Practice Economics

Let’s examine a documentation case for hospitalists providing daily care: A 65-year-old male patient is admitted with a left hip fracture. The patient also has hypertension and Type 2 diabetes, which might complicate his care. The orthopedic surgeon manages the patient’s perioperative course for the fracture while the hospitalist provides daily post-op care for hypertension and diabetes.

A common scenario is the hospitalist will provide concurrent care, along with a varying number of specialists, depending on the complexity of the patient’s presenting problems and existing comorbidities. Payors define concurrent care as more than one physician providing care to the same patient on the same date, or during the same hospitalization. Payors often consider two key principles before reimbursing concurrent care:

• Does the patient’s condition warrant more than one physician? and
• Are the services provided by each physician reasonable and necessary?¹

When more than one medical condition exists and each physician actively treats the condition related to their expertise, each physician can demonstrate medical necessity. As in the above example, the orthopedic surgeon cares for the patient’s fracture while the hospitalist oversees diabetes and hypertension management. Claim submission follows the same logic. Report each subsequent hospital care code (99231-99233) with the corresponding diagnosis each physician primarily manages (i.e., orthopedic surgeon: 9923x with 820.8; hospitalist: 9923x with 250.00, 401.1).

When each physician assigns a different primary diagnosis code to the visit code, each is more likely to receive payment. Because each of these physicians are in different specialties and different provider groups, most payors do not require modifier 25 (separately identifiable E/M service on the same day as a procedure or other service) appended to the visit code. However, some managed-care payors require each physician to append modifier 25 to the concurrent E/M visit code (i.e., 99232-25) despite claim submission under different tax identification numbers.

Unfortunately, the physicians might not realize this until a claim rejection has been issued. Furthermore, payors might want to see the proof before rendering payment. In other words, they pay the first claim received and deny any subsequent claim in order to confirm medical necessity of the concurrent visit. Appeal denied such claims rejections with supporting documentation that distinguishes each physician visit, if possible. This assists the payors in understanding each physician’s contribution to care.

Reasons for Denial

Concurrent care services are more easily distinguished when separate diagnoses are reported with each service. Conversely, payors are likely to deny services that are hard to differentiate. Furthermore, payors frequently deny concurrent care services for the following reasons:

• Services exceed normal frequency or duration for a given condition without documented circumstances requiring additional care; or
• Services by one physician duplicate or overlap those of another provider without recognizable distinction.²

For example, a hospitalist might be involved in the post-op care of patients with fractures and no other identifiable chronic or acute conditions or complications. In these cases, the hospitalist’s continued involvement might constitute a facility policy (e.g., quality of care, risk reduction, etc.) rather than active clinical management. Claim submission could erroneously occur with each physician reporting 9923x for 820.8. Payors deny medically unnecessary services, or request refunds for inappropriate payments.

Hospitalists might attempt to negotiate other terms with the facility to account for the unpaid time and effort directed toward these types of cases.

Group Practice

Physicians in the same group practice with the same specialty designation must report, and are paid, as a single physician. Multiple visits to the same patient can occur on the same day by members of the same group (e.g., hospitalist A evaluates the patient in the morning, and hospitalist B reviews test results and the resulting course of treatment in the afternoon). However, only one subsequent hospital care service can be reported for the day.

The hospitalists should select the visit level representative of the combined services and submit one appropriately determined code (e.g., 99233), thereby capturing the medically necessary efforts of each physician. To complicate matters, the hospitalists must determine which name to report on the claim: the physician who provided the first encounter, or the physician who provided the most extensive or best-documented encounter.

Tracking productivity for these cases proves challenging. Some practices develop an internal accounting system and credit each physician for their medically necessary efforts (a labor-intensive task for administrators and physicians). TH

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

References

1. Medicare Benefit Policy Manual: Concurrent Care. Chapter 15, Section 30.E. CMS website. Available at: www.cms.gov/manuals/Downloads/bp102c15.pdf. Accessed July 9, 2010.
2. Medicare Claims Processing Manual: Physicians in Group Practice. Chapter 12, Section 30.6.5. CMS website. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed July 9, 2010.
3. Pohlig, C. Daily care conundrums. The Hospitalist website. Available at: www.the-hospitalist.org/details/article/188735/Daily_Care_Conundrums_.html. Accessed July 9, 2010.
4. Medicare Claims Processing Manual: Hospital Visits Same Day But by Different Physicians. Chapter 12, Section 30.6.9.C. CMS website. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed July 9, 2010.
5. Abraham M, Beebe M, Dalton J, Evans D, Glenn R. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2010:15.

Let’s examine a documentation case for hospitalists providing daily care: A 65-year-old male patient is admitted with a left hip fracture. The patient also has hypertension and Type 2 diabetes, which might complicate his care. The orthopedic surgeon manages the patient’s perioperative course for the fracture while the hospitalist provides daily post-op care for hypertension and diabetes.

A common scenario is the hospitalist will provide concurrent care, along with a varying number of specialists, depending on the complexity of the patient’s presenting problems and existing comorbidities. Payors define concurrent care as more than one physician providing care to the same patient on the same date, or during the same hospitalization. Payors often consider two key principles before reimbursing concurrent care:

• Does the patient’s condition warrant more than one physician? and
• Are the services provided by each physician reasonable and necessary?¹

When more than one medical condition exists and each physician actively treats the condition related to their expertise, each physician can demonstrate medical necessity. As in the above example, the orthopedic surgeon cares for the patient’s fracture while the hospitalist oversees diabetes and hypertension management. Claim submission follows the same logic. Report each subsequent hospital care code (99231-99233) with the corresponding diagnosis each physician primarily manages (i.e., orthopedic surgeon: 9923x with 820.8; hospitalist: 9923x with 250.00, 401.1).

When each physician assigns a different primary diagnosis code to the visit code, each is more likely to receive payment. Because each of these physicians are in different specialties and different provider groups, most payors do not require modifier 25 (separately identifiable E/M service on the same day as a procedure or other service) appended to the visit code. However, some managed-care payors require each physician to append modifier 25 to the concurrent E/M visit code (i.e., 99232-25) despite claim submission under different tax identification numbers.

Unfortunately, the physicians might not realize this until a claim rejection has been issued. Furthermore, payors might want to see the proof before rendering payment. In other words, they pay the first claim received and deny any subsequent claim in order to confirm medical necessity of the concurrent visit. Appeal denied such claims rejections with supporting documentation that distinguishes each physician visit, if possible. This assists the payors in understanding each physician’s contribution to care.

Reasons for Denial

Concurrent care services are more easily distinguished when separate diagnoses are reported with each service. Conversely, payors are likely to deny services that are hard to differentiate. Furthermore, payors frequently deny concurrent care services for the following reasons:

• Services exceed normal frequency or duration for a given condition without documented circumstances requiring additional care; or
• Services by one physician duplicate or overlap those of another provider without recognizable distinction.²

For example, a hospitalist might be involved in the post-op care of patients with fractures and no other identifiable chronic or acute conditions or complications. In these cases, the hospitalist’s continued involvement might constitute a facility policy (e.g., quality of care, risk reduction, etc.) rather than active clinical management. Claim submission could erroneously occur with each physician reporting 9923x for 820.8. Payors deny medically unnecessary services, or request refunds for inappropriate payments.

Hospitalists might attempt to negotiate other terms with the facility to account for the unpaid time and effort directed toward these types of cases.

Group Practice

Physicians in the same group practice with the same specialty designation must report, and are paid, as a single physician. Multiple visits to the same patient can occur on the same day by members of the same group (e.g., hospitalist A evaluates the patient in the morning, and hospitalist B reviews test results and the resulting course of treatment in the afternoon). However, only one subsequent hospital care service can be reported for the day.

The hospitalists should select the visit level representative of the combined services and submit one appropriately determined code (e.g., 99233), thereby capturing the medically necessary efforts of each physician. To complicate matters, the hospitalists must determine which name to report on the claim: the physician who provided the first encounter, or the physician who provided the most extensive or best-documented encounter.

Tracking productivity for these cases proves challenging. Some practices develop an internal accounting system and credit each physician for their medically necessary efforts (a labor-intensive task for administrators and physicians). TH

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

References

1. Medicare Benefit Policy Manual: Concurrent Care. Chapter 15, Section 30.E. CMS website. Available at: www.cms.gov/manuals/Downloads/bp102c15.pdf. Accessed July 9, 2010.
2. Medicare Claims Processing Manual: Physicians in Group Practice. Chapter 12, Section 30.6.5. CMS website. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed July 9, 2010.
3. Pohlig, C. Daily care conundrums. The Hospitalist website. Available at: www.the-hospitalist.org/details/article/188735/Daily_Care_Conundrums_.html. Accessed July 9, 2010.
4. Medicare Claims Processing Manual: Hospital Visits Same Day But by Different Physicians. Chapter 12, Section 30.6.9.C. CMS website. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed July 9, 2010.
5. Abraham M, Beebe M, Dalton J, Evans D, Glenn R. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2010:15.

Let’s examine a documentation case for hospitalists providing daily care: A 65-year-old male patient is admitted with a left hip fracture. The patient also has hypertension and Type 2 diabetes, which might complicate his care. The orthopedic surgeon manages the patient’s perioperative course for the fracture while the hospitalist provides daily post-op care for hypertension and diabetes.

A common scenario is the hospitalist will provide concurrent care, along with a varying number of specialists, depending on the complexity of the patient’s presenting problems and existing comorbidities. Payors define concurrent care as more than one physician providing care to the same patient on the same date, or during the same hospitalization. Payors often consider two key principles before reimbursing concurrent care:

• Does the patient’s condition warrant more than one physician? and
• Are the services provided by each physician reasonable and necessary?¹

When more than one medical condition exists and each physician actively treats the condition related to their expertise, each physician can demonstrate medical necessity. As in the above example, the orthopedic surgeon cares for the patient’s fracture while the hospitalist oversees diabetes and hypertension management. Claim submission follows the same logic. Report each subsequent hospital care code (99231-99233) with the corresponding diagnosis each physician primarily manages (i.e., orthopedic surgeon: 9923x with 820.8; hospitalist: 9923x with 250.00, 401.1).

When each physician assigns a different primary diagnosis code to the visit code, each is more likely to receive payment. Because each of these physicians are in different specialties and different provider groups, most payors do not require modifier 25 (separately identifiable E/M service on the same day as a procedure or other service) appended to the visit code. However, some managed-care payors require each physician to append modifier 25 to the concurrent E/M visit code (i.e., 99232-25) despite claim submission under different tax identification numbers.

Unfortunately, the physicians might not realize this until a claim rejection has been issued. Furthermore, payors might want to see the proof before rendering payment. In other words, they pay the first claim received and deny any subsequent claim in order to confirm medical necessity of the concurrent visit. Appeal denied such claims rejections with supporting documentation that distinguishes each physician visit, if possible. This assists the payors in understanding each physician’s contribution to care.

Reasons for Denial

Concurrent care services are more easily distinguished when separate diagnoses are reported with each service. Conversely, payors are likely to deny services that are hard to differentiate. Furthermore, payors frequently deny concurrent care services for the following reasons:

• Services exceed normal frequency or duration for a given condition without documented circumstances requiring additional care; or
• Services by one physician duplicate or overlap those of another provider without recognizable distinction.²

For example, a hospitalist might be involved in the post-op care of patients with fractures and no other identifiable chronic or acute conditions or complications. In these cases, the hospitalist’s continued involvement might constitute a facility policy (e.g., quality of care, risk reduction, etc.) rather than active clinical management. Claim submission could erroneously occur with each physician reporting 9923x for 820.8. Payors deny medically unnecessary services, or request refunds for inappropriate payments.

Hospitalists might attempt to negotiate other terms with the facility to account for the unpaid time and effort directed toward these types of cases.

Group Practice

Physicians in the same group practice with the same specialty designation must report, and are paid, as a single physician. Multiple visits to the same patient can occur on the same day by members of the same group (e.g., hospitalist A evaluates the patient in the morning, and hospitalist B reviews test results and the resulting course of treatment in the afternoon). However, only one subsequent hospital care service can be reported for the day.

The hospitalists should select the visit level representative of the combined services and submit one appropriately determined code (e.g., 99233), thereby capturing the medically necessary efforts of each physician. To complicate matters, the hospitalists must determine which name to report on the claim: the physician who provided the first encounter, or the physician who provided the most extensive or best-documented encounter.

Tracking productivity for these cases proves challenging. Some practices develop an internal accounting system and credit each physician for their medically necessary efforts (a labor-intensive task for administrators and physicians). TH

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

References

1. Medicare Benefit Policy Manual: Concurrent Care. Chapter 15, Section 30.E. CMS website. Available at: www.cms.gov/manuals/Downloads/bp102c15.pdf. Accessed July 9, 2010.
2. Medicare Claims Processing Manual: Physicians in Group Practice. Chapter 12, Section 30.6.5. CMS website. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed July 9, 2010.
3. Pohlig, C. Daily care conundrums. The Hospitalist website. Available at: www.the-hospitalist.org/details/article/188735/Daily_Care_Conundrums_.html. Accessed July 9, 2010.
4. Medicare Claims Processing Manual: Hospital Visits Same Day But by Different Physicians. Chapter 12, Section 30.6.9.C. CMS website. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed July 9, 2010.
5. Abraham M, Beebe M, Dalton J, Evans D, Glenn R. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2010:15.

The providers in every hospitalist practice should be a good fit for the practice’s culture. They should have reasonable relationships with their colleagues in the practice, patients and families, and other staff at the hospital.

I can’t imagine anyone arguing with this point of view. But in my work with hundreds of hospitalist practices over the past 15 years, I’ve found that many practices seem to have a hard time ensuring their providers meet that standard. I can think of lots of reasons for this. The first that comes to mind is the difficult HM recruiting environment. Almost all hospitalist practices needed to grow quickly, and many lowered the bar in the qualifications and the fit of the candidates they hired to make sure they filled all of their positions.

Even if it later becomes clear a provider isn’t a good fit for the group culture, or worse still lacks the knowledge base and judgment to perform well, many practices are reluctant to replace the hospitalist because it might be difficult to find a replacement—and there is no guarantee the new person will perform any better. Because of this, a number of practices have ended up with providers who in many cases have a negative influence on others in the practice, and both the practice and the problem provider would be better off if the provider went elsewhere.

The Problem Physician

To their credit, most practices do act when a provider simply lacks the skill and judgment to perform adequately. This can mean close proctoring/mentoring for an extended period, or requiring specific CME course work to correct a skill that is lacking. But it also means reassigning the person to a different job, or termination.

But in the case of someone with a toxic personality, practices often are more reluctant to act. I’ll often hear the leadership of a practice say something like, “We knew Alice wasn’t a good fit for our practice within a few weeks of her start date.” The start date was several years ago and nothing has been done about this. Not surprisingly, Alice still performs poorly.

I’m not talking about someone who has occasional problems. I’m talking about people who cause problems almost every time they show up to work. Here are some real anecdotes, with fictitious names to ensure anonymity for the person and institution:

• Dr. Lee routinely disappears for several hours, during which he doesn’t answer pages. This even happens when he is the only doctor covering the practice.
• Dr. Lifeson, while generally getting along well with his fellow hospitalists and the nursing staff, can be counted on to complain bitterly about all levels of the hospital administration and leadership. He never misses an opportunity to try to convince other hospitalists that the leadership is not only inept, but also clearly has a malicious intent toward hospitalists.
• Dr. Peart complains incessantly about even tiny inequities in the work schedule or patient load. Others in the group have found that it is easier to ensure he always has the best schedule and lightest patient load, hoping they won’t have to hear his constant complaining. But even that hasn’t stemmed the steady downpour of negativity from him.

In all three of these cases, it seemed clear that the doctor should be terminated. And while the practice leadership agreed with me, they offered several excuses for why they hadn’t taken this step.

• “Who knows if we can find a replacement who will be any better?”
• “But he’s actually a decent doctor and doesn’t get a lot of complaints from patients.”
• “He’s such an angry guy, we worry about litigation if we fire him.”

I can’t offer any clear rule about when a practice should stop trying to improve a provider’s behavior and recognize that it is time to terminate the provider. But it is worth remembering that waiting too long has many costs, including the satisfaction of others in the group. Everyone will think less of the practice they are part of if poor behavior is tolerated.

Assess the Situation, Then Take Action

Most doctors who serve as the lead physician for their group have little or no experience dealing with problem behavior, let alone experience ensuring that necessary steps are followed prior to disciplining or terminating someone. But every hospital has someone who is very knowledgeable about these things; they should be engaged for advice, and, in the case of hospital-employed groups, should participate in the process of counseling and/or termination. It is important to take advantage of the expertise that is available.

Of course, the best approach is to prevent such problems from coming up. The best way to do this is to be very careful when hiring new providers. Checking references carefully is probably the best way to get an idea about whether someone might have behavior or personality problems. There are “job fit” survey instruments that you can use, but I’m not sure how effective they are, or how much value they add for a hospitalist practice beyond other means of assessing the candidate. And in the process of hiring someone, be sure to set behavior expectations very clearly. A new candidate should know that you will not tolerate not living up to behavioral expectations.

When dealing with bad behavior, make sure that you follow a careful and well-documented process. If someone still makes it through the hiring process only to be revealed as a troublemaker soon after their start date, don’t wait to sit that person down for very clear counseling; insist that their behavior change. Take notes of each meeting, and consider having the problem doctor sign and date the notes. While it might be easier to just wait and see if the first instance of bad behavior was an anomaly, that usually is a bad idea.

You should consider bringing the problem provider into the tent. The root of some bad behavior (i.e. criticism of leadership) is a person’s insecurity and lack of a feeling of ownership or control of their role in the practice. In that case, it might be reasonable to invite such a person into a role of greater responsibility in the practice so that they feel more in control. For example, a doctor who constantly complains about the work schedule might be invited to join the group’s executive committee or take on some other formal leadership role in the practice. This could backfire, so it should be tried only in carefully selected cases, and with the problem doctor’s clear understanding that they are being given a chance to have a bigger role in the practice but must improve their behavior or face serious consequences that could include termination.

I have seen this work beautifully in some cases, curing the problem behavior and turning the doctor into a valuable asset. I only wish there were a reliable way to know when to try this strategy. Sadly, it just requires judgment and intuition. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program.” This column represents his views and is not intended to reflect an official position of SHM.

The providers in every hospitalist practice should be a good fit for the practice’s culture. They should have reasonable relationships with their colleagues in the practice, patients and families, and other staff at the hospital.

I can’t imagine anyone arguing with this point of view. But in my work with hundreds of hospitalist practices over the past 15 years, I’ve found that many practices seem to have a hard time ensuring their providers meet that standard. I can think of lots of reasons for this. The first that comes to mind is the difficult HM recruiting environment. Almost all hospitalist practices needed to grow quickly, and many lowered the bar in the qualifications and the fit of the candidates they hired to make sure they filled all of their positions.

Even if it later becomes clear a provider isn’t a good fit for the group culture, or worse still lacks the knowledge base and judgment to perform well, many practices are reluctant to replace the hospitalist because it might be difficult to find a replacement—and there is no guarantee the new person will perform any better. Because of this, a number of practices have ended up with providers who in many cases have a negative influence on others in the practice, and both the practice and the problem provider would be better off if the provider went elsewhere.

The Problem Physician

To their credit, most practices do act when a provider simply lacks the skill and judgment to perform adequately. This can mean close proctoring/mentoring for an extended period, or requiring specific CME course work to correct a skill that is lacking. But it also means reassigning the person to a different job, or termination.

But in the case of someone with a toxic personality, practices often are more reluctant to act. I’ll often hear the leadership of a practice say something like, “We knew Alice wasn’t a good fit for our practice within a few weeks of her start date.” The start date was several years ago and nothing has been done about this. Not surprisingly, Alice still performs poorly.

I’m not talking about someone who has occasional problems. I’m talking about people who cause problems almost every time they show up to work. Here are some real anecdotes, with fictitious names to ensure anonymity for the person and institution:

• Dr. Lee routinely disappears for several hours, during which he doesn’t answer pages. This even happens when he is the only doctor covering the practice.
• Dr. Lifeson, while generally getting along well with his fellow hospitalists and the nursing staff, can be counted on to complain bitterly about all levels of the hospital administration and leadership. He never misses an opportunity to try to convince other hospitalists that the leadership is not only inept, but also clearly has a malicious intent toward hospitalists.
• Dr. Peart complains incessantly about even tiny inequities in the work schedule or patient load. Others in the group have found that it is easier to ensure he always has the best schedule and lightest patient load, hoping they won’t have to hear his constant complaining. But even that hasn’t stemmed the steady downpour of negativity from him.

In all three of these cases, it seemed clear that the doctor should be terminated. And while the practice leadership agreed with me, they offered several excuses for why they hadn’t taken this step.

• “Who knows if we can find a replacement who will be any better?”
• “But he’s actually a decent doctor and doesn’t get a lot of complaints from patients.”
• “He’s such an angry guy, we worry about litigation if we fire him.”

I can’t offer any clear rule about when a practice should stop trying to improve a provider’s behavior and recognize that it is time to terminate the provider. But it is worth remembering that waiting too long has many costs, including the satisfaction of others in the group. Everyone will think less of the practice they are part of if poor behavior is tolerated.

Assess the Situation, Then Take Action

Most doctors who serve as the lead physician for their group have little or no experience dealing with problem behavior, let alone experience ensuring that necessary steps are followed prior to disciplining or terminating someone. But every hospital has someone who is very knowledgeable about these things; they should be engaged for advice, and, in the case of hospital-employed groups, should participate in the process of counseling and/or termination. It is important to take advantage of the expertise that is available.

Of course, the best approach is to prevent such problems from coming up. The best way to do this is to be very careful when hiring new providers. Checking references carefully is probably the best way to get an idea about whether someone might have behavior or personality problems. There are “job fit” survey instruments that you can use, but I’m not sure how effective they are, or how much value they add for a hospitalist practice beyond other means of assessing the candidate. And in the process of hiring someone, be sure to set behavior expectations very clearly. A new candidate should know that you will not tolerate not living up to behavioral expectations.

When dealing with bad behavior, make sure that you follow a careful and well-documented process. If someone still makes it through the hiring process only to be revealed as a troublemaker soon after their start date, don’t wait to sit that person down for very clear counseling; insist that their behavior change. Take notes of each meeting, and consider having the problem doctor sign and date the notes. While it might be easier to just wait and see if the first instance of bad behavior was an anomaly, that usually is a bad idea.

You should consider bringing the problem provider into the tent. The root of some bad behavior (i.e. criticism of leadership) is a person’s insecurity and lack of a feeling of ownership or control of their role in the practice. In that case, it might be reasonable to invite such a person into a role of greater responsibility in the practice so that they feel more in control. For example, a doctor who constantly complains about the work schedule might be invited to join the group’s executive committee or take on some other formal leadership role in the practice. This could backfire, so it should be tried only in carefully selected cases, and with the problem doctor’s clear understanding that they are being given a chance to have a bigger role in the practice but must improve their behavior or face serious consequences that could include termination.

I have seen this work beautifully in some cases, curing the problem behavior and turning the doctor into a valuable asset. I only wish there were a reliable way to know when to try this strategy. Sadly, it just requires judgment and intuition. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program.” This column represents his views and is not intended to reflect an official position of SHM.

The providers in every hospitalist practice should be a good fit for the practice’s culture. They should have reasonable relationships with their colleagues in the practice, patients and families, and other staff at the hospital.

I can’t imagine anyone arguing with this point of view. But in my work with hundreds of hospitalist practices over the past 15 years, I’ve found that many practices seem to have a hard time ensuring their providers meet that standard. I can think of lots of reasons for this. The first that comes to mind is the difficult HM recruiting environment. Almost all hospitalist practices needed to grow quickly, and many lowered the bar in the qualifications and the fit of the candidates they hired to make sure they filled all of their positions.

Even if it later becomes clear a provider isn’t a good fit for the group culture, or worse still lacks the knowledge base and judgment to perform well, many practices are reluctant to replace the hospitalist because it might be difficult to find a replacement—and there is no guarantee the new person will perform any better. Because of this, a number of practices have ended up with providers who in many cases have a negative influence on others in the practice, and both the practice and the problem provider would be better off if the provider went elsewhere.

The Problem Physician

To their credit, most practices do act when a provider simply lacks the skill and judgment to perform adequately. This can mean close proctoring/mentoring for an extended period, or requiring specific CME course work to correct a skill that is lacking. But it also means reassigning the person to a different job, or termination.

But in the case of someone with a toxic personality, practices often are more reluctant to act. I’ll often hear the leadership of a practice say something like, “We knew Alice wasn’t a good fit for our practice within a few weeks of her start date.” The start date was several years ago and nothing has been done about this. Not surprisingly, Alice still performs poorly.

I’m not talking about someone who has occasional problems. I’m talking about people who cause problems almost every time they show up to work. Here are some real anecdotes, with fictitious names to ensure anonymity for the person and institution:

• Dr. Lee routinely disappears for several hours, during which he doesn’t answer pages. This even happens when he is the only doctor covering the practice.
• Dr. Lifeson, while generally getting along well with his fellow hospitalists and the nursing staff, can be counted on to complain bitterly about all levels of the hospital administration and leadership. He never misses an opportunity to try to convince other hospitalists that the leadership is not only inept, but also clearly has a malicious intent toward hospitalists.
• Dr. Peart complains incessantly about even tiny inequities in the work schedule or patient load. Others in the group have found that it is easier to ensure he always has the best schedule and lightest patient load, hoping they won’t have to hear his constant complaining. But even that hasn’t stemmed the steady downpour of negativity from him.

In all three of these cases, it seemed clear that the doctor should be terminated. And while the practice leadership agreed with me, they offered several excuses for why they hadn’t taken this step.

• “Who knows if we can find a replacement who will be any better?”
• “But he’s actually a decent doctor and doesn’t get a lot of complaints from patients.”
• “He’s such an angry guy, we worry about litigation if we fire him.”

I can’t offer any clear rule about when a practice should stop trying to improve a provider’s behavior and recognize that it is time to terminate the provider. But it is worth remembering that waiting too long has many costs, including the satisfaction of others in the group. Everyone will think less of the practice they are part of if poor behavior is tolerated.

Assess the Situation, Then Take Action

Most doctors who serve as the lead physician for their group have little or no experience dealing with problem behavior, let alone experience ensuring that necessary steps are followed prior to disciplining or terminating someone. But every hospital has someone who is very knowledgeable about these things; they should be engaged for advice, and, in the case of hospital-employed groups, should participate in the process of counseling and/or termination. It is important to take advantage of the expertise that is available.

Of course, the best approach is to prevent such problems from coming up. The best way to do this is to be very careful when hiring new providers. Checking references carefully is probably the best way to get an idea about whether someone might have behavior or personality problems. There are “job fit” survey instruments that you can use, but I’m not sure how effective they are, or how much value they add for a hospitalist practice beyond other means of assessing the candidate. And in the process of hiring someone, be sure to set behavior expectations very clearly. A new candidate should know that you will not tolerate not living up to behavioral expectations.

When dealing with bad behavior, make sure that you follow a careful and well-documented process. If someone still makes it through the hiring process only to be revealed as a troublemaker soon after their start date, don’t wait to sit that person down for very clear counseling; insist that their behavior change. Take notes of each meeting, and consider having the problem doctor sign and date the notes. While it might be easier to just wait and see if the first instance of bad behavior was an anomaly, that usually is a bad idea.

You should consider bringing the problem provider into the tent. The root of some bad behavior (i.e. criticism of leadership) is a person’s insecurity and lack of a feeling of ownership or control of their role in the practice. In that case, it might be reasonable to invite such a person into a role of greater responsibility in the practice so that they feel more in control. For example, a doctor who constantly complains about the work schedule might be invited to join the group’s executive committee or take on some other formal leadership role in the practice. This could backfire, so it should be tried only in carefully selected cases, and with the problem doctor’s clear understanding that they are being given a chance to have a bigger role in the practice but must improve their behavior or face serious consequences that could include termination.

I have seen this work beautifully in some cases, curing the problem behavior and turning the doctor into a valuable asset. I only wish there were a reliable way to know when to try this strategy. Sadly, it just requires judgment and intuition. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program.” This column represents his views and is not intended to reflect an official position of SHM.

They have grown up in an era of reality television and hyperbolic politics. They prefer news alerts and fantasy football on their handhelds to daily newspapers and leather-bound novels. They text, they text, they text.

The generation known as millennials—those who were born in the years 1982 to 1995—is a breed unto itself. Millennials have grown up in the information age, are adept with new technologies, and have been trained under the umbrella of duty-hour guidelines that protect both the patient and the physician.

So when you hire a millennial for your hospitalist group, you’d better be clear about your expectations. “Millennials are looking for jobs that provide flexibility—time with family, time with friends, time to do other things,” says Troy Ahlstrom, MD, FHM, CFO of Traverse City-based Hospitalists of Northern Michigan and a member of SHM’s Practice Analysis committee. “There is nothing wrong with that, except that the baby boomers look at millennials and say, ‘Gosh, you slugs don’t want to work.’ ”

Dr. Ahlstrom says the influx of millennials into HM in recent years has had a significant impact on group administration—namely, an increase in use of 24/7 on-site coverage. The State of Hospital Medicine: 2010 Report Based on 2009 Data shows 68% of hospitalist groups provide on-site coverage at night. SHM’s 2007-2008 survey data showed only 53% of HM groups provided on-site coverage at night; the 2005-2006 figure was 51%. (Although the 2010 report includes a small percentage of truly academic hospitalist groups and, therefore, probably pushes the on-site coverage a little higher than in past years, Dr. Ahlstrom says he expects the trend toward on-site coverage at night to continue in the near future.)

“Baby boomers are perfectly fine with the idea of working more. They grew up working those horrifically long shifts, 36 hours straight,” Dr. Ahlstrom says. “The millennials would rather have clearly defined shifts, with nocturnists around to work the nights. Or maybe they get to be the nocturnist and work the nights. That’s the trend with younger physicians: They are more interested in seeing that split, where the days and nights are clearly set off.”

Then again, not all physicians, young or old, are against the idea of working long hours. And plenty of well-seasoned physicians are more than happy to have a nocturnist around, “but not if it’s going to cost them a lot of money or productivity,” Dr. Ahlstrom says.

They have grown up in an era of reality television and hyperbolic politics. They prefer news alerts and fantasy football on their handhelds to daily newspapers and leather-bound novels. They text, they text, they text.

The generation known as millennials—those who were born in the years 1982 to 1995—is a breed unto itself. Millennials have grown up in the information age, are adept with new technologies, and have been trained under the umbrella of duty-hour guidelines that protect both the patient and the physician.

So when you hire a millennial for your hospitalist group, you’d better be clear about your expectations. “Millennials are looking for jobs that provide flexibility—time with family, time with friends, time to do other things,” says Troy Ahlstrom, MD, FHM, CFO of Traverse City-based Hospitalists of Northern Michigan and a member of SHM’s Practice Analysis committee. “There is nothing wrong with that, except that the baby boomers look at millennials and say, ‘Gosh, you slugs don’t want to work.’ ”

Dr. Ahlstrom says the influx of millennials into HM in recent years has had a significant impact on group administration—namely, an increase in use of 24/7 on-site coverage. The State of Hospital Medicine: 2010 Report Based on 2009 Data shows 68% of hospitalist groups provide on-site coverage at night. SHM’s 2007-2008 survey data showed only 53% of HM groups provided on-site coverage at night; the 2005-2006 figure was 51%. (Although the 2010 report includes a small percentage of truly academic hospitalist groups and, therefore, probably pushes the on-site coverage a little higher than in past years, Dr. Ahlstrom says he expects the trend toward on-site coverage at night to continue in the near future.)

“Baby boomers are perfectly fine with the idea of working more. They grew up working those horrifically long shifts, 36 hours straight,” Dr. Ahlstrom says. “The millennials would rather have clearly defined shifts, with nocturnists around to work the nights. Or maybe they get to be the nocturnist and work the nights. That’s the trend with younger physicians: They are more interested in seeing that split, where the days and nights are clearly set off.”

Then again, not all physicians, young or old, are against the idea of working long hours. And plenty of well-seasoned physicians are more than happy to have a nocturnist around, “but not if it’s going to cost them a lot of money or productivity,” Dr. Ahlstrom says.

They have grown up in an era of reality television and hyperbolic politics. They prefer news alerts and fantasy football on their handhelds to daily newspapers and leather-bound novels. They text, they text, they text.

The generation known as millennials—those who were born in the years 1982 to 1995—is a breed unto itself. Millennials have grown up in the information age, are adept with new technologies, and have been trained under the umbrella of duty-hour guidelines that protect both the patient and the physician.

So when you hire a millennial for your hospitalist group, you’d better be clear about your expectations. “Millennials are looking for jobs that provide flexibility—time with family, time with friends, time to do other things,” says Troy Ahlstrom, MD, FHM, CFO of Traverse City-based Hospitalists of Northern Michigan and a member of SHM’s Practice Analysis committee. “There is nothing wrong with that, except that the baby boomers look at millennials and say, ‘Gosh, you slugs don’t want to work.’ ”

Dr. Ahlstrom says the influx of millennials into HM in recent years has had a significant impact on group administration—namely, an increase in use of 24/7 on-site coverage. The State of Hospital Medicine: 2010 Report Based on 2009 Data shows 68% of hospitalist groups provide on-site coverage at night. SHM’s 2007-2008 survey data showed only 53% of HM groups provided on-site coverage at night; the 2005-2006 figure was 51%. (Although the 2010 report includes a small percentage of truly academic hospitalist groups and, therefore, probably pushes the on-site coverage a little higher than in past years, Dr. Ahlstrom says he expects the trend toward on-site coverage at night to continue in the near future.)

“Baby boomers are perfectly fine with the idea of working more. They grew up working those horrifically long shifts, 36 hours straight,” Dr. Ahlstrom says. “The millennials would rather have clearly defined shifts, with nocturnists around to work the nights. Or maybe they get to be the nocturnist and work the nights. That’s the trend with younger physicians: They are more interested in seeing that split, where the days and nights are clearly set off.”

Then again, not all physicians, young or old, are against the idea of working long hours. And plenty of well-seasoned physicians are more than happy to have a nocturnist around, “but not if it’s going to cost them a lot of money or productivity,” Dr. Ahlstrom says.

Over the past couple of decades, the ever-increasing medical-legal, financial, and patient-safety demands have led to a mushrooming of the amount of documentation needed during patient care, especially in the inpatient setting. With the advent of HM, that burden simply shifted to hospitalists, along with rapidly expanding patient loads as PCPs started delegating inpatient care. The problem was further compounded in teaching hospitals by a gradual decline in resident support as patient caps and work-hour limits were instituted.

Not surprisingly, the quality and accuracy of physicians’ progress notes started to suffer. It became frequently difficult to remember the details of encounters from earlier in the day, and fatigue sometimes led to details essential to continuity of care being left out completely.

A potential—and very intriguing—solution presented itself, however, as we were designing family-centered team rounds. Apparently, the ED group at the adjacent Abbott-Northwestern Hospital in Minneapolis had been using scribes for several years. The scribes captured the providers’ notes during each encounter, and the group had developed a polished system of scribe recruitment and training (mostly pre-med students awaiting acceptance to medical schools).

But would this model work in the inpatient setting where workflow was completely different? This was a total unknown, given that there has been no precedent in the literature about inpatient scribe utilization. Although relatively meager in number, the published articles about outpatient use of scribes were generally favorable, with the authors noting improved productivity and increased patient and staff satisfaction.^1,2,3,4

Operationally, the main difference between inpatient and outpatient scribe use lied in the rounding mechanism itself; it was not just a provider-patient interaction, as in the ED, but rather a sometimes cacophonous collection of multiple inputs from families, providers, students, residents, nurses, and ancillary staff. The challenge here was to train the scribes (natural ability played a significant role) to produce a coherent document out of this interaction; the document had to accurately reflect current status and plans of care. The first step was to create a template for the daily progress notes with all the necessary headings, as well as age-appropriate normal exams, with the ability to directly import from the EMR such dynamic data as vital signs, medication lists, and lab results.

Each morning prior to rounds, the scribe was provided a list of patients to be rounded on, and the scribe spent about 30 minutes creating partial notes on each patient, as well as a brief patient identification statement. This proved to be a significant time-saver during rounds and allowed the scribes to keep up with the care team. Each note was pre-pended with the following statements, as recommended by the hospital’s risk-management team:

• I, (scribe name), am serving as a scribe to document services personally performed by (hospitalist name), MD, based on my observation and the provider’s statements to me.
• I, (hospitalist name), MD, attest that (scribe name) is acting in a scribe capacity, has observed my performance of the services, and has documented them in accordance with my direction.

A computer-on-wheels (COW) station was assigned to the scribes and accompanied the rounding team into the patient rooms, making it possible for them to follow the interactions in real time. The scribes were encouraged to hold their hands up and interrupt the conversation at any time if they needed clarification, something that happened rather infrequently. On the other hand, the care team was directed to speak clearly and the residents were instructed to present their cases using the same format as the progress-note template, thus minimizing guesswork on the part of the scribes. The only part of the interaction the scribes could not transcribe directly was the physical examination, and typically the attending physician dictated abnormal findings as well as systems not assessed, if any, at the end. All the scribe-generated notes were forwarded to the rounding provider’s EMR inbox and reviewed by the latter, amended when necessary, and signed electronically. The review of the scribe-generated notes proved to be initially a time-consuming process, typically two hours. However, as the scribes gained experience, the time commitment on the part of the providers decreased rapidly; after about three months, the time spent was about 30 minutes on busy days, even less otherwise, with a concomitant increase in satisfaction with the scribing process.

Not too unexpectedly, our transcription service initially pushed back on this idea because of their fear of job loss. However, this issue was resolved by eliminating the need for outsourcing overflow dictations. In addition, the relative terseness of the scribed notes did not sit well initially with some of our colleagues used to excessive verbosity, and this issue again gradually faded away as physicians realized that all the necessary information for care was preserved.

Does a scribe program make sense in all situations? Not likely. This kind of setup will work best in busy tertiary-care centers with residency programs and family-centered team rounds. Furthermore, a nearby college or university is a must if cost-efficient hiring of pre-med students is to be possible.

Walid Maalouli, MD, FAAP,

medical director, hospitalist department,

Children’s Hospitals & Clinics of Minnesota, Minneapolis

References

1. Arya R, Salovich DM, Ohman-Strickland P, Merlin MA. Impact of scribes on performance indicators in the emergency department. Acad Emerg Med. 2010;17(5):490- 494.
2. Koshy S, Feustel PJ, Hong M, Kogan BA. Scribes in an ambulatory urology practice: patient and physician satisfaction. J Urol. 2010;184(1):258-262.
3. Conn J. Getting it in writing. Docs using scribes to ease the transition to EHRs. Mod Healthc. 2010;40(6):30,32.
4. Expanded scribe role boosts staff morale. ED Manag. 2009;21(7):75-77.

Over the past couple of decades, the ever-increasing medical-legal, financial, and patient-safety demands have led to a mushrooming of the amount of documentation needed during patient care, especially in the inpatient setting. With the advent of HM, that burden simply shifted to hospitalists, along with rapidly expanding patient loads as PCPs started delegating inpatient care. The problem was further compounded in teaching hospitals by a gradual decline in resident support as patient caps and work-hour limits were instituted.

Not surprisingly, the quality and accuracy of physicians’ progress notes started to suffer. It became frequently difficult to remember the details of encounters from earlier in the day, and fatigue sometimes led to details essential to continuity of care being left out completely.

A potential—and very intriguing—solution presented itself, however, as we were designing family-centered team rounds. Apparently, the ED group at the adjacent Abbott-Northwestern Hospital in Minneapolis had been using scribes for several years. The scribes captured the providers’ notes during each encounter, and the group had developed a polished system of scribe recruitment and training (mostly pre-med students awaiting acceptance to medical schools).

But would this model work in the inpatient setting where workflow was completely different? This was a total unknown, given that there has been no precedent in the literature about inpatient scribe utilization. Although relatively meager in number, the published articles about outpatient use of scribes were generally favorable, with the authors noting improved productivity and increased patient and staff satisfaction.^1,2,3,4

Operationally, the main difference between inpatient and outpatient scribe use lied in the rounding mechanism itself; it was not just a provider-patient interaction, as in the ED, but rather a sometimes cacophonous collection of multiple inputs from families, providers, students, residents, nurses, and ancillary staff. The challenge here was to train the scribes (natural ability played a significant role) to produce a coherent document out of this interaction; the document had to accurately reflect current status and plans of care. The first step was to create a template for the daily progress notes with all the necessary headings, as well as age-appropriate normal exams, with the ability to directly import from the EMR such dynamic data as vital signs, medication lists, and lab results.

Each morning prior to rounds, the scribe was provided a list of patients to be rounded on, and the scribe spent about 30 minutes creating partial notes on each patient, as well as a brief patient identification statement. This proved to be a significant time-saver during rounds and allowed the scribes to keep up with the care team. Each note was pre-pended with the following statements, as recommended by the hospital’s risk-management team:

• I, (scribe name), am serving as a scribe to document services personally performed by (hospitalist name), MD, based on my observation and the provider’s statements to me.
• I, (hospitalist name), MD, attest that (scribe name) is acting in a scribe capacity, has observed my performance of the services, and has documented them in accordance with my direction.

A computer-on-wheels (COW) station was assigned to the scribes and accompanied the rounding team into the patient rooms, making it possible for them to follow the interactions in real time. The scribes were encouraged to hold their hands up and interrupt the conversation at any time if they needed clarification, something that happened rather infrequently. On the other hand, the care team was directed to speak clearly and the residents were instructed to present their cases using the same format as the progress-note template, thus minimizing guesswork on the part of the scribes. The only part of the interaction the scribes could not transcribe directly was the physical examination, and typically the attending physician dictated abnormal findings as well as systems not assessed, if any, at the end. All the scribe-generated notes were forwarded to the rounding provider’s EMR inbox and reviewed by the latter, amended when necessary, and signed electronically. The review of the scribe-generated notes proved to be initially a time-consuming process, typically two hours. However, as the scribes gained experience, the time commitment on the part of the providers decreased rapidly; after about three months, the time spent was about 30 minutes on busy days, even less otherwise, with a concomitant increase in satisfaction with the scribing process.

Not too unexpectedly, our transcription service initially pushed back on this idea because of their fear of job loss. However, this issue was resolved by eliminating the need for outsourcing overflow dictations. In addition, the relative terseness of the scribed notes did not sit well initially with some of our colleagues used to excessive verbosity, and this issue again gradually faded away as physicians realized that all the necessary information for care was preserved.

Does a scribe program make sense in all situations? Not likely. This kind of setup will work best in busy tertiary-care centers with residency programs and family-centered team rounds. Furthermore, a nearby college or university is a must if cost-efficient hiring of pre-med students is to be possible.

Walid Maalouli, MD, FAAP,

medical director, hospitalist department,

Children’s Hospitals & Clinics of Minnesota, Minneapolis

References

1. Arya R, Salovich DM, Ohman-Strickland P, Merlin MA. Impact of scribes on performance indicators in the emergency department. Acad Emerg Med. 2010;17(5):490- 494.
2. Koshy S, Feustel PJ, Hong M, Kogan BA. Scribes in an ambulatory urology practice: patient and physician satisfaction. J Urol. 2010;184(1):258-262.
3. Conn J. Getting it in writing. Docs using scribes to ease the transition to EHRs. Mod Healthc. 2010;40(6):30,32.
4. Expanded scribe role boosts staff morale. ED Manag. 2009;21(7):75-77.

Over the past couple of decades, the ever-increasing medical-legal, financial, and patient-safety demands have led to a mushrooming of the amount of documentation needed during patient care, especially in the inpatient setting. With the advent of HM, that burden simply shifted to hospitalists, along with rapidly expanding patient loads as PCPs started delegating inpatient care. The problem was further compounded in teaching hospitals by a gradual decline in resident support as patient caps and work-hour limits were instituted.

Not surprisingly, the quality and accuracy of physicians’ progress notes started to suffer. It became frequently difficult to remember the details of encounters from earlier in the day, and fatigue sometimes led to details essential to continuity of care being left out completely.

A potential—and very intriguing—solution presented itself, however, as we were designing family-centered team rounds. Apparently, the ED group at the adjacent Abbott-Northwestern Hospital in Minneapolis had been using scribes for several years. The scribes captured the providers’ notes during each encounter, and the group had developed a polished system of scribe recruitment and training (mostly pre-med students awaiting acceptance to medical schools).

But would this model work in the inpatient setting where workflow was completely different? This was a total unknown, given that there has been no precedent in the literature about inpatient scribe utilization. Although relatively meager in number, the published articles about outpatient use of scribes were generally favorable, with the authors noting improved productivity and increased patient and staff satisfaction.^1,2,3,4

Operationally, the main difference between inpatient and outpatient scribe use lied in the rounding mechanism itself; it was not just a provider-patient interaction, as in the ED, but rather a sometimes cacophonous collection of multiple inputs from families, providers, students, residents, nurses, and ancillary staff. The challenge here was to train the scribes (natural ability played a significant role) to produce a coherent document out of this interaction; the document had to accurately reflect current status and plans of care. The first step was to create a template for the daily progress notes with all the necessary headings, as well as age-appropriate normal exams, with the ability to directly import from the EMR such dynamic data as vital signs, medication lists, and lab results.

Each morning prior to rounds, the scribe was provided a list of patients to be rounded on, and the scribe spent about 30 minutes creating partial notes on each patient, as well as a brief patient identification statement. This proved to be a significant time-saver during rounds and allowed the scribes to keep up with the care team. Each note was pre-pended with the following statements, as recommended by the hospital’s risk-management team:

• I, (scribe name), am serving as a scribe to document services personally performed by (hospitalist name), MD, based on my observation and the provider’s statements to me.
• I, (hospitalist name), MD, attest that (scribe name) is acting in a scribe capacity, has observed my performance of the services, and has documented them in accordance with my direction.

A computer-on-wheels (COW) station was assigned to the scribes and accompanied the rounding team into the patient rooms, making it possible for them to follow the interactions in real time. The scribes were encouraged to hold their hands up and interrupt the conversation at any time if they needed clarification, something that happened rather infrequently. On the other hand, the care team was directed to speak clearly and the residents were instructed to present their cases using the same format as the progress-note template, thus minimizing guesswork on the part of the scribes. The only part of the interaction the scribes could not transcribe directly was the physical examination, and typically the attending physician dictated abnormal findings as well as systems not assessed, if any, at the end. All the scribe-generated notes were forwarded to the rounding provider’s EMR inbox and reviewed by the latter, amended when necessary, and signed electronically. The review of the scribe-generated notes proved to be initially a time-consuming process, typically two hours. However, as the scribes gained experience, the time commitment on the part of the providers decreased rapidly; after about three months, the time spent was about 30 minutes on busy days, even less otherwise, with a concomitant increase in satisfaction with the scribing process.

Not too unexpectedly, our transcription service initially pushed back on this idea because of their fear of job loss. However, this issue was resolved by eliminating the need for outsourcing overflow dictations. In addition, the relative terseness of the scribed notes did not sit well initially with some of our colleagues used to excessive verbosity, and this issue again gradually faded away as physicians realized that all the necessary information for care was preserved.

Does a scribe program make sense in all situations? Not likely. This kind of setup will work best in busy tertiary-care centers with residency programs and family-centered team rounds. Furthermore, a nearby college or university is a must if cost-efficient hiring of pre-med students is to be possible.

Walid Maalouli, MD, FAAP,

medical director, hospitalist department,

Children’s Hospitals & Clinics of Minnesota, Minneapolis

References

1. Arya R, Salovich DM, Ohman-Strickland P, Merlin MA. Impact of scribes on performance indicators in the emergency department. Acad Emerg Med. 2010;17(5):490- 494.
2. Koshy S, Feustel PJ, Hong M, Kogan BA. Scribes in an ambulatory urology practice: patient and physician satisfaction. J Urol. 2010;184(1):258-262.
3. Conn J. Getting it in writing. Docs using scribes to ease the transition to EHRs. Mod Healthc. 2010;40(6):30,32.
4. Expanded scribe role boosts staff morale. ED Manag. 2009;21(7):75-77.

Let’s examine a documentation case for hospitalists providing daily care: A 65-year-old male patient is admitted with a left hip fracture. The patient also has hypertension and Type 2 diabetes, which might complicate his care. The orthopedic surgeon manages the patient’s perioperative course for the fracture while the hospitalist provides daily post-op care for hypertension and diabetes.

A common scenario is the hospitalist will provide concurrent care, along with a varying number of specialists, depending on the complexity of the patient’s presenting problems and existing comorbidities. Payors define concurrent care as more than one physician providing care to the same patient on the same date, or during the same hospitalization. Payors often consider two key principles before reimbursing concurrent care:

• Does the patient’s condition warrant more than one physician? and
• Are the services provided by each physician reasonable and necessary?¹

When more than one medical condition exists and each physician actively treats the condition related to their expertise, each physician can demonstrate medical necessity. As in the above example, the orthopedic surgeon cares for the patient’s fracture while the hospitalist oversees diabetes and hypertension management. Claim submission follows the same logic. Report each subsequent hospital care code (99231-99233) with the corresponding diagnosis each physician primarily manages (i.e., orthopedic surgeon: 9923x with 820.8; hospitalist: 9923x with 250.00, 401.1).

When each physician assigns a different primary diagnosis code to the visit code, each is more likely to receive payment. Because each of these physicians are in different specialties and different provider groups, most payors do not require modifier 25 (separately identifiable E/M service on the same day as a procedure or other service) appended to the visit code. However, some managed-care payors require each physician to append modifier 25 to the concurrent E/M visit code (i.e., 99232-25) despite claim submission under different tax identification numbers.

Unfortunately, the physicians might not realize this until a claim rejection has been issued. Furthermore, payors might want to see the proof before rendering payment. In other words, they pay the first claim received and deny any subsequent claim in order to confirm medical necessity of the concurrent visit. Appeal denied such claims rejections with supporting documentation that distinguishes each physician visit, if possible. This assists the payors in understanding each physician’s contribution to care.

Reasons for Denial

Concurrent care services are more easily distinguished when separate diagnoses are reported with each service. Conversely, payors are likely to deny services that are hard to differentiate. Furthermore, payors frequently deny concurrent care services for the following reasons:

• Services exceed normal frequency or duration for a given condition without documented circumstances requiring additional care; or
• Services by one physician duplicate or overlap those of another provider without recognizable distinction.²

For example, a hospitalist might be involved in the post-op care of patients with fractures and no other identifiable chronic or acute conditions or complications. In these cases, the hospitalist’s continued involvement might constitute a facility policy (e.g., quality of care, risk reduction, etc.) rather than active clinical management. Claim submission could erroneously occur with each physician reporting 9923x for 820.8. Payors deny medically unnecessary services, or request refunds for inappropriate payments.

Hospitalists might attempt to negotiate other terms with the facility to account for the unpaid time and effort directed toward these types of cases.

Group Practice

Physicians in the same group practice with the same specialty designation must report, and are paid, as a single physician. Multiple visits to the same patient can occur on the same day by members of the same group (e.g., hospitalist A evaluates the patient in the morning, and hospitalist B reviews test results and the resulting course of treatment in the afternoon). However, only one subsequent hospital care service can be reported for the day.

The hospitalists should select the visit level representative of the combined services and submit one appropriately determined code (e.g., 99233), thereby capturing the medically necessary efforts of each physician. To complicate matters, the hospitalists must determine which name to report on the claim: the physician who provided the first encounter, or the physician who provided the most extensive or best-documented encounter.

Tracking productivity for these cases proves challenging. Some practices develop an internal accounting system and credit each physician for their medically necessary efforts (a labor-intensive task for administrators and physicians). TH

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

References

1. Medicare Benefit Policy Manual: Concurrent Care. Chapter 15, Section 30.E. CMS website. Available at: www.cms.gov/manuals/Downloads/bp102c15.pdf. Accessed July 9, 2010.
2. Medicare Claims Processing Manual: Physicians in Group Practice. Chapter 12, Section 30.6.5. CMS website. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed July 9, 2010.
3. Pohlig, C. Daily care conundrums. The Hospitalist website. Available at: www.the-hospitalist.org/details/article/188735/Daily_Care_Conundrums_.html. Accessed July 9, 2010.
4. Medicare Claims Processing Manual: Hospital Visits Same Day But by Different Physicians. Chapter 12, Section 30.6.9.C. CMS website. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed July 9, 2010.
5. Abraham M, Beebe M, Dalton J, Evans D, Glenn R. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2010:15.

Let’s examine a documentation case for hospitalists providing daily care: A 65-year-old male patient is admitted with a left hip fracture. The patient also has hypertension and Type 2 diabetes, which might complicate his care. The orthopedic surgeon manages the patient’s perioperative course for the fracture while the hospitalist provides daily post-op care for hypertension and diabetes.

A common scenario is the hospitalist will provide concurrent care, along with a varying number of specialists, depending on the complexity of the patient’s presenting problems and existing comorbidities. Payors define concurrent care as more than one physician providing care to the same patient on the same date, or during the same hospitalization. Payors often consider two key principles before reimbursing concurrent care:

• Does the patient’s condition warrant more than one physician? and
• Are the services provided by each physician reasonable and necessary?¹

When more than one medical condition exists and each physician actively treats the condition related to their expertise, each physician can demonstrate medical necessity. As in the above example, the orthopedic surgeon cares for the patient’s fracture while the hospitalist oversees diabetes and hypertension management. Claim submission follows the same logic. Report each subsequent hospital care code (99231-99233) with the corresponding diagnosis each physician primarily manages (i.e., orthopedic surgeon: 9923x with 820.8; hospitalist: 9923x with 250.00, 401.1).

When each physician assigns a different primary diagnosis code to the visit code, each is more likely to receive payment. Because each of these physicians are in different specialties and different provider groups, most payors do not require modifier 25 (separately identifiable E/M service on the same day as a procedure or other service) appended to the visit code. However, some managed-care payors require each physician to append modifier 25 to the concurrent E/M visit code (i.e., 99232-25) despite claim submission under different tax identification numbers.

Unfortunately, the physicians might not realize this until a claim rejection has been issued. Furthermore, payors might want to see the proof before rendering payment. In other words, they pay the first claim received and deny any subsequent claim in order to confirm medical necessity of the concurrent visit. Appeal denied such claims rejections with supporting documentation that distinguishes each physician visit, if possible. This assists the payors in understanding each physician’s contribution to care.

Reasons for Denial

Concurrent care services are more easily distinguished when separate diagnoses are reported with each service. Conversely, payors are likely to deny services that are hard to differentiate. Furthermore, payors frequently deny concurrent care services for the following reasons:

• Services exceed normal frequency or duration for a given condition without documented circumstances requiring additional care; or
• Services by one physician duplicate or overlap those of another provider without recognizable distinction.²

For example, a hospitalist might be involved in the post-op care of patients with fractures and no other identifiable chronic or acute conditions or complications. In these cases, the hospitalist’s continued involvement might constitute a facility policy (e.g., quality of care, risk reduction, etc.) rather than active clinical management. Claim submission could erroneously occur with each physician reporting 9923x for 820.8. Payors deny medically unnecessary services, or request refunds for inappropriate payments.

Hospitalists might attempt to negotiate other terms with the facility to account for the unpaid time and effort directed toward these types of cases.

Group Practice

Physicians in the same group practice with the same specialty designation must report, and are paid, as a single physician. Multiple visits to the same patient can occur on the same day by members of the same group (e.g., hospitalist A evaluates the patient in the morning, and hospitalist B reviews test results and the resulting course of treatment in the afternoon). However, only one subsequent hospital care service can be reported for the day.

The hospitalists should select the visit level representative of the combined services and submit one appropriately determined code (e.g., 99233), thereby capturing the medically necessary efforts of each physician. To complicate matters, the hospitalists must determine which name to report on the claim: the physician who provided the first encounter, or the physician who provided the most extensive or best-documented encounter.

Tracking productivity for these cases proves challenging. Some practices develop an internal accounting system and credit each physician for their medically necessary efforts (a labor-intensive task for administrators and physicians). TH

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

References

1. Medicare Benefit Policy Manual: Concurrent Care. Chapter 15, Section 30.E. CMS website. Available at: www.cms.gov/manuals/Downloads/bp102c15.pdf. Accessed July 9, 2010.
2. Medicare Claims Processing Manual: Physicians in Group Practice. Chapter 12, Section 30.6.5. CMS website. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed July 9, 2010.
3. Pohlig, C. Daily care conundrums. The Hospitalist website. Available at: www.the-hospitalist.org/details/article/188735/Daily_Care_Conundrums_.html. Accessed July 9, 2010.
4. Medicare Claims Processing Manual: Hospital Visits Same Day But by Different Physicians. Chapter 12, Section 30.6.9.C. CMS website. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed July 9, 2010.
5. Abraham M, Beebe M, Dalton J, Evans D, Glenn R. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2010:15.

Let’s examine a documentation case for hospitalists providing daily care: A 65-year-old male patient is admitted with a left hip fracture. The patient also has hypertension and Type 2 diabetes, which might complicate his care. The orthopedic surgeon manages the patient’s perioperative course for the fracture while the hospitalist provides daily post-op care for hypertension and diabetes.

A common scenario is the hospitalist will provide concurrent care, along with a varying number of specialists, depending on the complexity of the patient’s presenting problems and existing comorbidities. Payors define concurrent care as more than one physician providing care to the same patient on the same date, or during the same hospitalization. Payors often consider two key principles before reimbursing concurrent care:

• Does the patient’s condition warrant more than one physician? and
• Are the services provided by each physician reasonable and necessary?¹

When more than one medical condition exists and each physician actively treats the condition related to their expertise, each physician can demonstrate medical necessity. As in the above example, the orthopedic surgeon cares for the patient’s fracture while the hospitalist oversees diabetes and hypertension management. Claim submission follows the same logic. Report each subsequent hospital care code (99231-99233) with the corresponding diagnosis each physician primarily manages (i.e., orthopedic surgeon: 9923x with 820.8; hospitalist: 9923x with 250.00, 401.1).

When each physician assigns a different primary diagnosis code to the visit code, each is more likely to receive payment. Because each of these physicians are in different specialties and different provider groups, most payors do not require modifier 25 (separately identifiable E/M service on the same day as a procedure or other service) appended to the visit code. However, some managed-care payors require each physician to append modifier 25 to the concurrent E/M visit code (i.e., 99232-25) despite claim submission under different tax identification numbers.

Unfortunately, the physicians might not realize this until a claim rejection has been issued. Furthermore, payors might want to see the proof before rendering payment. In other words, they pay the first claim received and deny any subsequent claim in order to confirm medical necessity of the concurrent visit. Appeal denied such claims rejections with supporting documentation that distinguishes each physician visit, if possible. This assists the payors in understanding each physician’s contribution to care.

Reasons for Denial

Concurrent care services are more easily distinguished when separate diagnoses are reported with each service. Conversely, payors are likely to deny services that are hard to differentiate. Furthermore, payors frequently deny concurrent care services for the following reasons:

• Services exceed normal frequency or duration for a given condition without documented circumstances requiring additional care; or
• Services by one physician duplicate or overlap those of another provider without recognizable distinction.²

For example, a hospitalist might be involved in the post-op care of patients with fractures and no other identifiable chronic or acute conditions or complications. In these cases, the hospitalist’s continued involvement might constitute a facility policy (e.g., quality of care, risk reduction, etc.) rather than active clinical management. Claim submission could erroneously occur with each physician reporting 9923x for 820.8. Payors deny medically unnecessary services, or request refunds for inappropriate payments.

Hospitalists might attempt to negotiate other terms with the facility to account for the unpaid time and effort directed toward these types of cases.

Group Practice

Physicians in the same group practice with the same specialty designation must report, and are paid, as a single physician. Multiple visits to the same patient can occur on the same day by members of the same group (e.g., hospitalist A evaluates the patient in the morning, and hospitalist B reviews test results and the resulting course of treatment in the afternoon). However, only one subsequent hospital care service can be reported for the day.

The hospitalists should select the visit level representative of the combined services and submit one appropriately determined code (e.g., 99233), thereby capturing the medically necessary efforts of each physician. To complicate matters, the hospitalists must determine which name to report on the claim: the physician who provided the first encounter, or the physician who provided the most extensive or best-documented encounter.

Tracking productivity for these cases proves challenging. Some practices develop an internal accounting system and credit each physician for their medically necessary efforts (a labor-intensive task for administrators and physicians). TH

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

References

1. Medicare Benefit Policy Manual: Concurrent Care. Chapter 15, Section 30.E. CMS website. Available at: www.cms.gov/manuals/Downloads/bp102c15.pdf. Accessed July 9, 2010.
2. Medicare Claims Processing Manual: Physicians in Group Practice. Chapter 12, Section 30.6.5. CMS website. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed July 9, 2010.
3. Pohlig, C. Daily care conundrums. The Hospitalist website. Available at: www.the-hospitalist.org/details/article/188735/Daily_Care_Conundrums_.html. Accessed July 9, 2010.
4. Medicare Claims Processing Manual: Hospital Visits Same Day But by Different Physicians. Chapter 12, Section 30.6.9.C. CMS website. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed July 9, 2010.
5. Abraham M, Beebe M, Dalton J, Evans D, Glenn R. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2010:15.

Dr. Pyke

Recent discussions on conflicts of interest in medical publications underscore the significance of the important yet fragile relationship between the pharmaceutical industry and healthcare professionals. Among these is an examination of how academic departments can maintain a relationship with the industry.¹ This study suggests that if appropriate boundaries are established between industry and academia, it is possible to collaborate. However, part of the policy in this investigation included “elimination of industry-supplied meals, gifts, and favors.”²

The Institute of Medicine’s “Conflict of Interest in Medical Research, Education, and Practice” included groundbreaking recommendations.3 Among them was a call for professionals to adopt a policy that prohibits “the acceptance of items of material value from pharmaceutical, medical device, and biotechnology companies, except in specified situations.”³

Our nation has been embroiled in a healthcare debate. Questions of right versus privilege, access versus affordability, and, of course, the perpetual political overlay have monopolized most of the discourse. Some contend that healthcare reform will redefine the current relationship between pharma and physicians . . . and not a moment too soon.

Lest there be ambiguity, though, the medical profession remains a noble vocation. This notwithstanding, until 2002, physicians freely participated in golf outings, received athletic tickets, and dined at five-star restaurants. But after the pharmaceutical industry smartly adopted voluntary guidelines that restrict gifting to doctors, we are left with drug samples and, of course, the “free lunch.” Certainly, pharma can claim it has made significant contributions to furthering medical education and research. Many could argue the tangible negative effects that would follow if the funding suddenly were absent.

But let’s not kid ourselves: There is a good reason the pharmaceutical industry spends more than $12 billion per year on marketing to doctors.⁴ In 2006, Rep. Henry Waxman (D-Calif.) said, “It is obvious that drug companies provide these free lunches so their sales reps can get the doctor’s ear and influence the prescribing practices.”² Most doctors would never admit any such influence. It would be, however, disingenuous for any practicing physician to say there is none.

A randomized trial conducted by Adair et al concluded the “access to drug samples in clinic influences resident prescribing decisions. This could affect resident education and increase drug costs for patients.”⁵ An earlier study by Chew et al concluded “the availability of drug samples led physicians to dispense and subsequently prescribe drugs that differ from their preferred drug choice. Physicians most often report using drug samples to avoid cost to the patient.”⁶

Sure, local culture drives some prescribing practice, but one must be mindful of the reality that the pharmaceutical industry has significant influence. Plus, free drug samples help patients in the short term. Once the samples are gone, an expensive prescription for that new drug will follow. It’s another win for the industry and another loss for the patient and the healthcare system.

Many studies have shown that gifting exerts influence, even if doctors are unwilling to admit it. But patients and doctors alike would like to state with clarity of conscience that the medication prescribed is only based on clinical evidence, not influence. TH

Dr. Pyke is a hospitalist at Geisinger Wyoming Valley Medical Systems in Mountain Top, Pa.

References

1. Dubovsky SL, Kaye DL, Pristach CA, DelRegno P, Pessar L, Stiles K. Can academic departments maintain industry relationships while promoting physician professionalism? Acad Med. 2010;85(1):68-73.
2. Salganik MW, Hopkins JS, Rockoff JD. Medical salesmen prescribe lunches. Catering trade feeds on rep-doctor meals. The Baltimore Sun. July 29, 2006.
3. Institute of Medicine Conflict of Interest in Medical Research, Education and Practice Full Recommendations. 4-28-09.
4. Wolfe SM. Why do American drug companies spend more than $12 billion a year pushing drugs? Is it education or promotion? J Gen Intern Med. 2007;11(10):637-639.
5. Adair RF, Holmgren LR. Do drug samples influence resident prescribing behavior? A randomized trial. Am J Med. 2005;118(8):881-884.
6. Chew LD, O’Young TS, Hazlet TK, Bradley KA, Maynard C, Lessler DS. A physician survey of the effect of drug sample availability on physicians’ behavior. J Gen Intern Med. 2000;15(7):478-483.

Dr. Pyke

Recent discussions on conflicts of interest in medical publications underscore the significance of the important yet fragile relationship between the pharmaceutical industry and healthcare professionals. Among these is an examination of how academic departments can maintain a relationship with the industry.¹ This study suggests that if appropriate boundaries are established between industry and academia, it is possible to collaborate. However, part of the policy in this investigation included “elimination of industry-supplied meals, gifts, and favors.”²

The Institute of Medicine’s “Conflict of Interest in Medical Research, Education, and Practice” included groundbreaking recommendations.3 Among them was a call for professionals to adopt a policy that prohibits “the acceptance of items of material value from pharmaceutical, medical device, and biotechnology companies, except in specified situations.”³

Our nation has been embroiled in a healthcare debate. Questions of right versus privilege, access versus affordability, and, of course, the perpetual political overlay have monopolized most of the discourse. Some contend that healthcare reform will redefine the current relationship between pharma and physicians . . . and not a moment too soon.

Lest there be ambiguity, though, the medical profession remains a noble vocation. This notwithstanding, until 2002, physicians freely participated in golf outings, received athletic tickets, and dined at five-star restaurants. But after the pharmaceutical industry smartly adopted voluntary guidelines that restrict gifting to doctors, we are left with drug samples and, of course, the “free lunch.” Certainly, pharma can claim it has made significant contributions to furthering medical education and research. Many could argue the tangible negative effects that would follow if the funding suddenly were absent.

But let’s not kid ourselves: There is a good reason the pharmaceutical industry spends more than $12 billion per year on marketing to doctors.⁴ In 2006, Rep. Henry Waxman (D-Calif.) said, “It is obvious that drug companies provide these free lunches so their sales reps can get the doctor’s ear and influence the prescribing practices.”² Most doctors would never admit any such influence. It would be, however, disingenuous for any practicing physician to say there is none.

A randomized trial conducted by Adair et al concluded the “access to drug samples in clinic influences resident prescribing decisions. This could affect resident education and increase drug costs for patients.”⁵ An earlier study by Chew et al concluded “the availability of drug samples led physicians to dispense and subsequently prescribe drugs that differ from their preferred drug choice. Physicians most often report using drug samples to avoid cost to the patient.”⁶

Sure, local culture drives some prescribing practice, but one must be mindful of the reality that the pharmaceutical industry has significant influence. Plus, free drug samples help patients in the short term. Once the samples are gone, an expensive prescription for that new drug will follow. It’s another win for the industry and another loss for the patient and the healthcare system.

Many studies have shown that gifting exerts influence, even if doctors are unwilling to admit it. But patients and doctors alike would like to state with clarity of conscience that the medication prescribed is only based on clinical evidence, not influence. TH

Dr. Pyke is a hospitalist at Geisinger Wyoming Valley Medical Systems in Mountain Top, Pa.

References

1. Dubovsky SL, Kaye DL, Pristach CA, DelRegno P, Pessar L, Stiles K. Can academic departments maintain industry relationships while promoting physician professionalism? Acad Med. 2010;85(1):68-73.
2. Salganik MW, Hopkins JS, Rockoff JD. Medical salesmen prescribe lunches. Catering trade feeds on rep-doctor meals. The Baltimore Sun. July 29, 2006.
3. Institute of Medicine Conflict of Interest in Medical Research, Education and Practice Full Recommendations. 4-28-09.
4. Wolfe SM. Why do American drug companies spend more than $12 billion a year pushing drugs? Is it education or promotion? J Gen Intern Med. 2007;11(10):637-639.
5. Adair RF, Holmgren LR. Do drug samples influence resident prescribing behavior? A randomized trial. Am J Med. 2005;118(8):881-884.
6. Chew LD, O’Young TS, Hazlet TK, Bradley KA, Maynard C, Lessler DS. A physician survey of the effect of drug sample availability on physicians’ behavior. J Gen Intern Med. 2000;15(7):478-483.

Dr. Pyke

Recent discussions on conflicts of interest in medical publications underscore the significance of the important yet fragile relationship between the pharmaceutical industry and healthcare professionals. Among these is an examination of how academic departments can maintain a relationship with the industry.¹ This study suggests that if appropriate boundaries are established between industry and academia, it is possible to collaborate. However, part of the policy in this investigation included “elimination of industry-supplied meals, gifts, and favors.”²

The Institute of Medicine’s “Conflict of Interest in Medical Research, Education, and Practice” included groundbreaking recommendations.3 Among them was a call for professionals to adopt a policy that prohibits “the acceptance of items of material value from pharmaceutical, medical device, and biotechnology companies, except in specified situations.”³

Our nation has been embroiled in a healthcare debate. Questions of right versus privilege, access versus affordability, and, of course, the perpetual political overlay have monopolized most of the discourse. Some contend that healthcare reform will redefine the current relationship between pharma and physicians . . . and not a moment too soon.

Lest there be ambiguity, though, the medical profession remains a noble vocation. This notwithstanding, until 2002, physicians freely participated in golf outings, received athletic tickets, and dined at five-star restaurants. But after the pharmaceutical industry smartly adopted voluntary guidelines that restrict gifting to doctors, we are left with drug samples and, of course, the “free lunch.” Certainly, pharma can claim it has made significant contributions to furthering medical education and research. Many could argue the tangible negative effects that would follow if the funding suddenly were absent.

But let’s not kid ourselves: There is a good reason the pharmaceutical industry spends more than $12 billion per year on marketing to doctors.⁴ In 2006, Rep. Henry Waxman (D-Calif.) said, “It is obvious that drug companies provide these free lunches so their sales reps can get the doctor’s ear and influence the prescribing practices.”² Most doctors would never admit any such influence. It would be, however, disingenuous for any practicing physician to say there is none.

A randomized trial conducted by Adair et al concluded the “access to drug samples in clinic influences resident prescribing decisions. This could affect resident education and increase drug costs for patients.”⁵ An earlier study by Chew et al concluded “the availability of drug samples led physicians to dispense and subsequently prescribe drugs that differ from their preferred drug choice. Physicians most often report using drug samples to avoid cost to the patient.”⁶

Sure, local culture drives some prescribing practice, but one must be mindful of the reality that the pharmaceutical industry has significant influence. Plus, free drug samples help patients in the short term. Once the samples are gone, an expensive prescription for that new drug will follow. It’s another win for the industry and another loss for the patient and the healthcare system.

Many studies have shown that gifting exerts influence, even if doctors are unwilling to admit it. But patients and doctors alike would like to state with clarity of conscience that the medication prescribed is only based on clinical evidence, not influence. TH

Dr. Pyke is a hospitalist at Geisinger Wyoming Valley Medical Systems in Mountain Top, Pa.

References

1. Dubovsky SL, Kaye DL, Pristach CA, DelRegno P, Pessar L, Stiles K. Can academic departments maintain industry relationships while promoting physician professionalism? Acad Med. 2010;85(1):68-73.
2. Salganik MW, Hopkins JS, Rockoff JD. Medical salesmen prescribe lunches. Catering trade feeds on rep-doctor meals. The Baltimore Sun. July 29, 2006.
3. Institute of Medicine Conflict of Interest in Medical Research, Education and Practice Full Recommendations. 4-28-09.
4. Wolfe SM. Why do American drug companies spend more than $12 billion a year pushing drugs? Is it education or promotion? J Gen Intern Med. 2007;11(10):637-639.
5. Adair RF, Holmgren LR. Do drug samples influence resident prescribing behavior? A randomized trial. Am J Med. 2005;118(8):881-884.
6. Chew LD, O’Young TS, Hazlet TK, Bradley KA, Maynard C, Lessler DS. A physician survey of the effect of drug sample availability on physicians’ behavior. J Gen Intern Med. 2000;15(7):478-483.

Dr. Brezina

The pharmaceutical industry is big business, and its goal is to make money. If the industry can convince physicians to prescribe its medicines, then it makes more money.

Although pharmaceutical representatives brief physicians on new medications in an effort to encourage the use of their brand-name products, they also provide substantive information on the drugs that serves an educational purpose.

In the past, pharmaceutical companies—along with the medical device and biotechnology industries—showered physicians with expensive gifts, raising ethical questions about physicians’ obligation to the drug companies. Fair enough. These excessive practices were identified and curtailed—to my knowledge—some years ago.

Dr. Brezina

Watchdog groups, however, have continued to call into question every suggestion of “being in the pay” of big pharma. Everything from a plastic pen to a piece of pizza is suspect. There is considerable concern that practicing clinicians are influenced by the smallest gesture, while many large medical institutions continue to accept pharmaceutical-company-funded research grants. If big-pharma investment in research does not corrupt institutions, why is it assumed that carrying a pharmaceutical pen has such a pernicious effect on clinicians?

As a corollary to this question, does anyone really want to discontinue these important research studies just because they are funded by industry dollars?

Listening to drug representatives—even being seen in the vicinity—raises the eyebrows of purists. Do we really want physicians completely divorced from all pharmaceutical company education and communication? Do we feel there is zero benefit to hearing about new medications from the company’s viewpoint?

If physicians completely shut out the representatives, it would be expected that pharmaceutical companies would direct their efforts elsewhere—most likely, to consumers. Is that a better and healthier scenario?

Clearly, there is potential for abuse in pharmaceutical gifts to physicians. The practice should be controlled and monitored. The suspicions raised by purist groups that physicians’ prescribing habits are unalterably biased after a five-minute pharmaceutical representative detail and a chicken sandwich is hyperbole. The voice of reason is silenced in the midst of the inquisition.

In the academic setting, fear of being accused of “bought bias” has physicians clearing their pockets of tainted pens and checking their desks for corrupting paraphernalia. The positive aspects of pharma-sponsored programs and medical lectures are lost for fear of appearing to be complicit with drug companies.

The Aristotelian Golden Mean is superior to extreme positions, and I submit that the best road is the center. Listen to what the drug company representatives have to say, just like you listen to a car salesman: You can learn from both—as long as you research the data and form your own opinion. TH

Dr. Brezina is a hospitalist at Durham Regional Hospital in North Carolina.

Dr. Brezina

The pharmaceutical industry is big business, and its goal is to make money. If the industry can convince physicians to prescribe its medicines, then it makes more money.

Although pharmaceutical representatives brief physicians on new medications in an effort to encourage the use of their brand-name products, they also provide substantive information on the drugs that serves an educational purpose.

In the past, pharmaceutical companies—along with the medical device and biotechnology industries—showered physicians with expensive gifts, raising ethical questions about physicians’ obligation to the drug companies. Fair enough. These excessive practices were identified and curtailed—to my knowledge—some years ago.

Dr. Brezina

Watchdog groups, however, have continued to call into question every suggestion of “being in the pay” of big pharma. Everything from a plastic pen to a piece of pizza is suspect. There is considerable concern that practicing clinicians are influenced by the smallest gesture, while many large medical institutions continue to accept pharmaceutical-company-funded research grants. If big-pharma investment in research does not corrupt institutions, why is it assumed that carrying a pharmaceutical pen has such a pernicious effect on clinicians?

As a corollary to this question, does anyone really want to discontinue these important research studies just because they are funded by industry dollars?

Listening to drug representatives—even being seen in the vicinity—raises the eyebrows of purists. Do we really want physicians completely divorced from all pharmaceutical company education and communication? Do we feel there is zero benefit to hearing about new medications from the company’s viewpoint?

If physicians completely shut out the representatives, it would be expected that pharmaceutical companies would direct their efforts elsewhere—most likely, to consumers. Is that a better and healthier scenario?

Clearly, there is potential for abuse in pharmaceutical gifts to physicians. The practice should be controlled and monitored. The suspicions raised by purist groups that physicians’ prescribing habits are unalterably biased after a five-minute pharmaceutical representative detail and a chicken sandwich is hyperbole. The voice of reason is silenced in the midst of the inquisition.

In the academic setting, fear of being accused of “bought bias” has physicians clearing their pockets of tainted pens and checking their desks for corrupting paraphernalia. The positive aspects of pharma-sponsored programs and medical lectures are lost for fear of appearing to be complicit with drug companies.

The Aristotelian Golden Mean is superior to extreme positions, and I submit that the best road is the center. Listen to what the drug company representatives have to say, just like you listen to a car salesman: You can learn from both—as long as you research the data and form your own opinion. TH

Dr. Brezina is a hospitalist at Durham Regional Hospital in North Carolina.

Dr. Brezina

The pharmaceutical industry is big business, and its goal is to make money. If the industry can convince physicians to prescribe its medicines, then it makes more money.

Although pharmaceutical representatives brief physicians on new medications in an effort to encourage the use of their brand-name products, they also provide substantive information on the drugs that serves an educational purpose.

In the past, pharmaceutical companies—along with the medical device and biotechnology industries—showered physicians with expensive gifts, raising ethical questions about physicians’ obligation to the drug companies. Fair enough. These excessive practices were identified and curtailed—to my knowledge—some years ago.

Dr. Brezina

Watchdog groups, however, have continued to call into question every suggestion of “being in the pay” of big pharma. Everything from a plastic pen to a piece of pizza is suspect. There is considerable concern that practicing clinicians are influenced by the smallest gesture, while many large medical institutions continue to accept pharmaceutical-company-funded research grants. If big-pharma investment in research does not corrupt institutions, why is it assumed that carrying a pharmaceutical pen has such a pernicious effect on clinicians?

As a corollary to this question, does anyone really want to discontinue these important research studies just because they are funded by industry dollars?

Listening to drug representatives—even being seen in the vicinity—raises the eyebrows of purists. Do we really want physicians completely divorced from all pharmaceutical company education and communication? Do we feel there is zero benefit to hearing about new medications from the company’s viewpoint?

If physicians completely shut out the representatives, it would be expected that pharmaceutical companies would direct their efforts elsewhere—most likely, to consumers. Is that a better and healthier scenario?

Clearly, there is potential for abuse in pharmaceutical gifts to physicians. The practice should be controlled and monitored. The suspicions raised by purist groups that physicians’ prescribing habits are unalterably biased after a five-minute pharmaceutical representative detail and a chicken sandwich is hyperbole. The voice of reason is silenced in the midst of the inquisition.

In the academic setting, fear of being accused of “bought bias” has physicians clearing their pockets of tainted pens and checking their desks for corrupting paraphernalia. The positive aspects of pharma-sponsored programs and medical lectures are lost for fear of appearing to be complicit with drug companies.

The Aristotelian Golden Mean is superior to extreme positions, and I submit that the best road is the center. Listen to what the drug company representatives have to say, just like you listen to a car salesman: You can learn from both—as long as you research the data and form your own opinion. TH

Dr. Brezina is a hospitalist at Durham Regional Hospital in North Carolina.

Last month I began looking at ways hospitalist practices can manage unpredictable increases in patient volume, also known as surge staffing. I provided my view of a “jeopardy” system and a patient volume cap for hospitalists. While both are potentially very effective, they have a high cost and in my view are imperfect solutions. This month I’ll examine some less common strategies to provide surge staffing. Although less popular, I think these options are more valuable.

Schedule More Providers

I’ve worked with a lot of practices and am struck by how patient volume for nearly all of them falls within a reasonably predictable range. While no one can predict with certainty which days will be unusually busy or slow, nearly all practices have a range of daily encounters that is roughly half to 1 1/2 of the mean. For example, if a practice has a mean of 60 billable encounters per day, it probably ranges from about 30 to 90 encounters on any given day. (The larger the practice, the more likely they are to conform to this range. Small practices, with average daily encounters fewer than 20, have a much wider range of daily volumes as a percent of the mean.)

Despite knowing that volumes will vary unpredictably, most practices provide the same fixed “dose” of provider staffing every day—that is, the single most common model for staffing and scheduling is to provide a fixed number of day-shift doctors (“rounders”) who work a fixed number of hours. For example, with an average of 60 billable encounters a day, a hospitalist group might decide to staff with four day-shift rounders working 12-hour shifts. This equates to a fixed 48 hours of daytime staffing. This is reasonable until the busy days arrive. Those four doctors will be much busier than average when there are 90 patients to see in a day, and will probably have a hard time seeing 22 or 23 patients each during their 12-hour shift. If such a busy day occurs more than a couple of times annually, then the practice should probably make some changes.

One approach to solving this type of staffing predicament is to add a fifth day-shift rounder. In other words, when making staffing decisions, consider giving more weight to the busiest days than the average day. This sounds fine until thinking about the practice budget. It will be pretty expensive to add doctors every day just so there are enough on duty when things get really busy. But if the hospitalists are willing to accept reduced compensation, then it might be financially reasonable to go ahead and add staff. This is easiest to do when the hospitalists are paid a significant (e.g. ≥50%) portion of their income based on their productivity, which will enable the hospitalists themselves to have a lot of say about when it is time to add staff. (Being paid on a nearly fixed annual salary means that it is the finance person who usually has the say about when it is time to add staff. And you can bet he’ll be making staffing decisions based on the average daily encounters, rather than the busy days.)

My own preference would be to do just that: Accept a reduction in compensation in return for protection against really busy and stressful days. I’m not suggesting others should agree with me, and in my experience, most don’t. (My own practice partners don’t agree with me on this one.) So I’m not really recommending it as a best practice, but I want to ensure that you don’t forget it is an option. And keep in mind you could adjust staffing by degrees; some settings might add a half-time physician or a nonphysician provider to try to find the sweet spot between having enough staff on duty every day to handle surges in volume and the cost of that staffing to the employer—or the hospitalists themselves.

Of course, if I were willing to reduce my compensation and average daily workload, then I would expect to be freed from the expectation that all rounding doctors work 12-hour shifts. Let’s turn our attention to the interplay between fixed day-shift durations and surge staffing.

Fixed-Shift Schedules Inhibit Surge Capacity

I think it usually is best to avoid fixed durations for day shifts. It might be necessary to require at least one daytime rounder to stay at least until a specified time (e.g. the arrival of the night-shift doctor), but in most cases it is reasonable for some rounders to leave when their work is done. They might need to continue responding to pages until the start of the night shift, but it usually isn’t necessary to have all rounders in the hospital until a predetermined end of the shift.

The problem is that when shifts have a fixed duration, the providers will focus on the start and stop time of their shift and might be unwilling to work beyond it. If instead there are no clearly fixed start and stop times for each day shift, then the hospitalists are likely to be willing to simply work longer on busy days, as long as they can work shorter on slow days. This is probably the most effective method of surge capacity, and it fits well with staffing each day with more providers than are required for the average patient volume.

Simply having the rounding doctors work longer on busy days must be done within reason. And there is a really wide range of opinion about what is reasonable. I think it is reasonable if a hospitalist works two or three hours longer than usual for three or four consecutive busy days, as long as the hospitalist is allowed to work less on days that are not very busy. But just what is a reasonable maximum daily amount of work for even one day is a topic that can lead to passionate debate. You’ll have to decide the details of what is and isn’t acceptable in your group.

Unit-Based Assignments

Aside from fixed-duration day shifts, unit-based assignment of hospitalists is the most common practice inhibiting surge capacity. Not long ago I worked with a practice that followed very strict unit-based assignments, which significantly inhibited “load-leveling,” and thus surge capacity. On any given day the patient volume for the whole practice might be very reasonable, but because it was never distributed evenly among the rounders, there was a very good chance that at least one doctor was drowning in work. And because of the strict approach, the other doctors didn’t come to the rescue.

I think the only reasonable approach is to deviate from such a strict unit-based assignment, at least a little. One rounder could be a utility doctor who doesn’t have her own unit and instead roams throughout the hospital, having been assigned patients based on the workload of each of her unit-based colleagues. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is cofounder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants (www.nelsonflores.com) and codirector and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.

Last month I began looking at ways hospitalist practices can manage unpredictable increases in patient volume, also known as surge staffing. I provided my view of a “jeopardy” system and a patient volume cap for hospitalists. While both are potentially very effective, they have a high cost and in my view are imperfect solutions. This month I’ll examine some less common strategies to provide surge staffing. Although less popular, I think these options are more valuable.

Schedule More Providers

I’ve worked with a lot of practices and am struck by how patient volume for nearly all of them falls within a reasonably predictable range. While no one can predict with certainty which days will be unusually busy or slow, nearly all practices have a range of daily encounters that is roughly half to 1 1/2 of the mean. For example, if a practice has a mean of 60 billable encounters per day, it probably ranges from about 30 to 90 encounters on any given day. (The larger the practice, the more likely they are to conform to this range. Small practices, with average daily encounters fewer than 20, have a much wider range of daily volumes as a percent of the mean.)

Despite knowing that volumes will vary unpredictably, most practices provide the same fixed “dose” of provider staffing every day—that is, the single most common model for staffing and scheduling is to provide a fixed number of day-shift doctors (“rounders”) who work a fixed number of hours. For example, with an average of 60 billable encounters a day, a hospitalist group might decide to staff with four day-shift rounders working 12-hour shifts. This equates to a fixed 48 hours of daytime staffing. This is reasonable until the busy days arrive. Those four doctors will be much busier than average when there are 90 patients to see in a day, and will probably have a hard time seeing 22 or 23 patients each during their 12-hour shift. If such a busy day occurs more than a couple of times annually, then the practice should probably make some changes.

One approach to solving this type of staffing predicament is to add a fifth day-shift rounder. In other words, when making staffing decisions, consider giving more weight to the busiest days than the average day. This sounds fine until thinking about the practice budget. It will be pretty expensive to add doctors every day just so there are enough on duty when things get really busy. But if the hospitalists are willing to accept reduced compensation, then it might be financially reasonable to go ahead and add staff. This is easiest to do when the hospitalists are paid a significant (e.g. ≥50%) portion of their income based on their productivity, which will enable the hospitalists themselves to have a lot of say about when it is time to add staff. (Being paid on a nearly fixed annual salary means that it is the finance person who usually has the say about when it is time to add staff. And you can bet he’ll be making staffing decisions based on the average daily encounters, rather than the busy days.)

My own preference would be to do just that: Accept a reduction in compensation in return for protection against really busy and stressful days. I’m not suggesting others should agree with me, and in my experience, most don’t. (My own practice partners don’t agree with me on this one.) So I’m not really recommending it as a best practice, but I want to ensure that you don’t forget it is an option. And keep in mind you could adjust staffing by degrees; some settings might add a half-time physician or a nonphysician provider to try to find the sweet spot between having enough staff on duty every day to handle surges in volume and the cost of that staffing to the employer—or the hospitalists themselves.

Of course, if I were willing to reduce my compensation and average daily workload, then I would expect to be freed from the expectation that all rounding doctors work 12-hour shifts. Let’s turn our attention to the interplay between fixed day-shift durations and surge staffing.

Fixed-Shift Schedules Inhibit Surge Capacity

I think it usually is best to avoid fixed durations for day shifts. It might be necessary to require at least one daytime rounder to stay at least until a specified time (e.g. the arrival of the night-shift doctor), but in most cases it is reasonable for some rounders to leave when their work is done. They might need to continue responding to pages until the start of the night shift, but it usually isn’t necessary to have all rounders in the hospital until a predetermined end of the shift.

The problem is that when shifts have a fixed duration, the providers will focus on the start and stop time of their shift and might be unwilling to work beyond it. If instead there are no clearly fixed start and stop times for each day shift, then the hospitalists are likely to be willing to simply work longer on busy days, as long as they can work shorter on slow days. This is probably the most effective method of surge capacity, and it fits well with staffing each day with more providers than are required for the average patient volume.

Simply having the rounding doctors work longer on busy days must be done within reason. And there is a really wide range of opinion about what is reasonable. I think it is reasonable if a hospitalist works two or three hours longer than usual for three or four consecutive busy days, as long as the hospitalist is allowed to work less on days that are not very busy. But just what is a reasonable maximum daily amount of work for even one day is a topic that can lead to passionate debate. You’ll have to decide the details of what is and isn’t acceptable in your group.

Unit-Based Assignments

Aside from fixed-duration day shifts, unit-based assignment of hospitalists is the most common practice inhibiting surge capacity. Not long ago I worked with a practice that followed very strict unit-based assignments, which significantly inhibited “load-leveling,” and thus surge capacity. On any given day the patient volume for the whole practice might be very reasonable, but because it was never distributed evenly among the rounders, there was a very good chance that at least one doctor was drowning in work. And because of the strict approach, the other doctors didn’t come to the rescue.

I think the only reasonable approach is to deviate from such a strict unit-based assignment, at least a little. One rounder could be a utility doctor who doesn’t have her own unit and instead roams throughout the hospital, having been assigned patients based on the workload of each of her unit-based colleagues. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is cofounder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants (www.nelsonflores.com) and codirector and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.

Last month I began looking at ways hospitalist practices can manage unpredictable increases in patient volume, also known as surge staffing. I provided my view of a “jeopardy” system and a patient volume cap for hospitalists. While both are potentially very effective, they have a high cost and in my view are imperfect solutions. This month I’ll examine some less common strategies to provide surge staffing. Although less popular, I think these options are more valuable.

Schedule More Providers

I’ve worked with a lot of practices and am struck by how patient volume for nearly all of them falls within a reasonably predictable range. While no one can predict with certainty which days will be unusually busy or slow, nearly all practices have a range of daily encounters that is roughly half to 1 1/2 of the mean. For example, if a practice has a mean of 60 billable encounters per day, it probably ranges from about 30 to 90 encounters on any given day. (The larger the practice, the more likely they are to conform to this range. Small practices, with average daily encounters fewer than 20, have a much wider range of daily volumes as a percent of the mean.)

Despite knowing that volumes will vary unpredictably, most practices provide the same fixed “dose” of provider staffing every day—that is, the single most common model for staffing and scheduling is to provide a fixed number of day-shift doctors (“rounders”) who work a fixed number of hours. For example, with an average of 60 billable encounters a day, a hospitalist group might decide to staff with four day-shift rounders working 12-hour shifts. This equates to a fixed 48 hours of daytime staffing. This is reasonable until the busy days arrive. Those four doctors will be much busier than average when there are 90 patients to see in a day, and will probably have a hard time seeing 22 or 23 patients each during their 12-hour shift. If such a busy day occurs more than a couple of times annually, then the practice should probably make some changes.

One approach to solving this type of staffing predicament is to add a fifth day-shift rounder. In other words, when making staffing decisions, consider giving more weight to the busiest days than the average day. This sounds fine until thinking about the practice budget. It will be pretty expensive to add doctors every day just so there are enough on duty when things get really busy. But if the hospitalists are willing to accept reduced compensation, then it might be financially reasonable to go ahead and add staff. This is easiest to do when the hospitalists are paid a significant (e.g. ≥50%) portion of their income based on their productivity, which will enable the hospitalists themselves to have a lot of say about when it is time to add staff. (Being paid on a nearly fixed annual salary means that it is the finance person who usually has the say about when it is time to add staff. And you can bet he’ll be making staffing decisions based on the average daily encounters, rather than the busy days.)

My own preference would be to do just that: Accept a reduction in compensation in return for protection against really busy and stressful days. I’m not suggesting others should agree with me, and in my experience, most don’t. (My own practice partners don’t agree with me on this one.) So I’m not really recommending it as a best practice, but I want to ensure that you don’t forget it is an option. And keep in mind you could adjust staffing by degrees; some settings might add a half-time physician or a nonphysician provider to try to find the sweet spot between having enough staff on duty every day to handle surges in volume and the cost of that staffing to the employer—or the hospitalists themselves.

Of course, if I were willing to reduce my compensation and average daily workload, then I would expect to be freed from the expectation that all rounding doctors work 12-hour shifts. Let’s turn our attention to the interplay between fixed day-shift durations and surge staffing.

Fixed-Shift Schedules Inhibit Surge Capacity

I think it usually is best to avoid fixed durations for day shifts. It might be necessary to require at least one daytime rounder to stay at least until a specified time (e.g. the arrival of the night-shift doctor), but in most cases it is reasonable for some rounders to leave when their work is done. They might need to continue responding to pages until the start of the night shift, but it usually isn’t necessary to have all rounders in the hospital until a predetermined end of the shift.

The problem is that when shifts have a fixed duration, the providers will focus on the start and stop time of their shift and might be unwilling to work beyond it. If instead there are no clearly fixed start and stop times for each day shift, then the hospitalists are likely to be willing to simply work longer on busy days, as long as they can work shorter on slow days. This is probably the most effective method of surge capacity, and it fits well with staffing each day with more providers than are required for the average patient volume.

Simply having the rounding doctors work longer on busy days must be done within reason. And there is a really wide range of opinion about what is reasonable. I think it is reasonable if a hospitalist works two or three hours longer than usual for three or four consecutive busy days, as long as the hospitalist is allowed to work less on days that are not very busy. But just what is a reasonable maximum daily amount of work for even one day is a topic that can lead to passionate debate. You’ll have to decide the details of what is and isn’t acceptable in your group.

Unit-Based Assignments

Aside from fixed-duration day shifts, unit-based assignment of hospitalists is the most common practice inhibiting surge capacity. Not long ago I worked with a practice that followed very strict unit-based assignments, which significantly inhibited “load-leveling,” and thus surge capacity. On any given day the patient volume for the whole practice might be very reasonable, but because it was never distributed evenly among the rounders, there was a very good chance that at least one doctor was drowning in work. And because of the strict approach, the other doctors didn’t come to the rescue.

I think the only reasonable approach is to deviate from such a strict unit-based assignment, at least a little. One rounder could be a utility doctor who doesn’t have her own unit and instead roams throughout the hospital, having been assigned patients based on the workload of each of her unit-based colleagues. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is cofounder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants (www.nelsonflores.com) and codirector and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.