Larry Wellikson, MD, FHM

As the healthcare system struggles with the definition of quality and the implementation of patient-centered care, renewed attention is being given to patient satisfaction.

Now, this performance measure has moved from the hospital’s marketing department into the C-suite, where senior administrators at some hospitals have patient satisfaction scores tied to their compensation.

Pressure is being applied to nudge key hospital care providers, including hospitalists, to keep their patients happy while giving them the care they deserve.

With the recent publishing of the Hospital Consumer Assessment of Healthcare providers and Systems (HCAHPS) scorecards for each hospital on the Hospital Compare Web site (www.hospitalcompare.hhs.gov), patients can see and compare local hospitals.

Because hospitalists are managing an ever-increasing portion of the hospital census, we can count on being right in the middle of all this. Coupled with the fact that 40% of hospitalists are directly employed by their hospital and a significant portion of other hospitalist groups have contracts with hospitals tied to quality improvement, we can expect a lot of pressure to not only improve patient satisfaction, but to make the “numbers” look better.

What Survey Measures

An important starting point for hospitalists and especially their leaders, who will be engaged in conversations with the C-suite about patient satisfaction data, is to better understand what the data indicate.

First, you need to know that the patient questionnaires were designed by several large vendors, the largest being Press Ganey.

While it is possible to segment the patients by those treated by a hospitalist and those not, the questions were not meant to describe, define, or compare the performance of different physicians. Remember, non-hospitalists for this purpose includes not only internists, but also surgeons, obstetricians, and other specialists.

Some questions on the survey about physicians include:

• During this hospital stay, how often did doctors treat you with respect? (never, sometimes, usually, always);
• During this hospital stay, how often did doctors explain things in a way you could understand? and
• During this hospital stay, how often did doctors listen carefully to you?

Other questions that might pertain to care directed by hospitalists but also relate to the entire care team include:

• How often was your pain controlled?
• Before giving you a new medicine, how often did staff tell you what it was for? and
• Before giving you a new medicine, how often did staff describe possible side effects in a way you could understand?

While you might aggregate all the replies specifically about the doctors’ performance and grade all the doctors separately, the all-important questions to the C-suite are the last two sections:

• How do patients rate the hospital? and
• Would patients recommend the hospital to friends and family?

Patients Are Different

It is important to understand the unique characteristics of the patients admitted and managed by hospitalists and to understand how these patients may respond differently to the standard patient satisfaction surveys than others in the patient population.

More often than not, hospitalists admit patients who are acutely ill, presenting through the emergency department (ED) with medical problems. Some studies have estimated that more than 70% of hospitalists’ patients come through the ED, while for the rest of the staff it is closer to 30% to 40%.

It is well known that patients admitted electively are more satisfied than those with an acute illness who come through the ED. In addition, patients admitted for medical problems have lower satisfaction ratings than those admitted for general surgery, subspecialty surgery, or obstetrics.

Therefore, if your hospital administration has pulled together statistics that purport to compare patient satisfaction for your hospitalist group versus all other admissions, you need to make sure that comparisons are made to a similar population, i.e., acutely ill patients admitted through the ED with medical diagnoses. The survey companies should be able to produce just such a comparison.

It is equally as important to make sure you focus on the total experience at the hospital and not just the questions specifically concerning only the doctors. Since hospitalists not only do front-line, face-to-face patient care, but also work with the team and attempt to improve the system to provide better overall quality, make sure to focus on questions like “How do patients rate the hospital?” and “Would patients recommend the hospital to friends and family?”

The other consideration is to understand how close the top quartile is to the bottom quartile, when comparisons are made with this data. In many of these surveys the patients are giving ratings on a scale of one to four, with many of the responses at three or four. Therefore, the top score might be a 3.6 and the bottom score average 3.2. It is important to understand if you are just minor adjustments away from being in a good range or if you are either so far above or below the standard of care that a real situation exists.

HM’s Role

Does the hospitalist model lead to better patient satisfaction? Like most things in hospital medicine, the answer is yes, no, and maybe. There are certain aspects of hospital medicine that should lead to happier patients:

• Present and easily available;
• Expert in hospital care;
• Improved coordination of care by specialists;
• Availability for multiple visits if patient condition changes;
• Availability to visit with loved-ones at their convenience; and
• Rapid response to nurse’s concerns.

There are aspects of getting your care from a hospitalist that may initially make the patient more concerned:

• They may be unfamiliar with the hospitalist and the hospitalist model;
• The hospitalist may demonstrate little or no knowledge of the patient’s history;
• The referring physician may not introduce the patient to the hospitalist; and
• The hospitalist may not explain the relationship with the referring physician.

How to Be Proactive

With all we have to do every day (and the list seems to get longer by the minute), it is easy to get perplexed by having to be responsible for the patients’ satisfaction with their hospital experience. That being said, hospitalists perform well when we step up to the plate and take action in these ways:

• Proactively meet with the person in the C-suite who oversees the patient satisfaction survey process or relates to the hospitalist group (e.g., vice president of medical affairs or chief medical officer) to better understand the survey results;
• Make sure if the data are being used to compare hospitalist care with non-hospitalist care that the comparison group of patients is equivalent (i.e., acutely ill medical patients admitted through the ED, not surgical or obstetrical patients);
• Make sure to focus not only on the “doctor-related” questions, but on patients’ overall satisfaction with the hospital; and
• Offer to help the C-suite improve patient satisfaction, but don’t attempt to “own” this performance measure for the entire hospital. Hospitalists can be helpful, but this is broader than any one group of physicians.

Further, make improving patient satisfaction a core goal for your group. Some strategies that may work include:

• Have a script for each patient encounter (“Hi, I’m Dr. Smith, I take care of Dr. Jones’ patients in the hospital. The way we communicate about your care is … The advantages to our partnership are …”);
• Hand out a brochure with your group’s hospitalists’ pictures, answers to frequently asked questions, and how to contact the hospitalist; and
• Sit down and shut up (i.e., patients will perceive you are taking time with them and listening if you are seated and let them speak without interruption).

Hospitals have been doing patient surveys for some time now. The Centers for Medicare and Medicaid Services and other payers are placing more emphasis on this quality measure. Now that the results easily are available to the public, major newspapers and broadcast media are calling attention to patient perspectives on their hospital care.

Once hospitalist groups understand the data, there is an opportunity to partner with their hospitals to better understand how our patients see their hospital care and allow for hospitalists to have an appropriate role in working with the other health professionals to improve patients’ experience with their care. TH

Dr. Wellikson is the CEO of SHM.

Note to readers: I would like to acknowledge SHM co-founder Win Whitcomb, MD, and SHM Senior Vice President Joe Miller for their assistance with this column.

As the healthcare system struggles with the definition of quality and the implementation of patient-centered care, renewed attention is being given to patient satisfaction.

Now, this performance measure has moved from the hospital’s marketing department into the C-suite, where senior administrators at some hospitals have patient satisfaction scores tied to their compensation.

Pressure is being applied to nudge key hospital care providers, including hospitalists, to keep their patients happy while giving them the care they deserve.

With the recent publishing of the Hospital Consumer Assessment of Healthcare providers and Systems (HCAHPS) scorecards for each hospital on the Hospital Compare Web site (www.hospitalcompare.hhs.gov), patients can see and compare local hospitals.

Because hospitalists are managing an ever-increasing portion of the hospital census, we can count on being right in the middle of all this. Coupled with the fact that 40% of hospitalists are directly employed by their hospital and a significant portion of other hospitalist groups have contracts with hospitals tied to quality improvement, we can expect a lot of pressure to not only improve patient satisfaction, but to make the “numbers” look better.

What Survey Measures

An important starting point for hospitalists and especially their leaders, who will be engaged in conversations with the C-suite about patient satisfaction data, is to better understand what the data indicate.

First, you need to know that the patient questionnaires were designed by several large vendors, the largest being Press Ganey.

While it is possible to segment the patients by those treated by a hospitalist and those not, the questions were not meant to describe, define, or compare the performance of different physicians. Remember, non-hospitalists for this purpose includes not only internists, but also surgeons, obstetricians, and other specialists.

Some questions on the survey about physicians include:

• During this hospital stay, how often did doctors treat you with respect? (never, sometimes, usually, always);
• During this hospital stay, how often did doctors explain things in a way you could understand? and
• During this hospital stay, how often did doctors listen carefully to you?

Other questions that might pertain to care directed by hospitalists but also relate to the entire care team include:

• How often was your pain controlled?
• Before giving you a new medicine, how often did staff tell you what it was for? and
• Before giving you a new medicine, how often did staff describe possible side effects in a way you could understand?

While you might aggregate all the replies specifically about the doctors’ performance and grade all the doctors separately, the all-important questions to the C-suite are the last two sections:

• How do patients rate the hospital? and
• Would patients recommend the hospital to friends and family?

Patients Are Different

It is important to understand the unique characteristics of the patients admitted and managed by hospitalists and to understand how these patients may respond differently to the standard patient satisfaction surveys than others in the patient population.

More often than not, hospitalists admit patients who are acutely ill, presenting through the emergency department (ED) with medical problems. Some studies have estimated that more than 70% of hospitalists’ patients come through the ED, while for the rest of the staff it is closer to 30% to 40%.

It is well known that patients admitted electively are more satisfied than those with an acute illness who come through the ED. In addition, patients admitted for medical problems have lower satisfaction ratings than those admitted for general surgery, subspecialty surgery, or obstetrics.

Therefore, if your hospital administration has pulled together statistics that purport to compare patient satisfaction for your hospitalist group versus all other admissions, you need to make sure that comparisons are made to a similar population, i.e., acutely ill patients admitted through the ED with medical diagnoses. The survey companies should be able to produce just such a comparison.

It is equally as important to make sure you focus on the total experience at the hospital and not just the questions specifically concerning only the doctors. Since hospitalists not only do front-line, face-to-face patient care, but also work with the team and attempt to improve the system to provide better overall quality, make sure to focus on questions like “How do patients rate the hospital?” and “Would patients recommend the hospital to friends and family?”

The other consideration is to understand how close the top quartile is to the bottom quartile, when comparisons are made with this data. In many of these surveys the patients are giving ratings on a scale of one to four, with many of the responses at three or four. Therefore, the top score might be a 3.6 and the bottom score average 3.2. It is important to understand if you are just minor adjustments away from being in a good range or if you are either so far above or below the standard of care that a real situation exists.

HM’s Role

Does the hospitalist model lead to better patient satisfaction? Like most things in hospital medicine, the answer is yes, no, and maybe. There are certain aspects of hospital medicine that should lead to happier patients:

• Present and easily available;
• Expert in hospital care;
• Improved coordination of care by specialists;
• Availability for multiple visits if patient condition changes;
• Availability to visit with loved-ones at their convenience; and
• Rapid response to nurse’s concerns.

There are aspects of getting your care from a hospitalist that may initially make the patient more concerned:

• They may be unfamiliar with the hospitalist and the hospitalist model;
• The hospitalist may demonstrate little or no knowledge of the patient’s history;
• The referring physician may not introduce the patient to the hospitalist; and
• The hospitalist may not explain the relationship with the referring physician.

How to Be Proactive

With all we have to do every day (and the list seems to get longer by the minute), it is easy to get perplexed by having to be responsible for the patients’ satisfaction with their hospital experience. That being said, hospitalists perform well when we step up to the plate and take action in these ways:

• Proactively meet with the person in the C-suite who oversees the patient satisfaction survey process or relates to the hospitalist group (e.g., vice president of medical affairs or chief medical officer) to better understand the survey results;
• Make sure if the data are being used to compare hospitalist care with non-hospitalist care that the comparison group of patients is equivalent (i.e., acutely ill medical patients admitted through the ED, not surgical or obstetrical patients);
• Make sure to focus not only on the “doctor-related” questions, but on patients’ overall satisfaction with the hospital; and
• Offer to help the C-suite improve patient satisfaction, but don’t attempt to “own” this performance measure for the entire hospital. Hospitalists can be helpful, but this is broader than any one group of physicians.

Further, make improving patient satisfaction a core goal for your group. Some strategies that may work include:

• Have a script for each patient encounter (“Hi, I’m Dr. Smith, I take care of Dr. Jones’ patients in the hospital. The way we communicate about your care is … The advantages to our partnership are …”);
• Hand out a brochure with your group’s hospitalists’ pictures, answers to frequently asked questions, and how to contact the hospitalist; and
• Sit down and shut up (i.e., patients will perceive you are taking time with them and listening if you are seated and let them speak without interruption).

Hospitals have been doing patient surveys for some time now. The Centers for Medicare and Medicaid Services and other payers are placing more emphasis on this quality measure. Now that the results easily are available to the public, major newspapers and broadcast media are calling attention to patient perspectives on their hospital care.

Once hospitalist groups understand the data, there is an opportunity to partner with their hospitals to better understand how our patients see their hospital care and allow for hospitalists to have an appropriate role in working with the other health professionals to improve patients’ experience with their care. TH

Dr. Wellikson is the CEO of SHM.

Note to readers: I would like to acknowledge SHM co-founder Win Whitcomb, MD, and SHM Senior Vice President Joe Miller for their assistance with this column.

As the healthcare system struggles with the definition of quality and the implementation of patient-centered care, renewed attention is being given to patient satisfaction.

Now, this performance measure has moved from the hospital’s marketing department into the C-suite, where senior administrators at some hospitals have patient satisfaction scores tied to their compensation.

Pressure is being applied to nudge key hospital care providers, including hospitalists, to keep their patients happy while giving them the care they deserve.

With the recent publishing of the Hospital Consumer Assessment of Healthcare providers and Systems (HCAHPS) scorecards for each hospital on the Hospital Compare Web site (www.hospitalcompare.hhs.gov), patients can see and compare local hospitals.

Because hospitalists are managing an ever-increasing portion of the hospital census, we can count on being right in the middle of all this. Coupled with the fact that 40% of hospitalists are directly employed by their hospital and a significant portion of other hospitalist groups have contracts with hospitals tied to quality improvement, we can expect a lot of pressure to not only improve patient satisfaction, but to make the “numbers” look better.

What Survey Measures

An important starting point for hospitalists and especially their leaders, who will be engaged in conversations with the C-suite about patient satisfaction data, is to better understand what the data indicate.

First, you need to know that the patient questionnaires were designed by several large vendors, the largest being Press Ganey.

While it is possible to segment the patients by those treated by a hospitalist and those not, the questions were not meant to describe, define, or compare the performance of different physicians. Remember, non-hospitalists for this purpose includes not only internists, but also surgeons, obstetricians, and other specialists.

Some questions on the survey about physicians include:

• During this hospital stay, how often did doctors treat you with respect? (never, sometimes, usually, always);
• During this hospital stay, how often did doctors explain things in a way you could understand? and
• During this hospital stay, how often did doctors listen carefully to you?

Other questions that might pertain to care directed by hospitalists but also relate to the entire care team include:

• How often was your pain controlled?
• Before giving you a new medicine, how often did staff tell you what it was for? and
• Before giving you a new medicine, how often did staff describe possible side effects in a way you could understand?

While you might aggregate all the replies specifically about the doctors’ performance and grade all the doctors separately, the all-important questions to the C-suite are the last two sections:

• How do patients rate the hospital? and
• Would patients recommend the hospital to friends and family?

Patients Are Different

It is important to understand the unique characteristics of the patients admitted and managed by hospitalists and to understand how these patients may respond differently to the standard patient satisfaction surveys than others in the patient population.

More often than not, hospitalists admit patients who are acutely ill, presenting through the emergency department (ED) with medical problems. Some studies have estimated that more than 70% of hospitalists’ patients come through the ED, while for the rest of the staff it is closer to 30% to 40%.

It is well known that patients admitted electively are more satisfied than those with an acute illness who come through the ED. In addition, patients admitted for medical problems have lower satisfaction ratings than those admitted for general surgery, subspecialty surgery, or obstetrics.

Therefore, if your hospital administration has pulled together statistics that purport to compare patient satisfaction for your hospitalist group versus all other admissions, you need to make sure that comparisons are made to a similar population, i.e., acutely ill patients admitted through the ED with medical diagnoses. The survey companies should be able to produce just such a comparison.

It is equally as important to make sure you focus on the total experience at the hospital and not just the questions specifically concerning only the doctors. Since hospitalists not only do front-line, face-to-face patient care, but also work with the team and attempt to improve the system to provide better overall quality, make sure to focus on questions like “How do patients rate the hospital?” and “Would patients recommend the hospital to friends and family?”

The other consideration is to understand how close the top quartile is to the bottom quartile, when comparisons are made with this data. In many of these surveys the patients are giving ratings on a scale of one to four, with many of the responses at three or four. Therefore, the top score might be a 3.6 and the bottom score average 3.2. It is important to understand if you are just minor adjustments away from being in a good range or if you are either so far above or below the standard of care that a real situation exists.

HM’s Role

Does the hospitalist model lead to better patient satisfaction? Like most things in hospital medicine, the answer is yes, no, and maybe. There are certain aspects of hospital medicine that should lead to happier patients:

• Present and easily available;
• Expert in hospital care;
• Improved coordination of care by specialists;
• Availability for multiple visits if patient condition changes;
• Availability to visit with loved-ones at their convenience; and
• Rapid response to nurse’s concerns.

There are aspects of getting your care from a hospitalist that may initially make the patient more concerned:

• They may be unfamiliar with the hospitalist and the hospitalist model;
• The hospitalist may demonstrate little or no knowledge of the patient’s history;
• The referring physician may not introduce the patient to the hospitalist; and
• The hospitalist may not explain the relationship with the referring physician.

How to Be Proactive

With all we have to do every day (and the list seems to get longer by the minute), it is easy to get perplexed by having to be responsible for the patients’ satisfaction with their hospital experience. That being said, hospitalists perform well when we step up to the plate and take action in these ways:

• Proactively meet with the person in the C-suite who oversees the patient satisfaction survey process or relates to the hospitalist group (e.g., vice president of medical affairs or chief medical officer) to better understand the survey results;
• Make sure if the data are being used to compare hospitalist care with non-hospitalist care that the comparison group of patients is equivalent (i.e., acutely ill medical patients admitted through the ED, not surgical or obstetrical patients);
• Make sure to focus not only on the “doctor-related” questions, but on patients’ overall satisfaction with the hospital; and
• Offer to help the C-suite improve patient satisfaction, but don’t attempt to “own” this performance measure for the entire hospital. Hospitalists can be helpful, but this is broader than any one group of physicians.

Further, make improving patient satisfaction a core goal for your group. Some strategies that may work include:

• Have a script for each patient encounter (“Hi, I’m Dr. Smith, I take care of Dr. Jones’ patients in the hospital. The way we communicate about your care is … The advantages to our partnership are …”);
• Hand out a brochure with your group’s hospitalists’ pictures, answers to frequently asked questions, and how to contact the hospitalist; and
• Sit down and shut up (i.e., patients will perceive you are taking time with them and listening if you are seated and let them speak without interruption).

Hospitals have been doing patient surveys for some time now. The Centers for Medicare and Medicaid Services and other payers are placing more emphasis on this quality measure. Now that the results easily are available to the public, major newspapers and broadcast media are calling attention to patient perspectives on their hospital care.

Once hospitalist groups understand the data, there is an opportunity to partner with their hospitals to better understand how our patients see their hospital care and allow for hospitalists to have an appropriate role in working with the other health professionals to improve patients’ experience with their care. TH

Dr. Wellikson is the CEO of SHM.

Note to readers: I would like to acknowledge SHM co-founder Win Whitcomb, MD, and SHM Senior Vice President Joe Miller for their assistance with this column.

Something is happening out there. Can you feel it?

It is like a small tremor before an earthquake or a brief lightning flash before a thunderstorm. It’s the signal that alerts us something is coming without indicating what it might be—ominous, promising, or revolutionary.

Our ossified, dysfunctional nonsystem of incentivizing the behavior of healthcare professionals gradually is eroding, even as the haves—the over-rewarded—cling to the past or rush to create the next procedure or modality to run by the insurance industry guardians of the dollar. The days of the system of paying for care in an a la carte manner—by the unit of the visit or performance of the procedure without consequence or reward for appropriate indications or demonstration of expected outcomes—clearly are numbered.

What will replace the current imperfect approach is not clear or perfect, but there are discernible, inexorable trends.

Performance Will Matter

Few sectors of our economy have been so devoid of standards—or, more to the point, of rewards for better service or outcomes—than healthcare.

Could you imagine paying the same for a 2008 Lexus as you would for a 1995 Toyota? Could you imagine a pricing system that couldn’t recognize or properly reward the difference between Motel 6 and the Ritz Carlton, excusing the inability to differentiate them by saying they both have beds, sheets, towels, and indoor plumbing? Today, the worst orthopedist in the country and the best are paid the same fee for a hip replacement—whether it’s indicated or not. Most patients or purchasers of healthcare have no way to know which is which.

Performance measurement and standards are here, and while imperfect and evolving, they will be with us throughout the rest of our professional careers. Whether you are in the “process” or “outcomes” camp, you and your institution will be measured. The carrot or the stick can take many forms.

Right now, it is much more than about just reporting. Disturbingly, only 30% of physicians have participated in the first round of the Physician Quality Reporting Initiative (PQRI). Look for Medicare to apply financial pressure on physicians who do not report.

On the hospital side, reporting has focused as much on embarrassment as anything. In April, every hospital received its mortality statistics for pneumonia from the Centers for Medicare and Medicaid Services (CMS). In July, these numbers will be made public. Look for a flurry of indignation and activity as hospitals try to regain the trust of their patients and assure them they indeed can manage something as basic to their core mission as pneumonia. SHM will be developing strategies to help hospitalists help their hospitals improve their performance.

Much has been made of paying for performance—and this may drive change at the hospital level. Yet, it is doubtful individual physicians will substantially change their work flow or processes, or purchase new systems for measurement, just to get an extra dollar or two for better glycemic control of their patients. What may carry more weight is if lack of performance means some physicians, or even hospitals, are restricted from performing certain procedures or caring for certain illnesses.

Bundling Episodes of Care

A move is afoot to change the unit of healthcare delivery. SHM has been in discussions with MedPAC, which advises CMS on changes to the reimbursement system, about aggregating a continuum of care as a “bundled” episode of care.

More than 15 years ago, the implementation of diagnosis-related groups (DRGs) moved hospital thinking from a la carte charging for each aspirin to managing the use of resources for the entire hospital stay, since their reimbursement was fixed. The DRG payment system as much as anything has encouraged hospitals to develop and support hospital medicine groups. Bundling would extend and expand a DRG-like concept to physicians.

Think of a future where physicians are not reimbursed for an admission work-up, three daily visits, and a discharge summary. Instead, they’d receive a global fee that might include the hospital care, transitions to the outpatient provider, and measurement of performance that might include patient satisfaction and a low readmission rate.

If we look at healthcare from the patient’s viewpoint, this is the kind of service for which they’re crying out. They want to move away from a system that even with the best providers leads to each expert doing his or her individual part well, but with voltage drops and white spaces as the patient moves through an uncoordinated non-system.

Hospitalists are in a unique position to be successful, especially as we look for strategies that align our performance with strong and engaged outpatient physicians and when we fully engage the entire healthcare team.

A Team Sport

Bundling and rewards driven by demonstrable performance create interlinking responsibilities for care among multiple physicians (primary care physicians, emergency physicians, surgeons, subspecialists, and hospitalists), as well as allied health professionals (registered nurses, nurse practitioners, physician assistants, pharmacists, therapists, social workers, and case managers).

While the makeup of the team is important, the environment in which it performs is most crucial for success. A system of healthcare delivery that focuses on and supports best practices and nudges—or forces—providers to make the right choice is of prime importance. In the end, a good system of care and one or two members of the team can save the entire enterprise, leading to the best outcome for the patient.

By the same token, a dysfunctional outlier on the team can sink everyone, including the patient. Think of the “new” healthcare as a crew team that needs a well-made boat (i.e., the system of care), a good coxswain (accountable physician), and a group of rowers, each of whom know and execute their roles. One rower can sink seven Olympians.

We are all in the boat together. We need to be clear where the finish line is and how best to get there. The future is in sight, and we need to continue to shape our role in helping the rest of the team get there. We must do this for ourselves, our profession, and—most of all—our patients today and tomorrow. TH

Dr. Wellikson is CEO of SHM.

Something is happening out there. Can you feel it?

It is like a small tremor before an earthquake or a brief lightning flash before a thunderstorm. It’s the signal that alerts us something is coming without indicating what it might be—ominous, promising, or revolutionary.

Our ossified, dysfunctional nonsystem of incentivizing the behavior of healthcare professionals gradually is eroding, even as the haves—the over-rewarded—cling to the past or rush to create the next procedure or modality to run by the insurance industry guardians of the dollar. The days of the system of paying for care in an a la carte manner—by the unit of the visit or performance of the procedure without consequence or reward for appropriate indications or demonstration of expected outcomes—clearly are numbered.

What will replace the current imperfect approach is not clear or perfect, but there are discernible, inexorable trends.

Performance Will Matter

Few sectors of our economy have been so devoid of standards—or, more to the point, of rewards for better service or outcomes—than healthcare.

Could you imagine paying the same for a 2008 Lexus as you would for a 1995 Toyota? Could you imagine a pricing system that couldn’t recognize or properly reward the difference between Motel 6 and the Ritz Carlton, excusing the inability to differentiate them by saying they both have beds, sheets, towels, and indoor plumbing? Today, the worst orthopedist in the country and the best are paid the same fee for a hip replacement—whether it’s indicated or not. Most patients or purchasers of healthcare have no way to know which is which.

Performance measurement and standards are here, and while imperfect and evolving, they will be with us throughout the rest of our professional careers. Whether you are in the “process” or “outcomes” camp, you and your institution will be measured. The carrot or the stick can take many forms.

Right now, it is much more than about just reporting. Disturbingly, only 30% of physicians have participated in the first round of the Physician Quality Reporting Initiative (PQRI). Look for Medicare to apply financial pressure on physicians who do not report.

On the hospital side, reporting has focused as much on embarrassment as anything. In April, every hospital received its mortality statistics for pneumonia from the Centers for Medicare and Medicaid Services (CMS). In July, these numbers will be made public. Look for a flurry of indignation and activity as hospitals try to regain the trust of their patients and assure them they indeed can manage something as basic to their core mission as pneumonia. SHM will be developing strategies to help hospitalists help their hospitals improve their performance.

Much has been made of paying for performance—and this may drive change at the hospital level. Yet, it is doubtful individual physicians will substantially change their work flow or processes, or purchase new systems for measurement, just to get an extra dollar or two for better glycemic control of their patients. What may carry more weight is if lack of performance means some physicians, or even hospitals, are restricted from performing certain procedures or caring for certain illnesses.

Bundling Episodes of Care

A move is afoot to change the unit of healthcare delivery. SHM has been in discussions with MedPAC, which advises CMS on changes to the reimbursement system, about aggregating a continuum of care as a “bundled” episode of care.

More than 15 years ago, the implementation of diagnosis-related groups (DRGs) moved hospital thinking from a la carte charging for each aspirin to managing the use of resources for the entire hospital stay, since their reimbursement was fixed. The DRG payment system as much as anything has encouraged hospitals to develop and support hospital medicine groups. Bundling would extend and expand a DRG-like concept to physicians.

Think of a future where physicians are not reimbursed for an admission work-up, three daily visits, and a discharge summary. Instead, they’d receive a global fee that might include the hospital care, transitions to the outpatient provider, and measurement of performance that might include patient satisfaction and a low readmission rate.

If we look at healthcare from the patient’s viewpoint, this is the kind of service for which they’re crying out. They want to move away from a system that even with the best providers leads to each expert doing his or her individual part well, but with voltage drops and white spaces as the patient moves through an uncoordinated non-system.

Hospitalists are in a unique position to be successful, especially as we look for strategies that align our performance with strong and engaged outpatient physicians and when we fully engage the entire healthcare team.

A Team Sport

Bundling and rewards driven by demonstrable performance create interlinking responsibilities for care among multiple physicians (primary care physicians, emergency physicians, surgeons, subspecialists, and hospitalists), as well as allied health professionals (registered nurses, nurse practitioners, physician assistants, pharmacists, therapists, social workers, and case managers).

While the makeup of the team is important, the environment in which it performs is most crucial for success. A system of healthcare delivery that focuses on and supports best practices and nudges—or forces—providers to make the right choice is of prime importance. In the end, a good system of care and one or two members of the team can save the entire enterprise, leading to the best outcome for the patient.

By the same token, a dysfunctional outlier on the team can sink everyone, including the patient. Think of the “new” healthcare as a crew team that needs a well-made boat (i.e., the system of care), a good coxswain (accountable physician), and a group of rowers, each of whom know and execute their roles. One rower can sink seven Olympians.

We are all in the boat together. We need to be clear where the finish line is and how best to get there. The future is in sight, and we need to continue to shape our role in helping the rest of the team get there. We must do this for ourselves, our profession, and—most of all—our patients today and tomorrow. TH

Dr. Wellikson is CEO of SHM.

Something is happening out there. Can you feel it?

It is like a small tremor before an earthquake or a brief lightning flash before a thunderstorm. It’s the signal that alerts us something is coming without indicating what it might be—ominous, promising, or revolutionary.

Our ossified, dysfunctional nonsystem of incentivizing the behavior of healthcare professionals gradually is eroding, even as the haves—the over-rewarded—cling to the past or rush to create the next procedure or modality to run by the insurance industry guardians of the dollar. The days of the system of paying for care in an a la carte manner—by the unit of the visit or performance of the procedure without consequence or reward for appropriate indications or demonstration of expected outcomes—clearly are numbered.

What will replace the current imperfect approach is not clear or perfect, but there are discernible, inexorable trends.

Performance Will Matter

Few sectors of our economy have been so devoid of standards—or, more to the point, of rewards for better service or outcomes—than healthcare.

Could you imagine paying the same for a 2008 Lexus as you would for a 1995 Toyota? Could you imagine a pricing system that couldn’t recognize or properly reward the difference between Motel 6 and the Ritz Carlton, excusing the inability to differentiate them by saying they both have beds, sheets, towels, and indoor plumbing? Today, the worst orthopedist in the country and the best are paid the same fee for a hip replacement—whether it’s indicated or not. Most patients or purchasers of healthcare have no way to know which is which.

Performance measurement and standards are here, and while imperfect and evolving, they will be with us throughout the rest of our professional careers. Whether you are in the “process” or “outcomes” camp, you and your institution will be measured. The carrot or the stick can take many forms.

Right now, it is much more than about just reporting. Disturbingly, only 30% of physicians have participated in the first round of the Physician Quality Reporting Initiative (PQRI). Look for Medicare to apply financial pressure on physicians who do not report.

On the hospital side, reporting has focused as much on embarrassment as anything. In April, every hospital received its mortality statistics for pneumonia from the Centers for Medicare and Medicaid Services (CMS). In July, these numbers will be made public. Look for a flurry of indignation and activity as hospitals try to regain the trust of their patients and assure them they indeed can manage something as basic to their core mission as pneumonia. SHM will be developing strategies to help hospitalists help their hospitals improve their performance.

Much has been made of paying for performance—and this may drive change at the hospital level. Yet, it is doubtful individual physicians will substantially change their work flow or processes, or purchase new systems for measurement, just to get an extra dollar or two for better glycemic control of their patients. What may carry more weight is if lack of performance means some physicians, or even hospitals, are restricted from performing certain procedures or caring for certain illnesses.

Bundling Episodes of Care

A move is afoot to change the unit of healthcare delivery. SHM has been in discussions with MedPAC, which advises CMS on changes to the reimbursement system, about aggregating a continuum of care as a “bundled” episode of care.

More than 15 years ago, the implementation of diagnosis-related groups (DRGs) moved hospital thinking from a la carte charging for each aspirin to managing the use of resources for the entire hospital stay, since their reimbursement was fixed. The DRG payment system as much as anything has encouraged hospitals to develop and support hospital medicine groups. Bundling would extend and expand a DRG-like concept to physicians.

Think of a future where physicians are not reimbursed for an admission work-up, three daily visits, and a discharge summary. Instead, they’d receive a global fee that might include the hospital care, transitions to the outpatient provider, and measurement of performance that might include patient satisfaction and a low readmission rate.

If we look at healthcare from the patient’s viewpoint, this is the kind of service for which they’re crying out. They want to move away from a system that even with the best providers leads to each expert doing his or her individual part well, but with voltage drops and white spaces as the patient moves through an uncoordinated non-system.

Hospitalists are in a unique position to be successful, especially as we look for strategies that align our performance with strong and engaged outpatient physicians and when we fully engage the entire healthcare team.

A Team Sport

Bundling and rewards driven by demonstrable performance create interlinking responsibilities for care among multiple physicians (primary care physicians, emergency physicians, surgeons, subspecialists, and hospitalists), as well as allied health professionals (registered nurses, nurse practitioners, physician assistants, pharmacists, therapists, social workers, and case managers).

While the makeup of the team is important, the environment in which it performs is most crucial for success. A system of healthcare delivery that focuses on and supports best practices and nudges—or forces—providers to make the right choice is of prime importance. In the end, a good system of care and one or two members of the team can save the entire enterprise, leading to the best outcome for the patient.

By the same token, a dysfunctional outlier on the team can sink everyone, including the patient. Think of the “new” healthcare as a crew team that needs a well-made boat (i.e., the system of care), a good coxswain (accountable physician), and a group of rowers, each of whom know and execute their roles. One rower can sink seven Olympians.

We are all in the boat together. We need to be clear where the finish line is and how best to get there. The future is in sight, and we need to continue to shape our role in helping the rest of the team get there. We must do this for ourselves, our profession, and—most of all—our patients today and tomorrow. TH

Dr. Wellikson is CEO of SHM.

Dear Hillary (or Rudy or Mitt or Barack):

I know you have a lot on your mind, what with not knowing whether you are in New Hampshire or South Carolina half the time during the campaign. But I wanted to drop you a note and let you know there is a big mess in healthcare.

Hospitalists are a growing army that can bring our country patient-centered care and measurable quality outcomes, all delivered by teams of health professionals—if you and Congress can give us some help.

In case you are not totally familiar with the concept, hospital medicine is the fastest-growing specialty in American medical history. We are more than 20,000 strong, and we treat more than 30% of medical inpatients in the country. Hospitalists are right where the action is in healthcare.

We know we can do our part to change our health communities, starting with our hospitals. But we need to improve the economics of healthcare—both what we pay for and what we reward—if we are to get the right physicians to go into hospital medicine and make this a sustainable career.

So here is our wish list.

Insure All Americans

There are about 50 million people without health insurance, give or take a million. Everyone knows these people are sicker and die quicker. I guess the good news is that when they eventually show up in distress at our hospitals, we hospitalists jump in and do the best we can—regardless of whether they can pay for their care or not.

The problem is these uninsured patients often should have seen us days or weeks earlier, which makes it harder for us to help them. If we are fortunate enough to get a handle on the crisis, too often lack of insurance makes it harder to find doctors in the community to follow up with these needy patients.

We are working with the American Cancer Society, which has recognized that even for those who think they have insurance coverage, many times it is inadequate. If you’re unlucky enough to get the “big C” you may end up with a choice between the best care and bankruptcy—or both.

I don’t know whether the solution is to:

• Expand the State Children’s Health Insurance Program to include all kids;
• Extend Medicare to people at age 55 (as Sen. Joe Biden, D-Del., has suggested); or
• Extend Medicare to those as young as 15 to get everybody covered.

I do know the time for talk is well past. It is time for leadership and action.

If you get a chance you might take a look at the November/December 2007 issue of Health Affairs. In it, experts like Victor Fuchs, Bill Roper, Bob Berenson, Len Schaeffer, and many others frame the issues of health reform in practical terms. At the very least direct your health staffer to get a copy.

Reform Payment

People should expect value in healthcare, as we do in almost everything else we buy and need. We have an outmoded payment system that insists on rewarding the doing of anything. We have to start paying for what we want.

We have to stop paying for the unit of the visit or unit of the procedure, which just leads to more visits or more procedures—even if they produce no appreciable improvement in outcomes or quality of care. We have to start figuring out what outcomes we want and reward those healthcare professionals who can produce. If we want our diabetics in good control, pay for that. Don’t pay for just seeing the diabetic patient.

The cornerstone of value-based purchasing—which is our goal—is performance measurement. Hospitalists are at the head of the line in agreeing to be measured and in working with other health professionals and patients to set goals for ideal hospital care. We don’t mind being held accountable for our performance; we just want to be involved in ensuring we’re measured on what matters and that we have a plan for and a part in our improvement.

We also question if measuring performance at the individual doctor level makes sense. We believe healthcare is a team sport. We view our role as working with the entire healthcare team to deliver measurable, quality care. Our teams and hospitals need to be held accountable for performance and outcomes—and payment for care should be commensurate with performance.

We can talk about whether this takes the form of case rates or diagnosis-related groups for physician care: Both can reward efficiency and systems improvement. Or perhaps we should aim for pay for performance or pay for outcomes that would reward effectiveness and value. The recent decree by the Centers for Medicare and Medicaid Services not to pay hospitals for so-called “never” events (hospitalization errors that should never happen) is a good start. But we need to plow those savings back into rewards for high performance.

In the short term, if you can’t change the structure of the current payment system, at least stop these annual 5% to 10% reimbursement cuts. We are young physicians at the lower end of the pay scale, and there is little room for us to cut our expenses or stop paying our medical school loans. We are the front-line doctors essential to caring for the acutely ill, especially the elderly, and we need a payment system that makes it attractive for other young doctors to join us. Throwing out across-the-board payment cuts makes it more likely the new, younger physicians will continue to choose higher-paying specialties like anesthesiology and dermatology—just when we need many more hospitalists.

Reward What You Want

We are stuck in this payment system where we only pay for direct, face-to-face, one-on-one patient care. While this is still necessary, patients, employers, and the system cry out for a different approach.

The system needs to be reworked with improved throughput and efficiency. Seamless communication and coordination of care are primary goals. Reformed infrastructure and culture should foster development of highly effective teams of healthcare professionals. Time must be built into the work day for end-of-life care, palliative care, and joint decision-making by patients and their families.

All this takes dedication, expertise, professionalism, and—most of all—time. But in a payment system that rewards scoping an orifice or cutting out a skin lesion and still hasn’t figured out how to pay for changing the system or building a team, where do you think most physicians’ work time is driven?

Nowhere is it truer than in healthcare that you get what you pay for. There is plenty of money in the U.S. healthcare system—more than $2 trillion annually. The problem is we’re funding a system that may have worked in the 1950s, and we expect it to meet 21st-century needs.

Hospitalists are young, energetic, and optimistic. We want to be part of the solution, not another self-interest group demanding our needs be met and the heck with the dysfunction they might create. We also have most of our professional lives ahead of us, and we have seen that when we work extra hard to correct our local hospital’s glitches, it helps us function better.

The problems won’t go away if we ignore them. We have no choice but to step up and take a chance at change. We challenge you to step up, be a leader, and dare to make a difference. We suggest you:

• Figure out a way to get all Americans insured;
• Create a value proposition in healthcare and set up a new payment system that rewards value, efficiency, and effectiveness; and
• Reward and incentivize a new paradigm of healthcare delivered by teams of health professionals performing in functional systems of care.

There are many entrenched institutions and constituencies that will see any change as a prescription for them to lose. Hospitalists are the future. We embrace change and accept that staying in a system that is not working is not an option. We can’t predict the outcome, but when you look for partners to take the healthcare system forward, hospitalists are ready to do their share and more. But we need your help, and we need it now. TH

Dr. Wellikson is CEO of SHM.

Dear Hillary (or Rudy or Mitt or Barack):

I know you have a lot on your mind, what with not knowing whether you are in New Hampshire or South Carolina half the time during the campaign. But I wanted to drop you a note and let you know there is a big mess in healthcare.

Hospitalists are a growing army that can bring our country patient-centered care and measurable quality outcomes, all delivered by teams of health professionals—if you and Congress can give us some help.

In case you are not totally familiar with the concept, hospital medicine is the fastest-growing specialty in American medical history. We are more than 20,000 strong, and we treat more than 30% of medical inpatients in the country. Hospitalists are right where the action is in healthcare.

We know we can do our part to change our health communities, starting with our hospitals. But we need to improve the economics of healthcare—both what we pay for and what we reward—if we are to get the right physicians to go into hospital medicine and make this a sustainable career.

So here is our wish list.

Insure All Americans

There are about 50 million people without health insurance, give or take a million. Everyone knows these people are sicker and die quicker. I guess the good news is that when they eventually show up in distress at our hospitals, we hospitalists jump in and do the best we can—regardless of whether they can pay for their care or not.

The problem is these uninsured patients often should have seen us days or weeks earlier, which makes it harder for us to help them. If we are fortunate enough to get a handle on the crisis, too often lack of insurance makes it harder to find doctors in the community to follow up with these needy patients.

We are working with the American Cancer Society, which has recognized that even for those who think they have insurance coverage, many times it is inadequate. If you’re unlucky enough to get the “big C” you may end up with a choice between the best care and bankruptcy—or both.

I don’t know whether the solution is to:

• Expand the State Children’s Health Insurance Program to include all kids;
• Extend Medicare to people at age 55 (as Sen. Joe Biden, D-Del., has suggested); or
• Extend Medicare to those as young as 15 to get everybody covered.

I do know the time for talk is well past. It is time for leadership and action.

If you get a chance you might take a look at the November/December 2007 issue of Health Affairs. In it, experts like Victor Fuchs, Bill Roper, Bob Berenson, Len Schaeffer, and many others frame the issues of health reform in practical terms. At the very least direct your health staffer to get a copy.

Reform Payment

People should expect value in healthcare, as we do in almost everything else we buy and need. We have an outmoded payment system that insists on rewarding the doing of anything. We have to start paying for what we want.

We have to stop paying for the unit of the visit or unit of the procedure, which just leads to more visits or more procedures—even if they produce no appreciable improvement in outcomes or quality of care. We have to start figuring out what outcomes we want and reward those healthcare professionals who can produce. If we want our diabetics in good control, pay for that. Don’t pay for just seeing the diabetic patient.

The cornerstone of value-based purchasing—which is our goal—is performance measurement. Hospitalists are at the head of the line in agreeing to be measured and in working with other health professionals and patients to set goals for ideal hospital care. We don’t mind being held accountable for our performance; we just want to be involved in ensuring we’re measured on what matters and that we have a plan for and a part in our improvement.

We also question if measuring performance at the individual doctor level makes sense. We believe healthcare is a team sport. We view our role as working with the entire healthcare team to deliver measurable, quality care. Our teams and hospitals need to be held accountable for performance and outcomes—and payment for care should be commensurate with performance.

We can talk about whether this takes the form of case rates or diagnosis-related groups for physician care: Both can reward efficiency and systems improvement. Or perhaps we should aim for pay for performance or pay for outcomes that would reward effectiveness and value. The recent decree by the Centers for Medicare and Medicaid Services not to pay hospitals for so-called “never” events (hospitalization errors that should never happen) is a good start. But we need to plow those savings back into rewards for high performance.

In the short term, if you can’t change the structure of the current payment system, at least stop these annual 5% to 10% reimbursement cuts. We are young physicians at the lower end of the pay scale, and there is little room for us to cut our expenses or stop paying our medical school loans. We are the front-line doctors essential to caring for the acutely ill, especially the elderly, and we need a payment system that makes it attractive for other young doctors to join us. Throwing out across-the-board payment cuts makes it more likely the new, younger physicians will continue to choose higher-paying specialties like anesthesiology and dermatology—just when we need many more hospitalists.

Reward What You Want

We are stuck in this payment system where we only pay for direct, face-to-face, one-on-one patient care. While this is still necessary, patients, employers, and the system cry out for a different approach.

The system needs to be reworked with improved throughput and efficiency. Seamless communication and coordination of care are primary goals. Reformed infrastructure and culture should foster development of highly effective teams of healthcare professionals. Time must be built into the work day for end-of-life care, palliative care, and joint decision-making by patients and their families.

All this takes dedication, expertise, professionalism, and—most of all—time. But in a payment system that rewards scoping an orifice or cutting out a skin lesion and still hasn’t figured out how to pay for changing the system or building a team, where do you think most physicians’ work time is driven?

Nowhere is it truer than in healthcare that you get what you pay for. There is plenty of money in the U.S. healthcare system—more than $2 trillion annually. The problem is we’re funding a system that may have worked in the 1950s, and we expect it to meet 21st-century needs.

Hospitalists are young, energetic, and optimistic. We want to be part of the solution, not another self-interest group demanding our needs be met and the heck with the dysfunction they might create. We also have most of our professional lives ahead of us, and we have seen that when we work extra hard to correct our local hospital’s glitches, it helps us function better.

The problems won’t go away if we ignore them. We have no choice but to step up and take a chance at change. We challenge you to step up, be a leader, and dare to make a difference. We suggest you:

• Figure out a way to get all Americans insured;
• Create a value proposition in healthcare and set up a new payment system that rewards value, efficiency, and effectiveness; and
• Reward and incentivize a new paradigm of healthcare delivered by teams of health professionals performing in functional systems of care.

There are many entrenched institutions and constituencies that will see any change as a prescription for them to lose. Hospitalists are the future. We embrace change and accept that staying in a system that is not working is not an option. We can’t predict the outcome, but when you look for partners to take the healthcare system forward, hospitalists are ready to do their share and more. But we need your help, and we need it now. TH

Dr. Wellikson is CEO of SHM.

Dear Hillary (or Rudy or Mitt or Barack):

I know you have a lot on your mind, what with not knowing whether you are in New Hampshire or South Carolina half the time during the campaign. But I wanted to drop you a note and let you know there is a big mess in healthcare.

Hospitalists are a growing army that can bring our country patient-centered care and measurable quality outcomes, all delivered by teams of health professionals—if you and Congress can give us some help.

In case you are not totally familiar with the concept, hospital medicine is the fastest-growing specialty in American medical history. We are more than 20,000 strong, and we treat more than 30% of medical inpatients in the country. Hospitalists are right where the action is in healthcare.

We know we can do our part to change our health communities, starting with our hospitals. But we need to improve the economics of healthcare—both what we pay for and what we reward—if we are to get the right physicians to go into hospital medicine and make this a sustainable career.

So here is our wish list.

Insure All Americans

There are about 50 million people without health insurance, give or take a million. Everyone knows these people are sicker and die quicker. I guess the good news is that when they eventually show up in distress at our hospitals, we hospitalists jump in and do the best we can—regardless of whether they can pay for their care or not.

The problem is these uninsured patients often should have seen us days or weeks earlier, which makes it harder for us to help them. If we are fortunate enough to get a handle on the crisis, too often lack of insurance makes it harder to find doctors in the community to follow up with these needy patients.

We are working with the American Cancer Society, which has recognized that even for those who think they have insurance coverage, many times it is inadequate. If you’re unlucky enough to get the “big C” you may end up with a choice between the best care and bankruptcy—or both.

I don’t know whether the solution is to:

• Expand the State Children’s Health Insurance Program to include all kids;
• Extend Medicare to people at age 55 (as Sen. Joe Biden, D-Del., has suggested); or
• Extend Medicare to those as young as 15 to get everybody covered.

I do know the time for talk is well past. It is time for leadership and action.

If you get a chance you might take a look at the November/December 2007 issue of Health Affairs. In it, experts like Victor Fuchs, Bill Roper, Bob Berenson, Len Schaeffer, and many others frame the issues of health reform in practical terms. At the very least direct your health staffer to get a copy.

Reform Payment

People should expect value in healthcare, as we do in almost everything else we buy and need. We have an outmoded payment system that insists on rewarding the doing of anything. We have to start paying for what we want.

We have to stop paying for the unit of the visit or unit of the procedure, which just leads to more visits or more procedures—even if they produce no appreciable improvement in outcomes or quality of care. We have to start figuring out what outcomes we want and reward those healthcare professionals who can produce. If we want our diabetics in good control, pay for that. Don’t pay for just seeing the diabetic patient.

The cornerstone of value-based purchasing—which is our goal—is performance measurement. Hospitalists are at the head of the line in agreeing to be measured and in working with other health professionals and patients to set goals for ideal hospital care. We don’t mind being held accountable for our performance; we just want to be involved in ensuring we’re measured on what matters and that we have a plan for and a part in our improvement.

We also question if measuring performance at the individual doctor level makes sense. We believe healthcare is a team sport. We view our role as working with the entire healthcare team to deliver measurable, quality care. Our teams and hospitals need to be held accountable for performance and outcomes—and payment for care should be commensurate with performance.

We can talk about whether this takes the form of case rates or diagnosis-related groups for physician care: Both can reward efficiency and systems improvement. Or perhaps we should aim for pay for performance or pay for outcomes that would reward effectiveness and value. The recent decree by the Centers for Medicare and Medicaid Services not to pay hospitals for so-called “never” events (hospitalization errors that should never happen) is a good start. But we need to plow those savings back into rewards for high performance.

In the short term, if you can’t change the structure of the current payment system, at least stop these annual 5% to 10% reimbursement cuts. We are young physicians at the lower end of the pay scale, and there is little room for us to cut our expenses or stop paying our medical school loans. We are the front-line doctors essential to caring for the acutely ill, especially the elderly, and we need a payment system that makes it attractive for other young doctors to join us. Throwing out across-the-board payment cuts makes it more likely the new, younger physicians will continue to choose higher-paying specialties like anesthesiology and dermatology—just when we need many more hospitalists.

Reward What You Want

We are stuck in this payment system where we only pay for direct, face-to-face, one-on-one patient care. While this is still necessary, patients, employers, and the system cry out for a different approach.

The system needs to be reworked with improved throughput and efficiency. Seamless communication and coordination of care are primary goals. Reformed infrastructure and culture should foster development of highly effective teams of healthcare professionals. Time must be built into the work day for end-of-life care, palliative care, and joint decision-making by patients and their families.

All this takes dedication, expertise, professionalism, and—most of all—time. But in a payment system that rewards scoping an orifice or cutting out a skin lesion and still hasn’t figured out how to pay for changing the system or building a team, where do you think most physicians’ work time is driven?

Nowhere is it truer than in healthcare that you get what you pay for. There is plenty of money in the U.S. healthcare system—more than $2 trillion annually. The problem is we’re funding a system that may have worked in the 1950s, and we expect it to meet 21st-century needs.

Hospitalists are young, energetic, and optimistic. We want to be part of the solution, not another self-interest group demanding our needs be met and the heck with the dysfunction they might create. We also have most of our professional lives ahead of us, and we have seen that when we work extra hard to correct our local hospital’s glitches, it helps us function better.

The problems won’t go away if we ignore them. We have no choice but to step up and take a chance at change. We challenge you to step up, be a leader, and dare to make a difference. We suggest you:

• Figure out a way to get all Americans insured;
• Create a value proposition in healthcare and set up a new payment system that rewards value, efficiency, and effectiveness; and
• Reward and incentivize a new paradigm of healthcare delivered by teams of health professionals performing in functional systems of care.

There are many entrenched institutions and constituencies that will see any change as a prescription for them to lose. Hospitalists are the future. We embrace change and accept that staying in a system that is not working is not an option. We can’t predict the outcome, but when you look for partners to take the healthcare system forward, hospitalists are ready to do their share and more. But we need your help, and we need it now. TH

Dr. Wellikson is CEO of SHM.

It’s hard to believe eight years have gone by since I came to SHM. More than that, it is strange to think of a world without hospitalists. Hospital medicine is part of the fabric of healthcare; there’s no longer a debate over whether hospitalists are good or bad. Now, the talk is about how hospitalists can help solve so many of the ills that vex our healthcare system.

This year has been an extraordinary year even by SHM standards. Witness our progress in the following areas.

ABIM Progress

In a landmark and revolutionary decision, the American Board of Internal Medicine (ABIM) recommended proceeding with a recognition of focused practice (RFP) in hospital medicine as an option in its maintenance of certification (MOC).

This is the culmination of a strategy SHM laid out three years ago. SHM is working with ABIM to continue to make the MOC process meaningful to hospitalists as the ABIM recommendations wend their way through the American Board of Medical Specialties. SHM continues to reach out to the pediatric and family medicine boards so the RFP can be available to all hospitalists.

JHM Listed

In its first year of publication, the Journal of Hospital Medicine (JHM) has been included in PubMed, the National Institutes of Health online archive of life science journals. JHM now resides among other established journals, fielding a marked increased in submissions for publication.

Quality

SHM received its third consecutive grant from the John A. Hartford Foundation, this one for $1.4 million over three years to develop interventions to improve care transitions for older adults at discharge.

As part of our work to improve quality for our nation’s seniors, SHM is developing discharge-planning tools and implementation strategies to limit the voltage drop in care at discharge. Hartford’s support means funders see that hospitalists, with SHM support, improve quality at their hospitals. SHM has become a leader in discharge planning tools and is helping set standards for transitions of care.

To help give hospitalists tools and resources to effect change on the front lines, SHM continues to develop online resource rooms and unique strategies such as mentored implementation.

We also have several hospitalist leaders on key panels at the National Quality Forum (NQF). The American Medical Association’s Physician Consortium on Practice Improvement has asked SHM to take the lead in forming a coalition for setting transitions-of-care measurements.

When the Institute for Healthcare Improvement needed a physician group to join the announcement of its 5 Million Lives Campaign, it reached out to SHM. President Rusty Holman took the stage to support the initiative, which intends to protect 5 million patients from incidents of medical harm over the next two years.

Further, the Joint Commission on Accreditation of Healthcare Organ­izations asked SHM to co-sponsor its medication reconciliation workgroup. Lastly, SHM continues to get significant visibility for hospitalists with our leadership of the deep-vein thrombosis awareness coalition of more than 35 organizations.

Annual Meeting

In May, SHM took over the Gaylord Texan in Dallas with professional meeting staging that rivaled older, larger organizations. With banners, Jumbotrons, and devices projecting the SHM logo, we transformed the Gaylord into a “hospitalist city.” We treated the nearly 1,200 attendees to three superlative speakers:

• David Brailer, MD, national coordinator for health information technology, United States Department of Health and Human Services;
• Jonathan Perlin, MD, former undersecretary for health at the Veterans Health Administration and now chief medical officer and senior vice president of quality for Hospital Corporation of America in Nashville; and
• Bob Wachter, MD, professor and chief of the division of hospital medicine at the University of California, San Francisco.

And, we had our largest poster session ever, with more than 200 submissions, and our largest exhibit hall. We plan to take it up a notch in San Diego in April.

Advocacy and Policy

Our presence in Washington, D.C., allows us to be active in Medicare payment reform. SHM leadership has met with senior staff at MedPAC, the organization that makes recommendations to the Centers for Medicare and Medicaid Services and Congress. MedPAC is interested in working with SHM as Medicare attempts to move away from paying for just visits and procedures and toward reimbursement strategies that drive performance and efficiency.

Current, Future Initiatives

In June, SHM forged a partnership with the Society of General Internal Medicine (SGIM) and the Association of Chiefs of General Internal Medicine to hold an academic summit to develop strategies for academic hospitalists to have a strong and sustainable career in teaching, training, and research in hospital medicine. When the Alliance for Academic Internal Medicine developed its proposal to redesign internal medicine training, SHM took the lead in crafting the hospitalist response.

In July, we joined the SGIM and American College of Physicians to hold a consensus conference on transitions of care. This coalition of more than 25 organizations produced a statement as the basis for future standards and measurements. Also in July, SHM worked with key leaders in emergency medicine and others to redefine the management and opportunities in observation units.

We held a multidisciplinary workforce summit in November to examine the challenges and solutions in growing hospital medicine from 20,000 to 40,000 or more physicians.

Diversity

While at times we may seem to focus more on internal-medicine-trained hospitalists, who make up more than 80% of the field, SHM continues to include hospitalists in family medicine and pediatrics, among other specialties. We also are home to nonphysician providers and physician assistants. We are working to support academic hospitalists, small groups, and multistate companies. In our toughest tightrope walk, SHM continues to be relevant and supportive of labor and management in hospital medicine.

Looking to 2008

The growth and influence of hospital medicine is relentless. Maybe 2008 is the year we will see hospitalists practicing in more than 3,000 hospitals or see the specialty grow to more than 25,000 hospitalists. One thing is for sure: SHM, with your suggestions, ideas, and energy, will be on the front lines with you, supporting and advocating a better healthcare system. TH

Dr. Wellikson is CEO of SHM.

It’s hard to believe eight years have gone by since I came to SHM. More than that, it is strange to think of a world without hospitalists. Hospital medicine is part of the fabric of healthcare; there’s no longer a debate over whether hospitalists are good or bad. Now, the talk is about how hospitalists can help solve so many of the ills that vex our healthcare system.

This year has been an extraordinary year even by SHM standards. Witness our progress in the following areas.

ABIM Progress

In a landmark and revolutionary decision, the American Board of Internal Medicine (ABIM) recommended proceeding with a recognition of focused practice (RFP) in hospital medicine as an option in its maintenance of certification (MOC).

This is the culmination of a strategy SHM laid out three years ago. SHM is working with ABIM to continue to make the MOC process meaningful to hospitalists as the ABIM recommendations wend their way through the American Board of Medical Specialties. SHM continues to reach out to the pediatric and family medicine boards so the RFP can be available to all hospitalists.

JHM Listed

In its first year of publication, the Journal of Hospital Medicine (JHM) has been included in PubMed, the National Institutes of Health online archive of life science journals. JHM now resides among other established journals, fielding a marked increased in submissions for publication.

Quality

SHM received its third consecutive grant from the John A. Hartford Foundation, this one for $1.4 million over three years to develop interventions to improve care transitions for older adults at discharge.

As part of our work to improve quality for our nation’s seniors, SHM is developing discharge-planning tools and implementation strategies to limit the voltage drop in care at discharge. Hartford’s support means funders see that hospitalists, with SHM support, improve quality at their hospitals. SHM has become a leader in discharge planning tools and is helping set standards for transitions of care.

To help give hospitalists tools and resources to effect change on the front lines, SHM continues to develop online resource rooms and unique strategies such as mentored implementation.

We also have several hospitalist leaders on key panels at the National Quality Forum (NQF). The American Medical Association’s Physician Consortium on Practice Improvement has asked SHM to take the lead in forming a coalition for setting transitions-of-care measurements.

When the Institute for Healthcare Improvement needed a physician group to join the announcement of its 5 Million Lives Campaign, it reached out to SHM. President Rusty Holman took the stage to support the initiative, which intends to protect 5 million patients from incidents of medical harm over the next two years.

Further, the Joint Commission on Accreditation of Healthcare Organ­izations asked SHM to co-sponsor its medication reconciliation workgroup. Lastly, SHM continues to get significant visibility for hospitalists with our leadership of the deep-vein thrombosis awareness coalition of more than 35 organizations.

Annual Meeting

In May, SHM took over the Gaylord Texan in Dallas with professional meeting staging that rivaled older, larger organizations. With banners, Jumbotrons, and devices projecting the SHM logo, we transformed the Gaylord into a “hospitalist city.” We treated the nearly 1,200 attendees to three superlative speakers:

• David Brailer, MD, national coordinator for health information technology, United States Department of Health and Human Services;
• Jonathan Perlin, MD, former undersecretary for health at the Veterans Health Administration and now chief medical officer and senior vice president of quality for Hospital Corporation of America in Nashville; and
• Bob Wachter, MD, professor and chief of the division of hospital medicine at the University of California, San Francisco.

And, we had our largest poster session ever, with more than 200 submissions, and our largest exhibit hall. We plan to take it up a notch in San Diego in April.

Advocacy and Policy

Our presence in Washington, D.C., allows us to be active in Medicare payment reform. SHM leadership has met with senior staff at MedPAC, the organization that makes recommendations to the Centers for Medicare and Medicaid Services and Congress. MedPAC is interested in working with SHM as Medicare attempts to move away from paying for just visits and procedures and toward reimbursement strategies that drive performance and efficiency.

Current, Future Initiatives

In June, SHM forged a partnership with the Society of General Internal Medicine (SGIM) and the Association of Chiefs of General Internal Medicine to hold an academic summit to develop strategies for academic hospitalists to have a strong and sustainable career in teaching, training, and research in hospital medicine. When the Alliance for Academic Internal Medicine developed its proposal to redesign internal medicine training, SHM took the lead in crafting the hospitalist response.

In July, we joined the SGIM and American College of Physicians to hold a consensus conference on transitions of care. This coalition of more than 25 organizations produced a statement as the basis for future standards and measurements. Also in July, SHM worked with key leaders in emergency medicine and others to redefine the management and opportunities in observation units.

We held a multidisciplinary workforce summit in November to examine the challenges and solutions in growing hospital medicine from 20,000 to 40,000 or more physicians.

Diversity

While at times we may seem to focus more on internal-medicine-trained hospitalists, who make up more than 80% of the field, SHM continues to include hospitalists in family medicine and pediatrics, among other specialties. We also are home to nonphysician providers and physician assistants. We are working to support academic hospitalists, small groups, and multistate companies. In our toughest tightrope walk, SHM continues to be relevant and supportive of labor and management in hospital medicine.

Looking to 2008

The growth and influence of hospital medicine is relentless. Maybe 2008 is the year we will see hospitalists practicing in more than 3,000 hospitals or see the specialty grow to more than 25,000 hospitalists. One thing is for sure: SHM, with your suggestions, ideas, and energy, will be on the front lines with you, supporting and advocating a better healthcare system. TH

Dr. Wellikson is CEO of SHM.

It’s hard to believe eight years have gone by since I came to SHM. More than that, it is strange to think of a world without hospitalists. Hospital medicine is part of the fabric of healthcare; there’s no longer a debate over whether hospitalists are good or bad. Now, the talk is about how hospitalists can help solve so many of the ills that vex our healthcare system.

This year has been an extraordinary year even by SHM standards. Witness our progress in the following areas.

ABIM Progress

In a landmark and revolutionary decision, the American Board of Internal Medicine (ABIM) recommended proceeding with a recognition of focused practice (RFP) in hospital medicine as an option in its maintenance of certification (MOC).

This is the culmination of a strategy SHM laid out three years ago. SHM is working with ABIM to continue to make the MOC process meaningful to hospitalists as the ABIM recommendations wend their way through the American Board of Medical Specialties. SHM continues to reach out to the pediatric and family medicine boards so the RFP can be available to all hospitalists.

JHM Listed

In its first year of publication, the Journal of Hospital Medicine (JHM) has been included in PubMed, the National Institutes of Health online archive of life science journals. JHM now resides among other established journals, fielding a marked increased in submissions for publication.

Quality

SHM received its third consecutive grant from the John A. Hartford Foundation, this one for $1.4 million over three years to develop interventions to improve care transitions for older adults at discharge.

As part of our work to improve quality for our nation’s seniors, SHM is developing discharge-planning tools and implementation strategies to limit the voltage drop in care at discharge. Hartford’s support means funders see that hospitalists, with SHM support, improve quality at their hospitals. SHM has become a leader in discharge planning tools and is helping set standards for transitions of care.

To help give hospitalists tools and resources to effect change on the front lines, SHM continues to develop online resource rooms and unique strategies such as mentored implementation.

We also have several hospitalist leaders on key panels at the National Quality Forum (NQF). The American Medical Association’s Physician Consortium on Practice Improvement has asked SHM to take the lead in forming a coalition for setting transitions-of-care measurements.

When the Institute for Healthcare Improvement needed a physician group to join the announcement of its 5 Million Lives Campaign, it reached out to SHM. President Rusty Holman took the stage to support the initiative, which intends to protect 5 million patients from incidents of medical harm over the next two years.

Further, the Joint Commission on Accreditation of Healthcare Organ­izations asked SHM to co-sponsor its medication reconciliation workgroup. Lastly, SHM continues to get significant visibility for hospitalists with our leadership of the deep-vein thrombosis awareness coalition of more than 35 organizations.

Annual Meeting

In May, SHM took over the Gaylord Texan in Dallas with professional meeting staging that rivaled older, larger organizations. With banners, Jumbotrons, and devices projecting the SHM logo, we transformed the Gaylord into a “hospitalist city.” We treated the nearly 1,200 attendees to three superlative speakers:

• David Brailer, MD, national coordinator for health information technology, United States Department of Health and Human Services;
• Jonathan Perlin, MD, former undersecretary for health at the Veterans Health Administration and now chief medical officer and senior vice president of quality for Hospital Corporation of America in Nashville; and
• Bob Wachter, MD, professor and chief of the division of hospital medicine at the University of California, San Francisco.

And, we had our largest poster session ever, with more than 200 submissions, and our largest exhibit hall. We plan to take it up a notch in San Diego in April.

Advocacy and Policy

Our presence in Washington, D.C., allows us to be active in Medicare payment reform. SHM leadership has met with senior staff at MedPAC, the organization that makes recommendations to the Centers for Medicare and Medicaid Services and Congress. MedPAC is interested in working with SHM as Medicare attempts to move away from paying for just visits and procedures and toward reimbursement strategies that drive performance and efficiency.

Current, Future Initiatives

In June, SHM forged a partnership with the Society of General Internal Medicine (SGIM) and the Association of Chiefs of General Internal Medicine to hold an academic summit to develop strategies for academic hospitalists to have a strong and sustainable career in teaching, training, and research in hospital medicine. When the Alliance for Academic Internal Medicine developed its proposal to redesign internal medicine training, SHM took the lead in crafting the hospitalist response.

In July, we joined the SGIM and American College of Physicians to hold a consensus conference on transitions of care. This coalition of more than 25 organizations produced a statement as the basis for future standards and measurements. Also in July, SHM worked with key leaders in emergency medicine and others to redefine the management and opportunities in observation units.

We held a multidisciplinary workforce summit in November to examine the challenges and solutions in growing hospital medicine from 20,000 to 40,000 or more physicians.

Diversity

While at times we may seem to focus more on internal-medicine-trained hospitalists, who make up more than 80% of the field, SHM continues to include hospitalists in family medicine and pediatrics, among other specialties. We also are home to nonphysician providers and physician assistants. We are working to support academic hospitalists, small groups, and multistate companies. In our toughest tightrope walk, SHM continues to be relevant and supportive of labor and management in hospital medicine.

Looking to 2008

The growth and influence of hospital medicine is relentless. Maybe 2008 is the year we will see hospitalists practicing in more than 3,000 hospitals or see the specialty grow to more than 25,000 hospitalists. One thing is for sure: SHM, with your suggestions, ideas, and energy, will be on the front lines with you, supporting and advocating a better healthcare system. TH

Dr. Wellikson is CEO of SHM.

If there is one thing most everyone in healthcare can agree on, it is that too often the information we need is not readily available.

Primary care physicians (PCP) complain that when recently hospitalized patients show up in their office—or, heaven forbid, call the first day after their hospital discharge—they don’t have their discharge information. We often hear that when hospitalists are called to admit an acutely ill patient information is sketchy or incomplete. We hear most hospitalized patients present not only as diagnostic challenges but as “unknowns” with insufficient history and medication information.

A 2006 study by the Common-wealth Fund found that in 32% of outpatient visits or referrals, crucial test results or clinical information were absent and consultation needed to be rescheduled.

In many ways the biggest knock on the hospitalist model is that, despite their better in-house availability, use of resources, or quality of care, hospitalists create another “interruption” in care coordination.

This “voltage drop” didn’t start with hospitalists. It has been around whenever patients are referred to specialists or for surgery—or most procedures, for that matter.

But hospitalists and SHM have seized on this perceived Achilles’ heel and formed coalitions to improve transitions of care and urge better care coordination. While working with many others in medicine, SHM also has had interesting discussions with key change agents not traditionally encountered in healthcare.

With grants from the John Hartford Foundation, SHM has developed state-of-the-art discharge planning tools available on the SHM Web site. And, SHM and Intel have discussed broader strategies for managing information.

In addition, I attended a recent American Hospital Association Leadership Summit and had lunch with Colin Powell, who is active at RevolutionHealth.com—the brainchild of AOL founder Steven Case.

One of RevolutionHealth.com’s projects is to create a widely used personal health record (PHR). This would be a Web database with the patient as the focal point. When a patient has a test, sees a physician, visits an ED, or is hospitalized, that information would flow into an updated record accessible by the patient or physician virtually anywhere, any time.

For hospitalists, this could be a source of complete, up-to-date medication lists, diagnoses, and test results. Hospitalists or case managers could update this PHR at discharge so it is immediately available to PCP or coverage partners, home healthcare providers, or a skilled nursing facility. This type of tool doesn’t require that every physician have an electronic medical record (EMR) and isn’t limited by interoperability issues.

Other strategies are gaining traction. At a recent conference on care coordination sponsored by the American Board of Internal Medicine Foundation (ABIM) in Montreal, Quebec, Canada, Chuck Kilo, MD, MPH, CEO of GreenField Health and The GreenField Group in Portland, Ore., showed how e-mail smoothes transitions and improves information flow.

Those in Dr. Kilo’s practice recognize that, while some professionals may have reservations about e-mails between patients and physicians, there seems less resistance to physicians and hospitals using e-mail to exchange information. With minimal expense and startup costs, PCPs can e-mail patients’ medication records, recent chart notes, and test results to a specialist for referral or a hospitalist for admission.

When the consultant or hospitalist is ready to provide information in the transition back to the PCP, e-mail is a quick solution. It’s not perfect, but it’s immediate. Certainly there are barriers to overcome: HIPAA issues are always important to resolve, and documents converted to PDFs don’t flow into an EMR. But this is a step forward.

These solutions get information to the point of decision when the patient is there and the acute need must be met. For those in the trenches this is good news—a great improvement on the hunt-and-peck paradigm.

In a broader strategic approach, SHM has advocated giving hospitalists a role in defining the standards and measures to be used in assessing performance in transitions of care. In July, SHM worked with the ABIM, the American College of Physicians, the Society of General Internal Medicine, the American Geriatrics Society, and the Agency for Healthcare Research and Quality to develop consensus on transitions-of-care standards. This group included most of the big players in the house of internal medicine as well as representatives from nursing, pharmacy, case management, home health, patients, and families. The American College of Emergency Physicians (ACEP) joined the discourse in August.

At the same time, SHM has been working with the American Medical Association’s Physician Consortium and the National Quality Forum to use standards conceived in consensus to develop measures for transitions of care. The measures would mark either stand-alone performance or performance with specific disease states (e.g., management of diabetes or acute heart failure).

Hospitalists will need resources and tools to give patients the best care and smoothest transitions (and score well on these measures). SHM has developed a Web-based quality-improvement resource room on transitions and continues to work with a broad coalition to improve the discharge process under our Hartford grant.

We add real value for our patients. But our job doesn’t end at the hospital door. Hospitalists recognize their obligation to patients as well those who will assume their care outside the hospital. Whether working on tools with Intel or RevolutionHealth or working with professional societies and organizations charged with developing performance standards and measures, hospitalists and SHM must take an active leadership role.

This is not easy stuff and can’t be solved in one meeting—or even one year.

A few years ago no one was talking much about patient safety, notes past SHM President Bob Wachter, MD, professor of medicine at the University of California, San Francisco, associate chairman of UCSF’s Department of Medicine, and chief of the Medical Service at UCSF Medical Center. That is, until the Institute of Medicine’s 2000 report “To Err Is Human: Building a Safer Health System” and some disastrous medical errors.

Transitions aren’t happening well, and care is sporadic and isolated. This is high on our agenda; SHM and hospitalists are willing to work with any group that will help all of us get closer to a solution. TH

Dr. Wellikson is the CEO of SHM.

If there is one thing most everyone in healthcare can agree on, it is that too often the information we need is not readily available.

Primary care physicians (PCP) complain that when recently hospitalized patients show up in their office—or, heaven forbid, call the first day after their hospital discharge—they don’t have their discharge information. We often hear that when hospitalists are called to admit an acutely ill patient information is sketchy or incomplete. We hear most hospitalized patients present not only as diagnostic challenges but as “unknowns” with insufficient history and medication information.

A 2006 study by the Common-wealth Fund found that in 32% of outpatient visits or referrals, crucial test results or clinical information were absent and consultation needed to be rescheduled.

In many ways the biggest knock on the hospitalist model is that, despite their better in-house availability, use of resources, or quality of care, hospitalists create another “interruption” in care coordination.

This “voltage drop” didn’t start with hospitalists. It has been around whenever patients are referred to specialists or for surgery—or most procedures, for that matter.

But hospitalists and SHM have seized on this perceived Achilles’ heel and formed coalitions to improve transitions of care and urge better care coordination. While working with many others in medicine, SHM also has had interesting discussions with key change agents not traditionally encountered in healthcare.

With grants from the John Hartford Foundation, SHM has developed state-of-the-art discharge planning tools available on the SHM Web site. And, SHM and Intel have discussed broader strategies for managing information.

In addition, I attended a recent American Hospital Association Leadership Summit and had lunch with Colin Powell, who is active at RevolutionHealth.com—the brainchild of AOL founder Steven Case.

One of RevolutionHealth.com’s projects is to create a widely used personal health record (PHR). This would be a Web database with the patient as the focal point. When a patient has a test, sees a physician, visits an ED, or is hospitalized, that information would flow into an updated record accessible by the patient or physician virtually anywhere, any time.

For hospitalists, this could be a source of complete, up-to-date medication lists, diagnoses, and test results. Hospitalists or case managers could update this PHR at discharge so it is immediately available to PCP or coverage partners, home healthcare providers, or a skilled nursing facility. This type of tool doesn’t require that every physician have an electronic medical record (EMR) and isn’t limited by interoperability issues.

Other strategies are gaining traction. At a recent conference on care coordination sponsored by the American Board of Internal Medicine Foundation (ABIM) in Montreal, Quebec, Canada, Chuck Kilo, MD, MPH, CEO of GreenField Health and The GreenField Group in Portland, Ore., showed how e-mail smoothes transitions and improves information flow.

Those in Dr. Kilo’s practice recognize that, while some professionals may have reservations about e-mails between patients and physicians, there seems less resistance to physicians and hospitals using e-mail to exchange information. With minimal expense and startup costs, PCPs can e-mail patients’ medication records, recent chart notes, and test results to a specialist for referral or a hospitalist for admission.

When the consultant or hospitalist is ready to provide information in the transition back to the PCP, e-mail is a quick solution. It’s not perfect, but it’s immediate. Certainly there are barriers to overcome: HIPAA issues are always important to resolve, and documents converted to PDFs don’t flow into an EMR. But this is a step forward.

These solutions get information to the point of decision when the patient is there and the acute need must be met. For those in the trenches this is good news—a great improvement on the hunt-and-peck paradigm.

In a broader strategic approach, SHM has advocated giving hospitalists a role in defining the standards and measures to be used in assessing performance in transitions of care. In July, SHM worked with the ABIM, the American College of Physicians, the Society of General Internal Medicine, the American Geriatrics Society, and the Agency for Healthcare Research and Quality to develop consensus on transitions-of-care standards. This group included most of the big players in the house of internal medicine as well as representatives from nursing, pharmacy, case management, home health, patients, and families. The American College of Emergency Physicians (ACEP) joined the discourse in August.

At the same time, SHM has been working with the American Medical Association’s Physician Consortium and the National Quality Forum to use standards conceived in consensus to develop measures for transitions of care. The measures would mark either stand-alone performance or performance with specific disease states (e.g., management of diabetes or acute heart failure).

Hospitalists will need resources and tools to give patients the best care and smoothest transitions (and score well on these measures). SHM has developed a Web-based quality-improvement resource room on transitions and continues to work with a broad coalition to improve the discharge process under our Hartford grant.

We add real value for our patients. But our job doesn’t end at the hospital door. Hospitalists recognize their obligation to patients as well those who will assume their care outside the hospital. Whether working on tools with Intel or RevolutionHealth or working with professional societies and organizations charged with developing performance standards and measures, hospitalists and SHM must take an active leadership role.

This is not easy stuff and can’t be solved in one meeting—or even one year.

A few years ago no one was talking much about patient safety, notes past SHM President Bob Wachter, MD, professor of medicine at the University of California, San Francisco, associate chairman of UCSF’s Department of Medicine, and chief of the Medical Service at UCSF Medical Center. That is, until the Institute of Medicine’s 2000 report “To Err Is Human: Building a Safer Health System” and some disastrous medical errors.

Transitions aren’t happening well, and care is sporadic and isolated. This is high on our agenda; SHM and hospitalists are willing to work with any group that will help all of us get closer to a solution. TH

Dr. Wellikson is the CEO of SHM.

If there is one thing most everyone in healthcare can agree on, it is that too often the information we need is not readily available.

Primary care physicians (PCP) complain that when recently hospitalized patients show up in their office—or, heaven forbid, call the first day after their hospital discharge—they don’t have their discharge information. We often hear that when hospitalists are called to admit an acutely ill patient information is sketchy or incomplete. We hear most hospitalized patients present not only as diagnostic challenges but as “unknowns” with insufficient history and medication information.

A 2006 study by the Common-wealth Fund found that in 32% of outpatient visits or referrals, crucial test results or clinical information were absent and consultation needed to be rescheduled.

In many ways the biggest knock on the hospitalist model is that, despite their better in-house availability, use of resources, or quality of care, hospitalists create another “interruption” in care coordination.

This “voltage drop” didn’t start with hospitalists. It has been around whenever patients are referred to specialists or for surgery—or most procedures, for that matter.

But hospitalists and SHM have seized on this perceived Achilles’ heel and formed coalitions to improve transitions of care and urge better care coordination. While working with many others in medicine, SHM also has had interesting discussions with key change agents not traditionally encountered in healthcare.

With grants from the John Hartford Foundation, SHM has developed state-of-the-art discharge planning tools available on the SHM Web site. And, SHM and Intel have discussed broader strategies for managing information.

In addition, I attended a recent American Hospital Association Leadership Summit and had lunch with Colin Powell, who is active at RevolutionHealth.com—the brainchild of AOL founder Steven Case.

One of RevolutionHealth.com’s projects is to create a widely used personal health record (PHR). This would be a Web database with the patient as the focal point. When a patient has a test, sees a physician, visits an ED, or is hospitalized, that information would flow into an updated record accessible by the patient or physician virtually anywhere, any time.

For hospitalists, this could be a source of complete, up-to-date medication lists, diagnoses, and test results. Hospitalists or case managers could update this PHR at discharge so it is immediately available to PCP or coverage partners, home healthcare providers, or a skilled nursing facility. This type of tool doesn’t require that every physician have an electronic medical record (EMR) and isn’t limited by interoperability issues.

Other strategies are gaining traction. At a recent conference on care coordination sponsored by the American Board of Internal Medicine Foundation (ABIM) in Montreal, Quebec, Canada, Chuck Kilo, MD, MPH, CEO of GreenField Health and The GreenField Group in Portland, Ore., showed how e-mail smoothes transitions and improves information flow.

Those in Dr. Kilo’s practice recognize that, while some professionals may have reservations about e-mails between patients and physicians, there seems less resistance to physicians and hospitals using e-mail to exchange information. With minimal expense and startup costs, PCPs can e-mail patients’ medication records, recent chart notes, and test results to a specialist for referral or a hospitalist for admission.

When the consultant or hospitalist is ready to provide information in the transition back to the PCP, e-mail is a quick solution. It’s not perfect, but it’s immediate. Certainly there are barriers to overcome: HIPAA issues are always important to resolve, and documents converted to PDFs don’t flow into an EMR. But this is a step forward.

These solutions get information to the point of decision when the patient is there and the acute need must be met. For those in the trenches this is good news—a great improvement on the hunt-and-peck paradigm.

In a broader strategic approach, SHM has advocated giving hospitalists a role in defining the standards and measures to be used in assessing performance in transitions of care. In July, SHM worked with the ABIM, the American College of Physicians, the Society of General Internal Medicine, the American Geriatrics Society, and the Agency for Healthcare Research and Quality to develop consensus on transitions-of-care standards. This group included most of the big players in the house of internal medicine as well as representatives from nursing, pharmacy, case management, home health, patients, and families. The American College of Emergency Physicians (ACEP) joined the discourse in August.

At the same time, SHM has been working with the American Medical Association’s Physician Consortium and the National Quality Forum to use standards conceived in consensus to develop measures for transitions of care. The measures would mark either stand-alone performance or performance with specific disease states (e.g., management of diabetes or acute heart failure).

Hospitalists will need resources and tools to give patients the best care and smoothest transitions (and score well on these measures). SHM has developed a Web-based quality-improvement resource room on transitions and continues to work with a broad coalition to improve the discharge process under our Hartford grant.

We add real value for our patients. But our job doesn’t end at the hospital door. Hospitalists recognize their obligation to patients as well those who will assume their care outside the hospital. Whether working on tools with Intel or RevolutionHealth or working with professional societies and organizations charged with developing performance standards and measures, hospitalists and SHM must take an active leadership role.

This is not easy stuff and can’t be solved in one meeting—or even one year.

A few years ago no one was talking much about patient safety, notes past SHM President Bob Wachter, MD, professor of medicine at the University of California, San Francisco, associate chairman of UCSF’s Department of Medicine, and chief of the Medical Service at UCSF Medical Center. That is, until the Institute of Medicine’s 2000 report “To Err Is Human: Building a Safer Health System” and some disastrous medical errors.

Transitions aren’t happening well, and care is sporadic and isolated. This is high on our agenda; SHM and hospitalists are willing to work with any group that will help all of us get closer to a solution. TH

Dr. Wellikson is the CEO of SHM.

There are more than 20,000 practicing hospitalists in the United States, and yet from every corner of hospital medicine it seems everyone is looking for more hospitalists.

While SHM has been touting that there will be 30,000 hospitalists in the next five years, others are now calling for 40,000 and more. At the SHM Annual Meeting in Dallas in May, Bob Wachter, MD, predicted a specialty with as many as 50,000 hospitalists. What is driving this logarithmic growth in hospital medicine?

Initial studies by Jon Lurie, MD, of Dartmouth Medical School, Hanover, N.H., and others dating back to the late 1990s cited the need for “only” 20,000 hospitalists. Ten years later, those studies seem almost primitive.

Originally, hospitalists were perceived necessary to replace the inpatient work for a small percentage of family practitioners and general internists—mainly at larger hospitals. While there was initial resistance from primary care physicians (PCP) in the early years of hospital medicine, the rapid adoption of hospital medicine by most PCPs has driven our rapid growth. Now, hospital administrators are frequently besieged by their PCP base to “get us some hospitalists” rather than to block hospitalists from the medical staff. And this occurs at not only 500-bed hospitals but at many hospitals with fewer than 100 beds.

More recently hospitalists have been active in co-managing surgical patients, handling glycemic control, preventing DVT, and writing scrips for the antibiotics. This frees the surgeon to concentrate on operative and post-operative surgical aspects of the case. This division of labor allows specialists to use their unique talents, which can lead to better patient outcomes. Hospitalists frequently also staff a pre-admission clinic to evaluate elective surgical patients prior to admission to the hospital. Surgical co-management also is happening with orthopedics and neurosurgery at community hospitals and major academic medical centers.

The increasing role of hospitalists in what was traditionally subspecialty cases is further fueling the growth of hospital medicine. Hospitalists now admit more heart failure patients than cardiologists, manage more inpatient diabetic cases than endocrinologists, and have virtually replaced neurologists to manage inpatient stroke patients. Once again this allows specialists to focus their expertise as best they can, while hospitalists manage the aspects of these complex cases that fall under their purview.

Hospitalists also find themselves with an expanded role in the critical care arena, working with an inadequate supply of intensivists to help manage patients in extremis. And hospitalists are being called into the emergency department (ED), where they serve as in-house consultant, improve the movement of patients out of the ED, and take over some or all the responsibilities of managing the observation units.

Add to this clinical work the time hospitalists must spend on quality improvement, team building, systems changing, and education. The workload is expanding all the time as the hospitalist job description grows and grows.

With the prospect that almost every hospital is starting and growing its hospital medicine group (HMG)—therefore expanding the scope of hospital medicine—it is no wonder predictions of the need for 50,000 hospitalists are becoming credible.

And almost every hospital medicine company is growing. At this year’s SHM Annual Meeting in Dallas I talked to leaders from Emcare (Dallas), Cogent Healthcare (Irvine, Calif.), TeamHealth (Knoxville, Tenn.), Sound Inpatient Physicians (Tacoma, Wash.), Eagle Hospital Physicians (Atlanta), PrimeDoc (Asheville, N.C.), IPC–The Hospitalist Company (North Hollywood, Calif.), and other large employers of hospitalists. Every one of them saw their organizations adding HMGs, needing more hospitalists, and wondering where they will find them.

SHM has benefited by this recruitment feeding frenzy. Just look at the ads in this issue of The Hospitalist, surf SHM’s Online Career Center, or visit our meeting’s Exhibit Hall to see the tangible expression of the need to find more hospitalists. This cannot be solved by hospitalists jumping from one place to another. We need to find a way to attract a new wave of qualified hospitalists into our specialty.

Where will these new hospitalists come from?

Right now about 8% of internal medicine residency graduates enter hospital medicine. While this is a steady stream of new hospitalists, the flow is but a trickle and we need a rapid current. Is it time for hospital medicine to develop a more aggressive recruitment strategy geared to third-year medical students to pull them into hospital medicine with offers of a job or loan repayment?

In addition, some general internists move into hospital medicine each year, but this is a shrinking pool of potential new hospitalists. While 3% of hospitalists have been trained as family practitioners, there are no good statistics on how many family practitioner residents select hospital medicine as a career or how many family practitioners in practice come to hospital medicine. While the guess is that the pool of family practitioners presents an opportunity for future hospitalists, there are some concerns about how well today’s family practitioner residency training prepares young physicians to step right into the role of a hospitalist.

There are other sources for hospitalist physicians from overseas. Currently 25% of the U.S. physician workforce is made up of international medical graduates (IMGs).1 Further, 35% of internal medicine residents and fellows are graduates of medical schools outside the United States.2 SHM’s surveys indicate that approximately 26% of hospitalists are IMGs. That said, hiring physicians from outside the U.S. can present residency and visa issues that complicate employment. Will hospital medicine employers need to look abroad in the same way the U.S. has become a major importer of RNs and other health professionals?

Speaking of nonphysician providers, 5% of hospitalists are PAs and NPs, and this segment appears to be growing. Are there strategies that allow for increased use of nonphysicians in the hospital medicine workforce that can allow a group of hospitalists to be more productive and meet all their stretch goals?

While the question is clear—where will the next 20,000 to 30,000 hospitalists come from?—the answer is somewhat muddled. With this in mind, SHM will hold the National Summit on Hospital Medicine Workforce Issues in late 2007. This will be a practical work group made up of the key national leaders of hospital medicine employers along with key decision makers from medical schools, family practice, pediatrics, internal medicine residency programs, the nonphysician provider community, and others who can help set a direction to solve what is rapidly becoming a crisis in manpower. From this summit SHM hopes to have clear, actionable strategies to create an environment for continued growth and maturation of hospital medicine and deliver on the promise of better healthcare for the patients and the communities we serve. TH

Dr. Wellikson is the CEO of SHM.

References

1. Mullan F. The metrics of the physician brain drain. N Engl J Med. 2005 Oct 27;353(17):1810-1818.
2. Brotherton SE, Rockey PH, Etzel SI. US graduate medical education, 2004-2005: Trends in primary care specialties. JAMA. 2005 Sep 7;294(9):1075-1082.

There are more than 20,000 practicing hospitalists in the United States, and yet from every corner of hospital medicine it seems everyone is looking for more hospitalists.

While SHM has been touting that there will be 30,000 hospitalists in the next five years, others are now calling for 40,000 and more. At the SHM Annual Meeting in Dallas in May, Bob Wachter, MD, predicted a specialty with as many as 50,000 hospitalists. What is driving this logarithmic growth in hospital medicine?

Initial studies by Jon Lurie, MD, of Dartmouth Medical School, Hanover, N.H., and others dating back to the late 1990s cited the need for “only” 20,000 hospitalists. Ten years later, those studies seem almost primitive.

Originally, hospitalists were perceived necessary to replace the inpatient work for a small percentage of family practitioners and general internists—mainly at larger hospitals. While there was initial resistance from primary care physicians (PCP) in the early years of hospital medicine, the rapid adoption of hospital medicine by most PCPs has driven our rapid growth. Now, hospital administrators are frequently besieged by their PCP base to “get us some hospitalists” rather than to block hospitalists from the medical staff. And this occurs at not only 500-bed hospitals but at many hospitals with fewer than 100 beds.

More recently hospitalists have been active in co-managing surgical patients, handling glycemic control, preventing DVT, and writing scrips for the antibiotics. This frees the surgeon to concentrate on operative and post-operative surgical aspects of the case. This division of labor allows specialists to use their unique talents, which can lead to better patient outcomes. Hospitalists frequently also staff a pre-admission clinic to evaluate elective surgical patients prior to admission to the hospital. Surgical co-management also is happening with orthopedics and neurosurgery at community hospitals and major academic medical centers.

The increasing role of hospitalists in what was traditionally subspecialty cases is further fueling the growth of hospital medicine. Hospitalists now admit more heart failure patients than cardiologists, manage more inpatient diabetic cases than endocrinologists, and have virtually replaced neurologists to manage inpatient stroke patients. Once again this allows specialists to focus their expertise as best they can, while hospitalists manage the aspects of these complex cases that fall under their purview.

Hospitalists also find themselves with an expanded role in the critical care arena, working with an inadequate supply of intensivists to help manage patients in extremis. And hospitalists are being called into the emergency department (ED), where they serve as in-house consultant, improve the movement of patients out of the ED, and take over some or all the responsibilities of managing the observation units.

Add to this clinical work the time hospitalists must spend on quality improvement, team building, systems changing, and education. The workload is expanding all the time as the hospitalist job description grows and grows.

With the prospect that almost every hospital is starting and growing its hospital medicine group (HMG)—therefore expanding the scope of hospital medicine—it is no wonder predictions of the need for 50,000 hospitalists are becoming credible.

And almost every hospital medicine company is growing. At this year’s SHM Annual Meeting in Dallas I talked to leaders from Emcare (Dallas), Cogent Healthcare (Irvine, Calif.), TeamHealth (Knoxville, Tenn.), Sound Inpatient Physicians (Tacoma, Wash.), Eagle Hospital Physicians (Atlanta), PrimeDoc (Asheville, N.C.), IPC–The Hospitalist Company (North Hollywood, Calif.), and other large employers of hospitalists. Every one of them saw their organizations adding HMGs, needing more hospitalists, and wondering where they will find them.

SHM has benefited by this recruitment feeding frenzy. Just look at the ads in this issue of The Hospitalist, surf SHM’s Online Career Center, or visit our meeting’s Exhibit Hall to see the tangible expression of the need to find more hospitalists. This cannot be solved by hospitalists jumping from one place to another. We need to find a way to attract a new wave of qualified hospitalists into our specialty.

Where will these new hospitalists come from?

Right now about 8% of internal medicine residency graduates enter hospital medicine. While this is a steady stream of new hospitalists, the flow is but a trickle and we need a rapid current. Is it time for hospital medicine to develop a more aggressive recruitment strategy geared to third-year medical students to pull them into hospital medicine with offers of a job or loan repayment?

In addition, some general internists move into hospital medicine each year, but this is a shrinking pool of potential new hospitalists. While 3% of hospitalists have been trained as family practitioners, there are no good statistics on how many family practitioner residents select hospital medicine as a career or how many family practitioners in practice come to hospital medicine. While the guess is that the pool of family practitioners presents an opportunity for future hospitalists, there are some concerns about how well today’s family practitioner residency training prepares young physicians to step right into the role of a hospitalist.

There are other sources for hospitalist physicians from overseas. Currently 25% of the U.S. physician workforce is made up of international medical graduates (IMGs).1 Further, 35% of internal medicine residents and fellows are graduates of medical schools outside the United States.2 SHM’s surveys indicate that approximately 26% of hospitalists are IMGs. That said, hiring physicians from outside the U.S. can present residency and visa issues that complicate employment. Will hospital medicine employers need to look abroad in the same way the U.S. has become a major importer of RNs and other health professionals?

Speaking of nonphysician providers, 5% of hospitalists are PAs and NPs, and this segment appears to be growing. Are there strategies that allow for increased use of nonphysicians in the hospital medicine workforce that can allow a group of hospitalists to be more productive and meet all their stretch goals?

While the question is clear—where will the next 20,000 to 30,000 hospitalists come from?—the answer is somewhat muddled. With this in mind, SHM will hold the National Summit on Hospital Medicine Workforce Issues in late 2007. This will be a practical work group made up of the key national leaders of hospital medicine employers along with key decision makers from medical schools, family practice, pediatrics, internal medicine residency programs, the nonphysician provider community, and others who can help set a direction to solve what is rapidly becoming a crisis in manpower. From this summit SHM hopes to have clear, actionable strategies to create an environment for continued growth and maturation of hospital medicine and deliver on the promise of better healthcare for the patients and the communities we serve. TH

Dr. Wellikson is the CEO of SHM.

References

1. Mullan F. The metrics of the physician brain drain. N Engl J Med. 2005 Oct 27;353(17):1810-1818.
2. Brotherton SE, Rockey PH, Etzel SI. US graduate medical education, 2004-2005: Trends in primary care specialties. JAMA. 2005 Sep 7;294(9):1075-1082.

There are more than 20,000 practicing hospitalists in the United States, and yet from every corner of hospital medicine it seems everyone is looking for more hospitalists.

While SHM has been touting that there will be 30,000 hospitalists in the next five years, others are now calling for 40,000 and more. At the SHM Annual Meeting in Dallas in May, Bob Wachter, MD, predicted a specialty with as many as 50,000 hospitalists. What is driving this logarithmic growth in hospital medicine?

Initial studies by Jon Lurie, MD, of Dartmouth Medical School, Hanover, N.H., and others dating back to the late 1990s cited the need for “only” 20,000 hospitalists. Ten years later, those studies seem almost primitive.

Originally, hospitalists were perceived necessary to replace the inpatient work for a small percentage of family practitioners and general internists—mainly at larger hospitals. While there was initial resistance from primary care physicians (PCP) in the early years of hospital medicine, the rapid adoption of hospital medicine by most PCPs has driven our rapid growth. Now, hospital administrators are frequently besieged by their PCP base to “get us some hospitalists” rather than to block hospitalists from the medical staff. And this occurs at not only 500-bed hospitals but at many hospitals with fewer than 100 beds.

More recently hospitalists have been active in co-managing surgical patients, handling glycemic control, preventing DVT, and writing scrips for the antibiotics. This frees the surgeon to concentrate on operative and post-operative surgical aspects of the case. This division of labor allows specialists to use their unique talents, which can lead to better patient outcomes. Hospitalists frequently also staff a pre-admission clinic to evaluate elective surgical patients prior to admission to the hospital. Surgical co-management also is happening with orthopedics and neurosurgery at community hospitals and major academic medical centers.

The increasing role of hospitalists in what was traditionally subspecialty cases is further fueling the growth of hospital medicine. Hospitalists now admit more heart failure patients than cardiologists, manage more inpatient diabetic cases than endocrinologists, and have virtually replaced neurologists to manage inpatient stroke patients. Once again this allows specialists to focus their expertise as best they can, while hospitalists manage the aspects of these complex cases that fall under their purview.

Hospitalists also find themselves with an expanded role in the critical care arena, working with an inadequate supply of intensivists to help manage patients in extremis. And hospitalists are being called into the emergency department (ED), where they serve as in-house consultant, improve the movement of patients out of the ED, and take over some or all the responsibilities of managing the observation units.

Add to this clinical work the time hospitalists must spend on quality improvement, team building, systems changing, and education. The workload is expanding all the time as the hospitalist job description grows and grows.

With the prospect that almost every hospital is starting and growing its hospital medicine group (HMG)—therefore expanding the scope of hospital medicine—it is no wonder predictions of the need for 50,000 hospitalists are becoming credible.

And almost every hospital medicine company is growing. At this year’s SHM Annual Meeting in Dallas I talked to leaders from Emcare (Dallas), Cogent Healthcare (Irvine, Calif.), TeamHealth (Knoxville, Tenn.), Sound Inpatient Physicians (Tacoma, Wash.), Eagle Hospital Physicians (Atlanta), PrimeDoc (Asheville, N.C.), IPC–The Hospitalist Company (North Hollywood, Calif.), and other large employers of hospitalists. Every one of them saw their organizations adding HMGs, needing more hospitalists, and wondering where they will find them.

SHM has benefited by this recruitment feeding frenzy. Just look at the ads in this issue of The Hospitalist, surf SHM’s Online Career Center, or visit our meeting’s Exhibit Hall to see the tangible expression of the need to find more hospitalists. This cannot be solved by hospitalists jumping from one place to another. We need to find a way to attract a new wave of qualified hospitalists into our specialty.

Where will these new hospitalists come from?

Right now about 8% of internal medicine residency graduates enter hospital medicine. While this is a steady stream of new hospitalists, the flow is but a trickle and we need a rapid current. Is it time for hospital medicine to develop a more aggressive recruitment strategy geared to third-year medical students to pull them into hospital medicine with offers of a job or loan repayment?

In addition, some general internists move into hospital medicine each year, but this is a shrinking pool of potential new hospitalists. While 3% of hospitalists have been trained as family practitioners, there are no good statistics on how many family practitioner residents select hospital medicine as a career or how many family practitioners in practice come to hospital medicine. While the guess is that the pool of family practitioners presents an opportunity for future hospitalists, there are some concerns about how well today’s family practitioner residency training prepares young physicians to step right into the role of a hospitalist.

There are other sources for hospitalist physicians from overseas. Currently 25% of the U.S. physician workforce is made up of international medical graduates (IMGs).1 Further, 35% of internal medicine residents and fellows are graduates of medical schools outside the United States.2 SHM’s surveys indicate that approximately 26% of hospitalists are IMGs. That said, hiring physicians from outside the U.S. can present residency and visa issues that complicate employment. Will hospital medicine employers need to look abroad in the same way the U.S. has become a major importer of RNs and other health professionals?

Speaking of nonphysician providers, 5% of hospitalists are PAs and NPs, and this segment appears to be growing. Are there strategies that allow for increased use of nonphysicians in the hospital medicine workforce that can allow a group of hospitalists to be more productive and meet all their stretch goals?

While the question is clear—where will the next 20,000 to 30,000 hospitalists come from?—the answer is somewhat muddled. With this in mind, SHM will hold the National Summit on Hospital Medicine Workforce Issues in late 2007. This will be a practical work group made up of the key national leaders of hospital medicine employers along with key decision makers from medical schools, family practice, pediatrics, internal medicine residency programs, the nonphysician provider community, and others who can help set a direction to solve what is rapidly becoming a crisis in manpower. From this summit SHM hopes to have clear, actionable strategies to create an environment for continued growth and maturation of hospital medicine and deliver on the promise of better healthcare for the patients and the communities we serve. TH

Dr. Wellikson is the CEO of SHM.

References

1. Mullan F. The metrics of the physician brain drain. N Engl J Med. 2005 Oct 27;353(17):1810-1818.
2. Brotherton SE, Rockey PH, Etzel SI. US graduate medical education, 2004-2005: Trends in primary care specialties. JAMA. 2005 Sep 7;294(9):1075-1082.

Even though the 2008 elections seem very far away, the presidential nomination process is in full swing. Obviously, the No. 1 issue for most Americans is the war in Iraq. But, interestingly, the No. 2 item on many peoples’ list is healthcare reform. This is of particular interest to hospitalists because they are not only young and early in their careers, but clearly at the center of acute healthcare.

There are opportunities to reshape the financing and delivery of healthcare in a way that will be better for our patients and for hospitalists for many years to come. This will require us to be lucky, which I define as being prepared when opportunities present themselves and being ready to step up and change even when the future is not clearly defined.

The driving forces are several, not the least of which is the fact that in the richest country on Earth almost 50 million Americans still have no health coverage. We know these people eventually find their way to emergency rooms and are admitted to hospitals, but studies show the uninsured are sicker and die more quickly than the insured population. The uninsured are not the unemployed or the illegal aliens, but generally those with full-time jobs, our neighbors, our friends, and often our children of working age.

Because of a failure to adopt a national policy, several states have decided to move forward with their own attempts to insure all their citizens. Massachusetts enacted its landmark plan in 2006. (See The Hospitalist, May 2007, p. 1.) California Gov. Arnold Schwarzenegger has proposed a broad plan to insure the 6 million Californians without coverage. Schwarzenegger’s plan would require sacrifice by all constituencies and would be financed in part by taxing 3%-4% of each physician’s gross collections and an equal percentage on the revenue of hospitals. As you might imagine, this has led to the usual squawking from physician and hospital organizations. He has also called on contributions from the state’s general fund and support from the federal government.

At a national level, the American College of Physicians has developed its Patient Centered Medical Home proposal and has drawn support from the American Academy of Pediatrics, the American Academy of Family Physicians, and others. Basically, this plan calls for changes in the payment structure to recognize the coordination of care in managing chronic illness and taking care of the patient over time. This is a marked departure from our current system, which pays by the episode of care—the visit or the procedure. In many ways this approach harkens back to the best of managed care without being dragged down by managed care’s image of rationing care and limiting resources.

There are increasing calls to develop a single-payer plan to squeeze out the funds now “wasted” on the insurance industry and unnecessary administrative cost. In a perfect world this would allow for >90% of the healthcare dollar to go for patient-care services at a time where some insurance companies retain as much of 30% of every health dollar for profit and administration.

Some say we have elements of this process in place in covering seniors and the disabled with Medicare, in covering the very poor with Medicaid, and in covering children with S-CHIP (State Children’s Health Insurance Program). Much of this discussion overlooks the fact that in order to support Medicare, Medicaid, and S-CHIP, there needs to be cost-shifting to the tune of >125% that now comes out of private insurance payments. This also needs to be thought of in context of a population that craves choice and freedom in their healthcare and are very suspicious of enlarging government programs.

Some are calling for DRGs (diagnosis related groups) for hospital care for the physician component, much as exist for the hospital facility charge. This case-based approach may work well for the hospitalist model, where efficiencies could result and rewards can be tied to performance. More modeling and projections need to be done before this can be a viable option.

This leads to thoughts of how much pay for performance (P4P) will be a part of any healthcare reform. Some see this as the panacea. Others see P4P as motivating systems or institutions, but doing little to change individual physician behaviors. Some feel performance standards need to be part of the equation because institutions need to provide a transparent accountability of just how good a job they are doing. Hospitalists are in a position to provide leadership and direction as quality and documentation of performance become valued.

All this is woven through a political process that is media- and sound-bite driven.

While Hillary Clinton probably has more insider knowledge of healthcare reform concepts, she is so associated with the failed Clinton plans of the early 1990s that she may be reluctant to make healthcare her main policy direction.

John Edwards and Barack Obama, who want to speak for the “other America,” seem positioned to take on healthcare reform as a way to level the playing field and bring the 50 million uninsured at least up to some sort of healthcare access parity with the rest of Americans. Any proposal that tries to include another 50 million people will by necessity cause a revolution in the current system with marked, probably seismic, shifts in payment and delivery of care.

As the Republican candidates get sorted out, expect healthcare reform as a popular issue that isn’t a war issue to take a higher priority, much the way Al Gore and George Bush were touting their own approaches to a pharmacy benefit for seniors in 2000.

Hospital medicine at age 10 can no longer sit on the sidelines and wait to see what will happen. SHM, along with other national partners in hospital medicine, must start developing the hospital medicine strategy so we can be active participants in the reform discussions. The current system of reimbursement at the level of the visit or the procedure does not recognize the full value hospitalists can bring in improving quality, reducing resource use, increasing throughput and efficiency, etc. In addition, being on the front lines, catching everyone who is acutely ill and needs hospitalization regardless of ability to pay, puts us squarely in the middle of dealing with those Americans who lack insurance.

The good news is that hospitalists present many fewer barriers than other physician groups. We know we will be measured and that we need to prove our performance. We know we will treat the uninsured. There is no escape. We know many of us will still practice in 2025 and 2030, and we need to fix the system now because we will live in this space for many years to come.

Reforming healthcare—an industry that accounts for $2 trillion and 16% of the GDP—is staggering, but signs appear to indicate change is coming. SHM and hospitalists everywhere are ready to be part of the solution. TH

Dr. Wellikson has been CEO of SHM since 2000.

Even though the 2008 elections seem very far away, the presidential nomination process is in full swing. Obviously, the No. 1 issue for most Americans is the war in Iraq. But, interestingly, the No. 2 item on many peoples’ list is healthcare reform. This is of particular interest to hospitalists because they are not only young and early in their careers, but clearly at the center of acute healthcare.

There are opportunities to reshape the financing and delivery of healthcare in a way that will be better for our patients and for hospitalists for many years to come. This will require us to be lucky, which I define as being prepared when opportunities present themselves and being ready to step up and change even when the future is not clearly defined.

The driving forces are several, not the least of which is the fact that in the richest country on Earth almost 50 million Americans still have no health coverage. We know these people eventually find their way to emergency rooms and are admitted to hospitals, but studies show the uninsured are sicker and die more quickly than the insured population. The uninsured are not the unemployed or the illegal aliens, but generally those with full-time jobs, our neighbors, our friends, and often our children of working age.

Because of a failure to adopt a national policy, several states have decided to move forward with their own attempts to insure all their citizens. Massachusetts enacted its landmark plan in 2006. (See The Hospitalist, May 2007, p. 1.) California Gov. Arnold Schwarzenegger has proposed a broad plan to insure the 6 million Californians without coverage. Schwarzenegger’s plan would require sacrifice by all constituencies and would be financed in part by taxing 3%-4% of each physician’s gross collections and an equal percentage on the revenue of hospitals. As you might imagine, this has led to the usual squawking from physician and hospital organizations. He has also called on contributions from the state’s general fund and support from the federal government.

At a national level, the American College of Physicians has developed its Patient Centered Medical Home proposal and has drawn support from the American Academy of Pediatrics, the American Academy of Family Physicians, and others. Basically, this plan calls for changes in the payment structure to recognize the coordination of care in managing chronic illness and taking care of the patient over time. This is a marked departure from our current system, which pays by the episode of care—the visit or the procedure. In many ways this approach harkens back to the best of managed care without being dragged down by managed care’s image of rationing care and limiting resources.

There are increasing calls to develop a single-payer plan to squeeze out the funds now “wasted” on the insurance industry and unnecessary administrative cost. In a perfect world this would allow for >90% of the healthcare dollar to go for patient-care services at a time where some insurance companies retain as much of 30% of every health dollar for profit and administration.

Some say we have elements of this process in place in covering seniors and the disabled with Medicare, in covering the very poor with Medicaid, and in covering children with S-CHIP (State Children’s Health Insurance Program). Much of this discussion overlooks the fact that in order to support Medicare, Medicaid, and S-CHIP, there needs to be cost-shifting to the tune of >125% that now comes out of private insurance payments. This also needs to be thought of in context of a population that craves choice and freedom in their healthcare and are very suspicious of enlarging government programs.

Some are calling for DRGs (diagnosis related groups) for hospital care for the physician component, much as exist for the hospital facility charge. This case-based approach may work well for the hospitalist model, where efficiencies could result and rewards can be tied to performance. More modeling and projections need to be done before this can be a viable option.

This leads to thoughts of how much pay for performance (P4P) will be a part of any healthcare reform. Some see this as the panacea. Others see P4P as motivating systems or institutions, but doing little to change individual physician behaviors. Some feel performance standards need to be part of the equation because institutions need to provide a transparent accountability of just how good a job they are doing. Hospitalists are in a position to provide leadership and direction as quality and documentation of performance become valued.

All this is woven through a political process that is media- and sound-bite driven.

While Hillary Clinton probably has more insider knowledge of healthcare reform concepts, she is so associated with the failed Clinton plans of the early 1990s that she may be reluctant to make healthcare her main policy direction.

John Edwards and Barack Obama, who want to speak for the “other America,” seem positioned to take on healthcare reform as a way to level the playing field and bring the 50 million uninsured at least up to some sort of healthcare access parity with the rest of Americans. Any proposal that tries to include another 50 million people will by necessity cause a revolution in the current system with marked, probably seismic, shifts in payment and delivery of care.

As the Republican candidates get sorted out, expect healthcare reform as a popular issue that isn’t a war issue to take a higher priority, much the way Al Gore and George Bush were touting their own approaches to a pharmacy benefit for seniors in 2000.

Hospital medicine at age 10 can no longer sit on the sidelines and wait to see what will happen. SHM, along with other national partners in hospital medicine, must start developing the hospital medicine strategy so we can be active participants in the reform discussions. The current system of reimbursement at the level of the visit or the procedure does not recognize the full value hospitalists can bring in improving quality, reducing resource use, increasing throughput and efficiency, etc. In addition, being on the front lines, catching everyone who is acutely ill and needs hospitalization regardless of ability to pay, puts us squarely in the middle of dealing with those Americans who lack insurance.

The good news is that hospitalists present many fewer barriers than other physician groups. We know we will be measured and that we need to prove our performance. We know we will treat the uninsured. There is no escape. We know many of us will still practice in 2025 and 2030, and we need to fix the system now because we will live in this space for many years to come.

Reforming healthcare—an industry that accounts for $2 trillion and 16% of the GDP—is staggering, but signs appear to indicate change is coming. SHM and hospitalists everywhere are ready to be part of the solution. TH

Dr. Wellikson has been CEO of SHM since 2000.

Even though the 2008 elections seem very far away, the presidential nomination process is in full swing. Obviously, the No. 1 issue for most Americans is the war in Iraq. But, interestingly, the No. 2 item on many peoples’ list is healthcare reform. This is of particular interest to hospitalists because they are not only young and early in their careers, but clearly at the center of acute healthcare.

There are opportunities to reshape the financing and delivery of healthcare in a way that will be better for our patients and for hospitalists for many years to come. This will require us to be lucky, which I define as being prepared when opportunities present themselves and being ready to step up and change even when the future is not clearly defined.

The driving forces are several, not the least of which is the fact that in the richest country on Earth almost 50 million Americans still have no health coverage. We know these people eventually find their way to emergency rooms and are admitted to hospitals, but studies show the uninsured are sicker and die more quickly than the insured population. The uninsured are not the unemployed or the illegal aliens, but generally those with full-time jobs, our neighbors, our friends, and often our children of working age.

Because of a failure to adopt a national policy, several states have decided to move forward with their own attempts to insure all their citizens. Massachusetts enacted its landmark plan in 2006. (See The Hospitalist, May 2007, p. 1.) California Gov. Arnold Schwarzenegger has proposed a broad plan to insure the 6 million Californians without coverage. Schwarzenegger’s plan would require sacrifice by all constituencies and would be financed in part by taxing 3%-4% of each physician’s gross collections and an equal percentage on the revenue of hospitals. As you might imagine, this has led to the usual squawking from physician and hospital organizations. He has also called on contributions from the state’s general fund and support from the federal government.

At a national level, the American College of Physicians has developed its Patient Centered Medical Home proposal and has drawn support from the American Academy of Pediatrics, the American Academy of Family Physicians, and others. Basically, this plan calls for changes in the payment structure to recognize the coordination of care in managing chronic illness and taking care of the patient over time. This is a marked departure from our current system, which pays by the episode of care—the visit or the procedure. In many ways this approach harkens back to the best of managed care without being dragged down by managed care’s image of rationing care and limiting resources.

There are increasing calls to develop a single-payer plan to squeeze out the funds now “wasted” on the insurance industry and unnecessary administrative cost. In a perfect world this would allow for >90% of the healthcare dollar to go for patient-care services at a time where some insurance companies retain as much of 30% of every health dollar for profit and administration.

Some say we have elements of this process in place in covering seniors and the disabled with Medicare, in covering the very poor with Medicaid, and in covering children with S-CHIP (State Children’s Health Insurance Program). Much of this discussion overlooks the fact that in order to support Medicare, Medicaid, and S-CHIP, there needs to be cost-shifting to the tune of >125% that now comes out of private insurance payments. This also needs to be thought of in context of a population that craves choice and freedom in their healthcare and are very suspicious of enlarging government programs.

Some are calling for DRGs (diagnosis related groups) for hospital care for the physician component, much as exist for the hospital facility charge. This case-based approach may work well for the hospitalist model, where efficiencies could result and rewards can be tied to performance. More modeling and projections need to be done before this can be a viable option.

This leads to thoughts of how much pay for performance (P4P) will be a part of any healthcare reform. Some see this as the panacea. Others see P4P as motivating systems or institutions, but doing little to change individual physician behaviors. Some feel performance standards need to be part of the equation because institutions need to provide a transparent accountability of just how good a job they are doing. Hospitalists are in a position to provide leadership and direction as quality and documentation of performance become valued.

All this is woven through a political process that is media- and sound-bite driven.

While Hillary Clinton probably has more insider knowledge of healthcare reform concepts, she is so associated with the failed Clinton plans of the early 1990s that she may be reluctant to make healthcare her main policy direction.

John Edwards and Barack Obama, who want to speak for the “other America,” seem positioned to take on healthcare reform as a way to level the playing field and bring the 50 million uninsured at least up to some sort of healthcare access parity with the rest of Americans. Any proposal that tries to include another 50 million people will by necessity cause a revolution in the current system with marked, probably seismic, shifts in payment and delivery of care.

As the Republican candidates get sorted out, expect healthcare reform as a popular issue that isn’t a war issue to take a higher priority, much the way Al Gore and George Bush were touting their own approaches to a pharmacy benefit for seniors in 2000.

Hospital medicine at age 10 can no longer sit on the sidelines and wait to see what will happen. SHM, along with other national partners in hospital medicine, must start developing the hospital medicine strategy so we can be active participants in the reform discussions. The current system of reimbursement at the level of the visit or the procedure does not recognize the full value hospitalists can bring in improving quality, reducing resource use, increasing throughput and efficiency, etc. In addition, being on the front lines, catching everyone who is acutely ill and needs hospitalization regardless of ability to pay, puts us squarely in the middle of dealing with those Americans who lack insurance.

The good news is that hospitalists present many fewer barriers than other physician groups. We know we will be measured and that we need to prove our performance. We know we will treat the uninsured. There is no escape. We know many of us will still practice in 2025 and 2030, and we need to fix the system now because we will live in this space for many years to come.

Reforming healthcare—an industry that accounts for $2 trillion and 16% of the GDP—is staggering, but signs appear to indicate change is coming. SHM and hospitalists everywhere are ready to be part of the solution. TH

Dr. Wellikson has been CEO of SHM since 2000.