Practice Management

Click here to listen to more of our interview with Divya Parikh

Click here to listen to more of our interview with Divya Parikh

Click here to listen to more of our interview with Divya Parikh

With the voluntary and incentive period for participating in the Physician Quality Reporting System (PQRS) quickly coming to a close, hospitalists are finding a limited number of PQRS measures broadly applicable to their practice. SHM, through its Performance Measurement and Reporting Committee (PMRC), is actively working on behalf of hospitalists to change that. At the same time, it is critical that hospitalists be proactive and participate in PQRS, not just to avoid the 2015 penalty, but to position themselves for success as the Value-Based Payment Modifier (VBPM) expands to all physicians by 2017.

In the current PQRS, the PMRC has identified the following measures that have appropriate inpatient codes for reporting and have potential relevance to hospitalists:

• Congestive Heart Failure (CHF): #5, ACE/ARB for LV systolic dysfunction; #8, beta-blocker prescribed for LV systolic dysfunction; #228, assessment of LV function.
• Stroke: #31, DVT prophylaxis; #32, discharge on antiplatelet therapy; #33, anticoagulation for atrial fibrillation; #35, dysphagia screening; #36, consideration of rehab; #187, thrombolytic therapy.
• Others: #47, advance care plan documented; #76, use of a central venous catheter insertion protocol.

Some of these measures are only reportable by registry. For groups who do not take care of stroke patients, the field is clearly limited. More detail on PQRS reporting and available codes can be found at the Centers for Medicare and Medicaid Services (CMS) website (www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/MeasuresCodes.html).

The committee is deeply concerned about the limited number of PQRS measures broadly applicable to hospitalists, and we are working to change this disparity. Over the past several months, the PMRC has successfully advocated to add inpatient codes to existing measures that will expand the field for hospitalists. So far, we have achieved the following changes for future PQRS reporting years:

• Community-acquired pneumonia (CAP): Measures #56 (vital signs) and #59 (empiric antibiotics) will have admission codes 99221, 99222, and 99223 added to the denominator.
• Osteoporosis/fractures: Measure #24 (communication with the outpatient provider) and #40 (DXA scan ordered or therapy initiated) will have discharge codes 99238 and 99239 added to their denominator, in recognition of the fact that many hospitalists partner with their orthopedic colleagues in the care of patients post-hip fracture.
• Medication reconciliation: Measure #130 (documentation of current medication list) will have admission codes 99221, 99222, and 99223 added to the denominator.
• Anticoagulation for acute pulmonary embolism:  Measure #252, intended for use by ED physicians, is being retired by CMS due to a loss of National Quality Forum endorsement. SHM is working with the American College of Emergency Physicians (ACEP) to appeal the decision, possibly maintain the measure, and add inpatient admission codes to the denominator. This remains a work in progress.

Finally, in response to SHM advocacy efforts, the recent FY2014 Physician Fee Schedule proposed rule sought comments from stakeholders about retooling certain hospital-based measures to allow for physician-level reporting. SHM supports the concept of allowing physician-level performance reporting on hospital metrics and recommended the inclusion of multiple measures from the Inpatient Quality Reporting Program.

The PMRC is charged with monitoring the rapidly evolving provider performance and measurement landscape to ensure that hospitalists are adequately represented. We will continue to work diligently with key stakeholders on behalf of our field.

Dr. Seymann is chief of the division of hospital medicine at the University of California San Diego and chair of SHM’s Performance Measurement and Reporting Committee. Josh Boswell is SHM’s senior manager of government relations.

With the voluntary and incentive period for participating in the Physician Quality Reporting System (PQRS) quickly coming to a close, hospitalists are finding a limited number of PQRS measures broadly applicable to their practice. SHM, through its Performance Measurement and Reporting Committee (PMRC), is actively working on behalf of hospitalists to change that. At the same time, it is critical that hospitalists be proactive and participate in PQRS, not just to avoid the 2015 penalty, but to position themselves for success as the Value-Based Payment Modifier (VBPM) expands to all physicians by 2017.

In the current PQRS, the PMRC has identified the following measures that have appropriate inpatient codes for reporting and have potential relevance to hospitalists:

• Congestive Heart Failure (CHF): #5, ACE/ARB for LV systolic dysfunction; #8, beta-blocker prescribed for LV systolic dysfunction; #228, assessment of LV function.
• Stroke: #31, DVT prophylaxis; #32, discharge on antiplatelet therapy; #33, anticoagulation for atrial fibrillation; #35, dysphagia screening; #36, consideration of rehab; #187, thrombolytic therapy.
• Others: #47, advance care plan documented; #76, use of a central venous catheter insertion protocol.

Some of these measures are only reportable by registry. For groups who do not take care of stroke patients, the field is clearly limited. More detail on PQRS reporting and available codes can be found at the Centers for Medicare and Medicaid Services (CMS) website (www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/MeasuresCodes.html).

The committee is deeply concerned about the limited number of PQRS measures broadly applicable to hospitalists, and we are working to change this disparity. Over the past several months, the PMRC has successfully advocated to add inpatient codes to existing measures that will expand the field for hospitalists. So far, we have achieved the following changes for future PQRS reporting years:

• Community-acquired pneumonia (CAP): Measures #56 (vital signs) and #59 (empiric antibiotics) will have admission codes 99221, 99222, and 99223 added to the denominator.
• Osteoporosis/fractures: Measure #24 (communication with the outpatient provider) and #40 (DXA scan ordered or therapy initiated) will have discharge codes 99238 and 99239 added to their denominator, in recognition of the fact that many hospitalists partner with their orthopedic colleagues in the care of patients post-hip fracture.
• Medication reconciliation: Measure #130 (documentation of current medication list) will have admission codes 99221, 99222, and 99223 added to the denominator.
• Anticoagulation for acute pulmonary embolism:  Measure #252, intended for use by ED physicians, is being retired by CMS due to a loss of National Quality Forum endorsement. SHM is working with the American College of Emergency Physicians (ACEP) to appeal the decision, possibly maintain the measure, and add inpatient admission codes to the denominator. This remains a work in progress.

Finally, in response to SHM advocacy efforts, the recent FY2014 Physician Fee Schedule proposed rule sought comments from stakeholders about retooling certain hospital-based measures to allow for physician-level reporting. SHM supports the concept of allowing physician-level performance reporting on hospital metrics and recommended the inclusion of multiple measures from the Inpatient Quality Reporting Program.

The PMRC is charged with monitoring the rapidly evolving provider performance and measurement landscape to ensure that hospitalists are adequately represented. We will continue to work diligently with key stakeholders on behalf of our field.

Dr. Seymann is chief of the division of hospital medicine at the University of California San Diego and chair of SHM’s Performance Measurement and Reporting Committee. Josh Boswell is SHM’s senior manager of government relations.

With the voluntary and incentive period for participating in the Physician Quality Reporting System (PQRS) quickly coming to a close, hospitalists are finding a limited number of PQRS measures broadly applicable to their practice. SHM, through its Performance Measurement and Reporting Committee (PMRC), is actively working on behalf of hospitalists to change that. At the same time, it is critical that hospitalists be proactive and participate in PQRS, not just to avoid the 2015 penalty, but to position themselves for success as the Value-Based Payment Modifier (VBPM) expands to all physicians by 2017.

In the current PQRS, the PMRC has identified the following measures that have appropriate inpatient codes for reporting and have potential relevance to hospitalists:

• Congestive Heart Failure (CHF): #5, ACE/ARB for LV systolic dysfunction; #8, beta-blocker prescribed for LV systolic dysfunction; #228, assessment of LV function.
• Stroke: #31, DVT prophylaxis; #32, discharge on antiplatelet therapy; #33, anticoagulation for atrial fibrillation; #35, dysphagia screening; #36, consideration of rehab; #187, thrombolytic therapy.
• Others: #47, advance care plan documented; #76, use of a central venous catheter insertion protocol.

Some of these measures are only reportable by registry. For groups who do not take care of stroke patients, the field is clearly limited. More detail on PQRS reporting and available codes can be found at the Centers for Medicare and Medicaid Services (CMS) website (www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/MeasuresCodes.html).

The committee is deeply concerned about the limited number of PQRS measures broadly applicable to hospitalists, and we are working to change this disparity. Over the past several months, the PMRC has successfully advocated to add inpatient codes to existing measures that will expand the field for hospitalists. So far, we have achieved the following changes for future PQRS reporting years:

• Community-acquired pneumonia (CAP): Measures #56 (vital signs) and #59 (empiric antibiotics) will have admission codes 99221, 99222, and 99223 added to the denominator.
• Osteoporosis/fractures: Measure #24 (communication with the outpatient provider) and #40 (DXA scan ordered or therapy initiated) will have discharge codes 99238 and 99239 added to their denominator, in recognition of the fact that many hospitalists partner with their orthopedic colleagues in the care of patients post-hip fracture.
• Medication reconciliation: Measure #130 (documentation of current medication list) will have admission codes 99221, 99222, and 99223 added to the denominator.
• Anticoagulation for acute pulmonary embolism:  Measure #252, intended for use by ED physicians, is being retired by CMS due to a loss of National Quality Forum endorsement. SHM is working with the American College of Emergency Physicians (ACEP) to appeal the decision, possibly maintain the measure, and add inpatient admission codes to the denominator. This remains a work in progress.

Finally, in response to SHM advocacy efforts, the recent FY2014 Physician Fee Schedule proposed rule sought comments from stakeholders about retooling certain hospital-based measures to allow for physician-level reporting. SHM supports the concept of allowing physician-level performance reporting on hospital metrics and recommended the inclusion of multiple measures from the Inpatient Quality Reporting Program.

The PMRC is charged with monitoring the rapidly evolving provider performance and measurement landscape to ensure that hospitalists are adequately represented. We will continue to work diligently with key stakeholders on behalf of our field.

Dr. Seymann is chief of the division of hospital medicine at the University of California San Diego and chair of SHM’s Performance Measurement and Reporting Committee. Josh Boswell is SHM’s senior manager of government relations.

The Society of Hospital Medicine’s 2012 State of Hospital Medicine report (SOHM) offers new insights about physician practice leaders.

Physician Leader Presence

“Choose a hospitalist leader with the right skills and experience. Selecting the right leader is fundamental to a successful hospitalist practice. These individuals are hard to find. They must be excellent clinically and have superb communication skills.”¹

The SOHM survey shows that the vast majority (97%) of hospital medicine groups (HMGs) in the U.S. now have a designated physician leader (see Figure 1). Given this high percentage, examining the outliers is intriguing. Of the 13 adult medicine HMGs that reported not having a physician leader, the large majority were hospital-owned, located in the South region, and situated in non-teaching hospitals. The size of the HMG impacted the presence of a physician leader: 100% of groups with 20 or more full-time equivalents had physician leaders.

click for large version

Dedicated Leadership Time

“The medical director of the hospitalist program needs sufficient, non-clinical time to address administrative and leadership issues.”¹

The 2007/2008 SOHM survey reported a median of 20% administrative time for physician leaders. In the 2012 survey, the median amount of time was 25% for adult medicine HMGs. The percentages were higher in the East and West regions, in hospital-owned programs, and in non- academic programs. The percentage of protected time also went up with group size.

Dr. Lovins

Compensation

The 2012 SOHM shows median compensation premiums for physician leaders of 20%; that is, leader compensation is 120% of the average salary in their group. The numbers across regions and sizes were remarkably consistent. Overall, it seems that a 15% to 20% compensation premium for hospitalist leaders is standard.

Key Takeaways

No. 1, hospitalist groups need physician hospitalist leaders with protected leadership, but who also work clinically as a hospitalist. Why? Because hospitalists need a leader they respect, someone that they believe understands their specific issues. Unless the physician in charge has worked those 12-hour overnight shifts, argued with the consultants, tried to discharge an ornery patient, received 20 pages in an hour about medication reconciliation, or disagreed with an ED doc about the appropriateness of an admission, it would be hard for that leader to fully understand the stresses hospitalists encounter on a daily basis.

Hospitalist leaders are taking on increasingly important roles to help their organizations realize key performance improvement goals.

Additionally, the roles of outpatient doctors are changing: “Many physicians are no longer able or willing to serve on hospital committees or play a leadership role for the medical staff. Hospitalists have the potential to step in and help address these key issues”¹

No. 2, size matters. Given increased responsibilities that include handling focused and ongoing professional practice evaluations, designing pathways to reduce adverse events, counseling, mentoring, disciplining, conducting yearly reviews, and investigating patient and staff complaints, it makes sense that larger programs also have leaders with more protected time and commensurate compensation.

As our healthcare systems ask hospitalists to offer higher reliability and to champion more administrative, safety, and quality projects, HM leaders—who are perfectly placed to organize and manage those projects—need the time and the compensation to do so. To borrow from hospitalist pioneer Bob Wachter, MD, MHM, our future C-suite leaders are percolating in hospitalist programs, learning the skills we will need to participate in the high reliability hospitals of our present and future.

Dr. Lovins is chief of hospital medicine at Middlesex Hospital in Middletown, Conn., and assistant clinical professor of medicine at Yale University School of Medicine. She is a member of SHM’s Practice Analysis Committee.

Reference

1. American Medical Association. Principles for a sustainable and successful hospitalist program. AMA website. Available at: http://www.ama-assn.org/resources/doc/omss/sustainable-hospitalist-program.pdf. Accessed September 18, 2013.

The Society of Hospital Medicine’s 2012 State of Hospital Medicine report (SOHM) offers new insights about physician practice leaders.

Physician Leader Presence

“Choose a hospitalist leader with the right skills and experience. Selecting the right leader is fundamental to a successful hospitalist practice. These individuals are hard to find. They must be excellent clinically and have superb communication skills.”¹

The SOHM survey shows that the vast majority (97%) of hospital medicine groups (HMGs) in the U.S. now have a designated physician leader (see Figure 1). Given this high percentage, examining the outliers is intriguing. Of the 13 adult medicine HMGs that reported not having a physician leader, the large majority were hospital-owned, located in the South region, and situated in non-teaching hospitals. The size of the HMG impacted the presence of a physician leader: 100% of groups with 20 or more full-time equivalents had physician leaders.

click for large version

Dedicated Leadership Time

“The medical director of the hospitalist program needs sufficient, non-clinical time to address administrative and leadership issues.”¹

The 2007/2008 SOHM survey reported a median of 20% administrative time for physician leaders. In the 2012 survey, the median amount of time was 25% for adult medicine HMGs. The percentages were higher in the East and West regions, in hospital-owned programs, and in non- academic programs. The percentage of protected time also went up with group size.

Dr. Lovins

Compensation

The 2012 SOHM shows median compensation premiums for physician leaders of 20%; that is, leader compensation is 120% of the average salary in their group. The numbers across regions and sizes were remarkably consistent. Overall, it seems that a 15% to 20% compensation premium for hospitalist leaders is standard.

Key Takeaways

No. 1, hospitalist groups need physician hospitalist leaders with protected leadership, but who also work clinically as a hospitalist. Why? Because hospitalists need a leader they respect, someone that they believe understands their specific issues. Unless the physician in charge has worked those 12-hour overnight shifts, argued with the consultants, tried to discharge an ornery patient, received 20 pages in an hour about medication reconciliation, or disagreed with an ED doc about the appropriateness of an admission, it would be hard for that leader to fully understand the stresses hospitalists encounter on a daily basis.

Hospitalist leaders are taking on increasingly important roles to help their organizations realize key performance improvement goals.

Additionally, the roles of outpatient doctors are changing: “Many physicians are no longer able or willing to serve on hospital committees or play a leadership role for the medical staff. Hospitalists have the potential to step in and help address these key issues”¹

No. 2, size matters. Given increased responsibilities that include handling focused and ongoing professional practice evaluations, designing pathways to reduce adverse events, counseling, mentoring, disciplining, conducting yearly reviews, and investigating patient and staff complaints, it makes sense that larger programs also have leaders with more protected time and commensurate compensation.

As our healthcare systems ask hospitalists to offer higher reliability and to champion more administrative, safety, and quality projects, HM leaders—who are perfectly placed to organize and manage those projects—need the time and the compensation to do so. To borrow from hospitalist pioneer Bob Wachter, MD, MHM, our future C-suite leaders are percolating in hospitalist programs, learning the skills we will need to participate in the high reliability hospitals of our present and future.

Dr. Lovins is chief of hospital medicine at Middlesex Hospital in Middletown, Conn., and assistant clinical professor of medicine at Yale University School of Medicine. She is a member of SHM’s Practice Analysis Committee.

Reference

1. American Medical Association. Principles for a sustainable and successful hospitalist program. AMA website. Available at: http://www.ama-assn.org/resources/doc/omss/sustainable-hospitalist-program.pdf. Accessed September 18, 2013.

The Society of Hospital Medicine’s 2012 State of Hospital Medicine report (SOHM) offers new insights about physician practice leaders.

Physician Leader Presence

“Choose a hospitalist leader with the right skills and experience. Selecting the right leader is fundamental to a successful hospitalist practice. These individuals are hard to find. They must be excellent clinically and have superb communication skills.”¹

The SOHM survey shows that the vast majority (97%) of hospital medicine groups (HMGs) in the U.S. now have a designated physician leader (see Figure 1). Given this high percentage, examining the outliers is intriguing. Of the 13 adult medicine HMGs that reported not having a physician leader, the large majority were hospital-owned, located in the South region, and situated in non-teaching hospitals. The size of the HMG impacted the presence of a physician leader: 100% of groups with 20 or more full-time equivalents had physician leaders.

click for large version

Dedicated Leadership Time

“The medical director of the hospitalist program needs sufficient, non-clinical time to address administrative and leadership issues.”¹

The 2007/2008 SOHM survey reported a median of 20% administrative time for physician leaders. In the 2012 survey, the median amount of time was 25% for adult medicine HMGs. The percentages were higher in the East and West regions, in hospital-owned programs, and in non- academic programs. The percentage of protected time also went up with group size.

Dr. Lovins

Compensation

The 2012 SOHM shows median compensation premiums for physician leaders of 20%; that is, leader compensation is 120% of the average salary in their group. The numbers across regions and sizes were remarkably consistent. Overall, it seems that a 15% to 20% compensation premium for hospitalist leaders is standard.

Key Takeaways

No. 1, hospitalist groups need physician hospitalist leaders with protected leadership, but who also work clinically as a hospitalist. Why? Because hospitalists need a leader they respect, someone that they believe understands their specific issues. Unless the physician in charge has worked those 12-hour overnight shifts, argued with the consultants, tried to discharge an ornery patient, received 20 pages in an hour about medication reconciliation, or disagreed with an ED doc about the appropriateness of an admission, it would be hard for that leader to fully understand the stresses hospitalists encounter on a daily basis.

Hospitalist leaders are taking on increasingly important roles to help their organizations realize key performance improvement goals.

Additionally, the roles of outpatient doctors are changing: “Many physicians are no longer able or willing to serve on hospital committees or play a leadership role for the medical staff. Hospitalists have the potential to step in and help address these key issues”¹

No. 2, size matters. Given increased responsibilities that include handling focused and ongoing professional practice evaluations, designing pathways to reduce adverse events, counseling, mentoring, disciplining, conducting yearly reviews, and investigating patient and staff complaints, it makes sense that larger programs also have leaders with more protected time and commensurate compensation.

As our healthcare systems ask hospitalists to offer higher reliability and to champion more administrative, safety, and quality projects, HM leaders—who are perfectly placed to organize and manage those projects—need the time and the compensation to do so. To borrow from hospitalist pioneer Bob Wachter, MD, MHM, our future C-suite leaders are percolating in hospitalist programs, learning the skills we will need to participate in the high reliability hospitals of our present and future.

Dr. Lovins is chief of hospital medicine at Middlesex Hospital in Middletown, Conn., and assistant clinical professor of medicine at Yale University School of Medicine. She is a member of SHM’s Practice Analysis Committee.

Reference

1. American Medical Association. Principles for a sustainable and successful hospitalist program. AMA website. Available at: http://www.ama-assn.org/resources/doc/omss/sustainable-hospitalist-program.pdf. Accessed September 18, 2013.

Hospitalist Allen Kachalia, MD, JD, of Brigham and Women’s Hospital in Boston, sees defensive medicine as a source of unnecessary costs—and a threat to patient safety.

In fact, he and his colleagues offered an oral presentation at HM13 earlier this year titled, “Overutilization and Defensive Medicine in U.S. Hospitals: A Randomized National Survey of Hospitalists.” In a survey of 1,020 hospitalists, it was reported that defensive medicine was practiced in 37% of pre-operative evaluations and 58% of syncope cases.

Dr. Kachalia says he understands the pressures that can lead physicians to order unnecessary tests, particularly when patients request them. So what does he say about those requests?

Dr. Kachalia

“The answer is a simple one but takes time and effort: If you don’t think that something is clinically indicated, you should talk with the patient, explaining to them why you don’t think it’s necessary,” he says. “And, hopefully, you can come to mutual agreement. Ordering things just for the sake of preventing legal liability is just not the right thing to do.”

Dr. Kachalia says he believes that a paradigm shift in how medical liability is handled in this country is needed to change those habits.

But culture change also takes time.

Bryan Weiss, MBA, managing director of the consulting services practice at Irving, Texas-based MedSynergies, says the first step of that change may be having physicians admit that few doctors know a lot about malpractice issues, because they are typically negotiated, arranged, and paid for by their employers, whether that’s a hospital or large management companies.

“It’s not me versus them,” says Weiss, a Team Hospitalist member. “As a specialty, we need to be in this together, to push the education and awareness that it’s OK not to know, so let’s work together to make it better. But it’s not going to happen overnight.”

Hospitalist Allen Kachalia, MD, JD, of Brigham and Women’s Hospital in Boston, sees defensive medicine as a source of unnecessary costs—and a threat to patient safety.

In fact, he and his colleagues offered an oral presentation at HM13 earlier this year titled, “Overutilization and Defensive Medicine in U.S. Hospitals: A Randomized National Survey of Hospitalists.” In a survey of 1,020 hospitalists, it was reported that defensive medicine was practiced in 37% of pre-operative evaluations and 58% of syncope cases.

Dr. Kachalia says he understands the pressures that can lead physicians to order unnecessary tests, particularly when patients request them. So what does he say about those requests?

Dr. Kachalia

“The answer is a simple one but takes time and effort: If you don’t think that something is clinically indicated, you should talk with the patient, explaining to them why you don’t think it’s necessary,” he says. “And, hopefully, you can come to mutual agreement. Ordering things just for the sake of preventing legal liability is just not the right thing to do.”

Dr. Kachalia says he believes that a paradigm shift in how medical liability is handled in this country is needed to change those habits.

But culture change also takes time.

Bryan Weiss, MBA, managing director of the consulting services practice at Irving, Texas-based MedSynergies, says the first step of that change may be having physicians admit that few doctors know a lot about malpractice issues, because they are typically negotiated, arranged, and paid for by their employers, whether that’s a hospital or large management companies.

“It’s not me versus them,” says Weiss, a Team Hospitalist member. “As a specialty, we need to be in this together, to push the education and awareness that it’s OK not to know, so let’s work together to make it better. But it’s not going to happen overnight.”

Hospitalist Allen Kachalia, MD, JD, of Brigham and Women’s Hospital in Boston, sees defensive medicine as a source of unnecessary costs—and a threat to patient safety.

In fact, he and his colleagues offered an oral presentation at HM13 earlier this year titled, “Overutilization and Defensive Medicine in U.S. Hospitals: A Randomized National Survey of Hospitalists.” In a survey of 1,020 hospitalists, it was reported that defensive medicine was practiced in 37% of pre-operative evaluations and 58% of syncope cases.

Dr. Kachalia says he understands the pressures that can lead physicians to order unnecessary tests, particularly when patients request them. So what does he say about those requests?

Dr. Kachalia

“The answer is a simple one but takes time and effort: If you don’t think that something is clinically indicated, you should talk with the patient, explaining to them why you don’t think it’s necessary,” he says. “And, hopefully, you can come to mutual agreement. Ordering things just for the sake of preventing legal liability is just not the right thing to do.”

Dr. Kachalia says he believes that a paradigm shift in how medical liability is handled in this country is needed to change those habits.

But culture change also takes time.

Bryan Weiss, MBA, managing director of the consulting services practice at Irving, Texas-based MedSynergies, says the first step of that change may be having physicians admit that few doctors know a lot about malpractice issues, because they are typically negotiated, arranged, and paid for by their employers, whether that’s a hospital or large management companies.

“It’s not me versus them,” says Weiss, a Team Hospitalist member. “As a specialty, we need to be in this together, to push the education and awareness that it’s OK not to know, so let’s work together to make it better. But it’s not going to happen overnight.”

click for large version

Ten years ago, the national headlines on malpractice insurance were staggering. Media reports catalogued OB-GYNs who proclaimed they were shutting down their private practices in the face of runaway premiums. Surgeons and other proceduralists decried payments tied to lawsuits they’d argue were arbitrary and capricious. And the American Medical Association (AMA) made announcement after announcement about states being in a “malpractice crisis.”

In recent years, premiums have actually dropped and stabilized at levels that most physicians agree are manageable for bottom lines. But, in that time, there has been scant discussion about hospital medicine’s relationship with malpractice. It’s not because the issue isn’t omnipresent for all healthcare practitioners, including the relatively nascent specialty that is HM.

Practice management experts say anecdotally that delayed diagnosis of, or treatment for, a spinal epidural abscess (SEA) is likely to get more than a few hospitalists sued. And, the proliferation of co-management of other specialties—particularly those with higher risk of incidence and higher premiums than internal medicine—open up hospitalists to further liability.

The issue is that at less than 20 years as a specialty, HM is in its infancy when it comes to its interaction with malpractice premiums. Health insurance companies and trade groups that track the insurance industry are just beginning to have enough data on claims, premiums, and payouts to make recommendations on risk factors, risk mitigation, and potential trends.

Still, even in a landscape of limited information, there are a few rules of thumb hospitalist group leaders should live by when it comes to managing exposure to malpractice cases, according to interviews with a half dozen healthcare professionals:

• Know how your coverage works. Is there “tail coverage” that ensures you have protection for incidents that happened at an institution where you no longer practice? Even though hospital-employed physicians rarely have rate discussions directly (the hospital typically covers premiums as part of the compensation package), take the time to learn the basic details.
• Be diligent in documentation. Note concerns in charts when appropriate, and stand up for your point of view. There’s a fine line between picking fights with other physicians involved in a patient’s care and making your concerns known, but don’t be afraid to put your clinical view on the record.
• Avoid the practice of “defensive medicine.” Ordering tests and procedures that aren’t clinically necessary might seem like it can serve as a protection from later lawsuits, but it adds to healthcare costs and is just not the right thing to do, says hospitalist Allen Kachalia, MD, JD, of Brigham and Women’s Hospital in Boston, who has studied the phenomenon (see “Culture Shift Necessary to Defeat “Defensive” Medicine,” on p. 38).
• Recognize the risks associated with co-management. Caring for neurology, cardiology, and other subspecialty patients is a revenue boost for HM groups, but when some of those complex cases have adverse events, the hospitalist who interacted with the patient daily could be included in a lawsuit.
• Focus on communication skills. An analysis of claims data by The Doctors Company (TDC) (www.thedoctors.com), a medical malpractice insurance company exclusively endorsed by SHM, reports that the second most common factor contributing to patient injury by hospitalists is “communication breakdown among healthcare professionals.”
• Manage workloads to avoid burnout. Don’t take on too many patients at the expense of being involved in hospital committees or quality initiatives.

To be sure, many of the same tenets of being a productive hospitalist with high patient satisfaction scores—maintain manageable censuses; focus on patient centeredness; and use checklists, technology, and regimented protocols to reduce adverse events—translate very well to being a lower-risk hospitalist in relation to malpractice cases.

When you’re “thinking of patient satisfaction strategies, also think of them as risk mitigation strategies,” says John Nelson, MD, MHM, FACP, medical director of the hospitalist practice at Overlake Hospital Medical Center in Bellevue, Wash., an SHM co-founder and practice management columnist for The Hospitalist. “They overlap tremendously.”

A History Lesson

Medical malpractice has been around for centuries and has two prevailing goals: 1) to provide monetary remuneration to patients who have been injured via substandard care and 2) to deter that poor treatment through fiscal punishment.

Malpractice lawsuits were not prevalent enough to be a major medical concern until the early 1800s. By the middle of the 19th century, the country hit its first periods of crisis.¹ Cycles ebbed and flowed from there, with malpractice premiums causing crises in the 1980s and again in the early 2000s.

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Now, rates for medical professional liability insurance have been dropping for seven years, and an eighth straight annual decline is expected this year, according to Mike Matray, the editor of trade publication Medical Liability Monitor and the chief content officer of its associated website, www.mymedicalmalpracticeinsurance.com.

“We are in the longest, deepest soft market that the malpractice insurance industry has ever been in,” he says. “Right now, things are really good for the doctors, as far as rates coming down.”

Matray says he understands that declining rates may seem immaterial to a physician who receives an insurance bill that eats into the bottom line. For some specialties, that premium can be as high as $200,000 per physician, per year—or more.

“I’m not saying it isn’t expensive,” he adds. “It’s expensive to run a medical practice. At the same time, medical malpractice insurance is less expensive in today’s dollars than it was in 2005.”

The reduction in rates is multi-faceted. Prominently, state-level tort reforms like non-economic damage caps, health courts, and arbitration hearings are making it harder to bring cases to trial, particularly for lawyers who take cases on contingency. Second, frivolous lawsuits “are making an impression on jury pools,” Matray says, which means fewer filed claims and fewer cases that make it to trial. Third, this soft cycle has outlasted the typical pattern of rates falling for three to four years before rebounding.

“A lot of smart actuaries keep saying this has to change soon, because in a soft market there is a lot of competition,” he says, noting that in order to compete for low rates, insurance companies offer credits to clients and use their own reserve cash piles. “So things are really going to change in the next couple of years.”

“Hospital medicine is different than other specialties, because the hospitalist treats a broad range of patients in an acute care setting—from a pediatric patient to an adult patient with many chronic illnesses.”

—Robin Diamond, senior vice president and chief patient safety officer, The Doctors Company

In Need of Data, Patience

So what does it all mean for hospitalists and HM group leaders looking to be proactive about medical malpractice liability insurance? Patience is required.

For starters, there is no designated premium category for hospitalists. Much like the situation that exists for coding issues, the closest proxy for HM is internal medicine. According to Medical Liability Monitor, the premium paid by internal medicine physicians as of July 1, 2012, varied widely across the country. In South Florida, internal medicine insurance premiums in Miami, Dade, and Broward counties were between $42,000 and $46,000 per year. In South Dakota, one insurer reported rates of just under $4,000 per year. There is no average or median figure available, and Matray notes that actual rates paid can vary from county to county.

Moreover, it is difficult for group leaders or hospital executives to use past history to negotiate rates with insurers because of a shortage of reliable data. In its spring 2013 newsletter, the PIAA (formerly known as the Physician Insurers Association of America) published its first report on hospitalist claims reported to its Data Sharing Project. Of the 92,868 closed claims reported from 2002-2011, just 312, or 0.3%, named hospitalists as the defendant.

The data also showed that, of those claims, 20% were settled through insurance company payments. Those payments totaled $17.1 million, with an average payout to a claimant (known as the indemnity) of $272,553 per claim. Overall, hospitalists had a 20% paid-to-closed ratio, totaling more than $17.1 million. By comparison, the percent of paid-to-closed claims for all physicians was 29.3%, according to PIAA.

In a separate data set compiled this year by TDC, 34% of allegations against hospitalists were related to missed or failed diagnoses, with 28% tied to “improper management of treatment.” Twelve percent of allegations were the result of either improper medication management or ordering errors.

Robin Diamond, TDC’s senior vice president and chief patient safety officer, says that teasing out trends from the initial data can be challenging. Hospitalists, she says, can deal with so many different patients, diseases, and severity levels that it is difficult to draw conclusions.

“Hospital medicine is different than other specialties, because the hospitalist treats a broad range of patients in an acute care setting—from a pediatric patient to an adult patient with many chronic illnesses,” she says.

Divya Parikh, PIAA’s director of research and loss prevention, says HM group leaders should avoid reading too much into the first batch of data, because it’s a small sample size.

“A big part of that is we feel that a lot of hospitalists are intermingled into the other medical specialties,” she says. “So this becomes a very small subset where they are distinctly identified as hospitalists. And that’s the challenge.”

In particular, Parikh is curious to see whether HM’s rate of claims paid through insurance payments drops from 20% (already below the overall healthcare industry average). “It will be interesting as we proceed...to see if they begin to mitigate areas of risk where we used to see a lot of claims,” she adds. “If you look at a hospital setting, there has been some shift change in what the errors are. And, what you’d hope with hospitalists within these environments who are really owning this specialty, is that you’d see a decrease in that. There would be that connective care. There would be the patient that felt that they had an individual who was their go-to individual throughout their care at a hospital.”

A Peek at the Future

Insurers have begun compiling claims data on hospitalists and are taking a longer-term view of the specialty. TDC, for example, has analyzed its data and identified characteristics it says make a low-risk hospitalist, an analysis the company says is the first of its kind (see Figure 1). The insurer adds that it sees its responsibility as making sure everyone understands the hospitalist’s role within the acute care setting so that its pricing is commensurate with the liability risk.

click for large version

“We’re looking at the systems within the hospitalist group, as well as how well that group is integrating with the hospital where they’re practicing,” Diamond says. “What kind of patient mix is this particular hospitalist group seeing in that particular hospital, because it can be different in a large healthcare corporation in Manhattan, New York, from a community hospital in rural Texas.”

The growing popularity of hospitalists taking on co-management responsibilities for other specialties is another trend to keep an eye on, as it creates what insurers call “vicarious liability.” Working together in teams with other specialties can improve communication, reduce errors during transitions of care, and create better outcomes. However, in instances where there are problems, being on a care team means hospitalists can open themselves to liability. To mitigate that risk, hospitalists can look to other groups that have dealt with shared liability issues in the past, Parikh says.

“Historically, you would have seen it with anesthesiology,” she explains. “And one huge improvement anesthesiologists have made when a patient comes in for a surgery now is they come out, introduce themselves, say hello, and tell you what’s going on. They put a face to the name, so that it’s not just a no-name anesthesiologist who gets included in the lawsuit as well because they’re naming everybody in the group.”

But, holistically, the best long-term mitigation strategy appears to be tort reform and new ways of looking at the way in which healthcare liability issues are handled in the U.S., says Anupam Jena, MD, PhD, assistant professor of healthcare policy and medicine at Harvard Medical School, and an internist at Massachusetts General Hospital, both in Boston. Dr. Jena says that there is limited evidence that enacted malpractice reforms have produced more than a 2% to 5% reduction in healthcare spending compared to states that have not.² Instead, healthcare leaders should push for the elimination of defensive medicine, which he says contributes the lion’s share of the estimated $50 billion annual cost of malpractice liability across the country.

“Do I think the country is in a malpractice crisis? No,” he says. “Do I think that defensive medicine is larger than we think it is? Yes.

“If physicians practice as they felt they should practice without ordering extra tests and procedures, my guess would be you could reduce healthcare spending by substantially more than $50 billion.”

Richard Quinn is a freelance writer in New Jersey.

References

1. Spiegel AD, Kavaler F. America’s first medical malpractice crisis, 1835-1865. J Community Health. 1997;22:283-308.
2. Chandra A, Jena A, Seabury, S. Defensive medicine may be costlier than it seems. The Wall Street Journal website. http://online.wsj.com/article/SB10001424127887323701904578280112638373302.html. Accessed September 21, 2013.

click for large version

Ten years ago, the national headlines on malpractice insurance were staggering. Media reports catalogued OB-GYNs who proclaimed they were shutting down their private practices in the face of runaway premiums. Surgeons and other proceduralists decried payments tied to lawsuits they’d argue were arbitrary and capricious. And the American Medical Association (AMA) made announcement after announcement about states being in a “malpractice crisis.”

In recent years, premiums have actually dropped and stabilized at levels that most physicians agree are manageable for bottom lines. But, in that time, there has been scant discussion about hospital medicine’s relationship with malpractice. It’s not because the issue isn’t omnipresent for all healthcare practitioners, including the relatively nascent specialty that is HM.

Practice management experts say anecdotally that delayed diagnosis of, or treatment for, a spinal epidural abscess (SEA) is likely to get more than a few hospitalists sued. And, the proliferation of co-management of other specialties—particularly those with higher risk of incidence and higher premiums than internal medicine—open up hospitalists to further liability.

The issue is that at less than 20 years as a specialty, HM is in its infancy when it comes to its interaction with malpractice premiums. Health insurance companies and trade groups that track the insurance industry are just beginning to have enough data on claims, premiums, and payouts to make recommendations on risk factors, risk mitigation, and potential trends.

Still, even in a landscape of limited information, there are a few rules of thumb hospitalist group leaders should live by when it comes to managing exposure to malpractice cases, according to interviews with a half dozen healthcare professionals:

• Know how your coverage works. Is there “tail coverage” that ensures you have protection for incidents that happened at an institution where you no longer practice? Even though hospital-employed physicians rarely have rate discussions directly (the hospital typically covers premiums as part of the compensation package), take the time to learn the basic details.
• Be diligent in documentation. Note concerns in charts when appropriate, and stand up for your point of view. There’s a fine line between picking fights with other physicians involved in a patient’s care and making your concerns known, but don’t be afraid to put your clinical view on the record.
• Avoid the practice of “defensive medicine.” Ordering tests and procedures that aren’t clinically necessary might seem like it can serve as a protection from later lawsuits, but it adds to healthcare costs and is just not the right thing to do, says hospitalist Allen Kachalia, MD, JD, of Brigham and Women’s Hospital in Boston, who has studied the phenomenon (see “Culture Shift Necessary to Defeat “Defensive” Medicine,” on p. 38).
• Recognize the risks associated with co-management. Caring for neurology, cardiology, and other subspecialty patients is a revenue boost for HM groups, but when some of those complex cases have adverse events, the hospitalist who interacted with the patient daily could be included in a lawsuit.
• Focus on communication skills. An analysis of claims data by The Doctors Company (TDC) (www.thedoctors.com), a medical malpractice insurance company exclusively endorsed by SHM, reports that the second most common factor contributing to patient injury by hospitalists is “communication breakdown among healthcare professionals.”
• Manage workloads to avoid burnout. Don’t take on too many patients at the expense of being involved in hospital committees or quality initiatives.

To be sure, many of the same tenets of being a productive hospitalist with high patient satisfaction scores—maintain manageable censuses; focus on patient centeredness; and use checklists, technology, and regimented protocols to reduce adverse events—translate very well to being a lower-risk hospitalist in relation to malpractice cases.

When you’re “thinking of patient satisfaction strategies, also think of them as risk mitigation strategies,” says John Nelson, MD, MHM, FACP, medical director of the hospitalist practice at Overlake Hospital Medical Center in Bellevue, Wash., an SHM co-founder and practice management columnist for The Hospitalist. “They overlap tremendously.”

A History Lesson

Medical malpractice has been around for centuries and has two prevailing goals: 1) to provide monetary remuneration to patients who have been injured via substandard care and 2) to deter that poor treatment through fiscal punishment.

Malpractice lawsuits were not prevalent enough to be a major medical concern until the early 1800s. By the middle of the 19th century, the country hit its first periods of crisis.¹ Cycles ebbed and flowed from there, with malpractice premiums causing crises in the 1980s and again in the early 2000s.

continued below...

Now, rates for medical professional liability insurance have been dropping for seven years, and an eighth straight annual decline is expected this year, according to Mike Matray, the editor of trade publication Medical Liability Monitor and the chief content officer of its associated website, www.mymedicalmalpracticeinsurance.com.

“We are in the longest, deepest soft market that the malpractice insurance industry has ever been in,” he says. “Right now, things are really good for the doctors, as far as rates coming down.”

Matray says he understands that declining rates may seem immaterial to a physician who receives an insurance bill that eats into the bottom line. For some specialties, that premium can be as high as $200,000 per physician, per year—or more.

“I’m not saying it isn’t expensive,” he adds. “It’s expensive to run a medical practice. At the same time, medical malpractice insurance is less expensive in today’s dollars than it was in 2005.”

The reduction in rates is multi-faceted. Prominently, state-level tort reforms like non-economic damage caps, health courts, and arbitration hearings are making it harder to bring cases to trial, particularly for lawyers who take cases on contingency. Second, frivolous lawsuits “are making an impression on jury pools,” Matray says, which means fewer filed claims and fewer cases that make it to trial. Third, this soft cycle has outlasted the typical pattern of rates falling for three to four years before rebounding.

“A lot of smart actuaries keep saying this has to change soon, because in a soft market there is a lot of competition,” he says, noting that in order to compete for low rates, insurance companies offer credits to clients and use their own reserve cash piles. “So things are really going to change in the next couple of years.”

“Hospital medicine is different than other specialties, because the hospitalist treats a broad range of patients in an acute care setting—from a pediatric patient to an adult patient with many chronic illnesses.”

—Robin Diamond, senior vice president and chief patient safety officer, The Doctors Company

In Need of Data, Patience

So what does it all mean for hospitalists and HM group leaders looking to be proactive about medical malpractice liability insurance? Patience is required.

For starters, there is no designated premium category for hospitalists. Much like the situation that exists for coding issues, the closest proxy for HM is internal medicine. According to Medical Liability Monitor, the premium paid by internal medicine physicians as of July 1, 2012, varied widely across the country. In South Florida, internal medicine insurance premiums in Miami, Dade, and Broward counties were between $42,000 and $46,000 per year. In South Dakota, one insurer reported rates of just under $4,000 per year. There is no average or median figure available, and Matray notes that actual rates paid can vary from county to county.

Moreover, it is difficult for group leaders or hospital executives to use past history to negotiate rates with insurers because of a shortage of reliable data. In its spring 2013 newsletter, the PIAA (formerly known as the Physician Insurers Association of America) published its first report on hospitalist claims reported to its Data Sharing Project. Of the 92,868 closed claims reported from 2002-2011, just 312, or 0.3%, named hospitalists as the defendant.

The data also showed that, of those claims, 20% were settled through insurance company payments. Those payments totaled $17.1 million, with an average payout to a claimant (known as the indemnity) of $272,553 per claim. Overall, hospitalists had a 20% paid-to-closed ratio, totaling more than $17.1 million. By comparison, the percent of paid-to-closed claims for all physicians was 29.3%, according to PIAA.

In a separate data set compiled this year by TDC, 34% of allegations against hospitalists were related to missed or failed diagnoses, with 28% tied to “improper management of treatment.” Twelve percent of allegations were the result of either improper medication management or ordering errors.

Robin Diamond, TDC’s senior vice president and chief patient safety officer, says that teasing out trends from the initial data can be challenging. Hospitalists, she says, can deal with so many different patients, diseases, and severity levels that it is difficult to draw conclusions.

“Hospital medicine is different than other specialties, because the hospitalist treats a broad range of patients in an acute care setting—from a pediatric patient to an adult patient with many chronic illnesses,” she says.

Divya Parikh, PIAA’s director of research and loss prevention, says HM group leaders should avoid reading too much into the first batch of data, because it’s a small sample size.

“A big part of that is we feel that a lot of hospitalists are intermingled into the other medical specialties,” she says. “So this becomes a very small subset where they are distinctly identified as hospitalists. And that’s the challenge.”

In particular, Parikh is curious to see whether HM’s rate of claims paid through insurance payments drops from 20% (already below the overall healthcare industry average). “It will be interesting as we proceed...to see if they begin to mitigate areas of risk where we used to see a lot of claims,” she adds. “If you look at a hospital setting, there has been some shift change in what the errors are. And, what you’d hope with hospitalists within these environments who are really owning this specialty, is that you’d see a decrease in that. There would be that connective care. There would be the patient that felt that they had an individual who was their go-to individual throughout their care at a hospital.”

A Peek at the Future

Insurers have begun compiling claims data on hospitalists and are taking a longer-term view of the specialty. TDC, for example, has analyzed its data and identified characteristics it says make a low-risk hospitalist, an analysis the company says is the first of its kind (see Figure 1). The insurer adds that it sees its responsibility as making sure everyone understands the hospitalist’s role within the acute care setting so that its pricing is commensurate with the liability risk.

click for large version

“We’re looking at the systems within the hospitalist group, as well as how well that group is integrating with the hospital where they’re practicing,” Diamond says. “What kind of patient mix is this particular hospitalist group seeing in that particular hospital, because it can be different in a large healthcare corporation in Manhattan, New York, from a community hospital in rural Texas.”

The growing popularity of hospitalists taking on co-management responsibilities for other specialties is another trend to keep an eye on, as it creates what insurers call “vicarious liability.” Working together in teams with other specialties can improve communication, reduce errors during transitions of care, and create better outcomes. However, in instances where there are problems, being on a care team means hospitalists can open themselves to liability. To mitigate that risk, hospitalists can look to other groups that have dealt with shared liability issues in the past, Parikh says.

“Historically, you would have seen it with anesthesiology,” she explains. “And one huge improvement anesthesiologists have made when a patient comes in for a surgery now is they come out, introduce themselves, say hello, and tell you what’s going on. They put a face to the name, so that it’s not just a no-name anesthesiologist who gets included in the lawsuit as well because they’re naming everybody in the group.”

But, holistically, the best long-term mitigation strategy appears to be tort reform and new ways of looking at the way in which healthcare liability issues are handled in the U.S., says Anupam Jena, MD, PhD, assistant professor of healthcare policy and medicine at Harvard Medical School, and an internist at Massachusetts General Hospital, both in Boston. Dr. Jena says that there is limited evidence that enacted malpractice reforms have produced more than a 2% to 5% reduction in healthcare spending compared to states that have not.² Instead, healthcare leaders should push for the elimination of defensive medicine, which he says contributes the lion’s share of the estimated $50 billion annual cost of malpractice liability across the country.

“Do I think the country is in a malpractice crisis? No,” he says. “Do I think that defensive medicine is larger than we think it is? Yes.

“If physicians practice as they felt they should practice without ordering extra tests and procedures, my guess would be you could reduce healthcare spending by substantially more than $50 billion.”

Richard Quinn is a freelance writer in New Jersey.

References

1. Spiegel AD, Kavaler F. America’s first medical malpractice crisis, 1835-1865. J Community Health. 1997;22:283-308.
2. Chandra A, Jena A, Seabury, S. Defensive medicine may be costlier than it seems. The Wall Street Journal website. http://online.wsj.com/article/SB10001424127887323701904578280112638373302.html. Accessed September 21, 2013.

click for large version

Ten years ago, the national headlines on malpractice insurance were staggering. Media reports catalogued OB-GYNs who proclaimed they were shutting down their private practices in the face of runaway premiums. Surgeons and other proceduralists decried payments tied to lawsuits they’d argue were arbitrary and capricious. And the American Medical Association (AMA) made announcement after announcement about states being in a “malpractice crisis.”

In recent years, premiums have actually dropped and stabilized at levels that most physicians agree are manageable for bottom lines. But, in that time, there has been scant discussion about hospital medicine’s relationship with malpractice. It’s not because the issue isn’t omnipresent for all healthcare practitioners, including the relatively nascent specialty that is HM.

Practice management experts say anecdotally that delayed diagnosis of, or treatment for, a spinal epidural abscess (SEA) is likely to get more than a few hospitalists sued. And, the proliferation of co-management of other specialties—particularly those with higher risk of incidence and higher premiums than internal medicine—open up hospitalists to further liability.

The issue is that at less than 20 years as a specialty, HM is in its infancy when it comes to its interaction with malpractice premiums. Health insurance companies and trade groups that track the insurance industry are just beginning to have enough data on claims, premiums, and payouts to make recommendations on risk factors, risk mitigation, and potential trends.

Still, even in a landscape of limited information, there are a few rules of thumb hospitalist group leaders should live by when it comes to managing exposure to malpractice cases, according to interviews with a half dozen healthcare professionals:

• Know how your coverage works. Is there “tail coverage” that ensures you have protection for incidents that happened at an institution where you no longer practice? Even though hospital-employed physicians rarely have rate discussions directly (the hospital typically covers premiums as part of the compensation package), take the time to learn the basic details.
• Be diligent in documentation. Note concerns in charts when appropriate, and stand up for your point of view. There’s a fine line between picking fights with other physicians involved in a patient’s care and making your concerns known, but don’t be afraid to put your clinical view on the record.
• Avoid the practice of “defensive medicine.” Ordering tests and procedures that aren’t clinically necessary might seem like it can serve as a protection from later lawsuits, but it adds to healthcare costs and is just not the right thing to do, says hospitalist Allen Kachalia, MD, JD, of Brigham and Women’s Hospital in Boston, who has studied the phenomenon (see “Culture Shift Necessary to Defeat “Defensive” Medicine,” on p. 38).
• Recognize the risks associated with co-management. Caring for neurology, cardiology, and other subspecialty patients is a revenue boost for HM groups, but when some of those complex cases have adverse events, the hospitalist who interacted with the patient daily could be included in a lawsuit.
• Focus on communication skills. An analysis of claims data by The Doctors Company (TDC) (www.thedoctors.com), a medical malpractice insurance company exclusively endorsed by SHM, reports that the second most common factor contributing to patient injury by hospitalists is “communication breakdown among healthcare professionals.”
• Manage workloads to avoid burnout. Don’t take on too many patients at the expense of being involved in hospital committees or quality initiatives.

To be sure, many of the same tenets of being a productive hospitalist with high patient satisfaction scores—maintain manageable censuses; focus on patient centeredness; and use checklists, technology, and regimented protocols to reduce adverse events—translate very well to being a lower-risk hospitalist in relation to malpractice cases.

When you’re “thinking of patient satisfaction strategies, also think of them as risk mitigation strategies,” says John Nelson, MD, MHM, FACP, medical director of the hospitalist practice at Overlake Hospital Medical Center in Bellevue, Wash., an SHM co-founder and practice management columnist for The Hospitalist. “They overlap tremendously.”

A History Lesson

Medical malpractice has been around for centuries and has two prevailing goals: 1) to provide monetary remuneration to patients who have been injured via substandard care and 2) to deter that poor treatment through fiscal punishment.

Malpractice lawsuits were not prevalent enough to be a major medical concern until the early 1800s. By the middle of the 19th century, the country hit its first periods of crisis.¹ Cycles ebbed and flowed from there, with malpractice premiums causing crises in the 1980s and again in the early 2000s.

continued below...

Now, rates for medical professional liability insurance have been dropping for seven years, and an eighth straight annual decline is expected this year, according to Mike Matray, the editor of trade publication Medical Liability Monitor and the chief content officer of its associated website, www.mymedicalmalpracticeinsurance.com.

“We are in the longest, deepest soft market that the malpractice insurance industry has ever been in,” he says. “Right now, things are really good for the doctors, as far as rates coming down.”

Matray says he understands that declining rates may seem immaterial to a physician who receives an insurance bill that eats into the bottom line. For some specialties, that premium can be as high as $200,000 per physician, per year—or more.

“I’m not saying it isn’t expensive,” he adds. “It’s expensive to run a medical practice. At the same time, medical malpractice insurance is less expensive in today’s dollars than it was in 2005.”

The reduction in rates is multi-faceted. Prominently, state-level tort reforms like non-economic damage caps, health courts, and arbitration hearings are making it harder to bring cases to trial, particularly for lawyers who take cases on contingency. Second, frivolous lawsuits “are making an impression on jury pools,” Matray says, which means fewer filed claims and fewer cases that make it to trial. Third, this soft cycle has outlasted the typical pattern of rates falling for three to four years before rebounding.

“A lot of smart actuaries keep saying this has to change soon, because in a soft market there is a lot of competition,” he says, noting that in order to compete for low rates, insurance companies offer credits to clients and use their own reserve cash piles. “So things are really going to change in the next couple of years.”

“Hospital medicine is different than other specialties, because the hospitalist treats a broad range of patients in an acute care setting—from a pediatric patient to an adult patient with many chronic illnesses.”

—Robin Diamond, senior vice president and chief patient safety officer, The Doctors Company

In Need of Data, Patience

So what does it all mean for hospitalists and HM group leaders looking to be proactive about medical malpractice liability insurance? Patience is required.

For starters, there is no designated premium category for hospitalists. Much like the situation that exists for coding issues, the closest proxy for HM is internal medicine. According to Medical Liability Monitor, the premium paid by internal medicine physicians as of July 1, 2012, varied widely across the country. In South Florida, internal medicine insurance premiums in Miami, Dade, and Broward counties were between $42,000 and $46,000 per year. In South Dakota, one insurer reported rates of just under $4,000 per year. There is no average or median figure available, and Matray notes that actual rates paid can vary from county to county.

Moreover, it is difficult for group leaders or hospital executives to use past history to negotiate rates with insurers because of a shortage of reliable data. In its spring 2013 newsletter, the PIAA (formerly known as the Physician Insurers Association of America) published its first report on hospitalist claims reported to its Data Sharing Project. Of the 92,868 closed claims reported from 2002-2011, just 312, or 0.3%, named hospitalists as the defendant.

The data also showed that, of those claims, 20% were settled through insurance company payments. Those payments totaled $17.1 million, with an average payout to a claimant (known as the indemnity) of $272,553 per claim. Overall, hospitalists had a 20% paid-to-closed ratio, totaling more than $17.1 million. By comparison, the percent of paid-to-closed claims for all physicians was 29.3%, according to PIAA.

In a separate data set compiled this year by TDC, 34% of allegations against hospitalists were related to missed or failed diagnoses, with 28% tied to “improper management of treatment.” Twelve percent of allegations were the result of either improper medication management or ordering errors.

Robin Diamond, TDC’s senior vice president and chief patient safety officer, says that teasing out trends from the initial data can be challenging. Hospitalists, she says, can deal with so many different patients, diseases, and severity levels that it is difficult to draw conclusions.

“Hospital medicine is different than other specialties, because the hospitalist treats a broad range of patients in an acute care setting—from a pediatric patient to an adult patient with many chronic illnesses,” she says.

Divya Parikh, PIAA’s director of research and loss prevention, says HM group leaders should avoid reading too much into the first batch of data, because it’s a small sample size.

“A big part of that is we feel that a lot of hospitalists are intermingled into the other medical specialties,” she says. “So this becomes a very small subset where they are distinctly identified as hospitalists. And that’s the challenge.”

In particular, Parikh is curious to see whether HM’s rate of claims paid through insurance payments drops from 20% (already below the overall healthcare industry average). “It will be interesting as we proceed...to see if they begin to mitigate areas of risk where we used to see a lot of claims,” she adds. “If you look at a hospital setting, there has been some shift change in what the errors are. And, what you’d hope with hospitalists within these environments who are really owning this specialty, is that you’d see a decrease in that. There would be that connective care. There would be the patient that felt that they had an individual who was their go-to individual throughout their care at a hospital.”

A Peek at the Future

Insurers have begun compiling claims data on hospitalists and are taking a longer-term view of the specialty. TDC, for example, has analyzed its data and identified characteristics it says make a low-risk hospitalist, an analysis the company says is the first of its kind (see Figure 1). The insurer adds that it sees its responsibility as making sure everyone understands the hospitalist’s role within the acute care setting so that its pricing is commensurate with the liability risk.

click for large version

“We’re looking at the systems within the hospitalist group, as well as how well that group is integrating with the hospital where they’re practicing,” Diamond says. “What kind of patient mix is this particular hospitalist group seeing in that particular hospital, because it can be different in a large healthcare corporation in Manhattan, New York, from a community hospital in rural Texas.”

The growing popularity of hospitalists taking on co-management responsibilities for other specialties is another trend to keep an eye on, as it creates what insurers call “vicarious liability.” Working together in teams with other specialties can improve communication, reduce errors during transitions of care, and create better outcomes. However, in instances where there are problems, being on a care team means hospitalists can open themselves to liability. To mitigate that risk, hospitalists can look to other groups that have dealt with shared liability issues in the past, Parikh says.

“Historically, you would have seen it with anesthesiology,” she explains. “And one huge improvement anesthesiologists have made when a patient comes in for a surgery now is they come out, introduce themselves, say hello, and tell you what’s going on. They put a face to the name, so that it’s not just a no-name anesthesiologist who gets included in the lawsuit as well because they’re naming everybody in the group.”

But, holistically, the best long-term mitigation strategy appears to be tort reform and new ways of looking at the way in which healthcare liability issues are handled in the U.S., says Anupam Jena, MD, PhD, assistant professor of healthcare policy and medicine at Harvard Medical School, and an internist at Massachusetts General Hospital, both in Boston. Dr. Jena says that there is limited evidence that enacted malpractice reforms have produced more than a 2% to 5% reduction in healthcare spending compared to states that have not.² Instead, healthcare leaders should push for the elimination of defensive medicine, which he says contributes the lion’s share of the estimated $50 billion annual cost of malpractice liability across the country.

“Do I think the country is in a malpractice crisis? No,” he says. “Do I think that defensive medicine is larger than we think it is? Yes.

“If physicians practice as they felt they should practice without ordering extra tests and procedures, my guess would be you could reduce healthcare spending by substantially more than $50 billion.”

Richard Quinn is a freelance writer in New Jersey.

References

1. Spiegel AD, Kavaler F. America’s first medical malpractice crisis, 1835-1865. J Community Health. 1997;22:283-308.
2. Chandra A, Jena A, Seabury, S. Defensive medicine may be costlier than it seems. The Wall Street Journal website. http://online.wsj.com/article/SB10001424127887323701904578280112638373302.html. Accessed September 21, 2013.

Click here to listen to more of our interview with Paul Roscoe, CEO of the Washington, D.C.-based Advisory Board Company

Click here to listen to more of our interview with Paul Roscoe, CEO of the Washington, D.C.-based Advisory Board Company

Click here to listen to more of our interview with Paul Roscoe, CEO of the Washington, D.C.-based Advisory Board Company

Click here to listen to excerpts of our interview with Dr. Deitelzweig, chair of SHM’s Practice Analysis Committee.

Click here to listen to excerpts of our interview with Dr. Deitelzweig, chair of SHM’s Practice Analysis Committee.

Click here to listen to excerpts of our interview with Dr. Deitelzweig, chair of SHM’s Practice Analysis Committee.

The Medical Group Management Association (MGMA) surveys regard both a doctor who works the standard number of annual shifts their practice defines as full time, and a doctor who works many extra shifts, as one full-time equivalent (FTE). This can cause confusion when assessing productivity per FTE (see “SHM and MGMA Survey History,” right).

For example, consider a hospitalist who generated 4,000 wRVUs while working 182 shifts—the standard number of shifts to be full time in that doctor’s practice—during the survey year. In the same practice, another hospitalist worked 39 extra shifts over the same year for a total of 220 shifts, generating 4,860 wRVUs. If the survey contained only these two doctors, it would show them both as full time, with an average productivity per FTE of 4,430 wRVUs. But that would be misleading because 1.0 FTE worth of work as defined by their practice for both doctors would have come to 4,000 wRVUs generated while working 182 shifts.

In prior columns, I’ve highlighted some other numbers in hospitalist productivity and compensation surveys that can lead to confusion. But the MGMA survey methodology, which assigns a particular FTE to a single doctor, may be the most confusing issue, potentially leading to meaningful misunderstandings.

More Details on FTE Definition

MGMA has been conducting physician compensation and productivity surveys across essentially all medical specialties for decades. Competing organizations conduct similar surveys, but most regard the MGMA survey as the most relevant and valuable.

For a long time, MGMA has regarded as “full time” any doctor working 0.75 FTE or greater, using the respondent practice’s definition of an FTE. No single doctor can ever be counted as more than 1.0 FTE, regardless of how much extra the doctor may have worked. Any doctor working 0.35-0.75 FTE is regarded as part time, and those working less than 0.35 FTE are excluded from the survey report. The fact that each practice might have a different definition of what constitutes an FTE is addressed by having a large number of respondents in most medical specialties.

I’m uncertain how MGMA ended up not counting any single doctor as more than 1.0 FTE, even when they work a lot of extra shifts. But my guess is that for the first years, or even decades, that MGMA conducted its survey, few, if any, medical practices even had a strict definition of what constituted 1.0 FTE and simply didn’t keep track of which doctors worked extra shifts or days. So even if MGMA had wanted to know, for example, when a doctor worked extra shifts and should be counted as more than 1.0 FTE, few if any practices even thought about the precise number of shifts or days worked constituting full time versus what was an “extra” shift. So it probably made sense to simply have two categories: full time and part time.

As more practices began assigning FTE with greater precision, like nearly all hospitalist practices do, then using 0.75 FTE to separate full time and part time seemed practical, though imprecise. But keep in mind it also means that all of the doctors who work from 0.75 to 0.99 FTE (that is, something less than 1.0) offset, at least partially, those who work lots of extra shifts (i.e., above 1.0 FTE).

Data Application

My anecdotal experience is that a large portion of hospitalists, probably around half, work more shifts than what their practice regards as full time. I don’t know of any survey database that quantifies this, but my guess is that 25% to 35% of full-time hospitalists work extra shifts at their own practice, and maybe another 15% to 20% moonlight at a different practice. Let’s consider only those in the first category.

Chronic staffing shortages is one of the reasons hospitalists so commonly work extra shifts at their own practice. Extra shifts are sometimes even required by the practice to make up for open positions. And in some places, the hospitalists choose not to fill positions to preserve their ability to continue working more than the number of shifts required to be full time.

It would be great if we had a precise way to adjust the MGMA survey data for hospitalists who work above 1.0 FTE. For example, let’s make three assumptions so that we can then adjust the reported compensation and productivity data to remove the effect of the many doctors working extra shifts, thereby more clearly matching 1.0 FTE. These numbers are my guesses based on lots of anecdotal experience. But they are only guesses. Don’t make too much of them.

Assume 25% of hospitalists nationally work an average of 20% more than the full-time number of shifts for their practice. That is my best guess and intentionally leaves out those who moonlight for a practice other than their own.

Some portion of those working extra shifts (above 1.0 FTE) is offset by survey respondents working between 0.75 and 1.0 FTE, resulting in a wild guess of a net 20% of hospitalists working extra shifts.

Last, let’s assume that their productivity and compensation on extra shifts is identical to their “normal” shifts. This is not true for many practices, but when aggregating the data, it is probably reasonably close.

Using these assumptions (guesses, really), we can decrease both the reported survey mean and median productivity and compensation by about 5% to more accurately reflect results for hospitalists doing only the number of shifts required by the practice to be full time—no extra shifts. I’ll spare you the simple math showing how I arrived at the approximately 5%, but basically it is removing the 20% additional compensation and productivity generated by the net 20% of hospitalists who work extra shifts above 1.0 FTE.

Does It Really Matter?

The whole issue of hospitalists working many extra shifts yet only counting as 1.0 FTE in the MGMA survey might matter a lot for some, and others might see it as useless hand-wringing. As long as a meaningful number of hospitalists work extra shifts, then survey values for productivity and compensation will always be a little higher than the “average” 1.0 FTE hospitalists working no extra shifts. But it may still be well within the range of error of the survey anyway. And the compensation per unit of work (wRVUs or encounters) probably isn’t much affected by this FTE issue.

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

The Medical Group Management Association (MGMA) surveys regard both a doctor who works the standard number of annual shifts their practice defines as full time, and a doctor who works many extra shifts, as one full-time equivalent (FTE). This can cause confusion when assessing productivity per FTE (see “SHM and MGMA Survey History,” right).

For example, consider a hospitalist who generated 4,000 wRVUs while working 182 shifts—the standard number of shifts to be full time in that doctor’s practice—during the survey year. In the same practice, another hospitalist worked 39 extra shifts over the same year for a total of 220 shifts, generating 4,860 wRVUs. If the survey contained only these two doctors, it would show them both as full time, with an average productivity per FTE of 4,430 wRVUs. But that would be misleading because 1.0 FTE worth of work as defined by their practice for both doctors would have come to 4,000 wRVUs generated while working 182 shifts.

In prior columns, I’ve highlighted some other numbers in hospitalist productivity and compensation surveys that can lead to confusion. But the MGMA survey methodology, which assigns a particular FTE to a single doctor, may be the most confusing issue, potentially leading to meaningful misunderstandings.

More Details on FTE Definition

MGMA has been conducting physician compensation and productivity surveys across essentially all medical specialties for decades. Competing organizations conduct similar surveys, but most regard the MGMA survey as the most relevant and valuable.

For a long time, MGMA has regarded as “full time” any doctor working 0.75 FTE or greater, using the respondent practice’s definition of an FTE. No single doctor can ever be counted as more than 1.0 FTE, regardless of how much extra the doctor may have worked. Any doctor working 0.35-0.75 FTE is regarded as part time, and those working less than 0.35 FTE are excluded from the survey report. The fact that each practice might have a different definition of what constitutes an FTE is addressed by having a large number of respondents in most medical specialties.

I’m uncertain how MGMA ended up not counting any single doctor as more than 1.0 FTE, even when they work a lot of extra shifts. But my guess is that for the first years, or even decades, that MGMA conducted its survey, few, if any, medical practices even had a strict definition of what constituted 1.0 FTE and simply didn’t keep track of which doctors worked extra shifts or days. So even if MGMA had wanted to know, for example, when a doctor worked extra shifts and should be counted as more than 1.0 FTE, few if any practices even thought about the precise number of shifts or days worked constituting full time versus what was an “extra” shift. So it probably made sense to simply have two categories: full time and part time.

As more practices began assigning FTE with greater precision, like nearly all hospitalist practices do, then using 0.75 FTE to separate full time and part time seemed practical, though imprecise. But keep in mind it also means that all of the doctors who work from 0.75 to 0.99 FTE (that is, something less than 1.0) offset, at least partially, those who work lots of extra shifts (i.e., above 1.0 FTE).

Data Application

My anecdotal experience is that a large portion of hospitalists, probably around half, work more shifts than what their practice regards as full time. I don’t know of any survey database that quantifies this, but my guess is that 25% to 35% of full-time hospitalists work extra shifts at their own practice, and maybe another 15% to 20% moonlight at a different practice. Let’s consider only those in the first category.

Chronic staffing shortages is one of the reasons hospitalists so commonly work extra shifts at their own practice. Extra shifts are sometimes even required by the practice to make up for open positions. And in some places, the hospitalists choose not to fill positions to preserve their ability to continue working more than the number of shifts required to be full time.

It would be great if we had a precise way to adjust the MGMA survey data for hospitalists who work above 1.0 FTE. For example, let’s make three assumptions so that we can then adjust the reported compensation and productivity data to remove the effect of the many doctors working extra shifts, thereby more clearly matching 1.0 FTE. These numbers are my guesses based on lots of anecdotal experience. But they are only guesses. Don’t make too much of them.

Assume 25% of hospitalists nationally work an average of 20% more than the full-time number of shifts for their practice. That is my best guess and intentionally leaves out those who moonlight for a practice other than their own.

Some portion of those working extra shifts (above 1.0 FTE) is offset by survey respondents working between 0.75 and 1.0 FTE, resulting in a wild guess of a net 20% of hospitalists working extra shifts.

Last, let’s assume that their productivity and compensation on extra shifts is identical to their “normal” shifts. This is not true for many practices, but when aggregating the data, it is probably reasonably close.

Using these assumptions (guesses, really), we can decrease both the reported survey mean and median productivity and compensation by about 5% to more accurately reflect results for hospitalists doing only the number of shifts required by the practice to be full time—no extra shifts. I’ll spare you the simple math showing how I arrived at the approximately 5%, but basically it is removing the 20% additional compensation and productivity generated by the net 20% of hospitalists who work extra shifts above 1.0 FTE.

Does It Really Matter?

The whole issue of hospitalists working many extra shifts yet only counting as 1.0 FTE in the MGMA survey might matter a lot for some, and others might see it as useless hand-wringing. As long as a meaningful number of hospitalists work extra shifts, then survey values for productivity and compensation will always be a little higher than the “average” 1.0 FTE hospitalists working no extra shifts. But it may still be well within the range of error of the survey anyway. And the compensation per unit of work (wRVUs or encounters) probably isn’t much affected by this FTE issue.

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

The Medical Group Management Association (MGMA) surveys regard both a doctor who works the standard number of annual shifts their practice defines as full time, and a doctor who works many extra shifts, as one full-time equivalent (FTE). This can cause confusion when assessing productivity per FTE (see “SHM and MGMA Survey History,” right).

For example, consider a hospitalist who generated 4,000 wRVUs while working 182 shifts—the standard number of shifts to be full time in that doctor’s practice—during the survey year. In the same practice, another hospitalist worked 39 extra shifts over the same year for a total of 220 shifts, generating 4,860 wRVUs. If the survey contained only these two doctors, it would show them both as full time, with an average productivity per FTE of 4,430 wRVUs. But that would be misleading because 1.0 FTE worth of work as defined by their practice for both doctors would have come to 4,000 wRVUs generated while working 182 shifts.

In prior columns, I’ve highlighted some other numbers in hospitalist productivity and compensation surveys that can lead to confusion. But the MGMA survey methodology, which assigns a particular FTE to a single doctor, may be the most confusing issue, potentially leading to meaningful misunderstandings.

More Details on FTE Definition

MGMA has been conducting physician compensation and productivity surveys across essentially all medical specialties for decades. Competing organizations conduct similar surveys, but most regard the MGMA survey as the most relevant and valuable.

For a long time, MGMA has regarded as “full time” any doctor working 0.75 FTE or greater, using the respondent practice’s definition of an FTE. No single doctor can ever be counted as more than 1.0 FTE, regardless of how much extra the doctor may have worked. Any doctor working 0.35-0.75 FTE is regarded as part time, and those working less than 0.35 FTE are excluded from the survey report. The fact that each practice might have a different definition of what constitutes an FTE is addressed by having a large number of respondents in most medical specialties.

I’m uncertain how MGMA ended up not counting any single doctor as more than 1.0 FTE, even when they work a lot of extra shifts. But my guess is that for the first years, or even decades, that MGMA conducted its survey, few, if any, medical practices even had a strict definition of what constituted 1.0 FTE and simply didn’t keep track of which doctors worked extra shifts or days. So even if MGMA had wanted to know, for example, when a doctor worked extra shifts and should be counted as more than 1.0 FTE, few if any practices even thought about the precise number of shifts or days worked constituting full time versus what was an “extra” shift. So it probably made sense to simply have two categories: full time and part time.

As more practices began assigning FTE with greater precision, like nearly all hospitalist practices do, then using 0.75 FTE to separate full time and part time seemed practical, though imprecise. But keep in mind it also means that all of the doctors who work from 0.75 to 0.99 FTE (that is, something less than 1.0) offset, at least partially, those who work lots of extra shifts (i.e., above 1.0 FTE).

Data Application

My anecdotal experience is that a large portion of hospitalists, probably around half, work more shifts than what their practice regards as full time. I don’t know of any survey database that quantifies this, but my guess is that 25% to 35% of full-time hospitalists work extra shifts at their own practice, and maybe another 15% to 20% moonlight at a different practice. Let’s consider only those in the first category.

Chronic staffing shortages is one of the reasons hospitalists so commonly work extra shifts at their own practice. Extra shifts are sometimes even required by the practice to make up for open positions. And in some places, the hospitalists choose not to fill positions to preserve their ability to continue working more than the number of shifts required to be full time.

It would be great if we had a precise way to adjust the MGMA survey data for hospitalists who work above 1.0 FTE. For example, let’s make three assumptions so that we can then adjust the reported compensation and productivity data to remove the effect of the many doctors working extra shifts, thereby more clearly matching 1.0 FTE. These numbers are my guesses based on lots of anecdotal experience. But they are only guesses. Don’t make too much of them.

Assume 25% of hospitalists nationally work an average of 20% more than the full-time number of shifts for their practice. That is my best guess and intentionally leaves out those who moonlight for a practice other than their own.

Some portion of those working extra shifts (above 1.0 FTE) is offset by survey respondents working between 0.75 and 1.0 FTE, resulting in a wild guess of a net 20% of hospitalists working extra shifts.

Last, let’s assume that their productivity and compensation on extra shifts is identical to their “normal” shifts. This is not true for many practices, but when aggregating the data, it is probably reasonably close.

Using these assumptions (guesses, really), we can decrease both the reported survey mean and median productivity and compensation by about 5% to more accurately reflect results for hospitalists doing only the number of shifts required by the practice to be full time—no extra shifts. I’ll spare you the simple math showing how I arrived at the approximately 5%, but basically it is removing the 20% additional compensation and productivity generated by the net 20% of hospitalists who work extra shifts above 1.0 FTE.

Does It Really Matter?

The whole issue of hospitalists working many extra shifts yet only counting as 1.0 FTE in the MGMA survey might matter a lot for some, and others might see it as useless hand-wringing. As long as a meaningful number of hospitalists work extra shifts, then survey values for productivity and compensation will always be a little higher than the “average” 1.0 FTE hospitalists working no extra shifts. But it may still be well within the range of error of the survey anyway. And the compensation per unit of work (wRVUs or encounters) probably isn’t much affected by this FTE issue.

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

The View from

Looking for more information to formulate a plan of attack? SHM offers a variety of HVBP resources to orient hospitalists and hospital leaders. The “What Every Hospitalist Should Know About Hospital Value-Based Purchasing” webinar and SHM’s free resource library (www.hospitalmedicine.org/hvbp) offer basic orientation on what to expect on pay-for-performance-related issues. The HVBP resource center also provides multiple case studies from various hospitals across the country, with success stories related to reducing readmissions, increasing evidence-based care focus, and enhancing performance on core measures.

In order to proactively address CMS’ new 30-day readmissions criteria for COPD, SHM’s COPD Resource Center (www.hospitalmedicine.org/copd) provides hospitalists with the most up-to-date guidelines, reviews, and peer-reviewed clinical trials that define evidence-based practice for the care of the COPD patient.

Hospitalists not only are under pressure to help improve hospital-level performance, but also will need to begin reporting physician-level measures. Beginning in 2015, CMS’s Physician Quality Reporting System (PQRS) will apply a penalty to all physicians who do not satisfactorily report data on quality measures for covered professional services.

The time to act is now. Reporting during the 2013 PQRS program year will be used to determine whether a 1.5% penalty applies in 2015. SHM has partnered with CECity to offer discounted access to PQRIwizard, a tool that facilitates PQRS reporting through SHM’s Learning Portal (www.shmlearningportal.org).

October is the beginning of a new year—in this case, fiscal-year 2014 for the Centers for Medicare & Medicaid Services (CMS). It’s a time when the new rules kick in. This month, we’ll look at some highlights, focusing on the new developments affecting your practice. Because you are held accountable for hospital-side performance on programs such as hospital value-based purchasing (HVBP) and the Readmissions Reduction Program, a working knowledge of the 2014 edition of the programs is crucial.

Close the Loop on HVBP

How will your hospital get paid under the 2014 version of HVBP? This past July, your hospital received a report outlining how its Medicare payments will be affected based on your hospital’s performance on process of care (heart failure, pneumonia, myocardial infarction, and surgery), patient experience (HCAHPS), and outcomes (30-day mortality for heart failure, pneumonia, and myocardial infarction).

Here are two hypothetical hospitals and how their performance in the program affects their 2014 payment. As background, in 2014, all hospitals have their base diagnosis related group (DRG) payments reduced by 1.25% for HVBP. They can earn back some, all, or an amount in excess of the 1.25% based on their performance. Payment is based on performance during the April 1 to Dec. 31, 2012, period. Under HVBP, CMS incentive payments occur at the level of individual patients, each of which is assigned a DRG.

Let’s look at two examples:

Hospital 1

• Base DRG payment reduction: 1.25% (all hospitals).
• Portion of base DRG earned back based on performance (process/patient experience/outcome metrics): 1.48%.
• Net change in base DRG payment: +0.23%.

Hospital 2

• Base DRG payment reduction: 1.25% (all hospitals).
• Portion of base DRG earned back based on performance (process/patient experience/outcome metrics): 1.08%.
• Net change in base DRG payment: -0.17%.

Hospital 1 performed relatively well, getting a bump of 0.23% in its base DRG rate. Hospital 2 did not perform so well, so it took a 0.17% hit on its base DRG rate.

In order to determine total dollars made or lost for your hospital, one multiplies the total number of eligible Medicare inpatients for 2014 times the base DRG payment times the percent change in base DRG payment. If Hospital 1 has 10,000 eligible patients in 2014 and a base DRG payment of $5,000, the value is 10,000 x $5,000 x 0.0023 (0.23%) = $115,000 gained. Hospital 2, with the same number of patients and base DRG payment, loses (10,000 x $5,000 x 0.0017 = $85,000).

Readmissions and Penalties

For 2014, CMS is adding 30-day readmissions for COPD to readmissions for heart failure, pneumonia, and myocardial infarction for its penalty program. CMS added COPD because it is the fourth-leading cause of readmissions, according to a recent Medicare Payment Advisory Commission report, and because there is wide variation in the rates (from 18% to 25%) of COPD hospital readmissions.

For 2014, CMS raises the ceiling on readmission penalties to a maximum of 2% of reimbursement for all of a hospital’s Medicare inpatients. (The maximum hit during the first round of readmission penalties, which began in October 2012, was 1%.) More than 2,200 U.S. hospitals will face some financial penalty for excess 30-day readmissions.

Disappointingly, CMS did not add a risk adjustment for socioeconomic status despite being under pressure to do so. There is growing evidence that these factors have a major impact on readmission rates.^1,2

New Definition of an Admission

Amidst confusion from many and major blowback from beneficiaries saddled with large out-of-pocket expenses for observation stays and subsequent skilled-nursing-facility stays, CMS is clarifying the definition of an inpatient admission. The agency will define an admission as a hospital stay that spans at least two midnights. If a patient is in the hospital for a shorter period of time, CMS will deem the patient to be on observation status, unless medical record documentation supports a physician’s expectation “that the beneficiary would need care spanning at least two midnights” but unanticipated events led to a shorter stay.

Plan of Attack

For HVBP, make contact with your director of quality to understand your hospital’s performance and payment for 2014. If you have incentive compensation riding on HVBP, make sure you understand how your employer or contracted hospital is calculating the payout (because, for example, the performance period was in 2012!) and that your hospitalist group understands the payout calculation.

For COPD readmissions prevention, ensure patients have a home management plan; appropriate specialist follow-up and that they understand medication use, including inhalers and supplemental oxygen; and that you consider early referral for pulmonary rehabilitation for eligible patients.

For the new definition of inpatient admission, work with your hospital’s physician advisor and case management to ensure your group is getting appropriate guidance on documentation requirements. You are probably being held accountable for your hospital’s total number of observation hours, so remember to track these metrics following implementation of the new rule, as they (hopefully) should decrease. If they do, take some of the credit!

References

1. Joynt KE, Orav EJ, Jha AK. Thirty-day readmission rates for Medicare beneficiaries by race and site of care. JAMA. 2011;305(7):675-681.
2. Lindenauer PK, Lagu T, Rothberg MB, et al. Income inequality and 30 day outcomes after acute myocardial infarction, heart failure, and pneumonia: retrospective cohort study. BMJ. 2013;346:f521.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is co-founder and past president of SHM. Email him at wfwhit@comcast.net.

The View from

Looking for more information to formulate a plan of attack? SHM offers a variety of HVBP resources to orient hospitalists and hospital leaders. The “What Every Hospitalist Should Know About Hospital Value-Based Purchasing” webinar and SHM’s free resource library (www.hospitalmedicine.org/hvbp) offer basic orientation on what to expect on pay-for-performance-related issues. The HVBP resource center also provides multiple case studies from various hospitals across the country, with success stories related to reducing readmissions, increasing evidence-based care focus, and enhancing performance on core measures.

In order to proactively address CMS’ new 30-day readmissions criteria for COPD, SHM’s COPD Resource Center (www.hospitalmedicine.org/copd) provides hospitalists with the most up-to-date guidelines, reviews, and peer-reviewed clinical trials that define evidence-based practice for the care of the COPD patient.

Hospitalists not only are under pressure to help improve hospital-level performance, but also will need to begin reporting physician-level measures. Beginning in 2015, CMS’s Physician Quality Reporting System (PQRS) will apply a penalty to all physicians who do not satisfactorily report data on quality measures for covered professional services.

The time to act is now. Reporting during the 2013 PQRS program year will be used to determine whether a 1.5% penalty applies in 2015. SHM has partnered with CECity to offer discounted access to PQRIwizard, a tool that facilitates PQRS reporting through SHM’s Learning Portal (www.shmlearningportal.org).

October is the beginning of a new year—in this case, fiscal-year 2014 for the Centers for Medicare & Medicaid Services (CMS). It’s a time when the new rules kick in. This month, we’ll look at some highlights, focusing on the new developments affecting your practice. Because you are held accountable for hospital-side performance on programs such as hospital value-based purchasing (HVBP) and the Readmissions Reduction Program, a working knowledge of the 2014 edition of the programs is crucial.

Close the Loop on HVBP

How will your hospital get paid under the 2014 version of HVBP? This past July, your hospital received a report outlining how its Medicare payments will be affected based on your hospital’s performance on process of care (heart failure, pneumonia, myocardial infarction, and surgery), patient experience (HCAHPS), and outcomes (30-day mortality for heart failure, pneumonia, and myocardial infarction).

Here are two hypothetical hospitals and how their performance in the program affects their 2014 payment. As background, in 2014, all hospitals have their base diagnosis related group (DRG) payments reduced by 1.25% for HVBP. They can earn back some, all, or an amount in excess of the 1.25% based on their performance. Payment is based on performance during the April 1 to Dec. 31, 2012, period. Under HVBP, CMS incentive payments occur at the level of individual patients, each of which is assigned a DRG.

Let’s look at two examples:

Hospital 1

• Base DRG payment reduction: 1.25% (all hospitals).
• Portion of base DRG earned back based on performance (process/patient experience/outcome metrics): 1.48%.
• Net change in base DRG payment: +0.23%.

Hospital 2

• Base DRG payment reduction: 1.25% (all hospitals).
• Portion of base DRG earned back based on performance (process/patient experience/outcome metrics): 1.08%.
• Net change in base DRG payment: -0.17%.

Hospital 1 performed relatively well, getting a bump of 0.23% in its base DRG rate. Hospital 2 did not perform so well, so it took a 0.17% hit on its base DRG rate.

In order to determine total dollars made or lost for your hospital, one multiplies the total number of eligible Medicare inpatients for 2014 times the base DRG payment times the percent change in base DRG payment. If Hospital 1 has 10,000 eligible patients in 2014 and a base DRG payment of $5,000, the value is 10,000 x $5,000 x 0.0023 (0.23%) = $115,000 gained. Hospital 2, with the same number of patients and base DRG payment, loses (10,000 x $5,000 x 0.0017 = $85,000).

Readmissions and Penalties

For 2014, CMS is adding 30-day readmissions for COPD to readmissions for heart failure, pneumonia, and myocardial infarction for its penalty program. CMS added COPD because it is the fourth-leading cause of readmissions, according to a recent Medicare Payment Advisory Commission report, and because there is wide variation in the rates (from 18% to 25%) of COPD hospital readmissions.

For 2014, CMS raises the ceiling on readmission penalties to a maximum of 2% of reimbursement for all of a hospital’s Medicare inpatients. (The maximum hit during the first round of readmission penalties, which began in October 2012, was 1%.) More than 2,200 U.S. hospitals will face some financial penalty for excess 30-day readmissions.

Disappointingly, CMS did not add a risk adjustment for socioeconomic status despite being under pressure to do so. There is growing evidence that these factors have a major impact on readmission rates.^1,2

New Definition of an Admission

Amidst confusion from many and major blowback from beneficiaries saddled with large out-of-pocket expenses for observation stays and subsequent skilled-nursing-facility stays, CMS is clarifying the definition of an inpatient admission. The agency will define an admission as a hospital stay that spans at least two midnights. If a patient is in the hospital for a shorter period of time, CMS will deem the patient to be on observation status, unless medical record documentation supports a physician’s expectation “that the beneficiary would need care spanning at least two midnights” but unanticipated events led to a shorter stay.

Plan of Attack

For HVBP, make contact with your director of quality to understand your hospital’s performance and payment for 2014. If you have incentive compensation riding on HVBP, make sure you understand how your employer or contracted hospital is calculating the payout (because, for example, the performance period was in 2012!) and that your hospitalist group understands the payout calculation.

For COPD readmissions prevention, ensure patients have a home management plan; appropriate specialist follow-up and that they understand medication use, including inhalers and supplemental oxygen; and that you consider early referral for pulmonary rehabilitation for eligible patients.

For the new definition of inpatient admission, work with your hospital’s physician advisor and case management to ensure your group is getting appropriate guidance on documentation requirements. You are probably being held accountable for your hospital’s total number of observation hours, so remember to track these metrics following implementation of the new rule, as they (hopefully) should decrease. If they do, take some of the credit!

References

1. Joynt KE, Orav EJ, Jha AK. Thirty-day readmission rates for Medicare beneficiaries by race and site of care. JAMA. 2011;305(7):675-681.
2. Lindenauer PK, Lagu T, Rothberg MB, et al. Income inequality and 30 day outcomes after acute myocardial infarction, heart failure, and pneumonia: retrospective cohort study. BMJ. 2013;346:f521.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is co-founder and past president of SHM. Email him at wfwhit@comcast.net.

The View from

Looking for more information to formulate a plan of attack? SHM offers a variety of HVBP resources to orient hospitalists and hospital leaders. The “What Every Hospitalist Should Know About Hospital Value-Based Purchasing” webinar and SHM’s free resource library (www.hospitalmedicine.org/hvbp) offer basic orientation on what to expect on pay-for-performance-related issues. The HVBP resource center also provides multiple case studies from various hospitals across the country, with success stories related to reducing readmissions, increasing evidence-based care focus, and enhancing performance on core measures.

In order to proactively address CMS’ new 30-day readmissions criteria for COPD, SHM’s COPD Resource Center (www.hospitalmedicine.org/copd) provides hospitalists with the most up-to-date guidelines, reviews, and peer-reviewed clinical trials that define evidence-based practice for the care of the COPD patient.

Hospitalists not only are under pressure to help improve hospital-level performance, but also will need to begin reporting physician-level measures. Beginning in 2015, CMS’s Physician Quality Reporting System (PQRS) will apply a penalty to all physicians who do not satisfactorily report data on quality measures for covered professional services.

The time to act is now. Reporting during the 2013 PQRS program year will be used to determine whether a 1.5% penalty applies in 2015. SHM has partnered with CECity to offer discounted access to PQRIwizard, a tool that facilitates PQRS reporting through SHM’s Learning Portal (www.shmlearningportal.org).

October is the beginning of a new year—in this case, fiscal-year 2014 for the Centers for Medicare & Medicaid Services (CMS). It’s a time when the new rules kick in. This month, we’ll look at some highlights, focusing on the new developments affecting your practice. Because you are held accountable for hospital-side performance on programs such as hospital value-based purchasing (HVBP) and the Readmissions Reduction Program, a working knowledge of the 2014 edition of the programs is crucial.

Close the Loop on HVBP

How will your hospital get paid under the 2014 version of HVBP? This past July, your hospital received a report outlining how its Medicare payments will be affected based on your hospital’s performance on process of care (heart failure, pneumonia, myocardial infarction, and surgery), patient experience (HCAHPS), and outcomes (30-day mortality for heart failure, pneumonia, and myocardial infarction).

Here are two hypothetical hospitals and how their performance in the program affects their 2014 payment. As background, in 2014, all hospitals have their base diagnosis related group (DRG) payments reduced by 1.25% for HVBP. They can earn back some, all, or an amount in excess of the 1.25% based on their performance. Payment is based on performance during the April 1 to Dec. 31, 2012, period. Under HVBP, CMS incentive payments occur at the level of individual patients, each of which is assigned a DRG.

Let’s look at two examples:

Hospital 1

• Base DRG payment reduction: 1.25% (all hospitals).
• Portion of base DRG earned back based on performance (process/patient experience/outcome metrics): 1.48%.
• Net change in base DRG payment: +0.23%.

Hospital 2

• Base DRG payment reduction: 1.25% (all hospitals).
• Portion of base DRG earned back based on performance (process/patient experience/outcome metrics): 1.08%.
• Net change in base DRG payment: -0.17%.

Hospital 1 performed relatively well, getting a bump of 0.23% in its base DRG rate. Hospital 2 did not perform so well, so it took a 0.17% hit on its base DRG rate.

In order to determine total dollars made or lost for your hospital, one multiplies the total number of eligible Medicare inpatients for 2014 times the base DRG payment times the percent change in base DRG payment. If Hospital 1 has 10,000 eligible patients in 2014 and a base DRG payment of $5,000, the value is 10,000 x $5,000 x 0.0023 (0.23%) = $115,000 gained. Hospital 2, with the same number of patients and base DRG payment, loses (10,000 x $5,000 x 0.0017 = $85,000).

Readmissions and Penalties

For 2014, CMS is adding 30-day readmissions for COPD to readmissions for heart failure, pneumonia, and myocardial infarction for its penalty program. CMS added COPD because it is the fourth-leading cause of readmissions, according to a recent Medicare Payment Advisory Commission report, and because there is wide variation in the rates (from 18% to 25%) of COPD hospital readmissions.

For 2014, CMS raises the ceiling on readmission penalties to a maximum of 2% of reimbursement for all of a hospital’s Medicare inpatients. (The maximum hit during the first round of readmission penalties, which began in October 2012, was 1%.) More than 2,200 U.S. hospitals will face some financial penalty for excess 30-day readmissions.

Disappointingly, CMS did not add a risk adjustment for socioeconomic status despite being under pressure to do so. There is growing evidence that these factors have a major impact on readmission rates.^1,2

New Definition of an Admission

Amidst confusion from many and major blowback from beneficiaries saddled with large out-of-pocket expenses for observation stays and subsequent skilled-nursing-facility stays, CMS is clarifying the definition of an inpatient admission. The agency will define an admission as a hospital stay that spans at least two midnights. If a patient is in the hospital for a shorter period of time, CMS will deem the patient to be on observation status, unless medical record documentation supports a physician’s expectation “that the beneficiary would need care spanning at least two midnights” but unanticipated events led to a shorter stay.

Plan of Attack

For HVBP, make contact with your director of quality to understand your hospital’s performance and payment for 2014. If you have incentive compensation riding on HVBP, make sure you understand how your employer or contracted hospital is calculating the payout (because, for example, the performance period was in 2012!) and that your hospitalist group understands the payout calculation.

For COPD readmissions prevention, ensure patients have a home management plan; appropriate specialist follow-up and that they understand medication use, including inhalers and supplemental oxygen; and that you consider early referral for pulmonary rehabilitation for eligible patients.

For the new definition of inpatient admission, work with your hospital’s physician advisor and case management to ensure your group is getting appropriate guidance on documentation requirements. You are probably being held accountable for your hospital’s total number of observation hours, so remember to track these metrics following implementation of the new rule, as they (hopefully) should decrease. If they do, take some of the credit!

References

1. Joynt KE, Orav EJ, Jha AK. Thirty-day readmission rates for Medicare beneficiaries by race and site of care. JAMA. 2011;305(7):675-681.
2. Lindenauer PK, Lagu T, Rothberg MB, et al. Income inequality and 30 day outcomes after acute myocardial infarction, heart failure, and pneumonia: retrospective cohort study. BMJ. 2013;346:f521.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is co-founder and past president of SHM. Email him at wfwhit@comcast.net.

Lean thinking teaches you that change and improvement do not come down from leadership, but rather develop up from front-line workers. Group leaders need to continue seeing patients to truly understand the processes and problems inherent in clinical work.

It took a while for James J. O’Callaghan, MD, FAAP, FHM, to settle on a career path. First, he pursued the life of a chemical engineer. Then, in his third year at Rensselaer Polytechnic Institute in Troy, N.Y., he realized the kind of job he would be getting into was not quite for him. His then-girlfriend was a pre-med student, and it wasn’t long until he switched majors.

Hospital medicine drew his interest during residency, when he spent a monthlong rotation with a small group of physicians at a community hospital in Cleveland.

“Their days consisted of rounding on pediatric inpatients, examining normal newborns, completing pediatric consults in the ED, and performing minor procedures on the floor,” he says. “To me, it seemed the perfect job.”

Dr. O’Callaghan married an adult-medicine hospitalist and moved to Seattle, but he could not find a good fit in a hospitalist practice. He did private practice for two years, and in 2004, he landed a position in pediatric hospital medicine.

“I quickly changed career paths,” he says.

Dr. O’Callaghan is now a regional pediatric hospitalist at Evergreen Hospital in Kirkland, Wash., and a medical hospitalist at Seattle Children’s Hospital. He is a clinical assistant professor at the University of Washington and one of nine new Team Hospitalist members, The Hospitalist’s volunteer editorial advisory group.

As the section head for pediatrics at Evergreen, Dr. O’Callaghan spends most of his time seeing patients. However, he has in recent years developed a keen interest in quality improvement (QI). He’s the lead pediatric hospitalist on two clinical pathways at Seattle Children’s and has been an active member of SHM’s Hospital Quality and Patient Safety Committee since 2012.

“I want to continue to expand on this QI work,” he says, “with the goal of developing into a formal QI role at either, or both, hospitals.”

Question: What do you like most about working as a hospitalist?

Answer: I like the fact that the work I am doing as a hospitalist can have both an immediate impact on a single patient and a prolonged impact on multiple patients. I can admit a child with community-acquired pneumonia and, through my treatment, prevent serious sequelae from developing. However, I can also develop an evidenced-based, community-acquired pneumonia pathway and, potentially, affect the care of hundreds of children. There is immediate gratification in treating today’s patient and delayed gratification knowing that you are helping many of tomorrow’s patients.

Q: What do you dislike?

A: One of the hardest parts of a career in HM is trying to effect culture change. Hospital systems are typically large, complex organizations with their own culture. In order to successfully produce sustainable, long-term improvement, you must change this culture. You can perform a robust search of the literature to produce a brilliant clinical-care path, but unless you can affect behavior, your work and effort may not last. It can be frustrating to think you have the answer to a clinical problem only to see your effort fail because you could not change culture.

Q: What’s the biggest change you’ve seen in HM in your career?

A: In the early years, much of the conversation in HM was centered on the viability of a career in HM. Could one make a sustainable career in HM? Would hospitals and health systems continue to support physicians in HM? The biggest change I have seen is that we are no longer having those conversations. Now, the conversations are focused on determining which areas of medicine will be owned by HM: First it was QI work, then patient safety, and now resource utilization and cost containment. We are no longer spending time and energy worrying about the future of HM, but rather now our efforts are focused on the present work of HM. As a sustainable career, HM is here to stay.

Q: For group leaders, why is it important for you to continue seeing patients?

A: In my QI work, I have studied Lean thinking and methodology. Lean thinking teaches you that change and improvement do not come down from leadership, but rather develop up from front-line workers. Group leaders need to continue seeing patients to truly understand the processes and problems inherent in clinical work. Effective solutions must come from those actually doing the work, rather than from those managing the work from above.

Q: What does it mean to you to be elected a Fellow in Hospital Medicine?

A: It meant that I had committed fully to a career in hospital medicine. I use the FHM designation proudly in all my communications, as a signal to others of my commitment and dedication to hospital medicine. Someday, I hope to earn the designation of SFHM, as a validation and recognition of my contributions to the field of pediatric hospital medicine.

Q: When you aren’t working, what is important to you?

A: After family, it is important for me to maintain a healthy lifestyle and stay in shape. I am able to commute to Seattle Children’s Hospital by bicycle and I try to run two to three times a week. I squeeze in half-marathons and marathons, along with century [100 miles] and double-century bicycle rides each year.

Q: If you weren’t a doctor, what would you be doing right now?

A: I would love to be a stay-at-home father for my boys and also devote the time and energy into pursuing a career in trail running.

Q: What’s the best book you’ve read recently?

A: I recently read Jim Collins’ “Good to Great” as part of a management training course at Seattle Children’s Hospital. This easy-to-read, highly entertaining book clearly demonstrates the culture changes that need to occur for companies to move from good to great. As a field, hospital medicine, with its focus on QI work and patient safety, is now in the midst of trying to become “great.”

Q: How many Apple products (phones, iPods, tablets, iTunes, etc.) do you interface with in a given week?

A: As many as possible. My wife and I own two iPhones, two iPads, and a MacBook Air, which she thinks we share but, in actuality, is mine. We are hoping to purchase a Mac desktop, and then we will have fully given over to the dark side.

Richard Quinn is a freelance writer in New Jersey.

Lean thinking teaches you that change and improvement do not come down from leadership, but rather develop up from front-line workers. Group leaders need to continue seeing patients to truly understand the processes and problems inherent in clinical work.

It took a while for James J. O’Callaghan, MD, FAAP, FHM, to settle on a career path. First, he pursued the life of a chemical engineer. Then, in his third year at Rensselaer Polytechnic Institute in Troy, N.Y., he realized the kind of job he would be getting into was not quite for him. His then-girlfriend was a pre-med student, and it wasn’t long until he switched majors.

Hospital medicine drew his interest during residency, when he spent a monthlong rotation with a small group of physicians at a community hospital in Cleveland.

“Their days consisted of rounding on pediatric inpatients, examining normal newborns, completing pediatric consults in the ED, and performing minor procedures on the floor,” he says. “To me, it seemed the perfect job.”

Dr. O’Callaghan married an adult-medicine hospitalist and moved to Seattle, but he could not find a good fit in a hospitalist practice. He did private practice for two years, and in 2004, he landed a position in pediatric hospital medicine.

“I quickly changed career paths,” he says.

Dr. O’Callaghan is now a regional pediatric hospitalist at Evergreen Hospital in Kirkland, Wash., and a medical hospitalist at Seattle Children’s Hospital. He is a clinical assistant professor at the University of Washington and one of nine new Team Hospitalist members, The Hospitalist’s volunteer editorial advisory group.

As the section head for pediatrics at Evergreen, Dr. O’Callaghan spends most of his time seeing patients. However, he has in recent years developed a keen interest in quality improvement (QI). He’s the lead pediatric hospitalist on two clinical pathways at Seattle Children’s and has been an active member of SHM’s Hospital Quality and Patient Safety Committee since 2012.

“I want to continue to expand on this QI work,” he says, “with the goal of developing into a formal QI role at either, or both, hospitals.”

Question: What do you like most about working as a hospitalist?

Answer: I like the fact that the work I am doing as a hospitalist can have both an immediate impact on a single patient and a prolonged impact on multiple patients. I can admit a child with community-acquired pneumonia and, through my treatment, prevent serious sequelae from developing. However, I can also develop an evidenced-based, community-acquired pneumonia pathway and, potentially, affect the care of hundreds of children. There is immediate gratification in treating today’s patient and delayed gratification knowing that you are helping many of tomorrow’s patients.

Q: What do you dislike?

A: One of the hardest parts of a career in HM is trying to effect culture change. Hospital systems are typically large, complex organizations with their own culture. In order to successfully produce sustainable, long-term improvement, you must change this culture. You can perform a robust search of the literature to produce a brilliant clinical-care path, but unless you can affect behavior, your work and effort may not last. It can be frustrating to think you have the answer to a clinical problem only to see your effort fail because you could not change culture.

Q: What’s the biggest change you’ve seen in HM in your career?

A: In the early years, much of the conversation in HM was centered on the viability of a career in HM. Could one make a sustainable career in HM? Would hospitals and health systems continue to support physicians in HM? The biggest change I have seen is that we are no longer having those conversations. Now, the conversations are focused on determining which areas of medicine will be owned by HM: First it was QI work, then patient safety, and now resource utilization and cost containment. We are no longer spending time and energy worrying about the future of HM, but rather now our efforts are focused on the present work of HM. As a sustainable career, HM is here to stay.

Q: For group leaders, why is it important for you to continue seeing patients?

A: In my QI work, I have studied Lean thinking and methodology. Lean thinking teaches you that change and improvement do not come down from leadership, but rather develop up from front-line workers. Group leaders need to continue seeing patients to truly understand the processes and problems inherent in clinical work. Effective solutions must come from those actually doing the work, rather than from those managing the work from above.

Q: What does it mean to you to be elected a Fellow in Hospital Medicine?

A: It meant that I had committed fully to a career in hospital medicine. I use the FHM designation proudly in all my communications, as a signal to others of my commitment and dedication to hospital medicine. Someday, I hope to earn the designation of SFHM, as a validation and recognition of my contributions to the field of pediatric hospital medicine.

Q: When you aren’t working, what is important to you?

A: After family, it is important for me to maintain a healthy lifestyle and stay in shape. I am able to commute to Seattle Children’s Hospital by bicycle and I try to run two to three times a week. I squeeze in half-marathons and marathons, along with century [100 miles] and double-century bicycle rides each year.

Q: If you weren’t a doctor, what would you be doing right now?

A: I would love to be a stay-at-home father for my boys and also devote the time and energy into pursuing a career in trail running.

Q: What’s the best book you’ve read recently?

A: I recently read Jim Collins’ “Good to Great” as part of a management training course at Seattle Children’s Hospital. This easy-to-read, highly entertaining book clearly demonstrates the culture changes that need to occur for companies to move from good to great. As a field, hospital medicine, with its focus on QI work and patient safety, is now in the midst of trying to become “great.”

Q: How many Apple products (phones, iPods, tablets, iTunes, etc.) do you interface with in a given week?

A: As many as possible. My wife and I own two iPhones, two iPads, and a MacBook Air, which she thinks we share but, in actuality, is mine. We are hoping to purchase a Mac desktop, and then we will have fully given over to the dark side.

Richard Quinn is a freelance writer in New Jersey.

Lean thinking teaches you that change and improvement do not come down from leadership, but rather develop up from front-line workers. Group leaders need to continue seeing patients to truly understand the processes and problems inherent in clinical work.

It took a while for James J. O’Callaghan, MD, FAAP, FHM, to settle on a career path. First, he pursued the life of a chemical engineer. Then, in his third year at Rensselaer Polytechnic Institute in Troy, N.Y., he realized the kind of job he would be getting into was not quite for him. His then-girlfriend was a pre-med student, and it wasn’t long until he switched majors.

Hospital medicine drew his interest during residency, when he spent a monthlong rotation with a small group of physicians at a community hospital in Cleveland.

“Their days consisted of rounding on pediatric inpatients, examining normal newborns, completing pediatric consults in the ED, and performing minor procedures on the floor,” he says. “To me, it seemed the perfect job.”

Dr. O’Callaghan married an adult-medicine hospitalist and moved to Seattle, but he could not find a good fit in a hospitalist practice. He did private practice for two years, and in 2004, he landed a position in pediatric hospital medicine.

“I quickly changed career paths,” he says.

Dr. O’Callaghan is now a regional pediatric hospitalist at Evergreen Hospital in Kirkland, Wash., and a medical hospitalist at Seattle Children’s Hospital. He is a clinical assistant professor at the University of Washington and one of nine new Team Hospitalist members, The Hospitalist’s volunteer editorial advisory group.

As the section head for pediatrics at Evergreen, Dr. O’Callaghan spends most of his time seeing patients. However, he has in recent years developed a keen interest in quality improvement (QI). He’s the lead pediatric hospitalist on two clinical pathways at Seattle Children’s and has been an active member of SHM’s Hospital Quality and Patient Safety Committee since 2012.

“I want to continue to expand on this QI work,” he says, “with the goal of developing into a formal QI role at either, or both, hospitals.”

Question: What do you like most about working as a hospitalist?

Answer: I like the fact that the work I am doing as a hospitalist can have both an immediate impact on a single patient and a prolonged impact on multiple patients. I can admit a child with community-acquired pneumonia and, through my treatment, prevent serious sequelae from developing. However, I can also develop an evidenced-based, community-acquired pneumonia pathway and, potentially, affect the care of hundreds of children. There is immediate gratification in treating today’s patient and delayed gratification knowing that you are helping many of tomorrow’s patients.

Q: What do you dislike?

A: One of the hardest parts of a career in HM is trying to effect culture change. Hospital systems are typically large, complex organizations with their own culture. In order to successfully produce sustainable, long-term improvement, you must change this culture. You can perform a robust search of the literature to produce a brilliant clinical-care path, but unless you can affect behavior, your work and effort may not last. It can be frustrating to think you have the answer to a clinical problem only to see your effort fail because you could not change culture.

Q: What’s the biggest change you’ve seen in HM in your career?

A: In the early years, much of the conversation in HM was centered on the viability of a career in HM. Could one make a sustainable career in HM? Would hospitals and health systems continue to support physicians in HM? The biggest change I have seen is that we are no longer having those conversations. Now, the conversations are focused on determining which areas of medicine will be owned by HM: First it was QI work, then patient safety, and now resource utilization and cost containment. We are no longer spending time and energy worrying about the future of HM, but rather now our efforts are focused on the present work of HM. As a sustainable career, HM is here to stay.

Q: For group leaders, why is it important for you to continue seeing patients?

A: In my QI work, I have studied Lean thinking and methodology. Lean thinking teaches you that change and improvement do not come down from leadership, but rather develop up from front-line workers. Group leaders need to continue seeing patients to truly understand the processes and problems inherent in clinical work. Effective solutions must come from those actually doing the work, rather than from those managing the work from above.

Q: What does it mean to you to be elected a Fellow in Hospital Medicine?

A: It meant that I had committed fully to a career in hospital medicine. I use the FHM designation proudly in all my communications, as a signal to others of my commitment and dedication to hospital medicine. Someday, I hope to earn the designation of SFHM, as a validation and recognition of my contributions to the field of pediatric hospital medicine.

Q: When you aren’t working, what is important to you?

A: After family, it is important for me to maintain a healthy lifestyle and stay in shape. I am able to commute to Seattle Children’s Hospital by bicycle and I try to run two to three times a week. I squeeze in half-marathons and marathons, along with century [100 miles] and double-century bicycle rides each year.

Q: If you weren’t a doctor, what would you be doing right now?

A: I would love to be a stay-at-home father for my boys and also devote the time and energy into pursuing a career in trail running.

Q: What’s the best book you’ve read recently?

A: I recently read Jim Collins’ “Good to Great” as part of a management training course at Seattle Children’s Hospital. This easy-to-read, highly entertaining book clearly demonstrates the culture changes that need to occur for companies to move from good to great. As a field, hospital medicine, with its focus on QI work and patient safety, is now in the midst of trying to become “great.”

Q: How many Apple products (phones, iPods, tablets, iTunes, etc.) do you interface with in a given week?

A: As many as possible. My wife and I own two iPhones, two iPads, and a MacBook Air, which she thinks we share but, in actuality, is mine. We are hoping to purchase a Mac desktop, and then we will have fully given over to the dark side.

Richard Quinn is a freelance writer in New Jersey.