and were last globally consolidated in May 2004. CMS annually updates using National Correct Coding Initiative Edits, with which most coders are familiar. The CPT code is tied to the infusion or type of infusion that is given and even incorporates the amount of time it takes to administer. Prior to 2004, the codes incorporated practice expense as well as malpractice relative value units (RVUs), but zero physician RVUs. Since then, a lot has changed. Although a physician can usually bill for services using E&M codes, most require face-to-face time to be allowable. If you would like to bill independently as a prescriber for your services, I recommend you sit down with your coders and decide if it’s feasible.

Dr. Hospitalist

“Infusion Privileges” a Simple Answer to Complex Issue

I have a couple of questions based on the following scenario: hospital infusion center treating patients referred by physicians who are not members of hospital staff and don’t have hospital privileges. Since they are not credentialed at the hospital, they cannot give orders for infusion treatment for their patients. And they are not interested in applying for membership and hospital privileges. First, is it OK for the referring physicians to talk to our hospitalist of the day and give an infusion treatment order? Second, what CPT code would the hospitalist use for just writing an infusion treatment order—and can they bill the service?

—Glena Loyola

Dr. Hospitalist responds:

The alternate site infusion therapy market has exploded in the U.S. in the past 25 years. Most of this surge has been driven by increased emphasis on cost containment and the desires of patients to resume their usual lifestyles while recovering from illness. Most recent estimates show that these services represent approximately $9-$11 billion a year. Although the cost is substantial, it is far lower than the cost of inpatient treatment.

Many hospitals have infusion centers, both as revenue-generating ventures and to provide a service for their patients without admitting them to the hospital. Initially, most centers focused on oncologic medications; most now provide a variety of infusion services and therapies. Having clinical staff, prescribing physicians, and pharmacists under the same roof, or in the same healthcare system, should lead to better communication, which is key when administering these specialty drugs. The center at my hospital is of average size, and it seems there are at least one or two medical emergencies there every month. I can imagine the wasted time and lives lost in situations where a full cadre of emergency staff was not immediately available.

The processes and procedures developed by hospital administrators to allow physicians to administer these medications are highly variable. When the centers first came on the scene, most of the prescribing physicians were practicing oncologists and active members of the medical staff. While oncologists still make up the largest group utilizing these centers, rheumatologists, cardiologists, and endocrinologists also are active participants. As these clinicians have aged, and as the services, as well as the variety of infusions, have expanded, hospitals have needed alternate staffing models to keep up.

My CMO created specific “infusion privileges” for health system physicians working on alternate campuses. This privilege allows them to write for the medications but does not give them core privileges like most courtesy staff designations. There is no associated hospital call or ED coverage requirement, and no quality monitoring is needed with this “special” designation. We did consider having our hospitalist write the orders for these docs, but there were many reasons not to go that route—most importantly the logistics and our current HM program’s bandwidth.

The situation you describe, in which physicians call in and give infusion orders to another physician/hospitalist, is the one I believe is most fraught with problems. The potential for prescribing error is very high. Plus, the multiple downstream opportunities for the patient’s care to be compromised are myriad. Because the consequences of a medication error with many of these infusions can be catastrophic, most institutions (including ours) limit who can prescribe them to those specializing in that field. Many also require physicians to use computerized physician order entry, which has been shown to reduce medication errors, for these agents.

The billing requirements for infusion centers and prescribers are very complex and were last globally consolidated in May 2004. CMS annually updates using National Correct Coding Initiative Edits, with which most coders are familiar. The CPT code is tied to the infusion or type of infusion that is given and even incorporates the amount of time it takes to administer. Prior to 2004, the codes incorporated practice expense as well as malpractice relative value units (RVUs), but zero physician RVUs. Since then, a lot has changed. Although a physician can usually bill for services using E&M codes, most require face-to-face time to be allowable. If you would like to bill independently as a prescriber for your services, I recommend you sit down with your coders and decide if it’s feasible.

Dr. Hospitalist

My hospitalist group, which has nine employees, is hospital-employed in a small Midwest town. We use the traditional seven-on and seven-off rotation and hire locum tenens to fill schedule gaps, as we have a couple of MDs who recently left the group. A few of us are concerned because our “boss,” who controls the schedule, does not put himself in rotation regularly. Instead, he puts locum or part-timers on the schedule, even on weeks when he is available. We all know that the hospital is paying him extra to take care of administrative work, and that it costs more for the hospital to pay part-time/locums. In your experience, is this a common occurrence? Should we be upset? Lastly, should we bring this issue to administration, because many of us think that they are not aware this is happening.

–Mismatched in the Midwest

Dr. Hospitalist responds:

Opinions vary when it comes to the amount of clinical time hospitalist leaders should devote to their groups. As we have become more involved in the administrative aspects of the hospital, there are increasing demands placed on directors. Along with increased administrative demands comes the desire of many of these physician-leaders to remain adept in the practice of hospital medicine. Without a strong clinical connection and familiarity with what the others experience day to day, the group leader risks losing credibility and whatever leverage the title might offer.

Many groups have devised formulas based on the number of members in the group to help them derive a “fair” amount of administrative time to allow the director. For example, for every five full-time equivalents (FTEs) on staff, the director receives 0.1 FTE in admin time; so, for a group of 25 members, the director would get 0.5 admin time. The remainder of time would be clinical, but again, how that clinical time is managed is also highly variable.

This seems like a reasonable formula to me, because those with larger programs will have larger hospitals, more people to manage, and more personalities to deal with. The potential rewards and job satisfaction are also greater. (Another potential scheduling issue: Does the group leader “fall right into” the rotation or only work the services with light census or teaching services in an academic institution?)

Some groups that work the traditional seven-on/seven-off schedule have allowed the hospitalist physician-leader to work Monday through Friday and carry a smaller census (10-12). This allows the leader to be in the hospital during those critical times when most administrative duties are fulfilled, while also allowing for a mechanism to place overflow patients on those high census days—as long as it is a rare occurrence. He or she should also occasionally work all the different shifts (nocturnist, admitter, teams, and so on) to best understand the group’s opportunities for improvement and its challenges.

There are likely as many iterations of how to devise a fair division of time as there are hospitalist groups, but, most importantly, the days of getting someone to volunteer to be a hospitalist director without some form of compensation are long gone. In most programs, the job has become much more complex.

Many believe it is a conflict of interest for the group leader to prepare the schedule. There is too much room for perceived favoritism or mistreatment by the members when the schedule doesn’t work in everyone’s favor (which it never will). There are proprietary programs on the market that allow for easy and reliable scheduling; they also remove the potential for bias. In a group as small as yours, an astute administrative assistant or associate director can be entrusted with the schedule.

With regard to speaking up, you say a “few” in your group are concerned, so I assume more than one but still a small number of your group has expressed some dissatisfaction. There may be other members with similar sentiments, so it is important to have a discussion with all the group members and solicit their opinions. Instead of approaching the administrators with your concerns, I suggest you and your colleagues have an open and candid discussion with your group leader. After the discussion, if you still remain dissatisfied with the director’s level of clinical involvement, you are left with several choices:

1. Approach hospital administration and see if they approve of how your director is carrying out his clinical responsibilities. Be prepared for the director to find out.
2. Continue to do your job and let this issue rest.
3. Start looking for another job. If the situation really bothers you, I favor the latter!

Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to drhospit@wiley.com.

Dr. Hospitalist

My hospitalist group, which has nine employees, is hospital-employed in a small Midwest town. We use the traditional seven-on and seven-off rotation and hire locum tenens to fill schedule gaps, as we have a couple of MDs who recently left the group. A few of us are concerned because our “boss,” who controls the schedule, does not put himself in rotation regularly. Instead, he puts locum or part-timers on the schedule, even on weeks when he is available. We all know that the hospital is paying him extra to take care of administrative work, and that it costs more for the hospital to pay part-time/locums. In your experience, is this a common occurrence? Should we be upset? Lastly, should we bring this issue to administration, because many of us think that they are not aware this is happening.

–Mismatched in the Midwest

Dr. Hospitalist responds:

Opinions vary when it comes to the amount of clinical time hospitalist leaders should devote to their groups. As we have become more involved in the administrative aspects of the hospital, there are increasing demands placed on directors. Along with increased administrative demands comes the desire of many of these physician-leaders to remain adept in the practice of hospital medicine. Without a strong clinical connection and familiarity with what the others experience day to day, the group leader risks losing credibility and whatever leverage the title might offer.

Many groups have devised formulas based on the number of members in the group to help them derive a “fair” amount of administrative time to allow the director. For example, for every five full-time equivalents (FTEs) on staff, the director receives 0.1 FTE in admin time; so, for a group of 25 members, the director would get 0.5 admin time. The remainder of time would be clinical, but again, how that clinical time is managed is also highly variable.

This seems like a reasonable formula to me, because those with larger programs will have larger hospitals, more people to manage, and more personalities to deal with. The potential rewards and job satisfaction are also greater. (Another potential scheduling issue: Does the group leader “fall right into” the rotation or only work the services with light census or teaching services in an academic institution?)

Some groups that work the traditional seven-on/seven-off schedule have allowed the hospitalist physician-leader to work Monday through Friday and carry a smaller census (10-12). This allows the leader to be in the hospital during those critical times when most administrative duties are fulfilled, while also allowing for a mechanism to place overflow patients on those high census days—as long as it is a rare occurrence. He or she should also occasionally work all the different shifts (nocturnist, admitter, teams, and so on) to best understand the group’s opportunities for improvement and its challenges.

There are likely as many iterations of how to devise a fair division of time as there are hospitalist groups, but, most importantly, the days of getting someone to volunteer to be a hospitalist director without some form of compensation are long gone. In most programs, the job has become much more complex.

Many believe it is a conflict of interest for the group leader to prepare the schedule. There is too much room for perceived favoritism or mistreatment by the members when the schedule doesn’t work in everyone’s favor (which it never will). There are proprietary programs on the market that allow for easy and reliable scheduling; they also remove the potential for bias. In a group as small as yours, an astute administrative assistant or associate director can be entrusted with the schedule.

With regard to speaking up, you say a “few” in your group are concerned, so I assume more than one but still a small number of your group has expressed some dissatisfaction. There may be other members with similar sentiments, so it is important to have a discussion with all the group members and solicit their opinions. Instead of approaching the administrators with your concerns, I suggest you and your colleagues have an open and candid discussion with your group leader. After the discussion, if you still remain dissatisfied with the director’s level of clinical involvement, you are left with several choices:

1. Approach hospital administration and see if they approve of how your director is carrying out his clinical responsibilities. Be prepared for the director to find out.
2. Continue to do your job and let this issue rest.
3. Start looking for another job. If the situation really bothers you, I favor the latter!

Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to drhospit@wiley.com.

Dr. Hospitalist

My hospitalist group, which has nine employees, is hospital-employed in a small Midwest town. We use the traditional seven-on and seven-off rotation and hire locum tenens to fill schedule gaps, as we have a couple of MDs who recently left the group. A few of us are concerned because our “boss,” who controls the schedule, does not put himself in rotation regularly. Instead, he puts locum or part-timers on the schedule, even on weeks when he is available. We all know that the hospital is paying him extra to take care of administrative work, and that it costs more for the hospital to pay part-time/locums. In your experience, is this a common occurrence? Should we be upset? Lastly, should we bring this issue to administration, because many of us think that they are not aware this is happening.

–Mismatched in the Midwest

Dr. Hospitalist responds:

Opinions vary when it comes to the amount of clinical time hospitalist leaders should devote to their groups. As we have become more involved in the administrative aspects of the hospital, there are increasing demands placed on directors. Along with increased administrative demands comes the desire of many of these physician-leaders to remain adept in the practice of hospital medicine. Without a strong clinical connection and familiarity with what the others experience day to day, the group leader risks losing credibility and whatever leverage the title might offer.

Many groups have devised formulas based on the number of members in the group to help them derive a “fair” amount of administrative time to allow the director. For example, for every five full-time equivalents (FTEs) on staff, the director receives 0.1 FTE in admin time; so, for a group of 25 members, the director would get 0.5 admin time. The remainder of time would be clinical, but again, how that clinical time is managed is also highly variable.

This seems like a reasonable formula to me, because those with larger programs will have larger hospitals, more people to manage, and more personalities to deal with. The potential rewards and job satisfaction are also greater. (Another potential scheduling issue: Does the group leader “fall right into” the rotation or only work the services with light census or teaching services in an academic institution?)

Some groups that work the traditional seven-on/seven-off schedule have allowed the hospitalist physician-leader to work Monday through Friday and carry a smaller census (10-12). This allows the leader to be in the hospital during those critical times when most administrative duties are fulfilled, while also allowing for a mechanism to place overflow patients on those high census days—as long as it is a rare occurrence. He or she should also occasionally work all the different shifts (nocturnist, admitter, teams, and so on) to best understand the group’s opportunities for improvement and its challenges.

There are likely as many iterations of how to devise a fair division of time as there are hospitalist groups, but, most importantly, the days of getting someone to volunteer to be a hospitalist director without some form of compensation are long gone. In most programs, the job has become much more complex.

Many believe it is a conflict of interest for the group leader to prepare the schedule. There is too much room for perceived favoritism or mistreatment by the members when the schedule doesn’t work in everyone’s favor (which it never will). There are proprietary programs on the market that allow for easy and reliable scheduling; they also remove the potential for bias. In a group as small as yours, an astute administrative assistant or associate director can be entrusted with the schedule.

With regard to speaking up, you say a “few” in your group are concerned, so I assume more than one but still a small number of your group has expressed some dissatisfaction. There may be other members with similar sentiments, so it is important to have a discussion with all the group members and solicit their opinions. Instead of approaching the administrators with your concerns, I suggest you and your colleagues have an open and candid discussion with your group leader. After the discussion, if you still remain dissatisfied with the director’s level of clinical involvement, you are left with several choices:

1. Approach hospital administration and see if they approve of how your director is carrying out his clinical responsibilities. Be prepared for the director to find out.
2. Continue to do your job and let this issue rest.
3. Start looking for another job. If the situation really bothers you, I favor the latter!

Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to drhospit@wiley.com.

Dr. Hospitalist

Fellowships Available to Family Physicians Considering Hospital Medicine Career

I am in my final year of family practice residency. I discovered that I enjoyed hospital medicine much more than I thought I would. I am considering a hospitalist fellowship (one year) to add depth and breadth to my clinical skills. Do you view the clinical knowledge from a fellowship as beneficial to outpatient practice, and, with respect to hospitalist opportunities, are they available to an FP physician?

–Ward Harbin, MD

Dr. Hospitalist responds:

Congratulations on completing your residency. I know it has been a long and arduous journey, but you’re almost there!

I do believe HM fellowships are beneficial for anyone aspiring to become a hospitalist. Even though fewer than 5% of U.S. hospitalists are family practice graduates, there are many opportunities for FP residents to do a fellowship in hospital medicine. Many hospitalist programs limit their recruitment to board-certified internal medicine candidates, but this is probably more a reflection of internists having sustained a foothold in the HM movement and staking out their turf. Nearly all fellowships are one year in length, and most only offer one or two slots. As you can imagine, with such a limited number of positions, the competition is fairly keen, especially in the larger academic programs.

Most programs offer core rotations (similar to residency) but allow some flexibility in selection of electives. Some programs offer several different tracks. For example, Mayo Clinic in Rochester, Minn., offers clinical research, clinician educator, and quality tracks. These are becoming more popular, as they allow the fellow to focus early on a particular area of hospital medicine and, ideally, develop a niche, while becoming a much more attractive candidate for employment.

If I were considering the practice of outpatient adult medicine, I would think about a fellowship in general medicine and target a specific area (e.g., geriatrics or sports medicine). For many reasons, these tend to be less competitive, but as our population ages and current reimbursement strategies are challenged, this may soon change. While there are many clinical principles taught in an HM fellowship that are applicable to outpatient medicine, it would be best to choose the area of interest (inpatient vs. outpatient) and focus your efforts in that direction.

As hospitalists are increasingly being offered more administrative opportunities, several post-graduate degrees or areas of focus are becoming valuable. I would strongly consider pursuing a master’s degree in healthcare management (MHM) or healthcare administration (MHA). Those degrees are offered by a number of top-notch business schools. Nearly all are two-year programs with built-in schedule flexibility, basically geared toward the working professional. A master’s degree in public health (MPH) is also a valued degree and is offered by many outstanding programs. Although most programs attempt to emphasize and train healthcare professionals for the public health arena, there are opportunities to specialize in areas that can be used in hospital management.

As the hospitalist movement matures and the healthcare industry evolves due to market and governmental pressures, there will be many more administrative and clinical opportunities for hospitalists. The clinicians best positioned to take advantage of these opportunities will be those who have some form of post-graduate training supported by strong clinical skills.

Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to drhospit@wiley.com.

Dr. Hospitalist

Fellowships Available to Family Physicians Considering Hospital Medicine Career

I am in my final year of family practice residency. I discovered that I enjoyed hospital medicine much more than I thought I would. I am considering a hospitalist fellowship (one year) to add depth and breadth to my clinical skills. Do you view the clinical knowledge from a fellowship as beneficial to outpatient practice, and, with respect to hospitalist opportunities, are they available to an FP physician?

–Ward Harbin, MD

Dr. Hospitalist responds:

Congratulations on completing your residency. I know it has been a long and arduous journey, but you’re almost there!

I do believe HM fellowships are beneficial for anyone aspiring to become a hospitalist. Even though fewer than 5% of U.S. hospitalists are family practice graduates, there are many opportunities for FP residents to do a fellowship in hospital medicine. Many hospitalist programs limit their recruitment to board-certified internal medicine candidates, but this is probably more a reflection of internists having sustained a foothold in the HM movement and staking out their turf. Nearly all fellowships are one year in length, and most only offer one or two slots. As you can imagine, with such a limited number of positions, the competition is fairly keen, especially in the larger academic programs.

Most programs offer core rotations (similar to residency) but allow some flexibility in selection of electives. Some programs offer several different tracks. For example, Mayo Clinic in Rochester, Minn., offers clinical research, clinician educator, and quality tracks. These are becoming more popular, as they allow the fellow to focus early on a particular area of hospital medicine and, ideally, develop a niche, while becoming a much more attractive candidate for employment.

If I were considering the practice of outpatient adult medicine, I would think about a fellowship in general medicine and target a specific area (e.g., geriatrics or sports medicine). For many reasons, these tend to be less competitive, but as our population ages and current reimbursement strategies are challenged, this may soon change. While there are many clinical principles taught in an HM fellowship that are applicable to outpatient medicine, it would be best to choose the area of interest (inpatient vs. outpatient) and focus your efforts in that direction.

As hospitalists are increasingly being offered more administrative opportunities, several post-graduate degrees or areas of focus are becoming valuable. I would strongly consider pursuing a master’s degree in healthcare management (MHM) or healthcare administration (MHA). Those degrees are offered by a number of top-notch business schools. Nearly all are two-year programs with built-in schedule flexibility, basically geared toward the working professional. A master’s degree in public health (MPH) is also a valued degree and is offered by many outstanding programs. Although most programs attempt to emphasize and train healthcare professionals for the public health arena, there are opportunities to specialize in areas that can be used in hospital management.

As the hospitalist movement matures and the healthcare industry evolves due to market and governmental pressures, there will be many more administrative and clinical opportunities for hospitalists. The clinicians best positioned to take advantage of these opportunities will be those who have some form of post-graduate training supported by strong clinical skills.

Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to drhospit@wiley.com.

Dr. Hospitalist

Fellowships Available to Family Physicians Considering Hospital Medicine Career

I am in my final year of family practice residency. I discovered that I enjoyed hospital medicine much more than I thought I would. I am considering a hospitalist fellowship (one year) to add depth and breadth to my clinical skills. Do you view the clinical knowledge from a fellowship as beneficial to outpatient practice, and, with respect to hospitalist opportunities, are they available to an FP physician?

–Ward Harbin, MD

Dr. Hospitalist responds:

Congratulations on completing your residency. I know it has been a long and arduous journey, but you’re almost there!

I do believe HM fellowships are beneficial for anyone aspiring to become a hospitalist. Even though fewer than 5% of U.S. hospitalists are family practice graduates, there are many opportunities for FP residents to do a fellowship in hospital medicine. Many hospitalist programs limit their recruitment to board-certified internal medicine candidates, but this is probably more a reflection of internists having sustained a foothold in the HM movement and staking out their turf. Nearly all fellowships are one year in length, and most only offer one or two slots. As you can imagine, with such a limited number of positions, the competition is fairly keen, especially in the larger academic programs.

Most programs offer core rotations (similar to residency) but allow some flexibility in selection of electives. Some programs offer several different tracks. For example, Mayo Clinic in Rochester, Minn., offers clinical research, clinician educator, and quality tracks. These are becoming more popular, as they allow the fellow to focus early on a particular area of hospital medicine and, ideally, develop a niche, while becoming a much more attractive candidate for employment.

If I were considering the practice of outpatient adult medicine, I would think about a fellowship in general medicine and target a specific area (e.g., geriatrics or sports medicine). For many reasons, these tend to be less competitive, but as our population ages and current reimbursement strategies are challenged, this may soon change. While there are many clinical principles taught in an HM fellowship that are applicable to outpatient medicine, it would be best to choose the area of interest (inpatient vs. outpatient) and focus your efforts in that direction.

As hospitalists are increasingly being offered more administrative opportunities, several post-graduate degrees or areas of focus are becoming valuable. I would strongly consider pursuing a master’s degree in healthcare management (MHM) or healthcare administration (MHA). Those degrees are offered by a number of top-notch business schools. Nearly all are two-year programs with built-in schedule flexibility, basically geared toward the working professional. A master’s degree in public health (MPH) is also a valued degree and is offered by many outstanding programs. Although most programs attempt to emphasize and train healthcare professionals for the public health arena, there are opportunities to specialize in areas that can be used in hospital management.

As the hospitalist movement matures and the healthcare industry evolves due to market and governmental pressures, there will be many more administrative and clinical opportunities for hospitalists. The clinicians best positioned to take advantage of these opportunities will be those who have some form of post-graduate training supported by strong clinical skills.

Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to drhospit@wiley.com.