A recent study of care transitions for nursing home residents with advanced cognitive impairments (N Engl J Med. 2011; 365:1212-1221) finds that transitions into the hospital can be burdensome, with such negative outcomes as medical errors and hospital-acquired infections, but have limited clinical benefit for some patients, such as those with dementia and other impairments. One in 5 nursing home residents had at least one burdensome transition in the last 90 days of life, researchers found, and some experienced repeated hospitalizations.

Hospitals may not be able to prevent nursing home residents who are nearing the end of life from turning up in their EDs, says study coauthor Joan Teno, MD, from Brown University in Providence, R.I. But physicians and other members of the care team might help to stave off repeat visits by engaging in frank discussions with the patient (and/or patients’ family) about the course of a disease and goals of care. A referral to hospice or for a palliative-care consultation might be appropriate, or the patient could be sent back to long-term care with a “do not rehospitalize” order. In some cases, she adds, these conversations happen in the ED without an admission, and are facilitated by a palliative-care team.

“We have this assumption that hospitalization is a good thing. But hospitals can be dangerous places for some elderly patients,” Dr. Teno says.

A more proactive response could be to identify the nursing homes that transfer the majority of cognitively impaired patients and meet with them to talk about appropriate transfers, how to treat such conditions as pneumonia in place, and the use of advance directives and POLST (physician orders for life-sustaining treatment: www.ohsu.edu/polst/).

A recent study of care transitions for nursing home residents with advanced cognitive impairments (N Engl J Med. 2011; 365:1212-1221) finds that transitions into the hospital can be burdensome, with such negative outcomes as medical errors and hospital-acquired infections, but have limited clinical benefit for some patients, such as those with dementia and other impairments. One in 5 nursing home residents had at least one burdensome transition in the last 90 days of life, researchers found, and some experienced repeated hospitalizations.

Hospitals may not be able to prevent nursing home residents who are nearing the end of life from turning up in their EDs, says study coauthor Joan Teno, MD, from Brown University in Providence, R.I. But physicians and other members of the care team might help to stave off repeat visits by engaging in frank discussions with the patient (and/or patients’ family) about the course of a disease and goals of care. A referral to hospice or for a palliative-care consultation might be appropriate, or the patient could be sent back to long-term care with a “do not rehospitalize” order. In some cases, she adds, these conversations happen in the ED without an admission, and are facilitated by a palliative-care team.

“We have this assumption that hospitalization is a good thing. But hospitals can be dangerous places for some elderly patients,” Dr. Teno says.

A more proactive response could be to identify the nursing homes that transfer the majority of cognitively impaired patients and meet with them to talk about appropriate transfers, how to treat such conditions as pneumonia in place, and the use of advance directives and POLST (physician orders for life-sustaining treatment: www.ohsu.edu/polst/).

A recent study of care transitions for nursing home residents with advanced cognitive impairments (N Engl J Med. 2011; 365:1212-1221) finds that transitions into the hospital can be burdensome, with such negative outcomes as medical errors and hospital-acquired infections, but have limited clinical benefit for some patients, such as those with dementia and other impairments. One in 5 nursing home residents had at least one burdensome transition in the last 90 days of life, researchers found, and some experienced repeated hospitalizations.

Hospitals may not be able to prevent nursing home residents who are nearing the end of life from turning up in their EDs, says study coauthor Joan Teno, MD, from Brown University in Providence, R.I. But physicians and other members of the care team might help to stave off repeat visits by engaging in frank discussions with the patient (and/or patients’ family) about the course of a disease and goals of care. A referral to hospice or for a palliative-care consultation might be appropriate, or the patient could be sent back to long-term care with a “do not rehospitalize” order. In some cases, she adds, these conversations happen in the ED without an admission, and are facilitated by a palliative-care team.

“We have this assumption that hospitalization is a good thing. But hospitals can be dangerous places for some elderly patients,” Dr. Teno says.

A more proactive response could be to identify the nursing homes that transfer the majority of cognitively impaired patients and meet with them to talk about appropriate transfers, how to treat such conditions as pneumonia in place, and the use of advance directives and POLST (physician orders for life-sustaining treatment: www.ohsu.edu/polst/).

Akin to other doctors, hospitalists seek clinical and nonclinical continuing medical education (CME) opportunities in subjects that they hope will improve their professional skill set. But Emory School of Medicine’s Division of Hospital Medicine has tried to make this training more systematic for its 110 members. Since 2005, competitively awarded grants have supported faculty development training in the areas of administrative leadership, quality improvement and research, and education and training.

According to an abstract presented at HM11, Emory’s faculty development program has helped train 36 HM physicians. The upshot of the program: Thirty-three hospitalists now fill formal leadership positions in six Emory-affiliated hospitals. Examples include hospital chief medical officers, chief quality officers, and medical directors for care coordination.

“Hospital medicine is a young field, and we had a young group of clinicians lacking experience that other physicians might get in the course of a career,” says Daniel Dressler, MD, MSc, SFHM, director of education for the hospital medicine division of the Atlanta-based group. “If we were going to be asked to do things, leadershipwise, in the hospital, we needed to build a program to help individuals get additional training for them.”

The physicians pick courses in areas where they want to better themselves, either local educational offerings or national conferences. A committee applies a structured process for reviewing their applications, with funding coming from the department. “We ask the doctors to come back and report on what they learned,” says Dr. Dressler, an SHM board member.

Akin to other doctors, hospitalists seek clinical and nonclinical continuing medical education (CME) opportunities in subjects that they hope will improve their professional skill set. But Emory School of Medicine’s Division of Hospital Medicine has tried to make this training more systematic for its 110 members. Since 2005, competitively awarded grants have supported faculty development training in the areas of administrative leadership, quality improvement and research, and education and training.

According to an abstract presented at HM11, Emory’s faculty development program has helped train 36 HM physicians. The upshot of the program: Thirty-three hospitalists now fill formal leadership positions in six Emory-affiliated hospitals. Examples include hospital chief medical officers, chief quality officers, and medical directors for care coordination.

“Hospital medicine is a young field, and we had a young group of clinicians lacking experience that other physicians might get in the course of a career,” says Daniel Dressler, MD, MSc, SFHM, director of education for the hospital medicine division of the Atlanta-based group. “If we were going to be asked to do things, leadershipwise, in the hospital, we needed to build a program to help individuals get additional training for them.”

The physicians pick courses in areas where they want to better themselves, either local educational offerings or national conferences. A committee applies a structured process for reviewing their applications, with funding coming from the department. “We ask the doctors to come back and report on what they learned,” says Dr. Dressler, an SHM board member.

Akin to other doctors, hospitalists seek clinical and nonclinical continuing medical education (CME) opportunities in subjects that they hope will improve their professional skill set. But Emory School of Medicine’s Division of Hospital Medicine has tried to make this training more systematic for its 110 members. Since 2005, competitively awarded grants have supported faculty development training in the areas of administrative leadership, quality improvement and research, and education and training.

According to an abstract presented at HM11, Emory’s faculty development program has helped train 36 HM physicians. The upshot of the program: Thirty-three hospitalists now fill formal leadership positions in six Emory-affiliated hospitals. Examples include hospital chief medical officers, chief quality officers, and medical directors for care coordination.

“Hospital medicine is a young field, and we had a young group of clinicians lacking experience that other physicians might get in the course of a career,” says Daniel Dressler, MD, MSc, SFHM, director of education for the hospital medicine division of the Atlanta-based group. “If we were going to be asked to do things, leadershipwise, in the hospital, we needed to build a program to help individuals get additional training for them.”

The physicians pick courses in areas where they want to better themselves, either local educational offerings or national conferences. A committee applies a structured process for reviewing their applications, with funding coming from the department. “We ask the doctors to come back and report on what they learned,” says Dr. Dressler, an SHM board member.

The Center to Advance Palliative Care recently issued its 2011 state-by-state report card, “America’s Care of Serious Illness”

(www.capc.org/reportcard), counting the proportion of each state’s hospitals with access to organized palliative-care programs. Eight states and the District of Columbia received “A” grades, as 80% of their acute-care hospitals also provided palliative-care services. Two states, Delaware and Mississippi, received “F” grades, as their hospitals hit only 20%.

The authors say palliative-care teams can reduce suffering and distress among patients with serious illnesses, regardless of age or disease state, improve communication, and reduce unwanted medical interventions. According to the most recent survey by the American Hospital Association, 1,894 U.S. hospitals have palliative-care programs, including 85% of those with 300 beds or more.

The Center to Advance Palliative Care recently issued its 2011 state-by-state report card, “America’s Care of Serious Illness”

(www.capc.org/reportcard), counting the proportion of each state’s hospitals with access to organized palliative-care programs. Eight states and the District of Columbia received “A” grades, as 80% of their acute-care hospitals also provided palliative-care services. Two states, Delaware and Mississippi, received “F” grades, as their hospitals hit only 20%.

The authors say palliative-care teams can reduce suffering and distress among patients with serious illnesses, regardless of age or disease state, improve communication, and reduce unwanted medical interventions. According to the most recent survey by the American Hospital Association, 1,894 U.S. hospitals have palliative-care programs, including 85% of those with 300 beds or more.

The Center to Advance Palliative Care recently issued its 2011 state-by-state report card, “America’s Care of Serious Illness”

(www.capc.org/reportcard), counting the proportion of each state’s hospitals with access to organized palliative-care programs. Eight states and the District of Columbia received “A” grades, as 80% of their acute-care hospitals also provided palliative-care services. Two states, Delaware and Mississippi, received “F” grades, as their hospitals hit only 20%.

The authors say palliative-care teams can reduce suffering and distress among patients with serious illnesses, regardless of age or disease state, improve communication, and reduce unwanted medical interventions. According to the most recent survey by the American Hospital Association, 1,894 U.S. hospitals have palliative-care programs, including 85% of those with 300 beds or more.

The Institute of Medicine in November issued a new report, “Patient Safety and Health IT (HIT): Building Safer Systems for Better Care,” which identifies potential harm that could stem from a digital healthcare system and proposes 10 recommendations. Many of the suggestions are directed at the U.S. Secretary of Health and Human Services, urging the office to work with the private sector and research groups on patient safety, ensure the free exchange of information on healthcare information technology (HIT) issues, and create a process for reporting HIT-related deaths and injuries.

“Concerns about potential harm are emerging as providers increasingly rely on electronic medical records, secure patient portals, and other technologies to deliver care,” the report states, but there is a lack of published research quantifying the risks. For more on the HIT report, check out the Policy Corner.

The Institute of Medicine in November issued a new report, “Patient Safety and Health IT (HIT): Building Safer Systems for Better Care,” which identifies potential harm that could stem from a digital healthcare system and proposes 10 recommendations. Many of the suggestions are directed at the U.S. Secretary of Health and Human Services, urging the office to work with the private sector and research groups on patient safety, ensure the free exchange of information on healthcare information technology (HIT) issues, and create a process for reporting HIT-related deaths and injuries.

“Concerns about potential harm are emerging as providers increasingly rely on electronic medical records, secure patient portals, and other technologies to deliver care,” the report states, but there is a lack of published research quantifying the risks. For more on the HIT report, check out the Policy Corner.

The Institute of Medicine in November issued a new report, “Patient Safety and Health IT (HIT): Building Safer Systems for Better Care,” which identifies potential harm that could stem from a digital healthcare system and proposes 10 recommendations. Many of the suggestions are directed at the U.S. Secretary of Health and Human Services, urging the office to work with the private sector and research groups on patient safety, ensure the free exchange of information on healthcare information technology (HIT) issues, and create a process for reporting HIT-related deaths and injuries.

“Concerns about potential harm are emerging as providers increasingly rely on electronic medical records, secure patient portals, and other technologies to deliver care,” the report states, but there is a lack of published research quantifying the risks. For more on the HIT report, check out the Policy Corner.

A new report shows that 1 in 5 community hospitals operates in the red, but the chief strategy officer of the firm that conducted the survey thinks hospitals can help change that.

The second annual survey from healthcare information technology (HIT) provider Anthelio and leadership group Community Hospital 100 found that 22% of community hospitals operate with margins below 2%; another 38% operate below 1%. Rick Kneipper, Anthelio’s cofounder and chief strategy officer, says that hospitalists can be at the forefront “of the creative changes needed” to reduce costs and improve profitability.

“Hospital medicine groups and hospitals could free up significant funds to devote to improved patient-care services if they focus on their core competency of patient care and farm out their non-core, back-office services to experts who can use leverage to provide more efficient services at significantly reduced costs,” Kneipper wrote in an email to The Hospitalist. “Financial pressures have historically forced most industries to stop trying to be vertically integrated [trying to be ‘all things to all people’] and instead to focus on their core competencies—it’s time for healthcare to do the same.”

HM’s foothold at the intersection of clinical care and safety and QI positions the specialty to “respond to the new challenges of readmission penalties, evidenced-based medicine requirements, EMR implementation, and operation challenges,” Kneipper wrote.

For the full survey, please visit www.antheliohealth.com and search “survey.”

A new report shows that 1 in 5 community hospitals operates in the red, but the chief strategy officer of the firm that conducted the survey thinks hospitals can help change that.

The second annual survey from healthcare information technology (HIT) provider Anthelio and leadership group Community Hospital 100 found that 22% of community hospitals operate with margins below 2%; another 38% operate below 1%. Rick Kneipper, Anthelio’s cofounder and chief strategy officer, says that hospitalists can be at the forefront “of the creative changes needed” to reduce costs and improve profitability.

“Hospital medicine groups and hospitals could free up significant funds to devote to improved patient-care services if they focus on their core competency of patient care and farm out their non-core, back-office services to experts who can use leverage to provide more efficient services at significantly reduced costs,” Kneipper wrote in an email to The Hospitalist. “Financial pressures have historically forced most industries to stop trying to be vertically integrated [trying to be ‘all things to all people’] and instead to focus on their core competencies—it’s time for healthcare to do the same.”

HM’s foothold at the intersection of clinical care and safety and QI positions the specialty to “respond to the new challenges of readmission penalties, evidenced-based medicine requirements, EMR implementation, and operation challenges,” Kneipper wrote.

For the full survey, please visit www.antheliohealth.com and search “survey.”

A new report shows that 1 in 5 community hospitals operates in the red, but the chief strategy officer of the firm that conducted the survey thinks hospitals can help change that.

The second annual survey from healthcare information technology (HIT) provider Anthelio and leadership group Community Hospital 100 found that 22% of community hospitals operate with margins below 2%; another 38% operate below 1%. Rick Kneipper, Anthelio’s cofounder and chief strategy officer, says that hospitalists can be at the forefront “of the creative changes needed” to reduce costs and improve profitability.

“Hospital medicine groups and hospitals could free up significant funds to devote to improved patient-care services if they focus on their core competency of patient care and farm out their non-core, back-office services to experts who can use leverage to provide more efficient services at significantly reduced costs,” Kneipper wrote in an email to The Hospitalist. “Financial pressures have historically forced most industries to stop trying to be vertically integrated [trying to be ‘all things to all people’] and instead to focus on their core competencies—it’s time for healthcare to do the same.”

HM’s foothold at the intersection of clinical care and safety and QI positions the specialty to “respond to the new challenges of readmission penalties, evidenced-based medicine requirements, EMR implementation, and operation challenges,” Kneipper wrote.

For the full survey, please visit www.antheliohealth.com and search “survey.”

As a charter member of SHM, I have been paying my annual membership dues since the late 1990s. For those of you who are SHM members, I thank you. Our small group, which organized in the late 1990s, has grown to thousands. In addition to improving patient care, your SHM membership dues help hospitalists advocate for hospitalists and support the profession we call hospital medicine.

In addition to joining SHM, there are many other ways to support SHM and do your part to support the profession. As a longtime leader of the Boston SHM chapter, I encourage you to not only attend your local SHM chapter meetings, but also become involved in its operation. You might be surprised where your attendance and participation at local SHM chapter meetings lead you.

My friend Kathleen Finn, MD, and I first organized our “Boston Hospitalist Meetings” in the late 1990s, when we signed up as members of NAIP (National Association of Inpatient Physicians), which later became SHM. Our goal for meetings was pretty simple: We wanted a venue for Boston area hospitalists to share ideas and figure out what we were supposed to do as “hospitalists.” Our first meeting was held at Beth Israel Deaconess Medical Center, and we invited Win Whitcomb, MD, MHM, to speak. Win is a cofounder of NAIP and resided in central Massachusetts. Never could I have imagined back in the late 1990s that, in 2011, Kathleen and I would still be holding our quarterly meetings, nor could I imagine that I would become SHM’s president. I am proud of the part we played in shaping HM locally, regionally, and nationally.

Something else I am proud of is the fact that SHM members have a voice when it comes to electing its leaders. Today I received an email asking me to cast my vote for the SHM board of directors. Like me, some of you are members of other professional medical societies. Think about this: How many other organizations ask you for your vote when it comes to selecting its leaders? The board of directors set the direction for SHM and our profession. They not only choose the editors for our publications (The Hospitalist and Journal of Hospital Medicine) and the director of our annual meeting, but they also hire our CEO and elect our president. They make some decisions that seem pretty important to our organization and to our profession, don’t you think?

Here is where it gets a bit puzzling to me. Despite the size of our society (around 10,000 members), relatively few SHM members choose to exercise their right to vote.

I liken the right to vote to getting the flu shot: Nobody seems to miss the flu shot until we hear there is a vaccine shortage. Then we are outraged there aren’t enough vaccines for everyone. Let’s think about the alternative. What if SHM were to change the way it picks its leaders? Why not act like most other professional medical societies and do away with membership elections and ask existing leadership to hand-select the organization’s future leaders? “We know better who should be leading our organization!” Would we be surprised when people pick their own friends and colleagues to replace them on the board? That doesn’t sound “American,” does it? What if we were to ask congressmen to select their own members? As costly and cumbersome as our election process might be (think “hanging chads” in Florida), there is something comforting in knowing that I have a voice in electing my leaders.

The right to vote is a founding principle of our great nation, right? It is the reason why many of us and/or our ancestors came to the U.S. My maternal grandparents left China in the 1950s so they could live “free” in Hong Kong. My parents moved our family to the U.S. in the mid-1970s because of the anticipated “handover” of Hong Kong from Great Britain to China in 1997. Look back far enough in your family tree, and you likely will find similar stories.

Should we be concerned with the “as is” process and plod along with our annual SHM elections, even if voter turnout is low? Is there a problem with the status quo? Voter apathy is a bigger problem than we may realize. Low voter turnout creates the potential for any one group to insidiously wrest over the control of any organization’s agenda.

There are typically three or four board seats up for election annually. This means half the 12-person board could change every two years. One could easily imagine a scenario in which a special-interest group could elect directors with a like-minded agenda simply by generating increased voter turnout over two election cycles.

Sound crazy? Is this is Joe’s “Occupy SHM” conspiracy theory? I don’t think so. Take a look around and ask yourself why there are multiple professional societies that represent ED physicians or pulmonary/critical-care physicians. The list goes on and on when it comes to medical societies. With enough numbers, groups with their own interests can take over an organization and advance their own agenda. Overnight, we could see the hospitalist community splinter into multiple professional societies, each with its own agenda. This could happen to us. For example, we could have a society for academic hospitalists, another for community hospitalists, etc.

I think our patients and profession are better served long-term if there is one professional organization representing all hospitalists, whether you are a pediatrician, family physician, nurse practitioner, internist, etc., and whether you are self-employed, work for a management company, work for a hospital, etc.

The list of special-interest groups could go on and on. But it should be viewed as a strength, not a weakness, to preserve one professional society that represents all of hospital medicine’s interests. I am interested in your thoughts on how we can increase voter turnout for SHM’s board of director elections. Please email me at JosephLi@HospitalMedicine.org.

Dr. Li is president of SHM.

As a charter member of SHM, I have been paying my annual membership dues since the late 1990s. For those of you who are SHM members, I thank you. Our small group, which organized in the late 1990s, has grown to thousands. In addition to improving patient care, your SHM membership dues help hospitalists advocate for hospitalists and support the profession we call hospital medicine.

In addition to joining SHM, there are many other ways to support SHM and do your part to support the profession. As a longtime leader of the Boston SHM chapter, I encourage you to not only attend your local SHM chapter meetings, but also become involved in its operation. You might be surprised where your attendance and participation at local SHM chapter meetings lead you.

My friend Kathleen Finn, MD, and I first organized our “Boston Hospitalist Meetings” in the late 1990s, when we signed up as members of NAIP (National Association of Inpatient Physicians), which later became SHM. Our goal for meetings was pretty simple: We wanted a venue for Boston area hospitalists to share ideas and figure out what we were supposed to do as “hospitalists.” Our first meeting was held at Beth Israel Deaconess Medical Center, and we invited Win Whitcomb, MD, MHM, to speak. Win is a cofounder of NAIP and resided in central Massachusetts. Never could I have imagined back in the late 1990s that, in 2011, Kathleen and I would still be holding our quarterly meetings, nor could I imagine that I would become SHM’s president. I am proud of the part we played in shaping HM locally, regionally, and nationally.

Something else I am proud of is the fact that SHM members have a voice when it comes to electing its leaders. Today I received an email asking me to cast my vote for the SHM board of directors. Like me, some of you are members of other professional medical societies. Think about this: How many other organizations ask you for your vote when it comes to selecting its leaders? The board of directors set the direction for SHM and our profession. They not only choose the editors for our publications (The Hospitalist and Journal of Hospital Medicine) and the director of our annual meeting, but they also hire our CEO and elect our president. They make some decisions that seem pretty important to our organization and to our profession, don’t you think?

Here is where it gets a bit puzzling to me. Despite the size of our society (around 10,000 members), relatively few SHM members choose to exercise their right to vote.

I liken the right to vote to getting the flu shot: Nobody seems to miss the flu shot until we hear there is a vaccine shortage. Then we are outraged there aren’t enough vaccines for everyone. Let’s think about the alternative. What if SHM were to change the way it picks its leaders? Why not act like most other professional medical societies and do away with membership elections and ask existing leadership to hand-select the organization’s future leaders? “We know better who should be leading our organization!” Would we be surprised when people pick their own friends and colleagues to replace them on the board? That doesn’t sound “American,” does it? What if we were to ask congressmen to select their own members? As costly and cumbersome as our election process might be (think “hanging chads” in Florida), there is something comforting in knowing that I have a voice in electing my leaders.

The right to vote is a founding principle of our great nation, right? It is the reason why many of us and/or our ancestors came to the U.S. My maternal grandparents left China in the 1950s so they could live “free” in Hong Kong. My parents moved our family to the U.S. in the mid-1970s because of the anticipated “handover” of Hong Kong from Great Britain to China in 1997. Look back far enough in your family tree, and you likely will find similar stories.

Should we be concerned with the “as is” process and plod along with our annual SHM elections, even if voter turnout is low? Is there a problem with the status quo? Voter apathy is a bigger problem than we may realize. Low voter turnout creates the potential for any one group to insidiously wrest over the control of any organization’s agenda.

There are typically three or four board seats up for election annually. This means half the 12-person board could change every two years. One could easily imagine a scenario in which a special-interest group could elect directors with a like-minded agenda simply by generating increased voter turnout over two election cycles.

Sound crazy? Is this is Joe’s “Occupy SHM” conspiracy theory? I don’t think so. Take a look around and ask yourself why there are multiple professional societies that represent ED physicians or pulmonary/critical-care physicians. The list goes on and on when it comes to medical societies. With enough numbers, groups with their own interests can take over an organization and advance their own agenda. Overnight, we could see the hospitalist community splinter into multiple professional societies, each with its own agenda. This could happen to us. For example, we could have a society for academic hospitalists, another for community hospitalists, etc.

I think our patients and profession are better served long-term if there is one professional organization representing all hospitalists, whether you are a pediatrician, family physician, nurse practitioner, internist, etc., and whether you are self-employed, work for a management company, work for a hospital, etc.

The list of special-interest groups could go on and on. But it should be viewed as a strength, not a weakness, to preserve one professional society that represents all of hospital medicine’s interests. I am interested in your thoughts on how we can increase voter turnout for SHM’s board of director elections. Please email me at JosephLi@HospitalMedicine.org.

Dr. Li is president of SHM.

As a charter member of SHM, I have been paying my annual membership dues since the late 1990s. For those of you who are SHM members, I thank you. Our small group, which organized in the late 1990s, has grown to thousands. In addition to improving patient care, your SHM membership dues help hospitalists advocate for hospitalists and support the profession we call hospital medicine.

In addition to joining SHM, there are many other ways to support SHM and do your part to support the profession. As a longtime leader of the Boston SHM chapter, I encourage you to not only attend your local SHM chapter meetings, but also become involved in its operation. You might be surprised where your attendance and participation at local SHM chapter meetings lead you.

My friend Kathleen Finn, MD, and I first organized our “Boston Hospitalist Meetings” in the late 1990s, when we signed up as members of NAIP (National Association of Inpatient Physicians), which later became SHM. Our goal for meetings was pretty simple: We wanted a venue for Boston area hospitalists to share ideas and figure out what we were supposed to do as “hospitalists.” Our first meeting was held at Beth Israel Deaconess Medical Center, and we invited Win Whitcomb, MD, MHM, to speak. Win is a cofounder of NAIP and resided in central Massachusetts. Never could I have imagined back in the late 1990s that, in 2011, Kathleen and I would still be holding our quarterly meetings, nor could I imagine that I would become SHM’s president. I am proud of the part we played in shaping HM locally, regionally, and nationally.

Something else I am proud of is the fact that SHM members have a voice when it comes to electing its leaders. Today I received an email asking me to cast my vote for the SHM board of directors. Like me, some of you are members of other professional medical societies. Think about this: How many other organizations ask you for your vote when it comes to selecting its leaders? The board of directors set the direction for SHM and our profession. They not only choose the editors for our publications (The Hospitalist and Journal of Hospital Medicine) and the director of our annual meeting, but they also hire our CEO and elect our president. They make some decisions that seem pretty important to our organization and to our profession, don’t you think?

Here is where it gets a bit puzzling to me. Despite the size of our society (around 10,000 members), relatively few SHM members choose to exercise their right to vote.

I liken the right to vote to getting the flu shot: Nobody seems to miss the flu shot until we hear there is a vaccine shortage. Then we are outraged there aren’t enough vaccines for everyone. Let’s think about the alternative. What if SHM were to change the way it picks its leaders? Why not act like most other professional medical societies and do away with membership elections and ask existing leadership to hand-select the organization’s future leaders? “We know better who should be leading our organization!” Would we be surprised when people pick their own friends and colleagues to replace them on the board? That doesn’t sound “American,” does it? What if we were to ask congressmen to select their own members? As costly and cumbersome as our election process might be (think “hanging chads” in Florida), there is something comforting in knowing that I have a voice in electing my leaders.

The right to vote is a founding principle of our great nation, right? It is the reason why many of us and/or our ancestors came to the U.S. My maternal grandparents left China in the 1950s so they could live “free” in Hong Kong. My parents moved our family to the U.S. in the mid-1970s because of the anticipated “handover” of Hong Kong from Great Britain to China in 1997. Look back far enough in your family tree, and you likely will find similar stories.

Should we be concerned with the “as is” process and plod along with our annual SHM elections, even if voter turnout is low? Is there a problem with the status quo? Voter apathy is a bigger problem than we may realize. Low voter turnout creates the potential for any one group to insidiously wrest over the control of any organization’s agenda.

There are typically three or four board seats up for election annually. This means half the 12-person board could change every two years. One could easily imagine a scenario in which a special-interest group could elect directors with a like-minded agenda simply by generating increased voter turnout over two election cycles.

Sound crazy? Is this is Joe’s “Occupy SHM” conspiracy theory? I don’t think so. Take a look around and ask yourself why there are multiple professional societies that represent ED physicians or pulmonary/critical-care physicians. The list goes on and on when it comes to medical societies. With enough numbers, groups with their own interests can take over an organization and advance their own agenda. Overnight, we could see the hospitalist community splinter into multiple professional societies, each with its own agenda. This could happen to us. For example, we could have a society for academic hospitalists, another for community hospitalists, etc.

I think our patients and profession are better served long-term if there is one professional organization representing all hospitalists, whether you are a pediatrician, family physician, nurse practitioner, internist, etc., and whether you are self-employed, work for a management company, work for a hospital, etc.

The list of special-interest groups could go on and on. But it should be viewed as a strength, not a weakness, to preserve one professional society that represents all of hospital medicine’s interests. I am interested in your thoughts on how we can increase voter turnout for SHM’s board of director elections. Please email me at JosephLi@HospitalMedicine.org.

Dr. Li is president of SHM.

It’s that time of year again. A new year is upon us. It’s resolution time.

I must admit, somewhat sheepishly, that I am a bit of “resolver.” What can I say? I like to resolve. I like to think about resolutions. I like to plan resolutions. I like to regale my uninterested wife with my resolutions. And I am, in fact, actually quite good at all phases of resolving, with one small exception—the follow-through.

You see, while I love to plan changes in my life, I’m horrible at making changes in my life. There’s nothing too shocking about that, I suppose. Most people fail when change is required. What is interesting, though, is that years of failure have yet to imbue me with the sense to stop resolving. I mean, how many times can a man fail at resolutions before he stumbles upon a resolution to stop resolving—a resolution I’d surely fail at?

But what are perhaps even more interesting are the things I’ve apparently resolved to do. I say “apparently” because not only do I typically not remember making the resolutions, but most often I also can’t even fathom why I’d resolve such things in the first place. But clearly I do. In fact, every year, I commit to about 10-20 resolutions. I actually write them down, threaten to make my wife read them, then stow them safely in my desk drawer, only to unearth them a year later to discover that I actually resolved to write a children’s book. True story; I just reviewed my resolutions from last year. I don’t remember why I put that on the list. But I did. And, of course, I failed—but I did, in fact, read a children’s book. Maybe that’s what I meant.

Over the years I’ve also resolved to make a hole-in-one, get better hair, and read War and Peace (on the toilet, during medical school). Fail, fail, and fail. The last one’s a great example of good intentions and no follow-through. Driven by the numerology (1,296 pages+1,296 days of medical school, excluding the last semester, of course, as most of us did=one page per day!) and the symbolism (medical school+grueling+war=challenging, long, grueling book about war) of the goal, I was ultimately undone by an inability to reliably differentiate a Bezukhov from a Bolkonsky, and constipation.

I bring this all up because it is time again for New Year’s resolutions. So here, in no particular order, are my 2012 resolutions.

Oh, That’s How Full Feels!

In 2012, I resolve to finally have a fully staffed HM group. From our group’s origins in 2003 to our current 30-member group, we have been intermittently understaffed to various degrees—a feeling I know most of you have experienced. For a couple of years we were fully staffed, but recent hospital expansions again place us at risk of being understaffed. As most of you know, it is exceedingly difficult to move the clinical, quality, and efficiency goals of a group forward without enough boots on the ground. So, if you’re in the market, the skiing in Colorado can’t be beat!

Appreciate VBP

I resolve to position our hospitalist group for the coming value-based purchasing world. We all know that the future belongs to those who can provide fundamental value—that is, higher-quality care at lower cost. This has been HM’s mantra the past decade. 2012 is the year I resolve to see our group fully realize this.

Leave the Cave

I resolve to (really) learn how to use Epic. We implemented our new Epic electronic health record in 2011. I’m a big proponent, but also a Luddite. I tinker around the edges of what is a truly powerful tool in advancing clinical care. I resolve to move past casual to highly functional user.

Make “10” Perfect

I resolve to figure out this new ICD-10 system. OK, technically it’s not “new.” It’s been complete since 1992 and in use in many countries for the better part of a decade. This is not a simple update of the ICD-9 system; rather, this is an entire overhaul that adds two more digits to the system. This takes the number of possible codes from 13,000 (ICD-9) to 68,000 (ICD-10). This allows for much more specificity and laterality—that is, you could have cellulitis of the right or left foot.

These changes are more than just job security for coders. The issue monetizes as payors decide not to pay for readmissions. Consider a patient who had a right-foot cellulitis, only to be admitted two weeks later with a left-foot cellulitis. ICD-9 does not have laterality, such that both stays would have the same code and the second admit could be denied as a 30-day readmission.

Twitter With Excitement

I resolve to figure out social media. I must admit that this is a red-alert, high-risk-of-failure resolution, partly because I don’t Facebook, tweet, or blog; heck, I’m not even LinkedIn! Additionally, I don’t have any friends. And finally, I just don’t get it. Then again, I didn’t get “The Simpsons” when they first came out. D’oh!

Get Hipper

And I resolve to re-enter the pop culture world in general. My social and cultural life came to a screeching halt near midnight on Sept. 29, 2007: One moment I was innocently watching the Colorado Rockies battle into their first playoffs in 12 years, and the next I was blasted onto a four-year hyper-blur of crying, spoon-feeding, and diaper-changing—for the non-parent readers, I’m describing child-rearing, not residency training, which is admittedly often marked by these same mileposts. Now 4 and 2 years old, my kiddos have finally reached the stages of self-care that allow for my gradual re-entry into the outside world.

As such, I resolve to go to a movie (in the theater) again. The last two movies we saw in the theatre in 2007 were chosen by my pregnant wife and contained an uncomfortable subliminal theme—Knocked Up (pregnant woman hates impregnating sloth of a man), Juno (pregnant woman has love-hate relationship with pasty, impregnating nerd in tight gym shorts).

I’m also interested to see what’s on TV and on the radio. When I last turned off the cathodes, “Lost” was big; ditto “The Sopranos.” And in a clearly ill-fated second season, “Dancing with the Stars” was well on its way to its undeniable cancellation. Musically, Britney was shaving her head and Jordin Sparks was edging out Sanjaya’s faux-hawk on “Idol.”

I’m also looking forward to learning what a Kardashian is (a sweater?), explaining the strange pull toward vampire romances, and discovering the difference between a Pippa and a Snooki. Should be fun. I just hope I don’t catch “Bieber Fever.”

Aspire To “Be The Cup”

Finally, in 2012, I resolve to live up to the coffee cup—you know, the Father’s Day 2011 gift emblazoned with “World’s Best Dad.” I’m sure you all feel this in your own way—that constant tension between work and life. In 2011, work won a few too many of the tug-o’-wars. Too many missed gymnastics lessons, soccer practices, parent events at daycare, and late dinners. 2012 will be different.

I resolve to teach my son the art of hitting a curveball (even if it’s off a tee) and my daughter her letters and numbers. The dogs will get more tennis balls, the wife fewer resolutions to review.

In fact, this year is going to be totally different. This is the year my to-do list doesn’t once again end as an “undid list.” This is the year I will accomplish my resolutions … not just one or two, but all of my resolutions.

And I might just write a children’s book for good measure.

Dr. Glasheen is The Hospitalist’s physician editor.

It’s that time of year again. A new year is upon us. It’s resolution time.

I must admit, somewhat sheepishly, that I am a bit of “resolver.” What can I say? I like to resolve. I like to think about resolutions. I like to plan resolutions. I like to regale my uninterested wife with my resolutions. And I am, in fact, actually quite good at all phases of resolving, with one small exception—the follow-through.

You see, while I love to plan changes in my life, I’m horrible at making changes in my life. There’s nothing too shocking about that, I suppose. Most people fail when change is required. What is interesting, though, is that years of failure have yet to imbue me with the sense to stop resolving. I mean, how many times can a man fail at resolutions before he stumbles upon a resolution to stop resolving—a resolution I’d surely fail at?

But what are perhaps even more interesting are the things I’ve apparently resolved to do. I say “apparently” because not only do I typically not remember making the resolutions, but most often I also can’t even fathom why I’d resolve such things in the first place. But clearly I do. In fact, every year, I commit to about 10-20 resolutions. I actually write them down, threaten to make my wife read them, then stow them safely in my desk drawer, only to unearth them a year later to discover that I actually resolved to write a children’s book. True story; I just reviewed my resolutions from last year. I don’t remember why I put that on the list. But I did. And, of course, I failed—but I did, in fact, read a children’s book. Maybe that’s what I meant.

Over the years I’ve also resolved to make a hole-in-one, get better hair, and read War and Peace (on the toilet, during medical school). Fail, fail, and fail. The last one’s a great example of good intentions and no follow-through. Driven by the numerology (1,296 pages+1,296 days of medical school, excluding the last semester, of course, as most of us did=one page per day!) and the symbolism (medical school+grueling+war=challenging, long, grueling book about war) of the goal, I was ultimately undone by an inability to reliably differentiate a Bezukhov from a Bolkonsky, and constipation.

I bring this all up because it is time again for New Year’s resolutions. So here, in no particular order, are my 2012 resolutions.

Oh, That’s How Full Feels!

In 2012, I resolve to finally have a fully staffed HM group. From our group’s origins in 2003 to our current 30-member group, we have been intermittently understaffed to various degrees—a feeling I know most of you have experienced. For a couple of years we were fully staffed, but recent hospital expansions again place us at risk of being understaffed. As most of you know, it is exceedingly difficult to move the clinical, quality, and efficiency goals of a group forward without enough boots on the ground. So, if you’re in the market, the skiing in Colorado can’t be beat!

Appreciate VBP

I resolve to position our hospitalist group for the coming value-based purchasing world. We all know that the future belongs to those who can provide fundamental value—that is, higher-quality care at lower cost. This has been HM’s mantra the past decade. 2012 is the year I resolve to see our group fully realize this.

Leave the Cave

I resolve to (really) learn how to use Epic. We implemented our new Epic electronic health record in 2011. I’m a big proponent, but also a Luddite. I tinker around the edges of what is a truly powerful tool in advancing clinical care. I resolve to move past casual to highly functional user.

Make “10” Perfect

I resolve to figure out this new ICD-10 system. OK, technically it’s not “new.” It’s been complete since 1992 and in use in many countries for the better part of a decade. This is not a simple update of the ICD-9 system; rather, this is an entire overhaul that adds two more digits to the system. This takes the number of possible codes from 13,000 (ICD-9) to 68,000 (ICD-10). This allows for much more specificity and laterality—that is, you could have cellulitis of the right or left foot.

These changes are more than just job security for coders. The issue monetizes as payors decide not to pay for readmissions. Consider a patient who had a right-foot cellulitis, only to be admitted two weeks later with a left-foot cellulitis. ICD-9 does not have laterality, such that both stays would have the same code and the second admit could be denied as a 30-day readmission.

Twitter With Excitement

I resolve to figure out social media. I must admit that this is a red-alert, high-risk-of-failure resolution, partly because I don’t Facebook, tweet, or blog; heck, I’m not even LinkedIn! Additionally, I don’t have any friends. And finally, I just don’t get it. Then again, I didn’t get “The Simpsons” when they first came out. D’oh!

Get Hipper

And I resolve to re-enter the pop culture world in general. My social and cultural life came to a screeching halt near midnight on Sept. 29, 2007: One moment I was innocently watching the Colorado Rockies battle into their first playoffs in 12 years, and the next I was blasted onto a four-year hyper-blur of crying, spoon-feeding, and diaper-changing—for the non-parent readers, I’m describing child-rearing, not residency training, which is admittedly often marked by these same mileposts. Now 4 and 2 years old, my kiddos have finally reached the stages of self-care that allow for my gradual re-entry into the outside world.

As such, I resolve to go to a movie (in the theater) again. The last two movies we saw in the theatre in 2007 were chosen by my pregnant wife and contained an uncomfortable subliminal theme—Knocked Up (pregnant woman hates impregnating sloth of a man), Juno (pregnant woman has love-hate relationship with pasty, impregnating nerd in tight gym shorts).

I’m also interested to see what’s on TV and on the radio. When I last turned off the cathodes, “Lost” was big; ditto “The Sopranos.” And in a clearly ill-fated second season, “Dancing with the Stars” was well on its way to its undeniable cancellation. Musically, Britney was shaving her head and Jordin Sparks was edging out Sanjaya’s faux-hawk on “Idol.”

I’m also looking forward to learning what a Kardashian is (a sweater?), explaining the strange pull toward vampire romances, and discovering the difference between a Pippa and a Snooki. Should be fun. I just hope I don’t catch “Bieber Fever.”

Aspire To “Be The Cup”

Finally, in 2012, I resolve to live up to the coffee cup—you know, the Father’s Day 2011 gift emblazoned with “World’s Best Dad.” I’m sure you all feel this in your own way—that constant tension between work and life. In 2011, work won a few too many of the tug-o’-wars. Too many missed gymnastics lessons, soccer practices, parent events at daycare, and late dinners. 2012 will be different.

I resolve to teach my son the art of hitting a curveball (even if it’s off a tee) and my daughter her letters and numbers. The dogs will get more tennis balls, the wife fewer resolutions to review.

In fact, this year is going to be totally different. This is the year my to-do list doesn’t once again end as an “undid list.” This is the year I will accomplish my resolutions … not just one or two, but all of my resolutions.

And I might just write a children’s book for good measure.

Dr. Glasheen is The Hospitalist’s physician editor.

It’s that time of year again. A new year is upon us. It’s resolution time.

I must admit, somewhat sheepishly, that I am a bit of “resolver.” What can I say? I like to resolve. I like to think about resolutions. I like to plan resolutions. I like to regale my uninterested wife with my resolutions. And I am, in fact, actually quite good at all phases of resolving, with one small exception—the follow-through.

You see, while I love to plan changes in my life, I’m horrible at making changes in my life. There’s nothing too shocking about that, I suppose. Most people fail when change is required. What is interesting, though, is that years of failure have yet to imbue me with the sense to stop resolving. I mean, how many times can a man fail at resolutions before he stumbles upon a resolution to stop resolving—a resolution I’d surely fail at?

But what are perhaps even more interesting are the things I’ve apparently resolved to do. I say “apparently” because not only do I typically not remember making the resolutions, but most often I also can’t even fathom why I’d resolve such things in the first place. But clearly I do. In fact, every year, I commit to about 10-20 resolutions. I actually write them down, threaten to make my wife read them, then stow them safely in my desk drawer, only to unearth them a year later to discover that I actually resolved to write a children’s book. True story; I just reviewed my resolutions from last year. I don’t remember why I put that on the list. But I did. And, of course, I failed—but I did, in fact, read a children’s book. Maybe that’s what I meant.

Over the years I’ve also resolved to make a hole-in-one, get better hair, and read War and Peace (on the toilet, during medical school). Fail, fail, and fail. The last one’s a great example of good intentions and no follow-through. Driven by the numerology (1,296 pages+1,296 days of medical school, excluding the last semester, of course, as most of us did=one page per day!) and the symbolism (medical school+grueling+war=challenging, long, grueling book about war) of the goal, I was ultimately undone by an inability to reliably differentiate a Bezukhov from a Bolkonsky, and constipation.

I bring this all up because it is time again for New Year’s resolutions. So here, in no particular order, are my 2012 resolutions.

Oh, That’s How Full Feels!

In 2012, I resolve to finally have a fully staffed HM group. From our group’s origins in 2003 to our current 30-member group, we have been intermittently understaffed to various degrees—a feeling I know most of you have experienced. For a couple of years we were fully staffed, but recent hospital expansions again place us at risk of being understaffed. As most of you know, it is exceedingly difficult to move the clinical, quality, and efficiency goals of a group forward without enough boots on the ground. So, if you’re in the market, the skiing in Colorado can’t be beat!

Appreciate VBP

I resolve to position our hospitalist group for the coming value-based purchasing world. We all know that the future belongs to those who can provide fundamental value—that is, higher-quality care at lower cost. This has been HM’s mantra the past decade. 2012 is the year I resolve to see our group fully realize this.

Leave the Cave

I resolve to (really) learn how to use Epic. We implemented our new Epic electronic health record in 2011. I’m a big proponent, but also a Luddite. I tinker around the edges of what is a truly powerful tool in advancing clinical care. I resolve to move past casual to highly functional user.

Make “10” Perfect

I resolve to figure out this new ICD-10 system. OK, technically it’s not “new.” It’s been complete since 1992 and in use in many countries for the better part of a decade. This is not a simple update of the ICD-9 system; rather, this is an entire overhaul that adds two more digits to the system. This takes the number of possible codes from 13,000 (ICD-9) to 68,000 (ICD-10). This allows for much more specificity and laterality—that is, you could have cellulitis of the right or left foot.

These changes are more than just job security for coders. The issue monetizes as payors decide not to pay for readmissions. Consider a patient who had a right-foot cellulitis, only to be admitted two weeks later with a left-foot cellulitis. ICD-9 does not have laterality, such that both stays would have the same code and the second admit could be denied as a 30-day readmission.

Twitter With Excitement

I resolve to figure out social media. I must admit that this is a red-alert, high-risk-of-failure resolution, partly because I don’t Facebook, tweet, or blog; heck, I’m not even LinkedIn! Additionally, I don’t have any friends. And finally, I just don’t get it. Then again, I didn’t get “The Simpsons” when they first came out. D’oh!

Get Hipper

And I resolve to re-enter the pop culture world in general. My social and cultural life came to a screeching halt near midnight on Sept. 29, 2007: One moment I was innocently watching the Colorado Rockies battle into their first playoffs in 12 years, and the next I was blasted onto a four-year hyper-blur of crying, spoon-feeding, and diaper-changing—for the non-parent readers, I’m describing child-rearing, not residency training, which is admittedly often marked by these same mileposts. Now 4 and 2 years old, my kiddos have finally reached the stages of self-care that allow for my gradual re-entry into the outside world.

As such, I resolve to go to a movie (in the theater) again. The last two movies we saw in the theatre in 2007 were chosen by my pregnant wife and contained an uncomfortable subliminal theme—Knocked Up (pregnant woman hates impregnating sloth of a man), Juno (pregnant woman has love-hate relationship with pasty, impregnating nerd in tight gym shorts).

I’m also interested to see what’s on TV and on the radio. When I last turned off the cathodes, “Lost” was big; ditto “The Sopranos.” And in a clearly ill-fated second season, “Dancing with the Stars” was well on its way to its undeniable cancellation. Musically, Britney was shaving her head and Jordin Sparks was edging out Sanjaya’s faux-hawk on “Idol.”

I’m also looking forward to learning what a Kardashian is (a sweater?), explaining the strange pull toward vampire romances, and discovering the difference between a Pippa and a Snooki. Should be fun. I just hope I don’t catch “Bieber Fever.”

Aspire To “Be The Cup”

Finally, in 2012, I resolve to live up to the coffee cup—you know, the Father’s Day 2011 gift emblazoned with “World’s Best Dad.” I’m sure you all feel this in your own way—that constant tension between work and life. In 2011, work won a few too many of the tug-o’-wars. Too many missed gymnastics lessons, soccer practices, parent events at daycare, and late dinners. 2012 will be different.

I resolve to teach my son the art of hitting a curveball (even if it’s off a tee) and my daughter her letters and numbers. The dogs will get more tennis balls, the wife fewer resolutions to review.

In fact, this year is going to be totally different. This is the year my to-do list doesn’t once again end as an “undid list.” This is the year I will accomplish my resolutions … not just one or two, but all of my resolutions.

And I might just write a children’s book for good measure.

Dr. Glasheen is The Hospitalist’s physician editor.

Doctors shouldn’t have to worry about financial issues. The welfare of our patients should be our only concern.

We should be able to devote our full attention to studying how best to serve the needs of the people we care for. We shouldn’t need to spend time learning about healthcare reform or things like ICD-9 (or ICD-10!)—things that don’t help us provide better care to patients.

But these are pie-in-the-sky dreams. As far as I can tell, all healthcare systems require caregivers to attend to economics and data management that aren’t directly tied to clinical care. Our system depends on all caregivers devoting some time to learn how the system is organized, and keeping up with how it evolves. And the crisis in runaway costs in U.S. healthcare only increases the need for all who work in healthcare to devote significant time (too much) to the operational (nonclinical side) of healthcare.

Hospitalist practice is a much simpler business to manage and operate than most forms of clinical practice. There usually is no building to rent, few nonclinical employees to manage, and a comparatively simple financial model. And if employed by a hospital or other large entity, nonclinicians handle most of the “business management.” So when it comes to the number of brain cells diverted to business rather than clinical concerns, hospitalists start with an advantage over most other specialties.

Still, we have a lot of nonclinical stuff to keep up with. Consider the concept of “managing to Medicare reimbursement.” This means managing a practice or hospital in a way that minimizes the failure to capture all appropriate Medicare reimbursement dollars. Even if you’ve never heard of this concept before, there are probably a lot of people at your hospital who have this as their main responsibility, and clinicians should know something about it.

So in an effort to distract the fewest brain cells away from clinical matters, here is a very simple overview of some components of managing to Medicare reimbursement relevant to hospitalists. This isn’t a comprehensive list, only some hospitalist-relevant highlights.

Medicare Reimbursement Today

Accurate determination of inpatient vs. observation status. Wow, this can get complicated. Most hospitals have people who devote significant time to doing this for patients every day, and even those experts sometimes disagree on the appropriate status. But all hospitalists should have a basic understanding of how this works and a willingness to answer questions from the hospital’s experts, and, when appropriate, write additional information in the chart to clarify the appropriate status.

Optimal resource utilization, including length of stay. Because Medicare pays an essentially fixed amount based on the diagnoses for each inpatient admission, managing costs is critical to a hospital’s financial well-being. Hospitalists have a huge role in this. And regardless of how Medicare reimburses for services, there is clinical rationale for being careful about resources used and how long someone stays in a hospital. In many cases, more is not better—and it even could be worse—for the patient.

Optimal clinical documentation and accurate DRG assignment. Good documentation is important for clinical care, but beyond that, the precise way things are documented can have significant influence on Medicare reimbursement. Low potassium might in some cases lead to higher reimbursement, but a doctor must write “hypokalemia”; simply writing K+ means the hospital can’t include hypokalemia as a diagnosis. (A doctor, nurse practitioner, or physician assistant must write out “hypokalemia” only once for Medicare purposes; it would then be fine to use K+ in the chart every other time.)

Say you have a patient with a UTI and sepsis. Write only “urosepsis,” and the hospital must bill for cystitis—low reimbursement. Write “urinary tract infection with sepsis,” and the hospital can bill for higher reimbursement.

There should be people at your hospital who are experts at this, and all hospitalists should work with them to learn appropriate documentation language to describe illnesses correctly for billing purposes. Many hospitals use a system of “DRG queries,” which hospitalists should always respond to (though they should agree with the issue raised, such as “was the pneumonia likely due to aspiration?” only when clinically appropriate).

Change Is Coming

Don’t make the mistake of thinking Medicare reimbursement is a static phenomenon. It is undergoing rapid and significant evolution. For example, the Affordable Care Act, aka healthcare reform legislation, provides for a number of changes hospitalists need to understand.

I suggest that you make sure to understand your hospital’s or medical group’s position on accountable-care organizations (ACOs). It is a pretty complicated program that, in the first few years, has modest impact on reimbursement. If the ACO performs well, the additional reimbursement to an organization might pay for little more than the staff salaries of the staff that managed the considerable complexity of enrolling in and reporting for the program. And there is a risk the organization could lose money if it doesn’t perform well. So many organizations have decided not to pursue participation as an ACO, but they may decide to put in place most of the elements of an ACO without enrolling in the program. Some refer to this as an “aco” rather than an “ACO.”

Value-based purchasing (VBP) is set to influence hospital reimbursement rates starting in 2013 based on a hospital’s performance in 2012. SHM has a terrific VBP toolkit available online.

Bundled payments and financial penalties for readmissions also take effect in 2013. Now is the time ensure that you understand the implications of these programs; they are designed so that the financial impact to most organizations will be modest.

Reimbursement penalties for a specified list of hospital-acquired conditions (HACs) will begin in 2015. Conditions most relevant for hospitalists include vascular catheter-related bloodstream infections, catheter-related urinary infection, or manifestations of poor glycemic control (HONK, DKA, hypo-/hyperglycemia).

I plan to address some of these programs in greater detail in future practice management columns.

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

Doctors shouldn’t have to worry about financial issues. The welfare of our patients should be our only concern.

We should be able to devote our full attention to studying how best to serve the needs of the people we care for. We shouldn’t need to spend time learning about healthcare reform or things like ICD-9 (or ICD-10!)—things that don’t help us provide better care to patients.

But these are pie-in-the-sky dreams. As far as I can tell, all healthcare systems require caregivers to attend to economics and data management that aren’t directly tied to clinical care. Our system depends on all caregivers devoting some time to learn how the system is organized, and keeping up with how it evolves. And the crisis in runaway costs in U.S. healthcare only increases the need for all who work in healthcare to devote significant time (too much) to the operational (nonclinical side) of healthcare.

Hospitalist practice is a much simpler business to manage and operate than most forms of clinical practice. There usually is no building to rent, few nonclinical employees to manage, and a comparatively simple financial model. And if employed by a hospital or other large entity, nonclinicians handle most of the “business management.” So when it comes to the number of brain cells diverted to business rather than clinical concerns, hospitalists start with an advantage over most other specialties.

Still, we have a lot of nonclinical stuff to keep up with. Consider the concept of “managing to Medicare reimbursement.” This means managing a practice or hospital in a way that minimizes the failure to capture all appropriate Medicare reimbursement dollars. Even if you’ve never heard of this concept before, there are probably a lot of people at your hospital who have this as their main responsibility, and clinicians should know something about it.

So in an effort to distract the fewest brain cells away from clinical matters, here is a very simple overview of some components of managing to Medicare reimbursement relevant to hospitalists. This isn’t a comprehensive list, only some hospitalist-relevant highlights.

Medicare Reimbursement Today

Accurate determination of inpatient vs. observation status. Wow, this can get complicated. Most hospitals have people who devote significant time to doing this for patients every day, and even those experts sometimes disagree on the appropriate status. But all hospitalists should have a basic understanding of how this works and a willingness to answer questions from the hospital’s experts, and, when appropriate, write additional information in the chart to clarify the appropriate status.

Optimal resource utilization, including length of stay. Because Medicare pays an essentially fixed amount based on the diagnoses for each inpatient admission, managing costs is critical to a hospital’s financial well-being. Hospitalists have a huge role in this. And regardless of how Medicare reimburses for services, there is clinical rationale for being careful about resources used and how long someone stays in a hospital. In many cases, more is not better—and it even could be worse—for the patient.

Optimal clinical documentation and accurate DRG assignment. Good documentation is important for clinical care, but beyond that, the precise way things are documented can have significant influence on Medicare reimbursement. Low potassium might in some cases lead to higher reimbursement, but a doctor must write “hypokalemia”; simply writing K+ means the hospital can’t include hypokalemia as a diagnosis. (A doctor, nurse practitioner, or physician assistant must write out “hypokalemia” only once for Medicare purposes; it would then be fine to use K+ in the chart every other time.)

Say you have a patient with a UTI and sepsis. Write only “urosepsis,” and the hospital must bill for cystitis—low reimbursement. Write “urinary tract infection with sepsis,” and the hospital can bill for higher reimbursement.

There should be people at your hospital who are experts at this, and all hospitalists should work with them to learn appropriate documentation language to describe illnesses correctly for billing purposes. Many hospitals use a system of “DRG queries,” which hospitalists should always respond to (though they should agree with the issue raised, such as “was the pneumonia likely due to aspiration?” only when clinically appropriate).

Change Is Coming

Don’t make the mistake of thinking Medicare reimbursement is a static phenomenon. It is undergoing rapid and significant evolution. For example, the Affordable Care Act, aka healthcare reform legislation, provides for a number of changes hospitalists need to understand.

I suggest that you make sure to understand your hospital’s or medical group’s position on accountable-care organizations (ACOs). It is a pretty complicated program that, in the first few years, has modest impact on reimbursement. If the ACO performs well, the additional reimbursement to an organization might pay for little more than the staff salaries of the staff that managed the considerable complexity of enrolling in and reporting for the program. And there is a risk the organization could lose money if it doesn’t perform well. So many organizations have decided not to pursue participation as an ACO, but they may decide to put in place most of the elements of an ACO without enrolling in the program. Some refer to this as an “aco” rather than an “ACO.”

Value-based purchasing (VBP) is set to influence hospital reimbursement rates starting in 2013 based on a hospital’s performance in 2012. SHM has a terrific VBP toolkit available online.

Bundled payments and financial penalties for readmissions also take effect in 2013. Now is the time ensure that you understand the implications of these programs; they are designed so that the financial impact to most organizations will be modest.

Reimbursement penalties for a specified list of hospital-acquired conditions (HACs) will begin in 2015. Conditions most relevant for hospitalists include vascular catheter-related bloodstream infections, catheter-related urinary infection, or manifestations of poor glycemic control (HONK, DKA, hypo-/hyperglycemia).

I plan to address some of these programs in greater detail in future practice management columns.

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

Doctors shouldn’t have to worry about financial issues. The welfare of our patients should be our only concern.

We should be able to devote our full attention to studying how best to serve the needs of the people we care for. We shouldn’t need to spend time learning about healthcare reform or things like ICD-9 (or ICD-10!)—things that don’t help us provide better care to patients.

But these are pie-in-the-sky dreams. As far as I can tell, all healthcare systems require caregivers to attend to economics and data management that aren’t directly tied to clinical care. Our system depends on all caregivers devoting some time to learn how the system is organized, and keeping up with how it evolves. And the crisis in runaway costs in U.S. healthcare only increases the need for all who work in healthcare to devote significant time (too much) to the operational (nonclinical side) of healthcare.

Hospitalist practice is a much simpler business to manage and operate than most forms of clinical practice. There usually is no building to rent, few nonclinical employees to manage, and a comparatively simple financial model. And if employed by a hospital or other large entity, nonclinicians handle most of the “business management.” So when it comes to the number of brain cells diverted to business rather than clinical concerns, hospitalists start with an advantage over most other specialties.

Still, we have a lot of nonclinical stuff to keep up with. Consider the concept of “managing to Medicare reimbursement.” This means managing a practice or hospital in a way that minimizes the failure to capture all appropriate Medicare reimbursement dollars. Even if you’ve never heard of this concept before, there are probably a lot of people at your hospital who have this as their main responsibility, and clinicians should know something about it.

So in an effort to distract the fewest brain cells away from clinical matters, here is a very simple overview of some components of managing to Medicare reimbursement relevant to hospitalists. This isn’t a comprehensive list, only some hospitalist-relevant highlights.

Medicare Reimbursement Today

Accurate determination of inpatient vs. observation status. Wow, this can get complicated. Most hospitals have people who devote significant time to doing this for patients every day, and even those experts sometimes disagree on the appropriate status. But all hospitalists should have a basic understanding of how this works and a willingness to answer questions from the hospital’s experts, and, when appropriate, write additional information in the chart to clarify the appropriate status.

Optimal resource utilization, including length of stay. Because Medicare pays an essentially fixed amount based on the diagnoses for each inpatient admission, managing costs is critical to a hospital’s financial well-being. Hospitalists have a huge role in this. And regardless of how Medicare reimburses for services, there is clinical rationale for being careful about resources used and how long someone stays in a hospital. In many cases, more is not better—and it even could be worse—for the patient.

Optimal clinical documentation and accurate DRG assignment. Good documentation is important for clinical care, but beyond that, the precise way things are documented can have significant influence on Medicare reimbursement. Low potassium might in some cases lead to higher reimbursement, but a doctor must write “hypokalemia”; simply writing K+ means the hospital can’t include hypokalemia as a diagnosis. (A doctor, nurse practitioner, or physician assistant must write out “hypokalemia” only once for Medicare purposes; it would then be fine to use K+ in the chart every other time.)

Say you have a patient with a UTI and sepsis. Write only “urosepsis,” and the hospital must bill for cystitis—low reimbursement. Write “urinary tract infection with sepsis,” and the hospital can bill for higher reimbursement.

There should be people at your hospital who are experts at this, and all hospitalists should work with them to learn appropriate documentation language to describe illnesses correctly for billing purposes. Many hospitals use a system of “DRG queries,” which hospitalists should always respond to (though they should agree with the issue raised, such as “was the pneumonia likely due to aspiration?” only when clinically appropriate).

Change Is Coming

Don’t make the mistake of thinking Medicare reimbursement is a static phenomenon. It is undergoing rapid and significant evolution. For example, the Affordable Care Act, aka healthcare reform legislation, provides for a number of changes hospitalists need to understand.

I suggest that you make sure to understand your hospital’s or medical group’s position on accountable-care organizations (ACOs). It is a pretty complicated program that, in the first few years, has modest impact on reimbursement. If the ACO performs well, the additional reimbursement to an organization might pay for little more than the staff salaries of the staff that managed the considerable complexity of enrolling in and reporting for the program. And there is a risk the organization could lose money if it doesn’t perform well. So many organizations have decided not to pursue participation as an ACO, but they may decide to put in place most of the elements of an ACO without enrolling in the program. Some refer to this as an “aco” rather than an “ACO.”

Value-based purchasing (VBP) is set to influence hospital reimbursement rates starting in 2013 based on a hospital’s performance in 2012. SHM has a terrific VBP toolkit available online.

Bundled payments and financial penalties for readmissions also take effect in 2013. Now is the time ensure that you understand the implications of these programs; they are designed so that the financial impact to most organizations will be modest.

Reimbursement penalties for a specified list of hospital-acquired conditions (HACs) will begin in 2015. Conditions most relevant for hospitalists include vascular catheter-related bloodstream infections, catheter-related urinary infection, or manifestations of poor glycemic control (HONK, DKA, hypo-/hyperglycemia).

I plan to address some of these programs in greater detail in future practice management columns.

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

Last month, we looked at the three main factors affecting workload variability across different HM practices and its relationship to compensation. This month we will examine how physician pay varies within a single site.

For the purposes of this discussion, we will ignore volume of encounters by physician. It goes without saying that if two physicians are working and producing an equal amount at the same site, their compensation will be similar. Outside of volume variability, then, what causes differences in compensation?

Leadership: This is a hugely important piece of the puzzle, and one that merits some attention. There always should be differential pay attached to those physicians willing to shoulder the leadership burden. In my honest opinion, local HM group leaders are horrifically, grotesquely, and shockingly underpaid. They tend to be very hard-working, almost servants to the other members of the group, and usually are vastly underappreciated.

Money isn’t necessarily the answer here; maybe the reward is a lighter schedule or lighter rounding load, but the bottom line is that there should be a substantial differential for leaders. Unfortunately, I think that still tends to be the exception rather than the rule. Hospitalist group leaders have a heck of a hard job trying to lead other physicians, and they should be paid accordingly.

At the same time, the best leaders are the ones that are still working a clinical schedule and, because of that, still understand the day-to-day demands of the job. I am always a bit skeptical of the folks who are in positions of power but aren’t experiencing the daily workload.

Experience: This is a little bit tricky. In their simplest form, physician practices tend to have partners and non-partners. The timeline from employment to partnership is about two to three years. Upon becoming partner, additional benefits accrue, generally in the form of higher compensation or the ability to work a reduced schedule.

However, “experience” prima facie will not vault one into the partnership level upon joining a new group. That experience only counts for the group you are in. (And the partner collections from the insurance payor system? No change in reimbursement. We have a payor system that, at this point, does not adequately recognize experience or quality. I always have fun trying to explain this to my friends outside of healthcare. They tend to just shake their head and sigh. Hopefully we can get somewhere new with value-based purchasing and ACOs.) Anyway, enough digressing...

Nights: A fair number of groups use a night shift model. These shifts, due to their timing, will generate a lower volume of encounters and require a commensurately higher pay. As a result, the inclusion of nocturnist compensation in a pay model will skew the numbers. In a practice with a large number of hospitals and night shifts, nocturnists are a sought-after commodity.

Quality: Here is where things are going to get interesting in the very near future. A lot of hospitalist groups have quality measures that play a part in compensation, but it’s mostly small numbers, maybe 10% of total compensation. These measures tend to be internal quality metrics for things like chart completion, citizenship, or meeting attendance. Now, with the Centers for Medicare & Medicaid Services (CMS) getting into the game, hospitals are starting to sit up and pay attention. That means administrators want hospitalists to pay attention, too. Exactly how data for each physician will be extracted from the group, which typically is extracted from the hospital as a whole, is a valid question. However, expect quality measures to persistently factor into the compensation equation.

The response I’ve laid out is meant to foster discussion, not serve as a final determination, and represents only one hospitalist’s view on the subject.

Last month, we looked at the three main factors affecting workload variability across different HM practices and its relationship to compensation. This month we will examine how physician pay varies within a single site.

For the purposes of this discussion, we will ignore volume of encounters by physician. It goes without saying that if two physicians are working and producing an equal amount at the same site, their compensation will be similar. Outside of volume variability, then, what causes differences in compensation?

Leadership: This is a hugely important piece of the puzzle, and one that merits some attention. There always should be differential pay attached to those physicians willing to shoulder the leadership burden. In my honest opinion, local HM group leaders are horrifically, grotesquely, and shockingly underpaid. They tend to be very hard-working, almost servants to the other members of the group, and usually are vastly underappreciated.

Money isn’t necessarily the answer here; maybe the reward is a lighter schedule or lighter rounding load, but the bottom line is that there should be a substantial differential for leaders. Unfortunately, I think that still tends to be the exception rather than the rule. Hospitalist group leaders have a heck of a hard job trying to lead other physicians, and they should be paid accordingly.

At the same time, the best leaders are the ones that are still working a clinical schedule and, because of that, still understand the day-to-day demands of the job. I am always a bit skeptical of the folks who are in positions of power but aren’t experiencing the daily workload.

Experience: This is a little bit tricky. In their simplest form, physician practices tend to have partners and non-partners. The timeline from employment to partnership is about two to three years. Upon becoming partner, additional benefits accrue, generally in the form of higher compensation or the ability to work a reduced schedule.

However, “experience” prima facie will not vault one into the partnership level upon joining a new group. That experience only counts for the group you are in. (And the partner collections from the insurance payor system? No change in reimbursement. We have a payor system that, at this point, does not adequately recognize experience or quality. I always have fun trying to explain this to my friends outside of healthcare. They tend to just shake their head and sigh. Hopefully we can get somewhere new with value-based purchasing and ACOs.) Anyway, enough digressing...

Nights: A fair number of groups use a night shift model. These shifts, due to their timing, will generate a lower volume of encounters and require a commensurately higher pay. As a result, the inclusion of nocturnist compensation in a pay model will skew the numbers. In a practice with a large number of hospitals and night shifts, nocturnists are a sought-after commodity.

Quality: Here is where things are going to get interesting in the very near future. A lot of hospitalist groups have quality measures that play a part in compensation, but it’s mostly small numbers, maybe 10% of total compensation. These measures tend to be internal quality metrics for things like chart completion, citizenship, or meeting attendance. Now, with the Centers for Medicare & Medicaid Services (CMS) getting into the game, hospitals are starting to sit up and pay attention. That means administrators want hospitalists to pay attention, too. Exactly how data for each physician will be extracted from the group, which typically is extracted from the hospital as a whole, is a valid question. However, expect quality measures to persistently factor into the compensation equation.

The response I’ve laid out is meant to foster discussion, not serve as a final determination, and represents only one hospitalist’s view on the subject.

Last month, we looked at the three main factors affecting workload variability across different HM practices and its relationship to compensation. This month we will examine how physician pay varies within a single site.

For the purposes of this discussion, we will ignore volume of encounters by physician. It goes without saying that if two physicians are working and producing an equal amount at the same site, their compensation will be similar. Outside of volume variability, then, what causes differences in compensation?

Leadership: This is a hugely important piece of the puzzle, and one that merits some attention. There always should be differential pay attached to those physicians willing to shoulder the leadership burden. In my honest opinion, local HM group leaders are horrifically, grotesquely, and shockingly underpaid. They tend to be very hard-working, almost servants to the other members of the group, and usually are vastly underappreciated.

Money isn’t necessarily the answer here; maybe the reward is a lighter schedule or lighter rounding load, but the bottom line is that there should be a substantial differential for leaders. Unfortunately, I think that still tends to be the exception rather than the rule. Hospitalist group leaders have a heck of a hard job trying to lead other physicians, and they should be paid accordingly.

At the same time, the best leaders are the ones that are still working a clinical schedule and, because of that, still understand the day-to-day demands of the job. I am always a bit skeptical of the folks who are in positions of power but aren’t experiencing the daily workload.

Experience: This is a little bit tricky. In their simplest form, physician practices tend to have partners and non-partners. The timeline from employment to partnership is about two to three years. Upon becoming partner, additional benefits accrue, generally in the form of higher compensation or the ability to work a reduced schedule.

However, “experience” prima facie will not vault one into the partnership level upon joining a new group. That experience only counts for the group you are in. (And the partner collections from the insurance payor system? No change in reimbursement. We have a payor system that, at this point, does not adequately recognize experience or quality. I always have fun trying to explain this to my friends outside of healthcare. They tend to just shake their head and sigh. Hopefully we can get somewhere new with value-based purchasing and ACOs.) Anyway, enough digressing...

Nights: A fair number of groups use a night shift model. These shifts, due to their timing, will generate a lower volume of encounters and require a commensurately higher pay. As a result, the inclusion of nocturnist compensation in a pay model will skew the numbers. In a practice with a large number of hospitals and night shifts, nocturnists are a sought-after commodity.

Quality: Here is where things are going to get interesting in the very near future. A lot of hospitalist groups have quality measures that play a part in compensation, but it’s mostly small numbers, maybe 10% of total compensation. These measures tend to be internal quality metrics for things like chart completion, citizenship, or meeting attendance. Now, with the Centers for Medicare & Medicaid Services (CMS) getting into the game, hospitals are starting to sit up and pay attention. That means administrators want hospitalists to pay attention, too. Exactly how data for each physician will be extracted from the group, which typically is extracted from the hospital as a whole, is a valid question. However, expect quality measures to persistently factor into the compensation equation.

The response I’ve laid out is meant to foster discussion, not serve as a final determination, and represents only one hospitalist’s view on the subject.

Just a quick comment regarding your editorial “Fiddling as HM Burns” (The Hospitalist, August 2011, p. 62) with regard to our hospital in the Florida Panhandle. The 60-plus patients we see daily are:

1. Indigent (most) and uninsured working poor; and
2. Unassigned (the local providers see their own patients).

Our length of stay is less than the providers’, but, of course, our follow-up expenses are high—we have a 15% 30-day readmission rate, and with no providers in the area that accept Medicaid, and almost no provision by the county to take care of indigent patients, the ER is the main de facto provider of healthcare. The majority of our discharges, therefore, have no follow-up plan.

I wonder if other hospitals in the Annals study (Ann Intern Med. 2011;155:152-159) had similar circumstances.

Stephen R. Gilmore, MD

Just a quick comment regarding your editorial “Fiddling as HM Burns” (The Hospitalist, August 2011, p. 62) with regard to our hospital in the Florida Panhandle. The 60-plus patients we see daily are:

1. Indigent (most) and uninsured working poor; and
2. Unassigned (the local providers see their own patients).

Our length of stay is less than the providers’, but, of course, our follow-up expenses are high—we have a 15% 30-day readmission rate, and with no providers in the area that accept Medicaid, and almost no provision by the county to take care of indigent patients, the ER is the main de facto provider of healthcare. The majority of our discharges, therefore, have no follow-up plan.

I wonder if other hospitals in the Annals study (Ann Intern Med. 2011;155:152-159) had similar circumstances.

Stephen R. Gilmore, MD

Just a quick comment regarding your editorial “Fiddling as HM Burns” (The Hospitalist, August 2011, p. 62) with regard to our hospital in the Florida Panhandle. The 60-plus patients we see daily are:

1. Indigent (most) and uninsured working poor; and
2. Unassigned (the local providers see their own patients).

Our length of stay is less than the providers’, but, of course, our follow-up expenses are high—we have a 15% 30-day readmission rate, and with no providers in the area that accept Medicaid, and almost no provision by the county to take care of indigent patients, the ER is the main de facto provider of healthcare. The majority of our discharges, therefore, have no follow-up plan.

I wonder if other hospitals in the Annals study (Ann Intern Med. 2011;155:152-159) had similar circumstances.

Stephen R. Gilmore, MD