Dr.

Team Approach

Question: We work with a large orthopedic group. We would like to propose a more formal structure to this. We are interested in building business and partnerships. Do you know of any articles or references to support hospitalists doing this, or any sources to show the orthopedic group we can and would improve outcomes and their work life and workload?

Julie Lepzinski, director,

hospitalist medicine group,

Michigan

Dr. Hospitalist responds: I commend you and your hospitalist group for taking the initiative to develop a relationship with your orthopedics colleagues. Many hospitalist groups are exploring such relationships with not only orthopedists but also with other surgical and medical subspecialists.

As you mentioned, the opportunity exists to improve your group’s income and improve orthopedist work life. More importantly, there is a real opportunity to improve the medical care of patients admitted to the hospital primarily with orthopedic problems.

There are published data from an academic medical center on a hospitalist-orthopedics co-management model. Huddleston, et al., studied the effect of such a co-management model on the care of patients after elective hip and knee arthroplasty at the Mayo Clinic.1 They found that “the co-management medical hospitalist-orthopedic team model reduced minor postoperative complication rates with no statistically significant difference in length of stay or cost. The nurses and surgeons strongly preferred the co-management hospitalist model.”

This study would seem to support your notion that orthopedists may prefer the involvement of hospitalists in the care of their patients. Hospitalist involvement reduced minor complications (urinary tract infections, fever, electrolyte abnormalities). However, investigators did not find that hospitalist co-management reduced major postoperative complications (death, myocardial infarction, renal failure requiring hemodialysis) or intermediate ones (heart failure, pulmonary embolus, ileus, pneumonia).

Mayo Clinic hospitalists also studied the impact of a hospitalist-orthopedist co-management model of the care on elderly patients admitted to their hospital with hip fracture.2 Phy, et al., found that, “In elderly patients with hip fracture, a hospitalist model decreased time to surgery, time from surgery to dismissal and length of stay without adversely affecting inpatient deaths or 30-day readmission rates.” This study demonstrated that hospitalist co-management can decrease hospital length of stay in this population of patients.

We should recognize the obvious limitations of these studies. They were done at a single large academic institution with a largely Caucasian population at the turn of the century (2000-2001), early in the hospitalist movement. The hospitalist movement has matured, with approximately 20,000 hospitalists in the country. I hope we will soon see more robust data coming from multicenter trials that include a more diverse population of patients as well as a mix of community and academic institutions.

Start an HMG?

Question: We own a medical clinic in Arizona and are thinking of starting a hospitalist group as a separate business entity. Are you aware of any recommended reading or articles on how to start one, if it’s profitable, and in what shape or form? And most important--regarding the current trends and projections--I wonder if the need has changed, as most hospitals reduce their number of vendors.

Shawn Toloui, president and owner,

1st Care Medical Clinic,

Phoenix, Ariz.

Dr. Hospitalist responds: These are the kind of questions people have been asking since the term “hospitalist” was coined in 1996. Over the past decade, we have seen an explosion in the number of hospitalists in the country. Few folks in the 1990s thought there would be 20,000 hospitalists today.

If I understand you correctly, you are concerned that because many hospitals are reducing their numbers of vendors, this may have an adverse effect on the need for hospitalists. Hospitals will engage in business relationships with hospitalists as long as the hospitalists can bring solutions to problems and fulfill needs. To understand this better, let’s examine the reasons the numbers of hospitalists have grown over the past decade.

Costs: When Medicare started paying hospitals based on diagnosis-related groups (DRGs) in the early ’80s, this forced hospitals to “manage” patients’ length of stay. The DRG system pays a fixed fee regardless of the length of stay but allows for an adjusted higher payment based on a hospital’s case mix index (a measure of how “sick” patients are in a given hospital).

This reimbursement system encourages hospitals to take care of ill patients but also to “manage” their length of stay. It is difficult for doctors to manage any hospitalized patients from outpatient offices, let alone sick patients. Hospitals and payers found that hospitalists are able to manage sick patients and reduce costs, mostly by being available to admit, manage, and discharge patients in a timely manner. This increased throughput of patients also allows hospitals to put another patient in a bed sooner, bringing additional revenue.

Quality: By serendipity, the hospitalist movement coincided with the quality movement. Hospitalists have helped reduce variations in care by working locally to develop and implement clinical-care pathways. Hospitalists have also served as partners for hospitals to achieve compliance with payer quality mandates.

For example, in 2003, Medicare began requiring hospitals to report a handful of diagnosis-based quality measures it called the Core Measures. The number of measures continues to grow. In 2007, Medicare tied hospital reimbursement to performance on the Core Measures. I hear from hospital administrators that they find it easier to educate and work with a small group of hospitalists, rather than a large medical staff, to achieve optimal results on these measures.

Satisfaction: The exodus of primary care physicians (PCPs) from the hospital has fueled much of the growth in hospital medicine. PCPs have found it increasingly difficult to care for hospitalized patients while juggling the demands of a busy outpatient practice. In hospitalists, nurses have found a physician partner who is available physically to work with them in the care of acutely ill patients.

PCPs and nurses have been very satisfied with the hospitalist model of care. Although provider satisfaction is important, satisfaction in healthcare begins and ends with patients. Despite the discontinuity of care of meeting a new provider during hospitalization, patients have been satisfied with hospitalist care. Patients view hospitalists as providers available to provide for their acute needs while also communicating with the patients’ outpatient providers to understand their long-term needs.

I expect the number of hospitalists to grow over the next decade, albeit at a slower pace as most programs begin to fill their available positions. SHM believes the numbers of hospitalists will grow to 40,000.

There are a number of resources that can help you understand how to develop, manage, and grow a hospitalist program. I suggest you visit the “Practice Resources” section of the SHM Web site at www.hospitalmedicine.org. In particular, I recommend the “Best Practices in Managing a Hospital Medicine Program,” held twice a year. The spring program is held in conjunction with the SHM Annual Meeting in San Diego, April 3-5. The fall program is held in conjunction with the University of California, San Francisco’s “Management of the Hospitalized Patient” course in San Francisco. Also, the book Hospitalists: A Guide to Building and Sustaining a Successful Program by SHM Senior Vice President Joe Miller and SHM cofounders John Nelson, MD, and Winthrop F. Whitcomb, MD, is a must read for anybody looking to build a hospitalist program. TH

References

1. Huddleston JM, Long KH, Naessens JM, Vanness DJ, Larson D, Trousdale R, Plevak M, et al. Medical and surgical comanagement after elective hip and knee arthroplasty. Ann Intern Med. 2004 July 6;141(1):28-38.
2. Phy MP, Vanness DJ, Melton JL, Hallong K, Schleck C, Larson DR, Huddleston PM. et al. Effects of a hospitalist model on elderly patients with hip fracture. Arch Intern Med. 2005;165:796-801.

Team Approach

Question: We work with a large orthopedic group. We would like to propose a more formal structure to this. We are interested in building business and partnerships. Do you know of any articles or references to support hospitalists doing this, or any sources to show the orthopedic group we can and would improve outcomes and their work life and workload?

Julie Lepzinski, director,

hospitalist medicine group,

Michigan

Dr. Hospitalist responds: I commend you and your hospitalist group for taking the initiative to develop a relationship with your orthopedics colleagues. Many hospitalist groups are exploring such relationships with not only orthopedists but also with other surgical and medical subspecialists.

As you mentioned, the opportunity exists to improve your group’s income and improve orthopedist work life. More importantly, there is a real opportunity to improve the medical care of patients admitted to the hospital primarily with orthopedic problems.

There are published data from an academic medical center on a hospitalist-orthopedics co-management model. Huddleston, et al., studied the effect of such a co-management model on the care of patients after elective hip and knee arthroplasty at the Mayo Clinic.1 They found that “the co-management medical hospitalist-orthopedic team model reduced minor postoperative complication rates with no statistically significant difference in length of stay or cost. The nurses and surgeons strongly preferred the co-management hospitalist model.”

This study would seem to support your notion that orthopedists may prefer the involvement of hospitalists in the care of their patients. Hospitalist involvement reduced minor complications (urinary tract infections, fever, electrolyte abnormalities). However, investigators did not find that hospitalist co-management reduced major postoperative complications (death, myocardial infarction, renal failure requiring hemodialysis) or intermediate ones (heart failure, pulmonary embolus, ileus, pneumonia).

Mayo Clinic hospitalists also studied the impact of a hospitalist-orthopedist co-management model of the care on elderly patients admitted to their hospital with hip fracture.2 Phy, et al., found that, “In elderly patients with hip fracture, a hospitalist model decreased time to surgery, time from surgery to dismissal and length of stay without adversely affecting inpatient deaths or 30-day readmission rates.” This study demonstrated that hospitalist co-management can decrease hospital length of stay in this population of patients.

We should recognize the obvious limitations of these studies. They were done at a single large academic institution with a largely Caucasian population at the turn of the century (2000-2001), early in the hospitalist movement. The hospitalist movement has matured, with approximately 20,000 hospitalists in the country. I hope we will soon see more robust data coming from multicenter trials that include a more diverse population of patients as well as a mix of community and academic institutions.

Start an HMG?

Question: We own a medical clinic in Arizona and are thinking of starting a hospitalist group as a separate business entity. Are you aware of any recommended reading or articles on how to start one, if it’s profitable, and in what shape or form? And most important--regarding the current trends and projections--I wonder if the need has changed, as most hospitals reduce their number of vendors.

Shawn Toloui, president and owner,

1st Care Medical Clinic,

Phoenix, Ariz.

Dr. Hospitalist responds: These are the kind of questions people have been asking since the term “hospitalist” was coined in 1996. Over the past decade, we have seen an explosion in the number of hospitalists in the country. Few folks in the 1990s thought there would be 20,000 hospitalists today.

If I understand you correctly, you are concerned that because many hospitals are reducing their numbers of vendors, this may have an adverse effect on the need for hospitalists. Hospitals will engage in business relationships with hospitalists as long as the hospitalists can bring solutions to problems and fulfill needs. To understand this better, let’s examine the reasons the numbers of hospitalists have grown over the past decade.

Costs: When Medicare started paying hospitals based on diagnosis-related groups (DRGs) in the early ’80s, this forced hospitals to “manage” patients’ length of stay. The DRG system pays a fixed fee regardless of the length of stay but allows for an adjusted higher payment based on a hospital’s case mix index (a measure of how “sick” patients are in a given hospital).

This reimbursement system encourages hospitals to take care of ill patients but also to “manage” their length of stay. It is difficult for doctors to manage any hospitalized patients from outpatient offices, let alone sick patients. Hospitals and payers found that hospitalists are able to manage sick patients and reduce costs, mostly by being available to admit, manage, and discharge patients in a timely manner. This increased throughput of patients also allows hospitals to put another patient in a bed sooner, bringing additional revenue.

Quality: By serendipity, the hospitalist movement coincided with the quality movement. Hospitalists have helped reduce variations in care by working locally to develop and implement clinical-care pathways. Hospitalists have also served as partners for hospitals to achieve compliance with payer quality mandates.

For example, in 2003, Medicare began requiring hospitals to report a handful of diagnosis-based quality measures it called the Core Measures. The number of measures continues to grow. In 2007, Medicare tied hospital reimbursement to performance on the Core Measures. I hear from hospital administrators that they find it easier to educate and work with a small group of hospitalists, rather than a large medical staff, to achieve optimal results on these measures.

Satisfaction: The exodus of primary care physicians (PCPs) from the hospital has fueled much of the growth in hospital medicine. PCPs have found it increasingly difficult to care for hospitalized patients while juggling the demands of a busy outpatient practice. In hospitalists, nurses have found a physician partner who is available physically to work with them in the care of acutely ill patients.

PCPs and nurses have been very satisfied with the hospitalist model of care. Although provider satisfaction is important, satisfaction in healthcare begins and ends with patients. Despite the discontinuity of care of meeting a new provider during hospitalization, patients have been satisfied with hospitalist care. Patients view hospitalists as providers available to provide for their acute needs while also communicating with the patients’ outpatient providers to understand their long-term needs.

I expect the number of hospitalists to grow over the next decade, albeit at a slower pace as most programs begin to fill their available positions. SHM believes the numbers of hospitalists will grow to 40,000.

There are a number of resources that can help you understand how to develop, manage, and grow a hospitalist program. I suggest you visit the “Practice Resources” section of the SHM Web site at www.hospitalmedicine.org. In particular, I recommend the “Best Practices in Managing a Hospital Medicine Program,” held twice a year. The spring program is held in conjunction with the SHM Annual Meeting in San Diego, April 3-5. The fall program is held in conjunction with the University of California, San Francisco’s “Management of the Hospitalized Patient” course in San Francisco. Also, the book Hospitalists: A Guide to Building and Sustaining a Successful Program by SHM Senior Vice President Joe Miller and SHM cofounders John Nelson, MD, and Winthrop F. Whitcomb, MD, is a must read for anybody looking to build a hospitalist program. TH

References

1. Huddleston JM, Long KH, Naessens JM, Vanness DJ, Larson D, Trousdale R, Plevak M, et al. Medical and surgical comanagement after elective hip and knee arthroplasty. Ann Intern Med. 2004 July 6;141(1):28-38.
2. Phy MP, Vanness DJ, Melton JL, Hallong K, Schleck C, Larson DR, Huddleston PM. et al. Effects of a hospitalist model on elderly patients with hip fracture. Arch Intern Med. 2005;165:796-801.

Team Approach

Question: We work with a large orthopedic group. We would like to propose a more formal structure to this. We are interested in building business and partnerships. Do you know of any articles or references to support hospitalists doing this, or any sources to show the orthopedic group we can and would improve outcomes and their work life and workload?

Julie Lepzinski, director,

hospitalist medicine group,

Michigan

Dr. Hospitalist responds: I commend you and your hospitalist group for taking the initiative to develop a relationship with your orthopedics colleagues. Many hospitalist groups are exploring such relationships with not only orthopedists but also with other surgical and medical subspecialists.

As you mentioned, the opportunity exists to improve your group’s income and improve orthopedist work life. More importantly, there is a real opportunity to improve the medical care of patients admitted to the hospital primarily with orthopedic problems.

There are published data from an academic medical center on a hospitalist-orthopedics co-management model. Huddleston, et al., studied the effect of such a co-management model on the care of patients after elective hip and knee arthroplasty at the Mayo Clinic.1 They found that “the co-management medical hospitalist-orthopedic team model reduced minor postoperative complication rates with no statistically significant difference in length of stay or cost. The nurses and surgeons strongly preferred the co-management hospitalist model.”

This study would seem to support your notion that orthopedists may prefer the involvement of hospitalists in the care of their patients. Hospitalist involvement reduced minor complications (urinary tract infections, fever, electrolyte abnormalities). However, investigators did not find that hospitalist co-management reduced major postoperative complications (death, myocardial infarction, renal failure requiring hemodialysis) or intermediate ones (heart failure, pulmonary embolus, ileus, pneumonia).

Mayo Clinic hospitalists also studied the impact of a hospitalist-orthopedist co-management model of the care on elderly patients admitted to their hospital with hip fracture.2 Phy, et al., found that, “In elderly patients with hip fracture, a hospitalist model decreased time to surgery, time from surgery to dismissal and length of stay without adversely affecting inpatient deaths or 30-day readmission rates.” This study demonstrated that hospitalist co-management can decrease hospital length of stay in this population of patients.

We should recognize the obvious limitations of these studies. They were done at a single large academic institution with a largely Caucasian population at the turn of the century (2000-2001), early in the hospitalist movement. The hospitalist movement has matured, with approximately 20,000 hospitalists in the country. I hope we will soon see more robust data coming from multicenter trials that include a more diverse population of patients as well as a mix of community and academic institutions.

Start an HMG?

Question: We own a medical clinic in Arizona and are thinking of starting a hospitalist group as a separate business entity. Are you aware of any recommended reading or articles on how to start one, if it’s profitable, and in what shape or form? And most important--regarding the current trends and projections--I wonder if the need has changed, as most hospitals reduce their number of vendors.

Shawn Toloui, president and owner,

1st Care Medical Clinic,

Phoenix, Ariz.

Dr. Hospitalist responds: These are the kind of questions people have been asking since the term “hospitalist” was coined in 1996. Over the past decade, we have seen an explosion in the number of hospitalists in the country. Few folks in the 1990s thought there would be 20,000 hospitalists today.

If I understand you correctly, you are concerned that because many hospitals are reducing their numbers of vendors, this may have an adverse effect on the need for hospitalists. Hospitals will engage in business relationships with hospitalists as long as the hospitalists can bring solutions to problems and fulfill needs. To understand this better, let’s examine the reasons the numbers of hospitalists have grown over the past decade.

Costs: When Medicare started paying hospitals based on diagnosis-related groups (DRGs) in the early ’80s, this forced hospitals to “manage” patients’ length of stay. The DRG system pays a fixed fee regardless of the length of stay but allows for an adjusted higher payment based on a hospital’s case mix index (a measure of how “sick” patients are in a given hospital).

This reimbursement system encourages hospitals to take care of ill patients but also to “manage” their length of stay. It is difficult for doctors to manage any hospitalized patients from outpatient offices, let alone sick patients. Hospitals and payers found that hospitalists are able to manage sick patients and reduce costs, mostly by being available to admit, manage, and discharge patients in a timely manner. This increased throughput of patients also allows hospitals to put another patient in a bed sooner, bringing additional revenue.

Quality: By serendipity, the hospitalist movement coincided with the quality movement. Hospitalists have helped reduce variations in care by working locally to develop and implement clinical-care pathways. Hospitalists have also served as partners for hospitals to achieve compliance with payer quality mandates.

For example, in 2003, Medicare began requiring hospitals to report a handful of diagnosis-based quality measures it called the Core Measures. The number of measures continues to grow. In 2007, Medicare tied hospital reimbursement to performance on the Core Measures. I hear from hospital administrators that they find it easier to educate and work with a small group of hospitalists, rather than a large medical staff, to achieve optimal results on these measures.

Satisfaction: The exodus of primary care physicians (PCPs) from the hospital has fueled much of the growth in hospital medicine. PCPs have found it increasingly difficult to care for hospitalized patients while juggling the demands of a busy outpatient practice. In hospitalists, nurses have found a physician partner who is available physically to work with them in the care of acutely ill patients.

PCPs and nurses have been very satisfied with the hospitalist model of care. Although provider satisfaction is important, satisfaction in healthcare begins and ends with patients. Despite the discontinuity of care of meeting a new provider during hospitalization, patients have been satisfied with hospitalist care. Patients view hospitalists as providers available to provide for their acute needs while also communicating with the patients’ outpatient providers to understand their long-term needs.

I expect the number of hospitalists to grow over the next decade, albeit at a slower pace as most programs begin to fill their available positions. SHM believes the numbers of hospitalists will grow to 40,000.

There are a number of resources that can help you understand how to develop, manage, and grow a hospitalist program. I suggest you visit the “Practice Resources” section of the SHM Web site at www.hospitalmedicine.org. In particular, I recommend the “Best Practices in Managing a Hospital Medicine Program,” held twice a year. The spring program is held in conjunction with the SHM Annual Meeting in San Diego, April 3-5. The fall program is held in conjunction with the University of California, San Francisco’s “Management of the Hospitalized Patient” course in San Francisco. Also, the book Hospitalists: A Guide to Building and Sustaining a Successful Program by SHM Senior Vice President Joe Miller and SHM cofounders John Nelson, MD, and Winthrop F. Whitcomb, MD, is a must read for anybody looking to build a hospitalist program. TH

References

1. Huddleston JM, Long KH, Naessens JM, Vanness DJ, Larson D, Trousdale R, Plevak M, et al. Medical and surgical comanagement after elective hip and knee arthroplasty. Ann Intern Med. 2004 July 6;141(1):28-38.
2. Phy MP, Vanness DJ, Melton JL, Hallong K, Schleck C, Larson DR, Huddleston PM. et al. Effects of a hospitalist model on elderly patients with hip fracture. Arch Intern Med. 2005;165:796-801.

Sore Loser?

Question: I just heard Medicare will no longer pay for care if a patient develops a bedsore during their hospital stay. Is this true?

Concerned,

Austin, Texas

Dr. Hospitalist responds: Beginning Oct. 1, the Center for Medicare and Medicaid Services (CMS) rolled out the latest change to the Inpatient Prospective Payment System by implementing the following Present on Admission (POA) Indicators:

• Object left in patient after surgery;
• Air embolism;
• Blood incompatibility;
• Catheter-associated urinary tract infections;
• Pressure ulcers (decubitus ulcers);
• Vascular catheter-associated infection;
• Mediastinitis after coronary artery bypass graft;
• Hospital-acquired injuries (fractures, dislocations, intracranial injury); and
• Crushing injury, burn, and other unspecified effects of external causes.

What exactly does this mean? Simply put, if a patient develops any of these conditions during his/her hospital stay, CMS no longer will pay the hospital for additional services associated with treatment of these conditions.

As a healthcare consumer and taxpayer, I believe this measure is long overdue. No patient should ever receive incompatible blood or have an object left in after surgery. Why should we pay for such errors? As hospitalists, our challenge is to develop processes to ensure these events never occur in the hospital. This will require implementing systems as well as educating and training every individual who works in our hospitals.

Coding for these events began Oct. 1 of last year, but payment will not be restricted until Oct. 1 of this year. Coding these events will not only affect hospital payment but will allow for public reporting of hospital performance.

CMS has proposed adding several other conditions for the next fiscal year and is analyzing still more possible conditions.

Proposed for this October:

• DVT and PE;
• Staph aureus septicemia; and
• Ventilator associated pneumonia (VAP).

Conditions under consideration:

• Methicillin-resistant Staphylococcus aureus;
• C. difficile-associated disease; and
• Wrong surgery.

Hospitals are turning to hospitalists not only to help them comply, but to lead the development of systems to improve inpatient care. I encourage you to think about how you can do this at your hospital.

Heart Murmurs

Question: Can you explain why my hospital is asking me to change the way I document heart failure in the chart? They are telling me it is the result of some diagnosis-related group (DRG) rule changes at Medicare that affects how much the hospital gets paid. Is this accurate?

Taking Note,

Louisville, Ky.

Dr. Hospitalist responds: The changes in physician documentation of inpatients with heart failure are part of a larger change in Medicare’s Inpatient Prospective Payment System. The new changes, called Medicare Severity-Adjusted DRGs (MSDRGs), restructured the DRGs to more fully account for the severity of a patient’s medical condition. The change expanded the number of DRGs from 583 to 745 by splitting the DRGs into three tiers:

• Major complication/co-morbidity (MCC);
• -Complication/co-morbidity (CC); and
• No CC.

Physician documentation that reflects chronic systolic and/or diastolic heart failure represents a CC. Documentation of acute systolic and/or acute diastolic heart failure represents an MCC. Documentation that does not describe the type and acuity of a patient’s heart failure condition will result in no CC.

Each DRG has a payment weight assigned to it, based on the average resources used to treat Medicare patients in that DRG. A higher DRG weight represents a more medically complex patient and a correspondingly higher payment. These new classifications affect the heart failure DRG weight values as follows:

Old DRG, heart failure/shock: 1.0490.

New MSDRG, heart failure/shock:

• With MCC: 1.2565;
• With CC: 1.0134; and
• Without CC: 0.8765.

I recently spoke with a hospital administrator at a large urban teaching hospital. Nearly a quarter of the hospital’s Medicare inpatients have heart failure. How physicians document heart failure represents a significant opportunity for hospital revenue ($3 million to $5 million a year). Because of this, I expect you are not alone. Hospital administrators all over the country are likely speaking with their hospitalists about their documentation.

Talk Balk

Question: A pharmaceutical company offered an honorarium for me to give a talk. I heard from a colleague that the company is required to report this payment to the government, which makes this information publicly available. Is this true?

Keynote Doc,

Minneapolis, Minn.

Dr. Hospitalist responds: The answer presently depends on where you live. Five states (California, Maine, Minnesota, West Virginia, Vermont) and the District of Columbia have some form of mandatory disclosure of payments made to physicians by pharmaceutical companies.

Minnesota and Vermont make this information publicly available. Other states may not be far behind. In 2006, 11 states considered similar legislation. But according to Ross, et. al., “the Vermont and Minnesota laws requiring full disclosure of payments do not provide easy access to payment information for the public and are of limited quality once accessed.”1

Proposed federal legislation may resolve this issue. Last fall, Sen. Charles Grassley, R-Iowa, introduced a bill called the Physicians Payments Sunshine Act of 2007. This bill would require drug and device manufacturing companies with more than $25 million in annual revenues to report all gifts in excess of $25 in value to physicians and other prescribing clinicians.

Drug/device samples and payment for clinical trials would be exempt. This data would be available in a public, searchable online database. Companies that fail to disclose would face penalties $10,000 to $100,000 for each undisclosed physician payment.

Industry support has been and will continue to be a controversial issue. Many doctors do not believe honoraria influence prescribing. But it is clear financial payments from industry are facing increasing scrutiny. You’ll need to decide whether you’re comfortable accepting this honorarium if your name will be listed on a publicly available database. TH

Reference

1. Ross JS, Lackner JE, Lurie P, et al. Pharmaceutical company payments to physicians: early experiences with disclosure laws in Vermont and Minnesota. JAMA. 2007;297(11):1216-1223.

Sore Loser?

Question: I just heard Medicare will no longer pay for care if a patient develops a bedsore during their hospital stay. Is this true?

Concerned,

Austin, Texas

Dr. Hospitalist responds: Beginning Oct. 1, the Center for Medicare and Medicaid Services (CMS) rolled out the latest change to the Inpatient Prospective Payment System by implementing the following Present on Admission (POA) Indicators:

• Object left in patient after surgery;
• Air embolism;
• Blood incompatibility;
• Catheter-associated urinary tract infections;
• Pressure ulcers (decubitus ulcers);
• Vascular catheter-associated infection;
• Mediastinitis after coronary artery bypass graft;
• Hospital-acquired injuries (fractures, dislocations, intracranial injury); and
• Crushing injury, burn, and other unspecified effects of external causes.

What exactly does this mean? Simply put, if a patient develops any of these conditions during his/her hospital stay, CMS no longer will pay the hospital for additional services associated with treatment of these conditions.

As a healthcare consumer and taxpayer, I believe this measure is long overdue. No patient should ever receive incompatible blood or have an object left in after surgery. Why should we pay for such errors? As hospitalists, our challenge is to develop processes to ensure these events never occur in the hospital. This will require implementing systems as well as educating and training every individual who works in our hospitals.

Coding for these events began Oct. 1 of last year, but payment will not be restricted until Oct. 1 of this year. Coding these events will not only affect hospital payment but will allow for public reporting of hospital performance.

CMS has proposed adding several other conditions for the next fiscal year and is analyzing still more possible conditions.

Proposed for this October:

• DVT and PE;
• Staph aureus septicemia; and
• Ventilator associated pneumonia (VAP).

Conditions under consideration:

• Methicillin-resistant Staphylococcus aureus;
• C. difficile-associated disease; and
• Wrong surgery.

Hospitals are turning to hospitalists not only to help them comply, but to lead the development of systems to improve inpatient care. I encourage you to think about how you can do this at your hospital.

Heart Murmurs

Question: Can you explain why my hospital is asking me to change the way I document heart failure in the chart? They are telling me it is the result of some diagnosis-related group (DRG) rule changes at Medicare that affects how much the hospital gets paid. Is this accurate?

Taking Note,

Louisville, Ky.

Dr. Hospitalist responds: The changes in physician documentation of inpatients with heart failure are part of a larger change in Medicare’s Inpatient Prospective Payment System. The new changes, called Medicare Severity-Adjusted DRGs (MSDRGs), restructured the DRGs to more fully account for the severity of a patient’s medical condition. The change expanded the number of DRGs from 583 to 745 by splitting the DRGs into three tiers:

• Major complication/co-morbidity (MCC);
• -Complication/co-morbidity (CC); and
• No CC.

Physician documentation that reflects chronic systolic and/or diastolic heart failure represents a CC. Documentation of acute systolic and/or acute diastolic heart failure represents an MCC. Documentation that does not describe the type and acuity of a patient’s heart failure condition will result in no CC.

Each DRG has a payment weight assigned to it, based on the average resources used to treat Medicare patients in that DRG. A higher DRG weight represents a more medically complex patient and a correspondingly higher payment. These new classifications affect the heart failure DRG weight values as follows:

Old DRG, heart failure/shock: 1.0490.

New MSDRG, heart failure/shock:

• With MCC: 1.2565;
• With CC: 1.0134; and
• Without CC: 0.8765.

I recently spoke with a hospital administrator at a large urban teaching hospital. Nearly a quarter of the hospital’s Medicare inpatients have heart failure. How physicians document heart failure represents a significant opportunity for hospital revenue ($3 million to $5 million a year). Because of this, I expect you are not alone. Hospital administrators all over the country are likely speaking with their hospitalists about their documentation.

Talk Balk

Question: A pharmaceutical company offered an honorarium for me to give a talk. I heard from a colleague that the company is required to report this payment to the government, which makes this information publicly available. Is this true?

Keynote Doc,

Minneapolis, Minn.

Dr. Hospitalist responds: The answer presently depends on where you live. Five states (California, Maine, Minnesota, West Virginia, Vermont) and the District of Columbia have some form of mandatory disclosure of payments made to physicians by pharmaceutical companies.

Minnesota and Vermont make this information publicly available. Other states may not be far behind. In 2006, 11 states considered similar legislation. But according to Ross, et. al., “the Vermont and Minnesota laws requiring full disclosure of payments do not provide easy access to payment information for the public and are of limited quality once accessed.”1

Proposed federal legislation may resolve this issue. Last fall, Sen. Charles Grassley, R-Iowa, introduced a bill called the Physicians Payments Sunshine Act of 2007. This bill would require drug and device manufacturing companies with more than $25 million in annual revenues to report all gifts in excess of $25 in value to physicians and other prescribing clinicians.

Drug/device samples and payment for clinical trials would be exempt. This data would be available in a public, searchable online database. Companies that fail to disclose would face penalties $10,000 to $100,000 for each undisclosed physician payment.

Industry support has been and will continue to be a controversial issue. Many doctors do not believe honoraria influence prescribing. But it is clear financial payments from industry are facing increasing scrutiny. You’ll need to decide whether you’re comfortable accepting this honorarium if your name will be listed on a publicly available database. TH

Reference

1. Ross JS, Lackner JE, Lurie P, et al. Pharmaceutical company payments to physicians: early experiences with disclosure laws in Vermont and Minnesota. JAMA. 2007;297(11):1216-1223.

Sore Loser?

Question: I just heard Medicare will no longer pay for care if a patient develops a bedsore during their hospital stay. Is this true?

Concerned,

Austin, Texas

Dr. Hospitalist responds: Beginning Oct. 1, the Center for Medicare and Medicaid Services (CMS) rolled out the latest change to the Inpatient Prospective Payment System by implementing the following Present on Admission (POA) Indicators:

• Object left in patient after surgery;
• Air embolism;
• Blood incompatibility;
• Catheter-associated urinary tract infections;
• Pressure ulcers (decubitus ulcers);
• Vascular catheter-associated infection;
• Mediastinitis after coronary artery bypass graft;
• Hospital-acquired injuries (fractures, dislocations, intracranial injury); and
• Crushing injury, burn, and other unspecified effects of external causes.

What exactly does this mean? Simply put, if a patient develops any of these conditions during his/her hospital stay, CMS no longer will pay the hospital for additional services associated with treatment of these conditions.

As a healthcare consumer and taxpayer, I believe this measure is long overdue. No patient should ever receive incompatible blood or have an object left in after surgery. Why should we pay for such errors? As hospitalists, our challenge is to develop processes to ensure these events never occur in the hospital. This will require implementing systems as well as educating and training every individual who works in our hospitals.

Coding for these events began Oct. 1 of last year, but payment will not be restricted until Oct. 1 of this year. Coding these events will not only affect hospital payment but will allow for public reporting of hospital performance.

CMS has proposed adding several other conditions for the next fiscal year and is analyzing still more possible conditions.

Proposed for this October:

• DVT and PE;
• Staph aureus septicemia; and
• Ventilator associated pneumonia (VAP).

Conditions under consideration:

• Methicillin-resistant Staphylococcus aureus;
• C. difficile-associated disease; and
• Wrong surgery.

Hospitals are turning to hospitalists not only to help them comply, but to lead the development of systems to improve inpatient care. I encourage you to think about how you can do this at your hospital.

Heart Murmurs

Question: Can you explain why my hospital is asking me to change the way I document heart failure in the chart? They are telling me it is the result of some diagnosis-related group (DRG) rule changes at Medicare that affects how much the hospital gets paid. Is this accurate?

Taking Note,

Louisville, Ky.

Dr. Hospitalist responds: The changes in physician documentation of inpatients with heart failure are part of a larger change in Medicare’s Inpatient Prospective Payment System. The new changes, called Medicare Severity-Adjusted DRGs (MSDRGs), restructured the DRGs to more fully account for the severity of a patient’s medical condition. The change expanded the number of DRGs from 583 to 745 by splitting the DRGs into three tiers:

• Major complication/co-morbidity (MCC);
• -Complication/co-morbidity (CC); and
• No CC.

Physician documentation that reflects chronic systolic and/or diastolic heart failure represents a CC. Documentation of acute systolic and/or acute diastolic heart failure represents an MCC. Documentation that does not describe the type and acuity of a patient’s heart failure condition will result in no CC.

Each DRG has a payment weight assigned to it, based on the average resources used to treat Medicare patients in that DRG. A higher DRG weight represents a more medically complex patient and a correspondingly higher payment. These new classifications affect the heart failure DRG weight values as follows:

Old DRG, heart failure/shock: 1.0490.

New MSDRG, heart failure/shock:

• With MCC: 1.2565;
• With CC: 1.0134; and
• Without CC: 0.8765.

I recently spoke with a hospital administrator at a large urban teaching hospital. Nearly a quarter of the hospital’s Medicare inpatients have heart failure. How physicians document heart failure represents a significant opportunity for hospital revenue ($3 million to $5 million a year). Because of this, I expect you are not alone. Hospital administrators all over the country are likely speaking with their hospitalists about their documentation.

Talk Balk

Question: A pharmaceutical company offered an honorarium for me to give a talk. I heard from a colleague that the company is required to report this payment to the government, which makes this information publicly available. Is this true?

Keynote Doc,

Minneapolis, Minn.

Dr. Hospitalist responds: The answer presently depends on where you live. Five states (California, Maine, Minnesota, West Virginia, Vermont) and the District of Columbia have some form of mandatory disclosure of payments made to physicians by pharmaceutical companies.

Minnesota and Vermont make this information publicly available. Other states may not be far behind. In 2006, 11 states considered similar legislation. But according to Ross, et. al., “the Vermont and Minnesota laws requiring full disclosure of payments do not provide easy access to payment information for the public and are of limited quality once accessed.”1

Proposed federal legislation may resolve this issue. Last fall, Sen. Charles Grassley, R-Iowa, introduced a bill called the Physicians Payments Sunshine Act of 2007. This bill would require drug and device manufacturing companies with more than $25 million in annual revenues to report all gifts in excess of $25 in value to physicians and other prescribing clinicians.

Drug/device samples and payment for clinical trials would be exempt. This data would be available in a public, searchable online database. Companies that fail to disclose would face penalties $10,000 to $100,000 for each undisclosed physician payment.

Industry support has been and will continue to be a controversial issue. Many doctors do not believe honoraria influence prescribing. But it is clear financial payments from industry are facing increasing scrutiny. You’ll need to decide whether you’re comfortable accepting this honorarium if your name will be listed on a publicly available database. TH

Reference

1. Ross JS, Lackner JE, Lurie P, et al. Pharmaceutical company payments to physicians: early experiences with disclosure laws in Vermont and Minnesota. JAMA. 2007;297(11):1216-1223.

Docs Around the Clock

Our hospitalist group presently takes out-of-house call at night, but our hospital is pressuring us to move into the hospital 24/7. What should we do?

Afraid of the Dark,

Provo, Utah

Dr. Hospitalist responds: It can be a real challenge to find sufficient providers to staff the hospital nightly. But I encourage you to take this step. I believe there is a quality advantage to having hospitalists in house 24/7 versus having physicians on call at night from outside the hospital.

Hospitalized patients are no less likely to become acutely ill at night as during the day. From a quality perspective, it has never made sense to me why hospitals do not routinely have a physician in house 24/7. Many hospitals say they cannot afford to pay a physician to work in house at night because there are few opportunities to generate revenue. But in today’s environment, can you afford not to have a hospitalist in at night?

Hospitals without hospitalists in at night often encounter issues with patient throughput each morning. Nurses are waiting for physician orders, and physicians are scrambling to write admission notes on patients admitted overnight. This delays morning discharges and admissions, leading to other problems including overcrowding in the emergency department.

Hospitalized patients are now sicker than ever. Delays in evaluations can mean adverse outcomes. Just because the doctor is not in the hospital does not relieve them of any responsibility if a patient suffers an adverse outcome as a result of delay in care. Patients and payers are not only scrutinizing the care patients receive in the hospital but also paying based on performance. Can you and your hospital afford to not provide the timeliest care possible?

Right Night Solution?

Do you think it is better to have dedicated nocturnist(s) or have hospitalist staff members take turns working nights?

Sleepless in San Diego

Dr. Hospitalist responds: There are advantages and disadvantages of having a dedicated nocturnist versus having a rotation model with regular hospitalist staff members taking turns working nights in the hospital. If your hospital has different groups of nurses for days and nights, there may be an advantage to having nocturnists.

This model allows the doctors and nurses to work closely and develop a cohesive team. This would be more difficult if the doctor at night changes frequently. Using nocturnists to staff nights can also make daytime staffing easier or more difficult.

Consider this analogy. At the end of this baseball season, the New York Yankees faced the decision of whether or not to re-sign arguably the best player on the planet, Alex Rodriguez. With A-Rod’s high price tag ($30 million-plus annually), would the Yankees be better served taking this money and signing several players (because we assume no single player could match his talent)? What would happen if they signed A-Rod and he got hurt? Wouldn’t that leave a hole in the lineup the size of the Milky Way?

How different are nocturnists in today’s hospitalist workplace? Most hospitalist programs covet them. They can do things others can’t—work a large number of nights on the schedule. This means fewer or no nights for colleagues, which makes them happier. Nocturnists command a high salary, and if one leaves for your program for any reason, they leave a gaping hole in the schedule.

My advice is to hire a nocturnist but don’t rely solely on nocturnists to cover nights. Covering your night schedule with a mix of nocturnists and staff hospitalists will allow everyone to appreciate the nocturnist but won’t put you in the uncomfortable position of relying solely on nocturnists to keep your program running effectively.

Performance Anxiety

I just started working as a hospitalist. I was told that the federal government surveys patients about the care I provide in the hospital. Is this true?

Newbie in Fort Lauderdale

Dr. Hospitalist responds: I believe you are referring to the Consumer Assessment of Healthcare Providers and Systems (CAHPS) hospital survey. It is a standardized instrument designed to measure patients’ perspective of care in acute care hospitals.

Hospital participation is optional. Many hospitals survey patients about their perceptions of care after they leave the hospital. Press Ganey Associates works with hospitals nationwide to conduct the surveys. The Centers for Medicare and Medicaid Services (CMS) and the Joint Commission encourage hospitals to incorporate the CAHPS questions into any other surveys being performed. The survey has 27 questions that cover seven topic areas:

• Communication with doctors;
• Communication with nurses;
• Hospital staff responsiveness;
• Pain management;
• Communication about medicines;
• Hospital environment; and
• Discharge information.

Three questions ask about communication with doctors:

• How often did the doctors treat you with courtesy and respect?
• How often did doctors listen carefully to you?
• How often did doctors explain things so you could understand?

The survey will produce data that not only will “allow comparison between hospitals, it will create an incentive for hospitals to improve quality of care and to increase accountability by increasing transparency.” Data collection for the initial period from October 2006 to June 2007 will be publicly reported in March 2008 on the Hospital Compare Web site: www.hospitalcompare.hhs.gov. For additional information, go to www.hcaphsonline.org. TH

Docs Around the Clock

Our hospitalist group presently takes out-of-house call at night, but our hospital is pressuring us to move into the hospital 24/7. What should we do?

Afraid of the Dark,

Provo, Utah

Dr. Hospitalist responds: It can be a real challenge to find sufficient providers to staff the hospital nightly. But I encourage you to take this step. I believe there is a quality advantage to having hospitalists in house 24/7 versus having physicians on call at night from outside the hospital.

Hospitalized patients are no less likely to become acutely ill at night as during the day. From a quality perspective, it has never made sense to me why hospitals do not routinely have a physician in house 24/7. Many hospitals say they cannot afford to pay a physician to work in house at night because there are few opportunities to generate revenue. But in today’s environment, can you afford not to have a hospitalist in at night?

Hospitals without hospitalists in at night often encounter issues with patient throughput each morning. Nurses are waiting for physician orders, and physicians are scrambling to write admission notes on patients admitted overnight. This delays morning discharges and admissions, leading to other problems including overcrowding in the emergency department.

Hospitalized patients are now sicker than ever. Delays in evaluations can mean adverse outcomes. Just because the doctor is not in the hospital does not relieve them of any responsibility if a patient suffers an adverse outcome as a result of delay in care. Patients and payers are not only scrutinizing the care patients receive in the hospital but also paying based on performance. Can you and your hospital afford to not provide the timeliest care possible?

Right Night Solution?

Do you think it is better to have dedicated nocturnist(s) or have hospitalist staff members take turns working nights?

Sleepless in San Diego

Dr. Hospitalist responds: There are advantages and disadvantages of having a dedicated nocturnist versus having a rotation model with regular hospitalist staff members taking turns working nights in the hospital. If your hospital has different groups of nurses for days and nights, there may be an advantage to having nocturnists.

This model allows the doctors and nurses to work closely and develop a cohesive team. This would be more difficult if the doctor at night changes frequently. Using nocturnists to staff nights can also make daytime staffing easier or more difficult.

Consider this analogy. At the end of this baseball season, the New York Yankees faced the decision of whether or not to re-sign arguably the best player on the planet, Alex Rodriguez. With A-Rod’s high price tag ($30 million-plus annually), would the Yankees be better served taking this money and signing several players (because we assume no single player could match his talent)? What would happen if they signed A-Rod and he got hurt? Wouldn’t that leave a hole in the lineup the size of the Milky Way?

How different are nocturnists in today’s hospitalist workplace? Most hospitalist programs covet them. They can do things others can’t—work a large number of nights on the schedule. This means fewer or no nights for colleagues, which makes them happier. Nocturnists command a high salary, and if one leaves for your program for any reason, they leave a gaping hole in the schedule.

My advice is to hire a nocturnist but don’t rely solely on nocturnists to cover nights. Covering your night schedule with a mix of nocturnists and staff hospitalists will allow everyone to appreciate the nocturnist but won’t put you in the uncomfortable position of relying solely on nocturnists to keep your program running effectively.

Performance Anxiety

I just started working as a hospitalist. I was told that the federal government surveys patients about the care I provide in the hospital. Is this true?

Newbie in Fort Lauderdale

Dr. Hospitalist responds: I believe you are referring to the Consumer Assessment of Healthcare Providers and Systems (CAHPS) hospital survey. It is a standardized instrument designed to measure patients’ perspective of care in acute care hospitals.

Hospital participation is optional. Many hospitals survey patients about their perceptions of care after they leave the hospital. Press Ganey Associates works with hospitals nationwide to conduct the surveys. The Centers for Medicare and Medicaid Services (CMS) and the Joint Commission encourage hospitals to incorporate the CAHPS questions into any other surveys being performed. The survey has 27 questions that cover seven topic areas:

• Communication with doctors;
• Communication with nurses;
• Hospital staff responsiveness;
• Pain management;
• Communication about medicines;
• Hospital environment; and
• Discharge information.

Three questions ask about communication with doctors:

• How often did the doctors treat you with courtesy and respect?
• How often did doctors listen carefully to you?
• How often did doctors explain things so you could understand?

The survey will produce data that not only will “allow comparison between hospitals, it will create an incentive for hospitals to improve quality of care and to increase accountability by increasing transparency.” Data collection for the initial period from October 2006 to June 2007 will be publicly reported in March 2008 on the Hospital Compare Web site: www.hospitalcompare.hhs.gov. For additional information, go to www.hcaphsonline.org. TH

Docs Around the Clock

Our hospitalist group presently takes out-of-house call at night, but our hospital is pressuring us to move into the hospital 24/7. What should we do?

Afraid of the Dark,

Provo, Utah

Dr. Hospitalist responds: It can be a real challenge to find sufficient providers to staff the hospital nightly. But I encourage you to take this step. I believe there is a quality advantage to having hospitalists in house 24/7 versus having physicians on call at night from outside the hospital.

Hospitalized patients are no less likely to become acutely ill at night as during the day. From a quality perspective, it has never made sense to me why hospitals do not routinely have a physician in house 24/7. Many hospitals say they cannot afford to pay a physician to work in house at night because there are few opportunities to generate revenue. But in today’s environment, can you afford not to have a hospitalist in at night?

Hospitals without hospitalists in at night often encounter issues with patient throughput each morning. Nurses are waiting for physician orders, and physicians are scrambling to write admission notes on patients admitted overnight. This delays morning discharges and admissions, leading to other problems including overcrowding in the emergency department.

Hospitalized patients are now sicker than ever. Delays in evaluations can mean adverse outcomes. Just because the doctor is not in the hospital does not relieve them of any responsibility if a patient suffers an adverse outcome as a result of delay in care. Patients and payers are not only scrutinizing the care patients receive in the hospital but also paying based on performance. Can you and your hospital afford to not provide the timeliest care possible?

Right Night Solution?

Do you think it is better to have dedicated nocturnist(s) or have hospitalist staff members take turns working nights?

Sleepless in San Diego

Dr. Hospitalist responds: There are advantages and disadvantages of having a dedicated nocturnist versus having a rotation model with regular hospitalist staff members taking turns working nights in the hospital. If your hospital has different groups of nurses for days and nights, there may be an advantage to having nocturnists.

This model allows the doctors and nurses to work closely and develop a cohesive team. This would be more difficult if the doctor at night changes frequently. Using nocturnists to staff nights can also make daytime staffing easier or more difficult.

Consider this analogy. At the end of this baseball season, the New York Yankees faced the decision of whether or not to re-sign arguably the best player on the planet, Alex Rodriguez. With A-Rod’s high price tag ($30 million-plus annually), would the Yankees be better served taking this money and signing several players (because we assume no single player could match his talent)? What would happen if they signed A-Rod and he got hurt? Wouldn’t that leave a hole in the lineup the size of the Milky Way?

How different are nocturnists in today’s hospitalist workplace? Most hospitalist programs covet them. They can do things others can’t—work a large number of nights on the schedule. This means fewer or no nights for colleagues, which makes them happier. Nocturnists command a high salary, and if one leaves for your program for any reason, they leave a gaping hole in the schedule.

My advice is to hire a nocturnist but don’t rely solely on nocturnists to cover nights. Covering your night schedule with a mix of nocturnists and staff hospitalists will allow everyone to appreciate the nocturnist but won’t put you in the uncomfortable position of relying solely on nocturnists to keep your program running effectively.

Performance Anxiety

I just started working as a hospitalist. I was told that the federal government surveys patients about the care I provide in the hospital. Is this true?

Newbie in Fort Lauderdale

Dr. Hospitalist responds: I believe you are referring to the Consumer Assessment of Healthcare Providers and Systems (CAHPS) hospital survey. It is a standardized instrument designed to measure patients’ perspective of care in acute care hospitals.

Hospital participation is optional. Many hospitals survey patients about their perceptions of care after they leave the hospital. Press Ganey Associates works with hospitals nationwide to conduct the surveys. The Centers for Medicare and Medicaid Services (CMS) and the Joint Commission encourage hospitals to incorporate the CAHPS questions into any other surveys being performed. The survey has 27 questions that cover seven topic areas:

• Communication with doctors;
• Communication with nurses;
• Hospital staff responsiveness;
• Pain management;
• Communication about medicines;
• Hospital environment; and
• Discharge information.

Three questions ask about communication with doctors:

• How often did the doctors treat you with courtesy and respect?
• How often did doctors listen carefully to you?
• How often did doctors explain things so you could understand?

The survey will produce data that not only will “allow comparison between hospitals, it will create an incentive for hospitals to improve quality of care and to increase accountability by increasing transparency.” Data collection for the initial period from October 2006 to June 2007 will be publicly reported in March 2008 on the Hospital Compare Web site: www.hospitalcompare.hhs.gov. For additional information, go to www.hcaphsonline.org. TH

Question: I am working too hard and getting paid too little. Is there any easy to figure out if I am getting paid what I am worth?

Show Me the Money, Austin, Texas

Dr. Hospitalist responds: I suspect you may have already asked hospitalists you know about how much they make and compared schedules. Although this may be sadistically fun (alas, misery loves company), there are problems with this approach.

Your perspective is limited to friends and colleagues willing to share this information. Some people are reluctant to talk money, others have a tendency to embellish their productivity. I am not saying folks would intentionally lie to you (wink, nod), but who would tell you they feel overpaid and do not work hard?

What you need are objective data. You and a couple of colleagues could develop a survey, send it to every hospitalist you know, and hope they respond. But even if you did, how often could you muster the energy to do this to keep your data up to date?

Remember, you are doing this survey to demonstrate you are compensated appropriately for how much work you produce. Lucky for you, several organizations collect physician productivity and compensation data, including SHM and the Medical Group Management Association (MGMA). But there are differences in the data.

Some believe the MGMA data set may include information from primary care groups with inpatient rounders in addition to full-time hospitalists. Meanwhile, SHM data were last collected in November 2005. SHM collects updated information from hospitalists around the country. They will make those findings available at the next SHM annual meeting in San Diego in April 2008.

This will also be the first survey done since Medicare moved to the new 2007 relative value unit (RVU) values. Hospitalists who contribute to the survey can access the data for free. I suppose critics could argue that the approach taken by these groups is subject to bias because individuals could submit false data. This is all the more reason I would encourage you to submit data to the SHM survey. The larger the sample size, the more difficult it will be for any one individual’s data to warp the survey.

Speak Up

Question: I know hospitalists should communicate with primary care physicians (PCPs) about their patients, but I find it takes a lot of time for me to call their offices. Is there an easier way to do this? I am also not completely sure of when I should communicate. Any suggestions?

No Time to Talk, Atlanta

Dr. Hospitalist responds: Let me guess. Your “communication” with the PCP goes something like this: You pick up the telephone to call a patient’s PCP. After sitting on hold for what seems like eternity (your pager rings repeatedly during this time), a voice on the other end of line tells you that the doctor is in an exam room. “Do you want me to interrupt him?”

Do you say yes and run the risk of sitting on hold another five minutes? Or do you decide whatever you had to say really isn’t that important? But don’t you need that outpatient medication list? Do you really have to tell the PCP about the ongoing end of life discussions with the patient? What’s a hospitalist to do?

This method of communication may have worked when you were a resident in training, when your workload was capped and your attending physician had to make time for your calls. But try this as a hospitalist and you’ll quickly discover you don’t have enough hours each day.

When working out a relationship with a PCP, hospitalists should engage the PCP in a discussion about how they should communicate. For example, the hospitalist and PCP may agree that each time a patient presents for admission, the hospitalist will ask the hospitalist administrative assistant to fax the PCP office. A fax with admission diagnoses will not only serve as notification of admission but also as a request for information from the PCP.

As important as it is for the hospitalist to get his staff to fax the request in a timely manner, the PCP will have to do the same with his/her office staff. In such a system, the hospitalist and the PCP communicate about admissions via their administrative staff. If the PCP or hospitalist has further questions, the expectation may be that a page will be in order. But for the majority of admissions, that won’t be necessary.

I have seen hospitalists and PCPs handle routine communication in a variety of ways: phone calls, face-to-face discussion, e-mail, voicemail, discharge summaries/letters, fax notification of admission, pages. No single method works well with all groups all the time. To succeed, communication:

• Must be timely, easy to understand, and concise;
• Must be efficient for the communicator and the recipient, not labor intensive;
• Should occur at each transition in care; and
• Should meet privacy guidelines.

Communicators must understand the rules of engagement and share common expectations. Ideally, there should be a paper trail or other record.

Hiring is Work

Question: My group is having a hard time recruiting physicians. How can we do better?

Need Help, Richmond, Va.

Dr. Hospitalist responds: If it’s any consolation, you’re not alone. Look at the number of pages devoted to job ads in this issue of The Hospitalist and you’ll understand the high demand for hospitalists. There are about 20,000 hospitalists in the country, and many believe there is room for double that number. Advertising and hiring qualified staff is not a challenge unique to hospital medicine, but most hospitalists received no training on how to do it. Most hospitalists underestimate the time and resources it takes to recruit and hire staff.

Here are some hiring hints to help you and your hospitalist program maximize your success.

The first step is to create a job description. Before you can describe the job to prospective hospitalists, you need a clear understanding yourself. I would expect applicants to ask some of the following questions:

• Do your hospitalists to work days, nights or a combination of both?
• What about weekdays versus weekends?
• How does your group handle admissions versus daily rounding?
• Do your hospitalists provide consultative services?
• Are there teaching responsibilities?
• How many patients do you expect each hospitalists to see daily?

Based on your job description, how do you expect to compensate your hospitalists? Do your homework and find out what competitors are paying for similar job descriptions. While there are many reasons prospective hospitalists might accept an offer, salary is often not the only reason. What else is part of your compensation package? It might include some of the following:

• A retirement plan, like a 401k/ 403b or a pension;
• Paid parking;
• Continuing-education stipend;
• Productivity incentive;
• Access to health, life and/or disability insurance;
• Paid malpractice insurance; and
• Ownership/equity opportunity.

Once you create an attractive job description with a competitive compensation package, it’s time to get the word out. There are many options for reaching prospective candidates:

• Advertise in journals and online;
• Advertise at meetings;
• Tell friends, colleagues and nurses;
• Work with your hospital’s recruiter;
• Send targeted mailings; and
• Be seen at local hospitalist events.

Once you have an applicant interested, it’s time to close the deal. Qualified applicants are likely going to field offers from several groups. Why should the applicant accept your offer over another? Here are several incentives:

• Signing bonus;
• Relocation package;
• Loan forgiveness;
• Title for an administrative role; and
• Opportunity for advancement.

Don’t underestimate the effect of a simple phone call or e-mail to your candidate after the interview. I can’t emphasize how often I hear people say they joined a group because they felt as though they fit in well.

Hiring is a year-round group effort. The most important resource in any hospitalist program is staff. Recruitment, hiring, and retention should be a primary goal of any hospitalist medical director. TH

Question: I am working too hard and getting paid too little. Is there any easy to figure out if I am getting paid what I am worth?

Show Me the Money, Austin, Texas

Dr. Hospitalist responds: I suspect you may have already asked hospitalists you know about how much they make and compared schedules. Although this may be sadistically fun (alas, misery loves company), there are problems with this approach.

Your perspective is limited to friends and colleagues willing to share this information. Some people are reluctant to talk money, others have a tendency to embellish their productivity. I am not saying folks would intentionally lie to you (wink, nod), but who would tell you they feel overpaid and do not work hard?

What you need are objective data. You and a couple of colleagues could develop a survey, send it to every hospitalist you know, and hope they respond. But even if you did, how often could you muster the energy to do this to keep your data up to date?

Remember, you are doing this survey to demonstrate you are compensated appropriately for how much work you produce. Lucky for you, several organizations collect physician productivity and compensation data, including SHM and the Medical Group Management Association (MGMA). But there are differences in the data.

Some believe the MGMA data set may include information from primary care groups with inpatient rounders in addition to full-time hospitalists. Meanwhile, SHM data were last collected in November 2005. SHM collects updated information from hospitalists around the country. They will make those findings available at the next SHM annual meeting in San Diego in April 2008.

This will also be the first survey done since Medicare moved to the new 2007 relative value unit (RVU) values. Hospitalists who contribute to the survey can access the data for free. I suppose critics could argue that the approach taken by these groups is subject to bias because individuals could submit false data. This is all the more reason I would encourage you to submit data to the SHM survey. The larger the sample size, the more difficult it will be for any one individual’s data to warp the survey.

Speak Up

Question: I know hospitalists should communicate with primary care physicians (PCPs) about their patients, but I find it takes a lot of time for me to call their offices. Is there an easier way to do this? I am also not completely sure of when I should communicate. Any suggestions?

No Time to Talk, Atlanta

Dr. Hospitalist responds: Let me guess. Your “communication” with the PCP goes something like this: You pick up the telephone to call a patient’s PCP. After sitting on hold for what seems like eternity (your pager rings repeatedly during this time), a voice on the other end of line tells you that the doctor is in an exam room. “Do you want me to interrupt him?”

Do you say yes and run the risk of sitting on hold another five minutes? Or do you decide whatever you had to say really isn’t that important? But don’t you need that outpatient medication list? Do you really have to tell the PCP about the ongoing end of life discussions with the patient? What’s a hospitalist to do?

This method of communication may have worked when you were a resident in training, when your workload was capped and your attending physician had to make time for your calls. But try this as a hospitalist and you’ll quickly discover you don’t have enough hours each day.

When working out a relationship with a PCP, hospitalists should engage the PCP in a discussion about how they should communicate. For example, the hospitalist and PCP may agree that each time a patient presents for admission, the hospitalist will ask the hospitalist administrative assistant to fax the PCP office. A fax with admission diagnoses will not only serve as notification of admission but also as a request for information from the PCP.

As important as it is for the hospitalist to get his staff to fax the request in a timely manner, the PCP will have to do the same with his/her office staff. In such a system, the hospitalist and the PCP communicate about admissions via their administrative staff. If the PCP or hospitalist has further questions, the expectation may be that a page will be in order. But for the majority of admissions, that won’t be necessary.

I have seen hospitalists and PCPs handle routine communication in a variety of ways: phone calls, face-to-face discussion, e-mail, voicemail, discharge summaries/letters, fax notification of admission, pages. No single method works well with all groups all the time. To succeed, communication:

• Must be timely, easy to understand, and concise;
• Must be efficient for the communicator and the recipient, not labor intensive;
• Should occur at each transition in care; and
• Should meet privacy guidelines.

Communicators must understand the rules of engagement and share common expectations. Ideally, there should be a paper trail or other record.

Hiring is Work

Question: My group is having a hard time recruiting physicians. How can we do better?

Need Help, Richmond, Va.

Dr. Hospitalist responds: If it’s any consolation, you’re not alone. Look at the number of pages devoted to job ads in this issue of The Hospitalist and you’ll understand the high demand for hospitalists. There are about 20,000 hospitalists in the country, and many believe there is room for double that number. Advertising and hiring qualified staff is not a challenge unique to hospital medicine, but most hospitalists received no training on how to do it. Most hospitalists underestimate the time and resources it takes to recruit and hire staff.

Here are some hiring hints to help you and your hospitalist program maximize your success.

The first step is to create a job description. Before you can describe the job to prospective hospitalists, you need a clear understanding yourself. I would expect applicants to ask some of the following questions:

• Do your hospitalists to work days, nights or a combination of both?
• What about weekdays versus weekends?
• How does your group handle admissions versus daily rounding?
• Do your hospitalists provide consultative services?
• Are there teaching responsibilities?
• How many patients do you expect each hospitalists to see daily?

Based on your job description, how do you expect to compensate your hospitalists? Do your homework and find out what competitors are paying for similar job descriptions. While there are many reasons prospective hospitalists might accept an offer, salary is often not the only reason. What else is part of your compensation package? It might include some of the following:

• A retirement plan, like a 401k/ 403b or a pension;
• Paid parking;
• Continuing-education stipend;
• Productivity incentive;
• Access to health, life and/or disability insurance;
• Paid malpractice insurance; and
• Ownership/equity opportunity.

Once you create an attractive job description with a competitive compensation package, it’s time to get the word out. There are many options for reaching prospective candidates:

• Advertise in journals and online;
• Advertise at meetings;
• Tell friends, colleagues and nurses;
• Work with your hospital’s recruiter;
• Send targeted mailings; and
• Be seen at local hospitalist events.

Once you have an applicant interested, it’s time to close the deal. Qualified applicants are likely going to field offers from several groups. Why should the applicant accept your offer over another? Here are several incentives:

• Signing bonus;
• Relocation package;
• Loan forgiveness;
• Title for an administrative role; and
• Opportunity for advancement.

Don’t underestimate the effect of a simple phone call or e-mail to your candidate after the interview. I can’t emphasize how often I hear people say they joined a group because they felt as though they fit in well.

Hiring is a year-round group effort. The most important resource in any hospitalist program is staff. Recruitment, hiring, and retention should be a primary goal of any hospitalist medical director. TH

Question: I am working too hard and getting paid too little. Is there any easy to figure out if I am getting paid what I am worth?

Show Me the Money, Austin, Texas

Dr. Hospitalist responds: I suspect you may have already asked hospitalists you know about how much they make and compared schedules. Although this may be sadistically fun (alas, misery loves company), there are problems with this approach.

Your perspective is limited to friends and colleagues willing to share this information. Some people are reluctant to talk money, others have a tendency to embellish their productivity. I am not saying folks would intentionally lie to you (wink, nod), but who would tell you they feel overpaid and do not work hard?

What you need are objective data. You and a couple of colleagues could develop a survey, send it to every hospitalist you know, and hope they respond. But even if you did, how often could you muster the energy to do this to keep your data up to date?

Remember, you are doing this survey to demonstrate you are compensated appropriately for how much work you produce. Lucky for you, several organizations collect physician productivity and compensation data, including SHM and the Medical Group Management Association (MGMA). But there are differences in the data.

Some believe the MGMA data set may include information from primary care groups with inpatient rounders in addition to full-time hospitalists. Meanwhile, SHM data were last collected in November 2005. SHM collects updated information from hospitalists around the country. They will make those findings available at the next SHM annual meeting in San Diego in April 2008.

This will also be the first survey done since Medicare moved to the new 2007 relative value unit (RVU) values. Hospitalists who contribute to the survey can access the data for free. I suppose critics could argue that the approach taken by these groups is subject to bias because individuals could submit false data. This is all the more reason I would encourage you to submit data to the SHM survey. The larger the sample size, the more difficult it will be for any one individual’s data to warp the survey.

Speak Up

Question: I know hospitalists should communicate with primary care physicians (PCPs) about their patients, but I find it takes a lot of time for me to call their offices. Is there an easier way to do this? I am also not completely sure of when I should communicate. Any suggestions?

No Time to Talk, Atlanta

Dr. Hospitalist responds: Let me guess. Your “communication” with the PCP goes something like this: You pick up the telephone to call a patient’s PCP. After sitting on hold for what seems like eternity (your pager rings repeatedly during this time), a voice on the other end of line tells you that the doctor is in an exam room. “Do you want me to interrupt him?”

Do you say yes and run the risk of sitting on hold another five minutes? Or do you decide whatever you had to say really isn’t that important? But don’t you need that outpatient medication list? Do you really have to tell the PCP about the ongoing end of life discussions with the patient? What’s a hospitalist to do?

This method of communication may have worked when you were a resident in training, when your workload was capped and your attending physician had to make time for your calls. But try this as a hospitalist and you’ll quickly discover you don’t have enough hours each day.

When working out a relationship with a PCP, hospitalists should engage the PCP in a discussion about how they should communicate. For example, the hospitalist and PCP may agree that each time a patient presents for admission, the hospitalist will ask the hospitalist administrative assistant to fax the PCP office. A fax with admission diagnoses will not only serve as notification of admission but also as a request for information from the PCP.

As important as it is for the hospitalist to get his staff to fax the request in a timely manner, the PCP will have to do the same with his/her office staff. In such a system, the hospitalist and the PCP communicate about admissions via their administrative staff. If the PCP or hospitalist has further questions, the expectation may be that a page will be in order. But for the majority of admissions, that won’t be necessary.

I have seen hospitalists and PCPs handle routine communication in a variety of ways: phone calls, face-to-face discussion, e-mail, voicemail, discharge summaries/letters, fax notification of admission, pages. No single method works well with all groups all the time. To succeed, communication:

• Must be timely, easy to understand, and concise;
• Must be efficient for the communicator and the recipient, not labor intensive;
• Should occur at each transition in care; and
• Should meet privacy guidelines.

Communicators must understand the rules of engagement and share common expectations. Ideally, there should be a paper trail or other record.

Hiring is Work

Question: My group is having a hard time recruiting physicians. How can we do better?

Need Help, Richmond, Va.

Dr. Hospitalist responds: If it’s any consolation, you’re not alone. Look at the number of pages devoted to job ads in this issue of The Hospitalist and you’ll understand the high demand for hospitalists. There are about 20,000 hospitalists in the country, and many believe there is room for double that number. Advertising and hiring qualified staff is not a challenge unique to hospital medicine, but most hospitalists received no training on how to do it. Most hospitalists underestimate the time and resources it takes to recruit and hire staff.

Here are some hiring hints to help you and your hospitalist program maximize your success.

The first step is to create a job description. Before you can describe the job to prospective hospitalists, you need a clear understanding yourself. I would expect applicants to ask some of the following questions:

• Do your hospitalists to work days, nights or a combination of both?
• What about weekdays versus weekends?
• How does your group handle admissions versus daily rounding?
• Do your hospitalists provide consultative services?
• Are there teaching responsibilities?
• How many patients do you expect each hospitalists to see daily?

Based on your job description, how do you expect to compensate your hospitalists? Do your homework and find out what competitors are paying for similar job descriptions. While there are many reasons prospective hospitalists might accept an offer, salary is often not the only reason. What else is part of your compensation package? It might include some of the following:

• A retirement plan, like a 401k/ 403b or a pension;
• Paid parking;
• Continuing-education stipend;
• Productivity incentive;
• Access to health, life and/or disability insurance;
• Paid malpractice insurance; and
• Ownership/equity opportunity.

Once you create an attractive job description with a competitive compensation package, it’s time to get the word out. There are many options for reaching prospective candidates:

• Advertise in journals and online;
• Advertise at meetings;
• Tell friends, colleagues and nurses;
• Work with your hospital’s recruiter;
• Send targeted mailings; and
• Be seen at local hospitalist events.

Once you have an applicant interested, it’s time to close the deal. Qualified applicants are likely going to field offers from several groups. Why should the applicant accept your offer over another? Here are several incentives:

• Signing bonus;
• Relocation package;
• Loan forgiveness;
• Title for an administrative role; and
• Opportunity for advancement.

Don’t underestimate the effect of a simple phone call or e-mail to your candidate after the interview. I can’t emphasize how often I hear people say they joined a group because they felt as though they fit in well.

Hiring is a year-round group effort. The most important resource in any hospitalist program is staff. Recruitment, hiring, and retention should be a primary goal of any hospitalist medical director. TH

The Boutique Lure

Question: I recently received a brochure in the mail about a hospital that caters only to cardiac patients. While I think this job sounds intriguing, I’m concerned that this may be a boutique hospital. What do you think of the movement toward boutique hospitals? Do you think they are ethical?

Curious in Boston

Dr. Hospitalist responds: Boutique or specialty hospitals have been hotly debated among healthcare policymakers over the past few years. Compared with the number of general hospitals, the numbers of specialty hospitals—typically those that focus on cardiac, orthopedic, surgical, and women’s procedures—are small.

A Government Accounting Office (GAO) report in 2003 identified 100 such hospitals in the country. More than two-thirds of the hospitals are in seven states (Arizona, California, Kansas, Oklahoma, Louisiana, South Dakota, and Texas).

The GAO found that compared with general hospitals, specialty hospitals are “much less likely to have emergency departments, treated smaller percentages of Medicaid patients and derived a smaller share of their revenues from inpatient services.” Although small, this is a growing segment of the healthcare industry.

Specialty hospitals are controversial because many are for-profit and often owned by some of the physicians who work at the hospital. Specialty hospital supporters believe competition between specialty and general hospitals for services can lower costs and improve care.

A 2005 Medicare Payment Advisory Commission study found that physician-owned specialty hospitals decreased lengths of stay but didn’t lower costs for Medicare patients.

In general, specialty hospitals treated less-severe cases and tended to have lower numbers of Medicaid patients than community hospitals.

Specialty care hospital critics are concerned that specialty hospitals take care of the most profitable patients (those who are less ill) and leave the general hospital with the sicker patients who incur higher costs.

They fear growing numbers of specialty hospitals will make it financially difficult for general hospitals to meet all of a community’s needs, including charity care and emergency services.

Critics are also concerned that physician ownership of specialty hospitals could affect physicians’ clinical behavior by driving inappropriate referrals.

You may remember that the federal Stark law (named after Rep. Peter Stark, D-Calif.) generally prohibits physicians from referring Medicare patients for healthcare services to facilities where they have financial interests.

This law was enacted after several studies demonstrated that physicians with ownership interest in clinical laboratories, diagnostic imaging centers, and physical therapy providers made more referrals to these centers and ordered more services at higher costs.

The Stark law lets physicians who have an ownership interest in an entire hospital and are authorized to perform services there to refer patients to that hospital.

As you consider this opportunity, further investigate the risks, benefits, and potential effect of the specialty hospital on your community and our healthcare system.

Holiday Dilemma

Question: I just took over scheduling for our hospitalist group. I’ve been practicing nearly two years and am wondering how to staff holidays. I’m finding it difficult handling the multiple requests for Thanksgiving, Christmas, and New Year’s Eve. Do you know of any innovative scheduling techniques?

Schedule Grinch in Philadelphia

Dr. Hospitalist responds: Congratulations on your new responsibility! I write this with my tongue firmly planted in my cheek. As you now realize, completing the schedule is not easy.

Unfortunately, most hospitalists don’t recognize the enormous challenge one faces in filling the schedule until they are given the task.

Unless you were a chief medical resident, you probably didn’t learn or practice scheduling in the course of your medical training. Inevitably, everyone wants and expects to get their choice of days off. Of course, that is rarely possible.

How do you make everyone happy? It is important to recognize that making everyone happy every time is not possible. But it is possible and important to be fair to everyone all the time. There are some steps you can take to ensure the scheduling process is fair.

The first step is to set appropriate expectations. It is critical for the group leader and the staff member making the schedule to help each group member understand the enormous challenges that come with scheduling.

Providers who understand the difficulties of scheduling will be more understanding and accommodating in their requests.

The second step is to establish and clearly state the rules of engagement. For example, be explicit in explaining the rules for submitting requests and the deadline for requests. Avoid misconceptions by stating when the final schedule will be revealed.

The last step is to clearly state how to handle requests for schedule changes. Many hospitalist groups keep track of who works which holidays so the distribution of work on holidays is fair from year to year.

I have one last suggestion. Consider rotating the job of scheduling so everyone understands firsthand the challenges of the job. To entice people to assume this responsibility, the job should come with remuneration—either salary support and/or preference in choosing their own holiday schedule.

Of course, recognize that not everyone will want the job or be good at it. An effective group leader helps individuals identify opportunities and helps them succeed.

Foreign Medical Grads

Question: What’s your opinion on the effect of foreign medical graduates in the U.S.?

IMG in Cincinnati

Dr. Hospitalist responds: The U.S. healthcare system would be quite different without foreign (aka international) medical graduates (IMGs), who play important clinical, educational, administrative, and research roles.

Some physicians and patients believe medical education outside this country is inferior. In some cases, they are correct—in others, they could not be more wrong. Medical education outside this country varies in standards and curricula.

Many people are not aware that IMGs who wish to enter an Accreditation Council for Graduate Medical Education residency of fellowship program in the United States must have Educational Commission for Foreign Medical Graduates (ECFMG) certification. ECFMG certification requires the applicant to pass a series of examinations, including United States Medical Licensing Examination (USMLE) Steps 1 and 2.

ECFMG certification is also required before an applicant can take Step 3 of the USMLE and is required before a physician can obtain an unrestricted license to practice medicine in the United States.

I suspect some IMGs face discrimination in this country because some may speak with an accent. But truth be told, the United States healthcare system could not exist without the contributions made by IMGs. TH

The Boutique Lure

Question: I recently received a brochure in the mail about a hospital that caters only to cardiac patients. While I think this job sounds intriguing, I’m concerned that this may be a boutique hospital. What do you think of the movement toward boutique hospitals? Do you think they are ethical?

Curious in Boston

Dr. Hospitalist responds: Boutique or specialty hospitals have been hotly debated among healthcare policymakers over the past few years. Compared with the number of general hospitals, the numbers of specialty hospitals—typically those that focus on cardiac, orthopedic, surgical, and women’s procedures—are small.

A Government Accounting Office (GAO) report in 2003 identified 100 such hospitals in the country. More than two-thirds of the hospitals are in seven states (Arizona, California, Kansas, Oklahoma, Louisiana, South Dakota, and Texas).

The GAO found that compared with general hospitals, specialty hospitals are “much less likely to have emergency departments, treated smaller percentages of Medicaid patients and derived a smaller share of their revenues from inpatient services.” Although small, this is a growing segment of the healthcare industry.

Specialty hospitals are controversial because many are for-profit and often owned by some of the physicians who work at the hospital. Specialty hospital supporters believe competition between specialty and general hospitals for services can lower costs and improve care.

A 2005 Medicare Payment Advisory Commission study found that physician-owned specialty hospitals decreased lengths of stay but didn’t lower costs for Medicare patients.

In general, specialty hospitals treated less-severe cases and tended to have lower numbers of Medicaid patients than community hospitals.

Specialty care hospital critics are concerned that specialty hospitals take care of the most profitable patients (those who are less ill) and leave the general hospital with the sicker patients who incur higher costs.

They fear growing numbers of specialty hospitals will make it financially difficult for general hospitals to meet all of a community’s needs, including charity care and emergency services.

Critics are also concerned that physician ownership of specialty hospitals could affect physicians’ clinical behavior by driving inappropriate referrals.

You may remember that the federal Stark law (named after Rep. Peter Stark, D-Calif.) generally prohibits physicians from referring Medicare patients for healthcare services to facilities where they have financial interests.

This law was enacted after several studies demonstrated that physicians with ownership interest in clinical laboratories, diagnostic imaging centers, and physical therapy providers made more referrals to these centers and ordered more services at higher costs.

The Stark law lets physicians who have an ownership interest in an entire hospital and are authorized to perform services there to refer patients to that hospital.

As you consider this opportunity, further investigate the risks, benefits, and potential effect of the specialty hospital on your community and our healthcare system.

Holiday Dilemma

Question: I just took over scheduling for our hospitalist group. I’ve been practicing nearly two years and am wondering how to staff holidays. I’m finding it difficult handling the multiple requests for Thanksgiving, Christmas, and New Year’s Eve. Do you know of any innovative scheduling techniques?

Schedule Grinch in Philadelphia

Dr. Hospitalist responds: Congratulations on your new responsibility! I write this with my tongue firmly planted in my cheek. As you now realize, completing the schedule is not easy.

Unfortunately, most hospitalists don’t recognize the enormous challenge one faces in filling the schedule until they are given the task.

Unless you were a chief medical resident, you probably didn’t learn or practice scheduling in the course of your medical training. Inevitably, everyone wants and expects to get their choice of days off. Of course, that is rarely possible.

How do you make everyone happy? It is important to recognize that making everyone happy every time is not possible. But it is possible and important to be fair to everyone all the time. There are some steps you can take to ensure the scheduling process is fair.

The first step is to set appropriate expectations. It is critical for the group leader and the staff member making the schedule to help each group member understand the enormous challenges that come with scheduling.

Providers who understand the difficulties of scheduling will be more understanding and accommodating in their requests.

The second step is to establish and clearly state the rules of engagement. For example, be explicit in explaining the rules for submitting requests and the deadline for requests. Avoid misconceptions by stating when the final schedule will be revealed.

The last step is to clearly state how to handle requests for schedule changes. Many hospitalist groups keep track of who works which holidays so the distribution of work on holidays is fair from year to year.

I have one last suggestion. Consider rotating the job of scheduling so everyone understands firsthand the challenges of the job. To entice people to assume this responsibility, the job should come with remuneration—either salary support and/or preference in choosing their own holiday schedule.

Of course, recognize that not everyone will want the job or be good at it. An effective group leader helps individuals identify opportunities and helps them succeed.

Foreign Medical Grads

Question: What’s your opinion on the effect of foreign medical graduates in the U.S.?

IMG in Cincinnati

Dr. Hospitalist responds: The U.S. healthcare system would be quite different without foreign (aka international) medical graduates (IMGs), who play important clinical, educational, administrative, and research roles.

Some physicians and patients believe medical education outside this country is inferior. In some cases, they are correct—in others, they could not be more wrong. Medical education outside this country varies in standards and curricula.

Many people are not aware that IMGs who wish to enter an Accreditation Council for Graduate Medical Education residency of fellowship program in the United States must have Educational Commission for Foreign Medical Graduates (ECFMG) certification. ECFMG certification requires the applicant to pass a series of examinations, including United States Medical Licensing Examination (USMLE) Steps 1 and 2.

ECFMG certification is also required before an applicant can take Step 3 of the USMLE and is required before a physician can obtain an unrestricted license to practice medicine in the United States.

I suspect some IMGs face discrimination in this country because some may speak with an accent. But truth be told, the United States healthcare system could not exist without the contributions made by IMGs. TH

The Boutique Lure

Question: I recently received a brochure in the mail about a hospital that caters only to cardiac patients. While I think this job sounds intriguing, I’m concerned that this may be a boutique hospital. What do you think of the movement toward boutique hospitals? Do you think they are ethical?

Curious in Boston

Dr. Hospitalist responds: Boutique or specialty hospitals have been hotly debated among healthcare policymakers over the past few years. Compared with the number of general hospitals, the numbers of specialty hospitals—typically those that focus on cardiac, orthopedic, surgical, and women’s procedures—are small.

A Government Accounting Office (GAO) report in 2003 identified 100 such hospitals in the country. More than two-thirds of the hospitals are in seven states (Arizona, California, Kansas, Oklahoma, Louisiana, South Dakota, and Texas).

The GAO found that compared with general hospitals, specialty hospitals are “much less likely to have emergency departments, treated smaller percentages of Medicaid patients and derived a smaller share of their revenues from inpatient services.” Although small, this is a growing segment of the healthcare industry.

Specialty hospitals are controversial because many are for-profit and often owned by some of the physicians who work at the hospital. Specialty hospital supporters believe competition between specialty and general hospitals for services can lower costs and improve care.

A 2005 Medicare Payment Advisory Commission study found that physician-owned specialty hospitals decreased lengths of stay but didn’t lower costs for Medicare patients.

In general, specialty hospitals treated less-severe cases and tended to have lower numbers of Medicaid patients than community hospitals.

Specialty care hospital critics are concerned that specialty hospitals take care of the most profitable patients (those who are less ill) and leave the general hospital with the sicker patients who incur higher costs.

They fear growing numbers of specialty hospitals will make it financially difficult for general hospitals to meet all of a community’s needs, including charity care and emergency services.

Critics are also concerned that physician ownership of specialty hospitals could affect physicians’ clinical behavior by driving inappropriate referrals.

You may remember that the federal Stark law (named after Rep. Peter Stark, D-Calif.) generally prohibits physicians from referring Medicare patients for healthcare services to facilities where they have financial interests.

This law was enacted after several studies demonstrated that physicians with ownership interest in clinical laboratories, diagnostic imaging centers, and physical therapy providers made more referrals to these centers and ordered more services at higher costs.

The Stark law lets physicians who have an ownership interest in an entire hospital and are authorized to perform services there to refer patients to that hospital.

As you consider this opportunity, further investigate the risks, benefits, and potential effect of the specialty hospital on your community and our healthcare system.

Holiday Dilemma

Question: I just took over scheduling for our hospitalist group. I’ve been practicing nearly two years and am wondering how to staff holidays. I’m finding it difficult handling the multiple requests for Thanksgiving, Christmas, and New Year’s Eve. Do you know of any innovative scheduling techniques?

Schedule Grinch in Philadelphia

Dr. Hospitalist responds: Congratulations on your new responsibility! I write this with my tongue firmly planted in my cheek. As you now realize, completing the schedule is not easy.

Unfortunately, most hospitalists don’t recognize the enormous challenge one faces in filling the schedule until they are given the task.

Unless you were a chief medical resident, you probably didn’t learn or practice scheduling in the course of your medical training. Inevitably, everyone wants and expects to get their choice of days off. Of course, that is rarely possible.

How do you make everyone happy? It is important to recognize that making everyone happy every time is not possible. But it is possible and important to be fair to everyone all the time. There are some steps you can take to ensure the scheduling process is fair.

The first step is to set appropriate expectations. It is critical for the group leader and the staff member making the schedule to help each group member understand the enormous challenges that come with scheduling.

Providers who understand the difficulties of scheduling will be more understanding and accommodating in their requests.

The second step is to establish and clearly state the rules of engagement. For example, be explicit in explaining the rules for submitting requests and the deadline for requests. Avoid misconceptions by stating when the final schedule will be revealed.

The last step is to clearly state how to handle requests for schedule changes. Many hospitalist groups keep track of who works which holidays so the distribution of work on holidays is fair from year to year.

I have one last suggestion. Consider rotating the job of scheduling so everyone understands firsthand the challenges of the job. To entice people to assume this responsibility, the job should come with remuneration—either salary support and/or preference in choosing their own holiday schedule.

Of course, recognize that not everyone will want the job or be good at it. An effective group leader helps individuals identify opportunities and helps them succeed.

Foreign Medical Grads

Question: What’s your opinion on the effect of foreign medical graduates in the U.S.?

IMG in Cincinnati

Dr. Hospitalist responds: The U.S. healthcare system would be quite different without foreign (aka international) medical graduates (IMGs), who play important clinical, educational, administrative, and research roles.

Some physicians and patients believe medical education outside this country is inferior. In some cases, they are correct—in others, they could not be more wrong. Medical education outside this country varies in standards and curricula.

Many people are not aware that IMGs who wish to enter an Accreditation Council for Graduate Medical Education residency of fellowship program in the United States must have Educational Commission for Foreign Medical Graduates (ECFMG) certification. ECFMG certification requires the applicant to pass a series of examinations, including United States Medical Licensing Examination (USMLE) Steps 1 and 2.

ECFMG certification is also required before an applicant can take Step 3 of the USMLE and is required before a physician can obtain an unrestricted license to practice medicine in the United States.

I suspect some IMGs face discrimination in this country because some may speak with an accent. But truth be told, the United States healthcare system could not exist without the contributions made by IMGs. TH

Question: I’m a hospitalist in a small hospitalist group, so I stay pretty busy and sometimes I have to turn away a lot of requests for help. Recently I did a curbside consult on a surgical patient with diabetes. It was a hectic day, as usual, but I made time to do it because, to be honest, I’m very interested in these kinds of cases (for personal reasons). Problem is, another physician saw me give the consult and then asked me to do one for him about an hour later ... and I said no! I felt bad, but honestly, I had several patients to follow up with and felt I had to press on. I feel like I might have damaged my relationship with this doctor (a cardiologist). How can I help rebuild our relationship?

Boo-Boo in Beloit, Wis.

Dr. Hospitalist responds: Dear Boo Boo: Feel like you worked your way into a pile of doo doo? I generally go by the rule that if I feel something went wrong with an interaction, something probably did and damage control is in order.

Ignoring the encounter may lead the cardiologist to believe that you don’t value your relationship. I suggest you explain your predicament to the cardiologist and let him/her know that you are addressing problems with your schedule. To fix this “problem,” you need to examine why it occurred and understand how you can prevent it.

If you feel like you are “turn(ing) away a lot of requests for help,” I suspect you are missing a significant amount of business. You can view this as a problem or view this as an opportunity. Also recognize this is an opportunity for competitors. Referring physicians will send referrals elsewhere if you are not able to consistently provide the necessary service.

What’s not clear to me is whether your inability to accommodate requests for referrals is due to inadequate staffing, inefficiency, inappropriate billing, or a combination of factors.

To elucidate this situation, you need data. You will never know the facts until you gather the data.

If you are not measuring your program’s performance presently, it is never too late to start. Begin by tracking your work relative value units (wRVUs). This is a commonly used marker of productivity. SHM’s biannual productivity and compensation survey benchmarks this data. Are your wRVU data comparable with hospitalists with similar job descriptions? If so, consider adding staff to your program. If your wRVU data fall short of expectations, does the problem lie in billing? Are you billing for each encounter? Are you billing at appropriate levels for service provided? An audit of your notes and bills can be insightful. Or is inefficiency contributing to your problem? If so, consider an examination of your workflow. A workflow redesign with implementation of tools like templates may markedly improve your efficiency.

Career, Committee Work

Question: My career growth is very important to me. I’m presently the only hospitalist in our program, which I started about a year ago. I have many requests to serve on hospital committees. I’ve tried to serve on as many as possible but feel overstretched. Should I stop serving on committees and concentrate on my clinical work? Would this be bad for my career?

Too Busy in Ohio

Dr. Hospitalist responds: Dear Too Busy: Kudos for taking your job seriously, but don’t feel like you have to serve on all committees. Your concern about burnout is legitimate. There are many reasons hospitalists serve on hospital committees.

Seats at the table of some committees clearly have a higher potential impact than other committees. Participation in some committees can foster relationships with other hospital leaders and better position you and your hospitalist program. Others serve because committee participation may be tied to financial remuneration. I suggest you serve on committees where you believe you can be of most benefit to the hospital and for your program.

Ask yourself, “Does the committee work fit with the goals of the hospital or hospitalist program?” I always remind folks that they should not just think of committees as a way to get paid or better themselves. Some of the most meaningful work comes from serving on committees where members make difficult decisions and often sacrifice their individual goals for the betterment of patients and families. Consider limiting your participation to certain committees. Pick wisely, and you may find that you will cherish your participation.

An Unfortunate Encounter

Question: About a week ago, I was rounding with our CEO and a visiting doctor who is a friend of his. The CEO likes to tag along every so often to stay in touch with ‘‘the trenches.” At one point, they witnessed as I conducted a hand-off. I keep apprised of my peers’ discussions on how to do a proper hand-off, so I was following what I think is a pretty sound checklist of steps.

Unbelievably, my CEO’s doctor pal began ‘‘whispering’’ comments to the CEO about how he thought such and such I was doing wasn’t entirely necessary. (I could hear them clearly, as could the physician to whom I was handing off the patient, and the patient herself!)

I happen to know for a fact that the CEO has mused aloud and behind closed doors about the value of our hospital group. I’ve heard him, and friends have told me they have, too. I feel as though he’s undermining our efforts to adhere to a sound hand-off routine. How can I try to make him understand the value of a sound hand-off plan? Even if I can’t, how can I get my peers to buy in to better hand-off rules?

Angry in Helena, Mont.

Dr. Hospitalist responds: Dear Angry: it is laudable that your CEO makes hospital rounds. More CEOs and hospital administrators should do the same. Whether they are to “keep in touch” or for the appearance of doing so is probably less important. Inevitably they will see things on rounds that will help them understand the challenges doctors and nurses face every day in the hospital.

I share your concern that a colleague—but more importantly, a patient—heard your CEO’s friend make derogatory comments about your work. Although your CEO has made public comments previously about the value of your hospitalist program, he missed the boat on this one. He had a great chance to show you, your colleagues, and your patient how much he values the care you and your colleagues provide.

It may very well be that your CEO did not feel like his relationship with his friend could stand the conflict, but I am concerned that his lack of action may have created irreparable damage to his reputation as a leader. I have seen interactions like this breed gossip, which spreads like wildfire. Soon thereafter, discussions of the situation may bear little resemblance to what actually happened.

Make an appointment to meet with your CEO and describe to him what you saw, heard, and felt. Any smart CEO will understand that aside from an explanation, an apology is in order—if not to appease you, then to save his reputation as a leader. TH

Question: I’m a hospitalist in a small hospitalist group, so I stay pretty busy and sometimes I have to turn away a lot of requests for help. Recently I did a curbside consult on a surgical patient with diabetes. It was a hectic day, as usual, but I made time to do it because, to be honest, I’m very interested in these kinds of cases (for personal reasons). Problem is, another physician saw me give the consult and then asked me to do one for him about an hour later ... and I said no! I felt bad, but honestly, I had several patients to follow up with and felt I had to press on. I feel like I might have damaged my relationship with this doctor (a cardiologist). How can I help rebuild our relationship?

Boo-Boo in Beloit, Wis.

Dr. Hospitalist responds: Dear Boo Boo: Feel like you worked your way into a pile of doo doo? I generally go by the rule that if I feel something went wrong with an interaction, something probably did and damage control is in order.

Ignoring the encounter may lead the cardiologist to believe that you don’t value your relationship. I suggest you explain your predicament to the cardiologist and let him/her know that you are addressing problems with your schedule. To fix this “problem,” you need to examine why it occurred and understand how you can prevent it.

If you feel like you are “turn(ing) away a lot of requests for help,” I suspect you are missing a significant amount of business. You can view this as a problem or view this as an opportunity. Also recognize this is an opportunity for competitors. Referring physicians will send referrals elsewhere if you are not able to consistently provide the necessary service.

What’s not clear to me is whether your inability to accommodate requests for referrals is due to inadequate staffing, inefficiency, inappropriate billing, or a combination of factors.

To elucidate this situation, you need data. You will never know the facts until you gather the data.

If you are not measuring your program’s performance presently, it is never too late to start. Begin by tracking your work relative value units (wRVUs). This is a commonly used marker of productivity. SHM’s biannual productivity and compensation survey benchmarks this data. Are your wRVU data comparable with hospitalists with similar job descriptions? If so, consider adding staff to your program. If your wRVU data fall short of expectations, does the problem lie in billing? Are you billing for each encounter? Are you billing at appropriate levels for service provided? An audit of your notes and bills can be insightful. Or is inefficiency contributing to your problem? If so, consider an examination of your workflow. A workflow redesign with implementation of tools like templates may markedly improve your efficiency.

Career, Committee Work

Question: My career growth is very important to me. I’m presently the only hospitalist in our program, which I started about a year ago. I have many requests to serve on hospital committees. I’ve tried to serve on as many as possible but feel overstretched. Should I stop serving on committees and concentrate on my clinical work? Would this be bad for my career?

Too Busy in Ohio

Dr. Hospitalist responds: Dear Too Busy: Kudos for taking your job seriously, but don’t feel like you have to serve on all committees. Your concern about burnout is legitimate. There are many reasons hospitalists serve on hospital committees.

Seats at the table of some committees clearly have a higher potential impact than other committees. Participation in some committees can foster relationships with other hospital leaders and better position you and your hospitalist program. Others serve because committee participation may be tied to financial remuneration. I suggest you serve on committees where you believe you can be of most benefit to the hospital and for your program.

Ask yourself, “Does the committee work fit with the goals of the hospital or hospitalist program?” I always remind folks that they should not just think of committees as a way to get paid or better themselves. Some of the most meaningful work comes from serving on committees where members make difficult decisions and often sacrifice their individual goals for the betterment of patients and families. Consider limiting your participation to certain committees. Pick wisely, and you may find that you will cherish your participation.

An Unfortunate Encounter

Question: About a week ago, I was rounding with our CEO and a visiting doctor who is a friend of his. The CEO likes to tag along every so often to stay in touch with ‘‘the trenches.” At one point, they witnessed as I conducted a hand-off. I keep apprised of my peers’ discussions on how to do a proper hand-off, so I was following what I think is a pretty sound checklist of steps.

Unbelievably, my CEO’s doctor pal began ‘‘whispering’’ comments to the CEO about how he thought such and such I was doing wasn’t entirely necessary. (I could hear them clearly, as could the physician to whom I was handing off the patient, and the patient herself!)

I happen to know for a fact that the CEO has mused aloud and behind closed doors about the value of our hospital group. I’ve heard him, and friends have told me they have, too. I feel as though he’s undermining our efforts to adhere to a sound hand-off routine. How can I try to make him understand the value of a sound hand-off plan? Even if I can’t, how can I get my peers to buy in to better hand-off rules?

Angry in Helena, Mont.

Dr. Hospitalist responds: Dear Angry: it is laudable that your CEO makes hospital rounds. More CEOs and hospital administrators should do the same. Whether they are to “keep in touch” or for the appearance of doing so is probably less important. Inevitably they will see things on rounds that will help them understand the challenges doctors and nurses face every day in the hospital.

I share your concern that a colleague—but more importantly, a patient—heard your CEO’s friend make derogatory comments about your work. Although your CEO has made public comments previously about the value of your hospitalist program, he missed the boat on this one. He had a great chance to show you, your colleagues, and your patient how much he values the care you and your colleagues provide.

It may very well be that your CEO did not feel like his relationship with his friend could stand the conflict, but I am concerned that his lack of action may have created irreparable damage to his reputation as a leader. I have seen interactions like this breed gossip, which spreads like wildfire. Soon thereafter, discussions of the situation may bear little resemblance to what actually happened.

Make an appointment to meet with your CEO and describe to him what you saw, heard, and felt. Any smart CEO will understand that aside from an explanation, an apology is in order—if not to appease you, then to save his reputation as a leader. TH

Question: I’m a hospitalist in a small hospitalist group, so I stay pretty busy and sometimes I have to turn away a lot of requests for help. Recently I did a curbside consult on a surgical patient with diabetes. It was a hectic day, as usual, but I made time to do it because, to be honest, I’m very interested in these kinds of cases (for personal reasons). Problem is, another physician saw me give the consult and then asked me to do one for him about an hour later ... and I said no! I felt bad, but honestly, I had several patients to follow up with and felt I had to press on. I feel like I might have damaged my relationship with this doctor (a cardiologist). How can I help rebuild our relationship?

Boo-Boo in Beloit, Wis.

Dr. Hospitalist responds: Dear Boo Boo: Feel like you worked your way into a pile of doo doo? I generally go by the rule that if I feel something went wrong with an interaction, something probably did and damage control is in order.

Ignoring the encounter may lead the cardiologist to believe that you don’t value your relationship. I suggest you explain your predicament to the cardiologist and let him/her know that you are addressing problems with your schedule. To fix this “problem,” you need to examine why it occurred and understand how you can prevent it.

If you feel like you are “turn(ing) away a lot of requests for help,” I suspect you are missing a significant amount of business. You can view this as a problem or view this as an opportunity. Also recognize this is an opportunity for competitors. Referring physicians will send referrals elsewhere if you are not able to consistently provide the necessary service.

What’s not clear to me is whether your inability to accommodate requests for referrals is due to inadequate staffing, inefficiency, inappropriate billing, or a combination of factors.

To elucidate this situation, you need data. You will never know the facts until you gather the data.

If you are not measuring your program’s performance presently, it is never too late to start. Begin by tracking your work relative value units (wRVUs). This is a commonly used marker of productivity. SHM’s biannual productivity and compensation survey benchmarks this data. Are your wRVU data comparable with hospitalists with similar job descriptions? If so, consider adding staff to your program. If your wRVU data fall short of expectations, does the problem lie in billing? Are you billing for each encounter? Are you billing at appropriate levels for service provided? An audit of your notes and bills can be insightful. Or is inefficiency contributing to your problem? If so, consider an examination of your workflow. A workflow redesign with implementation of tools like templates may markedly improve your efficiency.

Career, Committee Work

Question: My career growth is very important to me. I’m presently the only hospitalist in our program, which I started about a year ago. I have many requests to serve on hospital committees. I’ve tried to serve on as many as possible but feel overstretched. Should I stop serving on committees and concentrate on my clinical work? Would this be bad for my career?

Too Busy in Ohio

Dr. Hospitalist responds: Dear Too Busy: Kudos for taking your job seriously, but don’t feel like you have to serve on all committees. Your concern about burnout is legitimate. There are many reasons hospitalists serve on hospital committees.

Seats at the table of some committees clearly have a higher potential impact than other committees. Participation in some committees can foster relationships with other hospital leaders and better position you and your hospitalist program. Others serve because committee participation may be tied to financial remuneration. I suggest you serve on committees where you believe you can be of most benefit to the hospital and for your program.

Ask yourself, “Does the committee work fit with the goals of the hospital or hospitalist program?” I always remind folks that they should not just think of committees as a way to get paid or better themselves. Some of the most meaningful work comes from serving on committees where members make difficult decisions and often sacrifice their individual goals for the betterment of patients and families. Consider limiting your participation to certain committees. Pick wisely, and you may find that you will cherish your participation.

An Unfortunate Encounter

Question: About a week ago, I was rounding with our CEO and a visiting doctor who is a friend of his. The CEO likes to tag along every so often to stay in touch with ‘‘the trenches.” At one point, they witnessed as I conducted a hand-off. I keep apprised of my peers’ discussions on how to do a proper hand-off, so I was following what I think is a pretty sound checklist of steps.

Unbelievably, my CEO’s doctor pal began ‘‘whispering’’ comments to the CEO about how he thought such and such I was doing wasn’t entirely necessary. (I could hear them clearly, as could the physician to whom I was handing off the patient, and the patient herself!)

I happen to know for a fact that the CEO has mused aloud and behind closed doors about the value of our hospital group. I’ve heard him, and friends have told me they have, too. I feel as though he’s undermining our efforts to adhere to a sound hand-off routine. How can I try to make him understand the value of a sound hand-off plan? Even if I can’t, how can I get my peers to buy in to better hand-off rules?

Angry in Helena, Mont.

Dr. Hospitalist responds: Dear Angry: it is laudable that your CEO makes hospital rounds. More CEOs and hospital administrators should do the same. Whether they are to “keep in touch” or for the appearance of doing so is probably less important. Inevitably they will see things on rounds that will help them understand the challenges doctors and nurses face every day in the hospital.

I share your concern that a colleague—but more importantly, a patient—heard your CEO’s friend make derogatory comments about your work. Although your CEO has made public comments previously about the value of your hospitalist program, he missed the boat on this one. He had a great chance to show you, your colleagues, and your patient how much he values the care you and your colleagues provide.

It may very well be that your CEO did not feel like his relationship with his friend could stand the conflict, but I am concerned that his lack of action may have created irreparable damage to his reputation as a leader. I have seen interactions like this breed gossip, which spreads like wildfire. Soon thereafter, discussions of the situation may bear little resemblance to what actually happened.

Make an appointment to meet with your CEO and describe to him what you saw, heard, and felt. Any smart CEO will understand that aside from an explanation, an apology is in order—if not to appease you, then to save his reputation as a leader. TH