Practice Economics

What this has done is impose additional administrative requirements that now take time away from our seeing patients or doing clinical activity.

—Joshua Lenchus, DO, RPh, FACP, SFHM

Hospitalist leaders are taking a wait-and-see approach to the Physician Payment Sunshine Act, which requires reporting of payments and gifts from drug and medical device companies. But as wary as many are after publication of the Final Rule 1 in February, SHM and other groups already have claimed at least one victory in tweaking the new rules.

The Sunshine Rule, as it’s known, was included in the Affordable Care Act of 2010. The rule, created by the Centers for Medicaid & Medicare Services (CMS), requires manufacturers to publicly report gifts, payments, or other transfers of value to physicians from pharmaceutical and medical device manufacturers worth more than $10 (see “Dos and Don’ts,” below).¹

One major change to the law sought by SHM and others was tied to the reporting of indirect payments to speakers at accredited continuing medical education (CME) classes or courses. The proposed rule required reporting of those payments even if a particular industry group did not select the speakers or pay them. SHM and three dozen other societies lobbied CMS to change the rule.² The final rule says indirect payments don’t have to be reported if the CME program meets widely accepted accreditation standards and the industry participant is neither directly paid nor selected by the vendor.

CME Coalition, a Washington, D.C.-based advocacy group, said in a statement the caveat recognizes that CMS “is sending a strong message to commercial supporters: Underwriting accredited continuing education programs for health-care providers is to be applauded, not restricted.”

SHM Public Policy Committee member Joshua Lenchus, DO, RPh, FACP, SFHM, said the initial rule was too restrictive and could have reduced physician participation in important CME activities. He said the Accreditation Council for Continuing Medical Education (ACCME) and other industry groups already govern the ethical issue of accepting direct payments that could imply bias to patients.

“I’m not so sure we needed the Sunshine Act as part of the ACA at all because these same things were in effect from the ACCME and other CME accrediting organizations,” said Dr. Lenchus, a Team Hospitalist member and president of the medical staff at Jackson Health System in Miami. “What this has done is impose additional administrative requirements that now take time away from our seeing patients or doing clinical activity.”

Those costs will add up quickly, according to figures from the Federal Register, Dr. Lenchus said. CMS projects the administrative costs of reviewing reports at $1.9 million for teaching hospital staff—the category Dr. Lenchus says is most applicable to hospitalists.

Dr. Lenchus says there was discussion within the Public Policy Committee about how much information needed to be publicly reported in relation to CME. Some members “wanted nothing recorded” and “some people wanted everything recorded.”

“The rule that has been implemented strikes a nice balance between the two,” he said.

Transparent Process

Industry groups and group purchasing organizations (GPOs) currently are working to put in place systems and procedures to begin collecting the data in August. Data will be collected through the end of 2013 and must be reported to CMS by March 31, 2014. CMS will then unveil a public website showcasing the information by Sept. 30, 2014.

Public Policy Committee member Jack Percelay, MD, MPH, FAAP, SFHM, said some hospitalists might feel they are “being picked on again” by having to report the added information. He instead looks at the intended push toward added transparency as “a set of obligations we have as physicians.”

“We have tremendous discretion about how health-care dollars are spent and with that comes a fiduciary responsibility, both to the patient and to the public,” he said. “This does not seem terribly burdensome to me. If I was getting nickel and dimed for every piece of candy I took through the exhibit hall during a meeting, that would be ridiculous. I’m happy to do this in a reasoned way.”

Dr. Percelay noted that the Sunshine Rule does not prevent industry payments to physicians or groups, but simply requires the public reporting and display of the remuneration. In that vein, he likened it to ethical rules that govern those who hold elected office.

“Someone should be able to Google and see that I’ve [received] funds from market research,” he said. “It’s not much different from politicians. It’s then up to the public and the media to do their due diligence.”

Dr. Lenchus said the public database has the potential to be misinterpreted by a public unfamiliar with how health care works. In particular, patients might not be able to discern the differences between the value of lunches, the payments for being on advisory boards, and industry-funded research.

“I really fear the public will look at this website, see there is any financial inducement to any physician, and erroneously conclude that any prescription of that company’s medication means that person is getting a kickback,” he says. “And we know that’s absolutely false.”

Richard Quinn is a freelance writer in New Jersey.

References

1. Centers for Medicare & Medicaid Services. Medicare, Medicaid, Children’s Health Insurance Programs; transparency reports and reporting of physician ownership or investment interests. Federal Register website. Available at: https://www.federalregister.gov/articles/2013/02/08/2013-02572/medicare-mediaid-childrens-health-insurance-programs-transparency-reports-and-reporting-of. Accessed March 24, 2013.
2. Council of Medical Specialty Societies. Letter to CMS. SHM website. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Letters_to_Congress_ and_Regulatory_Agencies&Template=/CM/ContentDisplay.cfm&ContentID=30674. Accessed March 24, 2013.

What this has done is impose additional administrative requirements that now take time away from our seeing patients or doing clinical activity.

—Joshua Lenchus, DO, RPh, FACP, SFHM

Hospitalist leaders are taking a wait-and-see approach to the Physician Payment Sunshine Act, which requires reporting of payments and gifts from drug and medical device companies. But as wary as many are after publication of the Final Rule 1 in February, SHM and other groups already have claimed at least one victory in tweaking the new rules.

The Sunshine Rule, as it’s known, was included in the Affordable Care Act of 2010. The rule, created by the Centers for Medicaid & Medicare Services (CMS), requires manufacturers to publicly report gifts, payments, or other transfers of value to physicians from pharmaceutical and medical device manufacturers worth more than $10 (see “Dos and Don’ts,” below).¹

One major change to the law sought by SHM and others was tied to the reporting of indirect payments to speakers at accredited continuing medical education (CME) classes or courses. The proposed rule required reporting of those payments even if a particular industry group did not select the speakers or pay them. SHM and three dozen other societies lobbied CMS to change the rule.² The final rule says indirect payments don’t have to be reported if the CME program meets widely accepted accreditation standards and the industry participant is neither directly paid nor selected by the vendor.

CME Coalition, a Washington, D.C.-based advocacy group, said in a statement the caveat recognizes that CMS “is sending a strong message to commercial supporters: Underwriting accredited continuing education programs for health-care providers is to be applauded, not restricted.”

SHM Public Policy Committee member Joshua Lenchus, DO, RPh, FACP, SFHM, said the initial rule was too restrictive and could have reduced physician participation in important CME activities. He said the Accreditation Council for Continuing Medical Education (ACCME) and other industry groups already govern the ethical issue of accepting direct payments that could imply bias to patients.

“I’m not so sure we needed the Sunshine Act as part of the ACA at all because these same things were in effect from the ACCME and other CME accrediting organizations,” said Dr. Lenchus, a Team Hospitalist member and president of the medical staff at Jackson Health System in Miami. “What this has done is impose additional administrative requirements that now take time away from our seeing patients or doing clinical activity.”

Those costs will add up quickly, according to figures from the Federal Register, Dr. Lenchus said. CMS projects the administrative costs of reviewing reports at $1.9 million for teaching hospital staff—the category Dr. Lenchus says is most applicable to hospitalists.

Dr. Lenchus says there was discussion within the Public Policy Committee about how much information needed to be publicly reported in relation to CME. Some members “wanted nothing recorded” and “some people wanted everything recorded.”

“The rule that has been implemented strikes a nice balance between the two,” he said.

Transparent Process

Industry groups and group purchasing organizations (GPOs) currently are working to put in place systems and procedures to begin collecting the data in August. Data will be collected through the end of 2013 and must be reported to CMS by March 31, 2014. CMS will then unveil a public website showcasing the information by Sept. 30, 2014.

Public Policy Committee member Jack Percelay, MD, MPH, FAAP, SFHM, said some hospitalists might feel they are “being picked on again” by having to report the added information. He instead looks at the intended push toward added transparency as “a set of obligations we have as physicians.”

“We have tremendous discretion about how health-care dollars are spent and with that comes a fiduciary responsibility, both to the patient and to the public,” he said. “This does not seem terribly burdensome to me. If I was getting nickel and dimed for every piece of candy I took through the exhibit hall during a meeting, that would be ridiculous. I’m happy to do this in a reasoned way.”

Dr. Percelay noted that the Sunshine Rule does not prevent industry payments to physicians or groups, but simply requires the public reporting and display of the remuneration. In that vein, he likened it to ethical rules that govern those who hold elected office.

“Someone should be able to Google and see that I’ve [received] funds from market research,” he said. “It’s not much different from politicians. It’s then up to the public and the media to do their due diligence.”

Dr. Lenchus said the public database has the potential to be misinterpreted by a public unfamiliar with how health care works. In particular, patients might not be able to discern the differences between the value of lunches, the payments for being on advisory boards, and industry-funded research.

“I really fear the public will look at this website, see there is any financial inducement to any physician, and erroneously conclude that any prescription of that company’s medication means that person is getting a kickback,” he says. “And we know that’s absolutely false.”

Richard Quinn is a freelance writer in New Jersey.

References

1. Centers for Medicare & Medicaid Services. Medicare, Medicaid, Children’s Health Insurance Programs; transparency reports and reporting of physician ownership or investment interests. Federal Register website. Available at: https://www.federalregister.gov/articles/2013/02/08/2013-02572/medicare-mediaid-childrens-health-insurance-programs-transparency-reports-and-reporting-of. Accessed March 24, 2013.
2. Council of Medical Specialty Societies. Letter to CMS. SHM website. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Letters_to_Congress_ and_Regulatory_Agencies&Template=/CM/ContentDisplay.cfm&ContentID=30674. Accessed March 24, 2013.

What this has done is impose additional administrative requirements that now take time away from our seeing patients or doing clinical activity.

—Joshua Lenchus, DO, RPh, FACP, SFHM

Hospitalist leaders are taking a wait-and-see approach to the Physician Payment Sunshine Act, which requires reporting of payments and gifts from drug and medical device companies. But as wary as many are after publication of the Final Rule 1 in February, SHM and other groups already have claimed at least one victory in tweaking the new rules.

The Sunshine Rule, as it’s known, was included in the Affordable Care Act of 2010. The rule, created by the Centers for Medicaid & Medicare Services (CMS), requires manufacturers to publicly report gifts, payments, or other transfers of value to physicians from pharmaceutical and medical device manufacturers worth more than $10 (see “Dos and Don’ts,” below).¹

One major change to the law sought by SHM and others was tied to the reporting of indirect payments to speakers at accredited continuing medical education (CME) classes or courses. The proposed rule required reporting of those payments even if a particular industry group did not select the speakers or pay them. SHM and three dozen other societies lobbied CMS to change the rule.² The final rule says indirect payments don’t have to be reported if the CME program meets widely accepted accreditation standards and the industry participant is neither directly paid nor selected by the vendor.

CME Coalition, a Washington, D.C.-based advocacy group, said in a statement the caveat recognizes that CMS “is sending a strong message to commercial supporters: Underwriting accredited continuing education programs for health-care providers is to be applauded, not restricted.”

SHM Public Policy Committee member Joshua Lenchus, DO, RPh, FACP, SFHM, said the initial rule was too restrictive and could have reduced physician participation in important CME activities. He said the Accreditation Council for Continuing Medical Education (ACCME) and other industry groups already govern the ethical issue of accepting direct payments that could imply bias to patients.

“I’m not so sure we needed the Sunshine Act as part of the ACA at all because these same things were in effect from the ACCME and other CME accrediting organizations,” said Dr. Lenchus, a Team Hospitalist member and president of the medical staff at Jackson Health System in Miami. “What this has done is impose additional administrative requirements that now take time away from our seeing patients or doing clinical activity.”

Those costs will add up quickly, according to figures from the Federal Register, Dr. Lenchus said. CMS projects the administrative costs of reviewing reports at $1.9 million for teaching hospital staff—the category Dr. Lenchus says is most applicable to hospitalists.

Dr. Lenchus says there was discussion within the Public Policy Committee about how much information needed to be publicly reported in relation to CME. Some members “wanted nothing recorded” and “some people wanted everything recorded.”

“The rule that has been implemented strikes a nice balance between the two,” he said.

Transparent Process

Industry groups and group purchasing organizations (GPOs) currently are working to put in place systems and procedures to begin collecting the data in August. Data will be collected through the end of 2013 and must be reported to CMS by March 31, 2014. CMS will then unveil a public website showcasing the information by Sept. 30, 2014.

Public Policy Committee member Jack Percelay, MD, MPH, FAAP, SFHM, said some hospitalists might feel they are “being picked on again” by having to report the added information. He instead looks at the intended push toward added transparency as “a set of obligations we have as physicians.”

“We have tremendous discretion about how health-care dollars are spent and with that comes a fiduciary responsibility, both to the patient and to the public,” he said. “This does not seem terribly burdensome to me. If I was getting nickel and dimed for every piece of candy I took through the exhibit hall during a meeting, that would be ridiculous. I’m happy to do this in a reasoned way.”

Dr. Percelay noted that the Sunshine Rule does not prevent industry payments to physicians or groups, but simply requires the public reporting and display of the remuneration. In that vein, he likened it to ethical rules that govern those who hold elected office.

“Someone should be able to Google and see that I’ve [received] funds from market research,” he said. “It’s not much different from politicians. It’s then up to the public and the media to do their due diligence.”

Dr. Lenchus said the public database has the potential to be misinterpreted by a public unfamiliar with how health care works. In particular, patients might not be able to discern the differences between the value of lunches, the payments for being on advisory boards, and industry-funded research.

“I really fear the public will look at this website, see there is any financial inducement to any physician, and erroneously conclude that any prescription of that company’s medication means that person is getting a kickback,” he says. “And we know that’s absolutely false.”

Richard Quinn is a freelance writer in New Jersey.

References

1. Centers for Medicare & Medicaid Services. Medicare, Medicaid, Children’s Health Insurance Programs; transparency reports and reporting of physician ownership or investment interests. Federal Register website. Available at: https://www.federalregister.gov/articles/2013/02/08/2013-02572/medicare-mediaid-childrens-health-insurance-programs-transparency-reports-and-reporting-of. Accessed March 24, 2013.
2. Council of Medical Specialty Societies. Letter to CMS. SHM website. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Letters_to_Congress_ and_Regulatory_Agencies&Template=/CM/ContentDisplay.cfm&ContentID=30674. Accessed March 24, 2013.

The “Billing and Coding Bandwagon” article in the May 2011 issue of The Hospitalist (p. 26) recently was brought to my attention and I have some concerns that the following statement gives a false impression of acceptable documentation: “When I first started working, I couldn’t believe that I could get audited and fined just because I didn’t add ‘10-point’ or ‘12-point’ to my note of ‘review of systems: negative,’” says hospitalist Amaka Nweke, MD, assistant director with Hospitalists Management Group (HMG) at Kenosha Medical Center in Kenosha, Wis. “I had a lot of frustration, because I had to repackage and re-present my notes in a manner that makes sense to Medicare but makes no sense to physicians.”

In fact, that would still not be considered acceptable documentation for services that require a complete review of systems (99222, 99223, 99219, 99220, 99235, and 99236). The documentation guidelines clearly state: “A complete ROS [review of systems] inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional body systems.” At least 10 organ systems must be reviewed. Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least 10 systems must be individually documented.

What Medicare is saying is the provider must have inquired about all 14 systems, not just 10 or 12. The term “point” means nothing in an ROS statement. “Systems” is the correct terminology, not “points.”

I am afraid the article is misleading and could be providing inappropriate documentation advice to hospitalists dealing with CMS and AMA guidelines.

The “Billing and Coding Bandwagon” article in the May 2011 issue of The Hospitalist (p. 26) recently was brought to my attention and I have some concerns that the following statement gives a false impression of acceptable documentation: “When I first started working, I couldn’t believe that I could get audited and fined just because I didn’t add ‘10-point’ or ‘12-point’ to my note of ‘review of systems: negative,’” says hospitalist Amaka Nweke, MD, assistant director with Hospitalists Management Group (HMG) at Kenosha Medical Center in Kenosha, Wis. “I had a lot of frustration, because I had to repackage and re-present my notes in a manner that makes sense to Medicare but makes no sense to physicians.”

In fact, that would still not be considered acceptable documentation for services that require a complete review of systems (99222, 99223, 99219, 99220, 99235, and 99236). The documentation guidelines clearly state: “A complete ROS [review of systems] inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional body systems.” At least 10 organ systems must be reviewed. Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least 10 systems must be individually documented.

What Medicare is saying is the provider must have inquired about all 14 systems, not just 10 or 12. The term “point” means nothing in an ROS statement. “Systems” is the correct terminology, not “points.”

I am afraid the article is misleading and could be providing inappropriate documentation advice to hospitalists dealing with CMS and AMA guidelines.

The “Billing and Coding Bandwagon” article in the May 2011 issue of The Hospitalist (p. 26) recently was brought to my attention and I have some concerns that the following statement gives a false impression of acceptable documentation: “When I first started working, I couldn’t believe that I could get audited and fined just because I didn’t add ‘10-point’ or ‘12-point’ to my note of ‘review of systems: negative,’” says hospitalist Amaka Nweke, MD, assistant director with Hospitalists Management Group (HMG) at Kenosha Medical Center in Kenosha, Wis. “I had a lot of frustration, because I had to repackage and re-present my notes in a manner that makes sense to Medicare but makes no sense to physicians.”

In fact, that would still not be considered acceptable documentation for services that require a complete review of systems (99222, 99223, 99219, 99220, 99235, and 99236). The documentation guidelines clearly state: “A complete ROS [review of systems] inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional body systems.” At least 10 organ systems must be reviewed. Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least 10 systems must be individually documented.

What Medicare is saying is the provider must have inquired about all 14 systems, not just 10 or 12. The term “point” means nothing in an ROS statement. “Systems” is the correct terminology, not “points.”

I am afraid the article is misleading and could be providing inappropriate documentation advice to hospitalists dealing with CMS and AMA guidelines.

There is an inherent power differential in the patient-doctor relationship: The patient comes to the doctor as an authority on his/her physical or emotional state and is thus either intellectually or emotionally dependent on the doctor’s treatment plan and advice. It is therefore absolutely essential that the doctor respect the patient as an equal participant in the treatment. Although the doctor certainly has knowledge about how similar conditions were successfully treated in the past, hopefully a medical professional will display an attitude of respect and mutual collaboration with the patient to resolve his/her problem.

Listening is a key component of conveying an attitude of respect toward the patient. Nowadays practitioners are most often taking notes at their computers while speaking with the patient. This is certainly time-efficient and may in fact be necessary in order for a medical practice to remain solvent with the demands of Medicare and insurance companies. However, multitasking does not convey to the patient that they are connecting with the doctor. Listening is a complex action, which not only involves the ears, but the eyes, the kinesthetic responses of the whole body, and attention to the patient’s nonverbal communication.

Some of the key faux pas to avoid when listening to the patient include:

• Not centering oneself before engaging in a “crucial conversation”;
• Not listening because one is thinking ahead to his/her own response;
• Not maintaining eye contact;
• Not being aware of when one feels challenged and/or defensive;
• Discouraging the patient from contributing his/her own ideas;
• Not allowing the patient to give feedback on what s/he heard as instructions; and
• Taking phone calls or allowing interruptions during a consultation.

It is always helpful to give a patient clear, written instructions about medications, diet, exercise, etc., that result from the consultation. Some doctors send this report via secure email to the patient for review, which is an excellent technique.

The art of apology is another topic that greatly impacts the doctor-patient relationship, as well as the doctor’s relationship with the patient’s family members. This art is a process that has recently emerged in the medical and medical insurance industries. Kaiser Permanente’s director of medical-legal affairs has adopted the practice of asking permission to videotape the actual conversation in which a physician apologizes to a patient for a mistake in a procedure. These conversations are meant to help medical professionals learn how to admit mistakes and ask for forgiveness. Oftentimes patients are looking for just such a communication, which may allow them to put to rest feelings of resentment, bitterness, and regret.

Our patients’ well-being is our ideal goal. Knowing that they have been heard and their feelings understood may in the long run allow patients and their families to heal mind/body/soul more powerfully than we had ever thought. Of course, in our litigious society this may well be an art that remains to be developed over the long term.

There is an inherent power differential in the patient-doctor relationship: The patient comes to the doctor as an authority on his/her physical or emotional state and is thus either intellectually or emotionally dependent on the doctor’s treatment plan and advice. It is therefore absolutely essential that the doctor respect the patient as an equal participant in the treatment. Although the doctor certainly has knowledge about how similar conditions were successfully treated in the past, hopefully a medical professional will display an attitude of respect and mutual collaboration with the patient to resolve his/her problem.

Listening is a key component of conveying an attitude of respect toward the patient. Nowadays practitioners are most often taking notes at their computers while speaking with the patient. This is certainly time-efficient and may in fact be necessary in order for a medical practice to remain solvent with the demands of Medicare and insurance companies. However, multitasking does not convey to the patient that they are connecting with the doctor. Listening is a complex action, which not only involves the ears, but the eyes, the kinesthetic responses of the whole body, and attention to the patient’s nonverbal communication.

Some of the key faux pas to avoid when listening to the patient include:

• Not centering oneself before engaging in a “crucial conversation”;
• Not listening because one is thinking ahead to his/her own response;
• Not maintaining eye contact;
• Not being aware of when one feels challenged and/or defensive;
• Discouraging the patient from contributing his/her own ideas;
• Not allowing the patient to give feedback on what s/he heard as instructions; and
• Taking phone calls or allowing interruptions during a consultation.

It is always helpful to give a patient clear, written instructions about medications, diet, exercise, etc., that result from the consultation. Some doctors send this report via secure email to the patient for review, which is an excellent technique.

The art of apology is another topic that greatly impacts the doctor-patient relationship, as well as the doctor’s relationship with the patient’s family members. This art is a process that has recently emerged in the medical and medical insurance industries. Kaiser Permanente’s director of medical-legal affairs has adopted the practice of asking permission to videotape the actual conversation in which a physician apologizes to a patient for a mistake in a procedure. These conversations are meant to help medical professionals learn how to admit mistakes and ask for forgiveness. Oftentimes patients are looking for just such a communication, which may allow them to put to rest feelings of resentment, bitterness, and regret.

Our patients’ well-being is our ideal goal. Knowing that they have been heard and their feelings understood may in the long run allow patients and their families to heal mind/body/soul more powerfully than we had ever thought. Of course, in our litigious society this may well be an art that remains to be developed over the long term.

There is an inherent power differential in the patient-doctor relationship: The patient comes to the doctor as an authority on his/her physical or emotional state and is thus either intellectually or emotionally dependent on the doctor’s treatment plan and advice. It is therefore absolutely essential that the doctor respect the patient as an equal participant in the treatment. Although the doctor certainly has knowledge about how similar conditions were successfully treated in the past, hopefully a medical professional will display an attitude of respect and mutual collaboration with the patient to resolve his/her problem.

Listening is a key component of conveying an attitude of respect toward the patient. Nowadays practitioners are most often taking notes at their computers while speaking with the patient. This is certainly time-efficient and may in fact be necessary in order for a medical practice to remain solvent with the demands of Medicare and insurance companies. However, multitasking does not convey to the patient that they are connecting with the doctor. Listening is a complex action, which not only involves the ears, but the eyes, the kinesthetic responses of the whole body, and attention to the patient’s nonverbal communication.

Some of the key faux pas to avoid when listening to the patient include:

• Not centering oneself before engaging in a “crucial conversation”;
• Not listening because one is thinking ahead to his/her own response;
• Not maintaining eye contact;
• Not being aware of when one feels challenged and/or defensive;
• Discouraging the patient from contributing his/her own ideas;
• Not allowing the patient to give feedback on what s/he heard as instructions; and
• Taking phone calls or allowing interruptions during a consultation.

It is always helpful to give a patient clear, written instructions about medications, diet, exercise, etc., that result from the consultation. Some doctors send this report via secure email to the patient for review, which is an excellent technique.

The art of apology is another topic that greatly impacts the doctor-patient relationship, as well as the doctor’s relationship with the patient’s family members. This art is a process that has recently emerged in the medical and medical insurance industries. Kaiser Permanente’s director of medical-legal affairs has adopted the practice of asking permission to videotape the actual conversation in which a physician apologizes to a patient for a mistake in a procedure. These conversations are meant to help medical professionals learn how to admit mistakes and ask for forgiveness. Oftentimes patients are looking for just such a communication, which may allow them to put to rest feelings of resentment, bitterness, and regret.

Our patients’ well-being is our ideal goal. Knowing that they have been heard and their feelings understood may in the long run allow patients and their families to heal mind/body/soul more powerfully than we had ever thought. Of course, in our litigious society this may well be an art that remains to be developed over the long term.

To my way of thinking, a person’s diagnosis or pathophysiology is not as strong a predictor of needing inpatient hospital care as it might have been 10 or 20 years ago. Rather than the clinical diagnosis (e.g. pneumonia), it seems to me that frailty or social complexity often are the principal determinants of which patients are admitted to a hospital for medical conditions.

Some of these patients are admitted frequently but appear to realize little or no benefit from hospitalization. These patients typically have little or no social support, and they often have either significant mental health disorders or substance abuse, or both. Much has been written about these patients, and I recommend an article by Dr. Atul Gawande in the Jan. 24, 2011, issue of The New Yorker titled “The Hot Spotters: Can We Lower Medical Costs by Giving the Neediest Patients Better Care?”

The Agency for Healthcare Research and Quality’s “Statistical Brief 354” on how health-care expenditures are allocated across the population reported that 1% of the population accounted for more than 22% of health-care spending in 2008. One in 5 of those were in that category again in 2009. Some of these patients would benefit from care plans.

The Role of Care Plans

It seems that there may be few effective inpatient interventions that will benefit these patients. After all, they have chronic issues that require ongoing relationships with outpatient providers, something that many of these patients lack. But for some (most?) of these patients, it seems clear that frequent hospitalizations don’t help and sometimes just perpetuate or worsen the patient’s dependence on the hospital at a high financial cost to society—and significant frustration and burnout on the part of hospital caregivers, including hospitalists.

For most hospitals, this problem is significant enough to require some sort of coordinated approach to the care of the dozens of types of patients in this category. Implementing whatever plan of care seems appropriate to the caregivers during each admission is frustrating, ensures lots of variation in care, and makes it easier for manipulative patients to abuse the hospital resources and personnel.

A better approach is to follow the same plan of care from one hospital visit to the next. You already knew that. But developing a care plan to follow during each ED visit and admission is time-consuming and often fraught with uncertainty about where boundaries should be set. So if you’re like me, you might just try to guide the patient to discharge this time and hope that whoever sees the patient on the next admission will take the initiative to develop the care plan. The result is that few such plans are developed.

Your Hospital Needs a Care Plan

Relying on individual doctors or nurses to take the initiative to develop care plans will almost always mean few plans are developed, they will vary in their effectiveness, and other providers may not be aware a plan exists. This was the case at the hospital where I practice until I heard Dr. Rick Hilger, MD, SFHM, a hospitalist at Regions Hospital in Minneapolis, present on this topic at HM12 in San Diego.

Dr. Hilger led a multidisciplinary team to develop care plans (they call them “restriction care plans”) and found that they dramatically reduced the rate of hospital admissions and ED visits for these patients. Hearing about this experience served as a kick in the pants for me, so I did much the same thing at “my” hospital. We have now developed plans for more than 20 patients and found that they visit our ED and are admitted less often. And, anecdotally at least, hospitalists and other hospital staff find that the care plans reduce, at least a little, the stress of caring for these patients.

Unanswered Questions

Although it seems clear that care plans reduce visits to the hospital that develops them, I suspect that some of these patients aren’t consuming any fewer health-care resources. They may just seek care from a different hospital.

My home state of Washington is working to develop individual patient care plans available to all hospitals in the state. A system called the Emergency Department Information Exchange (EDIE) has been adopted by nearly all the hospitals in the state. It allows them to share information on ED visits and such things as care plans with one another. For example, through EDIE, each hospital could see the opiate dosing schedule and admission criteria agreed to by patient and primary-care physician.

So it seems that care plans and the technology to share them can make it more difficult for patients to harm themselves by visiting many hospitals to get excessive opiate prescriptions, for example. This should benefit the patient and lower ED and hospital expenditures for these patients. But we don’t know what portion of costs simply is shifted to other settings, so there is no easy way to know the net effect on health-care costs.

An important unanswered question is whether these care plans improve patient well-being. It seems clear they do in some cases, but it is hard to know whether some patients may be worse off because of the plan.

Conclusion

I think nearly every hospital would benefit from a care plan committee composed of at least one hospitalist, ED physician, a nursing representative, and potentially other disciplines (see “Care Plan Attributes,” above). Our committee includes our inpatient psychiatrist, a really valuable contributor.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at john.nelson@nelsonflores.com.

To my way of thinking, a person’s diagnosis or pathophysiology is not as strong a predictor of needing inpatient hospital care as it might have been 10 or 20 years ago. Rather than the clinical diagnosis (e.g. pneumonia), it seems to me that frailty or social complexity often are the principal determinants of which patients are admitted to a hospital for medical conditions.

Some of these patients are admitted frequently but appear to realize little or no benefit from hospitalization. These patients typically have little or no social support, and they often have either significant mental health disorders or substance abuse, or both. Much has been written about these patients, and I recommend an article by Dr. Atul Gawande in the Jan. 24, 2011, issue of The New Yorker titled “The Hot Spotters: Can We Lower Medical Costs by Giving the Neediest Patients Better Care?”

The Agency for Healthcare Research and Quality’s “Statistical Brief 354” on how health-care expenditures are allocated across the population reported that 1% of the population accounted for more than 22% of health-care spending in 2008. One in 5 of those were in that category again in 2009. Some of these patients would benefit from care plans.

The Role of Care Plans

It seems that there may be few effective inpatient interventions that will benefit these patients. After all, they have chronic issues that require ongoing relationships with outpatient providers, something that many of these patients lack. But for some (most?) of these patients, it seems clear that frequent hospitalizations don’t help and sometimes just perpetuate or worsen the patient’s dependence on the hospital at a high financial cost to society—and significant frustration and burnout on the part of hospital caregivers, including hospitalists.

For most hospitals, this problem is significant enough to require some sort of coordinated approach to the care of the dozens of types of patients in this category. Implementing whatever plan of care seems appropriate to the caregivers during each admission is frustrating, ensures lots of variation in care, and makes it easier for manipulative patients to abuse the hospital resources and personnel.

A better approach is to follow the same plan of care from one hospital visit to the next. You already knew that. But developing a care plan to follow during each ED visit and admission is time-consuming and often fraught with uncertainty about where boundaries should be set. So if you’re like me, you might just try to guide the patient to discharge this time and hope that whoever sees the patient on the next admission will take the initiative to develop the care plan. The result is that few such plans are developed.

Your Hospital Needs a Care Plan

Relying on individual doctors or nurses to take the initiative to develop care plans will almost always mean few plans are developed, they will vary in their effectiveness, and other providers may not be aware a plan exists. This was the case at the hospital where I practice until I heard Dr. Rick Hilger, MD, SFHM, a hospitalist at Regions Hospital in Minneapolis, present on this topic at HM12 in San Diego.

Dr. Hilger led a multidisciplinary team to develop care plans (they call them “restriction care plans”) and found that they dramatically reduced the rate of hospital admissions and ED visits for these patients. Hearing about this experience served as a kick in the pants for me, so I did much the same thing at “my” hospital. We have now developed plans for more than 20 patients and found that they visit our ED and are admitted less often. And, anecdotally at least, hospitalists and other hospital staff find that the care plans reduce, at least a little, the stress of caring for these patients.

Unanswered Questions

Although it seems clear that care plans reduce visits to the hospital that develops them, I suspect that some of these patients aren’t consuming any fewer health-care resources. They may just seek care from a different hospital.

My home state of Washington is working to develop individual patient care plans available to all hospitals in the state. A system called the Emergency Department Information Exchange (EDIE) has been adopted by nearly all the hospitals in the state. It allows them to share information on ED visits and such things as care plans with one another. For example, through EDIE, each hospital could see the opiate dosing schedule and admission criteria agreed to by patient and primary-care physician.

So it seems that care plans and the technology to share them can make it more difficult for patients to harm themselves by visiting many hospitals to get excessive opiate prescriptions, for example. This should benefit the patient and lower ED and hospital expenditures for these patients. But we don’t know what portion of costs simply is shifted to other settings, so there is no easy way to know the net effect on health-care costs.

An important unanswered question is whether these care plans improve patient well-being. It seems clear they do in some cases, but it is hard to know whether some patients may be worse off because of the plan.

Conclusion

I think nearly every hospital would benefit from a care plan committee composed of at least one hospitalist, ED physician, a nursing representative, and potentially other disciplines (see “Care Plan Attributes,” above). Our committee includes our inpatient psychiatrist, a really valuable contributor.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at john.nelson@nelsonflores.com.

To my way of thinking, a person’s diagnosis or pathophysiology is not as strong a predictor of needing inpatient hospital care as it might have been 10 or 20 years ago. Rather than the clinical diagnosis (e.g. pneumonia), it seems to me that frailty or social complexity often are the principal determinants of which patients are admitted to a hospital for medical conditions.

Some of these patients are admitted frequently but appear to realize little or no benefit from hospitalization. These patients typically have little or no social support, and they often have either significant mental health disorders or substance abuse, or both. Much has been written about these patients, and I recommend an article by Dr. Atul Gawande in the Jan. 24, 2011, issue of The New Yorker titled “The Hot Spotters: Can We Lower Medical Costs by Giving the Neediest Patients Better Care?”

The Agency for Healthcare Research and Quality’s “Statistical Brief 354” on how health-care expenditures are allocated across the population reported that 1% of the population accounted for more than 22% of health-care spending in 2008. One in 5 of those were in that category again in 2009. Some of these patients would benefit from care plans.

The Role of Care Plans

It seems that there may be few effective inpatient interventions that will benefit these patients. After all, they have chronic issues that require ongoing relationships with outpatient providers, something that many of these patients lack. But for some (most?) of these patients, it seems clear that frequent hospitalizations don’t help and sometimes just perpetuate or worsen the patient’s dependence on the hospital at a high financial cost to society—and significant frustration and burnout on the part of hospital caregivers, including hospitalists.

For most hospitals, this problem is significant enough to require some sort of coordinated approach to the care of the dozens of types of patients in this category. Implementing whatever plan of care seems appropriate to the caregivers during each admission is frustrating, ensures lots of variation in care, and makes it easier for manipulative patients to abuse the hospital resources and personnel.

A better approach is to follow the same plan of care from one hospital visit to the next. You already knew that. But developing a care plan to follow during each ED visit and admission is time-consuming and often fraught with uncertainty about where boundaries should be set. So if you’re like me, you might just try to guide the patient to discharge this time and hope that whoever sees the patient on the next admission will take the initiative to develop the care plan. The result is that few such plans are developed.

Your Hospital Needs a Care Plan

Relying on individual doctors or nurses to take the initiative to develop care plans will almost always mean few plans are developed, they will vary in their effectiveness, and other providers may not be aware a plan exists. This was the case at the hospital where I practice until I heard Dr. Rick Hilger, MD, SFHM, a hospitalist at Regions Hospital in Minneapolis, present on this topic at HM12 in San Diego.

Dr. Hilger led a multidisciplinary team to develop care plans (they call them “restriction care plans”) and found that they dramatically reduced the rate of hospital admissions and ED visits for these patients. Hearing about this experience served as a kick in the pants for me, so I did much the same thing at “my” hospital. We have now developed plans for more than 20 patients and found that they visit our ED and are admitted less often. And, anecdotally at least, hospitalists and other hospital staff find that the care plans reduce, at least a little, the stress of caring for these patients.

Unanswered Questions

Although it seems clear that care plans reduce visits to the hospital that develops them, I suspect that some of these patients aren’t consuming any fewer health-care resources. They may just seek care from a different hospital.

My home state of Washington is working to develop individual patient care plans available to all hospitals in the state. A system called the Emergency Department Information Exchange (EDIE) has been adopted by nearly all the hospitals in the state. It allows them to share information on ED visits and such things as care plans with one another. For example, through EDIE, each hospital could see the opiate dosing schedule and admission criteria agreed to by patient and primary-care physician.

So it seems that care plans and the technology to share them can make it more difficult for patients to harm themselves by visiting many hospitals to get excessive opiate prescriptions, for example. This should benefit the patient and lower ED and hospital expenditures for these patients. But we don’t know what portion of costs simply is shifted to other settings, so there is no easy way to know the net effect on health-care costs.

An important unanswered question is whether these care plans improve patient well-being. It seems clear they do in some cases, but it is hard to know whether some patients may be worse off because of the plan.

Conclusion

I think nearly every hospital would benefit from a care plan committee composed of at least one hospitalist, ED physician, a nursing representative, and potentially other disciplines (see “Care Plan Attributes,” above). Our committee includes our inpatient psychiatrist, a really valuable contributor.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at john.nelson@nelsonflores.com.

Twenty-four-hour coverage is standard practice for all successful hospitalist groups. At Lehigh Valley Hospital in Allentown, Pa., the hospitalist group features 17 FTEs that split time in a traditional seven-on/seven-off schedule. Five doctors per week round on units seeing patients; one works triage/admitting in the morning and sees some follow-ups in the afternoon; and one works a middle shift for admissions, consults, and ICU transfers.

The foundation of this coverage comes at night. We employ an overnight doctor—a nocturnist—every day of the year. This doctor’s sole responsibility is to cover night admissions, rapid responses, floor calls, and transfers.

Change Is Necessary, Difficult

Lehigh Valley’s change to a nocturnist model came about when members of the group asked for it. We needed to put a model in place that could help the group, improve morale, and improve our care at night. Of all of our shifts, nobody wanted to work overnight. Each clinician was working about four weeks of nights per year, and we started to notice that our new hires from residency were the only ones truly capable of handling the sleep challenges—or, more truthfully, our veteran hospitalists were having difficulty with the nights.

For such a large group, having a nocturnist makes sense. However, there are a few issues to contend with in hiring a nocturnist. Most notably, nocturnists are hard to come by. It takes a special type of person to come in and work the opposite schedule from everyone else. Nocturnists are typically alone in the hospital and don’t always have the support of other hospitalists when times get tough. They usually are at the mercy of other stakeholders. Namely, they are at the mercy of the ED. If the ED is busy, then so is the nocturnist. That special type of person knows the balance and becomes a specialist in ED dynamics, as well as in ED night staffing.

Nocturnists are expensive; we looked at MGMA and SHM data and realized that we would have to pay a 20% to 50% premium if we wanted to employ a true seven-on nocturnist. And if we wanted all nights covered, we would have to hire two of these doctors.

Another point of contention is the buy-in from administration. CEOs and CMOs often don’t understand the need to pay for a nocturnist, and more often than not, they fail to see the need to have a nocturnist employed in the first place.

Finally, in the event of sick time, holidays, or vacation time, the hospitalist team is at the mercy of the nocturnist in terms of necessitating coverage.

Internal Solution=Perfect Remedy

In addition to the aforementioned concerns, I recently experienced a “what’s most important to me?” moment at work with the expectation of my first child. I planned on returning to work after my maternity leave, but I was reassessing just exactly how much I wanted to come back to work. It was in this setting that I began to brainstorm ways to help the group with our concerns regarding working nights, as well as my own feelings of being torn with such a grueling schedule while having a new baby at home.

Then the solution hit me: a new nocturnist model.

After long discussions with the group and group leadership, we found, not surprisingly, there were a good number of people who valued time more than money. I fell into the category of desiring more time away over a premium salary. We also found two others like me who fit this same category. None of us were considered “nocturnists” up to this point, and none of us would have gone for the idea of being seven-on/seven-off nocturnists, either. So we needed a new plan.

And with a little brainstorming and schedule-wrenching, the new nocturnist was born at Lehigh Valley. We are a group of 17. By taking the three willing participants out of the pool of 17 hospitalists and asking them to exclusively work nights, rotating in a one-week-on, two-weeks-off rotation, we were able to still leave 14 doctors to run the day shifts. The daytime hospitalists would no longer have to work nights, drastically improving their quality of work life.

This was a huge step forward for our group. It was a morale boost for the daytime doctors and actually allowed the group to save money. We were looking for doctors 18 and 19, and instead found internal solutions to our night problems. The schedule fit together like a patchwork quilt.

In exchange for two weeks off, the three nocturnists agreed to no additional vacation time. Our salaries stayed the same, too. So from a budgetary standpoint, nothing changed. From a quality-of-life standpoint, everyone was happy. My nocturnist colleagues and I were happy to exchange working nights every third week for the same salary in exchange for more days off.

The new schedule even allowed the group to eliminate the middle shift, creating an additional hospitalist available for daytime rounding. And having three nocturnists creates a pool of night doctors who are readily available to cover each other’s sick or personal time.

In all fairness, this new model was not an easy sell to administration. But as the group became more stable and morale increased, we, as members of the group, relied on this stability. We also noticed an increase in recruitment. Veterans and rookies wanted to start in a practice that had its nights covered. Ultimately, increasing our daytime capacity increased our inpatient encounters, and by increasing recruitment and retaining our current staff, our administration saw the benefits.

Employing a team of nocturnists maintains group stability, is cost-effective, helps with retention, boosts morale, and is attractive new recruits. Hospitalist programs that are struggling with staffing should consider a similar approach—and remember that they might be able to change everyday life without changing the ever-important bottom line.

Dr. Verdetti-Healy is a nocturnist at Lehigh Valley Hospital in Allentown, Pa.

Daniel Bitetto, MD, SFHM, chief of the section of hospital medicine at Lehigh Valley Hospital in Allentown, Pa., contributed to this report.

Twenty-four-hour coverage is standard practice for all successful hospitalist groups. At Lehigh Valley Hospital in Allentown, Pa., the hospitalist group features 17 FTEs that split time in a traditional seven-on/seven-off schedule. Five doctors per week round on units seeing patients; one works triage/admitting in the morning and sees some follow-ups in the afternoon; and one works a middle shift for admissions, consults, and ICU transfers.

The foundation of this coverage comes at night. We employ an overnight doctor—a nocturnist—every day of the year. This doctor’s sole responsibility is to cover night admissions, rapid responses, floor calls, and transfers.

Change Is Necessary, Difficult

Lehigh Valley’s change to a nocturnist model came about when members of the group asked for it. We needed to put a model in place that could help the group, improve morale, and improve our care at night. Of all of our shifts, nobody wanted to work overnight. Each clinician was working about four weeks of nights per year, and we started to notice that our new hires from residency were the only ones truly capable of handling the sleep challenges—or, more truthfully, our veteran hospitalists were having difficulty with the nights.

For such a large group, having a nocturnist makes sense. However, there are a few issues to contend with in hiring a nocturnist. Most notably, nocturnists are hard to come by. It takes a special type of person to come in and work the opposite schedule from everyone else. Nocturnists are typically alone in the hospital and don’t always have the support of other hospitalists when times get tough. They usually are at the mercy of other stakeholders. Namely, they are at the mercy of the ED. If the ED is busy, then so is the nocturnist. That special type of person knows the balance and becomes a specialist in ED dynamics, as well as in ED night staffing.

Nocturnists are expensive; we looked at MGMA and SHM data and realized that we would have to pay a 20% to 50% premium if we wanted to employ a true seven-on nocturnist. And if we wanted all nights covered, we would have to hire two of these doctors.

Another point of contention is the buy-in from administration. CEOs and CMOs often don’t understand the need to pay for a nocturnist, and more often than not, they fail to see the need to have a nocturnist employed in the first place.

Finally, in the event of sick time, holidays, or vacation time, the hospitalist team is at the mercy of the nocturnist in terms of necessitating coverage.

Internal Solution=Perfect Remedy

In addition to the aforementioned concerns, I recently experienced a “what’s most important to me?” moment at work with the expectation of my first child. I planned on returning to work after my maternity leave, but I was reassessing just exactly how much I wanted to come back to work. It was in this setting that I began to brainstorm ways to help the group with our concerns regarding working nights, as well as my own feelings of being torn with such a grueling schedule while having a new baby at home.

Then the solution hit me: a new nocturnist model.

After long discussions with the group and group leadership, we found, not surprisingly, there were a good number of people who valued time more than money. I fell into the category of desiring more time away over a premium salary. We also found two others like me who fit this same category. None of us were considered “nocturnists” up to this point, and none of us would have gone for the idea of being seven-on/seven-off nocturnists, either. So we needed a new plan.

And with a little brainstorming and schedule-wrenching, the new nocturnist was born at Lehigh Valley. We are a group of 17. By taking the three willing participants out of the pool of 17 hospitalists and asking them to exclusively work nights, rotating in a one-week-on, two-weeks-off rotation, we were able to still leave 14 doctors to run the day shifts. The daytime hospitalists would no longer have to work nights, drastically improving their quality of work life.

This was a huge step forward for our group. It was a morale boost for the daytime doctors and actually allowed the group to save money. We were looking for doctors 18 and 19, and instead found internal solutions to our night problems. The schedule fit together like a patchwork quilt.

In exchange for two weeks off, the three nocturnists agreed to no additional vacation time. Our salaries stayed the same, too. So from a budgetary standpoint, nothing changed. From a quality-of-life standpoint, everyone was happy. My nocturnist colleagues and I were happy to exchange working nights every third week for the same salary in exchange for more days off.

The new schedule even allowed the group to eliminate the middle shift, creating an additional hospitalist available for daytime rounding. And having three nocturnists creates a pool of night doctors who are readily available to cover each other’s sick or personal time.

In all fairness, this new model was not an easy sell to administration. But as the group became more stable and morale increased, we, as members of the group, relied on this stability. We also noticed an increase in recruitment. Veterans and rookies wanted to start in a practice that had its nights covered. Ultimately, increasing our daytime capacity increased our inpatient encounters, and by increasing recruitment and retaining our current staff, our administration saw the benefits.

Employing a team of nocturnists maintains group stability, is cost-effective, helps with retention, boosts morale, and is attractive new recruits. Hospitalist programs that are struggling with staffing should consider a similar approach—and remember that they might be able to change everyday life without changing the ever-important bottom line.

Dr. Verdetti-Healy is a nocturnist at Lehigh Valley Hospital in Allentown, Pa.

Daniel Bitetto, MD, SFHM, chief of the section of hospital medicine at Lehigh Valley Hospital in Allentown, Pa., contributed to this report.

Twenty-four-hour coverage is standard practice for all successful hospitalist groups. At Lehigh Valley Hospital in Allentown, Pa., the hospitalist group features 17 FTEs that split time in a traditional seven-on/seven-off schedule. Five doctors per week round on units seeing patients; one works triage/admitting in the morning and sees some follow-ups in the afternoon; and one works a middle shift for admissions, consults, and ICU transfers.

The foundation of this coverage comes at night. We employ an overnight doctor—a nocturnist—every day of the year. This doctor’s sole responsibility is to cover night admissions, rapid responses, floor calls, and transfers.

Change Is Necessary, Difficult

Lehigh Valley’s change to a nocturnist model came about when members of the group asked for it. We needed to put a model in place that could help the group, improve morale, and improve our care at night. Of all of our shifts, nobody wanted to work overnight. Each clinician was working about four weeks of nights per year, and we started to notice that our new hires from residency were the only ones truly capable of handling the sleep challenges—or, more truthfully, our veteran hospitalists were having difficulty with the nights.

For such a large group, having a nocturnist makes sense. However, there are a few issues to contend with in hiring a nocturnist. Most notably, nocturnists are hard to come by. It takes a special type of person to come in and work the opposite schedule from everyone else. Nocturnists are typically alone in the hospital and don’t always have the support of other hospitalists when times get tough. They usually are at the mercy of other stakeholders. Namely, they are at the mercy of the ED. If the ED is busy, then so is the nocturnist. That special type of person knows the balance and becomes a specialist in ED dynamics, as well as in ED night staffing.

Nocturnists are expensive; we looked at MGMA and SHM data and realized that we would have to pay a 20% to 50% premium if we wanted to employ a true seven-on nocturnist. And if we wanted all nights covered, we would have to hire two of these doctors.

Another point of contention is the buy-in from administration. CEOs and CMOs often don’t understand the need to pay for a nocturnist, and more often than not, they fail to see the need to have a nocturnist employed in the first place.

Finally, in the event of sick time, holidays, or vacation time, the hospitalist team is at the mercy of the nocturnist in terms of necessitating coverage.

Internal Solution=Perfect Remedy

In addition to the aforementioned concerns, I recently experienced a “what’s most important to me?” moment at work with the expectation of my first child. I planned on returning to work after my maternity leave, but I was reassessing just exactly how much I wanted to come back to work. It was in this setting that I began to brainstorm ways to help the group with our concerns regarding working nights, as well as my own feelings of being torn with such a grueling schedule while having a new baby at home.

Then the solution hit me: a new nocturnist model.

After long discussions with the group and group leadership, we found, not surprisingly, there were a good number of people who valued time more than money. I fell into the category of desiring more time away over a premium salary. We also found two others like me who fit this same category. None of us were considered “nocturnists” up to this point, and none of us would have gone for the idea of being seven-on/seven-off nocturnists, either. So we needed a new plan.

And with a little brainstorming and schedule-wrenching, the new nocturnist was born at Lehigh Valley. We are a group of 17. By taking the three willing participants out of the pool of 17 hospitalists and asking them to exclusively work nights, rotating in a one-week-on, two-weeks-off rotation, we were able to still leave 14 doctors to run the day shifts. The daytime hospitalists would no longer have to work nights, drastically improving their quality of work life.

This was a huge step forward for our group. It was a morale boost for the daytime doctors and actually allowed the group to save money. We were looking for doctors 18 and 19, and instead found internal solutions to our night problems. The schedule fit together like a patchwork quilt.

In exchange for two weeks off, the three nocturnists agreed to no additional vacation time. Our salaries stayed the same, too. So from a budgetary standpoint, nothing changed. From a quality-of-life standpoint, everyone was happy. My nocturnist colleagues and I were happy to exchange working nights every third week for the same salary in exchange for more days off.

The new schedule even allowed the group to eliminate the middle shift, creating an additional hospitalist available for daytime rounding. And having three nocturnists creates a pool of night doctors who are readily available to cover each other’s sick or personal time.

In all fairness, this new model was not an easy sell to administration. But as the group became more stable and morale increased, we, as members of the group, relied on this stability. We also noticed an increase in recruitment. Veterans and rookies wanted to start in a practice that had its nights covered. Ultimately, increasing our daytime capacity increased our inpatient encounters, and by increasing recruitment and retaining our current staff, our administration saw the benefits.

Employing a team of nocturnists maintains group stability, is cost-effective, helps with retention, boosts morale, and is attractive new recruits. Hospitalist programs that are struggling with staffing should consider a similar approach—and remember that they might be able to change everyday life without changing the ever-important bottom line.

Dr. Verdetti-Healy is a nocturnist at Lehigh Valley Hospital in Allentown, Pa.

Daniel Bitetto, MD, SFHM, chief of the section of hospital medicine at Lehigh Valley Hospital in Allentown, Pa., contributed to this report.

Experienced hospitalists and medical directors agree that the key to multiple hospitalist groups coexisting effectively under one roof—whether directly competing or not—is good communication. Effective communication can take time to build.

“Start by working together on something—anything, [such as] a hospital committee of some sort where there’s not likely to be much tension,” says hospitalist pioneer and practice consultant John Nelson, MD, MHM.

Dr. Nelson practices at Overlake Hospital in Bellevue, Wash., which has a hospitalist group employed by the hospital and another employed by Group Health Cooperative, a nonprofit health system in Washington state. It is important to put some trust in the trust bank, he says, “and that’s hard if you have no social connections at all. At my hospital, we enjoy each other’s company, we visit each other at lunch, and we even tried to have a journal club.” The two hospitalist groups work together on developing care protocols. Dr. Nelson says it also makes sense for the groups’ leaders to sit down together on a regular basis and have a venue for discussing important issues and solving problems that may arise.

Other suggestions for hospitalist groups working together under one roof include:

• Clearly define each group’s territory. The groups’ representatives can go out and try to persuade health plans or physician groups to shift their hospitalist allegiances, but there should be no “trolling” or “poaching” of patients going on inside the hospital’s walls. That will only confuse patients and disrupt the hospital’s larger service goals.
• Inform the ED and other key staff of your schedules. It’s important that everyone know exactly who is supposed to get which patients, and how these referrals get made. But recognize that mistakes happen and, hopefully, these will even out between the groups over time.
• Transparency, honesty, and even-handed treatment of all hospitalists can prevent resentment. Clearly defined guidelines and expectations are helpful. If the policy spells out transfers for an incorrectly referred patient, both sides should be accessible and cooperative with that process.
• Identify areas of common interest and agree to work together on these areas (i.e. competition-free zones). It might be possible, for example, for competing groups to take each others’ after-hours call on a rotating basis, with a firm commitment not to steal patients along the way.
• Spell out responsibilities in a way that everyone can agree is fair, such as alternating referrals or taking call on alternating days. For example, if subsidies are paid to more than one hospitalist group, is this done equitably, such as based on the number of hospitalist FTEs or shifts?
• Restrictive covenants and contractual noncompete clauses could become an issue in areas where multiple groups practice. Rather than using overly broad, blanket language, it could be clarified that such pacts apply only to the hospital where the physician currently works, and within a reasonable time frame. But everyone involved should be aware of what these covenants contain and, if they appear unreasonable, don’t sign them.

—Larry Beresford

Experienced hospitalists and medical directors agree that the key to multiple hospitalist groups coexisting effectively under one roof—whether directly competing or not—is good communication. Effective communication can take time to build.

“Start by working together on something—anything, [such as] a hospital committee of some sort where there’s not likely to be much tension,” says hospitalist pioneer and practice consultant John Nelson, MD, MHM.

Dr. Nelson practices at Overlake Hospital in Bellevue, Wash., which has a hospitalist group employed by the hospital and another employed by Group Health Cooperative, a nonprofit health system in Washington state. It is important to put some trust in the trust bank, he says, “and that’s hard if you have no social connections at all. At my hospital, we enjoy each other’s company, we visit each other at lunch, and we even tried to have a journal club.” The two hospitalist groups work together on developing care protocols. Dr. Nelson says it also makes sense for the groups’ leaders to sit down together on a regular basis and have a venue for discussing important issues and solving problems that may arise.

Other suggestions for hospitalist groups working together under one roof include:

• Clearly define each group’s territory. The groups’ representatives can go out and try to persuade health plans or physician groups to shift their hospitalist allegiances, but there should be no “trolling” or “poaching” of patients going on inside the hospital’s walls. That will only confuse patients and disrupt the hospital’s larger service goals.
• Inform the ED and other key staff of your schedules. It’s important that everyone know exactly who is supposed to get which patients, and how these referrals get made. But recognize that mistakes happen and, hopefully, these will even out between the groups over time.
• Transparency, honesty, and even-handed treatment of all hospitalists can prevent resentment. Clearly defined guidelines and expectations are helpful. If the policy spells out transfers for an incorrectly referred patient, both sides should be accessible and cooperative with that process.
• Identify areas of common interest and agree to work together on these areas (i.e. competition-free zones). It might be possible, for example, for competing groups to take each others’ after-hours call on a rotating basis, with a firm commitment not to steal patients along the way.
• Spell out responsibilities in a way that everyone can agree is fair, such as alternating referrals or taking call on alternating days. For example, if subsidies are paid to more than one hospitalist group, is this done equitably, such as based on the number of hospitalist FTEs or shifts?
• Restrictive covenants and contractual noncompete clauses could become an issue in areas where multiple groups practice. Rather than using overly broad, blanket language, it could be clarified that such pacts apply only to the hospital where the physician currently works, and within a reasonable time frame. But everyone involved should be aware of what these covenants contain and, if they appear unreasonable, don’t sign them.

—Larry Beresford

Experienced hospitalists and medical directors agree that the key to multiple hospitalist groups coexisting effectively under one roof—whether directly competing or not—is good communication. Effective communication can take time to build.

“Start by working together on something—anything, [such as] a hospital committee of some sort where there’s not likely to be much tension,” says hospitalist pioneer and practice consultant John Nelson, MD, MHM.

Dr. Nelson practices at Overlake Hospital in Bellevue, Wash., which has a hospitalist group employed by the hospital and another employed by Group Health Cooperative, a nonprofit health system in Washington state. It is important to put some trust in the trust bank, he says, “and that’s hard if you have no social connections at all. At my hospital, we enjoy each other’s company, we visit each other at lunch, and we even tried to have a journal club.” The two hospitalist groups work together on developing care protocols. Dr. Nelson says it also makes sense for the groups’ leaders to sit down together on a regular basis and have a venue for discussing important issues and solving problems that may arise.

Other suggestions for hospitalist groups working together under one roof include:

• Clearly define each group’s territory. The groups’ representatives can go out and try to persuade health plans or physician groups to shift their hospitalist allegiances, but there should be no “trolling” or “poaching” of patients going on inside the hospital’s walls. That will only confuse patients and disrupt the hospital’s larger service goals.
• Inform the ED and other key staff of your schedules. It’s important that everyone know exactly who is supposed to get which patients, and how these referrals get made. But recognize that mistakes happen and, hopefully, these will even out between the groups over time.
• Transparency, honesty, and even-handed treatment of all hospitalists can prevent resentment. Clearly defined guidelines and expectations are helpful. If the policy spells out transfers for an incorrectly referred patient, both sides should be accessible and cooperative with that process.
• Identify areas of common interest and agree to work together on these areas (i.e. competition-free zones). It might be possible, for example, for competing groups to take each others’ after-hours call on a rotating basis, with a firm commitment not to steal patients along the way.
• Spell out responsibilities in a way that everyone can agree is fair, such as alternating referrals or taking call on alternating days. For example, if subsidies are paid to more than one hospitalist group, is this done equitably, such as based on the number of hospitalist FTEs or shifts?
• Restrictive covenants and contractual noncompete clauses could become an issue in areas where multiple groups practice. Rather than using overly broad, blanket language, it could be clarified that such pacts apply only to the hospital where the physician currently works, and within a reasonable time frame. But everyone involved should be aware of what these covenants contain and, if they appear unreasonable, don’t sign them.

—Larry Beresford

When hospitalists work in academic centers, medical and surgical services are furnished, in part, by a resident within the scope of the hospitalists’ training program. A resident is “an individual who participates in an approved graduate medical education (GME) program or a physician who is not in an approved GME program but who is authorized to practice only in a hospital setting.”¹ Resident services are covered by Centers for Medicare & Medicaid Services (CMS) and paid by the Fiscal Intermediary through direct GME and Indirect Medical Education (IME) payments. These services are not billed or paid using the Medicare Physician Fee Schedule. The teaching physician is responsible for supervising the resident’s health-care delivery but is not paid for the resident’s work. The teaching physician is paid for their personal and medically necessary service in providing patient care. The teaching physician has the option to perform the entire service, or perform the self-determined critical or key portion(s) of the service.

Comprehensive Service

Teaching physicians independently see the patient and perform all required elements to support the visit level (e.g. 99233: subsequent hospital care, per day, which requires at least two of the following three key components: a detailed interval history, a detailed examination, or high-complexity medical decision-making).² The teaching physician writes a note independent of a resident encounter with the patient or documentation. The teaching physician note “stands alone” and does not rely on the resident’s documentation. If the resident saw the patient and documented the encounter, the teaching physician might choose to “link to” the resident note in lieu of personally documenting the entire service. The linking statement must demonstrate teaching physician involvement in the patient encounter and participation in patient management. Use of CMS-approved statements is best to meet these requirements. Statement examples include:³

• “I performed a history and physical examination of the patient and discussed his management with the resident. I reviewed the resident’s note and agree with the documented findings and plan of care.”
• “I saw and evaluated the patient. I agree with the findings and the plan of care as documented in the resident’s note.”
• “I saw and examined the patient. I agree with the resident’s note, except the heart murmur is louder, so I will obtain an echo to evaluate.”

Each of these statements meets the minimum requirements for billing. However, teaching physicians should offer more information in support of other clinical, quality, and regulatory initiatives and mandates, better exemplified in the last example. The reported visit level will be supported by the combined documentation (teaching physician and resident).

The teaching physician submits a claim in their name and, if it is a Medicare claim, appends modifier GC to the selected visit level (e.g. 99223-GC). This alerts the Medicare contractor that services were provided under teaching physician rules. Requests for documentation should include a response with medical record entries from the teaching physician and resident.

Critical/Key Portion

“Supervised” service: The resident and teaching physician can round together; they can see the patient at the same time. The teaching physician observes the resident’s performance during the patient encounter, or personally performs self-determined elements of patient care. The resident documents their patient care. The attending must still note their presence in the medical record, performance of the critical or key portions of the service, and involvement in patient management. CMS-accepted statements include:³

• “I was present with the resident during the history and exam. I discussed the case with the resident and agree with the findings and plan as documented in the resident’s note.”
• “I saw the patient with the resident and agree with the resident’s findings and plan.”

Although these statements demonstrate acceptable billing language, they lack patient-specific details that support the teaching physician’s personal contribution to patient care and the quality of their expertise. The teaching physician selects the visit level that represents the combined documentation and, if it is a Medicare claim, appends modifier GC to the selected visit level (e.g. 99232-GC).

“Shared” service: The resident sees the patient unaccompanied and documents the corresponding care provided. The teaching physician sees the patient at a different time but performs only the critical or key portions of the service. The case is subsequently discussed with the resident. The teaching physician must document their presence and performance of the critical or key portions of the service, along with any patient management. Using CMS-quoted statements ensures regulatory compliance:³

• “I saw and evaluated the patient. I reviewed the resident’s note and agree, except that the picture is more consistent with pericarditis than myocardial ischemia. Will begin NSAIDs.”
• “I saw and evaluated the patient. Discussed with resident and agree with resident’s findings and plan as documented in the resident’s note.”
• “See resident’s note for details. I saw and evaluated the patient and agree with the resident’s finding and plans as written.”
• “I saw and evaluated the patient. Agree with resident’s note, but lower extremities are weaker, now 3/5; MRI of L/S spine today.”

Once again, the teaching physician selects the visit level that represents the combined documentation and, if it is a Medicare claim, appends modifier GC to the selected visit level (e.g. 99233-GC).

EHR Considerations

When seeing patients independent of one another, the timing of the teaching physician and resident encounters does not impact billing. However, the time that the resident encounter is documented in the medical record can significantly impact the payment when reviewed by external auditors. When the resident note is dated and timed later than the teaching physician’s entry, the teaching physician cannot consider the resident’s note for visit-level selection. The teaching physician should not “link to” a resident note that is viewed as “not having been written” prior to the teaching physician note. This would not fulfill the requirements represented in the CMS-approved language “I reviewed the resident’s note and agree.”

Electronic health record (EHR) systems sometimes hinder compliance. If the resident completes the note but does not “finalize” or “close” the encounter until after the teaching physician documents their own note, it can falsely appear that the resident note did not exist at the time the teaching physician created their entry. Because an auditor can only view the finalized entries, the timing of each entry might be erroneously represented. Proper training and closing of encounters can diminish these issues.

Additionally, scribing the attestation is not permitted. Residents cannot document the teaching physician attestation on behalf of the physician under any circumstance. CMS rules require the teaching physician to document their presence, participation, and management of the patient. In an EHR, the teaching physician must document this entry under his/her own log-in and password, which is not to be shared with anyone.

Students

CMS defines student as “an individual who participates in an accredited educational program [e.g. a medical school] that is not an approved GME program.”1 A student is not regarded as a “physician in training,” and the service is not eligible for reimbursement consideration under the teaching physician rules.

Per CMS guidelines, students can document services in the medical record, but the teaching physician may only refer to the student’s systems review and past/family/social history entries. The teaching physician must verify and redocument the history of present illness. A student’s physical exam findings or medical decision-making are not suitable for tethering, and the teaching physician must personally perform and redocument the physical exam and medical decision-making. The visit level reflects only the teaching physician’s personally performed and documented service.

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

References

1. Centers for Medicare and Medicaid Services. Guidelines for Teaching Physicians, Interns, Residents. CMS website. Available at: http://www.cms.gov/MLNProducts/downloads/gdelinesteachgresfctsht.pdf. Accessed Jan. 8, 2013.
2. Abraham M, Ahlman J, Anderson C, Boudreau A, Connelly J. Current Procedural Terminology 2012 Professional Edition. Chicago: American Medical Association Press; 2011.
3. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 100. CMS website. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed Jan. 8, 2013.
4. Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual: Chapter 15, Section 30.2. CMS website. Available at: http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf. Accessed Jan. 8, 2013.

When hospitalists work in academic centers, medical and surgical services are furnished, in part, by a resident within the scope of the hospitalists’ training program. A resident is “an individual who participates in an approved graduate medical education (GME) program or a physician who is not in an approved GME program but who is authorized to practice only in a hospital setting.”¹ Resident services are covered by Centers for Medicare & Medicaid Services (CMS) and paid by the Fiscal Intermediary through direct GME and Indirect Medical Education (IME) payments. These services are not billed or paid using the Medicare Physician Fee Schedule. The teaching physician is responsible for supervising the resident’s health-care delivery but is not paid for the resident’s work. The teaching physician is paid for their personal and medically necessary service in providing patient care. The teaching physician has the option to perform the entire service, or perform the self-determined critical or key portion(s) of the service.

Comprehensive Service

Teaching physicians independently see the patient and perform all required elements to support the visit level (e.g. 99233: subsequent hospital care, per day, which requires at least two of the following three key components: a detailed interval history, a detailed examination, or high-complexity medical decision-making).² The teaching physician writes a note independent of a resident encounter with the patient or documentation. The teaching physician note “stands alone” and does not rely on the resident’s documentation. If the resident saw the patient and documented the encounter, the teaching physician might choose to “link to” the resident note in lieu of personally documenting the entire service. The linking statement must demonstrate teaching physician involvement in the patient encounter and participation in patient management. Use of CMS-approved statements is best to meet these requirements. Statement examples include:³

• “I performed a history and physical examination of the patient and discussed his management with the resident. I reviewed the resident’s note and agree with the documented findings and plan of care.”
• “I saw and evaluated the patient. I agree with the findings and the plan of care as documented in the resident’s note.”
• “I saw and examined the patient. I agree with the resident’s note, except the heart murmur is louder, so I will obtain an echo to evaluate.”

Each of these statements meets the minimum requirements for billing. However, teaching physicians should offer more information in support of other clinical, quality, and regulatory initiatives and mandates, better exemplified in the last example. The reported visit level will be supported by the combined documentation (teaching physician and resident).

The teaching physician submits a claim in their name and, if it is a Medicare claim, appends modifier GC to the selected visit level (e.g. 99223-GC). This alerts the Medicare contractor that services were provided under teaching physician rules. Requests for documentation should include a response with medical record entries from the teaching physician and resident.

Critical/Key Portion

“Supervised” service: The resident and teaching physician can round together; they can see the patient at the same time. The teaching physician observes the resident’s performance during the patient encounter, or personally performs self-determined elements of patient care. The resident documents their patient care. The attending must still note their presence in the medical record, performance of the critical or key portions of the service, and involvement in patient management. CMS-accepted statements include:³

• “I was present with the resident during the history and exam. I discussed the case with the resident and agree with the findings and plan as documented in the resident’s note.”
• “I saw the patient with the resident and agree with the resident’s findings and plan.”

Although these statements demonstrate acceptable billing language, they lack patient-specific details that support the teaching physician’s personal contribution to patient care and the quality of their expertise. The teaching physician selects the visit level that represents the combined documentation and, if it is a Medicare claim, appends modifier GC to the selected visit level (e.g. 99232-GC).

“Shared” service: The resident sees the patient unaccompanied and documents the corresponding care provided. The teaching physician sees the patient at a different time but performs only the critical or key portions of the service. The case is subsequently discussed with the resident. The teaching physician must document their presence and performance of the critical or key portions of the service, along with any patient management. Using CMS-quoted statements ensures regulatory compliance:³

• “I saw and evaluated the patient. I reviewed the resident’s note and agree, except that the picture is more consistent with pericarditis than myocardial ischemia. Will begin NSAIDs.”
• “I saw and evaluated the patient. Discussed with resident and agree with resident’s findings and plan as documented in the resident’s note.”
• “See resident’s note for details. I saw and evaluated the patient and agree with the resident’s finding and plans as written.”
• “I saw and evaluated the patient. Agree with resident’s note, but lower extremities are weaker, now 3/5; MRI of L/S spine today.”

Once again, the teaching physician selects the visit level that represents the combined documentation and, if it is a Medicare claim, appends modifier GC to the selected visit level (e.g. 99233-GC).

EHR Considerations

When seeing patients independent of one another, the timing of the teaching physician and resident encounters does not impact billing. However, the time that the resident encounter is documented in the medical record can significantly impact the payment when reviewed by external auditors. When the resident note is dated and timed later than the teaching physician’s entry, the teaching physician cannot consider the resident’s note for visit-level selection. The teaching physician should not “link to” a resident note that is viewed as “not having been written” prior to the teaching physician note. This would not fulfill the requirements represented in the CMS-approved language “I reviewed the resident’s note and agree.”

Electronic health record (EHR) systems sometimes hinder compliance. If the resident completes the note but does not “finalize” or “close” the encounter until after the teaching physician documents their own note, it can falsely appear that the resident note did not exist at the time the teaching physician created their entry. Because an auditor can only view the finalized entries, the timing of each entry might be erroneously represented. Proper training and closing of encounters can diminish these issues.

Additionally, scribing the attestation is not permitted. Residents cannot document the teaching physician attestation on behalf of the physician under any circumstance. CMS rules require the teaching physician to document their presence, participation, and management of the patient. In an EHR, the teaching physician must document this entry under his/her own log-in and password, which is not to be shared with anyone.

Students

CMS defines student as “an individual who participates in an accredited educational program [e.g. a medical school] that is not an approved GME program.”1 A student is not regarded as a “physician in training,” and the service is not eligible for reimbursement consideration under the teaching physician rules.

Per CMS guidelines, students can document services in the medical record, but the teaching physician may only refer to the student’s systems review and past/family/social history entries. The teaching physician must verify and redocument the history of present illness. A student’s physical exam findings or medical decision-making are not suitable for tethering, and the teaching physician must personally perform and redocument the physical exam and medical decision-making. The visit level reflects only the teaching physician’s personally performed and documented service.

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

References

1. Centers for Medicare and Medicaid Services. Guidelines for Teaching Physicians, Interns, Residents. CMS website. Available at: http://www.cms.gov/MLNProducts/downloads/gdelinesteachgresfctsht.pdf. Accessed Jan. 8, 2013.
2. Abraham M, Ahlman J, Anderson C, Boudreau A, Connelly J. Current Procedural Terminology 2012 Professional Edition. Chicago: American Medical Association Press; 2011.
3. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 100. CMS website. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed Jan. 8, 2013.
4. Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual: Chapter 15, Section 30.2. CMS website. Available at: http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf. Accessed Jan. 8, 2013.

When hospitalists work in academic centers, medical and surgical services are furnished, in part, by a resident within the scope of the hospitalists’ training program. A resident is “an individual who participates in an approved graduate medical education (GME) program or a physician who is not in an approved GME program but who is authorized to practice only in a hospital setting.”¹ Resident services are covered by Centers for Medicare & Medicaid Services (CMS) and paid by the Fiscal Intermediary through direct GME and Indirect Medical Education (IME) payments. These services are not billed or paid using the Medicare Physician Fee Schedule. The teaching physician is responsible for supervising the resident’s health-care delivery but is not paid for the resident’s work. The teaching physician is paid for their personal and medically necessary service in providing patient care. The teaching physician has the option to perform the entire service, or perform the self-determined critical or key portion(s) of the service.

Comprehensive Service

Teaching physicians independently see the patient and perform all required elements to support the visit level (e.g. 99233: subsequent hospital care, per day, which requires at least two of the following three key components: a detailed interval history, a detailed examination, or high-complexity medical decision-making).² The teaching physician writes a note independent of a resident encounter with the patient or documentation. The teaching physician note “stands alone” and does not rely on the resident’s documentation. If the resident saw the patient and documented the encounter, the teaching physician might choose to “link to” the resident note in lieu of personally documenting the entire service. The linking statement must demonstrate teaching physician involvement in the patient encounter and participation in patient management. Use of CMS-approved statements is best to meet these requirements. Statement examples include:³

• “I performed a history and physical examination of the patient and discussed his management with the resident. I reviewed the resident’s note and agree with the documented findings and plan of care.”
• “I saw and evaluated the patient. I agree with the findings and the plan of care as documented in the resident’s note.”
• “I saw and examined the patient. I agree with the resident’s note, except the heart murmur is louder, so I will obtain an echo to evaluate.”

Each of these statements meets the minimum requirements for billing. However, teaching physicians should offer more information in support of other clinical, quality, and regulatory initiatives and mandates, better exemplified in the last example. The reported visit level will be supported by the combined documentation (teaching physician and resident).

The teaching physician submits a claim in their name and, if it is a Medicare claim, appends modifier GC to the selected visit level (e.g. 99223-GC). This alerts the Medicare contractor that services were provided under teaching physician rules. Requests for documentation should include a response with medical record entries from the teaching physician and resident.

Critical/Key Portion

“Supervised” service: The resident and teaching physician can round together; they can see the patient at the same time. The teaching physician observes the resident’s performance during the patient encounter, or personally performs self-determined elements of patient care. The resident documents their patient care. The attending must still note their presence in the medical record, performance of the critical or key portions of the service, and involvement in patient management. CMS-accepted statements include:³

• “I was present with the resident during the history and exam. I discussed the case with the resident and agree with the findings and plan as documented in the resident’s note.”
• “I saw the patient with the resident and agree with the resident’s findings and plan.”

Although these statements demonstrate acceptable billing language, they lack patient-specific details that support the teaching physician’s personal contribution to patient care and the quality of their expertise. The teaching physician selects the visit level that represents the combined documentation and, if it is a Medicare claim, appends modifier GC to the selected visit level (e.g. 99232-GC).

“Shared” service: The resident sees the patient unaccompanied and documents the corresponding care provided. The teaching physician sees the patient at a different time but performs only the critical or key portions of the service. The case is subsequently discussed with the resident. The teaching physician must document their presence and performance of the critical or key portions of the service, along with any patient management. Using CMS-quoted statements ensures regulatory compliance:³

• “I saw and evaluated the patient. I reviewed the resident’s note and agree, except that the picture is more consistent with pericarditis than myocardial ischemia. Will begin NSAIDs.”
• “I saw and evaluated the patient. Discussed with resident and agree with resident’s findings and plan as documented in the resident’s note.”
• “See resident’s note for details. I saw and evaluated the patient and agree with the resident’s finding and plans as written.”
• “I saw and evaluated the patient. Agree with resident’s note, but lower extremities are weaker, now 3/5; MRI of L/S spine today.”

Once again, the teaching physician selects the visit level that represents the combined documentation and, if it is a Medicare claim, appends modifier GC to the selected visit level (e.g. 99233-GC).

EHR Considerations

When seeing patients independent of one another, the timing of the teaching physician and resident encounters does not impact billing. However, the time that the resident encounter is documented in the medical record can significantly impact the payment when reviewed by external auditors. When the resident note is dated and timed later than the teaching physician’s entry, the teaching physician cannot consider the resident’s note for visit-level selection. The teaching physician should not “link to” a resident note that is viewed as “not having been written” prior to the teaching physician note. This would not fulfill the requirements represented in the CMS-approved language “I reviewed the resident’s note and agree.”

Electronic health record (EHR) systems sometimes hinder compliance. If the resident completes the note but does not “finalize” or “close” the encounter until after the teaching physician documents their own note, it can falsely appear that the resident note did not exist at the time the teaching physician created their entry. Because an auditor can only view the finalized entries, the timing of each entry might be erroneously represented. Proper training and closing of encounters can diminish these issues.

Additionally, scribing the attestation is not permitted. Residents cannot document the teaching physician attestation on behalf of the physician under any circumstance. CMS rules require the teaching physician to document their presence, participation, and management of the patient. In an EHR, the teaching physician must document this entry under his/her own log-in and password, which is not to be shared with anyone.

Students

CMS defines student as “an individual who participates in an accredited educational program [e.g. a medical school] that is not an approved GME program.”1 A student is not regarded as a “physician in training,” and the service is not eligible for reimbursement consideration under the teaching physician rules.

Per CMS guidelines, students can document services in the medical record, but the teaching physician may only refer to the student’s systems review and past/family/social history entries. The teaching physician must verify and redocument the history of present illness. A student’s physical exam findings or medical decision-making are not suitable for tethering, and the teaching physician must personally perform and redocument the physical exam and medical decision-making. The visit level reflects only the teaching physician’s personally performed and documented service.

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

References

1. Centers for Medicare and Medicaid Services. Guidelines for Teaching Physicians, Interns, Residents. CMS website. Available at: http://www.cms.gov/MLNProducts/downloads/gdelinesteachgresfctsht.pdf. Accessed Jan. 8, 2013.
2. Abraham M, Ahlman J, Anderson C, Boudreau A, Connelly J. Current Procedural Terminology 2012 Professional Edition. Chicago: American Medical Association Press; 2011.
3. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 100. CMS website. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed Jan. 8, 2013.
4. Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual: Chapter 15, Section 30.2. CMS website. Available at: http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf. Accessed Jan. 8, 2013.

A quote in the March 2013 story “Lucky No. 7?” did not accurately represent comments expressed by Bradley Eshbaugh, MBA, FACMPE, chief administrator of Hospitalists of Northern Michigan (HNM) in Traverse City, Mich. His quote should have read: “I really believe that [seven-on/seven-off] scheduling is probably more desirable to Generation Y, which tends to have a lot more life quality and life balance as part of their mentality.”

A quote in the March 2013 story “Lucky No. 7?” did not accurately represent comments expressed by Bradley Eshbaugh, MBA, FACMPE, chief administrator of Hospitalists of Northern Michigan (HNM) in Traverse City, Mich. His quote should have read: “I really believe that [seven-on/seven-off] scheduling is probably more desirable to Generation Y, which tends to have a lot more life quality and life balance as part of their mentality.”

A quote in the March 2013 story “Lucky No. 7?” did not accurately represent comments expressed by Bradley Eshbaugh, MBA, FACMPE, chief administrator of Hospitalists of Northern Michigan (HNM) in Traverse City, Mich. His quote should have read: “I really believe that [seven-on/seven-off] scheduling is probably more desirable to Generation Y, which tends to have a lot more life quality and life balance as part of their mentality.”

In November 2011, the board of directors of Lee Memorial Health System in Fort Myers, Fla., voted to close access at its four hospitals to any hospitalist who didn’t already practice there or wasn’t affiliated with private practices that contracted with the health system. According to a report in a local newspaper, the proliferation of competing hospitalist practices at Lee Memorial was contributing to high rates of patient and referring physician dissatisfaction and hospitalist turnover.¹ As a result, the board limited new hospitalists from entering practice in their facilities until they could develop “rules of engagement” for the existing hospitalists through new contracts and standards of practice.

The Lee Memorial example of multiple, competing hospitalist groups—and individuals practicing hospital medicine, also known as “lone wolf” hospitalists—causing havoc is atypical of the fledgling medical specialty, which has seen rapid growth the past two decades. Even so, veteran hospitalists confirm that nowadays, with nearly 40,000 hospitalists practicing in a majority of U.S. hospitals, it’s not uncommon to have multiple groups or individuals working under the same hospital roof. What is concerning to some in the specialty is how the competition can turn ugly, especially considering SHM espouses such virtues as teamwork, leadership, and quality improvement (QI).

Even so, situations arise when multiple HM groups under one roof don’t get along. Sometimes those groups or individual practitioners compete, head to head, for new admissions. Some hospitals have patient populations carved out by capitated medical groups or staff/group model HMOs. Some specialty groups, cardiology or orthopedics, for example, choose to contract hospitalist groups for their patients, setting up potential conflicts with new admissions. Other hospitals have “lone wolf” hospitalists, basically a practice of one.

No matter the dynamic, hospital administrators are frustrated with their inability to control competitive situations, especially when competing groups or individuals do not act in conjunction with their strategic goals.

Depending on hospital bylaws and state regulations, it might be difficult to exclude hospitalists from practicing in the hospital or to cut off competition. Some hospitals even welcome competition—as a prime virtue in its own right, a way to advance quality, or to guard against staffing shortages. The challenge, hospitalists and administrators say, is to encourage multiple groups to work amicably alongside each other, cooperating on the hospital’s larger mission and working toward its quality targets—and to make sure clinicians focus less on competition and more on patients (see “The Magic Bullet: Communication,”).

It forces us to make sure the services we provide are meeting the customer’s expectations. We can and do learn from each other.

—Lowell Palmer, MD, FHM, hospitalist, Southwest Washington Medical Center, Vancouver

Purposeful, Team-Based Medicine

Scott Nygaard, MD, Lee Memorial’s chief medical officer for physician services, announced on Aug. 29, 2012, that the health system was contracting with a newly formed medical group called Inpatient Specialists of Southwest Florida (ISSF), a partnership between Cape Coral, Fla.-based Hospitalist Group of Southwest Florida (HGSF) and national management company Cogent HMG based in Brentwood, Tenn. HGSF and Cogent HMG already had established practices in two of Lee’s four hospitals.

Other existing hospitalist groups are permitted to continue practicing in these hospitals, although only a contracted group will be able to recruit or add new physicians, Dr. Nygaard says.

“The bylaws did not allow us to formally close access for staff already in practice,” he said. Physicians have the option of joining ISSF, and eventually, he says, the other groups dwindled in numbers through attrition. As Lee Memorial’s sole provider of hospitalist care, ISSF’s long-term goal is to put HM on a similar footing with other hospital-based specialties, such as emergency medicine and anesthesiology.

As of late 2012, six hospitalist groups and more than 80 hospitalists practice at Lee Memorial hospitals; 40 of those hospitalists belong to ISSF. “The other groups were all offered an opportunity to discuss a contractual relationship with the system, but they declined,” Dr. Nygaard says.

The remaining groups had worked amicably alongside each other but in an atmosphere Dr. Nygaard likens to a flea market, with each group practicing its own separate business and business model.

A standardized approach conducive to achieving the hospital’s quality and performance targets was lacking, however. As a result, Lee Memorial implemented an HM standard of care within the system. It helped somewhat, Dr. Nygaard says, but it didn’t fix all of the competition problems.

“We have learned that variation is the enemy of quality, especially in the highly complex environment of an acute-care hospital, trying to generate the kinds of measurable results we are now being asked to provide,” he explains. “We need to be more organized, structured, and purposeful in an era of team-based medicine. You need committed, aligned partnerships offering appropriate incentives.”

The ISSF contract contains such performance incentives.

“The joint venture formalizes an informal, long-standing, collaborative relationship” between the two participating HM groups, says Joseph Daley, MD, co-founder and director of quality services for Hospitalist Group of Southwest Florida. “We bring substantial, local expertise to the table, and have been quality partners with both Lee Memorial and Cogent HMG.”

And, as of April, Lee Memorial spokesperson Mary Briggs reported patient satisfaction scores for hospitalists are improving. “We believe the changes put in place were the right ones,” she emailed The Hospitalist.

We have learned that variation is the enemy of quality, especially in the highly complex environment of an acute-care hospital, trying to generate the kinds of measurable results we are now being asked to provide. We need to be more organized, structured, and purposeful in an era of team-based medicine.

—Scott Nygaard, MD, chief medical officer for physician services, Lee Memorial Health System, Fort Myers, Fla.

Supply and Demand

Every local hospital environment is different, with HM group arrangements shaped to a large degree by supply and demand for physicians, says Brian Hazen, MD, chief of hospital medicine at Inova Fairfax Hospital in Falls Church, Va., one of five hospitals in the Inova system. Inova Fairfax employs the hospitalists in Dr. Hazen’s group but is also home to other groups, including a neurohospitalist service and about a half dozen solo practitioners. Dr. Hazen’s group receives administrative support from the hospital and primarily is assigned patients through the ED. Some of the private hospitalists don’t want to take ED call, he says, instead preferring to get referrals of insured patients from primary-care-physician groups.

“Here in the D.C. area, we’re reasonably well staffed by hospitalists, but we’re not fighting over patients. In fact, if it weren’t for the private physicians, we’d have trouble meeting current staffing needs,” Dr. Hazen says. “I have also seen competition in other hospital settings, but I haven’t been in a situation where the doctors were fighting over patients.”

The “lone wolf” hospitalists at Inova Fairfax work very hard, Dr. Hazen adds. “A lot of them have private practices, see patients in the hospital, and also take call. If one of them has to leave town on short notice, we can help them out. On the flip side, if we’re busy in the emergency department, we’ll call on them,” he says.

The ED receives instruction on which hospitalist group admits which patient, but sometimes referral mistakes are made.

“If we accidently admit a patient who should have gone to one of the private people, who depend on these admissions for their income, I let them choose whether we should continue to see that patient or do a transfer,” Dr. Hazen says. “For the most part, we all try to be nice people.”

In the current health-care environment, hospital administrators might be reluctant to erect barriers to multiple hospitalist practices under one roof for fear of restraining trade, just as they don’t stand in the way of primary-care physicians who want to follow their own patients into the hospital. It might be easier to enact equally enforced requirements for the credentialing and privileging of all hospitalists who want to practice at the hospital, spelling out expectations in such areas as following protocols. (In 2011, SHM issued a position paper on hospitalist credentialing that addressed the appropriate time to institute a credentialing category with privileging criteria for hospitalists, and how to preserve maximum flexibility within this process.)²

Hospitals can limit who they contract with, who gets administrative support—and how much—using financial and quality performance to shape contracting decisions. In many communities, that could serve as an excluder of multiple groups in the same building, but in other locales, the payor mix might be attractive enough for physicians to survive on billing alone, says Leslie Flores, MPH, of Nelson Flores Hospital Medicine Consultants. If the hospital isn’t providing financial support, it will have less influence over how that group does things.

Dr. Hazen says his employed hospitalist group at Inova Fairfax is represented on more than 20 hospital committees and quality initiatives in the hospital, and has demonstrated its alignment with the hospital’s goals. Recently, in response to the administration’s concerns about throughput, his group initiated geographic, multidisciplinary rounding.

“I can do this because I have elite physicians, and because I protect them from unreasonable expectations,” he says. “Everyone needs to understand that the hospital needs to survive, so the hospital has a right to expect certain things from its hospitalists, such as performance on length of stay, throughput, other core measures, and promptly answering pages. Everyone should understand that those are the rules. Being fair, honest, and transparent about expectations is not an unreasonable expectation.”

Competition among hospitalists should be on a professional basis, experts emphasize, and cooperation is in everyone’s best interests. But Lowell Palmer, MD, FHM, a hospitalist at Southwest Washington Medical Center in Vancouver, Wash., thinks competition can be a healthy thing for hospitalist groups.

“It forces us to make sure the services we provide are meeting the customer’s expectations,” says Dr. Palmer, who works with Cogent Physician Services, one of the three HM groups at Southwest Washington. “We can and do learn from each other.”

Impact of Health-Care Reform

Beware the transformation health-care reform is having on the dynamics of hospital-based practice and the competitive landscape facing more hospitalist groups, says Roger Heroux, MHA, PhD, CHE, consultant with Hospitalist Management Resources LLC. Reforms mean hospitalists are seeing an increased emphasis on coordinating with post-acute-care providers, improving care transitions, preventing readmissions, and meeting hospital targets for quality and patient safety.

Primary-care groups, accountable-care organizations (ACOs), and health plans could choose specific hospitalist practices they want to partner with to manage the care of their hospitalized members, but they will have clear performance expectations that those groups will need to meet, spelled out in benchmarks. Or, as some experts believe, they might opt to bring in their own hospitalist group.

“We’re spending our time working with existing hospitalist programs to help them be more efficient and effective, to manage risk, and to become aggressive about meeting the clinical benchmarks,” Heroux says. Hospitals, ACOs, and capitated groups can’t afford not to have a high-performing hospitalist program, so this will become a hallmark of survival for hospitalist programs as well. “In a highly managed environment, patients will be managed by a hospitalist group that is responsive to these expectations,” he says.

Larry Beresford is a freelance writer in Oakland, Calif.

References

1. Gluck F. Lee Memorial Health Systems’ hospitalists under new controls. Fort Myers News Press. Dec. 1, 2011.
2. Society of Hospital Medicine Position Statement on Hospitalist Credentialing and Medical Staff Privileges. SHM website. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Where_We_Stand&Template=/CM/HTMLDisplay.cfm&ContentID=28262. Accessed April 1, 2013.

In November 2011, the board of directors of Lee Memorial Health System in Fort Myers, Fla., voted to close access at its four hospitals to any hospitalist who didn’t already practice there or wasn’t affiliated with private practices that contracted with the health system. According to a report in a local newspaper, the proliferation of competing hospitalist practices at Lee Memorial was contributing to high rates of patient and referring physician dissatisfaction and hospitalist turnover.¹ As a result, the board limited new hospitalists from entering practice in their facilities until they could develop “rules of engagement” for the existing hospitalists through new contracts and standards of practice.

The Lee Memorial example of multiple, competing hospitalist groups—and individuals practicing hospital medicine, also known as “lone wolf” hospitalists—causing havoc is atypical of the fledgling medical specialty, which has seen rapid growth the past two decades. Even so, veteran hospitalists confirm that nowadays, with nearly 40,000 hospitalists practicing in a majority of U.S. hospitals, it’s not uncommon to have multiple groups or individuals working under the same hospital roof. What is concerning to some in the specialty is how the competition can turn ugly, especially considering SHM espouses such virtues as teamwork, leadership, and quality improvement (QI).

Even so, situations arise when multiple HM groups under one roof don’t get along. Sometimes those groups or individual practitioners compete, head to head, for new admissions. Some hospitals have patient populations carved out by capitated medical groups or staff/group model HMOs. Some specialty groups, cardiology or orthopedics, for example, choose to contract hospitalist groups for their patients, setting up potential conflicts with new admissions. Other hospitals have “lone wolf” hospitalists, basically a practice of one.

No matter the dynamic, hospital administrators are frustrated with their inability to control competitive situations, especially when competing groups or individuals do not act in conjunction with their strategic goals.

Depending on hospital bylaws and state regulations, it might be difficult to exclude hospitalists from practicing in the hospital or to cut off competition. Some hospitals even welcome competition—as a prime virtue in its own right, a way to advance quality, or to guard against staffing shortages. The challenge, hospitalists and administrators say, is to encourage multiple groups to work amicably alongside each other, cooperating on the hospital’s larger mission and working toward its quality targets—and to make sure clinicians focus less on competition and more on patients (see “The Magic Bullet: Communication,”).

It forces us to make sure the services we provide are meeting the customer’s expectations. We can and do learn from each other.

—Lowell Palmer, MD, FHM, hospitalist, Southwest Washington Medical Center, Vancouver

Purposeful, Team-Based Medicine

Scott Nygaard, MD, Lee Memorial’s chief medical officer for physician services, announced on Aug. 29, 2012, that the health system was contracting with a newly formed medical group called Inpatient Specialists of Southwest Florida (ISSF), a partnership between Cape Coral, Fla.-based Hospitalist Group of Southwest Florida (HGSF) and national management company Cogent HMG based in Brentwood, Tenn. HGSF and Cogent HMG already had established practices in two of Lee’s four hospitals.

Other existing hospitalist groups are permitted to continue practicing in these hospitals, although only a contracted group will be able to recruit or add new physicians, Dr. Nygaard says.

“The bylaws did not allow us to formally close access for staff already in practice,” he said. Physicians have the option of joining ISSF, and eventually, he says, the other groups dwindled in numbers through attrition. As Lee Memorial’s sole provider of hospitalist care, ISSF’s long-term goal is to put HM on a similar footing with other hospital-based specialties, such as emergency medicine and anesthesiology.

As of late 2012, six hospitalist groups and more than 80 hospitalists practice at Lee Memorial hospitals; 40 of those hospitalists belong to ISSF. “The other groups were all offered an opportunity to discuss a contractual relationship with the system, but they declined,” Dr. Nygaard says.

The remaining groups had worked amicably alongside each other but in an atmosphere Dr. Nygaard likens to a flea market, with each group practicing its own separate business and business model.

A standardized approach conducive to achieving the hospital’s quality and performance targets was lacking, however. As a result, Lee Memorial implemented an HM standard of care within the system. It helped somewhat, Dr. Nygaard says, but it didn’t fix all of the competition problems.

“We have learned that variation is the enemy of quality, especially in the highly complex environment of an acute-care hospital, trying to generate the kinds of measurable results we are now being asked to provide,” he explains. “We need to be more organized, structured, and purposeful in an era of team-based medicine. You need committed, aligned partnerships offering appropriate incentives.”

The ISSF contract contains such performance incentives.

“The joint venture formalizes an informal, long-standing, collaborative relationship” between the two participating HM groups, says Joseph Daley, MD, co-founder and director of quality services for Hospitalist Group of Southwest Florida. “We bring substantial, local expertise to the table, and have been quality partners with both Lee Memorial and Cogent HMG.”

And, as of April, Lee Memorial spokesperson Mary Briggs reported patient satisfaction scores for hospitalists are improving. “We believe the changes put in place were the right ones,” she emailed The Hospitalist.

We have learned that variation is the enemy of quality, especially in the highly complex environment of an acute-care hospital, trying to generate the kinds of measurable results we are now being asked to provide. We need to be more organized, structured, and purposeful in an era of team-based medicine.

—Scott Nygaard, MD, chief medical officer for physician services, Lee Memorial Health System, Fort Myers, Fla.

Supply and Demand

Every local hospital environment is different, with HM group arrangements shaped to a large degree by supply and demand for physicians, says Brian Hazen, MD, chief of hospital medicine at Inova Fairfax Hospital in Falls Church, Va., one of five hospitals in the Inova system. Inova Fairfax employs the hospitalists in Dr. Hazen’s group but is also home to other groups, including a neurohospitalist service and about a half dozen solo practitioners. Dr. Hazen’s group receives administrative support from the hospital and primarily is assigned patients through the ED. Some of the private hospitalists don’t want to take ED call, he says, instead preferring to get referrals of insured patients from primary-care-physician groups.

“Here in the D.C. area, we’re reasonably well staffed by hospitalists, but we’re not fighting over patients. In fact, if it weren’t for the private physicians, we’d have trouble meeting current staffing needs,” Dr. Hazen says. “I have also seen competition in other hospital settings, but I haven’t been in a situation where the doctors were fighting over patients.”

The “lone wolf” hospitalists at Inova Fairfax work very hard, Dr. Hazen adds. “A lot of them have private practices, see patients in the hospital, and also take call. If one of them has to leave town on short notice, we can help them out. On the flip side, if we’re busy in the emergency department, we’ll call on them,” he says.

The ED receives instruction on which hospitalist group admits which patient, but sometimes referral mistakes are made.

“If we accidently admit a patient who should have gone to one of the private people, who depend on these admissions for their income, I let them choose whether we should continue to see that patient or do a transfer,” Dr. Hazen says. “For the most part, we all try to be nice people.”

In the current health-care environment, hospital administrators might be reluctant to erect barriers to multiple hospitalist practices under one roof for fear of restraining trade, just as they don’t stand in the way of primary-care physicians who want to follow their own patients into the hospital. It might be easier to enact equally enforced requirements for the credentialing and privileging of all hospitalists who want to practice at the hospital, spelling out expectations in such areas as following protocols. (In 2011, SHM issued a position paper on hospitalist credentialing that addressed the appropriate time to institute a credentialing category with privileging criteria for hospitalists, and how to preserve maximum flexibility within this process.)²

Hospitals can limit who they contract with, who gets administrative support—and how much—using financial and quality performance to shape contracting decisions. In many communities, that could serve as an excluder of multiple groups in the same building, but in other locales, the payor mix might be attractive enough for physicians to survive on billing alone, says Leslie Flores, MPH, of Nelson Flores Hospital Medicine Consultants. If the hospital isn’t providing financial support, it will have less influence over how that group does things.

Dr. Hazen says his employed hospitalist group at Inova Fairfax is represented on more than 20 hospital committees and quality initiatives in the hospital, and has demonstrated its alignment with the hospital’s goals. Recently, in response to the administration’s concerns about throughput, his group initiated geographic, multidisciplinary rounding.

“I can do this because I have elite physicians, and because I protect them from unreasonable expectations,” he says. “Everyone needs to understand that the hospital needs to survive, so the hospital has a right to expect certain things from its hospitalists, such as performance on length of stay, throughput, other core measures, and promptly answering pages. Everyone should understand that those are the rules. Being fair, honest, and transparent about expectations is not an unreasonable expectation.”

Competition among hospitalists should be on a professional basis, experts emphasize, and cooperation is in everyone’s best interests. But Lowell Palmer, MD, FHM, a hospitalist at Southwest Washington Medical Center in Vancouver, Wash., thinks competition can be a healthy thing for hospitalist groups.

“It forces us to make sure the services we provide are meeting the customer’s expectations,” says Dr. Palmer, who works with Cogent Physician Services, one of the three HM groups at Southwest Washington. “We can and do learn from each other.”

Impact of Health-Care Reform

Beware the transformation health-care reform is having on the dynamics of hospital-based practice and the competitive landscape facing more hospitalist groups, says Roger Heroux, MHA, PhD, CHE, consultant with Hospitalist Management Resources LLC. Reforms mean hospitalists are seeing an increased emphasis on coordinating with post-acute-care providers, improving care transitions, preventing readmissions, and meeting hospital targets for quality and patient safety.

Primary-care groups, accountable-care organizations (ACOs), and health plans could choose specific hospitalist practices they want to partner with to manage the care of their hospitalized members, but they will have clear performance expectations that those groups will need to meet, spelled out in benchmarks. Or, as some experts believe, they might opt to bring in their own hospitalist group.

“We’re spending our time working with existing hospitalist programs to help them be more efficient and effective, to manage risk, and to become aggressive about meeting the clinical benchmarks,” Heroux says. Hospitals, ACOs, and capitated groups can’t afford not to have a high-performing hospitalist program, so this will become a hallmark of survival for hospitalist programs as well. “In a highly managed environment, patients will be managed by a hospitalist group that is responsive to these expectations,” he says.

Larry Beresford is a freelance writer in Oakland, Calif.

References

1. Gluck F. Lee Memorial Health Systems’ hospitalists under new controls. Fort Myers News Press. Dec. 1, 2011.
2. Society of Hospital Medicine Position Statement on Hospitalist Credentialing and Medical Staff Privileges. SHM website. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Where_We_Stand&Template=/CM/HTMLDisplay.cfm&ContentID=28262. Accessed April 1, 2013.

In November 2011, the board of directors of Lee Memorial Health System in Fort Myers, Fla., voted to close access at its four hospitals to any hospitalist who didn’t already practice there or wasn’t affiliated with private practices that contracted with the health system. According to a report in a local newspaper, the proliferation of competing hospitalist practices at Lee Memorial was contributing to high rates of patient and referring physician dissatisfaction and hospitalist turnover.¹ As a result, the board limited new hospitalists from entering practice in their facilities until they could develop “rules of engagement” for the existing hospitalists through new contracts and standards of practice.

The Lee Memorial example of multiple, competing hospitalist groups—and individuals practicing hospital medicine, also known as “lone wolf” hospitalists—causing havoc is atypical of the fledgling medical specialty, which has seen rapid growth the past two decades. Even so, veteran hospitalists confirm that nowadays, with nearly 40,000 hospitalists practicing in a majority of U.S. hospitals, it’s not uncommon to have multiple groups or individuals working under the same hospital roof. What is concerning to some in the specialty is how the competition can turn ugly, especially considering SHM espouses such virtues as teamwork, leadership, and quality improvement (QI).

Even so, situations arise when multiple HM groups under one roof don’t get along. Sometimes those groups or individual practitioners compete, head to head, for new admissions. Some hospitals have patient populations carved out by capitated medical groups or staff/group model HMOs. Some specialty groups, cardiology or orthopedics, for example, choose to contract hospitalist groups for their patients, setting up potential conflicts with new admissions. Other hospitals have “lone wolf” hospitalists, basically a practice of one.

No matter the dynamic, hospital administrators are frustrated with their inability to control competitive situations, especially when competing groups or individuals do not act in conjunction with their strategic goals.

Depending on hospital bylaws and state regulations, it might be difficult to exclude hospitalists from practicing in the hospital or to cut off competition. Some hospitals even welcome competition—as a prime virtue in its own right, a way to advance quality, or to guard against staffing shortages. The challenge, hospitalists and administrators say, is to encourage multiple groups to work amicably alongside each other, cooperating on the hospital’s larger mission and working toward its quality targets—and to make sure clinicians focus less on competition and more on patients (see “The Magic Bullet: Communication,”).

It forces us to make sure the services we provide are meeting the customer’s expectations. We can and do learn from each other.

—Lowell Palmer, MD, FHM, hospitalist, Southwest Washington Medical Center, Vancouver

Purposeful, Team-Based Medicine

Scott Nygaard, MD, Lee Memorial’s chief medical officer for physician services, announced on Aug. 29, 2012, that the health system was contracting with a newly formed medical group called Inpatient Specialists of Southwest Florida (ISSF), a partnership between Cape Coral, Fla.-based Hospitalist Group of Southwest Florida (HGSF) and national management company Cogent HMG based in Brentwood, Tenn. HGSF and Cogent HMG already had established practices in two of Lee’s four hospitals.

Other existing hospitalist groups are permitted to continue practicing in these hospitals, although only a contracted group will be able to recruit or add new physicians, Dr. Nygaard says.

“The bylaws did not allow us to formally close access for staff already in practice,” he said. Physicians have the option of joining ISSF, and eventually, he says, the other groups dwindled in numbers through attrition. As Lee Memorial’s sole provider of hospitalist care, ISSF’s long-term goal is to put HM on a similar footing with other hospital-based specialties, such as emergency medicine and anesthesiology.

As of late 2012, six hospitalist groups and more than 80 hospitalists practice at Lee Memorial hospitals; 40 of those hospitalists belong to ISSF. “The other groups were all offered an opportunity to discuss a contractual relationship with the system, but they declined,” Dr. Nygaard says.

The remaining groups had worked amicably alongside each other but in an atmosphere Dr. Nygaard likens to a flea market, with each group practicing its own separate business and business model.

A standardized approach conducive to achieving the hospital’s quality and performance targets was lacking, however. As a result, Lee Memorial implemented an HM standard of care within the system. It helped somewhat, Dr. Nygaard says, but it didn’t fix all of the competition problems.

“We have learned that variation is the enemy of quality, especially in the highly complex environment of an acute-care hospital, trying to generate the kinds of measurable results we are now being asked to provide,” he explains. “We need to be more organized, structured, and purposeful in an era of team-based medicine. You need committed, aligned partnerships offering appropriate incentives.”

The ISSF contract contains such performance incentives.

“The joint venture formalizes an informal, long-standing, collaborative relationship” between the two participating HM groups, says Joseph Daley, MD, co-founder and director of quality services for Hospitalist Group of Southwest Florida. “We bring substantial, local expertise to the table, and have been quality partners with both Lee Memorial and Cogent HMG.”

And, as of April, Lee Memorial spokesperson Mary Briggs reported patient satisfaction scores for hospitalists are improving. “We believe the changes put in place were the right ones,” she emailed The Hospitalist.

We have learned that variation is the enemy of quality, especially in the highly complex environment of an acute-care hospital, trying to generate the kinds of measurable results we are now being asked to provide. We need to be more organized, structured, and purposeful in an era of team-based medicine.

—Scott Nygaard, MD, chief medical officer for physician services, Lee Memorial Health System, Fort Myers, Fla.

Supply and Demand

Every local hospital environment is different, with HM group arrangements shaped to a large degree by supply and demand for physicians, says Brian Hazen, MD, chief of hospital medicine at Inova Fairfax Hospital in Falls Church, Va., one of five hospitals in the Inova system. Inova Fairfax employs the hospitalists in Dr. Hazen’s group but is also home to other groups, including a neurohospitalist service and about a half dozen solo practitioners. Dr. Hazen’s group receives administrative support from the hospital and primarily is assigned patients through the ED. Some of the private hospitalists don’t want to take ED call, he says, instead preferring to get referrals of insured patients from primary-care-physician groups.

“Here in the D.C. area, we’re reasonably well staffed by hospitalists, but we’re not fighting over patients. In fact, if it weren’t for the private physicians, we’d have trouble meeting current staffing needs,” Dr. Hazen says. “I have also seen competition in other hospital settings, but I haven’t been in a situation where the doctors were fighting over patients.”

The “lone wolf” hospitalists at Inova Fairfax work very hard, Dr. Hazen adds. “A lot of them have private practices, see patients in the hospital, and also take call. If one of them has to leave town on short notice, we can help them out. On the flip side, if we’re busy in the emergency department, we’ll call on them,” he says.

The ED receives instruction on which hospitalist group admits which patient, but sometimes referral mistakes are made.

“If we accidently admit a patient who should have gone to one of the private people, who depend on these admissions for their income, I let them choose whether we should continue to see that patient or do a transfer,” Dr. Hazen says. “For the most part, we all try to be nice people.”

In the current health-care environment, hospital administrators might be reluctant to erect barriers to multiple hospitalist practices under one roof for fear of restraining trade, just as they don’t stand in the way of primary-care physicians who want to follow their own patients into the hospital. It might be easier to enact equally enforced requirements for the credentialing and privileging of all hospitalists who want to practice at the hospital, spelling out expectations in such areas as following protocols. (In 2011, SHM issued a position paper on hospitalist credentialing that addressed the appropriate time to institute a credentialing category with privileging criteria for hospitalists, and how to preserve maximum flexibility within this process.)²

Hospitals can limit who they contract with, who gets administrative support—and how much—using financial and quality performance to shape contracting decisions. In many communities, that could serve as an excluder of multiple groups in the same building, but in other locales, the payor mix might be attractive enough for physicians to survive on billing alone, says Leslie Flores, MPH, of Nelson Flores Hospital Medicine Consultants. If the hospital isn’t providing financial support, it will have less influence over how that group does things.

Dr. Hazen says his employed hospitalist group at Inova Fairfax is represented on more than 20 hospital committees and quality initiatives in the hospital, and has demonstrated its alignment with the hospital’s goals. Recently, in response to the administration’s concerns about throughput, his group initiated geographic, multidisciplinary rounding.

“I can do this because I have elite physicians, and because I protect them from unreasonable expectations,” he says. “Everyone needs to understand that the hospital needs to survive, so the hospital has a right to expect certain things from its hospitalists, such as performance on length of stay, throughput, other core measures, and promptly answering pages. Everyone should understand that those are the rules. Being fair, honest, and transparent about expectations is not an unreasonable expectation.”

Competition among hospitalists should be on a professional basis, experts emphasize, and cooperation is in everyone’s best interests. But Lowell Palmer, MD, FHM, a hospitalist at Southwest Washington Medical Center in Vancouver, Wash., thinks competition can be a healthy thing for hospitalist groups.

“It forces us to make sure the services we provide are meeting the customer’s expectations,” says Dr. Palmer, who works with Cogent Physician Services, one of the three HM groups at Southwest Washington. “We can and do learn from each other.”

Impact of Health-Care Reform

Beware the transformation health-care reform is having on the dynamics of hospital-based practice and the competitive landscape facing more hospitalist groups, says Roger Heroux, MHA, PhD, CHE, consultant with Hospitalist Management Resources LLC. Reforms mean hospitalists are seeing an increased emphasis on coordinating with post-acute-care providers, improving care transitions, preventing readmissions, and meeting hospital targets for quality and patient safety.

Primary-care groups, accountable-care organizations (ACOs), and health plans could choose specific hospitalist practices they want to partner with to manage the care of their hospitalized members, but they will have clear performance expectations that those groups will need to meet, spelled out in benchmarks. Or, as some experts believe, they might opt to bring in their own hospitalist group.

“We’re spending our time working with existing hospitalist programs to help them be more efficient and effective, to manage risk, and to become aggressive about meeting the clinical benchmarks,” Heroux says. Hospitals, ACOs, and capitated groups can’t afford not to have a high-performing hospitalist program, so this will become a hallmark of survival for hospitalist programs as well. “In a highly managed environment, patients will be managed by a hospitalist group that is responsive to these expectations,” he says.

Larry Beresford is a freelance writer in Oakland, Calif.

References

1. Gluck F. Lee Memorial Health Systems’ hospitalists under new controls. Fort Myers News Press. Dec. 1, 2011.
2. Society of Hospital Medicine Position Statement on Hospitalist Credentialing and Medical Staff Privileges. SHM website. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Where_We_Stand&Template=/CM/HTMLDisplay.cfm&ContentID=28262. Accessed April 1, 2013.

New national legislation proposed in March would change Medicare billing rules to allow patients to more easily access Medicare’s institutional skilled nursing care benefit following a hospital discharge. Currently, patients can get the benefit only after a qualifying three-day hospital stay. If they don’t qualify, they often have to pay out of pocket for the subsequent skilled nursing facility placement.

The Improving Access to Medicare Coverage Act, introduced by Reps. Joe Courtney (D-Conn.) and Tom Latham (R-Iowa) and Sen. Sherrod Brown (D-Ohio), would allow the time patients spend inside the hospital on “observation status” to count toward their required three-day hospital stay. It also would establish a 90-day appeal period for those who have been denied this benefit.

SHM is one of a dozen endorsing organizations, joining the American Medical Association, American Medical Directors Association, and AARP. For more information, check out this month’s “Policy Corner”.

Larry Beresford is a freelance writer in Oakland, Calif.

References

1. Quinn K, Neeman N, Mourad M, Sliwka D. Communication coaching: A multifaceted intervention to improve physician-patient communication [abstract]. J Hosp Med. 2012;7 Suppl 2:S108.
2. Sokol PE, Wynia MK. There and Home Again, Safely: Five Responsibilities of Ambulatory Practices in High Quality Care Transitions. American Medical Association website. http://www.ama-assn.org/resources/doc/patient-safety/ambulatory-practices.pdf. Accessed February 12, 2013.
3. Dharmarajan K, Hsieh AF, Lin Z, et al. Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. JAMA. 2013;309(4):355-363.
4. JAMA Internal Medicine. Nearly one-third of physicians report missing electronic notification of test results. JAMA Internal Medicine website. Available at: http://media.jamanetwork.com/news-item/nearly-one-third-of-physicians-report-missing-electronic-notification-of-test-results/.Accessed April 8, 2013.
5. Miliard M. VA enlists telehealth for disasters. Healthcare IT News website. http://www.healthcareitnews.com/news/va-enlists-telehealth-disasters. Published February 27, 2013. Accessed April 1, 2013.

New national legislation proposed in March would change Medicare billing rules to allow patients to more easily access Medicare’s institutional skilled nursing care benefit following a hospital discharge. Currently, patients can get the benefit only after a qualifying three-day hospital stay. If they don’t qualify, they often have to pay out of pocket for the subsequent skilled nursing facility placement.

The Improving Access to Medicare Coverage Act, introduced by Reps. Joe Courtney (D-Conn.) and Tom Latham (R-Iowa) and Sen. Sherrod Brown (D-Ohio), would allow the time patients spend inside the hospital on “observation status” to count toward their required three-day hospital stay. It also would establish a 90-day appeal period for those who have been denied this benefit.

SHM is one of a dozen endorsing organizations, joining the American Medical Association, American Medical Directors Association, and AARP. For more information, check out this month’s “Policy Corner”.

Larry Beresford is a freelance writer in Oakland, Calif.

References

1. Quinn K, Neeman N, Mourad M, Sliwka D. Communication coaching: A multifaceted intervention to improve physician-patient communication [abstract]. J Hosp Med. 2012;7 Suppl 2:S108.
2. Sokol PE, Wynia MK. There and Home Again, Safely: Five Responsibilities of Ambulatory Practices in High Quality Care Transitions. American Medical Association website. http://www.ama-assn.org/resources/doc/patient-safety/ambulatory-practices.pdf. Accessed February 12, 2013.
3. Dharmarajan K, Hsieh AF, Lin Z, et al. Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. JAMA. 2013;309(4):355-363.
4. JAMA Internal Medicine. Nearly one-third of physicians report missing electronic notification of test results. JAMA Internal Medicine website. Available at: http://media.jamanetwork.com/news-item/nearly-one-third-of-physicians-report-missing-electronic-notification-of-test-results/.Accessed April 8, 2013.
5. Miliard M. VA enlists telehealth for disasters. Healthcare IT News website. http://www.healthcareitnews.com/news/va-enlists-telehealth-disasters. Published February 27, 2013. Accessed April 1, 2013.

New national legislation proposed in March would change Medicare billing rules to allow patients to more easily access Medicare’s institutional skilled nursing care benefit following a hospital discharge. Currently, patients can get the benefit only after a qualifying three-day hospital stay. If they don’t qualify, they often have to pay out of pocket for the subsequent skilled nursing facility placement.

The Improving Access to Medicare Coverage Act, introduced by Reps. Joe Courtney (D-Conn.) and Tom Latham (R-Iowa) and Sen. Sherrod Brown (D-Ohio), would allow the time patients spend inside the hospital on “observation status” to count toward their required three-day hospital stay. It also would establish a 90-day appeal period for those who have been denied this benefit.

SHM is one of a dozen endorsing organizations, joining the American Medical Association, American Medical Directors Association, and AARP. For more information, check out this month’s “Policy Corner”.

Larry Beresford is a freelance writer in Oakland, Calif.

References

1. Quinn K, Neeman N, Mourad M, Sliwka D. Communication coaching: A multifaceted intervention to improve physician-patient communication [abstract]. J Hosp Med. 2012;7 Suppl 2:S108.
2. Sokol PE, Wynia MK. There and Home Again, Safely: Five Responsibilities of Ambulatory Practices in High Quality Care Transitions. American Medical Association website. http://www.ama-assn.org/resources/doc/patient-safety/ambulatory-practices.pdf. Accessed February 12, 2013.
3. Dharmarajan K, Hsieh AF, Lin Z, et al. Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. JAMA. 2013;309(4):355-363.
4. JAMA Internal Medicine. Nearly one-third of physicians report missing electronic notification of test results. JAMA Internal Medicine website. Available at: http://media.jamanetwork.com/news-item/nearly-one-third-of-physicians-report-missing-electronic-notification-of-test-results/.Accessed April 8, 2013.
5. Miliard M. VA enlists telehealth for disasters. Healthcare IT News website. http://www.healthcareitnews.com/news/va-enlists-telehealth-disasters. Published February 27, 2013. Accessed April 1, 2013.