If you have never heard of the Recovery Audit Contractor (RAC) program, it’s only a matter of time. A little bit of history is in order here. Between 2005 and 2008, a demonstration program that used Recovery Auditors identified Medicare overpayments, as well as underpayments, to both providers and suppliers of health care in random states. The result was that a whopping $900 million in overpayments was returned to the Medicare Trust Fund, while close to $38 million in underpayments was given to health care providers.

Obviously, this program was a tremendous success for the Centers for Medicare and Medicaid Services (CMS), and it has since taken off in all 50 states. And, you guessed it, it remains a great boon for the Medicare Trust Fund.

In fiscal year 2010, $75.4 million in overpayments was collected, and $16.9 million returned, and in fiscal year 2013, $2.2 billion in overpayments was collected, while $370 million was returned. Since the program’s inception, there has been $5.7 billion in total corrections, of which, $5.4 billion was collected from overpayments.

Surprised? I think most of us, and our hospitals, could benefit by hospitalists learning more about the RAC and what we could do to guard against a successful audit and penalty. The Program for Evaluating Payment Patterns Electronic Report (PEPPER) provides provider-specific Medicare data stats for discharges and services that are vulnerable. Pepperresources.org was developed by TMF Health Quality Institute, which was contracted by the CMS.

PEPPER has many uses, but one of the most useful for hospitals is to compare its claims data over time to identify concerning trends, such as significant changes in billing practices, increasing length of stay, and over- or undercoding. In 2013, practicing good medicine just isn’t enough. You have to make sure you are documenting appropriately to justify the codes you bill. Outliers beware!

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS.

If you have never heard of the Recovery Audit Contractor (RAC) program, it’s only a matter of time. A little bit of history is in order here. Between 2005 and 2008, a demonstration program that used Recovery Auditors identified Medicare overpayments, as well as underpayments, to both providers and suppliers of health care in random states. The result was that a whopping $900 million in overpayments was returned to the Medicare Trust Fund, while close to $38 million in underpayments was given to health care providers.

Obviously, this program was a tremendous success for the Centers for Medicare and Medicaid Services (CMS), and it has since taken off in all 50 states. And, you guessed it, it remains a great boon for the Medicare Trust Fund.

In fiscal year 2010, $75.4 million in overpayments was collected, and $16.9 million returned, and in fiscal year 2013, $2.2 billion in overpayments was collected, while $370 million was returned. Since the program’s inception, there has been $5.7 billion in total corrections, of which, $5.4 billion was collected from overpayments.

Surprised? I think most of us, and our hospitals, could benefit by hospitalists learning more about the RAC and what we could do to guard against a successful audit and penalty. The Program for Evaluating Payment Patterns Electronic Report (PEPPER) provides provider-specific Medicare data stats for discharges and services that are vulnerable. Pepperresources.org was developed by TMF Health Quality Institute, which was contracted by the CMS.

PEPPER has many uses, but one of the most useful for hospitals is to compare its claims data over time to identify concerning trends, such as significant changes in billing practices, increasing length of stay, and over- or undercoding. In 2013, practicing good medicine just isn’t enough. You have to make sure you are documenting appropriately to justify the codes you bill. Outliers beware!

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS.

If you have never heard of the Recovery Audit Contractor (RAC) program, it’s only a matter of time. A little bit of history is in order here. Between 2005 and 2008, a demonstration program that used Recovery Auditors identified Medicare overpayments, as well as underpayments, to both providers and suppliers of health care in random states. The result was that a whopping $900 million in overpayments was returned to the Medicare Trust Fund, while close to $38 million in underpayments was given to health care providers.

Obviously, this program was a tremendous success for the Centers for Medicare and Medicaid Services (CMS), and it has since taken off in all 50 states. And, you guessed it, it remains a great boon for the Medicare Trust Fund.

In fiscal year 2010, $75.4 million in overpayments was collected, and $16.9 million returned, and in fiscal year 2013, $2.2 billion in overpayments was collected, while $370 million was returned. Since the program’s inception, there has been $5.7 billion in total corrections, of which, $5.4 billion was collected from overpayments.

Surprised? I think most of us, and our hospitals, could benefit by hospitalists learning more about the RAC and what we could do to guard against a successful audit and penalty. The Program for Evaluating Payment Patterns Electronic Report (PEPPER) provides provider-specific Medicare data stats for discharges and services that are vulnerable. Pepperresources.org was developed by TMF Health Quality Institute, which was contracted by the CMS.

PEPPER has many uses, but one of the most useful for hospitals is to compare its claims data over time to identify concerning trends, such as significant changes in billing practices, increasing length of stay, and over- or undercoding. In 2013, practicing good medicine just isn’t enough. You have to make sure you are documenting appropriately to justify the codes you bill. Outliers beware!

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS.

ATLANTA – Sparing the hippocampus during whole brain irradiation can pay off in memory preservation for months to come, according to Dr. Vinai Gondi.

Adults with brain metastases who underwent whole brain radiation therapy (WBRT) with a conformal technique designed to minimize radiation dose to the hippocampus had a significantly smaller mean decline in verbal memory 4 months after treatment than did historical controls, reported Dr. Gondi, codirector of the Cadence Health Brain Tumor Center in Chicago and a coprincipal investigator in the Radiation Therapy Oncology Group Trial 0933.

Neil Osterweil/IMNG Medical Media

"These phase II results are promising, and highlight the importance of the hippocampus as a radiosensitive structure central to memory toxicity," Dr. Gondi said in a briefing prior to his presentation in a plenary session of the American Society for Radiation Oncology.

The hippocampus has been shown to play host to neural stem cells that are constantly differentiating into new neurons throughout adult life, a process important for maintaining memory function, he noted.

Previous studies have shown that cranial irradiation with WBRT is associated with a 4- to 6-month decline in memory function, as measured by the Hopkins Verbal Learning Test (HVLT) total recall and delayed recall items.

By using intensity modulated radiation therapy (IMRT) to shape the beam and largely spare the pocket of neural stem cells in the dentate gyrus portion of the hippocampus, the investigators hoped to avoid the decrements in memory function seen with earlier, less discriminating WBRT techniques, he said.

They enrolled 113 adults with brain metastases from various primary malignancies and assigned them to receive hippocampal-avoiding WBRT of 30 Gy delivered in 10 fractions. Radiation oncologists participating in the trial were trained in the technique, which involves careful identification of hippocampal landmarks and titration of the dose to minimize exposure of the hippocampus in general, and the dentate gyrus in particular. Under the protocol, the total radiation dose to the entire volume of the hippocampus can be no more than 10 Gy, and no single point in the hippocampus can receive more than 17 Gy.

Controls were patients in an earlier phase III clinical trial who underwent WBRT without hippocampal avoidance.

At 4 months, 100 patients treated with the hippocampal-sparing technique who were available for analysis had a 7% decline in the primary endpoint – delayed recall scores from baseline – compared with 30% for historical controls (P = .0003).

Among the 29 patients for whom 6-month data were available, the mean relative decline from baseline in delayed recall was 2% and in immediate recall was 0.7%. In contrast, there was a 3% increase in total recall scores.

The risk of metastasis to the hippocampus was 4.5% during follow-up, Dr. Gondi said.

The Radiation Oncology Therapy Group is currently developing a phase III trial of prophylactic cranial radiation with or without hippocampal avoidance for patients with small cell lung cancer.

The study demonstrates the value of improving and incorporating into practice newer radiation delivery technologies such as IMRT, said Dr. Bruce G. Haffty, a radiation oncologist at the Cancer Institute of New Jersey in New Brunswick, and ASTRO president-elect.

"It’s nice to have that technology available, and it’s now nice to see that we can use that technology to [reduce] memory loss and improve quality of life for our patients undergoing whole brain radiation therapy," he said.

Dr. Haffty moderated the briefing, but was not involved in the study.

RTOG 0993 was supported by the National Cancer Institute. Dr. Gondi and Dr. Haffty reported having no relevant financial conflicts.

ATLANTA – Sparing the hippocampus during whole brain irradiation can pay off in memory preservation for months to come, according to Dr. Vinai Gondi.

Adults with brain metastases who underwent whole brain radiation therapy (WBRT) with a conformal technique designed to minimize radiation dose to the hippocampus had a significantly smaller mean decline in verbal memory 4 months after treatment than did historical controls, reported Dr. Gondi, codirector of the Cadence Health Brain Tumor Center in Chicago and a coprincipal investigator in the Radiation Therapy Oncology Group Trial 0933.

Neil Osterweil/IMNG Medical Media

"These phase II results are promising, and highlight the importance of the hippocampus as a radiosensitive structure central to memory toxicity," Dr. Gondi said in a briefing prior to his presentation in a plenary session of the American Society for Radiation Oncology.

The hippocampus has been shown to play host to neural stem cells that are constantly differentiating into new neurons throughout adult life, a process important for maintaining memory function, he noted.

Previous studies have shown that cranial irradiation with WBRT is associated with a 4- to 6-month decline in memory function, as measured by the Hopkins Verbal Learning Test (HVLT) total recall and delayed recall items.

By using intensity modulated radiation therapy (IMRT) to shape the beam and largely spare the pocket of neural stem cells in the dentate gyrus portion of the hippocampus, the investigators hoped to avoid the decrements in memory function seen with earlier, less discriminating WBRT techniques, he said.

They enrolled 113 adults with brain metastases from various primary malignancies and assigned them to receive hippocampal-avoiding WBRT of 30 Gy delivered in 10 fractions. Radiation oncologists participating in the trial were trained in the technique, which involves careful identification of hippocampal landmarks and titration of the dose to minimize exposure of the hippocampus in general, and the dentate gyrus in particular. Under the protocol, the total radiation dose to the entire volume of the hippocampus can be no more than 10 Gy, and no single point in the hippocampus can receive more than 17 Gy.

Controls were patients in an earlier phase III clinical trial who underwent WBRT without hippocampal avoidance.

At 4 months, 100 patients treated with the hippocampal-sparing technique who were available for analysis had a 7% decline in the primary endpoint – delayed recall scores from baseline – compared with 30% for historical controls (P = .0003).

Among the 29 patients for whom 6-month data were available, the mean relative decline from baseline in delayed recall was 2% and in immediate recall was 0.7%. In contrast, there was a 3% increase in total recall scores.

The risk of metastasis to the hippocampus was 4.5% during follow-up, Dr. Gondi said.

The Radiation Oncology Therapy Group is currently developing a phase III trial of prophylactic cranial radiation with or without hippocampal avoidance for patients with small cell lung cancer.

The study demonstrates the value of improving and incorporating into practice newer radiation delivery technologies such as IMRT, said Dr. Bruce G. Haffty, a radiation oncologist at the Cancer Institute of New Jersey in New Brunswick, and ASTRO president-elect.

"It’s nice to have that technology available, and it’s now nice to see that we can use that technology to [reduce] memory loss and improve quality of life for our patients undergoing whole brain radiation therapy," he said.

Dr. Haffty moderated the briefing, but was not involved in the study.

RTOG 0993 was supported by the National Cancer Institute. Dr. Gondi and Dr. Haffty reported having no relevant financial conflicts.

ATLANTA – Sparing the hippocampus during whole brain irradiation can pay off in memory preservation for months to come, according to Dr. Vinai Gondi.

Adults with brain metastases who underwent whole brain radiation therapy (WBRT) with a conformal technique designed to minimize radiation dose to the hippocampus had a significantly smaller mean decline in verbal memory 4 months after treatment than did historical controls, reported Dr. Gondi, codirector of the Cadence Health Brain Tumor Center in Chicago and a coprincipal investigator in the Radiation Therapy Oncology Group Trial 0933.

Neil Osterweil/IMNG Medical Media

"These phase II results are promising, and highlight the importance of the hippocampus as a radiosensitive structure central to memory toxicity," Dr. Gondi said in a briefing prior to his presentation in a plenary session of the American Society for Radiation Oncology.

The hippocampus has been shown to play host to neural stem cells that are constantly differentiating into new neurons throughout adult life, a process important for maintaining memory function, he noted.

Previous studies have shown that cranial irradiation with WBRT is associated with a 4- to 6-month decline in memory function, as measured by the Hopkins Verbal Learning Test (HVLT) total recall and delayed recall items.

By using intensity modulated radiation therapy (IMRT) to shape the beam and largely spare the pocket of neural stem cells in the dentate gyrus portion of the hippocampus, the investigators hoped to avoid the decrements in memory function seen with earlier, less discriminating WBRT techniques, he said.

They enrolled 113 adults with brain metastases from various primary malignancies and assigned them to receive hippocampal-avoiding WBRT of 30 Gy delivered in 10 fractions. Radiation oncologists participating in the trial were trained in the technique, which involves careful identification of hippocampal landmarks and titration of the dose to minimize exposure of the hippocampus in general, and the dentate gyrus in particular. Under the protocol, the total radiation dose to the entire volume of the hippocampus can be no more than 10 Gy, and no single point in the hippocampus can receive more than 17 Gy.

Controls were patients in an earlier phase III clinical trial who underwent WBRT without hippocampal avoidance.

At 4 months, 100 patients treated with the hippocampal-sparing technique who were available for analysis had a 7% decline in the primary endpoint – delayed recall scores from baseline – compared with 30% for historical controls (P = .0003).

Among the 29 patients for whom 6-month data were available, the mean relative decline from baseline in delayed recall was 2% and in immediate recall was 0.7%. In contrast, there was a 3% increase in total recall scores.

The risk of metastasis to the hippocampus was 4.5% during follow-up, Dr. Gondi said.

The Radiation Oncology Therapy Group is currently developing a phase III trial of prophylactic cranial radiation with or without hippocampal avoidance for patients with small cell lung cancer.

The study demonstrates the value of improving and incorporating into practice newer radiation delivery technologies such as IMRT, said Dr. Bruce G. Haffty, a radiation oncologist at the Cancer Institute of New Jersey in New Brunswick, and ASTRO president-elect.

"It’s nice to have that technology available, and it’s now nice to see that we can use that technology to [reduce] memory loss and improve quality of life for our patients undergoing whole brain radiation therapy," he said.

Dr. Haffty moderated the briefing, but was not involved in the study.

RTOG 0993 was supported by the National Cancer Institute. Dr. Gondi and Dr. Haffty reported having no relevant financial conflicts.

Wait-and-See Approach Best for Newly Approved Meds

I am a new hospitalist, out of residency for two years, and feel very uncertain about using new or recently approved medications on my patients. Do you have any suggestions about how or when new medications should be used in practice?

–David Ray, MD

Dr. Hospitalist responds:

I certainly can understand your trepidation about using newly approved medications. Although our system of evaluating and approving medications for clinical use is considered the most rigorous in the world, 16 so-called novel medications were pulled from the shelves from 2000 to 2010, which equates to 6% of the total approved during that period. All in all, not a bad ratio, but the number of poor outcomes associated with a high-profile dud can be astronomical.

I think there are several major reasons why we have adverse issues with medications that have survived the rigors of the initial FDA approval process. First, many human drug trials are conducted in developing countries, where the human genome is much more homogenous and the liabilities for injuries are way less than in the U.S. Many researchers have acknowledged the significant role of pharmacogenomics, and how each physiology and pathology is unique. Couple these with the tendency to test drugs one at a time in younger cohorts—very few medications are administered in this manner in the U.S.—and one can quickly see how complex the equation becomes.

Another reason is the influence relegated to clinical trials. All clinicians should be familiar with the stages (0 to 4) and processes of how the FDA analyzes human drug trials. The FDA usually requires that two “adequate and well-controlled” trials confirm that a drug is safe and effective before it approves it for sale to the public. Once a drug completes Stage 3, an extensive statistical analysis is conducted to assure a drug’s demonstrated benefit is real and not the result of chance. But as it turns out, because the measured effects in most clinical trials are so small, chance is very hard to prove or disprove.

This was astutely demonstrated in a 2005 article published in the Journal of the American Medical Association (2005;294(2):218-228). John P. Ioannidis, MD, examined the results of 49 high-profile clinical-research studies in which 45 found that proposed intervention was effective. Of the 45 claiming effectiveness, seven (16%) were contradicted by subsequent studies, and seven others had found effects that were stronger than those of subsequent studies. Of the 26 randomly controlled trials that were followed up by larger trials, the initial finding was entirely contradicted in three cases (12%); another six cases (23%) found the benefit to be less than half of what had been initially reported.

In most instances, it wasn’t the therapy that changed but the sample size. In fact, many clinicians and biostatisticians believe many more so-called “evidence-based” practices or medicinals would be legitimately challenged if subjected to rigorous follow-up studies.

In my own personal experience as a hospitalist, I can think of two areas where the general medical community accepted initial studies only to refute them later: perioperative use of beta-blockers and inpatient glycemic control.

In light of the many high-profile medications that have been pulled from the market, I don’t like being in the first group to jump on the bandwagon. My general rule is to wait three to five years after a drug has been released before prescribing for patients. As always, there are exceptions. In instances where new medications have profound or life-altering potential (i.e. the new anticoagulants or gene-targeting meds for certain cancers) and the risks are substantiated, I’m all in!

Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to [email protected].

Wait-and-See Approach Best for Newly Approved Meds

I am a new hospitalist, out of residency for two years, and feel very uncertain about using new or recently approved medications on my patients. Do you have any suggestions about how or when new medications should be used in practice?

–David Ray, MD

Dr. Hospitalist responds:

I certainly can understand your trepidation about using newly approved medications. Although our system of evaluating and approving medications for clinical use is considered the most rigorous in the world, 16 so-called novel medications were pulled from the shelves from 2000 to 2010, which equates to 6% of the total approved during that period. All in all, not a bad ratio, but the number of poor outcomes associated with a high-profile dud can be astronomical.

I think there are several major reasons why we have adverse issues with medications that have survived the rigors of the initial FDA approval process. First, many human drug trials are conducted in developing countries, where the human genome is much more homogenous and the liabilities for injuries are way less than in the U.S. Many researchers have acknowledged the significant role of pharmacogenomics, and how each physiology and pathology is unique. Couple these with the tendency to test drugs one at a time in younger cohorts—very few medications are administered in this manner in the U.S.—and one can quickly see how complex the equation becomes.

Another reason is the influence relegated to clinical trials. All clinicians should be familiar with the stages (0 to 4) and processes of how the FDA analyzes human drug trials. The FDA usually requires that two “adequate and well-controlled” trials confirm that a drug is safe and effective before it approves it for sale to the public. Once a drug completes Stage 3, an extensive statistical analysis is conducted to assure a drug’s demonstrated benefit is real and not the result of chance. But as it turns out, because the measured effects in most clinical trials are so small, chance is very hard to prove or disprove.

This was astutely demonstrated in a 2005 article published in the Journal of the American Medical Association (2005;294(2):218-228). John P. Ioannidis, MD, examined the results of 49 high-profile clinical-research studies in which 45 found that proposed intervention was effective. Of the 45 claiming effectiveness, seven (16%) were contradicted by subsequent studies, and seven others had found effects that were stronger than those of subsequent studies. Of the 26 randomly controlled trials that were followed up by larger trials, the initial finding was entirely contradicted in three cases (12%); another six cases (23%) found the benefit to be less than half of what had been initially reported.

In most instances, it wasn’t the therapy that changed but the sample size. In fact, many clinicians and biostatisticians believe many more so-called “evidence-based” practices or medicinals would be legitimately challenged if subjected to rigorous follow-up studies.

In my own personal experience as a hospitalist, I can think of two areas where the general medical community accepted initial studies only to refute them later: perioperative use of beta-blockers and inpatient glycemic control.

In light of the many high-profile medications that have been pulled from the market, I don’t like being in the first group to jump on the bandwagon. My general rule is to wait three to five years after a drug has been released before prescribing for patients. As always, there are exceptions. In instances where new medications have profound or life-altering potential (i.e. the new anticoagulants or gene-targeting meds for certain cancers) and the risks are substantiated, I’m all in!

Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to [email protected].

Wait-and-See Approach Best for Newly Approved Meds

I am a new hospitalist, out of residency for two years, and feel very uncertain about using new or recently approved medications on my patients. Do you have any suggestions about how or when new medications should be used in practice?

–David Ray, MD

Dr. Hospitalist responds:

I certainly can understand your trepidation about using newly approved medications. Although our system of evaluating and approving medications for clinical use is considered the most rigorous in the world, 16 so-called novel medications were pulled from the shelves from 2000 to 2010, which equates to 6% of the total approved during that period. All in all, not a bad ratio, but the number of poor outcomes associated with a high-profile dud can be astronomical.

I think there are several major reasons why we have adverse issues with medications that have survived the rigors of the initial FDA approval process. First, many human drug trials are conducted in developing countries, where the human genome is much more homogenous and the liabilities for injuries are way less than in the U.S. Many researchers have acknowledged the significant role of pharmacogenomics, and how each physiology and pathology is unique. Couple these with the tendency to test drugs one at a time in younger cohorts—very few medications are administered in this manner in the U.S.—and one can quickly see how complex the equation becomes.

Another reason is the influence relegated to clinical trials. All clinicians should be familiar with the stages (0 to 4) and processes of how the FDA analyzes human drug trials. The FDA usually requires that two “adequate and well-controlled” trials confirm that a drug is safe and effective before it approves it for sale to the public. Once a drug completes Stage 3, an extensive statistical analysis is conducted to assure a drug’s demonstrated benefit is real and not the result of chance. But as it turns out, because the measured effects in most clinical trials are so small, chance is very hard to prove or disprove.

This was astutely demonstrated in a 2005 article published in the Journal of the American Medical Association (2005;294(2):218-228). John P. Ioannidis, MD, examined the results of 49 high-profile clinical-research studies in which 45 found that proposed intervention was effective. Of the 45 claiming effectiveness, seven (16%) were contradicted by subsequent studies, and seven others had found effects that were stronger than those of subsequent studies. Of the 26 randomly controlled trials that were followed up by larger trials, the initial finding was entirely contradicted in three cases (12%); another six cases (23%) found the benefit to be less than half of what had been initially reported.

In most instances, it wasn’t the therapy that changed but the sample size. In fact, many clinicians and biostatisticians believe many more so-called “evidence-based” practices or medicinals would be legitimately challenged if subjected to rigorous follow-up studies.

In my own personal experience as a hospitalist, I can think of two areas where the general medical community accepted initial studies only to refute them later: perioperative use of beta-blockers and inpatient glycemic control.

In light of the many high-profile medications that have been pulled from the market, I don’t like being in the first group to jump on the bandwagon. My general rule is to wait three to five years after a drug has been released before prescribing for patients. As always, there are exceptions. In instances where new medications have profound or life-altering potential (i.e. the new anticoagulants or gene-targeting meds for certain cancers) and the risks are substantiated, I’m all in!

Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to [email protected].

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 [email protected].

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 [email protected].

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 [email protected].

We all are too familiar with the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, a standardized set of questions randomly deployed to recently discharged patients. More recently, hospitalists have noticed the introduction of the Clinician and Groups Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) survey, randomly deployed to recently evaluated ambulatory patients. HCAHPS has been publicly reported since 2008. CG-CAHPS will be in the near future. In addition to these, there are a variety of other types of CAHPS surveys, ranging from ambulatory surgery to patient-centered medical homes. For HCAHPS alone, there are more than 8,200 adult surveys completed every day from almost 4,000 different U.S. hospitals.¹

In addition to these surveys being publicly reported and widely viewed online by patients, payors, and employers, the results now are tightly coupled to the reimbursement of hospitals and, in some cases, individual providers. As of October 2012, Medicare has relegated 30% of its hospital value-based purchasing (VBP) program to the results of hospitals’ HCAPHS survey results. For the foreseeable future, about one-third of the financial bonus—or penalty—of a hospital rests in the hands of how well our patients perceive their care. Many individual hospitals and practice groups have started coupling individual physicians’ compensation to their patients’ CAHPS scores. Within the (approximately) seven minutes it takes to complete the survey, our patients determine millions of dollars of physician and hospital reimbursement.¹

With all of the financial and reputational emphasis on HCAHPS, it is vital that hospitalists understand what it is these surveys are actually measuring, and if they have any correlation with the quality of the care the patient receives. The questions currently address 11 different domains of hospital care:

• Communication with doctors;
• Communication with nurses;
• Responsiveness of hospital staff;
• Pain management;
• Communication about medicines;
• Discharge information;
• Cleanliness of hospital environment;
• Quietness of hospital environment;
• Transitions of care;
• Overall rating of the hospital; and
• Willingness to recommend the hospital.

As the domains of care are all very different, one can imagine a wide range of answers to the various questions; a patient can perceive that communication was excellent but the quietness and cleanliness was disgraceful. And, depending on what they consider the most important aspects of their stay, they therefore may rate their overall stay as excellent or disgraceful. Why? Because each of these rest in the eye of the beholder.

But to keep pace, hospitals and providers across the country have invested millions of hours dissecting the meaning of the results and trying to improve upon them. My hospital has struggled for years with the “cleanliness” question, trying to figure out what our patients are trying to tell us: that we need to sweep and mop more often, that hospital supplies are cluttering our patient rooms, that the trashcans are overflowing or within eyesight? When we ask focus groups, we often get all of the above—and then try to implement several solutions all at once.

The quietness question is much easier to interpret but certainly difficult to improve upon. We have implemented “yacker trackers,” “quiet time,” and soft-wheeled trash cans. And the results of the surveys take months to come back and get analyzed, so it is difficult to quickly know if your interventions are actually working. Given that so many hospitals and providers are back-flipping to “play to the test,” we really need some validation that care is truly improving based on this patient feedback.

A recent New York Times article calls to light a natural paradox in the medical field, in that patients who understand more about disease processes and medical information actually feel less, rather than more, informed. In other words, those who are actually the most well-informed may rate communication the lowest. The article also calls to light the natural paradox between providers being honest and providers being likable, especially considering they routinely have to deliver messages that patients do not want to hear:

• You need to quit smoking;
• Your weight is affecting your health; and
• Your disease is not curable.

Given these natural paradoxes, the article argues that it is difficult to reconcile why hospitals and providers should be held financially accountable for their patients’ perception of care, when that perception may not equate to “real” care quality.²

However, there is some evidence that patient satisfaction surveys may actually be good proxies for care quality. A large study found that hospitals with the highest quartile HCAHPS ratings also have about 2%-3% higher quality scores for acute MI, CHF, pneumonia, and surgery, compared to those in the lowest quartile. The highest scoring hospitals also have about 2%-3% lower readmission rates for acute MI, CHF, and pneumonia.^3,4 And, similar to other quality metrics, there is evidence that the longer a hospital has been administering HCAHPS, the better are their scores. So maybe hospital systems and providers can improve not only the perception a patient has of the quality of the care they received, but improve the quality, as measured by the patient’s perception.

Although there are legitimate arguments on both sides as to whether a patient’s perception of care reflects “real” care quality, in the end these CAHPS surveys are, and have been publicly reported, and will be tightly coupled to reimbursement for hospitals and (likely) providers for the foreseeable future. So in the meantime, we should continue to focus on patient-centered care, take seriously any voiced concerns, and have a relentless pursuit of perfection for how patients perceive their care. Because in the end, you would do it for your family so we should do it for our patients.

References

1. Centers for Medicare & Medicaid Services. Spring 2013 HCAHPS Executive Insight Letter. Available at: www.hcahpsonline.org/Executive_Insight. Accessed Aug. 15, 2013.
2. Rosenbaum L. When doctors tell patients what they don’t want to hear. The New Yorker website. Available at: www.newyorker.com/online/blogs/elements/2013/07/when-doctors-tell-patients-what-they-dont-want-to-hear.html. Published July 23, 2013. Accessed Aug. 15, 2013.
3. Jha AK, Orav EJ, Zheng J, Epstein AM. Patients' perception of hospital care in the US. New Eng J Med. 2008;359(18):1921-1931.
4. Boulding W, Glickman SW, Manary MP, Schulman KA, Staelin R. Relationship between patient satisfaction with inpatient care and hospital readmission within 30 days. Am J Manag Care. 2011;17(1):41-48.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at [email protected].

We all are too familiar with the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, a standardized set of questions randomly deployed to recently discharged patients. More recently, hospitalists have noticed the introduction of the Clinician and Groups Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) survey, randomly deployed to recently evaluated ambulatory patients. HCAHPS has been publicly reported since 2008. CG-CAHPS will be in the near future. In addition to these, there are a variety of other types of CAHPS surveys, ranging from ambulatory surgery to patient-centered medical homes. For HCAHPS alone, there are more than 8,200 adult surveys completed every day from almost 4,000 different U.S. hospitals.¹

In addition to these surveys being publicly reported and widely viewed online by patients, payors, and employers, the results now are tightly coupled to the reimbursement of hospitals and, in some cases, individual providers. As of October 2012, Medicare has relegated 30% of its hospital value-based purchasing (VBP) program to the results of hospitals’ HCAPHS survey results. For the foreseeable future, about one-third of the financial bonus—or penalty—of a hospital rests in the hands of how well our patients perceive their care. Many individual hospitals and practice groups have started coupling individual physicians’ compensation to their patients’ CAHPS scores. Within the (approximately) seven minutes it takes to complete the survey, our patients determine millions of dollars of physician and hospital reimbursement.¹

With all of the financial and reputational emphasis on HCAHPS, it is vital that hospitalists understand what it is these surveys are actually measuring, and if they have any correlation with the quality of the care the patient receives. The questions currently address 11 different domains of hospital care:

• Communication with doctors;
• Communication with nurses;
• Responsiveness of hospital staff;
• Pain management;
• Communication about medicines;
• Discharge information;
• Cleanliness of hospital environment;
• Quietness of hospital environment;
• Transitions of care;
• Overall rating of the hospital; and
• Willingness to recommend the hospital.

As the domains of care are all very different, one can imagine a wide range of answers to the various questions; a patient can perceive that communication was excellent but the quietness and cleanliness was disgraceful. And, depending on what they consider the most important aspects of their stay, they therefore may rate their overall stay as excellent or disgraceful. Why? Because each of these rest in the eye of the beholder.

But to keep pace, hospitals and providers across the country have invested millions of hours dissecting the meaning of the results and trying to improve upon them. My hospital has struggled for years with the “cleanliness” question, trying to figure out what our patients are trying to tell us: that we need to sweep and mop more often, that hospital supplies are cluttering our patient rooms, that the trashcans are overflowing or within eyesight? When we ask focus groups, we often get all of the above—and then try to implement several solutions all at once.

The quietness question is much easier to interpret but certainly difficult to improve upon. We have implemented “yacker trackers,” “quiet time,” and soft-wheeled trash cans. And the results of the surveys take months to come back and get analyzed, so it is difficult to quickly know if your interventions are actually working. Given that so many hospitals and providers are back-flipping to “play to the test,” we really need some validation that care is truly improving based on this patient feedback.

A recent New York Times article calls to light a natural paradox in the medical field, in that patients who understand more about disease processes and medical information actually feel less, rather than more, informed. In other words, those who are actually the most well-informed may rate communication the lowest. The article also calls to light the natural paradox between providers being honest and providers being likable, especially considering they routinely have to deliver messages that patients do not want to hear:

• You need to quit smoking;
• Your weight is affecting your health; and
• Your disease is not curable.

Given these natural paradoxes, the article argues that it is difficult to reconcile why hospitals and providers should be held financially accountable for their patients’ perception of care, when that perception may not equate to “real” care quality.²

However, there is some evidence that patient satisfaction surveys may actually be good proxies for care quality. A large study found that hospitals with the highest quartile HCAHPS ratings also have about 2%-3% higher quality scores for acute MI, CHF, pneumonia, and surgery, compared to those in the lowest quartile. The highest scoring hospitals also have about 2%-3% lower readmission rates for acute MI, CHF, and pneumonia.^3,4 And, similar to other quality metrics, there is evidence that the longer a hospital has been administering HCAHPS, the better are their scores. So maybe hospital systems and providers can improve not only the perception a patient has of the quality of the care they received, but improve the quality, as measured by the patient’s perception.

Although there are legitimate arguments on both sides as to whether a patient’s perception of care reflects “real” care quality, in the end these CAHPS surveys are, and have been publicly reported, and will be tightly coupled to reimbursement for hospitals and (likely) providers for the foreseeable future. So in the meantime, we should continue to focus on patient-centered care, take seriously any voiced concerns, and have a relentless pursuit of perfection for how patients perceive their care. Because in the end, you would do it for your family so we should do it for our patients.

References

1. Centers for Medicare & Medicaid Services. Spring 2013 HCAHPS Executive Insight Letter. Available at: www.hcahpsonline.org/Executive_Insight. Accessed Aug. 15, 2013.
2. Rosenbaum L. When doctors tell patients what they don’t want to hear. The New Yorker website. Available at: www.newyorker.com/online/blogs/elements/2013/07/when-doctors-tell-patients-what-they-dont-want-to-hear.html. Published July 23, 2013. Accessed Aug. 15, 2013.
3. Jha AK, Orav EJ, Zheng J, Epstein AM. Patients' perception of hospital care in the US. New Eng J Med. 2008;359(18):1921-1931.
4. Boulding W, Glickman SW, Manary MP, Schulman KA, Staelin R. Relationship between patient satisfaction with inpatient care and hospital readmission within 30 days. Am J Manag Care. 2011;17(1):41-48.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at [email protected].

We all are too familiar with the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, a standardized set of questions randomly deployed to recently discharged patients. More recently, hospitalists have noticed the introduction of the Clinician and Groups Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) survey, randomly deployed to recently evaluated ambulatory patients. HCAHPS has been publicly reported since 2008. CG-CAHPS will be in the near future. In addition to these, there are a variety of other types of CAHPS surveys, ranging from ambulatory surgery to patient-centered medical homes. For HCAHPS alone, there are more than 8,200 adult surveys completed every day from almost 4,000 different U.S. hospitals.¹

In addition to these surveys being publicly reported and widely viewed online by patients, payors, and employers, the results now are tightly coupled to the reimbursement of hospitals and, in some cases, individual providers. As of October 2012, Medicare has relegated 30% of its hospital value-based purchasing (VBP) program to the results of hospitals’ HCAPHS survey results. For the foreseeable future, about one-third of the financial bonus—or penalty—of a hospital rests in the hands of how well our patients perceive their care. Many individual hospitals and practice groups have started coupling individual physicians’ compensation to their patients’ CAHPS scores. Within the (approximately) seven minutes it takes to complete the survey, our patients determine millions of dollars of physician and hospital reimbursement.¹

With all of the financial and reputational emphasis on HCAHPS, it is vital that hospitalists understand what it is these surveys are actually measuring, and if they have any correlation with the quality of the care the patient receives. The questions currently address 11 different domains of hospital care:

• Communication with doctors;
• Communication with nurses;
• Responsiveness of hospital staff;
• Pain management;
• Communication about medicines;
• Discharge information;
• Cleanliness of hospital environment;
• Quietness of hospital environment;
• Transitions of care;
• Overall rating of the hospital; and
• Willingness to recommend the hospital.

As the domains of care are all very different, one can imagine a wide range of answers to the various questions; a patient can perceive that communication was excellent but the quietness and cleanliness was disgraceful. And, depending on what they consider the most important aspects of their stay, they therefore may rate their overall stay as excellent or disgraceful. Why? Because each of these rest in the eye of the beholder.

But to keep pace, hospitals and providers across the country have invested millions of hours dissecting the meaning of the results and trying to improve upon them. My hospital has struggled for years with the “cleanliness” question, trying to figure out what our patients are trying to tell us: that we need to sweep and mop more often, that hospital supplies are cluttering our patient rooms, that the trashcans are overflowing or within eyesight? When we ask focus groups, we often get all of the above—and then try to implement several solutions all at once.

The quietness question is much easier to interpret but certainly difficult to improve upon. We have implemented “yacker trackers,” “quiet time,” and soft-wheeled trash cans. And the results of the surveys take months to come back and get analyzed, so it is difficult to quickly know if your interventions are actually working. Given that so many hospitals and providers are back-flipping to “play to the test,” we really need some validation that care is truly improving based on this patient feedback.

A recent New York Times article calls to light a natural paradox in the medical field, in that patients who understand more about disease processes and medical information actually feel less, rather than more, informed. In other words, those who are actually the most well-informed may rate communication the lowest. The article also calls to light the natural paradox between providers being honest and providers being likable, especially considering they routinely have to deliver messages that patients do not want to hear:

• You need to quit smoking;
• Your weight is affecting your health; and
• Your disease is not curable.

Given these natural paradoxes, the article argues that it is difficult to reconcile why hospitals and providers should be held financially accountable for their patients’ perception of care, when that perception may not equate to “real” care quality.²

However, there is some evidence that patient satisfaction surveys may actually be good proxies for care quality. A large study found that hospitals with the highest quartile HCAHPS ratings also have about 2%-3% higher quality scores for acute MI, CHF, pneumonia, and surgery, compared to those in the lowest quartile. The highest scoring hospitals also have about 2%-3% lower readmission rates for acute MI, CHF, and pneumonia.^3,4 And, similar to other quality metrics, there is evidence that the longer a hospital has been administering HCAHPS, the better are their scores. So maybe hospital systems and providers can improve not only the perception a patient has of the quality of the care they received, but improve the quality, as measured by the patient’s perception.

Although there are legitimate arguments on both sides as to whether a patient’s perception of care reflects “real” care quality, in the end these CAHPS surveys are, and have been publicly reported, and will be tightly coupled to reimbursement for hospitals and (likely) providers for the foreseeable future. So in the meantime, we should continue to focus on patient-centered care, take seriously any voiced concerns, and have a relentless pursuit of perfection for how patients perceive their care. Because in the end, you would do it for your family so we should do it for our patients.

References

1. Centers for Medicare & Medicaid Services. Spring 2013 HCAHPS Executive Insight Letter. Available at: www.hcahpsonline.org/Executive_Insight. Accessed Aug. 15, 2013.
2. Rosenbaum L. When doctors tell patients what they don’t want to hear. The New Yorker website. Available at: www.newyorker.com/online/blogs/elements/2013/07/when-doctors-tell-patients-what-they-dont-want-to-hear.html. Published July 23, 2013. Accessed Aug. 15, 2013.
3. Jha AK, Orav EJ, Zheng J, Epstein AM. Patients' perception of hospital care in the US. New Eng J Med. 2008;359(18):1921-1931.
4. Boulding W, Glickman SW, Manary MP, Schulman KA, Staelin R. Relationship between patient satisfaction with inpatient care and hospital readmission within 30 days. Am J Manag Care. 2011;17(1):41-48.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at [email protected].

Wikipedia defines “industrial engineering” as a branch of engineering that deals with the optimization of complex processes or systems. It goes on to link industrial engineering to “operations” and use of quantitative methods to “specify, predict, and evaluate” results. Any hospitalist that’s been tapped to reduce length of stay, help manage readmissions, implement an electronic health record, or increase the quality of care likely can relate to that definition. It seems to me that hospitalists often are the de facto industrial engineers in many of our hospitals.

The hospitalist as an industrial engineer makes perfect sense. What other group of physicians, nurse practitioners, and physician assistants provide services in virtually any clinical venue, from ED to DC, from (occasionally) PACU to ICU, the wards, and even post-discharge? Hospitalists see it all, from the first few hours of life (pediatrics) to life’s last stages (palliative care) and all stages in between. As a parody to “there’s an app for that,” Dr. Mindy Kantsiper, a hospitalist in Columbia, Md., says if there’s something that needs to be fixed, “there’s a hospitalist for that.” We are the Swiss Army knives of the medical world.

Looking through the HMX “Practice Management” discussions on the SHM website (www.hospitalmedicine.com/xchange) confirms my belief. Topics are as varied as using RNs in hospitalist practices, medication reconciliation, billing, outpatient orders (!!) after discharge, and patient-centered care/patient satisfaction. And that was just the last two weeks!

Type “hospitalist” into PubMed, and the words that auto-populate are: model, care, quality, discharge, communication, program, and handoff—all words I think of as system-related issues. Oh, sure, there are clinical-related topics, too, of course, just like for the “organ-based” specialties. However, none of the common organ-based specialties had any words auto-populate in PubMed that could be deemed related to “industrial engineering.”

Engineer Training

Like all engineers, we de facto industrial engineers need tools and skills to be effective at in our new engineering role. While we may not need slide rules and calculus like a more traditional engineer, many of the new skills we will need as industrial engineers were not taught in medical school, and the tools were not readily available for us to use in our training.

Fortunately, there are a plethora of options for us budding, de facto industrial engineers. Here are the ones I believe you will need and where to get them:

Skill No. 1: Negotiation.

HM is a team sport, and teams bring interpersonal dynamics and tension and conflict. Effective negotiation skills can help hospitalists use conflict to spur team growth and development rather than team dysfunction.

Tools: SHM’s Leadership Academies have effective negotiation modules in each of the leveled courses. If you can’t spare the time, then books to read include “Getting to Yes” by Fisher and Ury, or “Renegotiating Health Care” by Leonard Marcus (he lectures at SHM’s leadership academies).

Skill No. 2: Data analytics.

All engineers, including industrial engineers, need to be able to evaluate. Whether it’s quality and safety, clinical operations, or financial improvement, if you don’t measure it, you can’t change it. Some of the data will be handed to you, and you need to know the strengths and weaknesses to best interpret it. Some data you will need to define and develop measurement systems for on your own, and even basic dashboard development requires understanding data.

Tools: Wow. There are a lot here, so I am only going to mention the highlights. You could get your MBA, or MPH, or even a PhD! You certainly could train to become a “true” diploma-carrying industrial engineer. And I know of a few insightful hospitals that employ them. A less in-depth, but cheaper and faster, option is to take specific courses related to your area of interest.

The SHM-AAIM Quality and Safety Educators Academy and SHM’s Leadership Academies are two great examples. Participating in a mentored project (i.e., Project BOOST) provides structure and an experienced mentor with a cadre of experts to back them up. Many institutions have courses on data analytics, basic finance, and quality improvement. The easiest, cheapest, and probably the most common is to find a mentor at your own institution. CFOs, CNOs, CQOs, and CMOs often are eager to partner with clinicians—and frequently are delighted to talk about their areas of expertise.

Skill No. 3: Leadership.

I don’t know many leaders who were born that way. Most learned through experience and continuous self-improvement. Understanding your personality traits, the traits of others (as an introvert, I still am trying to understand how extroverts work, especially my wife), and how to get all of those different personalities to work together as a team is an important component of any team-based engineering success.

Tools: I have found the books “From Good to Great” by Jim Collins and “Switch” by Chip and Dan Heath to be invaluable. I think another one of my recent reads, “Drive” by Daniel Pink, had important lessons, too. Formal courses, such as SHM’s Leadership Academies, QSEA, and those offered by the American Hospital Association, are designed to provide hospitalists with the leadership skills they need in a variety of hospital environments.

Skill No. 4: Thinking “system” instead of “individual.”

So many of us were trained that to make improvements, we just need to “be better,” to know more, try harder, and to work longer. Good industrial engineers design systems that make it easier for our doctors, healthcare providers, and patients to succeed. Of course, we need to be accountable, too, but supportive systems are a key component to successful individuals. The airline industry learned this long ago.

Tools: I really think “Switch” is an excellent read for those of us trying to help re-engineer our complex systems. It discusses how humans are both rational and emotional, and how our environment can help both sides succeed. Another helpful tool for me is asking “why” whenever someone says “if only they would do something differently for a better outcome…”

For example, “if only the hospitalists would discharge before 2 p.m.,” or “if only the ED didn’t clump their admissions,” or “if only the nurse didn’t call during rounds”—these are all classic systems problems, not people problems, and the solution isn’t to mandate 2 p.m. discharges, or stand up in a meeting finger pointing at the ED, or admonish a nurse for calling during rounds. The solution is to find out why these behaviors occur, then eliminate, change, or minimize the reasons.

Hospitalists don’t discharge by 2 p.m. often because they are waiting on tests; ED docs work in an environment that has highly variable workloads, coupled with dysfunctional systems that promote “batching” work patterns; and nurses may not be included in rounds but still need to be able to manage minute-to-minute patient-care needs. Sure, there are a few bad apples that need to be scolded, but I bet most of the issues at your hospital aren’t related to evildoers but good people who are often trapped in dysfunctional, antiquated systems and are just trying to do the best they can for their patients.

In Closing

I’d like to say thank you to all of the “de facto” industrial engineers out there. Keep up the critically important work of that most complex system—the hospital.

Dr. Howell is president of SHM, chief of the division of hospital medicine at Johns Hopkins Bayview in Baltimore, and spends a significant part of his time and research on hospital operations. Email questions or comments to [email protected].

Wikipedia defines “industrial engineering” as a branch of engineering that deals with the optimization of complex processes or systems. It goes on to link industrial engineering to “operations” and use of quantitative methods to “specify, predict, and evaluate” results. Any hospitalist that’s been tapped to reduce length of stay, help manage readmissions, implement an electronic health record, or increase the quality of care likely can relate to that definition. It seems to me that hospitalists often are the de facto industrial engineers in many of our hospitals.

The hospitalist as an industrial engineer makes perfect sense. What other group of physicians, nurse practitioners, and physician assistants provide services in virtually any clinical venue, from ED to DC, from (occasionally) PACU to ICU, the wards, and even post-discharge? Hospitalists see it all, from the first few hours of life (pediatrics) to life’s last stages (palliative care) and all stages in between. As a parody to “there’s an app for that,” Dr. Mindy Kantsiper, a hospitalist in Columbia, Md., says if there’s something that needs to be fixed, “there’s a hospitalist for that.” We are the Swiss Army knives of the medical world.

Looking through the HMX “Practice Management” discussions on the SHM website (www.hospitalmedicine.com/xchange) confirms my belief. Topics are as varied as using RNs in hospitalist practices, medication reconciliation, billing, outpatient orders (!!) after discharge, and patient-centered care/patient satisfaction. And that was just the last two weeks!

Type “hospitalist” into PubMed, and the words that auto-populate are: model, care, quality, discharge, communication, program, and handoff—all words I think of as system-related issues. Oh, sure, there are clinical-related topics, too, of course, just like for the “organ-based” specialties. However, none of the common organ-based specialties had any words auto-populate in PubMed that could be deemed related to “industrial engineering.”

Engineer Training

Like all engineers, we de facto industrial engineers need tools and skills to be effective at in our new engineering role. While we may not need slide rules and calculus like a more traditional engineer, many of the new skills we will need as industrial engineers were not taught in medical school, and the tools were not readily available for us to use in our training.

Fortunately, there are a plethora of options for us budding, de facto industrial engineers. Here are the ones I believe you will need and where to get them:

Skill No. 1: Negotiation.

HM is a team sport, and teams bring interpersonal dynamics and tension and conflict. Effective negotiation skills can help hospitalists use conflict to spur team growth and development rather than team dysfunction.

Tools: SHM’s Leadership Academies have effective negotiation modules in each of the leveled courses. If you can’t spare the time, then books to read include “Getting to Yes” by Fisher and Ury, or “Renegotiating Health Care” by Leonard Marcus (he lectures at SHM’s leadership academies).

Skill No. 2: Data analytics.

All engineers, including industrial engineers, need to be able to evaluate. Whether it’s quality and safety, clinical operations, or financial improvement, if you don’t measure it, you can’t change it. Some of the data will be handed to you, and you need to know the strengths and weaknesses to best interpret it. Some data you will need to define and develop measurement systems for on your own, and even basic dashboard development requires understanding data.

Tools: Wow. There are a lot here, so I am only going to mention the highlights. You could get your MBA, or MPH, or even a PhD! You certainly could train to become a “true” diploma-carrying industrial engineer. And I know of a few insightful hospitals that employ them. A less in-depth, but cheaper and faster, option is to take specific courses related to your area of interest.

The SHM-AAIM Quality and Safety Educators Academy and SHM’s Leadership Academies are two great examples. Participating in a mentored project (i.e., Project BOOST) provides structure and an experienced mentor with a cadre of experts to back them up. Many institutions have courses on data analytics, basic finance, and quality improvement. The easiest, cheapest, and probably the most common is to find a mentor at your own institution. CFOs, CNOs, CQOs, and CMOs often are eager to partner with clinicians—and frequently are delighted to talk about their areas of expertise.

Skill No. 3: Leadership.

I don’t know many leaders who were born that way. Most learned through experience and continuous self-improvement. Understanding your personality traits, the traits of others (as an introvert, I still am trying to understand how extroverts work, especially my wife), and how to get all of those different personalities to work together as a team is an important component of any team-based engineering success.

Tools: I have found the books “From Good to Great” by Jim Collins and “Switch” by Chip and Dan Heath to be invaluable. I think another one of my recent reads, “Drive” by Daniel Pink, had important lessons, too. Formal courses, such as SHM’s Leadership Academies, QSEA, and those offered by the American Hospital Association, are designed to provide hospitalists with the leadership skills they need in a variety of hospital environments.

Skill No. 4: Thinking “system” instead of “individual.”

So many of us were trained that to make improvements, we just need to “be better,” to know more, try harder, and to work longer. Good industrial engineers design systems that make it easier for our doctors, healthcare providers, and patients to succeed. Of course, we need to be accountable, too, but supportive systems are a key component to successful individuals. The airline industry learned this long ago.

Tools: I really think “Switch” is an excellent read for those of us trying to help re-engineer our complex systems. It discusses how humans are both rational and emotional, and how our environment can help both sides succeed. Another helpful tool for me is asking “why” whenever someone says “if only they would do something differently for a better outcome…”

For example, “if only the hospitalists would discharge before 2 p.m.,” or “if only the ED didn’t clump their admissions,” or “if only the nurse didn’t call during rounds”—these are all classic systems problems, not people problems, and the solution isn’t to mandate 2 p.m. discharges, or stand up in a meeting finger pointing at the ED, or admonish a nurse for calling during rounds. The solution is to find out why these behaviors occur, then eliminate, change, or minimize the reasons.

Hospitalists don’t discharge by 2 p.m. often because they are waiting on tests; ED docs work in an environment that has highly variable workloads, coupled with dysfunctional systems that promote “batching” work patterns; and nurses may not be included in rounds but still need to be able to manage minute-to-minute patient-care needs. Sure, there are a few bad apples that need to be scolded, but I bet most of the issues at your hospital aren’t related to evildoers but good people who are often trapped in dysfunctional, antiquated systems and are just trying to do the best they can for their patients.

In Closing

I’d like to say thank you to all of the “de facto” industrial engineers out there. Keep up the critically important work of that most complex system—the hospital.

Dr. Howell is president of SHM, chief of the division of hospital medicine at Johns Hopkins Bayview in Baltimore, and spends a significant part of his time and research on hospital operations. Email questions or comments to [email protected].

Wikipedia defines “industrial engineering” as a branch of engineering that deals with the optimization of complex processes or systems. It goes on to link industrial engineering to “operations” and use of quantitative methods to “specify, predict, and evaluate” results. Any hospitalist that’s been tapped to reduce length of stay, help manage readmissions, implement an electronic health record, or increase the quality of care likely can relate to that definition. It seems to me that hospitalists often are the de facto industrial engineers in many of our hospitals.

The hospitalist as an industrial engineer makes perfect sense. What other group of physicians, nurse practitioners, and physician assistants provide services in virtually any clinical venue, from ED to DC, from (occasionally) PACU to ICU, the wards, and even post-discharge? Hospitalists see it all, from the first few hours of life (pediatrics) to life’s last stages (palliative care) and all stages in between. As a parody to “there’s an app for that,” Dr. Mindy Kantsiper, a hospitalist in Columbia, Md., says if there’s something that needs to be fixed, “there’s a hospitalist for that.” We are the Swiss Army knives of the medical world.

Looking through the HMX “Practice Management” discussions on the SHM website (www.hospitalmedicine.com/xchange) confirms my belief. Topics are as varied as using RNs in hospitalist practices, medication reconciliation, billing, outpatient orders (!!) after discharge, and patient-centered care/patient satisfaction. And that was just the last two weeks!

Type “hospitalist” into PubMed, and the words that auto-populate are: model, care, quality, discharge, communication, program, and handoff—all words I think of as system-related issues. Oh, sure, there are clinical-related topics, too, of course, just like for the “organ-based” specialties. However, none of the common organ-based specialties had any words auto-populate in PubMed that could be deemed related to “industrial engineering.”

Engineer Training

Like all engineers, we de facto industrial engineers need tools and skills to be effective at in our new engineering role. While we may not need slide rules and calculus like a more traditional engineer, many of the new skills we will need as industrial engineers were not taught in medical school, and the tools were not readily available for us to use in our training.

Fortunately, there are a plethora of options for us budding, de facto industrial engineers. Here are the ones I believe you will need and where to get them:

Skill No. 1: Negotiation.

HM is a team sport, and teams bring interpersonal dynamics and tension and conflict. Effective negotiation skills can help hospitalists use conflict to spur team growth and development rather than team dysfunction.

Tools: SHM’s Leadership Academies have effective negotiation modules in each of the leveled courses. If you can’t spare the time, then books to read include “Getting to Yes” by Fisher and Ury, or “Renegotiating Health Care” by Leonard Marcus (he lectures at SHM’s leadership academies).

Skill No. 2: Data analytics.

All engineers, including industrial engineers, need to be able to evaluate. Whether it’s quality and safety, clinical operations, or financial improvement, if you don’t measure it, you can’t change it. Some of the data will be handed to you, and you need to know the strengths and weaknesses to best interpret it. Some data you will need to define and develop measurement systems for on your own, and even basic dashboard development requires understanding data.

Tools: Wow. There are a lot here, so I am only going to mention the highlights. You could get your MBA, or MPH, or even a PhD! You certainly could train to become a “true” diploma-carrying industrial engineer. And I know of a few insightful hospitals that employ them. A less in-depth, but cheaper and faster, option is to take specific courses related to your area of interest.

The SHM-AAIM Quality and Safety Educators Academy and SHM’s Leadership Academies are two great examples. Participating in a mentored project (i.e., Project BOOST) provides structure and an experienced mentor with a cadre of experts to back them up. Many institutions have courses on data analytics, basic finance, and quality improvement. The easiest, cheapest, and probably the most common is to find a mentor at your own institution. CFOs, CNOs, CQOs, and CMOs often are eager to partner with clinicians—and frequently are delighted to talk about their areas of expertise.

Skill No. 3: Leadership.

I don’t know many leaders who were born that way. Most learned through experience and continuous self-improvement. Understanding your personality traits, the traits of others (as an introvert, I still am trying to understand how extroverts work, especially my wife), and how to get all of those different personalities to work together as a team is an important component of any team-based engineering success.

Tools: I have found the books “From Good to Great” by Jim Collins and “Switch” by Chip and Dan Heath to be invaluable. I think another one of my recent reads, “Drive” by Daniel Pink, had important lessons, too. Formal courses, such as SHM’s Leadership Academies, QSEA, and those offered by the American Hospital Association, are designed to provide hospitalists with the leadership skills they need in a variety of hospital environments.

Skill No. 4: Thinking “system” instead of “individual.”

So many of us were trained that to make improvements, we just need to “be better,” to know more, try harder, and to work longer. Good industrial engineers design systems that make it easier for our doctors, healthcare providers, and patients to succeed. Of course, we need to be accountable, too, but supportive systems are a key component to successful individuals. The airline industry learned this long ago.

Tools: I really think “Switch” is an excellent read for those of us trying to help re-engineer our complex systems. It discusses how humans are both rational and emotional, and how our environment can help both sides succeed. Another helpful tool for me is asking “why” whenever someone says “if only they would do something differently for a better outcome…”

For example, “if only the hospitalists would discharge before 2 p.m.,” or “if only the ED didn’t clump their admissions,” or “if only the nurse didn’t call during rounds”—these are all classic systems problems, not people problems, and the solution isn’t to mandate 2 p.m. discharges, or stand up in a meeting finger pointing at the ED, or admonish a nurse for calling during rounds. The solution is to find out why these behaviors occur, then eliminate, change, or minimize the reasons.

Hospitalists don’t discharge by 2 p.m. often because they are waiting on tests; ED docs work in an environment that has highly variable workloads, coupled with dysfunctional systems that promote “batching” work patterns; and nurses may not be included in rounds but still need to be able to manage minute-to-minute patient-care needs. Sure, there are a few bad apples that need to be scolded, but I bet most of the issues at your hospital aren’t related to evildoers but good people who are often trapped in dysfunctional, antiquated systems and are just trying to do the best they can for their patients.

In Closing

I’d like to say thank you to all of the “de facto” industrial engineers out there. Keep up the critically important work of that most complex system—the hospital.

Dr. Howell is president of SHM, chief of the division of hospital medicine at Johns Hopkins Bayview in Baltimore, and spends a significant part of his time and research on hospital operations. Email questions or comments to [email protected].

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 [email protected].

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 [email protected].

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 [email protected].

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.

Sometimes it’s impossible to know what the patient was or wasn’t taking, but it doesn’t mean you don’t do your best.

–Jeffrey Schnipper, MD, MPH, FHM

What is the best possible medication history? How is it done? Who should do it? When should it be done during a patient’s journey in and out of the hospital? What medication discrepancies—and potential adverse drug events—are most likely?

Those are questions veteran hospitalist Jason Stein, MD, tried to answer during an HM13 breakout session on medication reconciliation at the Gaylord National Resort and Conference Center in National Harbor, Md.

“How do you know as the discharging provider if the medication list you’re looking at is gold or garbage?” said Dr. Stein, associate director for quality improvement (QI) at Emory University in Atlanta and a mentor for SHM’s Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS) quality-research initiative.

The concept of the “best possible medication history” (BPMH) originated with patient-safety expert Edward Etchells, MD, MSc, at Sunnybrook Health Sciences Centre in Toronto. The concept is outlined on a pocket reminder card for MARQUIS participants, explained co-presenter and principal investigator Jeffrey Schnipper MD, MPH, FHM, a hospitalist at Brigham & Women’s Hospital in Boston.

“Sometimes it’s impossible to know what the patient was or wasn’t taking, but it doesn’t mean you don’t do your best,” he said, adding that hospitalists should attempt to get at least one reliable, corroborating source of information for a patient’s medical history.

Sometimes it is necessary to speak to family members or the community pharmacy, Dr. Schnipper said, because many patients can’t remember all of the drugs they are taking. Trying to do medication reconciliation at the time of discharge when BPMH has not been done can lead to more work for the provider, medication errors, or rehospitalizations. Ideally, knowledge of what the patient was taking before admission, as well as the patient’s health literacy and adherence history, should be gathered and documented once, early, and well during the hospitalization by a trained provider, according to Dr. Schnipper.

An SHM survey, however, showed 50% to 70% percent of front-line providers have never received BPMH training, and 60% say they are not given the time.

“Not knowing means a diligent provider would need to take a BPMH at discharge, which is a waste,” Dr. Stein said. It would be nice to tell from the electronic health record whether a true BPMH had been taken for every hospitalized patient—or at least every high-risk patient—but this goal is not well-supported by current information technology, MARQUIS investigators said they have learned.

The MARQUIS program was launched in 2011 with a grant from the federal Agency for Healthcare Research and Quality. It began with a thorough review of the literature on medication reconciliation and the development of a toolkit of best practices. In 2012, six pilot sites were offered a menu of 11 MARQUIS medication-reconciliation interventions to choose from and help in implementing them from an SHM mentor, with expertise in both QI and medication safety.

Participating sites have mobilized high-level hospital leadership and utilize a local champion, usually a hospitalist, tools for assessing high-risk patients, medication-reconciliation assistants or counselors, and pharmacist involvement. Different sites have employed different professional staff to take medication histories.

Dr. Schnipper said he expects another round of MARQUIS-mentored implementation, probably in 2014, after data from the first round have been analyzed. The program is tracking such outcomes as the number of potentially harmful, unintentional medication discrepancies per patient at participating sites.

The MARQUIS toolkit is available on the SHM website at www.hospitalmedicine.org/marquis.

Larry Beresford is a freelance writer in San Francisco.

Sometimes it’s impossible to know what the patient was or wasn’t taking, but it doesn’t mean you don’t do your best.

–Jeffrey Schnipper, MD, MPH, FHM

What is the best possible medication history? How is it done? Who should do it? When should it be done during a patient’s journey in and out of the hospital? What medication discrepancies—and potential adverse drug events—are most likely?

Those are questions veteran hospitalist Jason Stein, MD, tried to answer during an HM13 breakout session on medication reconciliation at the Gaylord National Resort and Conference Center in National Harbor, Md.

“How do you know as the discharging provider if the medication list you’re looking at is gold or garbage?” said Dr. Stein, associate director for quality improvement (QI) at Emory University in Atlanta and a mentor for SHM’s Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS) quality-research initiative.

The concept of the “best possible medication history” (BPMH) originated with patient-safety expert Edward Etchells, MD, MSc, at Sunnybrook Health Sciences Centre in Toronto. The concept is outlined on a pocket reminder card for MARQUIS participants, explained co-presenter and principal investigator Jeffrey Schnipper MD, MPH, FHM, a hospitalist at Brigham & Women’s Hospital in Boston.

“Sometimes it’s impossible to know what the patient was or wasn’t taking, but it doesn’t mean you don’t do your best,” he said, adding that hospitalists should attempt to get at least one reliable, corroborating source of information for a patient’s medical history.

Sometimes it is necessary to speak to family members or the community pharmacy, Dr. Schnipper said, because many patients can’t remember all of the drugs they are taking. Trying to do medication reconciliation at the time of discharge when BPMH has not been done can lead to more work for the provider, medication errors, or rehospitalizations. Ideally, knowledge of what the patient was taking before admission, as well as the patient’s health literacy and adherence history, should be gathered and documented once, early, and well during the hospitalization by a trained provider, according to Dr. Schnipper.

An SHM survey, however, showed 50% to 70% percent of front-line providers have never received BPMH training, and 60% say they are not given the time.

“Not knowing means a diligent provider would need to take a BPMH at discharge, which is a waste,” Dr. Stein said. It would be nice to tell from the electronic health record whether a true BPMH had been taken for every hospitalized patient—or at least every high-risk patient—but this goal is not well-supported by current information technology, MARQUIS investigators said they have learned.

The MARQUIS program was launched in 2011 with a grant from the federal Agency for Healthcare Research and Quality. It began with a thorough review of the literature on medication reconciliation and the development of a toolkit of best practices. In 2012, six pilot sites were offered a menu of 11 MARQUIS medication-reconciliation interventions to choose from and help in implementing them from an SHM mentor, with expertise in both QI and medication safety.

Participating sites have mobilized high-level hospital leadership and utilize a local champion, usually a hospitalist, tools for assessing high-risk patients, medication-reconciliation assistants or counselors, and pharmacist involvement. Different sites have employed different professional staff to take medication histories.

Dr. Schnipper said he expects another round of MARQUIS-mentored implementation, probably in 2014, after data from the first round have been analyzed. The program is tracking such outcomes as the number of potentially harmful, unintentional medication discrepancies per patient at participating sites.

The MARQUIS toolkit is available on the SHM website at www.hospitalmedicine.org/marquis.

Larry Beresford is a freelance writer in San Francisco.

Sometimes it’s impossible to know what the patient was or wasn’t taking, but it doesn’t mean you don’t do your best.

–Jeffrey Schnipper, MD, MPH, FHM

What is the best possible medication history? How is it done? Who should do it? When should it be done during a patient’s journey in and out of the hospital? What medication discrepancies—and potential adverse drug events—are most likely?

Those are questions veteran hospitalist Jason Stein, MD, tried to answer during an HM13 breakout session on medication reconciliation at the Gaylord National Resort and Conference Center in National Harbor, Md.

“How do you know as the discharging provider if the medication list you’re looking at is gold or garbage?” said Dr. Stein, associate director for quality improvement (QI) at Emory University in Atlanta and a mentor for SHM’s Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS) quality-research initiative.

The concept of the “best possible medication history” (BPMH) originated with patient-safety expert Edward Etchells, MD, MSc, at Sunnybrook Health Sciences Centre in Toronto. The concept is outlined on a pocket reminder card for MARQUIS participants, explained co-presenter and principal investigator Jeffrey Schnipper MD, MPH, FHM, a hospitalist at Brigham & Women’s Hospital in Boston.

“Sometimes it’s impossible to know what the patient was or wasn’t taking, but it doesn’t mean you don’t do your best,” he said, adding that hospitalists should attempt to get at least one reliable, corroborating source of information for a patient’s medical history.

Sometimes it is necessary to speak to family members or the community pharmacy, Dr. Schnipper said, because many patients can’t remember all of the drugs they are taking. Trying to do medication reconciliation at the time of discharge when BPMH has not been done can lead to more work for the provider, medication errors, or rehospitalizations. Ideally, knowledge of what the patient was taking before admission, as well as the patient’s health literacy and adherence history, should be gathered and documented once, early, and well during the hospitalization by a trained provider, according to Dr. Schnipper.

An SHM survey, however, showed 50% to 70% percent of front-line providers have never received BPMH training, and 60% say they are not given the time.

“Not knowing means a diligent provider would need to take a BPMH at discharge, which is a waste,” Dr. Stein said. It would be nice to tell from the electronic health record whether a true BPMH had been taken for every hospitalized patient—or at least every high-risk patient—but this goal is not well-supported by current information technology, MARQUIS investigators said they have learned.

The MARQUIS program was launched in 2011 with a grant from the federal Agency for Healthcare Research and Quality. It began with a thorough review of the literature on medication reconciliation and the development of a toolkit of best practices. In 2012, six pilot sites were offered a menu of 11 MARQUIS medication-reconciliation interventions to choose from and help in implementing them from an SHM mentor, with expertise in both QI and medication safety.

Participating sites have mobilized high-level hospital leadership and utilize a local champion, usually a hospitalist, tools for assessing high-risk patients, medication-reconciliation assistants or counselors, and pharmacist involvement. Different sites have employed different professional staff to take medication histories.

Dr. Schnipper said he expects another round of MARQUIS-mentored implementation, probably in 2014, after data from the first round have been analyzed. The program is tracking such outcomes as the number of potentially harmful, unintentional medication discrepancies per patient at participating sites.

The MARQUIS toolkit is available on the SHM website at www.hospitalmedicine.org/marquis.

Larry Beresford is a freelance writer in San Francisco.

click for large version

Are your critical-care claims at risk for denial or repayment upon review? Several payors have identified increased potential for critical-care reporting discrepancies, which has resulted in targeted prepayment reviews of this code.¹ Some payors have implemented 100% review when critical care is reported in settings other than inpatient hospitals, outpatient hospitals, or emergency departments.² To ensure a successful outcome, make sure the documentation meets the basic principles of the critical-care guidelines.

Defining Critical Illness/Injury

CPT and the Centers for Medicare & Medicaid Services (CMS) define “critical illness or injury” as a condition that acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient’s condition (e.g. central-nervous-system failure; circulatory failure; shock; renal, hepatic, metabolic, and/or respiratory failure).³ The provider’s time must be solely directed toward the critically ill patient. Highly complex decision-making and interventions of high intensity are required to prevent the patient’s inevitable decline if left untreated. Payment may be made for critical-care services provided in any reasonable location, as long as the care provided meets the definition of critical care. Critical-care services cannot be reported for a patient who is not critically ill but happens to be in a critical-care unit, or when a particular physician is only treating one of the patient’s conditions that is not considered the critical illness.⁴

Examples of patients who may not satisfy Medicare medical-necessity criteria, do not meet critical-care criteria, or who do not have a critical-care illness or injury and therefore are not eligible for critical-care payment:

• Patients admitted to a critical-care unit because no other hospital beds were available;
• Patients admitted to a critical-care unit for close nursing observation and/or frequent monitoring of vital signs (e.g. drug toxicity or overdose);
• Patients admitted to a critical-care unit because hospital rules require certain treatments (e.g. insulin infusions) to be administered in the critical-care unit; and
• Care of only a chronic illness in the absence of caring for a critical illness (e.g. daily management of a chronic ventilator patient; management of or care related to dialysis for an ESRD).

These circumstances would require using subsequent hospital care codes (99231-99233), initial hospital care codes (99221-99223), or hospital consultation codes (99251-99255) when applicable.^3,5

Because critical-care time is a cumulative service, providers keep track of their total time throughout a single calendar day. For each date and encounter entry, the physician’s progress notes shall document the total time that critical-care services were provided (e.g. 45 minutes).⁴ Some payors impose the notation of “start-and-stop time” per encounter (e.g. 10 to 10:45 a.m.).

Code This Case

Consider the following scenario: A hospitalist admits a 75-year-old patient to the ICU with acute respiratory failure. He spends 45 minutes in critical-care time. The patient’s family arrives soon thereafter to discuss the patient’s condition with a second hospitalist. The discussion lasts an additional 20 minutes, and the decision regarding the patient’s DNR status is made.

Family meetings must take place at the bedside or on the patient’s unit/floor. The patient must participate, unless they are medically unable or clinically incompetent to participate. A notation in the chart should indicate the patient’s inability to participate and the reason. Meeting time can only involve obtaining a medical history and/or discussing treatment options or the limitations of treatment. The conversation must bear directly on patient management.^5,6 Meetings that take place for family grief counseling (90846, 90847, 90849) are not included in critical-care time and cannot be billed separately.

Do not count time associated with periodic condition updates to the family or answering questions about the patient’s condition that are unrelated to decision-making.

Family discussions can take place via phone as long as the physician is calling from the patient’s unit/floor and the conversation involves the same criterion identified for face-to-face family meetings.⁶

Critically ill patients often require the care of multiple providers.³ Payors implement code logic in their systems that allow reimbursement for 99291 once per day when reported by physicians of the same group and specialty.⁸ Physicians of different specialties can separately report critical-care hours. Documentation must demonstrate that care is not duplicative of other specialists and does not overlap the same time period of any other physician reporting critical-care services.

Same-specialty physicians (two hospitalists from the same group practice) bill and are paid as one physician. The initial critical-care hour (99291) must be met by a single physician. Medically necessary critical-care time beyond the first hour (99292) may be met individually by the same physician or collectively with another physician from the same group. Cumulative physician time should be reported under one provider number on a single invoice in order to prevent denials from billing 99292 independently (see “Critical-Care Services: Time Reminders,”).

When a physician and a nurse practitioner (NP) see a patient on the same calendar day, critical-care reporting is handled differently. A single unit of critical-care time cannot be split or shared between a physician and a qualified NP. One individual must meet the entire time requirement of the reported service code.

More specifically, the hospitalist must individually meet the criteria for the first critical-care hour before reporting 99291, and the NP must individually meet the criteria for an additional 30 minutes of critical care before reporting 99292. The same is true if the NP provided the initial hour while the hospitalist provided the additional critical-care time.

Payors who recognize NPs as independent billing providers (e.g. Medicare and Aetna) require a “split” invoice: an invoice for 99291 with the hospitalist NPI and an invoice for 99292 with the NP’s NPI.9 This ensures reimbursement-rate accuracy, as the physician receives 100% of the allowable rate while the NP receives 85%. If the 99292 invoice is denied due to the payor’s system edits disallowing separate invoicing of add-on codes, appeal with documentation by both the hospitalist and NP to identify the circumstances and reclaim payment.

Critical-Care Services: Time Reminders

click for large version

Two available codes:

99291: Critical care, evaluation and management of the critically ill or critically injured patient: first 30-74 minutes. It is reported only once per day, per physician or group member of the same specialty.

+99292: Critical care, evaluation and management of the critically ill or critically injured patient: each additional 30 minutes (list separately in addition to code for primary service). Categorized as an “add on” code, it must be reported on the same invoice as its “primary” code, 99291. Multiple units of code 99292 can be reported per day per physician/group (see Table 1).

Critical-care time constitutes bedside time and time spent on the patient’s unit/floor where the physician is immediately available to the patient. Also count physician time associated with the performance and/or interpretation of labs, diagnostic studies, and procedures inherent to the provision of critical care:

• Cardiac output measurements (93561, 93562);
• Chest X-rays (71010, 71015, 71020);
• Pulse oximetry (94760, 94761, 94762);
• Blood gases and interpretation of data stored in computers (e.g. ECGs, blood pressures, hematologic data [99090]);
• Gastric intubation (43752, 91105);
• Temporary transcutaneous pacing (92953);
• Ventilation management (94002-94004, 94660, 94662); and
• Vascular access procedures (36000, 36410, 36415, 36591, 36600).⁵

Other separately billable services or procedures cannot be added to critical-care time. A notation in the medical record is highly recommended (e.g. “central-line insertion is not included as critical-care time”) for validation to prevent payor inquiries.

Do not count time associated with indirect care provided outside of the patient’s unit/floor (e.g. reviewing data or calling the family from the office) toward critical-care time. Activities on the floor/unit that do not directly contribute to patient care or management (e.g. review of literature, teaching rounds) cannot be counted toward critical-care time.

—Carol Pohlig

References

1. Cahaba Government Benefit Administrators LLC. Widespread prepayment targeted review notification—CPT 99291. Cahaba Government Benefit Administrators LLC website. Available at: http://www.cahabagba.com/news/widespread-prepayment-targeted-review-notification-part-b/. Accessed May 4, 2013.
2. First Coast Service Options Inc. Prepayment edit of evaluation and management (E/M) code 99291. First Coast Service Options Inc. website. Available at: http://medicare.fcso.com/Medical_documentation/249650.asp. Accessed May 5, 2013.
3. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 30.6.12A. Centers for Medicare and Medicaid Services website. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed May 5, 2013.
4. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 30.6.12B. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed May 5, 2013.
5. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 30.6.12E. Centers for Medicare and Medicaid Services website. Available at http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed May 6, 2013.
6. Abraham M, Ahlman J, Boudreau A, Connelly J, Levreau-Davis L. Current Procedural Terminology 2013 Professional Edition. Chicago: American Medical Association Press; 2012.
7. Novitas Solutions Inc. Evaluation & management: service-specific coding instructions. Novitas Solutions Inc. website. Available at: http://www.novitas-solutions.com/em/coding.html. Accessed May 7, 2013.
8. United Healthcare. Same day same service policy—adding edits. United Healthcare website. Available at: http://www.unitedhealthcareonline.com/ccmcontent/ ProviderII/ UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/News/Network_Bulletin_November _2012_Volume_52.pdf. Accessed May 7, 2013.
9. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 30.6.12I. Centers for Medicare and Medicaid Services website. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed May 10, 2013.
10. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 30.6.12G. Centers for Medicare and Medicaid Services website. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed May 4, 2013.

click for large version

Are your critical-care claims at risk for denial or repayment upon review? Several payors have identified increased potential for critical-care reporting discrepancies, which has resulted in targeted prepayment reviews of this code.¹ Some payors have implemented 100% review when critical care is reported in settings other than inpatient hospitals, outpatient hospitals, or emergency departments.² To ensure a successful outcome, make sure the documentation meets the basic principles of the critical-care guidelines.

Defining Critical Illness/Injury

CPT and the Centers for Medicare & Medicaid Services (CMS) define “critical illness or injury” as a condition that acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient’s condition (e.g. central-nervous-system failure; circulatory failure; shock; renal, hepatic, metabolic, and/or respiratory failure).³ The provider’s time must be solely directed toward the critically ill patient. Highly complex decision-making and interventions of high intensity are required to prevent the patient’s inevitable decline if left untreated. Payment may be made for critical-care services provided in any reasonable location, as long as the care provided meets the definition of critical care. Critical-care services cannot be reported for a patient who is not critically ill but happens to be in a critical-care unit, or when a particular physician is only treating one of the patient’s conditions that is not considered the critical illness.⁴

Examples of patients who may not satisfy Medicare medical-necessity criteria, do not meet critical-care criteria, or who do not have a critical-care illness or injury and therefore are not eligible for critical-care payment:

• Patients admitted to a critical-care unit because no other hospital beds were available;
• Patients admitted to a critical-care unit for close nursing observation and/or frequent monitoring of vital signs (e.g. drug toxicity or overdose);
• Patients admitted to a critical-care unit because hospital rules require certain treatments (e.g. insulin infusions) to be administered in the critical-care unit; and
• Care of only a chronic illness in the absence of caring for a critical illness (e.g. daily management of a chronic ventilator patient; management of or care related to dialysis for an ESRD).

These circumstances would require using subsequent hospital care codes (99231-99233), initial hospital care codes (99221-99223), or hospital consultation codes (99251-99255) when applicable.^3,5

Because critical-care time is a cumulative service, providers keep track of their total time throughout a single calendar day. For each date and encounter entry, the physician’s progress notes shall document the total time that critical-care services were provided (e.g. 45 minutes).⁴ Some payors impose the notation of “start-and-stop time” per encounter (e.g. 10 to 10:45 a.m.).

Code This Case

Consider the following scenario: A hospitalist admits a 75-year-old patient to the ICU with acute respiratory failure. He spends 45 minutes in critical-care time. The patient’s family arrives soon thereafter to discuss the patient’s condition with a second hospitalist. The discussion lasts an additional 20 minutes, and the decision regarding the patient’s DNR status is made.

Family meetings must take place at the bedside or on the patient’s unit/floor. The patient must participate, unless they are medically unable or clinically incompetent to participate. A notation in the chart should indicate the patient’s inability to participate and the reason. Meeting time can only involve obtaining a medical history and/or discussing treatment options or the limitations of treatment. The conversation must bear directly on patient management.^5,6 Meetings that take place for family grief counseling (90846, 90847, 90849) are not included in critical-care time and cannot be billed separately.

Do not count time associated with periodic condition updates to the family or answering questions about the patient’s condition that are unrelated to decision-making.

Family discussions can take place via phone as long as the physician is calling from the patient’s unit/floor and the conversation involves the same criterion identified for face-to-face family meetings.⁶

Critically ill patients often require the care of multiple providers.³ Payors implement code logic in their systems that allow reimbursement for 99291 once per day when reported by physicians of the same group and specialty.⁸ Physicians of different specialties can separately report critical-care hours. Documentation must demonstrate that care is not duplicative of other specialists and does not overlap the same time period of any other physician reporting critical-care services.

Same-specialty physicians (two hospitalists from the same group practice) bill and are paid as one physician. The initial critical-care hour (99291) must be met by a single physician. Medically necessary critical-care time beyond the first hour (99292) may be met individually by the same physician or collectively with another physician from the same group. Cumulative physician time should be reported under one provider number on a single invoice in order to prevent denials from billing 99292 independently (see “Critical-Care Services: Time Reminders,”).

When a physician and a nurse practitioner (NP) see a patient on the same calendar day, critical-care reporting is handled differently. A single unit of critical-care time cannot be split or shared between a physician and a qualified NP. One individual must meet the entire time requirement of the reported service code.

More specifically, the hospitalist must individually meet the criteria for the first critical-care hour before reporting 99291, and the NP must individually meet the criteria for an additional 30 minutes of critical care before reporting 99292. The same is true if the NP provided the initial hour while the hospitalist provided the additional critical-care time.

Payors who recognize NPs as independent billing providers (e.g. Medicare and Aetna) require a “split” invoice: an invoice for 99291 with the hospitalist NPI and an invoice for 99292 with the NP’s NPI.9 This ensures reimbursement-rate accuracy, as the physician receives 100% of the allowable rate while the NP receives 85%. If the 99292 invoice is denied due to the payor’s system edits disallowing separate invoicing of add-on codes, appeal with documentation by both the hospitalist and NP to identify the circumstances and reclaim payment.

Critical-Care Services: Time Reminders

click for large version

Two available codes:

99291: Critical care, evaluation and management of the critically ill or critically injured patient: first 30-74 minutes. It is reported only once per day, per physician or group member of the same specialty.

+99292: Critical care, evaluation and management of the critically ill or critically injured patient: each additional 30 minutes (list separately in addition to code for primary service). Categorized as an “add on” code, it must be reported on the same invoice as its “primary” code, 99291. Multiple units of code 99292 can be reported per day per physician/group (see Table 1).

Critical-care time constitutes bedside time and time spent on the patient’s unit/floor where the physician is immediately available to the patient. Also count physician time associated with the performance and/or interpretation of labs, diagnostic studies, and procedures inherent to the provision of critical care:

• Cardiac output measurements (93561, 93562);
• Chest X-rays (71010, 71015, 71020);
• Pulse oximetry (94760, 94761, 94762);
• Blood gases and interpretation of data stored in computers (e.g. ECGs, blood pressures, hematologic data [99090]);
• Gastric intubation (43752, 91105);
• Temporary transcutaneous pacing (92953);
• Ventilation management (94002-94004, 94660, 94662); and
• Vascular access procedures (36000, 36410, 36415, 36591, 36600).⁵

Other separately billable services or procedures cannot be added to critical-care time. A notation in the medical record is highly recommended (e.g. “central-line insertion is not included as critical-care time”) for validation to prevent payor inquiries.

Do not count time associated with indirect care provided outside of the patient’s unit/floor (e.g. reviewing data or calling the family from the office) toward critical-care time. Activities on the floor/unit that do not directly contribute to patient care or management (e.g. review of literature, teaching rounds) cannot be counted toward critical-care time.

—Carol Pohlig

References

1. Cahaba Government Benefit Administrators LLC. Widespread prepayment targeted review notification—CPT 99291. Cahaba Government Benefit Administrators LLC website. Available at: http://www.cahabagba.com/news/widespread-prepayment-targeted-review-notification-part-b/. Accessed May 4, 2013.
2. First Coast Service Options Inc. Prepayment edit of evaluation and management (E/M) code 99291. First Coast Service Options Inc. website. Available at: http://medicare.fcso.com/Medical_documentation/249650.asp. Accessed May 5, 2013.
3. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 30.6.12A. Centers for Medicare and Medicaid Services website. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed May 5, 2013.
4. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 30.6.12B. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed May 5, 2013.
5. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 30.6.12E. Centers for Medicare and Medicaid Services website. Available at http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed May 6, 2013.
6. Abraham M, Ahlman J, Boudreau A, Connelly J, Levreau-Davis L. Current Procedural Terminology 2013 Professional Edition. Chicago: American Medical Association Press; 2012.
7. Novitas Solutions Inc. Evaluation & management: service-specific coding instructions. Novitas Solutions Inc. website. Available at: http://www.novitas-solutions.com/em/coding.html. Accessed May 7, 2013.
8. United Healthcare. Same day same service policy—adding edits. United Healthcare website. Available at: http://www.unitedhealthcareonline.com/ccmcontent/ ProviderII/ UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/News/Network_Bulletin_November _2012_Volume_52.pdf. Accessed May 7, 2013.
9. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 30.6.12I. Centers for Medicare and Medicaid Services website. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed May 10, 2013.
10. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 30.6.12G. Centers for Medicare and Medicaid Services website. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed May 4, 2013.

click for large version

Are your critical-care claims at risk for denial or repayment upon review? Several payors have identified increased potential for critical-care reporting discrepancies, which has resulted in targeted prepayment reviews of this code.¹ Some payors have implemented 100% review when critical care is reported in settings other than inpatient hospitals, outpatient hospitals, or emergency departments.² To ensure a successful outcome, make sure the documentation meets the basic principles of the critical-care guidelines.

Defining Critical Illness/Injury

CPT and the Centers for Medicare & Medicaid Services (CMS) define “critical illness or injury” as a condition that acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient’s condition (e.g. central-nervous-system failure; circulatory failure; shock; renal, hepatic, metabolic, and/or respiratory failure).³ The provider’s time must be solely directed toward the critically ill patient. Highly complex decision-making and interventions of high intensity are required to prevent the patient’s inevitable decline if left untreated. Payment may be made for critical-care services provided in any reasonable location, as long as the care provided meets the definition of critical care. Critical-care services cannot be reported for a patient who is not critically ill but happens to be in a critical-care unit, or when a particular physician is only treating one of the patient’s conditions that is not considered the critical illness.⁴

Examples of patients who may not satisfy Medicare medical-necessity criteria, do not meet critical-care criteria, or who do not have a critical-care illness or injury and therefore are not eligible for critical-care payment:

• Patients admitted to a critical-care unit because no other hospital beds were available;
• Patients admitted to a critical-care unit for close nursing observation and/or frequent monitoring of vital signs (e.g. drug toxicity or overdose);
• Patients admitted to a critical-care unit because hospital rules require certain treatments (e.g. insulin infusions) to be administered in the critical-care unit; and
• Care of only a chronic illness in the absence of caring for a critical illness (e.g. daily management of a chronic ventilator patient; management of or care related to dialysis for an ESRD).

These circumstances would require using subsequent hospital care codes (99231-99233), initial hospital care codes (99221-99223), or hospital consultation codes (99251-99255) when applicable.^3,5

Because critical-care time is a cumulative service, providers keep track of their total time throughout a single calendar day. For each date and encounter entry, the physician’s progress notes shall document the total time that critical-care services were provided (e.g. 45 minutes).⁴ Some payors impose the notation of “start-and-stop time” per encounter (e.g. 10 to 10:45 a.m.).

Code This Case

Consider the following scenario: A hospitalist admits a 75-year-old patient to the ICU with acute respiratory failure. He spends 45 minutes in critical-care time. The patient’s family arrives soon thereafter to discuss the patient’s condition with a second hospitalist. The discussion lasts an additional 20 minutes, and the decision regarding the patient’s DNR status is made.

Family meetings must take place at the bedside or on the patient’s unit/floor. The patient must participate, unless they are medically unable or clinically incompetent to participate. A notation in the chart should indicate the patient’s inability to participate and the reason. Meeting time can only involve obtaining a medical history and/or discussing treatment options or the limitations of treatment. The conversation must bear directly on patient management.^5,6 Meetings that take place for family grief counseling (90846, 90847, 90849) are not included in critical-care time and cannot be billed separately.

Do not count time associated with periodic condition updates to the family or answering questions about the patient’s condition that are unrelated to decision-making.

Family discussions can take place via phone as long as the physician is calling from the patient’s unit/floor and the conversation involves the same criterion identified for face-to-face family meetings.⁶

Critically ill patients often require the care of multiple providers.³ Payors implement code logic in their systems that allow reimbursement for 99291 once per day when reported by physicians of the same group and specialty.⁸ Physicians of different specialties can separately report critical-care hours. Documentation must demonstrate that care is not duplicative of other specialists and does not overlap the same time period of any other physician reporting critical-care services.

Same-specialty physicians (two hospitalists from the same group practice) bill and are paid as one physician. The initial critical-care hour (99291) must be met by a single physician. Medically necessary critical-care time beyond the first hour (99292) may be met individually by the same physician or collectively with another physician from the same group. Cumulative physician time should be reported under one provider number on a single invoice in order to prevent denials from billing 99292 independently (see “Critical-Care Services: Time Reminders,”).

When a physician and a nurse practitioner (NP) see a patient on the same calendar day, critical-care reporting is handled differently. A single unit of critical-care time cannot be split or shared between a physician and a qualified NP. One individual must meet the entire time requirement of the reported service code.

More specifically, the hospitalist must individually meet the criteria for the first critical-care hour before reporting 99291, and the NP must individually meet the criteria for an additional 30 minutes of critical care before reporting 99292. The same is true if the NP provided the initial hour while the hospitalist provided the additional critical-care time.

Payors who recognize NPs as independent billing providers (e.g. Medicare and Aetna) require a “split” invoice: an invoice for 99291 with the hospitalist NPI and an invoice for 99292 with the NP’s NPI.9 This ensures reimbursement-rate accuracy, as the physician receives 100% of the allowable rate while the NP receives 85%. If the 99292 invoice is denied due to the payor’s system edits disallowing separate invoicing of add-on codes, appeal with documentation by both the hospitalist and NP to identify the circumstances and reclaim payment.

Critical-Care Services: Time Reminders

click for large version

Two available codes:

99291: Critical care, evaluation and management of the critically ill or critically injured patient: first 30-74 minutes. It is reported only once per day, per physician or group member of the same specialty.

+99292: Critical care, evaluation and management of the critically ill or critically injured patient: each additional 30 minutes (list separately in addition to code for primary service). Categorized as an “add on” code, it must be reported on the same invoice as its “primary” code, 99291. Multiple units of code 99292 can be reported per day per physician/group (see Table 1).

Critical-care time constitutes bedside time and time spent on the patient’s unit/floor where the physician is immediately available to the patient. Also count physician time associated with the performance and/or interpretation of labs, diagnostic studies, and procedures inherent to the provision of critical care:

• Cardiac output measurements (93561, 93562);
• Chest X-rays (71010, 71015, 71020);
• Pulse oximetry (94760, 94761, 94762);
• Blood gases and interpretation of data stored in computers (e.g. ECGs, blood pressures, hematologic data [99090]);
• Gastric intubation (43752, 91105);
• Temporary transcutaneous pacing (92953);
• Ventilation management (94002-94004, 94660, 94662); and
• Vascular access procedures (36000, 36410, 36415, 36591, 36600).⁵

Other separately billable services or procedures cannot be added to critical-care time. A notation in the medical record is highly recommended (e.g. “central-line insertion is not included as critical-care time”) for validation to prevent payor inquiries.

Do not count time associated with indirect care provided outside of the patient’s unit/floor (e.g. reviewing data or calling the family from the office) toward critical-care time. Activities on the floor/unit that do not directly contribute to patient care or management (e.g. review of literature, teaching rounds) cannot be counted toward critical-care time.

—Carol Pohlig

References

1. Cahaba Government Benefit Administrators LLC. Widespread prepayment targeted review notification—CPT 99291. Cahaba Government Benefit Administrators LLC website. Available at: http://www.cahabagba.com/news/widespread-prepayment-targeted-review-notification-part-b/. Accessed May 4, 2013.
2. First Coast Service Options Inc. Prepayment edit of evaluation and management (E/M) code 99291. First Coast Service Options Inc. website. Available at: http://medicare.fcso.com/Medical_documentation/249650.asp. Accessed May 5, 2013.
3. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 30.6.12A. Centers for Medicare and Medicaid Services website. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed May 5, 2013.
4. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 30.6.12B. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed May 5, 2013.
5. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 30.6.12E. Centers for Medicare and Medicaid Services website. Available at http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed May 6, 2013.
6. Abraham M, Ahlman J, Boudreau A, Connelly J, Levreau-Davis L. Current Procedural Terminology 2013 Professional Edition. Chicago: American Medical Association Press; 2012.
7. Novitas Solutions Inc. Evaluation & management: service-specific coding instructions. Novitas Solutions Inc. website. Available at: http://www.novitas-solutions.com/em/coding.html. Accessed May 7, 2013.
8. United Healthcare. Same day same service policy—adding edits. United Healthcare website. Available at: http://www.unitedhealthcareonline.com/ccmcontent/ ProviderII/ UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/News/Network_Bulletin_November _2012_Volume_52.pdf. Accessed May 7, 2013.
9. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 30.6.12I. Centers for Medicare and Medicaid Services website. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed May 10, 2013.
10. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 30.6.12G. Centers for Medicare and Medicaid Services website. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed May 4, 2013.