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Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM's "Best Practices in Managing a Hospital Medicine Program" course. Write to him at john.nelson@nelsonflores.com.
How to Use Hospitalist Productivity, Compensation Survey Data
The 2014 State of Hospital Medicine report (SOHM), published by SHM in the fall of even years, is unquestionably the most robust and informative data available to understand the hospitalist workforce marketplace. And if you are the person who returned a completed survey for your practice, you get a free copy of the report mailed to you.
Keep in mind that the Medical Group Management Association (MGMA) surveys and reports data on hospitalist productivity and compensation every year. And the data acquired by MGMA in even years is simply folded into the SOHM, along with a ton of additional information added by a separate SHM survey, including things like the amount of financial support provided to hospitalist groups by hospitals (now up to a median of $156, 063 per full-time equivalent, or FTE).
I’ve written previously about some of the ways that the data reported in both of these surveys can be tricky to interpret (September 2013 and October 2013), and in this column I’ll go a little deeper into how to use the data reported on number of shifts worked and productivity.
A Common Question
Assume that, to address a staffing shortage or simply as a way to boost their income, some of the doctors in your group are willing to work more shifts than required for full-time status. And, in your group, some portion of a doctor’s compensation is a function of their individual work relevant value unit (wRVU) productivity—for example, a bonus for wRVUs above a certain threshold. You want to know whether the wRVU productivity generated by a doctor on their extra shifts should factor into compensation the same way it does for “regular” shifts.
You might turn to the MGMA and SOHM surveys to see how other groups handle this issue. But here is where it gets tricky.
First, you need to realize that the MGMA surveys, and similar ones from the American Medical Group Association and others, report wRVUs and compensation per physician, not per FTE. So wRVUs generated by these doctors on extra shifts are included, and you can’t tell from the aggregate data what portion of wRVUs came from regular shifts and what portion came from extra shifts.
And it is critical to keep in mind that any doctor who works at least 0.8 FTE as defined by that particular practice is reported as full time. Those working 79% or less of full time are counted by MGMA as part time.
To summarize: The MGMA and similar surveys don’t provide data on wRVU productivity per FTE, even though in most cases that is how everyone describes the data. Instead, the surveys provide data per individual doctor, many of whom work more or less than 1.0 FTE. So, despite the fact that most people, including me, tend to quote data from the surveys as though it is per FTE, as in “The 2014 MGMA data shows median hospitalist compensation is $253,977 per FTE,” we should say “per doctor” instead.
Theoretically, doctors working slightly less than 1.0 FTE should offset the doctors working slightly more than 1.0 FTE. But, while I think that’s a reasonable assumption for most specialties, such a significant portion of hospitalist groups have had chronic staffing shortages that a lot of hospitalists across the country are working extra shifts, probably more than are working between 0.8 and 1.0 FTE. So the hospitalist survey wRVU data is probably at least a little higher than it would be if it were reported per FTE.
Unfortunately, there is no way to confirm my suspicion, because MGMA doesn’t allow any individual doctor to be reported as more than 1.0 FTE, even if he works far more shifts than the number that defines full time for that practice. In other words, extra shifts just aren’t accounted for in the MGMA survey.
Implications of Individual vs. FTE
For most purposes, it probably doesn’t make any difference if you are erroneously thinking about the compensation and productivity survey numbers on a per FTE basis. But, for some purposes, and for those who work significantly more shifts than most hospitalists, it can start to matter.
Now back to the original question. You’re thinking about whether wRVUs generated by the doctors in your group on extra shifts should count toward the wRVU bonus just like those generated on regular shifts. You’d like to handle this the same way as other groups, but, unfortunately, survey data just isn’t helpful here. You’ll have to decide this for yourself.
I think some, but probably not all, extra shift productivity should count toward your wRVU bonus. You might, for example, say that productivity for somewhere between three or five extra shifts per quarter—that’s totally arbitrary, and of course this would be a negotiation between you and hospital leadership—should count toward the productivity target, and the rest wouldn’t, or that those extra shifts above an agreed-upon number would result in an increase in the wRVU target. The biggest problem with this is that it would be a nightmare to administer—essentially impossible for many practices. But you could accomplish the same thing by including the first few shifts per quarter in the “base” FTE calculation and then, after that, adjusting each person’s FTE value up as they work more shifts.
One more thing about productivity targets…
It’s also important to remember that productivity targets make the most sense at the group—not the individual—level. The MGMA data includes hospitalists who work night shifts (including nocturnists) and doctors who work low-production shifts (i.e., pager or ED triage shifts), as well as daytime rounding doctors. So, if you have a doctor who only works days, you would expect him to generate wRVUs in excess of the global target of wRVUs per FTE to make up for the low-productivity shifts that other doctors have to work.
For example, your practice might decide the group as a whole is expected to generate the MGMA yearly median 4,298 wRVUs per doctor, multiplied by the number of FTEs in the group. But the nocturnists would be expected to generate fewer, while those who work most or all of their shifts in a daytime rounder would be expected to generate more. So the threshold to begin paying the wRVU bonus for daytime rounding doctors might be adjusted up to something like 4,500 wRVUs.
The above example is just as an illustration, of course, and there are all kinds of reasons it might be more appropriate to choose different thresholds for your practice. But it’s a good place to start the thinking.
The 2014 State of Hospital Medicine report (SOHM), published by SHM in the fall of even years, is unquestionably the most robust and informative data available to understand the hospitalist workforce marketplace. And if you are the person who returned a completed survey for your practice, you get a free copy of the report mailed to you.
Keep in mind that the Medical Group Management Association (MGMA) surveys and reports data on hospitalist productivity and compensation every year. And the data acquired by MGMA in even years is simply folded into the SOHM, along with a ton of additional information added by a separate SHM survey, including things like the amount of financial support provided to hospitalist groups by hospitals (now up to a median of $156, 063 per full-time equivalent, or FTE).
I’ve written previously about some of the ways that the data reported in both of these surveys can be tricky to interpret (September 2013 and October 2013), and in this column I’ll go a little deeper into how to use the data reported on number of shifts worked and productivity.
A Common Question
Assume that, to address a staffing shortage or simply as a way to boost their income, some of the doctors in your group are willing to work more shifts than required for full-time status. And, in your group, some portion of a doctor’s compensation is a function of their individual work relevant value unit (wRVU) productivity—for example, a bonus for wRVUs above a certain threshold. You want to know whether the wRVU productivity generated by a doctor on their extra shifts should factor into compensation the same way it does for “regular” shifts.
You might turn to the MGMA and SOHM surveys to see how other groups handle this issue. But here is where it gets tricky.
First, you need to realize that the MGMA surveys, and similar ones from the American Medical Group Association and others, report wRVUs and compensation per physician, not per FTE. So wRVUs generated by these doctors on extra shifts are included, and you can’t tell from the aggregate data what portion of wRVUs came from regular shifts and what portion came from extra shifts.
And it is critical to keep in mind that any doctor who works at least 0.8 FTE as defined by that particular practice is reported as full time. Those working 79% or less of full time are counted by MGMA as part time.
To summarize: The MGMA and similar surveys don’t provide data on wRVU productivity per FTE, even though in most cases that is how everyone describes the data. Instead, the surveys provide data per individual doctor, many of whom work more or less than 1.0 FTE. So, despite the fact that most people, including me, tend to quote data from the surveys as though it is per FTE, as in “The 2014 MGMA data shows median hospitalist compensation is $253,977 per FTE,” we should say “per doctor” instead.
Theoretically, doctors working slightly less than 1.0 FTE should offset the doctors working slightly more than 1.0 FTE. But, while I think that’s a reasonable assumption for most specialties, such a significant portion of hospitalist groups have had chronic staffing shortages that a lot of hospitalists across the country are working extra shifts, probably more than are working between 0.8 and 1.0 FTE. So the hospitalist survey wRVU data is probably at least a little higher than it would be if it were reported per FTE.
Unfortunately, there is no way to confirm my suspicion, because MGMA doesn’t allow any individual doctor to be reported as more than 1.0 FTE, even if he works far more shifts than the number that defines full time for that practice. In other words, extra shifts just aren’t accounted for in the MGMA survey.
Implications of Individual vs. FTE
For most purposes, it probably doesn’t make any difference if you are erroneously thinking about the compensation and productivity survey numbers on a per FTE basis. But, for some purposes, and for those who work significantly more shifts than most hospitalists, it can start to matter.
Now back to the original question. You’re thinking about whether wRVUs generated by the doctors in your group on extra shifts should count toward the wRVU bonus just like those generated on regular shifts. You’d like to handle this the same way as other groups, but, unfortunately, survey data just isn’t helpful here. You’ll have to decide this for yourself.
I think some, but probably not all, extra shift productivity should count toward your wRVU bonus. You might, for example, say that productivity for somewhere between three or five extra shifts per quarter—that’s totally arbitrary, and of course this would be a negotiation between you and hospital leadership—should count toward the productivity target, and the rest wouldn’t, or that those extra shifts above an agreed-upon number would result in an increase in the wRVU target. The biggest problem with this is that it would be a nightmare to administer—essentially impossible for many practices. But you could accomplish the same thing by including the first few shifts per quarter in the “base” FTE calculation and then, after that, adjusting each person’s FTE value up as they work more shifts.
One more thing about productivity targets…
It’s also important to remember that productivity targets make the most sense at the group—not the individual—level. The MGMA data includes hospitalists who work night shifts (including nocturnists) and doctors who work low-production shifts (i.e., pager or ED triage shifts), as well as daytime rounding doctors. So, if you have a doctor who only works days, you would expect him to generate wRVUs in excess of the global target of wRVUs per FTE to make up for the low-productivity shifts that other doctors have to work.
For example, your practice might decide the group as a whole is expected to generate the MGMA yearly median 4,298 wRVUs per doctor, multiplied by the number of FTEs in the group. But the nocturnists would be expected to generate fewer, while those who work most or all of their shifts in a daytime rounder would be expected to generate more. So the threshold to begin paying the wRVU bonus for daytime rounding doctors might be adjusted up to something like 4,500 wRVUs.
The above example is just as an illustration, of course, and there are all kinds of reasons it might be more appropriate to choose different thresholds for your practice. But it’s a good place to start the thinking.
The 2014 State of Hospital Medicine report (SOHM), published by SHM in the fall of even years, is unquestionably the most robust and informative data available to understand the hospitalist workforce marketplace. And if you are the person who returned a completed survey for your practice, you get a free copy of the report mailed to you.
Keep in mind that the Medical Group Management Association (MGMA) surveys and reports data on hospitalist productivity and compensation every year. And the data acquired by MGMA in even years is simply folded into the SOHM, along with a ton of additional information added by a separate SHM survey, including things like the amount of financial support provided to hospitalist groups by hospitals (now up to a median of $156, 063 per full-time equivalent, or FTE).
I’ve written previously about some of the ways that the data reported in both of these surveys can be tricky to interpret (September 2013 and October 2013), and in this column I’ll go a little deeper into how to use the data reported on number of shifts worked and productivity.
A Common Question
Assume that, to address a staffing shortage or simply as a way to boost their income, some of the doctors in your group are willing to work more shifts than required for full-time status. And, in your group, some portion of a doctor’s compensation is a function of their individual work relevant value unit (wRVU) productivity—for example, a bonus for wRVUs above a certain threshold. You want to know whether the wRVU productivity generated by a doctor on their extra shifts should factor into compensation the same way it does for “regular” shifts.
You might turn to the MGMA and SOHM surveys to see how other groups handle this issue. But here is where it gets tricky.
First, you need to realize that the MGMA surveys, and similar ones from the American Medical Group Association and others, report wRVUs and compensation per physician, not per FTE. So wRVUs generated by these doctors on extra shifts are included, and you can’t tell from the aggregate data what portion of wRVUs came from regular shifts and what portion came from extra shifts.
And it is critical to keep in mind that any doctor who works at least 0.8 FTE as defined by that particular practice is reported as full time. Those working 79% or less of full time are counted by MGMA as part time.
To summarize: The MGMA and similar surveys don’t provide data on wRVU productivity per FTE, even though in most cases that is how everyone describes the data. Instead, the surveys provide data per individual doctor, many of whom work more or less than 1.0 FTE. So, despite the fact that most people, including me, tend to quote data from the surveys as though it is per FTE, as in “The 2014 MGMA data shows median hospitalist compensation is $253,977 per FTE,” we should say “per doctor” instead.
Theoretically, doctors working slightly less than 1.0 FTE should offset the doctors working slightly more than 1.0 FTE. But, while I think that’s a reasonable assumption for most specialties, such a significant portion of hospitalist groups have had chronic staffing shortages that a lot of hospitalists across the country are working extra shifts, probably more than are working between 0.8 and 1.0 FTE. So the hospitalist survey wRVU data is probably at least a little higher than it would be if it were reported per FTE.
Unfortunately, there is no way to confirm my suspicion, because MGMA doesn’t allow any individual doctor to be reported as more than 1.0 FTE, even if he works far more shifts than the number that defines full time for that practice. In other words, extra shifts just aren’t accounted for in the MGMA survey.
Implications of Individual vs. FTE
For most purposes, it probably doesn’t make any difference if you are erroneously thinking about the compensation and productivity survey numbers on a per FTE basis. But, for some purposes, and for those who work significantly more shifts than most hospitalists, it can start to matter.
Now back to the original question. You’re thinking about whether wRVUs generated by the doctors in your group on extra shifts should count toward the wRVU bonus just like those generated on regular shifts. You’d like to handle this the same way as other groups, but, unfortunately, survey data just isn’t helpful here. You’ll have to decide this for yourself.
I think some, but probably not all, extra shift productivity should count toward your wRVU bonus. You might, for example, say that productivity for somewhere between three or five extra shifts per quarter—that’s totally arbitrary, and of course this would be a negotiation between you and hospital leadership—should count toward the productivity target, and the rest wouldn’t, or that those extra shifts above an agreed-upon number would result in an increase in the wRVU target. The biggest problem with this is that it would be a nightmare to administer—essentially impossible for many practices. But you could accomplish the same thing by including the first few shifts per quarter in the “base” FTE calculation and then, after that, adjusting each person’s FTE value up as they work more shifts.
One more thing about productivity targets…
It’s also important to remember that productivity targets make the most sense at the group—not the individual—level. The MGMA data includes hospitalists who work night shifts (including nocturnists) and doctors who work low-production shifts (i.e., pager or ED triage shifts), as well as daytime rounding doctors. So, if you have a doctor who only works days, you would expect him to generate wRVUs in excess of the global target of wRVUs per FTE to make up for the low-productivity shifts that other doctors have to work.
For example, your practice might decide the group as a whole is expected to generate the MGMA yearly median 4,298 wRVUs per doctor, multiplied by the number of FTEs in the group. But the nocturnists would be expected to generate fewer, while those who work most or all of their shifts in a daytime rounder would be expected to generate more. So the threshold to begin paying the wRVU bonus for daytime rounding doctors might be adjusted up to something like 4,500 wRVUs.
The above example is just as an illustration, of course, and there are all kinds of reasons it might be more appropriate to choose different thresholds for your practice. But it’s a good place to start the thinking.
Hospitals' Observation Status Designation May Trigger Malpractice Claims
I’m convinced that observation status is rapidly becoming a meaningful factor in patients’ decision to file a malpractice lawsuit.
First, let me concede that I don’t know of any hard data to support my claim. I even asked the nation’s largest malpractice insurer about this, and they didn’t have any data on it. I think that is because observation status has only become a really big issue in the last couple of years, and since it typically takes several years for a malpractice suit to conclude, it just hasn’t found its way onto their radar yet.
But I’m pretty sure that will change within the next few years.
Implications
As any seasoned practitioner in our field knows, all outpatient and inpatient physician charges for Medicare patients, along with those of other licensed practitioners, are billed through Medicare Part B. After meeting a deductible, patients with traditional fee-for-service Medicare are generally responsible for 20% of all approved Part B charges, with no upper limit. For patients seen by a large number of providers while hospitalized, this 20% can really add up. Some patients have a secondary insurance that pays for this.
Hospital charges for patients on inpatient status are billed through Medicare Part A. Patients have an annual Part A deductible, and only in the case of very long inpatient stays will they have to pay more than that for inpatient care each year.
But hospital charges for patients on observation status are billed through Part B. And because hospital charges add up so quickly, the 20% of this that the patient is responsible for can be a lot of money—thousands of dollars, even for stays of less than 24 hours. Understandably, patients are not at all happy about this.
Let’s say you’re admitted overnight on observation status and your doctor orders your usual Advair inhaler. You use it once. Most hospitals aren’t able to ensure compliance with regulations around dispensing medications for home use like a pharmacy, so they won’t let you take the inhaler home. A few weeks later you’re stunned to learn that the hospital charged $10,000 for all services provided, and you’re responsible for 20% of the allowable amount PLUS the cost of all “self administered” drugs, like inhalers, eye drops, and calcitonin nasal spray. You look over your bill to see that you’re asked to pay $350 for the inhaler you used once and couldn’t even take home with you! Many self-administered medications, including eye drops and calcitonin nasal spray, result in similarly alarming charges to patients.
On top of the unpleasant surprise of a large hospital bill, Medicare won’t pay for skilled nursing facility (SNF) care for patients who are on observation status. That is, observation is not a “qualifying” stay for beneficiaries to access their SNF benefit.
It is easy to see why patients are unhappy about observation status.
The Media Message
News media are making the public aware of the potentially high financial costs they face if placed on observation status. But, too often, they oversimplify the issue, making it seem as though the choice of observation vs. inpatient status is entirely up to the treating doctor.
Saying that this decision is entirely up to the doctor is a lot like saying it is entirely up to you to determine how fast you drive on a freeway. In a sense that is correct, because no one else is in your car to control how fast you go and, in theory, you could choose to go 100 mph or 30 mph. The only problem is that it wouldn’t be long before you’d be in trouble with the law. So you don’t have complete autonomy to choose your speed; you have to comply with the laws. The same is true for doctors choosing observation status. We must comply with regulations in choosing the status or face legal consequences like fines or accusations of fraud.
Most news stories, like this one from NBC news (www.nbcnews.com/video/nightly-news/54511352#54511352) in February, are generally accurate but leave out the important fact that hospitals and doctors have little autonomy to choose the status the patient prefers. Instead, media often simply encourage patients on observation status to argue for a change to inpatient status and “be persistent.” More and more often, patients and families are arguing with the treating doctor; in many cases, that is a hospitalist.
Complaints Surge
At the 2014 SHM annual meeting last spring in Las Vegas, I spoke with many hospitalists who said that, increasingly, they are targets of observation-status complaints. One hospitalist group recently had each doctor list his or her top three frustrations with work; difficult and stressful conversations about observation status topped the list.
Patient anger regarding observation status can turn a satisfied patient into an angry one. We all know that unhappy patients are the ones most likely to pursue malpractice lawsuits. While anger over observation status doesn’t equal medical malpractice, it can change a patient’s opinion of our care, which may in some cases result in a malpractice claim.
Solutions
Medicare is unlikely to do away with observation status, so the best way to prevent complaints is to ensure that all its implications are explained to patients and families, ideally before they’re put into the hospital (e.g., while still in the ED). I think it is best if this message is delivered by someone other than the treating doctor(s): For example, a case manager might handle the discussion. Of course, patients and families are often too overwhelmed in the ED to absorb this information, so the message may need to be repeated later.
Maybe everyone should tell observation patients, “We’re going to observe you” without using any form of the word “admission.” And having these patients stay in distinct observation units probably reduces misunderstandings and complaints compared to the common practice of mixing these patients in “regular” hospital floors housing those on inpatient status.
Unfortunately, I couldn’t find research data to support this idea.
I bet some hospitals have even more elegant and effective ways to reduce misunderstandings and complaints around observation status. I’d love to hear from you if you know of any. E-mail me at john.nelson@nelsonflores.com.
I’m convinced that observation status is rapidly becoming a meaningful factor in patients’ decision to file a malpractice lawsuit.
First, let me concede that I don’t know of any hard data to support my claim. I even asked the nation’s largest malpractice insurer about this, and they didn’t have any data on it. I think that is because observation status has only become a really big issue in the last couple of years, and since it typically takes several years for a malpractice suit to conclude, it just hasn’t found its way onto their radar yet.
But I’m pretty sure that will change within the next few years.
Implications
As any seasoned practitioner in our field knows, all outpatient and inpatient physician charges for Medicare patients, along with those of other licensed practitioners, are billed through Medicare Part B. After meeting a deductible, patients with traditional fee-for-service Medicare are generally responsible for 20% of all approved Part B charges, with no upper limit. For patients seen by a large number of providers while hospitalized, this 20% can really add up. Some patients have a secondary insurance that pays for this.
Hospital charges for patients on inpatient status are billed through Medicare Part A. Patients have an annual Part A deductible, and only in the case of very long inpatient stays will they have to pay more than that for inpatient care each year.
But hospital charges for patients on observation status are billed through Part B. And because hospital charges add up so quickly, the 20% of this that the patient is responsible for can be a lot of money—thousands of dollars, even for stays of less than 24 hours. Understandably, patients are not at all happy about this.
Let’s say you’re admitted overnight on observation status and your doctor orders your usual Advair inhaler. You use it once. Most hospitals aren’t able to ensure compliance with regulations around dispensing medications for home use like a pharmacy, so they won’t let you take the inhaler home. A few weeks later you’re stunned to learn that the hospital charged $10,000 for all services provided, and you’re responsible for 20% of the allowable amount PLUS the cost of all “self administered” drugs, like inhalers, eye drops, and calcitonin nasal spray. You look over your bill to see that you’re asked to pay $350 for the inhaler you used once and couldn’t even take home with you! Many self-administered medications, including eye drops and calcitonin nasal spray, result in similarly alarming charges to patients.
On top of the unpleasant surprise of a large hospital bill, Medicare won’t pay for skilled nursing facility (SNF) care for patients who are on observation status. That is, observation is not a “qualifying” stay for beneficiaries to access their SNF benefit.
It is easy to see why patients are unhappy about observation status.
The Media Message
News media are making the public aware of the potentially high financial costs they face if placed on observation status. But, too often, they oversimplify the issue, making it seem as though the choice of observation vs. inpatient status is entirely up to the treating doctor.
Saying that this decision is entirely up to the doctor is a lot like saying it is entirely up to you to determine how fast you drive on a freeway. In a sense that is correct, because no one else is in your car to control how fast you go and, in theory, you could choose to go 100 mph or 30 mph. The only problem is that it wouldn’t be long before you’d be in trouble with the law. So you don’t have complete autonomy to choose your speed; you have to comply with the laws. The same is true for doctors choosing observation status. We must comply with regulations in choosing the status or face legal consequences like fines or accusations of fraud.
Most news stories, like this one from NBC news (www.nbcnews.com/video/nightly-news/54511352#54511352) in February, are generally accurate but leave out the important fact that hospitals and doctors have little autonomy to choose the status the patient prefers. Instead, media often simply encourage patients on observation status to argue for a change to inpatient status and “be persistent.” More and more often, patients and families are arguing with the treating doctor; in many cases, that is a hospitalist.
Complaints Surge
At the 2014 SHM annual meeting last spring in Las Vegas, I spoke with many hospitalists who said that, increasingly, they are targets of observation-status complaints. One hospitalist group recently had each doctor list his or her top three frustrations with work; difficult and stressful conversations about observation status topped the list.
Patient anger regarding observation status can turn a satisfied patient into an angry one. We all know that unhappy patients are the ones most likely to pursue malpractice lawsuits. While anger over observation status doesn’t equal medical malpractice, it can change a patient’s opinion of our care, which may in some cases result in a malpractice claim.
Solutions
Medicare is unlikely to do away with observation status, so the best way to prevent complaints is to ensure that all its implications are explained to patients and families, ideally before they’re put into the hospital (e.g., while still in the ED). I think it is best if this message is delivered by someone other than the treating doctor(s): For example, a case manager might handle the discussion. Of course, patients and families are often too overwhelmed in the ED to absorb this information, so the message may need to be repeated later.
Maybe everyone should tell observation patients, “We’re going to observe you” without using any form of the word “admission.” And having these patients stay in distinct observation units probably reduces misunderstandings and complaints compared to the common practice of mixing these patients in “regular” hospital floors housing those on inpatient status.
Unfortunately, I couldn’t find research data to support this idea.
I bet some hospitals have even more elegant and effective ways to reduce misunderstandings and complaints around observation status. I’d love to hear from you if you know of any. E-mail me at john.nelson@nelsonflores.com.
I’m convinced that observation status is rapidly becoming a meaningful factor in patients’ decision to file a malpractice lawsuit.
First, let me concede that I don’t know of any hard data to support my claim. I even asked the nation’s largest malpractice insurer about this, and they didn’t have any data on it. I think that is because observation status has only become a really big issue in the last couple of years, and since it typically takes several years for a malpractice suit to conclude, it just hasn’t found its way onto their radar yet.
But I’m pretty sure that will change within the next few years.
Implications
As any seasoned practitioner in our field knows, all outpatient and inpatient physician charges for Medicare patients, along with those of other licensed practitioners, are billed through Medicare Part B. After meeting a deductible, patients with traditional fee-for-service Medicare are generally responsible for 20% of all approved Part B charges, with no upper limit. For patients seen by a large number of providers while hospitalized, this 20% can really add up. Some patients have a secondary insurance that pays for this.
Hospital charges for patients on inpatient status are billed through Medicare Part A. Patients have an annual Part A deductible, and only in the case of very long inpatient stays will they have to pay more than that for inpatient care each year.
But hospital charges for patients on observation status are billed through Part B. And because hospital charges add up so quickly, the 20% of this that the patient is responsible for can be a lot of money—thousands of dollars, even for stays of less than 24 hours. Understandably, patients are not at all happy about this.
Let’s say you’re admitted overnight on observation status and your doctor orders your usual Advair inhaler. You use it once. Most hospitals aren’t able to ensure compliance with regulations around dispensing medications for home use like a pharmacy, so they won’t let you take the inhaler home. A few weeks later you’re stunned to learn that the hospital charged $10,000 for all services provided, and you’re responsible for 20% of the allowable amount PLUS the cost of all “self administered” drugs, like inhalers, eye drops, and calcitonin nasal spray. You look over your bill to see that you’re asked to pay $350 for the inhaler you used once and couldn’t even take home with you! Many self-administered medications, including eye drops and calcitonin nasal spray, result in similarly alarming charges to patients.
On top of the unpleasant surprise of a large hospital bill, Medicare won’t pay for skilled nursing facility (SNF) care for patients who are on observation status. That is, observation is not a “qualifying” stay for beneficiaries to access their SNF benefit.
It is easy to see why patients are unhappy about observation status.
The Media Message
News media are making the public aware of the potentially high financial costs they face if placed on observation status. But, too often, they oversimplify the issue, making it seem as though the choice of observation vs. inpatient status is entirely up to the treating doctor.
Saying that this decision is entirely up to the doctor is a lot like saying it is entirely up to you to determine how fast you drive on a freeway. In a sense that is correct, because no one else is in your car to control how fast you go and, in theory, you could choose to go 100 mph or 30 mph. The only problem is that it wouldn’t be long before you’d be in trouble with the law. So you don’t have complete autonomy to choose your speed; you have to comply with the laws. The same is true for doctors choosing observation status. We must comply with regulations in choosing the status or face legal consequences like fines or accusations of fraud.
Most news stories, like this one from NBC news (www.nbcnews.com/video/nightly-news/54511352#54511352) in February, are generally accurate but leave out the important fact that hospitals and doctors have little autonomy to choose the status the patient prefers. Instead, media often simply encourage patients on observation status to argue for a change to inpatient status and “be persistent.” More and more often, patients and families are arguing with the treating doctor; in many cases, that is a hospitalist.
Complaints Surge
At the 2014 SHM annual meeting last spring in Las Vegas, I spoke with many hospitalists who said that, increasingly, they are targets of observation-status complaints. One hospitalist group recently had each doctor list his or her top three frustrations with work; difficult and stressful conversations about observation status topped the list.
Patient anger regarding observation status can turn a satisfied patient into an angry one. We all know that unhappy patients are the ones most likely to pursue malpractice lawsuits. While anger over observation status doesn’t equal medical malpractice, it can change a patient’s opinion of our care, which may in some cases result in a malpractice claim.
Solutions
Medicare is unlikely to do away with observation status, so the best way to prevent complaints is to ensure that all its implications are explained to patients and families, ideally before they’re put into the hospital (e.g., while still in the ED). I think it is best if this message is delivered by someone other than the treating doctor(s): For example, a case manager might handle the discussion. Of course, patients and families are often too overwhelmed in the ED to absorb this information, so the message may need to be repeated later.
Maybe everyone should tell observation patients, “We’re going to observe you” without using any form of the word “admission.” And having these patients stay in distinct observation units probably reduces misunderstandings and complaints compared to the common practice of mixing these patients in “regular” hospital floors housing those on inpatient status.
Unfortunately, I couldn’t find research data to support this idea.
I bet some hospitals have even more elegant and effective ways to reduce misunderstandings and complaints around observation status. I’d love to hear from you if you know of any. E-mail me at john.nelson@nelsonflores.com.
Put Key Principles, Characteristics of Effective Hospital Medicine Groups to Work
I hope you’re already familiar with “The Key Principles and Characteristics of an Effective Hospital Medicine Group: An Assessment Guide for Hospitals and Hospitalists” [www.hospitalmedicine.org/keychar] and have spent at least a few minutes reviewing the list of 10 “principles” and 47 “characteristics” thought to be associated with effective hospital medicine groups (HMGs). (Full disclosure: I was one of the authors of the article published in February 2014 in the Journal of Hospital Medicine.) Most of us are very busy, so the temptation might be high to set the article aside and risk forgetting it. But I hope many in our field, both clinicians and administrators, will look at it more carefully. There are a number of ways you could use the guide to stimulate thinking or change in your practice.
Grading Our Specialty
I just returned from a meeting of about 10 hospitalist leaders from different organizations around the country. Attendees represented the diversity of our field, including hospital-employed HMGs, large hospitalist management companies, and academic programs. We spent a portion of the meeting discussing what grade we as a group would give the whole specialty of hospital medicine on each of the 10 “principles.” Essentially, we generated a report card for the U.S. hospitalist movement.
This wasn’t a rigorous scientific exercise; instead, it was a robust and thought-provoking discussion around what grade to assign. Opinions regarding the appropriate grade varied significantly, but a common theme was that our specialty really “owns” the importance of pursuing many or most of the principles listed in the article and is devoting time and resources to them even if many individual HMGs might have a long way to go to perform optimally.
For example, meeting attendees thought our field has for a long time worked diligently to “support care coordination across the care continuum” (Principle 6). No one thought that all HMGs do this optimally, but the consensus was that most HMGs have invested effort to do it well. And most were concerned that many HMGs still lack “adequate resources” (Principle 3) and sufficiently “engaged hospitalists” (Principle 2)—and that the former contributes to the latter.
The opinion of the hospitalist leaders who happened to attend the meeting where this conversation took place doesn’t represent the final word on how our specialty is performing, but I think all involved found value in having the conversation, hearing different perspectives about what we’re doing well and where we should focus energy and resources to improve.
Grading Your HM Group
You might want to do something similar within your own group, but make it more relevant by grading how your own practice performs on each of the 10 principles. You could do this on your own just to stimulate your thinking, or you could have each member of your HMG generate a report card of your group’s performance—then discuss where there is agreement or disagreement within the group.
You could structure this sort of individual or group assessment simply as an exercise to generate ideas and conversation about the practice, or your group could take a more formal approach and use it as part of a planning process to determine future practice management-related goals. I know of some groups that scheduled strategic planning meetings specifically to discuss which of the elements to make a priority.
Discussion Document for Leadership
In addition to using the article to generate conversation among hospitalists within your group, it can be a really valuable tool in guiding conversations with hospital leaders and the entity that employs the hospitalists. For example, you could use the article to generate or update the job description of the lead hospitalist or practice manager. Or during annual budgeting for the hospitalist practice, the guide could be used as a checklist to think about whether there are important areas that would benefit from more resources.
Of course, there is a risk that hospital leaders or those who employ the hospitalists could use the article primarily to criticize a hospitalist group and its leader for not already having excellent performance on every one of the principles and characteristics listed. That would be pretty unfortunate; there probably isn’t a single group that performs well on every domain, and the real value of the article is to “be aspirational, helping to raise the bar” for each HMG and our specialty as a whole.
And, as discussed in the article, an HMG doesn’t need to be a stellar performer on all 47 characteristics to be effective. Some of the characteristics listed in the article may not apply to all groups, so all involved in the management of any individual HMG should think about whether to set some aside when assessing their own group.
Where to Go from Here
The article is based on expert opinion, with the help of many more people than those listed as author, and I’m hopeful it will stimulate researchers to study some of these principles and characteristics. For many reasons, we will probably never have robust data, but I’d be happy for whatever we can get.
There is a pretty good chance that the evolution in the work we do and the nature of the hospital setting mean that the principles and characteristics may need to be revised periodically. I would love to know how they might be different in 10 or 20 years.
Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at john.nelson@nelsonflores.com.
I hope you’re already familiar with “The Key Principles and Characteristics of an Effective Hospital Medicine Group: An Assessment Guide for Hospitals and Hospitalists” [www.hospitalmedicine.org/keychar] and have spent at least a few minutes reviewing the list of 10 “principles” and 47 “characteristics” thought to be associated with effective hospital medicine groups (HMGs). (Full disclosure: I was one of the authors of the article published in February 2014 in the Journal of Hospital Medicine.) Most of us are very busy, so the temptation might be high to set the article aside and risk forgetting it. But I hope many in our field, both clinicians and administrators, will look at it more carefully. There are a number of ways you could use the guide to stimulate thinking or change in your practice.
Grading Our Specialty
I just returned from a meeting of about 10 hospitalist leaders from different organizations around the country. Attendees represented the diversity of our field, including hospital-employed HMGs, large hospitalist management companies, and academic programs. We spent a portion of the meeting discussing what grade we as a group would give the whole specialty of hospital medicine on each of the 10 “principles.” Essentially, we generated a report card for the U.S. hospitalist movement.
This wasn’t a rigorous scientific exercise; instead, it was a robust and thought-provoking discussion around what grade to assign. Opinions regarding the appropriate grade varied significantly, but a common theme was that our specialty really “owns” the importance of pursuing many or most of the principles listed in the article and is devoting time and resources to them even if many individual HMGs might have a long way to go to perform optimally.
For example, meeting attendees thought our field has for a long time worked diligently to “support care coordination across the care continuum” (Principle 6). No one thought that all HMGs do this optimally, but the consensus was that most HMGs have invested effort to do it well. And most were concerned that many HMGs still lack “adequate resources” (Principle 3) and sufficiently “engaged hospitalists” (Principle 2)—and that the former contributes to the latter.
The opinion of the hospitalist leaders who happened to attend the meeting where this conversation took place doesn’t represent the final word on how our specialty is performing, but I think all involved found value in having the conversation, hearing different perspectives about what we’re doing well and where we should focus energy and resources to improve.
Grading Your HM Group
You might want to do something similar within your own group, but make it more relevant by grading how your own practice performs on each of the 10 principles. You could do this on your own just to stimulate your thinking, or you could have each member of your HMG generate a report card of your group’s performance—then discuss where there is agreement or disagreement within the group.
You could structure this sort of individual or group assessment simply as an exercise to generate ideas and conversation about the practice, or your group could take a more formal approach and use it as part of a planning process to determine future practice management-related goals. I know of some groups that scheduled strategic planning meetings specifically to discuss which of the elements to make a priority.
Discussion Document for Leadership
In addition to using the article to generate conversation among hospitalists within your group, it can be a really valuable tool in guiding conversations with hospital leaders and the entity that employs the hospitalists. For example, you could use the article to generate or update the job description of the lead hospitalist or practice manager. Or during annual budgeting for the hospitalist practice, the guide could be used as a checklist to think about whether there are important areas that would benefit from more resources.
Of course, there is a risk that hospital leaders or those who employ the hospitalists could use the article primarily to criticize a hospitalist group and its leader for not already having excellent performance on every one of the principles and characteristics listed. That would be pretty unfortunate; there probably isn’t a single group that performs well on every domain, and the real value of the article is to “be aspirational, helping to raise the bar” for each HMG and our specialty as a whole.
And, as discussed in the article, an HMG doesn’t need to be a stellar performer on all 47 characteristics to be effective. Some of the characteristics listed in the article may not apply to all groups, so all involved in the management of any individual HMG should think about whether to set some aside when assessing their own group.
Where to Go from Here
The article is based on expert opinion, with the help of many more people than those listed as author, and I’m hopeful it will stimulate researchers to study some of these principles and characteristics. For many reasons, we will probably never have robust data, but I’d be happy for whatever we can get.
There is a pretty good chance that the evolution in the work we do and the nature of the hospital setting mean that the principles and characteristics may need to be revised periodically. I would love to know how they might be different in 10 or 20 years.
Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at john.nelson@nelsonflores.com.
I hope you’re already familiar with “The Key Principles and Characteristics of an Effective Hospital Medicine Group: An Assessment Guide for Hospitals and Hospitalists” [www.hospitalmedicine.org/keychar] and have spent at least a few minutes reviewing the list of 10 “principles” and 47 “characteristics” thought to be associated with effective hospital medicine groups (HMGs). (Full disclosure: I was one of the authors of the article published in February 2014 in the Journal of Hospital Medicine.) Most of us are very busy, so the temptation might be high to set the article aside and risk forgetting it. But I hope many in our field, both clinicians and administrators, will look at it more carefully. There are a number of ways you could use the guide to stimulate thinking or change in your practice.
Grading Our Specialty
I just returned from a meeting of about 10 hospitalist leaders from different organizations around the country. Attendees represented the diversity of our field, including hospital-employed HMGs, large hospitalist management companies, and academic programs. We spent a portion of the meeting discussing what grade we as a group would give the whole specialty of hospital medicine on each of the 10 “principles.” Essentially, we generated a report card for the U.S. hospitalist movement.
This wasn’t a rigorous scientific exercise; instead, it was a robust and thought-provoking discussion around what grade to assign. Opinions regarding the appropriate grade varied significantly, but a common theme was that our specialty really “owns” the importance of pursuing many or most of the principles listed in the article and is devoting time and resources to them even if many individual HMGs might have a long way to go to perform optimally.
For example, meeting attendees thought our field has for a long time worked diligently to “support care coordination across the care continuum” (Principle 6). No one thought that all HMGs do this optimally, but the consensus was that most HMGs have invested effort to do it well. And most were concerned that many HMGs still lack “adequate resources” (Principle 3) and sufficiently “engaged hospitalists” (Principle 2)—and that the former contributes to the latter.
The opinion of the hospitalist leaders who happened to attend the meeting where this conversation took place doesn’t represent the final word on how our specialty is performing, but I think all involved found value in having the conversation, hearing different perspectives about what we’re doing well and where we should focus energy and resources to improve.
Grading Your HM Group
You might want to do something similar within your own group, but make it more relevant by grading how your own practice performs on each of the 10 principles. You could do this on your own just to stimulate your thinking, or you could have each member of your HMG generate a report card of your group’s performance—then discuss where there is agreement or disagreement within the group.
You could structure this sort of individual or group assessment simply as an exercise to generate ideas and conversation about the practice, or your group could take a more formal approach and use it as part of a planning process to determine future practice management-related goals. I know of some groups that scheduled strategic planning meetings specifically to discuss which of the elements to make a priority.
Discussion Document for Leadership
In addition to using the article to generate conversation among hospitalists within your group, it can be a really valuable tool in guiding conversations with hospital leaders and the entity that employs the hospitalists. For example, you could use the article to generate or update the job description of the lead hospitalist or practice manager. Or during annual budgeting for the hospitalist practice, the guide could be used as a checklist to think about whether there are important areas that would benefit from more resources.
Of course, there is a risk that hospital leaders or those who employ the hospitalists could use the article primarily to criticize a hospitalist group and its leader for not already having excellent performance on every one of the principles and characteristics listed. That would be pretty unfortunate; there probably isn’t a single group that performs well on every domain, and the real value of the article is to “be aspirational, helping to raise the bar” for each HMG and our specialty as a whole.
And, as discussed in the article, an HMG doesn’t need to be a stellar performer on all 47 characteristics to be effective. Some of the characteristics listed in the article may not apply to all groups, so all involved in the management of any individual HMG should think about whether to set some aside when assessing their own group.
Where to Go from Here
The article is based on expert opinion, with the help of many more people than those listed as author, and I’m hopeful it will stimulate researchers to study some of these principles and characteristics. For many reasons, we will probably never have robust data, but I’d be happy for whatever we can get.
There is a pretty good chance that the evolution in the work we do and the nature of the hospital setting mean that the principles and characteristics may need to be revised periodically. I would love to know how they might be different in 10 or 20 years.
Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at john.nelson@nelsonflores.com.
Proper Inpatient Documentation, Coding Essential to Avoid a Medicare Audit
Several years ago we sent a CPT coding auditor 15 chart notes generated by each doctor in our group. Among each doctors’ 15 notes were at least one or two billed as initial hospital care, follow up, discharge, critical care, and so on. This coding expert returned a report showing that, out of all the notes reviewed, a significant portion were not billed at the correct level. Most of the incorrectly billed notes were judged to reflect “up-coding,” and a few were seen as “down-coded.”
This was distressing and hard to believe.
So I took the same set of notes and paid a second coding expert for an independent review. She didn’t know about the first audit but returned a report that showed a nearly identical portion of incorrectly coded notes.
Two independent audits showing nearly the same portion of notes coded incorrectly was alarming. But it was difficult for my partners and me to address, because the auditors didn’t agree on the correct code for many of the notes. In some cases, both flagged a note as incorrectly coded but didn’t agree on the correct code. For a number of the notes, one auditor said the visit was “up-coded,” while the other said it was “down-coded.” There was so little agreement between the two of them that we had a hard time coming up with any firm conclusions about what we should do to improve our performance.
If experts who think about coding all the time can’t agree on the right code for a given note, how can hospitalists be expected to code nearly all of our visits accurately?
RAC: Recovery Audit Contractor
Despite what I believe is poor inter-rater reliability among coding auditors, we need to work diligently to comply with coding guidelines. A 2003 Federal law mandated a program of Recovery Audit Contractors, or RAC for short, to find cases of “up-coding” or other overbilling and require the provider to repay any resulting loss.
A number of companies are in the business of conducting RAC audits (one of them, CGI, is the Canadian company blamed for the failed “Obamacare” exchange websites), and there is a reasonable chance one of these companies has reviewed some of your charges—or those of your hospitalist colleagues.
The RAC auditors review information about your charges, and if they determine that you up-coded or overbilled, they send a “demand letter” summarizing their findings, along with the amount of money they have determined you should pay back. (Theoretically, they could notify you of “under-coding,” so that you can be paid more for past work, but I haven’t yet come across an example of that.)
It is common to appeal the RAC findings, but that can be a long process, and many organizations decide to pay back all the money requested by the RAC as quickly as possible to avoid paying interest on a delayed payment if the appeal is unsuccessful. In the case of a successful appeal, the money previously refunded by the doctor would be returned.
Page 338 of the CMS Fiscal Year 2015 “Justification of Estimates for Appropriations Committees” says that “…about 50 percent of the estimated 43,000 appeals [of adverse RAC audit findings] were fully or partially overturned…” This could mean the RACs are a sort of loose cannon, accusing many providers of overbilling while knowing that some won’t bother to appeal because they don’t understand the process or because the dollar amount involved for a single provider is too small to justify the time and expense of conducting the appeal. In this way, a RAC audit is like the $15 rebate on the last electronic gadget you bought. The seller knows that many people, including me, will fail to do the work required to claim the rebate.
Accuracy Strategies
There are a number of ways to help your group ensure appropriate CPT coding and reduce the chance a RAC will ask for money back.
Education. There are many ways to help providers in your practice understand the elements of documentation and coding. Periodic training classes (e.g. during orientation and annually thereafter) are useful but may not be enough. For me, this is a little like learning a foreign language by going to a couple of classes. Instead, I think “immersion training” is more effective. That might mean a doctor spends a few minutes with a certified coder on most working days for a few weeks. For example, they could meet for 15 minutes near lunchtime and review how the doctor plans to bill visits made that morning. Lastly, consider targeted education for each doctor, based on any problems found in an audit of his/her coding.
Review coding patterns. As I wrote in my August 2007 column, there is value in ensuring that each doctor in the group can see how her coding pattern differs from the group as a whole or any individual in the group. That is, what portion of follow-up visits was billed at the lowest, middle, and highest levels? What about admissions, discharges, and so on? I provided a sample report in that same column.
It also is worth taking the time to compare each doctor’s coding pattern to both the CMS Internal Medicine data and SHM’s State of Hospital Medicine report. The accompanying figure shows the most current data sets available.
Keep in mind that the goal is not to simply ensure that your coding pattern matches these external data sets; knowing where yours differs from these sets can suggest where you might want to investigate further or seek additional education.
Coding audits. Having a certified coder audit your performance at least annually is a good idea. It can help uncover areas in which you’d benefit from further review and training, and if, heaven forbid, questions are ever raised about whether you’re intentionally up-coding (fraud), showing that you’re audited regularly could help demonstrate your efforts to code correctly. In the latter case, it is probably more valuable if the audit is done independently of your employer.
Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at john.nelson@nelsonflores.com.
Several years ago we sent a CPT coding auditor 15 chart notes generated by each doctor in our group. Among each doctors’ 15 notes were at least one or two billed as initial hospital care, follow up, discharge, critical care, and so on. This coding expert returned a report showing that, out of all the notes reviewed, a significant portion were not billed at the correct level. Most of the incorrectly billed notes were judged to reflect “up-coding,” and a few were seen as “down-coded.”
This was distressing and hard to believe.
So I took the same set of notes and paid a second coding expert for an independent review. She didn’t know about the first audit but returned a report that showed a nearly identical portion of incorrectly coded notes.
Two independent audits showing nearly the same portion of notes coded incorrectly was alarming. But it was difficult for my partners and me to address, because the auditors didn’t agree on the correct code for many of the notes. In some cases, both flagged a note as incorrectly coded but didn’t agree on the correct code. For a number of the notes, one auditor said the visit was “up-coded,” while the other said it was “down-coded.” There was so little agreement between the two of them that we had a hard time coming up with any firm conclusions about what we should do to improve our performance.
If experts who think about coding all the time can’t agree on the right code for a given note, how can hospitalists be expected to code nearly all of our visits accurately?
RAC: Recovery Audit Contractor
Despite what I believe is poor inter-rater reliability among coding auditors, we need to work diligently to comply with coding guidelines. A 2003 Federal law mandated a program of Recovery Audit Contractors, or RAC for short, to find cases of “up-coding” or other overbilling and require the provider to repay any resulting loss.
A number of companies are in the business of conducting RAC audits (one of them, CGI, is the Canadian company blamed for the failed “Obamacare” exchange websites), and there is a reasonable chance one of these companies has reviewed some of your charges—or those of your hospitalist colleagues.
The RAC auditors review information about your charges, and if they determine that you up-coded or overbilled, they send a “demand letter” summarizing their findings, along with the amount of money they have determined you should pay back. (Theoretically, they could notify you of “under-coding,” so that you can be paid more for past work, but I haven’t yet come across an example of that.)
It is common to appeal the RAC findings, but that can be a long process, and many organizations decide to pay back all the money requested by the RAC as quickly as possible to avoid paying interest on a delayed payment if the appeal is unsuccessful. In the case of a successful appeal, the money previously refunded by the doctor would be returned.
Page 338 of the CMS Fiscal Year 2015 “Justification of Estimates for Appropriations Committees” says that “…about 50 percent of the estimated 43,000 appeals [of adverse RAC audit findings] were fully or partially overturned…” This could mean the RACs are a sort of loose cannon, accusing many providers of overbilling while knowing that some won’t bother to appeal because they don’t understand the process or because the dollar amount involved for a single provider is too small to justify the time and expense of conducting the appeal. In this way, a RAC audit is like the $15 rebate on the last electronic gadget you bought. The seller knows that many people, including me, will fail to do the work required to claim the rebate.
Accuracy Strategies
There are a number of ways to help your group ensure appropriate CPT coding and reduce the chance a RAC will ask for money back.
Education. There are many ways to help providers in your practice understand the elements of documentation and coding. Periodic training classes (e.g. during orientation and annually thereafter) are useful but may not be enough. For me, this is a little like learning a foreign language by going to a couple of classes. Instead, I think “immersion training” is more effective. That might mean a doctor spends a few minutes with a certified coder on most working days for a few weeks. For example, they could meet for 15 minutes near lunchtime and review how the doctor plans to bill visits made that morning. Lastly, consider targeted education for each doctor, based on any problems found in an audit of his/her coding.
Review coding patterns. As I wrote in my August 2007 column, there is value in ensuring that each doctor in the group can see how her coding pattern differs from the group as a whole or any individual in the group. That is, what portion of follow-up visits was billed at the lowest, middle, and highest levels? What about admissions, discharges, and so on? I provided a sample report in that same column.
It also is worth taking the time to compare each doctor’s coding pattern to both the CMS Internal Medicine data and SHM’s State of Hospital Medicine report. The accompanying figure shows the most current data sets available.
Keep in mind that the goal is not to simply ensure that your coding pattern matches these external data sets; knowing where yours differs from these sets can suggest where you might want to investigate further or seek additional education.
Coding audits. Having a certified coder audit your performance at least annually is a good idea. It can help uncover areas in which you’d benefit from further review and training, and if, heaven forbid, questions are ever raised about whether you’re intentionally up-coding (fraud), showing that you’re audited regularly could help demonstrate your efforts to code correctly. In the latter case, it is probably more valuable if the audit is done independently of your employer.
Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at john.nelson@nelsonflores.com.
Several years ago we sent a CPT coding auditor 15 chart notes generated by each doctor in our group. Among each doctors’ 15 notes were at least one or two billed as initial hospital care, follow up, discharge, critical care, and so on. This coding expert returned a report showing that, out of all the notes reviewed, a significant portion were not billed at the correct level. Most of the incorrectly billed notes were judged to reflect “up-coding,” and a few were seen as “down-coded.”
This was distressing and hard to believe.
So I took the same set of notes and paid a second coding expert for an independent review. She didn’t know about the first audit but returned a report that showed a nearly identical portion of incorrectly coded notes.
Two independent audits showing nearly the same portion of notes coded incorrectly was alarming. But it was difficult for my partners and me to address, because the auditors didn’t agree on the correct code for many of the notes. In some cases, both flagged a note as incorrectly coded but didn’t agree on the correct code. For a number of the notes, one auditor said the visit was “up-coded,” while the other said it was “down-coded.” There was so little agreement between the two of them that we had a hard time coming up with any firm conclusions about what we should do to improve our performance.
If experts who think about coding all the time can’t agree on the right code for a given note, how can hospitalists be expected to code nearly all of our visits accurately?
RAC: Recovery Audit Contractor
Despite what I believe is poor inter-rater reliability among coding auditors, we need to work diligently to comply with coding guidelines. A 2003 Federal law mandated a program of Recovery Audit Contractors, or RAC for short, to find cases of “up-coding” or other overbilling and require the provider to repay any resulting loss.
A number of companies are in the business of conducting RAC audits (one of them, CGI, is the Canadian company blamed for the failed “Obamacare” exchange websites), and there is a reasonable chance one of these companies has reviewed some of your charges—or those of your hospitalist colleagues.
The RAC auditors review information about your charges, and if they determine that you up-coded or overbilled, they send a “demand letter” summarizing their findings, along with the amount of money they have determined you should pay back. (Theoretically, they could notify you of “under-coding,” so that you can be paid more for past work, but I haven’t yet come across an example of that.)
It is common to appeal the RAC findings, but that can be a long process, and many organizations decide to pay back all the money requested by the RAC as quickly as possible to avoid paying interest on a delayed payment if the appeal is unsuccessful. In the case of a successful appeal, the money previously refunded by the doctor would be returned.
Page 338 of the CMS Fiscal Year 2015 “Justification of Estimates for Appropriations Committees” says that “…about 50 percent of the estimated 43,000 appeals [of adverse RAC audit findings] were fully or partially overturned…” This could mean the RACs are a sort of loose cannon, accusing many providers of overbilling while knowing that some won’t bother to appeal because they don’t understand the process or because the dollar amount involved for a single provider is too small to justify the time and expense of conducting the appeal. In this way, a RAC audit is like the $15 rebate on the last electronic gadget you bought. The seller knows that many people, including me, will fail to do the work required to claim the rebate.
Accuracy Strategies
There are a number of ways to help your group ensure appropriate CPT coding and reduce the chance a RAC will ask for money back.
Education. There are many ways to help providers in your practice understand the elements of documentation and coding. Periodic training classes (e.g. during orientation and annually thereafter) are useful but may not be enough. For me, this is a little like learning a foreign language by going to a couple of classes. Instead, I think “immersion training” is more effective. That might mean a doctor spends a few minutes with a certified coder on most working days for a few weeks. For example, they could meet for 15 minutes near lunchtime and review how the doctor plans to bill visits made that morning. Lastly, consider targeted education for each doctor, based on any problems found in an audit of his/her coding.
Review coding patterns. As I wrote in my August 2007 column, there is value in ensuring that each doctor in the group can see how her coding pattern differs from the group as a whole or any individual in the group. That is, what portion of follow-up visits was billed at the lowest, middle, and highest levels? What about admissions, discharges, and so on? I provided a sample report in that same column.
It also is worth taking the time to compare each doctor’s coding pattern to both the CMS Internal Medicine data and SHM’s State of Hospital Medicine report. The accompanying figure shows the most current data sets available.
Keep in mind that the goal is not to simply ensure that your coding pattern matches these external data sets; knowing where yours differs from these sets can suggest where you might want to investigate further or seek additional education.
Coding audits. Having a certified coder audit your performance at least annually is a good idea. It can help uncover areas in which you’d benefit from further review and training, and if, heaven forbid, questions are ever raised about whether you’re intentionally up-coding (fraud), showing that you’re audited regularly could help demonstrate your efforts to code correctly. In the latter case, it is probably more valuable if the audit is done independently of your employer.
Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at john.nelson@nelsonflores.com.
Hospitalists Working Hard to Improve Patient Care
Dear Ms. Bernstein:
I’m writing this letter to let you know about some of the things happening in hospital medicine, to ensure we are always improving the care we provide.
While we talked on New Year’s Eve, you reluctantly told me that you and many of your friends were not happy with the move toward hospital care being provided by hospitalists, rather than the PCP you know. I didn’t respond because we were having a nice lunch and I didn’t want to distract you from praising my kids and talking about your grandbaby and her sibling on the way. So I thought I’d respond by writing this open letter to you on the chance it might also be thought provoking for some of my hospitalist colleagues.
I think your reluctance to share with me the unflattering opinion you and many of your friends have of the hospitalist model of care stemmed from a desire not to offend me rather than any uncertainty in your conclusion. It isn’t difficult to find others, both healthcare providers and consumers, who share your opinion.
As I’ve told you before, outside of my own parents, you and Mr. B. are among the people who had the most influence on my upbringing, and your opinion still matters to me. So I’m writing this hoping to change your view, at least a little.
Updated Numbers of Hospitalists
Our field is now larger than many other specialties, and we are experiencing ever-increasing pressure to “get it right.” A 2012 survey of hospitals conducted by the American Hospital Association found more than 38,000 doctors who identify themselves as hospitalists. This number has been increasing rapidly for more than a decade. The Society of Hospital Medicine (SHM) estimates that the number has grown to more than 44,000 in 2014, and that there are hospitalists in 72% of U.S. hospitals—90% at hospitals with over 200 beds. In 1996, there were fewer than 1,000 hospitalists.
The rapid growth in our field has brought challenges, and we’re lucky to have attracted many dedicated and talented people who are helping all of us make strides to do better, both by providing better technical care (e.g. ensuring careful assessments and ordering the best tests and treatments) and by doing so in a way that ensures patients and their families are highly satisfied.
Tools to Support Ongoing Improvements in Hospitalist Practice
There are many outlets hospitalists can turn to for education on essentially any aspect of their practice. Several years ago, the SHM published “The Core Competencies in Hospital Medicine: A Framework for Curriculum Development,” a publication that continues to be valuable in guiding hospitalists’ professional scope of clinical skills as well as educational curricula for training programs and continuing education. SHM and other organizations generate a great deal of educational content for hospitalists, which is available in many forms, including in-person conferences, webinars, and written materials. And there are several scientific journals that have significant content for hospitalists, including SHM’s own Journal of Hospital Medicine.
Our field encourages and recognizes ongoing commitment to hospitalists’ growth and development in a number of ways. When it is time for a doctor to renew his/her board certification, the American Board of Internal Medicine (ABIM) offers the option to pursue “Focused Practice in Hospital Medicine.” And SHM’s designation of Fellow, Senior Fellow and Master in Hospital Medicine recognizes those who have “demonstrated a commitment to hospital medicine, system change, and quality improvement principles.” Many in our field have achieved one or both of these distinctions, and countless others are pursuing them now.
Through its foundation, the ABIM developed a campaign known as “Choosing Wisely” to “promote conversations between physicians and patients by helping patients choose care that is: supported by evidence, not duplicative of other tests or procedures already received, free from harm, and truly necessary.” SHM joined in this effort by developing separate criteria for hospitalists who care for adults or children.
New Tool Encourages High Performance
In February, an SHM workgroup published “The Key Principles and Characteristics of an Effective Hospital Medicine Group: An Assessment Guide for Hospitals and Hospitalists,” a document meant to serve as a road map for hospitalist groups to follow to improve their performance. I’m particularly interested in this, since I have spent much of my career thinking about and working with hospitalist groups to improve the way they perform, and I helped develop the characteristics and co-authored the document. But the real value of the document comes from the input of hundreds of people within and outside of SHM who provided thoughtful advice and feedback to identify those attributes of hospitalist groups that are most likely to ensure success.
The document describes 47 characteristics grouped into 10 different categories (“principles”). Some of the principles that you as a patient might be most interested in are ones specifying that a hospitalist group:
— Implements a practice model that is patient- and family-centered, is team-based, and emphasizes care coordination and effective communication.
— Supports care coordination across care settings; and
— Plays a leadership role in addressing key clinical issues in the hospital and/or health system: teaching, quality, safety, efficiency, and the patient/family experience.
Current State of Hospital Medicine
If you’ve had a less than satisfactory experience with care by a hospitalist, the things I’ve described here might not improve your opinion of hospitalists, or that of your friends. But maybe you can take some measure of comfort in knowing that our field as a whole is working hard to continuously improve all aspects of what we do. We’re serious about being good at what we do.
And, since this is published in a magazine read by hospitalists, maybe some of them will be reminded of the many ways our field encourages, supports, and recognizes their professional development.
Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at john.nelson@nelsonflores.com.
Dear Ms. Bernstein:
I’m writing this letter to let you know about some of the things happening in hospital medicine, to ensure we are always improving the care we provide.
While we talked on New Year’s Eve, you reluctantly told me that you and many of your friends were not happy with the move toward hospital care being provided by hospitalists, rather than the PCP you know. I didn’t respond because we were having a nice lunch and I didn’t want to distract you from praising my kids and talking about your grandbaby and her sibling on the way. So I thought I’d respond by writing this open letter to you on the chance it might also be thought provoking for some of my hospitalist colleagues.
I think your reluctance to share with me the unflattering opinion you and many of your friends have of the hospitalist model of care stemmed from a desire not to offend me rather than any uncertainty in your conclusion. It isn’t difficult to find others, both healthcare providers and consumers, who share your opinion.
As I’ve told you before, outside of my own parents, you and Mr. B. are among the people who had the most influence on my upbringing, and your opinion still matters to me. So I’m writing this hoping to change your view, at least a little.
Updated Numbers of Hospitalists
Our field is now larger than many other specialties, and we are experiencing ever-increasing pressure to “get it right.” A 2012 survey of hospitals conducted by the American Hospital Association found more than 38,000 doctors who identify themselves as hospitalists. This number has been increasing rapidly for more than a decade. The Society of Hospital Medicine (SHM) estimates that the number has grown to more than 44,000 in 2014, and that there are hospitalists in 72% of U.S. hospitals—90% at hospitals with over 200 beds. In 1996, there were fewer than 1,000 hospitalists.
The rapid growth in our field has brought challenges, and we’re lucky to have attracted many dedicated and talented people who are helping all of us make strides to do better, both by providing better technical care (e.g. ensuring careful assessments and ordering the best tests and treatments) and by doing so in a way that ensures patients and their families are highly satisfied.
Tools to Support Ongoing Improvements in Hospitalist Practice
There are many outlets hospitalists can turn to for education on essentially any aspect of their practice. Several years ago, the SHM published “The Core Competencies in Hospital Medicine: A Framework for Curriculum Development,” a publication that continues to be valuable in guiding hospitalists’ professional scope of clinical skills as well as educational curricula for training programs and continuing education. SHM and other organizations generate a great deal of educational content for hospitalists, which is available in many forms, including in-person conferences, webinars, and written materials. And there are several scientific journals that have significant content for hospitalists, including SHM’s own Journal of Hospital Medicine.
Our field encourages and recognizes ongoing commitment to hospitalists’ growth and development in a number of ways. When it is time for a doctor to renew his/her board certification, the American Board of Internal Medicine (ABIM) offers the option to pursue “Focused Practice in Hospital Medicine.” And SHM’s designation of Fellow, Senior Fellow and Master in Hospital Medicine recognizes those who have “demonstrated a commitment to hospital medicine, system change, and quality improvement principles.” Many in our field have achieved one or both of these distinctions, and countless others are pursuing them now.
Through its foundation, the ABIM developed a campaign known as “Choosing Wisely” to “promote conversations between physicians and patients by helping patients choose care that is: supported by evidence, not duplicative of other tests or procedures already received, free from harm, and truly necessary.” SHM joined in this effort by developing separate criteria for hospitalists who care for adults or children.
New Tool Encourages High Performance
In February, an SHM workgroup published “The Key Principles and Characteristics of an Effective Hospital Medicine Group: An Assessment Guide for Hospitals and Hospitalists,” a document meant to serve as a road map for hospitalist groups to follow to improve their performance. I’m particularly interested in this, since I have spent much of my career thinking about and working with hospitalist groups to improve the way they perform, and I helped develop the characteristics and co-authored the document. But the real value of the document comes from the input of hundreds of people within and outside of SHM who provided thoughtful advice and feedback to identify those attributes of hospitalist groups that are most likely to ensure success.
The document describes 47 characteristics grouped into 10 different categories (“principles”). Some of the principles that you as a patient might be most interested in are ones specifying that a hospitalist group:
— Implements a practice model that is patient- and family-centered, is team-based, and emphasizes care coordination and effective communication.
— Supports care coordination across care settings; and
— Plays a leadership role in addressing key clinical issues in the hospital and/or health system: teaching, quality, safety, efficiency, and the patient/family experience.
Current State of Hospital Medicine
If you’ve had a less than satisfactory experience with care by a hospitalist, the things I’ve described here might not improve your opinion of hospitalists, or that of your friends. But maybe you can take some measure of comfort in knowing that our field as a whole is working hard to continuously improve all aspects of what we do. We’re serious about being good at what we do.
And, since this is published in a magazine read by hospitalists, maybe some of them will be reminded of the many ways our field encourages, supports, and recognizes their professional development.
Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at john.nelson@nelsonflores.com.
Dear Ms. Bernstein:
I’m writing this letter to let you know about some of the things happening in hospital medicine, to ensure we are always improving the care we provide.
While we talked on New Year’s Eve, you reluctantly told me that you and many of your friends were not happy with the move toward hospital care being provided by hospitalists, rather than the PCP you know. I didn’t respond because we were having a nice lunch and I didn’t want to distract you from praising my kids and talking about your grandbaby and her sibling on the way. So I thought I’d respond by writing this open letter to you on the chance it might also be thought provoking for some of my hospitalist colleagues.
I think your reluctance to share with me the unflattering opinion you and many of your friends have of the hospitalist model of care stemmed from a desire not to offend me rather than any uncertainty in your conclusion. It isn’t difficult to find others, both healthcare providers and consumers, who share your opinion.
As I’ve told you before, outside of my own parents, you and Mr. B. are among the people who had the most influence on my upbringing, and your opinion still matters to me. So I’m writing this hoping to change your view, at least a little.
Updated Numbers of Hospitalists
Our field is now larger than many other specialties, and we are experiencing ever-increasing pressure to “get it right.” A 2012 survey of hospitals conducted by the American Hospital Association found more than 38,000 doctors who identify themselves as hospitalists. This number has been increasing rapidly for more than a decade. The Society of Hospital Medicine (SHM) estimates that the number has grown to more than 44,000 in 2014, and that there are hospitalists in 72% of U.S. hospitals—90% at hospitals with over 200 beds. In 1996, there were fewer than 1,000 hospitalists.
The rapid growth in our field has brought challenges, and we’re lucky to have attracted many dedicated and talented people who are helping all of us make strides to do better, both by providing better technical care (e.g. ensuring careful assessments and ordering the best tests and treatments) and by doing so in a way that ensures patients and their families are highly satisfied.
Tools to Support Ongoing Improvements in Hospitalist Practice
There are many outlets hospitalists can turn to for education on essentially any aspect of their practice. Several years ago, the SHM published “The Core Competencies in Hospital Medicine: A Framework for Curriculum Development,” a publication that continues to be valuable in guiding hospitalists’ professional scope of clinical skills as well as educational curricula for training programs and continuing education. SHM and other organizations generate a great deal of educational content for hospitalists, which is available in many forms, including in-person conferences, webinars, and written materials. And there are several scientific journals that have significant content for hospitalists, including SHM’s own Journal of Hospital Medicine.
Our field encourages and recognizes ongoing commitment to hospitalists’ growth and development in a number of ways. When it is time for a doctor to renew his/her board certification, the American Board of Internal Medicine (ABIM) offers the option to pursue “Focused Practice in Hospital Medicine.” And SHM’s designation of Fellow, Senior Fellow and Master in Hospital Medicine recognizes those who have “demonstrated a commitment to hospital medicine, system change, and quality improvement principles.” Many in our field have achieved one or both of these distinctions, and countless others are pursuing them now.
Through its foundation, the ABIM developed a campaign known as “Choosing Wisely” to “promote conversations between physicians and patients by helping patients choose care that is: supported by evidence, not duplicative of other tests or procedures already received, free from harm, and truly necessary.” SHM joined in this effort by developing separate criteria for hospitalists who care for adults or children.
New Tool Encourages High Performance
In February, an SHM workgroup published “The Key Principles and Characteristics of an Effective Hospital Medicine Group: An Assessment Guide for Hospitals and Hospitalists,” a document meant to serve as a road map for hospitalist groups to follow to improve their performance. I’m particularly interested in this, since I have spent much of my career thinking about and working with hospitalist groups to improve the way they perform, and I helped develop the characteristics and co-authored the document. But the real value of the document comes from the input of hundreds of people within and outside of SHM who provided thoughtful advice and feedback to identify those attributes of hospitalist groups that are most likely to ensure success.
The document describes 47 characteristics grouped into 10 different categories (“principles”). Some of the principles that you as a patient might be most interested in are ones specifying that a hospitalist group:
— Implements a practice model that is patient- and family-centered, is team-based, and emphasizes care coordination and effective communication.
— Supports care coordination across care settings; and
— Plays a leadership role in addressing key clinical issues in the hospital and/or health system: teaching, quality, safety, efficiency, and the patient/family experience.
Current State of Hospital Medicine
If you’ve had a less than satisfactory experience with care by a hospitalist, the things I’ve described here might not improve your opinion of hospitalists, or that of your friends. But maybe you can take some measure of comfort in knowing that our field as a whole is working hard to continuously improve all aspects of what we do. We’re serious about being good at what we do.
And, since this is published in a magazine read by hospitalists, maybe some of them will be reminded of the many ways our field encourages, supports, and recognizes their professional development.
Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at john.nelson@nelsonflores.com.
Problem Solving In Multi-Site Hospital Medicine Groups
Serving as the lead physician for a hospital medicine group (HMG) makes for challenging work. And the challenges and complexity only increase for anyone who serves as the physician leader for multiple practice sites in the same hospital system. In my November 2013 column on multi-site HMG leaders, I listed a few of the tricky issues they face and will mention a few more here.
Large-Small Friction
Unfortunately, tension between hospitalists at the big hospital and doctors at the small, “feeder” hospitals seems pretty common, and I think it’s due largely to high stress and a wide variation in workload, neither of which are in our direct control. At facilities where there is significant tension, I’m impressed by how vigorously the hospitalists at both the small and large hospitals argue that their own site faces the most stress and challenges. (This is a little like the endless debate about who works harder, those who work with residents and those who don’t.)
The hospitalists at the small site point out that they work with little or no subspecialty help and might even have to take night call from home while working during the day. Those at the big hospital say they are the ones with the very large scope of clinical practice and that, rather than making their life easier, the presence of lots of subspecialists makes for additional work coordinating care and communicating with all parties.
Where it exists, this tension is most evident during a transfer from one of the small hospitals to the large one. After all, one of the reasons to form a system of hospitals is so that nearly all patient needs can be met at one of the facilities in the system. Yet, for many reasons, the hospitalists at the large hospital are—sometimes—not as receptive to transfers as might be ideal. They might be short staffed or facing a high census or an unusually high number of admissions from their own ED. Or, perhaps, they’re concerned that the subspecialty services for which the patient is being transferred (e.g. to be scoped by a GI doctor) won’t be as helpful or prompt as needed. Or maybe they’ve felt “burned” by their colleagues at the small hospital for past transfers that didn’t seem necessary.
The result can be that the doctors at the smaller hospital complain that the “mother ship” hospitalists often are unfriendly and unreceptive to transfer requests. Although there may not be a definitive “cure” for this issue, there are several ways to help address the problem.
- In my last column, I mentioned the value of one or more in-person meetings between those who tend to be on the sending and receiving end of transfers, to establish some criteria regarding transfers that are appropriate and review the process of requesting a transfer and making the associated arrangements. In most cases there will be value in the parties meeting routinely—perhaps two to four times annually—to review how the system is working and address any difficulties.
- Periodic social meetings among the hospitalists at each site will help to form relationships that can make it less likely that any conversation about transfers will go in an unhelpful direction. Things can be very different when the people on each end of the phone call know each other personally.
- Record the phone calls between those seeking and accepting/declining each transfer. Scott Rissmiller, MD, the lead hospitalist for the 17 practice sites in Carolinas Healthcare, has said that having underperforming doctors listen to recordings of their phone calls about transfers has, in most cases he’s been involved with, proven to be a very effective way to encourage improvement.
Shared Staffing
The small hospitals in many systems sometimes struggle to find a way to provide economical night coverage. Hospitals below a certain size find it very difficult to justify a separate, in-house night provider. Some hospital systems have had success sharing night staffing, with the large hospital’s night hospitalist, nurse practitioner, or physician assistant providing telephone coverage for “cross cover” issues that arise after hours.
For example, when a nurse at the small hospital needs to contact a night hospitalist, staff will page the provider at the big hospital, and, in many cases, the issue can be managed effectively by phone. This works best when both hospitals are on the same electronic medical record, so that the responding provider can look through the record as needed.
The hospitalist at the small hospital typically stays on back-up call and is contacted if bedside attention is required.
Or, if the large and small hospitals are a short drive apart, the night hospitalist at the large facility might make the short drive to the small hospital when needed. In the case of emergencies (i.e., a code blue), the in-house night ED physician is relied on as the first responder.
Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at john.nelson@nelsonflores.com.
Serving as the lead physician for a hospital medicine group (HMG) makes for challenging work. And the challenges and complexity only increase for anyone who serves as the physician leader for multiple practice sites in the same hospital system. In my November 2013 column on multi-site HMG leaders, I listed a few of the tricky issues they face and will mention a few more here.
Large-Small Friction
Unfortunately, tension between hospitalists at the big hospital and doctors at the small, “feeder” hospitals seems pretty common, and I think it’s due largely to high stress and a wide variation in workload, neither of which are in our direct control. At facilities where there is significant tension, I’m impressed by how vigorously the hospitalists at both the small and large hospitals argue that their own site faces the most stress and challenges. (This is a little like the endless debate about who works harder, those who work with residents and those who don’t.)
The hospitalists at the small site point out that they work with little or no subspecialty help and might even have to take night call from home while working during the day. Those at the big hospital say they are the ones with the very large scope of clinical practice and that, rather than making their life easier, the presence of lots of subspecialists makes for additional work coordinating care and communicating with all parties.
Where it exists, this tension is most evident during a transfer from one of the small hospitals to the large one. After all, one of the reasons to form a system of hospitals is so that nearly all patient needs can be met at one of the facilities in the system. Yet, for many reasons, the hospitalists at the large hospital are—sometimes—not as receptive to transfers as might be ideal. They might be short staffed or facing a high census or an unusually high number of admissions from their own ED. Or, perhaps, they’re concerned that the subspecialty services for which the patient is being transferred (e.g. to be scoped by a GI doctor) won’t be as helpful or prompt as needed. Or maybe they’ve felt “burned” by their colleagues at the small hospital for past transfers that didn’t seem necessary.
The result can be that the doctors at the smaller hospital complain that the “mother ship” hospitalists often are unfriendly and unreceptive to transfer requests. Although there may not be a definitive “cure” for this issue, there are several ways to help address the problem.
- In my last column, I mentioned the value of one or more in-person meetings between those who tend to be on the sending and receiving end of transfers, to establish some criteria regarding transfers that are appropriate and review the process of requesting a transfer and making the associated arrangements. In most cases there will be value in the parties meeting routinely—perhaps two to four times annually—to review how the system is working and address any difficulties.
- Periodic social meetings among the hospitalists at each site will help to form relationships that can make it less likely that any conversation about transfers will go in an unhelpful direction. Things can be very different when the people on each end of the phone call know each other personally.
- Record the phone calls between those seeking and accepting/declining each transfer. Scott Rissmiller, MD, the lead hospitalist for the 17 practice sites in Carolinas Healthcare, has said that having underperforming doctors listen to recordings of their phone calls about transfers has, in most cases he’s been involved with, proven to be a very effective way to encourage improvement.
Shared Staffing
The small hospitals in many systems sometimes struggle to find a way to provide economical night coverage. Hospitals below a certain size find it very difficult to justify a separate, in-house night provider. Some hospital systems have had success sharing night staffing, with the large hospital’s night hospitalist, nurse practitioner, or physician assistant providing telephone coverage for “cross cover” issues that arise after hours.
For example, when a nurse at the small hospital needs to contact a night hospitalist, staff will page the provider at the big hospital, and, in many cases, the issue can be managed effectively by phone. This works best when both hospitals are on the same electronic medical record, so that the responding provider can look through the record as needed.
The hospitalist at the small hospital typically stays on back-up call and is contacted if bedside attention is required.
Or, if the large and small hospitals are a short drive apart, the night hospitalist at the large facility might make the short drive to the small hospital when needed. In the case of emergencies (i.e., a code blue), the in-house night ED physician is relied on as the first responder.
Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at john.nelson@nelsonflores.com.
Serving as the lead physician for a hospital medicine group (HMG) makes for challenging work. And the challenges and complexity only increase for anyone who serves as the physician leader for multiple practice sites in the same hospital system. In my November 2013 column on multi-site HMG leaders, I listed a few of the tricky issues they face and will mention a few more here.
Large-Small Friction
Unfortunately, tension between hospitalists at the big hospital and doctors at the small, “feeder” hospitals seems pretty common, and I think it’s due largely to high stress and a wide variation in workload, neither of which are in our direct control. At facilities where there is significant tension, I’m impressed by how vigorously the hospitalists at both the small and large hospitals argue that their own site faces the most stress and challenges. (This is a little like the endless debate about who works harder, those who work with residents and those who don’t.)
The hospitalists at the small site point out that they work with little or no subspecialty help and might even have to take night call from home while working during the day. Those at the big hospital say they are the ones with the very large scope of clinical practice and that, rather than making their life easier, the presence of lots of subspecialists makes for additional work coordinating care and communicating with all parties.
Where it exists, this tension is most evident during a transfer from one of the small hospitals to the large one. After all, one of the reasons to form a system of hospitals is so that nearly all patient needs can be met at one of the facilities in the system. Yet, for many reasons, the hospitalists at the large hospital are—sometimes—not as receptive to transfers as might be ideal. They might be short staffed or facing a high census or an unusually high number of admissions from their own ED. Or, perhaps, they’re concerned that the subspecialty services for which the patient is being transferred (e.g. to be scoped by a GI doctor) won’t be as helpful or prompt as needed. Or maybe they’ve felt “burned” by their colleagues at the small hospital for past transfers that didn’t seem necessary.
The result can be that the doctors at the smaller hospital complain that the “mother ship” hospitalists often are unfriendly and unreceptive to transfer requests. Although there may not be a definitive “cure” for this issue, there are several ways to help address the problem.
- In my last column, I mentioned the value of one or more in-person meetings between those who tend to be on the sending and receiving end of transfers, to establish some criteria regarding transfers that are appropriate and review the process of requesting a transfer and making the associated arrangements. In most cases there will be value in the parties meeting routinely—perhaps two to four times annually—to review how the system is working and address any difficulties.
- Periodic social meetings among the hospitalists at each site will help to form relationships that can make it less likely that any conversation about transfers will go in an unhelpful direction. Things can be very different when the people on each end of the phone call know each other personally.
- Record the phone calls between those seeking and accepting/declining each transfer. Scott Rissmiller, MD, the lead hospitalist for the 17 practice sites in Carolinas Healthcare, has said that having underperforming doctors listen to recordings of their phone calls about transfers has, in most cases he’s been involved with, proven to be a very effective way to encourage improvement.
Shared Staffing
The small hospitals in many systems sometimes struggle to find a way to provide economical night coverage. Hospitals below a certain size find it very difficult to justify a separate, in-house night provider. Some hospital systems have had success sharing night staffing, with the large hospital’s night hospitalist, nurse practitioner, or physician assistant providing telephone coverage for “cross cover” issues that arise after hours.
For example, when a nurse at the small hospital needs to contact a night hospitalist, staff will page the provider at the big hospital, and, in many cases, the issue can be managed effectively by phone. This works best when both hospitals are on the same electronic medical record, so that the responding provider can look through the record as needed.
The hospitalist at the small hospital typically stays on back-up call and is contacted if bedside attention is required.
Or, if the large and small hospitals are a short drive apart, the night hospitalist at the large facility might make the short drive to the small hospital when needed. In the case of emergencies (i.e., a code blue), the in-house night ED physician is relied on as the first responder.
Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at john.nelson@nelsonflores.com.
Principles and Characteristics of an HMG
With the continuing growth of the specialty of hospital medicine, the capabilities and performance of hospital medicine groups (HMGs) varies significantly. There are few guidelines that HMGs can reference as tools to guide self‐improvement. To address this deficiency, the Society of Hospital Medicine (SHM) Board of Directors authorized a process to identify the key principles and characteristics of an effective HMG.
METHODS
Topic Development and Validation Prework
In providing direction to this effort, the SHM board felt that the principles and characteristics should be directed at both hospitals and hospitalists, addressing the full range of managerial, organizational, clinical, and quality activities necessary to achieve effectiveness. Furthermore, the board defined effectiveness as consisting of 2 components. First, the HMG must assure that the patients managed by hospitalists receive high‐quality care that is sensitive to their needs and preferences. Second, the HMG must understand that the central role of the hospitalist is to coordinate patient care and foster interdisciplinary communication across the care continuum to provide optimal patient outcomes.
The SHM board appointed an HMG Characteristics Workgroup consisting of individuals who have experience with a wide array of HMG models and who could offer expert opinions on the subject. The HMG Characteristics Workgroup felt it important to review the work of other organizations that develop and administer criteria, standards, and/or requirements for healthcare organizations. Examples cited were the American College of Surgeons[1]; The Joint Commission[2]; American Nurse Credentialing Center[3]; the National Committee for Quality Assurance[4]; the American Medical Group Association[5]; and the American Association of Critical‐Care Nurses.[6]
In March 2012 and April 2012, SHM staff reviewed the websites and published materials of these organizations. For each program, information was captured on the qualifications of applicants, history of the program, timing of administering the program, the nature of recognition granted, and the program's keys to success. The summary of these findings was shared with the workgroup.
Background research and the broad scope of characteristics to be addressed led to the workgroup's decision to develop the principles and characteristics using a consensus process, emphasizing expert opinion supplemented by feedback from a broad group of stakeholders.
Initial Draft
During April 2012 and May 2012, the HMG Characteristics Workgroup identified 3 domains for the key characteristics: (1) program structure and operations, (2) clinical care delivery, and (3) organizational performance improvement. Over the course of several meetings, the HMG Characteristics Workgroup developed an initial draft of 83 characteristics, grouped into 29 subgroups within the 3 domains.
From June 2012 to November 2012, this initial draft was reviewed by a broad cross section of the hospital medicine community including members of SHM's committees, a group of academic hospitalists, focus groups in 2 communities (Philadelphia and Boston), and the leaders of several regional and national hospitalist management companies. Quantitative and qualitative feedback was obtained.
In November 2012, the SHM Board of Directors held its annual leadership meeting, attended by approximately 25 national hospitalist thought leaders and chairpersons of SHM committees. At this meeting, a series of exercises were conducted in which these leaders of the hospital medicine movement, including the SHM board members, were each assigned individual characteristics and asked to review and edit them for clarity and appropriateness.
As a result of feedback at that meeting and subsequent discussion by the SHM board, the workgroup was asked to modify the characteristics in 3 ways. First, the list should be streamlined, reducing the number of characteristics. Second, the 3 domains should be eliminated, and a better organizing framework should be created. Third, additional context should be added to the list of characteristics.
Second Draft
During the period from November 2012 to December 2012, the HMG Characteristics Workgroup went through a 2‐step Delphi process to consolidate characteristics and/or eliminate characteristics that were redundant or unnecessary. In the first step, members of the workgroup rated each characteristic from 1 to 3. A rating of 1 meant not important; good quality, but not required for an effective HMG. A rating of 2 meant important; most effective HMGs will meet requirement. A rating of 3 meant highly important; mandatory for an effective HMG. In the second step, members of the workgroup received feedback on the scores for each characteristic and came to a consensus on which characteristics should be eliminated or merged with other characteristics.
As a result, the number of characteristics was reduced and consolidated from 83 to 47, and a new framing structure was defined, replacing the 3 domains with 10 organizing principles. Finally, a rationale for each characteristic was added, defending its inclusion in the list. In addition, consideration was given to including a section describing how an HMG could demonstrate that their organization met each characteristic. However, the workgroup and the board decided that these demonstration requirements should be vetted before they were published.
From January 2013 to June 2013, the revised key principles and characteristics were reviewed by selected chairpersons of SHM committees and by 2 focus groups of HMG leaders. These reviews were conducted at the SHM Annual Meeting. Finally, in June 2013, the Committee on Clinical Leadership of the American Hospital Association reviewed and commented on the draft of the principles and characteristics.
In addition, based on feedback received from the reviewers, the wording of many of the characteristics went through revisions to assure precision and clarity. Before submission to the Journal of Hospital Medicine, a professional editor was engaged to assure that the format and language of the characteristics were clear and consistent.
Final Approval
The final draft of the 10 principles and 47 characteristics was approved for publication at a meeting of the SHM Board of Directors in September 2013 (Figure 1).
RESULTS
A recurring issue that the workgroup addressed was the applicability of the characteristics from 1 practice setting to another. Confounding factors include the HMG's employment/organizational model (eg, hospital employed, academic, multispecialty group, private practice, and management company), its population served (eg, adult vs pediatric, more than 1 hospital), and the type of hospital served (eg, academic vs community, the hospital has more than 1 HMG). The workgroup has made an effort to assure that all 47 characteristics can be applied to every type of HMG.
In developing the 10 principles, the workgroup attempted to construct a list of the basic ingredients needed to build and sustain an effective HMG. These 10 principles stand on their own, independent of the 47 key characteristics, and include issues such as effective leadership, clinician engagement, adequate resources, management infrastructure, key hospitalist roles and responsibilities, alignment with the hospital, and the recruitment and retention of qualified hospitalists.
A more detailed version of the Key Principles and Characteristics of an Effective HMG is available in the online version of this article (see Supporting Information, Appendix, in the online version of this article). The online Appendix includes the rationales for each of the characteristics, guidance on how to provide feedback to the SHM on the framework, and the SHM's plan for further development of the key principles and characteristics.
DISCUSSION
To address the variability in capabilities and performance of HMGs, these principles and characteristics are designed to provide a framework for HMGs seeking to conduct self‐assessments and develop pathways for improvement.
Although there may be HMG arrangements that do not directly involve the hospital and its executive team, and therefore alternative approaches may make sense, for most HMGs hospitals are directly involved with the HMG as either an employer or a contractor. For that reason, the Key Principles and Characteristics of an Effective HMG is written for 2 audiences: the executive leadership of the hospital (most specifically the chief medical officer or a similar role) and the hospitalists in the HMG (most specifically the practice medical director). To address the key characteristics requires the active participation of both parties. For the hospital executives, the framework establishes expectations for the HMG. For the hospitalists, the framework provides guidance in the development of an improvement plan.
Hospital executives and hospitalists can use the key characteristics in a broad spectrum of ways. The easiest and least formalized approach would be to use the framework as the basis of an ongoing dialogue between the hospital leadership and the HMG. A more formal approach would be to use the framework to guide the planning and budgeting activities of the HMG. Finally, a hospital or health system can use the key principles and characteristics as a way to evaluate their affiliated HMG(s)for example, the HMG must address 80% of the 47 characteristics.
The Key Principles and Characteristics of an Effective HMG should be considered akin to the Core Competencies in Hospital Medicine previously published in the Journal of Hospital Medicine.[7] However, instead of focusing on the competencies of individual physicians, this framework focuses on the characteristics of hospitalist groups. Just as a physician or other healthcare provider is not expected to demonstrate competency for every element in the core competencies document, an HMG does not need to have all 47 characteristics to be effective. Effective hospitalists may have skills other than those listed in the Core Competencies in Hospital Medicine. Similarly, the 47 characteristics do not represent an exhaustive list of every desirable HMG attribute. In general, effective HMGs should possess most of the characteristics.
In applying the framework, the HMG should not simply attempt to evaluate each characteristic with a yes or no assessment. For HMGs responding yes, there may be a wide range of performancefrom meeting the bare minimum requirements to employing sophisticated, expansive measures to excel in the characteristic.
SHM encourages hospital leaders and HMG leaders to use these characteristics to perform an HMG self‐assessment and to develop a plan. The plan could address implementation of selected characteristics that are not currently being addressed by the HMG or the development of additional behaviors, tools, resources, and capabilities that more fully incorporate those characteristics for which the HMG meets only minimum requirements. In addition, the plan could address the impact that a larger organization (eg, health system, hospital, or employer) may have on a given characteristic.
As outlined above, the process used to develop the Key Principles and Characteristics of an Effective HMG was grounded in expert opinion and extensive review and feedback. HMGs that use the framework should recognize that others might have a different opinion. For example, characteristic 5.2 states, The HMG's compensation model aligns hospitalist incentives with the goals of the hospital and the goals of the hospitalist's employer (if different). There are likely to be experienced hospitalist leaders who believe that an effective HMG does not need to have an incentive compensation system. However, the consensus process employed to develop the key characteristics led to the conclusion that an effective HMG should have an incentive compensation system.
The publication of the Key Principles and Characteristics of an Effective HMG may lead to negative and/or unintended consequences. A self‐assessment by an HMG using this framework could require a significant level of effort on behalf of the HMG, whereas implementing remedial efforts to address the characteristics could require an investment of time and money that could take away from other important issues facing the HMG. Many HMGs may be held accountable for addressing these characteristics without the necessary financial support from their hospital or medical group. Finally, the publication of the document could create a backlash from members of the hospitalist community who do not think that the SHM should be in the business of defining what characterizes an effective HMG, rather that this definition should be left to the marketplace.
Despite these concerns, the leadership of the SHM expects that the publication of the Key Principles and Characteristics of an Effective HMG will lead to overall improvement in the capabilities and performance of HMGs.
CONCLUSIONS
The Key Principles and Characteristics of an Effective HMG have been designed to be aspirational, helping to raise the bar for the specialty of hospital medicine. These principles and characteristics could provide a framework for HMGs seeking to conduct self‐assessments, outlining a pathway for improvement, and better defining the central role of hospitalists in coordinating team‐based, patient‐centered care in the acute care setting.
Acknowledgments
Disclosures: Patrick Cawley, MD: none; Steven Deitelzweig, MD: none; Leslie Flores, MHA: provides consulting to hospital medicine groups; Joseph A. Miller, MS: none; John Nelson, MD: provides consulting to hospital medicine groups; Scott Rissmiller, MD: none; Laurence Wellikson, MD: none; Winthrop F. Whitcomb, MD: provides consulting to hospital medicine groups.
- American College of Surgeons. New verification site visit outcomes. Available at: http://www.facs.org/trauma/verifivisitoutcomes.html. Accessed September 3, 2013.
- Hospital accreditation standards 2012. Oakbrook Terrace, IL: The Joint Commission; 2012. Available at: Amazon.com: http://www.amazon.com/Hospital‐Accreditation‐Standards‐Joint‐Commission/dp/1599404257
- The magnet model: components and sources of evidence. Silver Spring, MD: American Nurse Credentialing Center; 2011. Available at: Amazon.com: http://www.amazon.com/Magnet‐Model‐Components‐Sources‐Evidence/dp/1935213229.
- Patient Centered Medical Home Standards and Guidelines. National Committee for Quality Assurance. Available at: https://inetshop01.pub.ncqa.org/Publications/deptCate.asp?dept_id=21(suppl 1):2–95.
With the continuing growth of the specialty of hospital medicine, the capabilities and performance of hospital medicine groups (HMGs) varies significantly. There are few guidelines that HMGs can reference as tools to guide self‐improvement. To address this deficiency, the Society of Hospital Medicine (SHM) Board of Directors authorized a process to identify the key principles and characteristics of an effective HMG.
METHODS
Topic Development and Validation Prework
In providing direction to this effort, the SHM board felt that the principles and characteristics should be directed at both hospitals and hospitalists, addressing the full range of managerial, organizational, clinical, and quality activities necessary to achieve effectiveness. Furthermore, the board defined effectiveness as consisting of 2 components. First, the HMG must assure that the patients managed by hospitalists receive high‐quality care that is sensitive to their needs and preferences. Second, the HMG must understand that the central role of the hospitalist is to coordinate patient care and foster interdisciplinary communication across the care continuum to provide optimal patient outcomes.
The SHM board appointed an HMG Characteristics Workgroup consisting of individuals who have experience with a wide array of HMG models and who could offer expert opinions on the subject. The HMG Characteristics Workgroup felt it important to review the work of other organizations that develop and administer criteria, standards, and/or requirements for healthcare organizations. Examples cited were the American College of Surgeons[1]; The Joint Commission[2]; American Nurse Credentialing Center[3]; the National Committee for Quality Assurance[4]; the American Medical Group Association[5]; and the American Association of Critical‐Care Nurses.[6]
In March 2012 and April 2012, SHM staff reviewed the websites and published materials of these organizations. For each program, information was captured on the qualifications of applicants, history of the program, timing of administering the program, the nature of recognition granted, and the program's keys to success. The summary of these findings was shared with the workgroup.
Background research and the broad scope of characteristics to be addressed led to the workgroup's decision to develop the principles and characteristics using a consensus process, emphasizing expert opinion supplemented by feedback from a broad group of stakeholders.
Initial Draft
During April 2012 and May 2012, the HMG Characteristics Workgroup identified 3 domains for the key characteristics: (1) program structure and operations, (2) clinical care delivery, and (3) organizational performance improvement. Over the course of several meetings, the HMG Characteristics Workgroup developed an initial draft of 83 characteristics, grouped into 29 subgroups within the 3 domains.
From June 2012 to November 2012, this initial draft was reviewed by a broad cross section of the hospital medicine community including members of SHM's committees, a group of academic hospitalists, focus groups in 2 communities (Philadelphia and Boston), and the leaders of several regional and national hospitalist management companies. Quantitative and qualitative feedback was obtained.
In November 2012, the SHM Board of Directors held its annual leadership meeting, attended by approximately 25 national hospitalist thought leaders and chairpersons of SHM committees. At this meeting, a series of exercises were conducted in which these leaders of the hospital medicine movement, including the SHM board members, were each assigned individual characteristics and asked to review and edit them for clarity and appropriateness.
As a result of feedback at that meeting and subsequent discussion by the SHM board, the workgroup was asked to modify the characteristics in 3 ways. First, the list should be streamlined, reducing the number of characteristics. Second, the 3 domains should be eliminated, and a better organizing framework should be created. Third, additional context should be added to the list of characteristics.
Second Draft
During the period from November 2012 to December 2012, the HMG Characteristics Workgroup went through a 2‐step Delphi process to consolidate characteristics and/or eliminate characteristics that were redundant or unnecessary. In the first step, members of the workgroup rated each characteristic from 1 to 3. A rating of 1 meant not important; good quality, but not required for an effective HMG. A rating of 2 meant important; most effective HMGs will meet requirement. A rating of 3 meant highly important; mandatory for an effective HMG. In the second step, members of the workgroup received feedback on the scores for each characteristic and came to a consensus on which characteristics should be eliminated or merged with other characteristics.
As a result, the number of characteristics was reduced and consolidated from 83 to 47, and a new framing structure was defined, replacing the 3 domains with 10 organizing principles. Finally, a rationale for each characteristic was added, defending its inclusion in the list. In addition, consideration was given to including a section describing how an HMG could demonstrate that their organization met each characteristic. However, the workgroup and the board decided that these demonstration requirements should be vetted before they were published.
From January 2013 to June 2013, the revised key principles and characteristics were reviewed by selected chairpersons of SHM committees and by 2 focus groups of HMG leaders. These reviews were conducted at the SHM Annual Meeting. Finally, in June 2013, the Committee on Clinical Leadership of the American Hospital Association reviewed and commented on the draft of the principles and characteristics.
In addition, based on feedback received from the reviewers, the wording of many of the characteristics went through revisions to assure precision and clarity. Before submission to the Journal of Hospital Medicine, a professional editor was engaged to assure that the format and language of the characteristics were clear and consistent.
Final Approval
The final draft of the 10 principles and 47 characteristics was approved for publication at a meeting of the SHM Board of Directors in September 2013 (Figure 1).
RESULTS
A recurring issue that the workgroup addressed was the applicability of the characteristics from 1 practice setting to another. Confounding factors include the HMG's employment/organizational model (eg, hospital employed, academic, multispecialty group, private practice, and management company), its population served (eg, adult vs pediatric, more than 1 hospital), and the type of hospital served (eg, academic vs community, the hospital has more than 1 HMG). The workgroup has made an effort to assure that all 47 characteristics can be applied to every type of HMG.
In developing the 10 principles, the workgroup attempted to construct a list of the basic ingredients needed to build and sustain an effective HMG. These 10 principles stand on their own, independent of the 47 key characteristics, and include issues such as effective leadership, clinician engagement, adequate resources, management infrastructure, key hospitalist roles and responsibilities, alignment with the hospital, and the recruitment and retention of qualified hospitalists.
A more detailed version of the Key Principles and Characteristics of an Effective HMG is available in the online version of this article (see Supporting Information, Appendix, in the online version of this article). The online Appendix includes the rationales for each of the characteristics, guidance on how to provide feedback to the SHM on the framework, and the SHM's plan for further development of the key principles and characteristics.
DISCUSSION
To address the variability in capabilities and performance of HMGs, these principles and characteristics are designed to provide a framework for HMGs seeking to conduct self‐assessments and develop pathways for improvement.
Although there may be HMG arrangements that do not directly involve the hospital and its executive team, and therefore alternative approaches may make sense, for most HMGs hospitals are directly involved with the HMG as either an employer or a contractor. For that reason, the Key Principles and Characteristics of an Effective HMG is written for 2 audiences: the executive leadership of the hospital (most specifically the chief medical officer or a similar role) and the hospitalists in the HMG (most specifically the practice medical director). To address the key characteristics requires the active participation of both parties. For the hospital executives, the framework establishes expectations for the HMG. For the hospitalists, the framework provides guidance in the development of an improvement plan.
Hospital executives and hospitalists can use the key characteristics in a broad spectrum of ways. The easiest and least formalized approach would be to use the framework as the basis of an ongoing dialogue between the hospital leadership and the HMG. A more formal approach would be to use the framework to guide the planning and budgeting activities of the HMG. Finally, a hospital or health system can use the key principles and characteristics as a way to evaluate their affiliated HMG(s)for example, the HMG must address 80% of the 47 characteristics.
The Key Principles and Characteristics of an Effective HMG should be considered akin to the Core Competencies in Hospital Medicine previously published in the Journal of Hospital Medicine.[7] However, instead of focusing on the competencies of individual physicians, this framework focuses on the characteristics of hospitalist groups. Just as a physician or other healthcare provider is not expected to demonstrate competency for every element in the core competencies document, an HMG does not need to have all 47 characteristics to be effective. Effective hospitalists may have skills other than those listed in the Core Competencies in Hospital Medicine. Similarly, the 47 characteristics do not represent an exhaustive list of every desirable HMG attribute. In general, effective HMGs should possess most of the characteristics.
In applying the framework, the HMG should not simply attempt to evaluate each characteristic with a yes or no assessment. For HMGs responding yes, there may be a wide range of performancefrom meeting the bare minimum requirements to employing sophisticated, expansive measures to excel in the characteristic.
SHM encourages hospital leaders and HMG leaders to use these characteristics to perform an HMG self‐assessment and to develop a plan. The plan could address implementation of selected characteristics that are not currently being addressed by the HMG or the development of additional behaviors, tools, resources, and capabilities that more fully incorporate those characteristics for which the HMG meets only minimum requirements. In addition, the plan could address the impact that a larger organization (eg, health system, hospital, or employer) may have on a given characteristic.
As outlined above, the process used to develop the Key Principles and Characteristics of an Effective HMG was grounded in expert opinion and extensive review and feedback. HMGs that use the framework should recognize that others might have a different opinion. For example, characteristic 5.2 states, The HMG's compensation model aligns hospitalist incentives with the goals of the hospital and the goals of the hospitalist's employer (if different). There are likely to be experienced hospitalist leaders who believe that an effective HMG does not need to have an incentive compensation system. However, the consensus process employed to develop the key characteristics led to the conclusion that an effective HMG should have an incentive compensation system.
The publication of the Key Principles and Characteristics of an Effective HMG may lead to negative and/or unintended consequences. A self‐assessment by an HMG using this framework could require a significant level of effort on behalf of the HMG, whereas implementing remedial efforts to address the characteristics could require an investment of time and money that could take away from other important issues facing the HMG. Many HMGs may be held accountable for addressing these characteristics without the necessary financial support from their hospital or medical group. Finally, the publication of the document could create a backlash from members of the hospitalist community who do not think that the SHM should be in the business of defining what characterizes an effective HMG, rather that this definition should be left to the marketplace.
Despite these concerns, the leadership of the SHM expects that the publication of the Key Principles and Characteristics of an Effective HMG will lead to overall improvement in the capabilities and performance of HMGs.
CONCLUSIONS
The Key Principles and Characteristics of an Effective HMG have been designed to be aspirational, helping to raise the bar for the specialty of hospital medicine. These principles and characteristics could provide a framework for HMGs seeking to conduct self‐assessments, outlining a pathway for improvement, and better defining the central role of hospitalists in coordinating team‐based, patient‐centered care in the acute care setting.
Acknowledgments
Disclosures: Patrick Cawley, MD: none; Steven Deitelzweig, MD: none; Leslie Flores, MHA: provides consulting to hospital medicine groups; Joseph A. Miller, MS: none; John Nelson, MD: provides consulting to hospital medicine groups; Scott Rissmiller, MD: none; Laurence Wellikson, MD: none; Winthrop F. Whitcomb, MD: provides consulting to hospital medicine groups.
With the continuing growth of the specialty of hospital medicine, the capabilities and performance of hospital medicine groups (HMGs) varies significantly. There are few guidelines that HMGs can reference as tools to guide self‐improvement. To address this deficiency, the Society of Hospital Medicine (SHM) Board of Directors authorized a process to identify the key principles and characteristics of an effective HMG.
METHODS
Topic Development and Validation Prework
In providing direction to this effort, the SHM board felt that the principles and characteristics should be directed at both hospitals and hospitalists, addressing the full range of managerial, organizational, clinical, and quality activities necessary to achieve effectiveness. Furthermore, the board defined effectiveness as consisting of 2 components. First, the HMG must assure that the patients managed by hospitalists receive high‐quality care that is sensitive to their needs and preferences. Second, the HMG must understand that the central role of the hospitalist is to coordinate patient care and foster interdisciplinary communication across the care continuum to provide optimal patient outcomes.
The SHM board appointed an HMG Characteristics Workgroup consisting of individuals who have experience with a wide array of HMG models and who could offer expert opinions on the subject. The HMG Characteristics Workgroup felt it important to review the work of other organizations that develop and administer criteria, standards, and/or requirements for healthcare organizations. Examples cited were the American College of Surgeons[1]; The Joint Commission[2]; American Nurse Credentialing Center[3]; the National Committee for Quality Assurance[4]; the American Medical Group Association[5]; and the American Association of Critical‐Care Nurses.[6]
In March 2012 and April 2012, SHM staff reviewed the websites and published materials of these organizations. For each program, information was captured on the qualifications of applicants, history of the program, timing of administering the program, the nature of recognition granted, and the program's keys to success. The summary of these findings was shared with the workgroup.
Background research and the broad scope of characteristics to be addressed led to the workgroup's decision to develop the principles and characteristics using a consensus process, emphasizing expert opinion supplemented by feedback from a broad group of stakeholders.
Initial Draft
During April 2012 and May 2012, the HMG Characteristics Workgroup identified 3 domains for the key characteristics: (1) program structure and operations, (2) clinical care delivery, and (3) organizational performance improvement. Over the course of several meetings, the HMG Characteristics Workgroup developed an initial draft of 83 characteristics, grouped into 29 subgroups within the 3 domains.
From June 2012 to November 2012, this initial draft was reviewed by a broad cross section of the hospital medicine community including members of SHM's committees, a group of academic hospitalists, focus groups in 2 communities (Philadelphia and Boston), and the leaders of several regional and national hospitalist management companies. Quantitative and qualitative feedback was obtained.
In November 2012, the SHM Board of Directors held its annual leadership meeting, attended by approximately 25 national hospitalist thought leaders and chairpersons of SHM committees. At this meeting, a series of exercises were conducted in which these leaders of the hospital medicine movement, including the SHM board members, were each assigned individual characteristics and asked to review and edit them for clarity and appropriateness.
As a result of feedback at that meeting and subsequent discussion by the SHM board, the workgroup was asked to modify the characteristics in 3 ways. First, the list should be streamlined, reducing the number of characteristics. Second, the 3 domains should be eliminated, and a better organizing framework should be created. Third, additional context should be added to the list of characteristics.
Second Draft
During the period from November 2012 to December 2012, the HMG Characteristics Workgroup went through a 2‐step Delphi process to consolidate characteristics and/or eliminate characteristics that were redundant or unnecessary. In the first step, members of the workgroup rated each characteristic from 1 to 3. A rating of 1 meant not important; good quality, but not required for an effective HMG. A rating of 2 meant important; most effective HMGs will meet requirement. A rating of 3 meant highly important; mandatory for an effective HMG. In the second step, members of the workgroup received feedback on the scores for each characteristic and came to a consensus on which characteristics should be eliminated or merged with other characteristics.
As a result, the number of characteristics was reduced and consolidated from 83 to 47, and a new framing structure was defined, replacing the 3 domains with 10 organizing principles. Finally, a rationale for each characteristic was added, defending its inclusion in the list. In addition, consideration was given to including a section describing how an HMG could demonstrate that their organization met each characteristic. However, the workgroup and the board decided that these demonstration requirements should be vetted before they were published.
From January 2013 to June 2013, the revised key principles and characteristics were reviewed by selected chairpersons of SHM committees and by 2 focus groups of HMG leaders. These reviews were conducted at the SHM Annual Meeting. Finally, in June 2013, the Committee on Clinical Leadership of the American Hospital Association reviewed and commented on the draft of the principles and characteristics.
In addition, based on feedback received from the reviewers, the wording of many of the characteristics went through revisions to assure precision and clarity. Before submission to the Journal of Hospital Medicine, a professional editor was engaged to assure that the format and language of the characteristics were clear and consistent.
Final Approval
The final draft of the 10 principles and 47 characteristics was approved for publication at a meeting of the SHM Board of Directors in September 2013 (Figure 1).
RESULTS
A recurring issue that the workgroup addressed was the applicability of the characteristics from 1 practice setting to another. Confounding factors include the HMG's employment/organizational model (eg, hospital employed, academic, multispecialty group, private practice, and management company), its population served (eg, adult vs pediatric, more than 1 hospital), and the type of hospital served (eg, academic vs community, the hospital has more than 1 HMG). The workgroup has made an effort to assure that all 47 characteristics can be applied to every type of HMG.
In developing the 10 principles, the workgroup attempted to construct a list of the basic ingredients needed to build and sustain an effective HMG. These 10 principles stand on their own, independent of the 47 key characteristics, and include issues such as effective leadership, clinician engagement, adequate resources, management infrastructure, key hospitalist roles and responsibilities, alignment with the hospital, and the recruitment and retention of qualified hospitalists.
A more detailed version of the Key Principles and Characteristics of an Effective HMG is available in the online version of this article (see Supporting Information, Appendix, in the online version of this article). The online Appendix includes the rationales for each of the characteristics, guidance on how to provide feedback to the SHM on the framework, and the SHM's plan for further development of the key principles and characteristics.
DISCUSSION
To address the variability in capabilities and performance of HMGs, these principles and characteristics are designed to provide a framework for HMGs seeking to conduct self‐assessments and develop pathways for improvement.
Although there may be HMG arrangements that do not directly involve the hospital and its executive team, and therefore alternative approaches may make sense, for most HMGs hospitals are directly involved with the HMG as either an employer or a contractor. For that reason, the Key Principles and Characteristics of an Effective HMG is written for 2 audiences: the executive leadership of the hospital (most specifically the chief medical officer or a similar role) and the hospitalists in the HMG (most specifically the practice medical director). To address the key characteristics requires the active participation of both parties. For the hospital executives, the framework establishes expectations for the HMG. For the hospitalists, the framework provides guidance in the development of an improvement plan.
Hospital executives and hospitalists can use the key characteristics in a broad spectrum of ways. The easiest and least formalized approach would be to use the framework as the basis of an ongoing dialogue between the hospital leadership and the HMG. A more formal approach would be to use the framework to guide the planning and budgeting activities of the HMG. Finally, a hospital or health system can use the key principles and characteristics as a way to evaluate their affiliated HMG(s)for example, the HMG must address 80% of the 47 characteristics.
The Key Principles and Characteristics of an Effective HMG should be considered akin to the Core Competencies in Hospital Medicine previously published in the Journal of Hospital Medicine.[7] However, instead of focusing on the competencies of individual physicians, this framework focuses on the characteristics of hospitalist groups. Just as a physician or other healthcare provider is not expected to demonstrate competency for every element in the core competencies document, an HMG does not need to have all 47 characteristics to be effective. Effective hospitalists may have skills other than those listed in the Core Competencies in Hospital Medicine. Similarly, the 47 characteristics do not represent an exhaustive list of every desirable HMG attribute. In general, effective HMGs should possess most of the characteristics.
In applying the framework, the HMG should not simply attempt to evaluate each characteristic with a yes or no assessment. For HMGs responding yes, there may be a wide range of performancefrom meeting the bare minimum requirements to employing sophisticated, expansive measures to excel in the characteristic.
SHM encourages hospital leaders and HMG leaders to use these characteristics to perform an HMG self‐assessment and to develop a plan. The plan could address implementation of selected characteristics that are not currently being addressed by the HMG or the development of additional behaviors, tools, resources, and capabilities that more fully incorporate those characteristics for which the HMG meets only minimum requirements. In addition, the plan could address the impact that a larger organization (eg, health system, hospital, or employer) may have on a given characteristic.
As outlined above, the process used to develop the Key Principles and Characteristics of an Effective HMG was grounded in expert opinion and extensive review and feedback. HMGs that use the framework should recognize that others might have a different opinion. For example, characteristic 5.2 states, The HMG's compensation model aligns hospitalist incentives with the goals of the hospital and the goals of the hospitalist's employer (if different). There are likely to be experienced hospitalist leaders who believe that an effective HMG does not need to have an incentive compensation system. However, the consensus process employed to develop the key characteristics led to the conclusion that an effective HMG should have an incentive compensation system.
The publication of the Key Principles and Characteristics of an Effective HMG may lead to negative and/or unintended consequences. A self‐assessment by an HMG using this framework could require a significant level of effort on behalf of the HMG, whereas implementing remedial efforts to address the characteristics could require an investment of time and money that could take away from other important issues facing the HMG. Many HMGs may be held accountable for addressing these characteristics without the necessary financial support from their hospital or medical group. Finally, the publication of the document could create a backlash from members of the hospitalist community who do not think that the SHM should be in the business of defining what characterizes an effective HMG, rather that this definition should be left to the marketplace.
Despite these concerns, the leadership of the SHM expects that the publication of the Key Principles and Characteristics of an Effective HMG will lead to overall improvement in the capabilities and performance of HMGs.
CONCLUSIONS
The Key Principles and Characteristics of an Effective HMG have been designed to be aspirational, helping to raise the bar for the specialty of hospital medicine. These principles and characteristics could provide a framework for HMGs seeking to conduct self‐assessments, outlining a pathway for improvement, and better defining the central role of hospitalists in coordinating team‐based, patient‐centered care in the acute care setting.
Acknowledgments
Disclosures: Patrick Cawley, MD: none; Steven Deitelzweig, MD: none; Leslie Flores, MHA: provides consulting to hospital medicine groups; Joseph A. Miller, MS: none; John Nelson, MD: provides consulting to hospital medicine groups; Scott Rissmiller, MD: none; Laurence Wellikson, MD: none; Winthrop F. Whitcomb, MD: provides consulting to hospital medicine groups.
- American College of Surgeons. New verification site visit outcomes. Available at: http://www.facs.org/trauma/verifivisitoutcomes.html. Accessed September 3, 2013.
- Hospital accreditation standards 2012. Oakbrook Terrace, IL: The Joint Commission; 2012. Available at: Amazon.com: http://www.amazon.com/Hospital‐Accreditation‐Standards‐Joint‐Commission/dp/1599404257
- The magnet model: components and sources of evidence. Silver Spring, MD: American Nurse Credentialing Center; 2011. Available at: Amazon.com: http://www.amazon.com/Magnet‐Model‐Components‐Sources‐Evidence/dp/1935213229.
- Patient Centered Medical Home Standards and Guidelines. National Committee for Quality Assurance. Available at: https://inetshop01.pub.ncqa.org/Publications/deptCate.asp?dept_id=21(suppl 1):2–95.
- American College of Surgeons. New verification site visit outcomes. Available at: http://www.facs.org/trauma/verifivisitoutcomes.html. Accessed September 3, 2013.
- Hospital accreditation standards 2012. Oakbrook Terrace, IL: The Joint Commission; 2012. Available at: Amazon.com: http://www.amazon.com/Hospital‐Accreditation‐Standards‐Joint‐Commission/dp/1599404257
- The magnet model: components and sources of evidence. Silver Spring, MD: American Nurse Credentialing Center; 2011. Available at: Amazon.com: http://www.amazon.com/Magnet‐Model‐Components‐Sources‐Evidence/dp/1935213229.
- Patient Centered Medical Home Standards and Guidelines. National Committee for Quality Assurance. Available at: https://inetshop01.pub.ncqa.org/Publications/deptCate.asp?dept_id=21(suppl 1):2–95.
Shift from Productivity to Value-Based Compensation Gains Momentum
At the 2011 SHM annual meeting in Dallas, I served on an expert panel that reviewed the latest hospitalist survey data. Included in this review were the latest compensation and productivity figures. As the session concluded, I was satisfied that the panel had discussed important information in an accessible way; however, the keynote speaker who followed us to address an entirely different topic began his talk by pointing out that the data we had reviewed, including things like wRVUs, would very soon have little to do with compensation for any physician, regardless of specialty. He implied, quite persuasively, that we were pretty old school to be talking about wRVUs and compensation based on productivity; everyone should be prepared for and embrace compensation based on value, not production.
I hear a similar sentiment reasonably often. And I agree, but I think many make the mistake of oversimplifying the issue.
Physician Value-Based Payment
Measurement of physician performance using costs, quality, and outcomes has already begun and will influence Medicare payments to doctors beginning in 2015 for large groups (>100 providers with any mix of specialties billing under the same tax ID number) and in 2017 for smaller groups.
If Medicare is moving away from payment based on wRVUs, likely followed soon by other payors, then hospitalist compensation should do the same. But I don’t think that changes the potential role of compensation based on productivity.
Compensation Should Include Performance and Productivity Metrics
Survey data show a move from an essentially fixed annual compensation early in our field to an inclusion of components tied to performance several years before the introduction of the Physician Value-Based Payment Modifier program. Data from SHM’s 2010, 2011, and 2012 State of Hospital Medicine reports (www.hospitalmedicine.org/survey) show that a small, but probably increasing, part of compensation has been tied to performance on things like patient satisfaction and core measures (see “Distribution of Total Hospitalist Compensation,” below). Note that the percentages in the chart refer to the fraction of total compensation dollars allocated to each domain and not the portion of hospitalists who have compensation tied to each domain.
Over the same three years, the percentage of compensation tied to productivity has been decreasing overall, while “private groups are more likely to pay a higher proportion of compensation based on productivity, and hospital-employed groups are more likely to pay a higher proportion of compensation based on performance.”
Matching Performance Compensation to Medicare’s Value-Based Modifier
It makes sense for physician compensation to generally mirror Medicare and other payor professional fee reimbursement formulas. But, in that regard, hospitalists are ahead of the market already, because the portion of dollars allocated to performance (value) in hospitalist compensation plans already exceeds the 2% or less portion of Medicare reimbursement that is influenced by performance.
Medicare will steadily increase the portion of reimbursement allocated to performance (value) and decrease the part tied solely to wRVUs. So it makes sense that hospitalist compensation plans should do the same. Who knows, within the next 5-10 years, hospitalists, and potentially doctors in all specialties, might see 20% to 50% of their compensation tied to performance. I think that might be a good thing, as long as we can come up with effective measures of performance and value—not an easy thing to do in any business or industry.
Future Role of Productivity Compensation
I don’t think all the talk about value-based reimbursement means we should abandon the idea of connecting a portion of compensation to productivity. The first two practice management columns I wrote for The Hospitalist appeared in May 2006 (www.the-hospitalist.org/details/article/252413/The_Sweet_Spot.html) and June 2006 (www.the-hospitalist.org/details/article/246297.html) and recommended tying a meaningful portion of compensation to individual hospitalist productivity, and I think it still makes sense to do so.
Source: 2012 State of Hospital Medicine report
In any business or industry, financial performance is connected to the amount of product produced and its value. In the future, both metrics will determine reimbursement for even the highest performing healthcare providers. The new emphasis on value won’t ever make it unnecessary to produce at a reasonable level.
Unquestionably, there are many high-performing hospitalist practices with little or no productivity component in the compensation formula. So it isn’t an absolute sine qua non for success. But I think many practices dismiss it as a viable option when it might solve problems and liberate individuals in the group to exercise some autonomy in finding their own sweet spot between workload and compensation.
It will be interesting to see if future surveys show that the portion of dollars tied to hospitalist productivity continues to decrease, despite what I see as its potential benefits.
At the 2011 SHM annual meeting in Dallas, I served on an expert panel that reviewed the latest hospitalist survey data. Included in this review were the latest compensation and productivity figures. As the session concluded, I was satisfied that the panel had discussed important information in an accessible way; however, the keynote speaker who followed us to address an entirely different topic began his talk by pointing out that the data we had reviewed, including things like wRVUs, would very soon have little to do with compensation for any physician, regardless of specialty. He implied, quite persuasively, that we were pretty old school to be talking about wRVUs and compensation based on productivity; everyone should be prepared for and embrace compensation based on value, not production.
I hear a similar sentiment reasonably often. And I agree, but I think many make the mistake of oversimplifying the issue.
Physician Value-Based Payment
Measurement of physician performance using costs, quality, and outcomes has already begun and will influence Medicare payments to doctors beginning in 2015 for large groups (>100 providers with any mix of specialties billing under the same tax ID number) and in 2017 for smaller groups.
If Medicare is moving away from payment based on wRVUs, likely followed soon by other payors, then hospitalist compensation should do the same. But I don’t think that changes the potential role of compensation based on productivity.
Compensation Should Include Performance and Productivity Metrics
Survey data show a move from an essentially fixed annual compensation early in our field to an inclusion of components tied to performance several years before the introduction of the Physician Value-Based Payment Modifier program. Data from SHM’s 2010, 2011, and 2012 State of Hospital Medicine reports (www.hospitalmedicine.org/survey) show that a small, but probably increasing, part of compensation has been tied to performance on things like patient satisfaction and core measures (see “Distribution of Total Hospitalist Compensation,” below). Note that the percentages in the chart refer to the fraction of total compensation dollars allocated to each domain and not the portion of hospitalists who have compensation tied to each domain.
Over the same three years, the percentage of compensation tied to productivity has been decreasing overall, while “private groups are more likely to pay a higher proportion of compensation based on productivity, and hospital-employed groups are more likely to pay a higher proportion of compensation based on performance.”
Matching Performance Compensation to Medicare’s Value-Based Modifier
It makes sense for physician compensation to generally mirror Medicare and other payor professional fee reimbursement formulas. But, in that regard, hospitalists are ahead of the market already, because the portion of dollars allocated to performance (value) in hospitalist compensation plans already exceeds the 2% or less portion of Medicare reimbursement that is influenced by performance.
Medicare will steadily increase the portion of reimbursement allocated to performance (value) and decrease the part tied solely to wRVUs. So it makes sense that hospitalist compensation plans should do the same. Who knows, within the next 5-10 years, hospitalists, and potentially doctors in all specialties, might see 20% to 50% of their compensation tied to performance. I think that might be a good thing, as long as we can come up with effective measures of performance and value—not an easy thing to do in any business or industry.
Future Role of Productivity Compensation
I don’t think all the talk about value-based reimbursement means we should abandon the idea of connecting a portion of compensation to productivity. The first two practice management columns I wrote for The Hospitalist appeared in May 2006 (www.the-hospitalist.org/details/article/252413/The_Sweet_Spot.html) and June 2006 (www.the-hospitalist.org/details/article/246297.html) and recommended tying a meaningful portion of compensation to individual hospitalist productivity, and I think it still makes sense to do so.
Source: 2012 State of Hospital Medicine report
In any business or industry, financial performance is connected to the amount of product produced and its value. In the future, both metrics will determine reimbursement for even the highest performing healthcare providers. The new emphasis on value won’t ever make it unnecessary to produce at a reasonable level.
Unquestionably, there are many high-performing hospitalist practices with little or no productivity component in the compensation formula. So it isn’t an absolute sine qua non for success. But I think many practices dismiss it as a viable option when it might solve problems and liberate individuals in the group to exercise some autonomy in finding their own sweet spot between workload and compensation.
It will be interesting to see if future surveys show that the portion of dollars tied to hospitalist productivity continues to decrease, despite what I see as its potential benefits.
At the 2011 SHM annual meeting in Dallas, I served on an expert panel that reviewed the latest hospitalist survey data. Included in this review were the latest compensation and productivity figures. As the session concluded, I was satisfied that the panel had discussed important information in an accessible way; however, the keynote speaker who followed us to address an entirely different topic began his talk by pointing out that the data we had reviewed, including things like wRVUs, would very soon have little to do with compensation for any physician, regardless of specialty. He implied, quite persuasively, that we were pretty old school to be talking about wRVUs and compensation based on productivity; everyone should be prepared for and embrace compensation based on value, not production.
I hear a similar sentiment reasonably often. And I agree, but I think many make the mistake of oversimplifying the issue.
Physician Value-Based Payment
Measurement of physician performance using costs, quality, and outcomes has already begun and will influence Medicare payments to doctors beginning in 2015 for large groups (>100 providers with any mix of specialties billing under the same tax ID number) and in 2017 for smaller groups.
If Medicare is moving away from payment based on wRVUs, likely followed soon by other payors, then hospitalist compensation should do the same. But I don’t think that changes the potential role of compensation based on productivity.
Compensation Should Include Performance and Productivity Metrics
Survey data show a move from an essentially fixed annual compensation early in our field to an inclusion of components tied to performance several years before the introduction of the Physician Value-Based Payment Modifier program. Data from SHM’s 2010, 2011, and 2012 State of Hospital Medicine reports (www.hospitalmedicine.org/survey) show that a small, but probably increasing, part of compensation has been tied to performance on things like patient satisfaction and core measures (see “Distribution of Total Hospitalist Compensation,” below). Note that the percentages in the chart refer to the fraction of total compensation dollars allocated to each domain and not the portion of hospitalists who have compensation tied to each domain.
Over the same three years, the percentage of compensation tied to productivity has been decreasing overall, while “private groups are more likely to pay a higher proportion of compensation based on productivity, and hospital-employed groups are more likely to pay a higher proportion of compensation based on performance.”
Matching Performance Compensation to Medicare’s Value-Based Modifier
It makes sense for physician compensation to generally mirror Medicare and other payor professional fee reimbursement formulas. But, in that regard, hospitalists are ahead of the market already, because the portion of dollars allocated to performance (value) in hospitalist compensation plans already exceeds the 2% or less portion of Medicare reimbursement that is influenced by performance.
Medicare will steadily increase the portion of reimbursement allocated to performance (value) and decrease the part tied solely to wRVUs. So it makes sense that hospitalist compensation plans should do the same. Who knows, within the next 5-10 years, hospitalists, and potentially doctors in all specialties, might see 20% to 50% of their compensation tied to performance. I think that might be a good thing, as long as we can come up with effective measures of performance and value—not an easy thing to do in any business or industry.
Future Role of Productivity Compensation
I don’t think all the talk about value-based reimbursement means we should abandon the idea of connecting a portion of compensation to productivity. The first two practice management columns I wrote for The Hospitalist appeared in May 2006 (www.the-hospitalist.org/details/article/252413/The_Sweet_Spot.html) and June 2006 (www.the-hospitalist.org/details/article/246297.html) and recommended tying a meaningful portion of compensation to individual hospitalist productivity, and I think it still makes sense to do so.
Source: 2012 State of Hospital Medicine report
In any business or industry, financial performance is connected to the amount of product produced and its value. In the future, both metrics will determine reimbursement for even the highest performing healthcare providers. The new emphasis on value won’t ever make it unnecessary to produce at a reasonable level.
Unquestionably, there are many high-performing hospitalist practices with little or no productivity component in the compensation formula. So it isn’t an absolute sine qua non for success. But I think many practices dismiss it as a viable option when it might solve problems and liberate individuals in the group to exercise some autonomy in finding their own sweet spot between workload and compensation.
It will be interesting to see if future surveys show that the portion of dollars tied to hospitalist productivity continues to decrease, despite what I see as its potential benefits.
Electronic Health Records Can Complicate Who Does What in a Hospital
The accumulated wisdom, research data, and opinions regarding the use of electronic health records (EHRs) are vast. A quick Internet search turns up many informative articles on their positive and negative effects. But I haven’t found many that explicitly review the unanticipated effects EHRs have on who does what in the hospital.
For example, when reports such as admission and discharge notes are done via recorded dictation and transcription, the author would typically dictate where copies of the report should be sent (“copy to Dr. Matheny”) and rely on others to ensure it reached its intended destination. In many hospitals, such reports are now typed directly into the EHR, often using speech recognition software, and it is up to the author to click several buttons to ensure that it is routed to the intended recipients. So now a clerical function, sending reports, is handled by providers. This can be a good thing—reduced clerical staffing costs, faster transmission of reports—but often means that there is no documentation within the report itself of whom it was sent to (i.e., no list of “cc’s”). It also means that when the recipient isn’t easy to find, the report author is likely to give up, and the report may never be sent.
Any hospitalist using an EHR could easily list dozens of similar unanticipated effects, both good and bad. The magnitude and risk of these are difficult to quantify.
Altered Referral Patterns, Division of Labor
A hospitalist-specific side effect of EHR adoption is that they tend to cause many other doctors to resist serving as attending physician, instead asking hospitalists to replace them in that role. Even without EHRs, shifting attending responsibility to hospitalists has been a trend at nearly every hospital for years, but it can be accelerated dramatically at the time of a “go live.” So, in addition to the stress of adapting to the new EHR, hospitalists typically face higher than usual patient volumes resulting from increased referrals from other doctors.
If you’re a hospitalist facing an upcoming “go live,” it would be worth talking to other doctors in multiple specialties regarding your capacity to handle additional work. Keep in mind the possibility of higher than typical winter 2014 patient volumes that could result from patients who are newly insured through health exchanges.
Many factors, in addition to EHRs, are moving physicians away from a willingness to serve as attending, including the complexity of managing inpatient vs. observation status, keeping up with ever-changing documentation, pay-for-performance initiatives, the stress of ED call, and so on. As I’ve written before (see my January 2011 column, “Health IT Hurdles,”), I think effective management of hospital systems is becoming as complicated as safely piloting a jumbo jet. It will be increasingly difficult for doctors in any specialty to stay proficient at “piloting” a hospital unless they do it all or most of the time. And, staying proficient at multiple hospitals simultaneously may not be feasible at some point. We’ll see.
When Do Things Get Done?
A friend of mine, Dr. John Maa, is a general surgeon who was instrumental in establishing one of the first general surgery hospitalist practices. He tells a very personal and tragic story of his mother’s death, which, he has come to believe, might have been made more likely because of the unintended effect of an EHR.
She was a healthy 69-year-old who developed new onset atrial fibrillation and went to “one of the most highly regarded academic medical centers on the West Coast,” albeit not a facility where John was practicing. She was admitted with orders for anticoagulation but spent her first night on a stretcher in the ED because no inpatient bed was available. She went to a hospital room the next day, but her late arrival there delayed the planned transesophageal echo and cardioversion by another day.
Tragically, before the cardioversion could be done, she had a very large embolic stroke that led to brain herniation. A short time later, John and his father made the wrenching decision to discontinue mechanical ventilation. She died 112 hours after walking into the hospital.
What John later learned is that the admission orders written while she was in the ED were put into “sign and hold” status in the hospital’s EHR. Her caregivers had not anticipated a significant delay in moving her to an inpatient bed, and for the 18 or so hours she spent boarding in the ED, her admission orders were not acted on, and anticoagulation was delayed many hours. She might have had the same outcome even if anticoagulation had been started promptly, but it would have been much less likely.
John believes that the “sign and hold” status of the admission orders was a major contributor to the treatment delay. It increased the risk that the ED caregivers never acted on those orders, and may not have even seen them, since the EHR essentially holds them for presentation to the receiving inpatient unit.
John only recognized this vulnerability three years after his mother’s passing, when he underwent the physician training for the same EHR system. The course teachers agreed that this problem could arise if a patient was boarded in the ED for a prolonged period but felt that the responsibility rested with hospital administrators to minimize overcrowding in the ED. John also raised the issue with hospital leadership, who shared his concern but believed that a software remedy should be the solution. Ultimately, the answer may come from medical hospitalists, who recognize that every day and night, patients across America are at risk for a repeat of the incident John’s family suffered nearly five years ago.
In a very well written and moving essay, John describes his mother’s care.1 Though he doesn’t specifically mention the likely contribution of the “sign and hold” orders, it is one more example of EHR-related confusion that can arise around who does what and when they should do it. Clearly, the same sort of confusion exists in a non-EHR hospital, but it is the EHR-related change in the previous way of doing things that likely increases risk.
It can be very difficult—even impossible—to see all of these issues in advance. Even when acknowledged, the challenges can be difficult to address. But the first step is to recognize a problem, or potential problem, and think carefully about how it should be addressed.
Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at john.nelson@nelsonflores.com.
Reference
The accumulated wisdom, research data, and opinions regarding the use of electronic health records (EHRs) are vast. A quick Internet search turns up many informative articles on their positive and negative effects. But I haven’t found many that explicitly review the unanticipated effects EHRs have on who does what in the hospital.
For example, when reports such as admission and discharge notes are done via recorded dictation and transcription, the author would typically dictate where copies of the report should be sent (“copy to Dr. Matheny”) and rely on others to ensure it reached its intended destination. In many hospitals, such reports are now typed directly into the EHR, often using speech recognition software, and it is up to the author to click several buttons to ensure that it is routed to the intended recipients. So now a clerical function, sending reports, is handled by providers. This can be a good thing—reduced clerical staffing costs, faster transmission of reports—but often means that there is no documentation within the report itself of whom it was sent to (i.e., no list of “cc’s”). It also means that when the recipient isn’t easy to find, the report author is likely to give up, and the report may never be sent.
Any hospitalist using an EHR could easily list dozens of similar unanticipated effects, both good and bad. The magnitude and risk of these are difficult to quantify.
Altered Referral Patterns, Division of Labor
A hospitalist-specific side effect of EHR adoption is that they tend to cause many other doctors to resist serving as attending physician, instead asking hospitalists to replace them in that role. Even without EHRs, shifting attending responsibility to hospitalists has been a trend at nearly every hospital for years, but it can be accelerated dramatically at the time of a “go live.” So, in addition to the stress of adapting to the new EHR, hospitalists typically face higher than usual patient volumes resulting from increased referrals from other doctors.
If you’re a hospitalist facing an upcoming “go live,” it would be worth talking to other doctors in multiple specialties regarding your capacity to handle additional work. Keep in mind the possibility of higher than typical winter 2014 patient volumes that could result from patients who are newly insured through health exchanges.
Many factors, in addition to EHRs, are moving physicians away from a willingness to serve as attending, including the complexity of managing inpatient vs. observation status, keeping up with ever-changing documentation, pay-for-performance initiatives, the stress of ED call, and so on. As I’ve written before (see my January 2011 column, “Health IT Hurdles,”), I think effective management of hospital systems is becoming as complicated as safely piloting a jumbo jet. It will be increasingly difficult for doctors in any specialty to stay proficient at “piloting” a hospital unless they do it all or most of the time. And, staying proficient at multiple hospitals simultaneously may not be feasible at some point. We’ll see.
When Do Things Get Done?
A friend of mine, Dr. John Maa, is a general surgeon who was instrumental in establishing one of the first general surgery hospitalist practices. He tells a very personal and tragic story of his mother’s death, which, he has come to believe, might have been made more likely because of the unintended effect of an EHR.
She was a healthy 69-year-old who developed new onset atrial fibrillation and went to “one of the most highly regarded academic medical centers on the West Coast,” albeit not a facility where John was practicing. She was admitted with orders for anticoagulation but spent her first night on a stretcher in the ED because no inpatient bed was available. She went to a hospital room the next day, but her late arrival there delayed the planned transesophageal echo and cardioversion by another day.
Tragically, before the cardioversion could be done, she had a very large embolic stroke that led to brain herniation. A short time later, John and his father made the wrenching decision to discontinue mechanical ventilation. She died 112 hours after walking into the hospital.
What John later learned is that the admission orders written while she was in the ED were put into “sign and hold” status in the hospital’s EHR. Her caregivers had not anticipated a significant delay in moving her to an inpatient bed, and for the 18 or so hours she spent boarding in the ED, her admission orders were not acted on, and anticoagulation was delayed many hours. She might have had the same outcome even if anticoagulation had been started promptly, but it would have been much less likely.
John believes that the “sign and hold” status of the admission orders was a major contributor to the treatment delay. It increased the risk that the ED caregivers never acted on those orders, and may not have even seen them, since the EHR essentially holds them for presentation to the receiving inpatient unit.
John only recognized this vulnerability three years after his mother’s passing, when he underwent the physician training for the same EHR system. The course teachers agreed that this problem could arise if a patient was boarded in the ED for a prolonged period but felt that the responsibility rested with hospital administrators to minimize overcrowding in the ED. John also raised the issue with hospital leadership, who shared his concern but believed that a software remedy should be the solution. Ultimately, the answer may come from medical hospitalists, who recognize that every day and night, patients across America are at risk for a repeat of the incident John’s family suffered nearly five years ago.
In a very well written and moving essay, John describes his mother’s care.1 Though he doesn’t specifically mention the likely contribution of the “sign and hold” orders, it is one more example of EHR-related confusion that can arise around who does what and when they should do it. Clearly, the same sort of confusion exists in a non-EHR hospital, but it is the EHR-related change in the previous way of doing things that likely increases risk.
It can be very difficult—even impossible—to see all of these issues in advance. Even when acknowledged, the challenges can be difficult to address. But the first step is to recognize a problem, or potential problem, and think carefully about how it should be addressed.
Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at john.nelson@nelsonflores.com.
Reference
The accumulated wisdom, research data, and opinions regarding the use of electronic health records (EHRs) are vast. A quick Internet search turns up many informative articles on their positive and negative effects. But I haven’t found many that explicitly review the unanticipated effects EHRs have on who does what in the hospital.
For example, when reports such as admission and discharge notes are done via recorded dictation and transcription, the author would typically dictate where copies of the report should be sent (“copy to Dr. Matheny”) and rely on others to ensure it reached its intended destination. In many hospitals, such reports are now typed directly into the EHR, often using speech recognition software, and it is up to the author to click several buttons to ensure that it is routed to the intended recipients. So now a clerical function, sending reports, is handled by providers. This can be a good thing—reduced clerical staffing costs, faster transmission of reports—but often means that there is no documentation within the report itself of whom it was sent to (i.e., no list of “cc’s”). It also means that when the recipient isn’t easy to find, the report author is likely to give up, and the report may never be sent.
Any hospitalist using an EHR could easily list dozens of similar unanticipated effects, both good and bad. The magnitude and risk of these are difficult to quantify.
Altered Referral Patterns, Division of Labor
A hospitalist-specific side effect of EHR adoption is that they tend to cause many other doctors to resist serving as attending physician, instead asking hospitalists to replace them in that role. Even without EHRs, shifting attending responsibility to hospitalists has been a trend at nearly every hospital for years, but it can be accelerated dramatically at the time of a “go live.” So, in addition to the stress of adapting to the new EHR, hospitalists typically face higher than usual patient volumes resulting from increased referrals from other doctors.
If you’re a hospitalist facing an upcoming “go live,” it would be worth talking to other doctors in multiple specialties regarding your capacity to handle additional work. Keep in mind the possibility of higher than typical winter 2014 patient volumes that could result from patients who are newly insured through health exchanges.
Many factors, in addition to EHRs, are moving physicians away from a willingness to serve as attending, including the complexity of managing inpatient vs. observation status, keeping up with ever-changing documentation, pay-for-performance initiatives, the stress of ED call, and so on. As I’ve written before (see my January 2011 column, “Health IT Hurdles,”), I think effective management of hospital systems is becoming as complicated as safely piloting a jumbo jet. It will be increasingly difficult for doctors in any specialty to stay proficient at “piloting” a hospital unless they do it all or most of the time. And, staying proficient at multiple hospitals simultaneously may not be feasible at some point. We’ll see.
When Do Things Get Done?
A friend of mine, Dr. John Maa, is a general surgeon who was instrumental in establishing one of the first general surgery hospitalist practices. He tells a very personal and tragic story of his mother’s death, which, he has come to believe, might have been made more likely because of the unintended effect of an EHR.
She was a healthy 69-year-old who developed new onset atrial fibrillation and went to “one of the most highly regarded academic medical centers on the West Coast,” albeit not a facility where John was practicing. She was admitted with orders for anticoagulation but spent her first night on a stretcher in the ED because no inpatient bed was available. She went to a hospital room the next day, but her late arrival there delayed the planned transesophageal echo and cardioversion by another day.
Tragically, before the cardioversion could be done, she had a very large embolic stroke that led to brain herniation. A short time later, John and his father made the wrenching decision to discontinue mechanical ventilation. She died 112 hours after walking into the hospital.
What John later learned is that the admission orders written while she was in the ED were put into “sign and hold” status in the hospital’s EHR. Her caregivers had not anticipated a significant delay in moving her to an inpatient bed, and for the 18 or so hours she spent boarding in the ED, her admission orders were not acted on, and anticoagulation was delayed many hours. She might have had the same outcome even if anticoagulation had been started promptly, but it would have been much less likely.
John believes that the “sign and hold” status of the admission orders was a major contributor to the treatment delay. It increased the risk that the ED caregivers never acted on those orders, and may not have even seen them, since the EHR essentially holds them for presentation to the receiving inpatient unit.
John only recognized this vulnerability three years after his mother’s passing, when he underwent the physician training for the same EHR system. The course teachers agreed that this problem could arise if a patient was boarded in the ED for a prolonged period but felt that the responsibility rested with hospital administrators to minimize overcrowding in the ED. John also raised the issue with hospital leadership, who shared his concern but believed that a software remedy should be the solution. Ultimately, the answer may come from medical hospitalists, who recognize that every day and night, patients across America are at risk for a repeat of the incident John’s family suffered nearly five years ago.
In a very well written and moving essay, John describes his mother’s care.1 Though he doesn’t specifically mention the likely contribution of the “sign and hold” orders, it is one more example of EHR-related confusion that can arise around who does what and when they should do it. Clearly, the same sort of confusion exists in a non-EHR hospital, but it is the EHR-related change in the previous way of doing things that likely increases risk.
It can be very difficult—even impossible—to see all of these issues in advance. Even when acknowledged, the challenges can be difficult to address. But the first step is to recognize a problem, or potential problem, and think carefully about how it should be addressed.
Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at john.nelson@nelsonflores.com.
Reference
Get Ready for Transition to ICD-10 Medical Coding
By now, I’m sure you’re knowledgeable about things like healthcare exchanges and other parts of the Accountable Care Act, the increasing number of metrics within hospital value-based purchasing, the physician value-based payment modifier, the physician quality reporting system (PQRS), how to use your hospital’s new EHR efficiently, the new “two-midnight rule” to determine inpatient vs. observation status, and so on.
You’re to be commended if you’re staying on top of all these things and have effective plans in place to ensure good performance on each. And if you haven’t already, you should add at least one more important issue to this list—the transition to ICD-10 coding on Oct. 1, 2014.
An Overview
ICD stands for International Classification of Diseases, and the U.S. has been using the 9th revision (ICD-9) since 1978. ICD-9 is now significantly out of step with current medical knowledge and has run out of codes in some disease sections (“chapters”). This might mean, for example, that new codes for heart diseases would be assigned to the chapter for eye disease, because the former is full.
ICD-10 provides a way to fix these problems and, through more specific coding of diseases, should be able to yield more useful “big data” to measure things like safety and efficacy of care and more accurately identify diagnosis trends and epidemics. And, in theory, it could reduce the number of rejected billing claims, though I’m waiting to see if that happens. I worry that even after fixing all the initial bugs related to the ICD-10 transition, we will see more claim rejections than we experience today.
ICD codes can be thought of as diagnosis codes. CPT codes (Current Procedural Terminology) are an entirely separate set of codes that we use to report the work we do for the purposes of billing. We need to be familiar with both, but it is the ICD codes that are changing.
ICD-10 Basics and Trivia
The World Health Organization issued the ICD-10 in 1994, and it is already in use in many countries. Like some other countries, the U.S. made modifications to the WHO’s original code set, so we refer to ICD-10-CM (Clinical Modification), which contains diagnosis codes. The National Center for Health Statistics, a department of the CDC, is responsible for these modifications.
The WHO version of ICD-10 doesn’t have any procedure codes, so CMS developed ICD-10-PCS (Procedure Coding System) to report procedures, such as surgeries, done in U.S. hospitals. Most hospitalists won’t use these procedure codes often.
Table 1 (left) compares ICD-10-CM to ICD-9-CM. Most of the additional codes in the new version simply add information regarding whether the diagnosis is on the left or right of the body, acute or chronic, or an initial or subsequent visit for the condition. But the standard structure for each code had to be modified significantly to capture this additional information. Some highlights of the seven-character code structure are:
- Characters 1–3: category; first digit always a letter, second digit always a number, all other digits can be either; not case sensitive;
- Characters 4–6: etiology, anatomic site, severity, or other clinical detail; for example, 1=right, 2=left, 3-bilateral, and 0 or 9=unspecified; and
- Character 7: extension (i.e., A=initial encounter, D=subsequent encounter, S=sequelae).
- A placeholder “x” is used as needed to fill in empty characters to ensure that the seventh character stays in the seventh position. For example, T79.1xxA equates to “fat embolism, initial encounter.” (Note that the “dummy” characters could create problems for some IT systems.)
An example of more information contained in additional characters:
- S52=fracture of forearm.
- S52.5=fracture of lower end of radius.
- S52.52=torus fracture of lower end of radius.
- S52.521=torus fracture of lower end of right radius.
- S52.521A=torus fracture of lower end of right radius, initial encounter for closed fracture.
Compared to its predecessor, ICD-10 expands use of combination codes. These are single codes that can be used to classify either two diagnoses, a diagnosis with an associated secondary process, or a diagnosis with an associated complication. For example, rather than reporting acute cor pulmonale and septic pulmonary embolism separately, ICD-10 allows use of the code I26.01: septic pulmonary embolism with acute cor pulmonale.
Resources
In addition to resources on the SHM website, both the American Medical Association (www.ama-assn.org, search “ICD-10”) and the Centers for Medicare and Medicaid Services (www.cms.gov/icd10) have very informative microsites offering detailed ICD-10 information. Much of the information in this column, including the examples above, comes from those sites.
What to Expect
Your hospital and your employer are probably already working in earnest to prepare for the change. In some cases, hospitalists are actively involved in these preparations, but in most cases they will simply wait for an organization to notify them that they should begin training to understand the new coding system. Experts say that most physicians will need two to four hours of training on ICD-10, but because we use a universe of diagnosis codes that is much larger than many specialties, I wonder if hospitalists may need additional training.
Like nearly all the programs I listed at the beginning, the transition to ICD-10 has me concerned. Managing it poorly could mean significant loss in hospital and physician professional fee revenue, as well as lots of tedious and time-consuming work. So, doing it right is important. But, it is also important to do well on all the programs I listed at the beginning of this column, and many others, and there is a limit to just how much we can do effectively as individuals.
Collectively, these programs risk taking too much time and too many brain cells away from keeping up with clinical medicine. So, I wonder if, for many of us, ICD-10 will serve as a tipping point that results in physicians hiring professional coders to choose our diagnosis codes and CPT codes rather than doing it ourselves.
As with EHRs, ICD-10 is said to have many benefits. But the introduction of EHRs in many hospitals had the unintended effect of significantly reducing the number of doctors who were willing to serve as admitting and attending physicians; instead, many chose to refer to hospitalists. In a similar way, ICD-10 might lead many organizations to relieve physicians of the responsibility of looking up and entering codes for each patient, leaving them with more time and energy to be clinicians. We’ll have to wait and see.
Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at john.nelson@nelsonflores.com.
By now, I’m sure you’re knowledgeable about things like healthcare exchanges and other parts of the Accountable Care Act, the increasing number of metrics within hospital value-based purchasing, the physician value-based payment modifier, the physician quality reporting system (PQRS), how to use your hospital’s new EHR efficiently, the new “two-midnight rule” to determine inpatient vs. observation status, and so on.
You’re to be commended if you’re staying on top of all these things and have effective plans in place to ensure good performance on each. And if you haven’t already, you should add at least one more important issue to this list—the transition to ICD-10 coding on Oct. 1, 2014.
An Overview
ICD stands for International Classification of Diseases, and the U.S. has been using the 9th revision (ICD-9) since 1978. ICD-9 is now significantly out of step with current medical knowledge and has run out of codes in some disease sections (“chapters”). This might mean, for example, that new codes for heart diseases would be assigned to the chapter for eye disease, because the former is full.
ICD-10 provides a way to fix these problems and, through more specific coding of diseases, should be able to yield more useful “big data” to measure things like safety and efficacy of care and more accurately identify diagnosis trends and epidemics. And, in theory, it could reduce the number of rejected billing claims, though I’m waiting to see if that happens. I worry that even after fixing all the initial bugs related to the ICD-10 transition, we will see more claim rejections than we experience today.
ICD codes can be thought of as diagnosis codes. CPT codes (Current Procedural Terminology) are an entirely separate set of codes that we use to report the work we do for the purposes of billing. We need to be familiar with both, but it is the ICD codes that are changing.
ICD-10 Basics and Trivia
The World Health Organization issued the ICD-10 in 1994, and it is already in use in many countries. Like some other countries, the U.S. made modifications to the WHO’s original code set, so we refer to ICD-10-CM (Clinical Modification), which contains diagnosis codes. The National Center for Health Statistics, a department of the CDC, is responsible for these modifications.
The WHO version of ICD-10 doesn’t have any procedure codes, so CMS developed ICD-10-PCS (Procedure Coding System) to report procedures, such as surgeries, done in U.S. hospitals. Most hospitalists won’t use these procedure codes often.
Table 1 (left) compares ICD-10-CM to ICD-9-CM. Most of the additional codes in the new version simply add information regarding whether the diagnosis is on the left or right of the body, acute or chronic, or an initial or subsequent visit for the condition. But the standard structure for each code had to be modified significantly to capture this additional information. Some highlights of the seven-character code structure are:
- Characters 1–3: category; first digit always a letter, second digit always a number, all other digits can be either; not case sensitive;
- Characters 4–6: etiology, anatomic site, severity, or other clinical detail; for example, 1=right, 2=left, 3-bilateral, and 0 or 9=unspecified; and
- Character 7: extension (i.e., A=initial encounter, D=subsequent encounter, S=sequelae).
- A placeholder “x” is used as needed to fill in empty characters to ensure that the seventh character stays in the seventh position. For example, T79.1xxA equates to “fat embolism, initial encounter.” (Note that the “dummy” characters could create problems for some IT systems.)
An example of more information contained in additional characters:
- S52=fracture of forearm.
- S52.5=fracture of lower end of radius.
- S52.52=torus fracture of lower end of radius.
- S52.521=torus fracture of lower end of right radius.
- S52.521A=torus fracture of lower end of right radius, initial encounter for closed fracture.
Compared to its predecessor, ICD-10 expands use of combination codes. These are single codes that can be used to classify either two diagnoses, a diagnosis with an associated secondary process, or a diagnosis with an associated complication. For example, rather than reporting acute cor pulmonale and septic pulmonary embolism separately, ICD-10 allows use of the code I26.01: septic pulmonary embolism with acute cor pulmonale.
Resources
In addition to resources on the SHM website, both the American Medical Association (www.ama-assn.org, search “ICD-10”) and the Centers for Medicare and Medicaid Services (www.cms.gov/icd10) have very informative microsites offering detailed ICD-10 information. Much of the information in this column, including the examples above, comes from those sites.
What to Expect
Your hospital and your employer are probably already working in earnest to prepare for the change. In some cases, hospitalists are actively involved in these preparations, but in most cases they will simply wait for an organization to notify them that they should begin training to understand the new coding system. Experts say that most physicians will need two to four hours of training on ICD-10, but because we use a universe of diagnosis codes that is much larger than many specialties, I wonder if hospitalists may need additional training.
Like nearly all the programs I listed at the beginning, the transition to ICD-10 has me concerned. Managing it poorly could mean significant loss in hospital and physician professional fee revenue, as well as lots of tedious and time-consuming work. So, doing it right is important. But, it is also important to do well on all the programs I listed at the beginning of this column, and many others, and there is a limit to just how much we can do effectively as individuals.
Collectively, these programs risk taking too much time and too many brain cells away from keeping up with clinical medicine. So, I wonder if, for many of us, ICD-10 will serve as a tipping point that results in physicians hiring professional coders to choose our diagnosis codes and CPT codes rather than doing it ourselves.
As with EHRs, ICD-10 is said to have many benefits. But the introduction of EHRs in many hospitals had the unintended effect of significantly reducing the number of doctors who were willing to serve as admitting and attending physicians; instead, many chose to refer to hospitalists. In a similar way, ICD-10 might lead many organizations to relieve physicians of the responsibility of looking up and entering codes for each patient, leaving them with more time and energy to be clinicians. We’ll have to wait and see.
Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at john.nelson@nelsonflores.com.
By now, I’m sure you’re knowledgeable about things like healthcare exchanges and other parts of the Accountable Care Act, the increasing number of metrics within hospital value-based purchasing, the physician value-based payment modifier, the physician quality reporting system (PQRS), how to use your hospital’s new EHR efficiently, the new “two-midnight rule” to determine inpatient vs. observation status, and so on.
You’re to be commended if you’re staying on top of all these things and have effective plans in place to ensure good performance on each. And if you haven’t already, you should add at least one more important issue to this list—the transition to ICD-10 coding on Oct. 1, 2014.
An Overview
ICD stands for International Classification of Diseases, and the U.S. has been using the 9th revision (ICD-9) since 1978. ICD-9 is now significantly out of step with current medical knowledge and has run out of codes in some disease sections (“chapters”). This might mean, for example, that new codes for heart diseases would be assigned to the chapter for eye disease, because the former is full.
ICD-10 provides a way to fix these problems and, through more specific coding of diseases, should be able to yield more useful “big data” to measure things like safety and efficacy of care and more accurately identify diagnosis trends and epidemics. And, in theory, it could reduce the number of rejected billing claims, though I’m waiting to see if that happens. I worry that even after fixing all the initial bugs related to the ICD-10 transition, we will see more claim rejections than we experience today.
ICD codes can be thought of as diagnosis codes. CPT codes (Current Procedural Terminology) are an entirely separate set of codes that we use to report the work we do for the purposes of billing. We need to be familiar with both, but it is the ICD codes that are changing.
ICD-10 Basics and Trivia
The World Health Organization issued the ICD-10 in 1994, and it is already in use in many countries. Like some other countries, the U.S. made modifications to the WHO’s original code set, so we refer to ICD-10-CM (Clinical Modification), which contains diagnosis codes. The National Center for Health Statistics, a department of the CDC, is responsible for these modifications.
The WHO version of ICD-10 doesn’t have any procedure codes, so CMS developed ICD-10-PCS (Procedure Coding System) to report procedures, such as surgeries, done in U.S. hospitals. Most hospitalists won’t use these procedure codes often.
Table 1 (left) compares ICD-10-CM to ICD-9-CM. Most of the additional codes in the new version simply add information regarding whether the diagnosis is on the left or right of the body, acute or chronic, or an initial or subsequent visit for the condition. But the standard structure for each code had to be modified significantly to capture this additional information. Some highlights of the seven-character code structure are:
- Characters 1–3: category; first digit always a letter, second digit always a number, all other digits can be either; not case sensitive;
- Characters 4–6: etiology, anatomic site, severity, or other clinical detail; for example, 1=right, 2=left, 3-bilateral, and 0 or 9=unspecified; and
- Character 7: extension (i.e., A=initial encounter, D=subsequent encounter, S=sequelae).
- A placeholder “x” is used as needed to fill in empty characters to ensure that the seventh character stays in the seventh position. For example, T79.1xxA equates to “fat embolism, initial encounter.” (Note that the “dummy” characters could create problems for some IT systems.)
An example of more information contained in additional characters:
- S52=fracture of forearm.
- S52.5=fracture of lower end of radius.
- S52.52=torus fracture of lower end of radius.
- S52.521=torus fracture of lower end of right radius.
- S52.521A=torus fracture of lower end of right radius, initial encounter for closed fracture.
Compared to its predecessor, ICD-10 expands use of combination codes. These are single codes that can be used to classify either two diagnoses, a diagnosis with an associated secondary process, or a diagnosis with an associated complication. For example, rather than reporting acute cor pulmonale and septic pulmonary embolism separately, ICD-10 allows use of the code I26.01: septic pulmonary embolism with acute cor pulmonale.
Resources
In addition to resources on the SHM website, both the American Medical Association (www.ama-assn.org, search “ICD-10”) and the Centers for Medicare and Medicaid Services (www.cms.gov/icd10) have very informative microsites offering detailed ICD-10 information. Much of the information in this column, including the examples above, comes from those sites.
What to Expect
Your hospital and your employer are probably already working in earnest to prepare for the change. In some cases, hospitalists are actively involved in these preparations, but in most cases they will simply wait for an organization to notify them that they should begin training to understand the new coding system. Experts say that most physicians will need two to four hours of training on ICD-10, but because we use a universe of diagnosis codes that is much larger than many specialties, I wonder if hospitalists may need additional training.
Like nearly all the programs I listed at the beginning, the transition to ICD-10 has me concerned. Managing it poorly could mean significant loss in hospital and physician professional fee revenue, as well as lots of tedious and time-consuming work. So, doing it right is important. But, it is also important to do well on all the programs I listed at the beginning of this column, and many others, and there is a limit to just how much we can do effectively as individuals.
Collectively, these programs risk taking too much time and too many brain cells away from keeping up with clinical medicine. So, I wonder if, for many of us, ICD-10 will serve as a tipping point that results in physicians hiring professional coders to choose our diagnosis codes and CPT codes rather than doing it ourselves.
As with EHRs, ICD-10 is said to have many benefits. But the introduction of EHRs in many hospitals had the unintended effect of significantly reducing the number of doctors who were willing to serve as admitting and attending physicians; instead, many chose to refer to hospitalists. In a similar way, ICD-10 might lead many organizations to relieve physicians of the responsibility of looking up and entering codes for each patient, leaving them with more time and energy to be clinicians. We’ll have to wait and see.
Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at john.nelson@nelsonflores.com.