The SHM/MGMA 2011 State of Hospital Medicine report offers some intriguing glimpses into the world of pediatric hospital medicine. Last year, we received responses from 31 pediatric HM groups, more than half of which were academic (an additional 29 groups reported caring for both adults and children).

SHM Pediatrics Committee chair Doug Carlson, MD, SFHM, professor of pediatrics and director of the Division of Pediatric Hospital Medicine at Washington University in St. Louis, believes that the number of community hospitals with pediatric hospitalists is growing, based on his work with the workforce group of the Pediatric Hospital Medicine leadership group. Hopefully we will see more community pediatric HM groups in future surveys.

As is the case in adult HM, academic pediatric practices tend to be larger than their nonacademic counterparts, with a median size of 6.0 FTEs vs. 4.0 FTEs in nonacademic groups. In both cases, this is well below the median size of comparable adult HM groups.

“Community hospital programs are often started to improve the quality of care around the clock,” Dr. Carlson says. “But the minimum number of FTEs needed for a sustainable 24-hour program is about five—even in very small units. Group size can often be larger in academic settings because pediatric units are larger, and their tertiary nature creates more opportunities for involvement in surgical comanagement and other types of complex care.”

The report shows turnover was higher for both academic and nonacademic pediatric HM practices than for adult medicine practices. The median turnover for nonacademic pediatric groups was 15.5%, for example, compared with 8.2% for the nonacademic adult groups. The sample size for pediatric groups was much smaller, however.

Pediatric hospitalist Dan Rauch, MD, FAAP, FHM, associate professor of pediatrics at Mount Sinai School of Medicine in New York, N.Y., and a former SHM Practice Analysis Committee member, notes that because the typical pediatric group size is much smaller than an adult practice, the loss of only a single hospitalist will result in a much higher turnover rate.

“It’s also my sense that community-based pediatric hospitalist positions are more likely to be transient spots as opposed to academic positions, which are more likely to lead to sustained careers,” he says.

Table 1 (above) presents some key median indicators for nonacademic HM practices. As is true for pediatricians in traditional practice, the typical pediatric hospitalist earned quite a bit less than her colleagues in adult medicine.

Even so, the finances of a pediatric HM program are more challenging than for adult hospitalists. Although professional fee collections per work relative value unit (wRVU) were slightly higher for pediatric groups than for adult groups (a surprising finding as the primary payor for many pediatric hospitalist groups is Medicaid), pediatric hospitalists’ typical annual wRVU production was about 53% lower than that of adult hospitalists, according to the 2011 report. As a result, the compensation-to-collections ratio for pediatric hospitalists was 1.75, which means that pediatric hospitalists collected only about 57 cents in professional fee revenues for every dollar of compensation paid. Adult hospitalists, by comparison, collected about 80 cents for each dollar of compensation.

Dr. Rauch isn’t particularly surprised by those figures. “The goals of nonacademic pediatric hospital medicine programs are more about providing service and expertise than about volume,” he says. “Most community hospital-based pediatric programs simply don’t have the consistent volume to support hospitalists on a billing basis, especially since they typically experience seasonal census variations that academic children’s hospitals don’t have.”

Leslie Flores, SHM senior advisor, practice management

Last chance for both pediatric and adult HM practices to participate in the 2012 State of Hospital Medicine survey: The survey closes March 9. Visit www.hospitalmedicine.org/survey.

The SHM/MGMA 2011 State of Hospital Medicine report offers some intriguing glimpses into the world of pediatric hospital medicine. Last year, we received responses from 31 pediatric HM groups, more than half of which were academic (an additional 29 groups reported caring for both adults and children).

SHM Pediatrics Committee chair Doug Carlson, MD, SFHM, professor of pediatrics and director of the Division of Pediatric Hospital Medicine at Washington University in St. Louis, believes that the number of community hospitals with pediatric hospitalists is growing, based on his work with the workforce group of the Pediatric Hospital Medicine leadership group. Hopefully we will see more community pediatric HM groups in future surveys.

As is the case in adult HM, academic pediatric practices tend to be larger than their nonacademic counterparts, with a median size of 6.0 FTEs vs. 4.0 FTEs in nonacademic groups. In both cases, this is well below the median size of comparable adult HM groups.

“Community hospital programs are often started to improve the quality of care around the clock,” Dr. Carlson says. “But the minimum number of FTEs needed for a sustainable 24-hour program is about five—even in very small units. Group size can often be larger in academic settings because pediatric units are larger, and their tertiary nature creates more opportunities for involvement in surgical comanagement and other types of complex care.”

The report shows turnover was higher for both academic and nonacademic pediatric HM practices than for adult medicine practices. The median turnover for nonacademic pediatric groups was 15.5%, for example, compared with 8.2% for the nonacademic adult groups. The sample size for pediatric groups was much smaller, however.

Pediatric hospitalist Dan Rauch, MD, FAAP, FHM, associate professor of pediatrics at Mount Sinai School of Medicine in New York, N.Y., and a former SHM Practice Analysis Committee member, notes that because the typical pediatric group size is much smaller than an adult practice, the loss of only a single hospitalist will result in a much higher turnover rate.

“It’s also my sense that community-based pediatric hospitalist positions are more likely to be transient spots as opposed to academic positions, which are more likely to lead to sustained careers,” he says.

Table 1 (above) presents some key median indicators for nonacademic HM practices. As is true for pediatricians in traditional practice, the typical pediatric hospitalist earned quite a bit less than her colleagues in adult medicine.

Even so, the finances of a pediatric HM program are more challenging than for adult hospitalists. Although professional fee collections per work relative value unit (wRVU) were slightly higher for pediatric groups than for adult groups (a surprising finding as the primary payor for many pediatric hospitalist groups is Medicaid), pediatric hospitalists’ typical annual wRVU production was about 53% lower than that of adult hospitalists, according to the 2011 report. As a result, the compensation-to-collections ratio for pediatric hospitalists was 1.75, which means that pediatric hospitalists collected only about 57 cents in professional fee revenues for every dollar of compensation paid. Adult hospitalists, by comparison, collected about 80 cents for each dollar of compensation.

Dr. Rauch isn’t particularly surprised by those figures. “The goals of nonacademic pediatric hospital medicine programs are more about providing service and expertise than about volume,” he says. “Most community hospital-based pediatric programs simply don’t have the consistent volume to support hospitalists on a billing basis, especially since they typically experience seasonal census variations that academic children’s hospitals don’t have.”

Leslie Flores, SHM senior advisor, practice management

Last chance for both pediatric and adult HM practices to participate in the 2012 State of Hospital Medicine survey: The survey closes March 9. Visit www.hospitalmedicine.org/survey.

The SHM/MGMA 2011 State of Hospital Medicine report offers some intriguing glimpses into the world of pediatric hospital medicine. Last year, we received responses from 31 pediatric HM groups, more than half of which were academic (an additional 29 groups reported caring for both adults and children).

SHM Pediatrics Committee chair Doug Carlson, MD, SFHM, professor of pediatrics and director of the Division of Pediatric Hospital Medicine at Washington University in St. Louis, believes that the number of community hospitals with pediatric hospitalists is growing, based on his work with the workforce group of the Pediatric Hospital Medicine leadership group. Hopefully we will see more community pediatric HM groups in future surveys.

As is the case in adult HM, academic pediatric practices tend to be larger than their nonacademic counterparts, with a median size of 6.0 FTEs vs. 4.0 FTEs in nonacademic groups. In both cases, this is well below the median size of comparable adult HM groups.

“Community hospital programs are often started to improve the quality of care around the clock,” Dr. Carlson says. “But the minimum number of FTEs needed for a sustainable 24-hour program is about five—even in very small units. Group size can often be larger in academic settings because pediatric units are larger, and their tertiary nature creates more opportunities for involvement in surgical comanagement and other types of complex care.”

The report shows turnover was higher for both academic and nonacademic pediatric HM practices than for adult medicine practices. The median turnover for nonacademic pediatric groups was 15.5%, for example, compared with 8.2% for the nonacademic adult groups. The sample size for pediatric groups was much smaller, however.

Pediatric hospitalist Dan Rauch, MD, FAAP, FHM, associate professor of pediatrics at Mount Sinai School of Medicine in New York, N.Y., and a former SHM Practice Analysis Committee member, notes that because the typical pediatric group size is much smaller than an adult practice, the loss of only a single hospitalist will result in a much higher turnover rate.

“It’s also my sense that community-based pediatric hospitalist positions are more likely to be transient spots as opposed to academic positions, which are more likely to lead to sustained careers,” he says.

Table 1 (above) presents some key median indicators for nonacademic HM practices. As is true for pediatricians in traditional practice, the typical pediatric hospitalist earned quite a bit less than her colleagues in adult medicine.

Even so, the finances of a pediatric HM program are more challenging than for adult hospitalists. Although professional fee collections per work relative value unit (wRVU) were slightly higher for pediatric groups than for adult groups (a surprising finding as the primary payor for many pediatric hospitalist groups is Medicaid), pediatric hospitalists’ typical annual wRVU production was about 53% lower than that of adult hospitalists, according to the 2011 report. As a result, the compensation-to-collections ratio for pediatric hospitalists was 1.75, which means that pediatric hospitalists collected only about 57 cents in professional fee revenues for every dollar of compensation paid. Adult hospitalists, by comparison, collected about 80 cents for each dollar of compensation.

Dr. Rauch isn’t particularly surprised by those figures. “The goals of nonacademic pediatric hospital medicine programs are more about providing service and expertise than about volume,” he says. “Most community hospital-based pediatric programs simply don’t have the consistent volume to support hospitalists on a billing basis, especially since they typically experience seasonal census variations that academic children’s hospitals don’t have.”

Leslie Flores, SHM senior advisor, practice management

Last chance for both pediatric and adult HM practices to participate in the 2012 State of Hospital Medicine survey: The survey closes March 9. Visit www.hospitalmedicine.org/survey.

“A auick glance at the CMMI website didn’t provide much detail beyond uplifting language about the promise that the center represents.” —Policy Corner, January 2011

Alittle over a year ago, this column made the above statement about the launch of the Center for Medicare and Medicaid Innovation (CMMI) and its charge under the Affordable Care Act (ACA) to test ways to reduce costs while preserving or enhancing the quality of healthcare. A lot has happened in the past year at CMMI, and many details can now be filled in. Some of those details directly relate to the work of hospitalists.

The first and most-often-cited action taken by CMMI is the launch of the Pioneer ACO initiative. The Pioneer ACO model is designed specifically for groups of providers with experience working together to coordinate care for patients. The initiative is designed to test the effectiveness of several payment models and how they can provide better care for beneficiaries, work in coordination with private payors, and reduce Medicare cost growth.

In December 2011, 32 Pioneer ACOs were announced; a performance period began on Jan. 12. Thus, Pioneer ACOs are a reality, and several hospitalists have informed SHM that their institutions are participating.

Also on the ACO front, CMMI has made an effort to answer one of the most-cited barriers to ACO formation: start-up funding. In trying to answer this concern, CMMI has established the Advance Payment ACO Model. It is designed to provide support to rural and physician-owned organizations whose ability to successfully start an ACO would be improved with additional access to capital. This program will provide upfront payments and monthly payments to ACOs based on certain criteria. The first application period ended Feb. 1, so we should soon know which organizations are taking advantage of the opportunity.

A final example of CMMI activity is a $1 billion investment in the Partnership for Patients, an initiative to reduce preventable hospital-acquired conditions by 40% and hospital readmissions by 20% by 2013. The partnership has chosen 26 Hospital Engagement Networks to help identify solutions that already are working and spread those solutions to other hospitals and healthcare providers. Because the goals of the program cover areas in which hospitalists have both expertise and success, SHM is partnering with Hospital Engagement Networks to help achieve the goals of the program.

This update is by no means comprehensive. CMMI has started quite a few other programs over the past year, and all of them can be viewed in detail at http://innovations.cms.gov/.

Please let us know if you are involved with any of these initiatives. Your experience and insight could be helpful in advocating for the needs of hospitalists, and might also be useful to others who find themselves involved in the near future.

Joshua Boswell, interim senior manager, government relations

“A auick glance at the CMMI website didn’t provide much detail beyond uplifting language about the promise that the center represents.” —Policy Corner, January 2011

Alittle over a year ago, this column made the above statement about the launch of the Center for Medicare and Medicaid Innovation (CMMI) and its charge under the Affordable Care Act (ACA) to test ways to reduce costs while preserving or enhancing the quality of healthcare. A lot has happened in the past year at CMMI, and many details can now be filled in. Some of those details directly relate to the work of hospitalists.

The first and most-often-cited action taken by CMMI is the launch of the Pioneer ACO initiative. The Pioneer ACO model is designed specifically for groups of providers with experience working together to coordinate care for patients. The initiative is designed to test the effectiveness of several payment models and how they can provide better care for beneficiaries, work in coordination with private payors, and reduce Medicare cost growth.

In December 2011, 32 Pioneer ACOs were announced; a performance period began on Jan. 12. Thus, Pioneer ACOs are a reality, and several hospitalists have informed SHM that their institutions are participating.

Also on the ACO front, CMMI has made an effort to answer one of the most-cited barriers to ACO formation: start-up funding. In trying to answer this concern, CMMI has established the Advance Payment ACO Model. It is designed to provide support to rural and physician-owned organizations whose ability to successfully start an ACO would be improved with additional access to capital. This program will provide upfront payments and monthly payments to ACOs based on certain criteria. The first application period ended Feb. 1, so we should soon know which organizations are taking advantage of the opportunity.

A final example of CMMI activity is a $1 billion investment in the Partnership for Patients, an initiative to reduce preventable hospital-acquired conditions by 40% and hospital readmissions by 20% by 2013. The partnership has chosen 26 Hospital Engagement Networks to help identify solutions that already are working and spread those solutions to other hospitals and healthcare providers. Because the goals of the program cover areas in which hospitalists have both expertise and success, SHM is partnering with Hospital Engagement Networks to help achieve the goals of the program.

This update is by no means comprehensive. CMMI has started quite a few other programs over the past year, and all of them can be viewed in detail at http://innovations.cms.gov/.

Please let us know if you are involved with any of these initiatives. Your experience and insight could be helpful in advocating for the needs of hospitalists, and might also be useful to others who find themselves involved in the near future.

Joshua Boswell, interim senior manager, government relations

“A auick glance at the CMMI website didn’t provide much detail beyond uplifting language about the promise that the center represents.” —Policy Corner, January 2011

Alittle over a year ago, this column made the above statement about the launch of the Center for Medicare and Medicaid Innovation (CMMI) and its charge under the Affordable Care Act (ACA) to test ways to reduce costs while preserving or enhancing the quality of healthcare. A lot has happened in the past year at CMMI, and many details can now be filled in. Some of those details directly relate to the work of hospitalists.

The first and most-often-cited action taken by CMMI is the launch of the Pioneer ACO initiative. The Pioneer ACO model is designed specifically for groups of providers with experience working together to coordinate care for patients. The initiative is designed to test the effectiveness of several payment models and how they can provide better care for beneficiaries, work in coordination with private payors, and reduce Medicare cost growth.

In December 2011, 32 Pioneer ACOs were announced; a performance period began on Jan. 12. Thus, Pioneer ACOs are a reality, and several hospitalists have informed SHM that their institutions are participating.

Also on the ACO front, CMMI has made an effort to answer one of the most-cited barriers to ACO formation: start-up funding. In trying to answer this concern, CMMI has established the Advance Payment ACO Model. It is designed to provide support to rural and physician-owned organizations whose ability to successfully start an ACO would be improved with additional access to capital. This program will provide upfront payments and monthly payments to ACOs based on certain criteria. The first application period ended Feb. 1, so we should soon know which organizations are taking advantage of the opportunity.

A final example of CMMI activity is a $1 billion investment in the Partnership for Patients, an initiative to reduce preventable hospital-acquired conditions by 40% and hospital readmissions by 20% by 2013. The partnership has chosen 26 Hospital Engagement Networks to help identify solutions that already are working and spread those solutions to other hospitals and healthcare providers. Because the goals of the program cover areas in which hospitalists have both expertise and success, SHM is partnering with Hospital Engagement Networks to help achieve the goals of the program.

This update is by no means comprehensive. CMMI has started quite a few other programs over the past year, and all of them can be viewed in detail at http://innovations.cms.gov/.

Please let us know if you are involved with any of these initiatives. Your experience and insight could be helpful in advocating for the needs of hospitalists, and might also be useful to others who find themselves involved in the near future.

Joshua Boswell, interim senior manager, government relations

The near-viral adoption of smartphone technology in hospital settings has made headlines recently, raising concerns about distracted physicians, data security breaches, infection hazards from bacteria on devices, and even misplaced devices. Critics also note the problems will be multiplied as electronic health records gain traction and become even more linked with handheld devices.

Russ Cucina, MD, MS, a hospitalist and medical director of information technology at the University of California at San Francisco (UCSF) Medical Center, says these issues aren’t new, and they’ve been successfully addressed in other industries for years.

Peter J. Papadakos, MD, professor of anesthesiology, surgery, and neurosurgery at the University of Rochester in New York, wrote in Anesthesiology News in November about the dangers of “electronic distraction” from mobile devices.¹ He told The New York Times: “You walk around the hospital and what you see is not funny,” in terms of professional staff texting, surfing the Web, and playing games.² “My gut feeling is lives are in danger.”

In December, John Halamka, MD, chief information officer at Beth Israel Deaconess Medical Center in Boston and chair of the U.S. Healthcare Information Technology Standards Panel, commented on a multitasking medical mishap involving a resident who answered a text message about an upcoming party during rounds.³ He noted that BIDMC doctors and nurses at have purchased more than 1,000 iPads and 1,600 iPhones with their own funds. Because of increased risks for interruptions and inadvertent disclosure of protected health information, Dr. Halamka recommends that hospitals carefully consider best practices and implement policies and technologies to mitigate those risks.

In November, CIO.com called mobile devices “the dominant technology tool in American enterprise,” but also labeled them a “security minefield.”⁴ Amcom Software of Eden Prairie, Minn., recently produced a white paper, “Six Things Hospitals Need to Know about Supporting the Adoption of Smartphones,” with recommendations for integration, redundancy, and escalation in their use.⁵ And the Schumacher physician management group of Lafayette, La., has incorporated smartphone applications for its emergency physicians, with similar technology expected soon for its hospitalists.⁶

“To me, a lot of this discussion in medicine is 18 to 28 months behind the times,” Dr. Cucina says. “Perhaps it’s novel to Dr. Papadakos, but we’ve had the problem for some time. Everyone is using smartphones in the clinical environment. Everybody has one. The computers we have at work get a lot of use for personal business. It’s happening; we have arrived. Now, how are we going to deal with it?”

Other industries have placed technological or administrative limits on using company devices for personal use. At UCSF, bandwidth limits were placed on access to the online video service YouTube—with unintended consequences. “There is a lot of good clinical content on YouTube that could be used for patient education at the bedside,” Dr. Cucina admits.

Given the technological imperatives, Dr. Cucina says, it makes less sense for clinicians to carry two smartphones—“one to call your spouse, one to call up Epocrates. But if we’re all going to carry converged devices, how do we use them appropriately?” It also is important to be clear on what they do well, such as retrieving clinical information, but not inputting complex charting or expecting security, privacy, and guaranteed message delivery.

Ultimately, Dr. Cucina says, new technology brings into focus issues that have long been part of medicine. “The obligation to honor patients’ privacy goes back to Hippocrates. And we’ve had infection control issues with stethoscopes since they were invented,” he says, adding the issues—and solutions—are less technological than administrative and behavioral.

References

1. Papadakos P. Electronic distraction: an unmeasured variable in modern medicine. Anesthesiology News website. Available at: http://www.anesthesiologynews.com/ViewArticle.aspx?d=Commentary&d_id=449&i=November+2011&i_id=785&a_id=19643. Accessed Jan. 14, 2012.
2. Richtel M. As doctors use more devices, potential for distraction grows. The New York Times website. Available at: http://www.nytimes.com/2011/12/15/health/as-doctors-use-more-devices-potential-for-distraction-grows.html?_r=4&pagewanted=all%3Fsrc%3Dtp&smid=fb-share. Accessed Jan. 14, 2012.
3. Halamka J. Order interrupted by text: multitasking mishap. AHRQ website. Available at: http://webmm.ahrq.gov/case.aspx?caseID=257. Accessed Jan. 12, 2012.
4. Armerding T. In 2012, a mobile security minefield. CIO-IN website. Available at: http://www.cio.in/news/2012-mobile-security-minefield-199762011. Accessed Jan. 12, 2012.
5. Six things hospitals need to know about supporting the adoption of smartphones. Amcom website. Available at: http://www.amcomsoftware.com/gwf/?id=NDMy&name=Amcom+Website_Smartphone+Adoption+WP. Accessed Jan. 11, 2012.
6. Quinn R. HM embraces smartphones. The Hospitalist website. Available at: http://www.the-hospitalist.org/details/article/1418005/HM_Embraces_Smartphones.html. Accessed Jan. 14, 2012.

The near-viral adoption of smartphone technology in hospital settings has made headlines recently, raising concerns about distracted physicians, data security breaches, infection hazards from bacteria on devices, and even misplaced devices. Critics also note the problems will be multiplied as electronic health records gain traction and become even more linked with handheld devices.

Russ Cucina, MD, MS, a hospitalist and medical director of information technology at the University of California at San Francisco (UCSF) Medical Center, says these issues aren’t new, and they’ve been successfully addressed in other industries for years.

Peter J. Papadakos, MD, professor of anesthesiology, surgery, and neurosurgery at the University of Rochester in New York, wrote in Anesthesiology News in November about the dangers of “electronic distraction” from mobile devices.¹ He told The New York Times: “You walk around the hospital and what you see is not funny,” in terms of professional staff texting, surfing the Web, and playing games.² “My gut feeling is lives are in danger.”

In December, John Halamka, MD, chief information officer at Beth Israel Deaconess Medical Center in Boston and chair of the U.S. Healthcare Information Technology Standards Panel, commented on a multitasking medical mishap involving a resident who answered a text message about an upcoming party during rounds.³ He noted that BIDMC doctors and nurses at have purchased more than 1,000 iPads and 1,600 iPhones with their own funds. Because of increased risks for interruptions and inadvertent disclosure of protected health information, Dr. Halamka recommends that hospitals carefully consider best practices and implement policies and technologies to mitigate those risks.

In November, CIO.com called mobile devices “the dominant technology tool in American enterprise,” but also labeled them a “security minefield.”⁴ Amcom Software of Eden Prairie, Minn., recently produced a white paper, “Six Things Hospitals Need to Know about Supporting the Adoption of Smartphones,” with recommendations for integration, redundancy, and escalation in their use.⁵ And the Schumacher physician management group of Lafayette, La., has incorporated smartphone applications for its emergency physicians, with similar technology expected soon for its hospitalists.⁶

“To me, a lot of this discussion in medicine is 18 to 28 months behind the times,” Dr. Cucina says. “Perhaps it’s novel to Dr. Papadakos, but we’ve had the problem for some time. Everyone is using smartphones in the clinical environment. Everybody has one. The computers we have at work get a lot of use for personal business. It’s happening; we have arrived. Now, how are we going to deal with it?”

Other industries have placed technological or administrative limits on using company devices for personal use. At UCSF, bandwidth limits were placed on access to the online video service YouTube—with unintended consequences. “There is a lot of good clinical content on YouTube that could be used for patient education at the bedside,” Dr. Cucina admits.

Given the technological imperatives, Dr. Cucina says, it makes less sense for clinicians to carry two smartphones—“one to call your spouse, one to call up Epocrates. But if we’re all going to carry converged devices, how do we use them appropriately?” It also is important to be clear on what they do well, such as retrieving clinical information, but not inputting complex charting or expecting security, privacy, and guaranteed message delivery.

Ultimately, Dr. Cucina says, new technology brings into focus issues that have long been part of medicine. “The obligation to honor patients’ privacy goes back to Hippocrates. And we’ve had infection control issues with stethoscopes since they were invented,” he says, adding the issues—and solutions—are less technological than administrative and behavioral.

References

1. Papadakos P. Electronic distraction: an unmeasured variable in modern medicine. Anesthesiology News website. Available at: http://www.anesthesiologynews.com/ViewArticle.aspx?d=Commentary&d_id=449&i=November+2011&i_id=785&a_id=19643. Accessed Jan. 14, 2012.
2. Richtel M. As doctors use more devices, potential for distraction grows. The New York Times website. Available at: http://www.nytimes.com/2011/12/15/health/as-doctors-use-more-devices-potential-for-distraction-grows.html?_r=4&pagewanted=all%3Fsrc%3Dtp&smid=fb-share. Accessed Jan. 14, 2012.
3. Halamka J. Order interrupted by text: multitasking mishap. AHRQ website. Available at: http://webmm.ahrq.gov/case.aspx?caseID=257. Accessed Jan. 12, 2012.
4. Armerding T. In 2012, a mobile security minefield. CIO-IN website. Available at: http://www.cio.in/news/2012-mobile-security-minefield-199762011. Accessed Jan. 12, 2012.
5. Six things hospitals need to know about supporting the adoption of smartphones. Amcom website. Available at: http://www.amcomsoftware.com/gwf/?id=NDMy&name=Amcom+Website_Smartphone+Adoption+WP. Accessed Jan. 11, 2012.
6. Quinn R. HM embraces smartphones. The Hospitalist website. Available at: http://www.the-hospitalist.org/details/article/1418005/HM_Embraces_Smartphones.html. Accessed Jan. 14, 2012.

The near-viral adoption of smartphone technology in hospital settings has made headlines recently, raising concerns about distracted physicians, data security breaches, infection hazards from bacteria on devices, and even misplaced devices. Critics also note the problems will be multiplied as electronic health records gain traction and become even more linked with handheld devices.

Russ Cucina, MD, MS, a hospitalist and medical director of information technology at the University of California at San Francisco (UCSF) Medical Center, says these issues aren’t new, and they’ve been successfully addressed in other industries for years.

Peter J. Papadakos, MD, professor of anesthesiology, surgery, and neurosurgery at the University of Rochester in New York, wrote in Anesthesiology News in November about the dangers of “electronic distraction” from mobile devices.¹ He told The New York Times: “You walk around the hospital and what you see is not funny,” in terms of professional staff texting, surfing the Web, and playing games.² “My gut feeling is lives are in danger.”

In December, John Halamka, MD, chief information officer at Beth Israel Deaconess Medical Center in Boston and chair of the U.S. Healthcare Information Technology Standards Panel, commented on a multitasking medical mishap involving a resident who answered a text message about an upcoming party during rounds.³ He noted that BIDMC doctors and nurses at have purchased more than 1,000 iPads and 1,600 iPhones with their own funds. Because of increased risks for interruptions and inadvertent disclosure of protected health information, Dr. Halamka recommends that hospitals carefully consider best practices and implement policies and technologies to mitigate those risks.

In November, CIO.com called mobile devices “the dominant technology tool in American enterprise,” but also labeled them a “security minefield.”⁴ Amcom Software of Eden Prairie, Minn., recently produced a white paper, “Six Things Hospitals Need to Know about Supporting the Adoption of Smartphones,” with recommendations for integration, redundancy, and escalation in their use.⁵ And the Schumacher physician management group of Lafayette, La., has incorporated smartphone applications for its emergency physicians, with similar technology expected soon for its hospitalists.⁶

“To me, a lot of this discussion in medicine is 18 to 28 months behind the times,” Dr. Cucina says. “Perhaps it’s novel to Dr. Papadakos, but we’ve had the problem for some time. Everyone is using smartphones in the clinical environment. Everybody has one. The computers we have at work get a lot of use for personal business. It’s happening; we have arrived. Now, how are we going to deal with it?”

Other industries have placed technological or administrative limits on using company devices for personal use. At UCSF, bandwidth limits were placed on access to the online video service YouTube—with unintended consequences. “There is a lot of good clinical content on YouTube that could be used for patient education at the bedside,” Dr. Cucina admits.

Given the technological imperatives, Dr. Cucina says, it makes less sense for clinicians to carry two smartphones—“one to call your spouse, one to call up Epocrates. But if we’re all going to carry converged devices, how do we use them appropriately?” It also is important to be clear on what they do well, such as retrieving clinical information, but not inputting complex charting or expecting security, privacy, and guaranteed message delivery.

Ultimately, Dr. Cucina says, new technology brings into focus issues that have long been part of medicine. “The obligation to honor patients’ privacy goes back to Hippocrates. And we’ve had infection control issues with stethoscopes since they were invented,” he says, adding the issues—and solutions—are less technological than administrative and behavioral.

References

1. Papadakos P. Electronic distraction: an unmeasured variable in modern medicine. Anesthesiology News website. Available at: http://www.anesthesiologynews.com/ViewArticle.aspx?d=Commentary&d_id=449&i=November+2011&i_id=785&a_id=19643. Accessed Jan. 14, 2012.
2. Richtel M. As doctors use more devices, potential for distraction grows. The New York Times website. Available at: http://www.nytimes.com/2011/12/15/health/as-doctors-use-more-devices-potential-for-distraction-grows.html?_r=4&pagewanted=all%3Fsrc%3Dtp&smid=fb-share. Accessed Jan. 14, 2012.
3. Halamka J. Order interrupted by text: multitasking mishap. AHRQ website. Available at: http://webmm.ahrq.gov/case.aspx?caseID=257. Accessed Jan. 12, 2012.
4. Armerding T. In 2012, a mobile security minefield. CIO-IN website. Available at: http://www.cio.in/news/2012-mobile-security-minefield-199762011. Accessed Jan. 12, 2012.
5. Six things hospitals need to know about supporting the adoption of smartphones. Amcom website. Available at: http://www.amcomsoftware.com/gwf/?id=NDMy&name=Amcom+Website_Smartphone+Adoption+WP. Accessed Jan. 11, 2012.
6. Quinn R. HM embraces smartphones. The Hospitalist website. Available at: http://www.the-hospitalist.org/details/article/1418005/HM_Embraces_Smartphones.html. Accessed Jan. 14, 2012.

Percentage growth in health spending in 2010, to $2.6 trillion, according to a report in the January 2012 issue of Health Affairs.¹ The increase is only slightly more than the 3.8% increase in 2009, and it managed to keep health spending’s portion of the total economy essentially unchanged at 17.9% of GDP. Hospital spending grew 4.9% to $814 billion, which represents 30% of overall health spending and a lower rate of growth than in 2009 (6.4%).

Reference

1. Martin AB, Lassman D, Washington B, Catlin A, the National Health Expenditure Accounts Team Growth in U.S. health spending remained slow in 2010; health share of gross domestic product was unchanged from 2009. Health Affairs. 2012;31:208-219.

Percentage growth in health spending in 2010, to $2.6 trillion, according to a report in the January 2012 issue of Health Affairs.¹ The increase is only slightly more than the 3.8% increase in 2009, and it managed to keep health spending’s portion of the total economy essentially unchanged at 17.9% of GDP. Hospital spending grew 4.9% to $814 billion, which represents 30% of overall health spending and a lower rate of growth than in 2009 (6.4%).

Reference

1. Martin AB, Lassman D, Washington B, Catlin A, the National Health Expenditure Accounts Team Growth in U.S. health spending remained slow in 2010; health share of gross domestic product was unchanged from 2009. Health Affairs. 2012;31:208-219.

Percentage growth in health spending in 2010, to $2.6 trillion, according to a report in the January 2012 issue of Health Affairs.¹ The increase is only slightly more than the 3.8% increase in 2009, and it managed to keep health spending’s portion of the total economy essentially unchanged at 17.9% of GDP. Hospital spending grew 4.9% to $814 billion, which represents 30% of overall health spending and a lower rate of growth than in 2009 (6.4%).

Reference

1. Martin AB, Lassman D, Washington B, Catlin A, the National Health Expenditure Accounts Team Growth in U.S. health spending remained slow in 2010; health share of gross domestic product was unchanged from 2009. Health Affairs. 2012;31:208-219.

The Joint Commission in December issued a “Sentinel Event Alert” on the dangers of extended shift fatigue in healthcare workers, particularly for nurses who work shifts longer than 12.5 hours.¹ A long list of potentially unsafe practices resulting from fatigue includes memory lapses, irritability, impaired communication, diminished reaction time, indifference, loss of empathy, and on-the-job injury.

The Joint Commission’s alert recommends practices to prevent negative effects from lack of sleep, including revisiting patient hand-off processes to maximize safety; giving staff a voice in their scheduling; educating employees about fatigue; and establishing a fatigue management plan and a forum for staff to discuss these issues. The American College of Graduate Medical Education’s current “Duty Hours Standards,” effective July 2011, require faculty members and residents to recognize the signs of fatigue and sleep deprivation and to adopt processes to manage the potential effects of fatigue on patient care.²

References

1. Health care worker fatigue and patient safety. Joint Commission website. Available at: http://www.jointcommission.org/assets/1/18/sea_48.pdf. Accessed Jan. 10, 2012.
2. Accreditation Council for Graduate Medical Education website. Available at: http://www.acgme.org/acwebsite/dutyhours/dh_index.asp. Accessed Jan. 10, 2012.

The Joint Commission in December issued a “Sentinel Event Alert” on the dangers of extended shift fatigue in healthcare workers, particularly for nurses who work shifts longer than 12.5 hours.¹ A long list of potentially unsafe practices resulting from fatigue includes memory lapses, irritability, impaired communication, diminished reaction time, indifference, loss of empathy, and on-the-job injury.

The Joint Commission’s alert recommends practices to prevent negative effects from lack of sleep, including revisiting patient hand-off processes to maximize safety; giving staff a voice in their scheduling; educating employees about fatigue; and establishing a fatigue management plan and a forum for staff to discuss these issues. The American College of Graduate Medical Education’s current “Duty Hours Standards,” effective July 2011, require faculty members and residents to recognize the signs of fatigue and sleep deprivation and to adopt processes to manage the potential effects of fatigue on patient care.²

References

1. Health care worker fatigue and patient safety. Joint Commission website. Available at: http://www.jointcommission.org/assets/1/18/sea_48.pdf. Accessed Jan. 10, 2012.
2. Accreditation Council for Graduate Medical Education website. Available at: http://www.acgme.org/acwebsite/dutyhours/dh_index.asp. Accessed Jan. 10, 2012.

The Joint Commission in December issued a “Sentinel Event Alert” on the dangers of extended shift fatigue in healthcare workers, particularly for nurses who work shifts longer than 12.5 hours.¹ A long list of potentially unsafe practices resulting from fatigue includes memory lapses, irritability, impaired communication, diminished reaction time, indifference, loss of empathy, and on-the-job injury.

The Joint Commission’s alert recommends practices to prevent negative effects from lack of sleep, including revisiting patient hand-off processes to maximize safety; giving staff a voice in their scheduling; educating employees about fatigue; and establishing a fatigue management plan and a forum for staff to discuss these issues. The American College of Graduate Medical Education’s current “Duty Hours Standards,” effective July 2011, require faculty members and residents to recognize the signs of fatigue and sleep deprivation and to adopt processes to manage the potential effects of fatigue on patient care.²

References

1. Health care worker fatigue and patient safety. Joint Commission website. Available at: http://www.jointcommission.org/assets/1/18/sea_48.pdf. Accessed Jan. 10, 2012.
2. Accreditation Council for Graduate Medical Education website. Available at: http://www.acgme.org/acwebsite/dutyhours/dh_index.asp. Accessed Jan. 10, 2012.

Doctors Helping Doctors Transform Health Care, a foundation-supported, nonprofit campaign, was launched Dec. 1 in Washington, D.C., to spur greater and more effective use of health information technology (HIT) by physicians to improve quality, safety, and efficiency. The Doctors Helping Doctors website (www.doctorshelpingdoctorstransformhealthcare.org) provides physicians space to share their lessons learned and strategies via video, audio, written testimonials, and blog posts.

Chaired by Peter Basch, MD, a Washington internist and medical director of ambulatory electronic health records (HER) and HIT policy for MedStar Health, the collaborative campaign is sponsored by the Association of Medical Directors of Information Systems, the American Academy of Family Physicians, and several other medical societies. Doctors Helping Doctors aims to engage physicians from a diverse range of specialties and settings, including hospitalists.

Doctors Helping Doctors Transform Health Care, a foundation-supported, nonprofit campaign, was launched Dec. 1 in Washington, D.C., to spur greater and more effective use of health information technology (HIT) by physicians to improve quality, safety, and efficiency. The Doctors Helping Doctors website (www.doctorshelpingdoctorstransformhealthcare.org) provides physicians space to share their lessons learned and strategies via video, audio, written testimonials, and blog posts.

Chaired by Peter Basch, MD, a Washington internist and medical director of ambulatory electronic health records (HER) and HIT policy for MedStar Health, the collaborative campaign is sponsored by the Association of Medical Directors of Information Systems, the American Academy of Family Physicians, and several other medical societies. Doctors Helping Doctors aims to engage physicians from a diverse range of specialties and settings, including hospitalists.

Doctors Helping Doctors Transform Health Care, a foundation-supported, nonprofit campaign, was launched Dec. 1 in Washington, D.C., to spur greater and more effective use of health information technology (HIT) by physicians to improve quality, safety, and efficiency. The Doctors Helping Doctors website (www.doctorshelpingdoctorstransformhealthcare.org) provides physicians space to share their lessons learned and strategies via video, audio, written testimonials, and blog posts.

Chaired by Peter Basch, MD, a Washington internist and medical director of ambulatory electronic health records (HER) and HIT policy for MedStar Health, the collaborative campaign is sponsored by the Association of Medical Directors of Information Systems, the American Academy of Family Physicians, and several other medical societies. Doctors Helping Doctors aims to engage physicians from a diverse range of specialties and settings, including hospitalists.

A hospitalist-led project to improve bed assignment practices at Baystate Medical Center in Springfield, Mass., reduced errors in patient placements to 3.1% from 9.4%, according to an abstract presentation at HM11.

The project identified incorrect placement of patients in open beds due to incomplete understanding of the patient’s medical picture, explains lead author Christine Bryson, DO, SFHM, Baystate’s associate medical director for hospital medicine. For example, a patient with a diagnosis of pneumonia who was receiving peritoneal dialysis might be admitted to the respiratory unit, but then would need transfer to the renal unit, where the dialysis could be performed. Such incorrect bed placements and lateral transfers were happening eight times a day, at a cost conservatively estimated at $106 each for nursing, a nonphysician patient placement manager (PPM), and housekeeping services and supplies. That puts potential annual cost savings is $232,000, Dr. Bryson explains.

A committee led by Baystate hospitalists examined current admission processes in detail and recommended a new process: ED physicians confer with the PPM, the PPM reviews the chart and discusses the case with the admitting hospitalist, and then the PPM and hospitalist have an informed, three-way phone conversation about placement.

Hospitalists have been directed to return these calls within 15 minutes, which can be an issue all its own. Another identified barrier was the communications technology, so ED physicians have been issued cellphones so they don’t have to wait at a terminal for a callback from the hospitalist. Dr. Bryson says overall booking process time fell, as did the number of placement errors.

A hospitalist-led project to improve bed assignment practices at Baystate Medical Center in Springfield, Mass., reduced errors in patient placements to 3.1% from 9.4%, according to an abstract presentation at HM11.

The project identified incorrect placement of patients in open beds due to incomplete understanding of the patient’s medical picture, explains lead author Christine Bryson, DO, SFHM, Baystate’s associate medical director for hospital medicine. For example, a patient with a diagnosis of pneumonia who was receiving peritoneal dialysis might be admitted to the respiratory unit, but then would need transfer to the renal unit, where the dialysis could be performed. Such incorrect bed placements and lateral transfers were happening eight times a day, at a cost conservatively estimated at $106 each for nursing, a nonphysician patient placement manager (PPM), and housekeeping services and supplies. That puts potential annual cost savings is $232,000, Dr. Bryson explains.

A committee led by Baystate hospitalists examined current admission processes in detail and recommended a new process: ED physicians confer with the PPM, the PPM reviews the chart and discusses the case with the admitting hospitalist, and then the PPM and hospitalist have an informed, three-way phone conversation about placement.

Hospitalists have been directed to return these calls within 15 minutes, which can be an issue all its own. Another identified barrier was the communications technology, so ED physicians have been issued cellphones so they don’t have to wait at a terminal for a callback from the hospitalist. Dr. Bryson says overall booking process time fell, as did the number of placement errors.

A hospitalist-led project to improve bed assignment practices at Baystate Medical Center in Springfield, Mass., reduced errors in patient placements to 3.1% from 9.4%, according to an abstract presentation at HM11.

The project identified incorrect placement of patients in open beds due to incomplete understanding of the patient’s medical picture, explains lead author Christine Bryson, DO, SFHM, Baystate’s associate medical director for hospital medicine. For example, a patient with a diagnosis of pneumonia who was receiving peritoneal dialysis might be admitted to the respiratory unit, but then would need transfer to the renal unit, where the dialysis could be performed. Such incorrect bed placements and lateral transfers were happening eight times a day, at a cost conservatively estimated at $106 each for nursing, a nonphysician patient placement manager (PPM), and housekeeping services and supplies. That puts potential annual cost savings is $232,000, Dr. Bryson explains.

A committee led by Baystate hospitalists examined current admission processes in detail and recommended a new process: ED physicians confer with the PPM, the PPM reviews the chart and discusses the case with the admitting hospitalist, and then the PPM and hospitalist have an informed, three-way phone conversation about placement.

Hospitalists have been directed to return these calls within 15 minutes, which can be an issue all its own. Another identified barrier was the communications technology, so ED physicians have been issued cellphones so they don’t have to wait at a terminal for a callback from the hospitalist. Dr. Bryson says overall booking process time fell, as did the number of placement errors.

Pediatric hospitalist Jeff Sperring, MD, says he did not go into medicine with aspirations of becoming a hospital administrator. Last November, however, he was named president and CEO of Riley Hospital for Children at Indiana University Health in Indianapolis. It’s a path into healthcare leadership, he believes, that other pediatric hospitalists can and will follow.

“Being a hospitalist was critical to that progression. You are there; you understand what needs to be changed. More than anything else, it’s just being available, willing, and able to help,” Dr. Sperring says. “You lead one project, that leads to additional roles, and that leads to this.”

Dr. Sperring is one of a handful of pediatric hospitalists who have joined the C-suite and assumed major administrative responsibilities in their hospitals. Most say their HM experience was crucial to the journey.

Another pediatric hospitalist, Patrick Conway, MD, MSc, SFHM, earlier this year was named chief medical officer for the Centers for Medicare & Medicaid Services (see “Pediatric Hospitalist Takes CMS Leadership Position,” June 2011, p. 28), and is responsible for administering federal healthcare quality initiatives and setting the government’s quality agenda. Dr. Conway, previously director of hospital medicine at Cincinnati Children’s Hospital Medical Center, says that pediatric HM, in particular, lines up with major priorities in healthcare reform—most notably patient-centered care.

“Pediatricians often have strong communication skills honed by taking care of patients and their families,” Dr. Conway says. “Our training typically emphasizes team-based care and improving the health system.”

The path to hospital leadership might be a little different from the pediatric side. But he urges pediatric hospitalists to look for opportunities beyond pediatrics, within the larger healthcare system and the care of adult patients.

“I am an example of the potential for pediatric hospitalists to take on broader leadership roles,” Dr. Conway says. “I encourage medical students to consider pediatric hospital medicine, with its opportunities for leading change and taking care of patients at the same time.”

Change Agents

Leaders on the path to such C-suite positions as chief executive office (CEO), chief operating officer (COO), chief medical officer (CMO), or chief quality officer (CQO) stress the importance of finding mentors, both within and outside of the hospital, and creating effective teams in which to work. Whether a degree in business or a related field is an essential part of that journey is debatable. Dr. Sperring, for example, did not pursue formal business training, instead concentrating on leadership development. He took a one-year, part-time, multidisciplinary course on the subject offered by Indiana University. “To me, this is about understanding healthcare, how it is delivered, and then having the leadership skills to be able to make change,” he explains.

HM, with its bird’s-eye view of hospital processes and systems, is a good place to start, adds Paul Hain, MD, associate chief of staff and medical director for performance management and improvement at Monroe Carell Jr. Children’s Hospital at Vanderbilt in Nashville, Tenn. “I also think you have to understand quality improvement and be willing to measure, measure, measure.”

But advancing up the hospital’s organization chart requires something more, he notes. “A leader also needs to have a world view that things that are broken need to be fixed,” he says.

Dr. Hain studied engineering in college and worked as an engineer before attending medical school. That experience, he says, laid the foundation for “thinking about processes in healthcare systems, and the use of statistics to help understand those processes.”

The way we’re used to defining care is going to change dramatically. Hospitalists will play a key role, both in direct care delivery but also in leadership. I don’t think hospitalists have a choice but to lead change.

—Jeff Sperring, MD, hospitalist, president, CEO, Riley Hospital for Children at Indiana University Health, Indianapolis

Spearhead QI

For Dr. Sperring, advancement to the C-suite was a journey that began nine years ago, following four years in community-based practice. “I absolutely loved the relationships with my kids and families, but I missed the acute-care role,” he says.

In 2002, Riley Hospital recruited him to help start its pediatric hospitalist program. As the program grew to include 22 hospitalists at four affiliated hospitals, his responsibilities also grew to associate chief medical officer in 2007 and chief medical officer in 2009. Along the way, he worked on partnering with pediatricians in the community, spearheaded a quality program that successfully reduced length of stay in the hospital, and developed an integrated call center for hospital admissions across the health system.

By contrast, Steve Narang, MD, CMO of Banner Health System’s pediatric services and its new Cardon Children’s Medical Center in Mesa, Ariz., says he always had one eye on healthcare system and policy issues, even during residency.

“What clearly became the center of my work is the value equation,” he says. “I wanted to be in a career where I could impact on delivering and disseminating best practices in medical care. I wanted to find out what are the best approaches for taking care of patients.”

After residency, Dr. Narang moved to New Orleans in 2000, where he started an academic pediatric hospitalist program at Louisiana State University Medical Center. He later helped launch a firm called Pediatric Hospitalists Louisiana, which collaborated with hospitals across the state to improve pediatric care delivery. “That got me thinking about things more from the management perspective, how to fix gaps in the system and advance our ability to measure quality in pediatric hospital medicine,” he says.

“When you take your first job in the hospital and you start trying to define and design best practices, people look at you differently—not as a young, emerging physician but more as a physician leader. They come to you and say: ‘Will you chair this committee, or lead that effort?’” he says. “And then, suddenly, you run out of tools in your toolbox. That’s what happened to me.”

He enrolled at Harvard University in pursuit of a business degree, along the way learning new ways of looking at systems change and basic principles of financing.

Retain a Clinical Presence

“The great thing about being a hospitalist is that you’re at the intersection of everything that happens in the hospital,” Dr. Narang says. As the pediatric chief medical officer for Banner Health, he is responsible for strategic planning, quality improvement (QI), and patient safety for a 210-bed hospital. He also co-chairs the Clinical Consensus Group, which represents all of Banner’s 23 hospitals, where he is able to influence care processes at the other hospitals as well.

Many hospitalist leaders eventually confront the dilemma of whether growing administrative responsibilities stand in the way of a continuing clinical practice. Dr. Narang moonlights some evenings and weekends on hospitalist and emergency medicine shifts. However, despite still wanting to see patients, he wonders if he has reached the point where growing administrative responsibilities will make that impossible.

“It was a challenge when I became CMO to squeeze in clinical responsibilities,” Dr. Narang says. “But I believed that in order to be the right kind of CMO, I still needed to practice medicine … to know what’s happening on the floor and what still needs to be fixed. You also want your colleagues to see you as a credible physician.”

He hopes to maintain some clinical practice, and says hospitalists have the advantage of blocking out scheduled times on service.

Dr. Sperring says it is “an exciting time” to be a hospitalist. “The way we’re used to defining care is going to change dramatically. Hospitalists will play a key role, both in direct care delivery but also in leadership,” he says. “I don’t think hospitalists have a choice but to lead change. It becomes part of our value proposition and a competency for all hospitalists.”

Dr. Hain often is asked by other hospitalists how to get started with quality initiatives that might lead to something more. “I always say the first one is free, in order to show that you can solve a quality problem while being a full-time clinician,” he explains. “It says to administrators that you’re someone who can deliver, and that starts you on your way. There’s always something to be done to improve quality in the hospital.”

Larry Beresford is a freelance writer based in Oakland, Calif.

Pediatric hospitalist Jeff Sperring, MD, says he did not go into medicine with aspirations of becoming a hospital administrator. Last November, however, he was named president and CEO of Riley Hospital for Children at Indiana University Health in Indianapolis. It’s a path into healthcare leadership, he believes, that other pediatric hospitalists can and will follow.

“Being a hospitalist was critical to that progression. You are there; you understand what needs to be changed. More than anything else, it’s just being available, willing, and able to help,” Dr. Sperring says. “You lead one project, that leads to additional roles, and that leads to this.”

Dr. Sperring is one of a handful of pediatric hospitalists who have joined the C-suite and assumed major administrative responsibilities in their hospitals. Most say their HM experience was crucial to the journey.

Another pediatric hospitalist, Patrick Conway, MD, MSc, SFHM, earlier this year was named chief medical officer for the Centers for Medicare & Medicaid Services (see “Pediatric Hospitalist Takes CMS Leadership Position,” June 2011, p. 28), and is responsible for administering federal healthcare quality initiatives and setting the government’s quality agenda. Dr. Conway, previously director of hospital medicine at Cincinnati Children’s Hospital Medical Center, says that pediatric HM, in particular, lines up with major priorities in healthcare reform—most notably patient-centered care.

“Pediatricians often have strong communication skills honed by taking care of patients and their families,” Dr. Conway says. “Our training typically emphasizes team-based care and improving the health system.”

The path to hospital leadership might be a little different from the pediatric side. But he urges pediatric hospitalists to look for opportunities beyond pediatrics, within the larger healthcare system and the care of adult patients.

“I am an example of the potential for pediatric hospitalists to take on broader leadership roles,” Dr. Conway says. “I encourage medical students to consider pediatric hospital medicine, with its opportunities for leading change and taking care of patients at the same time.”

Change Agents

Leaders on the path to such C-suite positions as chief executive office (CEO), chief operating officer (COO), chief medical officer (CMO), or chief quality officer (CQO) stress the importance of finding mentors, both within and outside of the hospital, and creating effective teams in which to work. Whether a degree in business or a related field is an essential part of that journey is debatable. Dr. Sperring, for example, did not pursue formal business training, instead concentrating on leadership development. He took a one-year, part-time, multidisciplinary course on the subject offered by Indiana University. “To me, this is about understanding healthcare, how it is delivered, and then having the leadership skills to be able to make change,” he explains.

HM, with its bird’s-eye view of hospital processes and systems, is a good place to start, adds Paul Hain, MD, associate chief of staff and medical director for performance management and improvement at Monroe Carell Jr. Children’s Hospital at Vanderbilt in Nashville, Tenn. “I also think you have to understand quality improvement and be willing to measure, measure, measure.”

But advancing up the hospital’s organization chart requires something more, he notes. “A leader also needs to have a world view that things that are broken need to be fixed,” he says.

Dr. Hain studied engineering in college and worked as an engineer before attending medical school. That experience, he says, laid the foundation for “thinking about processes in healthcare systems, and the use of statistics to help understand those processes.”

The way we’re used to defining care is going to change dramatically. Hospitalists will play a key role, both in direct care delivery but also in leadership. I don’t think hospitalists have a choice but to lead change.

—Jeff Sperring, MD, hospitalist, president, CEO, Riley Hospital for Children at Indiana University Health, Indianapolis

Spearhead QI

For Dr. Sperring, advancement to the C-suite was a journey that began nine years ago, following four years in community-based practice. “I absolutely loved the relationships with my kids and families, but I missed the acute-care role,” he says.

In 2002, Riley Hospital recruited him to help start its pediatric hospitalist program. As the program grew to include 22 hospitalists at four affiliated hospitals, his responsibilities also grew to associate chief medical officer in 2007 and chief medical officer in 2009. Along the way, he worked on partnering with pediatricians in the community, spearheaded a quality program that successfully reduced length of stay in the hospital, and developed an integrated call center for hospital admissions across the health system.

By contrast, Steve Narang, MD, CMO of Banner Health System’s pediatric services and its new Cardon Children’s Medical Center in Mesa, Ariz., says he always had one eye on healthcare system and policy issues, even during residency.

“What clearly became the center of my work is the value equation,” he says. “I wanted to be in a career where I could impact on delivering and disseminating best practices in medical care. I wanted to find out what are the best approaches for taking care of patients.”

After residency, Dr. Narang moved to New Orleans in 2000, where he started an academic pediatric hospitalist program at Louisiana State University Medical Center. He later helped launch a firm called Pediatric Hospitalists Louisiana, which collaborated with hospitals across the state to improve pediatric care delivery. “That got me thinking about things more from the management perspective, how to fix gaps in the system and advance our ability to measure quality in pediatric hospital medicine,” he says.

“When you take your first job in the hospital and you start trying to define and design best practices, people look at you differently—not as a young, emerging physician but more as a physician leader. They come to you and say: ‘Will you chair this committee, or lead that effort?’” he says. “And then, suddenly, you run out of tools in your toolbox. That’s what happened to me.”

He enrolled at Harvard University in pursuit of a business degree, along the way learning new ways of looking at systems change and basic principles of financing.

Retain a Clinical Presence

“The great thing about being a hospitalist is that you’re at the intersection of everything that happens in the hospital,” Dr. Narang says. As the pediatric chief medical officer for Banner Health, he is responsible for strategic planning, quality improvement (QI), and patient safety for a 210-bed hospital. He also co-chairs the Clinical Consensus Group, which represents all of Banner’s 23 hospitals, where he is able to influence care processes at the other hospitals as well.

Many hospitalist leaders eventually confront the dilemma of whether growing administrative responsibilities stand in the way of a continuing clinical practice. Dr. Narang moonlights some evenings and weekends on hospitalist and emergency medicine shifts. However, despite still wanting to see patients, he wonders if he has reached the point where growing administrative responsibilities will make that impossible.

“It was a challenge when I became CMO to squeeze in clinical responsibilities,” Dr. Narang says. “But I believed that in order to be the right kind of CMO, I still needed to practice medicine … to know what’s happening on the floor and what still needs to be fixed. You also want your colleagues to see you as a credible physician.”

He hopes to maintain some clinical practice, and says hospitalists have the advantage of blocking out scheduled times on service.

Dr. Sperring says it is “an exciting time” to be a hospitalist. “The way we’re used to defining care is going to change dramatically. Hospitalists will play a key role, both in direct care delivery but also in leadership,” he says. “I don’t think hospitalists have a choice but to lead change. It becomes part of our value proposition and a competency for all hospitalists.”

Dr. Hain often is asked by other hospitalists how to get started with quality initiatives that might lead to something more. “I always say the first one is free, in order to show that you can solve a quality problem while being a full-time clinician,” he explains. “It says to administrators that you’re someone who can deliver, and that starts you on your way. There’s always something to be done to improve quality in the hospital.”

Larry Beresford is a freelance writer based in Oakland, Calif.

Pediatric hospitalist Jeff Sperring, MD, says he did not go into medicine with aspirations of becoming a hospital administrator. Last November, however, he was named president and CEO of Riley Hospital for Children at Indiana University Health in Indianapolis. It’s a path into healthcare leadership, he believes, that other pediatric hospitalists can and will follow.

“Being a hospitalist was critical to that progression. You are there; you understand what needs to be changed. More than anything else, it’s just being available, willing, and able to help,” Dr. Sperring says. “You lead one project, that leads to additional roles, and that leads to this.”

Dr. Sperring is one of a handful of pediatric hospitalists who have joined the C-suite and assumed major administrative responsibilities in their hospitals. Most say their HM experience was crucial to the journey.

Another pediatric hospitalist, Patrick Conway, MD, MSc, SFHM, earlier this year was named chief medical officer for the Centers for Medicare & Medicaid Services (see “Pediatric Hospitalist Takes CMS Leadership Position,” June 2011, p. 28), and is responsible for administering federal healthcare quality initiatives and setting the government’s quality agenda. Dr. Conway, previously director of hospital medicine at Cincinnati Children’s Hospital Medical Center, says that pediatric HM, in particular, lines up with major priorities in healthcare reform—most notably patient-centered care.

“Pediatricians often have strong communication skills honed by taking care of patients and their families,” Dr. Conway says. “Our training typically emphasizes team-based care and improving the health system.”

The path to hospital leadership might be a little different from the pediatric side. But he urges pediatric hospitalists to look for opportunities beyond pediatrics, within the larger healthcare system and the care of adult patients.

“I am an example of the potential for pediatric hospitalists to take on broader leadership roles,” Dr. Conway says. “I encourage medical students to consider pediatric hospital medicine, with its opportunities for leading change and taking care of patients at the same time.”

Change Agents

Leaders on the path to such C-suite positions as chief executive office (CEO), chief operating officer (COO), chief medical officer (CMO), or chief quality officer (CQO) stress the importance of finding mentors, both within and outside of the hospital, and creating effective teams in which to work. Whether a degree in business or a related field is an essential part of that journey is debatable. Dr. Sperring, for example, did not pursue formal business training, instead concentrating on leadership development. He took a one-year, part-time, multidisciplinary course on the subject offered by Indiana University. “To me, this is about understanding healthcare, how it is delivered, and then having the leadership skills to be able to make change,” he explains.

HM, with its bird’s-eye view of hospital processes and systems, is a good place to start, adds Paul Hain, MD, associate chief of staff and medical director for performance management and improvement at Monroe Carell Jr. Children’s Hospital at Vanderbilt in Nashville, Tenn. “I also think you have to understand quality improvement and be willing to measure, measure, measure.”

But advancing up the hospital’s organization chart requires something more, he notes. “A leader also needs to have a world view that things that are broken need to be fixed,” he says.

Dr. Hain studied engineering in college and worked as an engineer before attending medical school. That experience, he says, laid the foundation for “thinking about processes in healthcare systems, and the use of statistics to help understand those processes.”

The way we’re used to defining care is going to change dramatically. Hospitalists will play a key role, both in direct care delivery but also in leadership. I don’t think hospitalists have a choice but to lead change.

—Jeff Sperring, MD, hospitalist, president, CEO, Riley Hospital for Children at Indiana University Health, Indianapolis

Spearhead QI

For Dr. Sperring, advancement to the C-suite was a journey that began nine years ago, following four years in community-based practice. “I absolutely loved the relationships with my kids and families, but I missed the acute-care role,” he says.

In 2002, Riley Hospital recruited him to help start its pediatric hospitalist program. As the program grew to include 22 hospitalists at four affiliated hospitals, his responsibilities also grew to associate chief medical officer in 2007 and chief medical officer in 2009. Along the way, he worked on partnering with pediatricians in the community, spearheaded a quality program that successfully reduced length of stay in the hospital, and developed an integrated call center for hospital admissions across the health system.

By contrast, Steve Narang, MD, CMO of Banner Health System’s pediatric services and its new Cardon Children’s Medical Center in Mesa, Ariz., says he always had one eye on healthcare system and policy issues, even during residency.

“What clearly became the center of my work is the value equation,” he says. “I wanted to be in a career where I could impact on delivering and disseminating best practices in medical care. I wanted to find out what are the best approaches for taking care of patients.”

After residency, Dr. Narang moved to New Orleans in 2000, where he started an academic pediatric hospitalist program at Louisiana State University Medical Center. He later helped launch a firm called Pediatric Hospitalists Louisiana, which collaborated with hospitals across the state to improve pediatric care delivery. “That got me thinking about things more from the management perspective, how to fix gaps in the system and advance our ability to measure quality in pediatric hospital medicine,” he says.

“When you take your first job in the hospital and you start trying to define and design best practices, people look at you differently—not as a young, emerging physician but more as a physician leader. They come to you and say: ‘Will you chair this committee, or lead that effort?’” he says. “And then, suddenly, you run out of tools in your toolbox. That’s what happened to me.”

He enrolled at Harvard University in pursuit of a business degree, along the way learning new ways of looking at systems change and basic principles of financing.

Retain a Clinical Presence

“The great thing about being a hospitalist is that you’re at the intersection of everything that happens in the hospital,” Dr. Narang says. As the pediatric chief medical officer for Banner Health, he is responsible for strategic planning, quality improvement (QI), and patient safety for a 210-bed hospital. He also co-chairs the Clinical Consensus Group, which represents all of Banner’s 23 hospitals, where he is able to influence care processes at the other hospitals as well.

Many hospitalist leaders eventually confront the dilemma of whether growing administrative responsibilities stand in the way of a continuing clinical practice. Dr. Narang moonlights some evenings and weekends on hospitalist and emergency medicine shifts. However, despite still wanting to see patients, he wonders if he has reached the point where growing administrative responsibilities will make that impossible.

“It was a challenge when I became CMO to squeeze in clinical responsibilities,” Dr. Narang says. “But I believed that in order to be the right kind of CMO, I still needed to practice medicine … to know what’s happening on the floor and what still needs to be fixed. You also want your colleagues to see you as a credible physician.”

He hopes to maintain some clinical practice, and says hospitalists have the advantage of blocking out scheduled times on service.

Dr. Sperring says it is “an exciting time” to be a hospitalist. “The way we’re used to defining care is going to change dramatically. Hospitalists will play a key role, both in direct care delivery but also in leadership,” he says. “I don’t think hospitalists have a choice but to lead change. It becomes part of our value proposition and a competency for all hospitalists.”

Dr. Hain often is asked by other hospitalists how to get started with quality initiatives that might lead to something more. “I always say the first one is free, in order to show that you can solve a quality problem while being a full-time clinician,” he explains. “It says to administrators that you’re someone who can deliver, and that starts you on your way. There’s always something to be done to improve quality in the hospital.”

Larry Beresford is a freelance writer based in Oakland, Calif.

Next month marks the sixth anniversary of former Massachusetts governor Mitt Romney’s signing into law a health insurance reform bill that brought near-universal coverage to the state’s residents. The Massachusetts experience represents a microcosm of what might be expected on a national scale with the Affordable Care Act (ACA): success in covering the uninsured, but persistent access and cost challenges that can only be overcome with fundamental payment reform.

“There is more going on in Massachusetts than anywhere else in the country, by far—in terms of coverage, delivery, and finance reform of healthcare,” says Stuart H. Altman, PhD, professor of national health policy at Brandeis University in Waltham, Mass. “The state’s example sends the positive message that the healthcare delivery system can be improved, but it takes time. Massachusetts is ahead of most states.”

Positives & Negatives

The Massachusetts law expands Medicaid enrollment to those earning up to 300% of the federal poverty level; offers state-subsidized commercial health insurance coverage to all other uninsured citizens; and allows young adults to remain on a parent’s plan until age 25. The law also mandates that employers with more than 10 employees offer subsidized health insurance coverage, and that every state resident over 18 purchase coverage or face tax penalties.

There is more going on in Massachusetts than anywhere else in the country, by far—in terms of coverage, delivery, and finance reform of healthcare.

—Stuart H. Altman, PhD, professor of national health policy, Brandeis University, Waltham, Mass.

The law has brought coverage to nearly 412,000 previously uninsured residents (as of December 2010, the latest figures available), and less than 2% of residents remain uninsured—down from about 10% before the law was enacted.¹

The law has not constrained the cost of healthcare in Massachusetts, which remains among the most expensive in the nation, and which current Massachusetts Gov. Deval Patrick acknowledges is continuing to rise at an unsustainable rate. A bill before the state legislature would give the governor the authority to review reimbursement contracts, to determine whether the fees paid by insurers to providers are appropriate, before approving insurance premium rates.

More surprising are the serious healthcare access challenges that persist in the state despite nearly universal health insurance coverage. The Massachusetts Medical Society outlined these challenges in a December 2011 white paper (see “Access Problems Persist Despite Insurance,” left).¹

One of the biggest challenges the state faces is a dearth of primary-care physicians (PCPs). “One of the biggest lessons learned is that insurance expansion did not lead to better access,” observes Winthrop F. Whitcomb, MD, MHM, medical director of Healthcare Quality at Baystate Medical Center in Springfield, Mass., and co-founder of SHM. “Medicaid is a loss-leader and does not pay enough to cover the cost of running a medical practice. Expanding Medicaid may actually make access worse if primary-care physicians opt out of it.”

Insurance reform has not made it any easier for a hospitalist to find a PCP for a patient who comes to the hospital without one, Dr. Whitcomb says, or to discharge a patient to a long-term or post-acute-care setting that their insurance covers inadequately, if at all.

“We do continue to see ED visits and hospital admissions that would have been preventable had the patient seen a PCP first,” says SHM President Joseph Ming Wah Li, MD, SFHM, director of hospital medicine at Beth Israel Deaconess Medical Center in Boston.

Dr. Li says his group has experienced difficulties getting patients hooked up with timely and appropriate post-discharge follow-up care because of packed PCP schedules. In response, they developed a hospitalist-run, post-discharge clinic for outpatients to fill in the gap and provide their patients with the follow-up care they need.

“My hospitalists will manage the patient through their episode of care, regardless of whether they are an inpatient or outpatient, until their PCP is available,” Dr. Li says. “I would love to see our hospitalist-run, post-discharge clinic made obsolete by PCPs with available appointments.”

Fundamental Payment Reform

Access and cost problems like these have serious national implications, as Medicaid eligibility under the ACA is expected to grow by 16 million people by 2019, or roughly 25%. The Massachusetts experience suggests that decreasing financial barriers to care can raise other barriers, such as inadequate physician availability, and does nothing to address the 800-pound gorilla of spiraling costs.

Critics who dismiss the Massachusetts experiment as “doing nothing to control costs” miss the larger picture of innovation occurring in the state, however. Insurance reform was never intended to be the end of the story.

In response to a mandate to investigate reforming and restructuring the payment system as the next step in statewide healthcare reform, a Special Commission on the Health Care Payment System released recommendations in July 2009 (www.mass.gov/eohhs/docs/dhcfp/pc/final-report/final-report.pdf) that proposed that Massachusetts phase out fee-for-service reimbursement and replace it with an accountable-care approach that incorporated a global payment model combining elements of risk-adjusted capitation, pay-for-performance, evidence-based guidelines, and medical-home-style care coordination. Although a bill to accelerate statewide implementation of the model awaits a vote in the state legislature, the private health insurance market is well into the game.

Blue Cross Blue Shield of Massachusetts has been using a version of the model (known as the “alternative quality contract”) since 2009, with the goal of reducing healthcare cost growth by half over five years by holding providers accountable for cost and quality, and encouraging the most appropriate treatments by the right kind of providers in the most appropriate settings. Participating hospital and physician groups receive a monthly global fee for each patient (adjusted annually for patient health status and inflation) in return for providing them with all the preventive, primary, specialty, hospital, and follow-up care they need. Providers have the incentive to reduce inefficiencies, and they can earn additional incentive payments for meeting or exceeding clinical performance measures tied to process, outcomes, and patient care experience.

More than a third of the insurer’s provider network is participating in this alternative quality contract program, and early results are promising. A recent Harvard Medical School study found that medical spending at the end of the first year was nearly 2% lower among physicians and hospitals participating in the program compared with those working under traditional fee-for-service contracts, largely the result of physicians changing referral patterns and shifting care to lower-cost facilities.² Quality of care among participants was significantly higher than that of non-participants in the insurer’s network, especially for adults with chronic illness and for children.

Several major healthcare delivery systems in Massachusetts are taking the accountable-care model to the next level this year by participating in the Pioneer Accountable Care Organizations (ACO) initiative, which also replaces fee-for-service with global revenue sharing plus quality and care-coordination incentives.

Part of the reason that providers in Massachusetts and around the country have a genuine interest in testing global payments and other value-based models is that they fear the day when the government and private sectors say “We just don’t have the money” and exert draconian fee-for-service rate control, Altman maintains.

Hospitalist Impacts

Hospitalists could find their referral patterns shifted slightly under global payment arrangements—potentially seeing fewer consults for low-risk patients and seeing greater demand for their services for more medically complex patients, Dr. Whitcomb says. HM likely will be the most heavily involved in ACOs that cover the Medicare population, whose patients are of higher acuity and more frequently hospitalized.

When fee-for-service reimbursement ultimately does give way to alternative reimbursement models, such as global payments, effective team-based care will become paramount to ensure effective hospital discharges and that preventable readmissions are minimized, Dr. Li says. He urges hospitalists to prepare their programs to manage a sicker patient population, and to cultivate the strongest possible coordination and alignment with PCPs, discharge planning professionals, and outpatient providers of all sorts. That way, hospitalists will be positioned to leverage their value in a healthcare system that requires value.

Christopher Guadagnino is a freelance medical writer based in Philadelphia.

For SHM’s official position on issues like healthcare reform, value-based purchasing, and medical errors, visit www.hospitalmedicine.org/advocacy

Next month marks the sixth anniversary of former Massachusetts governor Mitt Romney’s signing into law a health insurance reform bill that brought near-universal coverage to the state’s residents. The Massachusetts experience represents a microcosm of what might be expected on a national scale with the Affordable Care Act (ACA): success in covering the uninsured, but persistent access and cost challenges that can only be overcome with fundamental payment reform.

“There is more going on in Massachusetts than anywhere else in the country, by far—in terms of coverage, delivery, and finance reform of healthcare,” says Stuart H. Altman, PhD, professor of national health policy at Brandeis University in Waltham, Mass. “The state’s example sends the positive message that the healthcare delivery system can be improved, but it takes time. Massachusetts is ahead of most states.”

Positives & Negatives

The Massachusetts law expands Medicaid enrollment to those earning up to 300% of the federal poverty level; offers state-subsidized commercial health insurance coverage to all other uninsured citizens; and allows young adults to remain on a parent’s plan until age 25. The law also mandates that employers with more than 10 employees offer subsidized health insurance coverage, and that every state resident over 18 purchase coverage or face tax penalties.

There is more going on in Massachusetts than anywhere else in the country, by far—in terms of coverage, delivery, and finance reform of healthcare.

—Stuart H. Altman, PhD, professor of national health policy, Brandeis University, Waltham, Mass.

The law has brought coverage to nearly 412,000 previously uninsured residents (as of December 2010, the latest figures available), and less than 2% of residents remain uninsured—down from about 10% before the law was enacted.¹

The law has not constrained the cost of healthcare in Massachusetts, which remains among the most expensive in the nation, and which current Massachusetts Gov. Deval Patrick acknowledges is continuing to rise at an unsustainable rate. A bill before the state legislature would give the governor the authority to review reimbursement contracts, to determine whether the fees paid by insurers to providers are appropriate, before approving insurance premium rates.

More surprising are the serious healthcare access challenges that persist in the state despite nearly universal health insurance coverage. The Massachusetts Medical Society outlined these challenges in a December 2011 white paper (see “Access Problems Persist Despite Insurance,” left).¹

One of the biggest challenges the state faces is a dearth of primary-care physicians (PCPs). “One of the biggest lessons learned is that insurance expansion did not lead to better access,” observes Winthrop F. Whitcomb, MD, MHM, medical director of Healthcare Quality at Baystate Medical Center in Springfield, Mass., and co-founder of SHM. “Medicaid is a loss-leader and does not pay enough to cover the cost of running a medical practice. Expanding Medicaid may actually make access worse if primary-care physicians opt out of it.”

Insurance reform has not made it any easier for a hospitalist to find a PCP for a patient who comes to the hospital without one, Dr. Whitcomb says, or to discharge a patient to a long-term or post-acute-care setting that their insurance covers inadequately, if at all.

“We do continue to see ED visits and hospital admissions that would have been preventable had the patient seen a PCP first,” says SHM President Joseph Ming Wah Li, MD, SFHM, director of hospital medicine at Beth Israel Deaconess Medical Center in Boston.

Dr. Li says his group has experienced difficulties getting patients hooked up with timely and appropriate post-discharge follow-up care because of packed PCP schedules. In response, they developed a hospitalist-run, post-discharge clinic for outpatients to fill in the gap and provide their patients with the follow-up care they need.

“My hospitalists will manage the patient through their episode of care, regardless of whether they are an inpatient or outpatient, until their PCP is available,” Dr. Li says. “I would love to see our hospitalist-run, post-discharge clinic made obsolete by PCPs with available appointments.”

Fundamental Payment Reform

Access and cost problems like these have serious national implications, as Medicaid eligibility under the ACA is expected to grow by 16 million people by 2019, or roughly 25%. The Massachusetts experience suggests that decreasing financial barriers to care can raise other barriers, such as inadequate physician availability, and does nothing to address the 800-pound gorilla of spiraling costs.

Critics who dismiss the Massachusetts experiment as “doing nothing to control costs” miss the larger picture of innovation occurring in the state, however. Insurance reform was never intended to be the end of the story.

In response to a mandate to investigate reforming and restructuring the payment system as the next step in statewide healthcare reform, a Special Commission on the Health Care Payment System released recommendations in July 2009 (www.mass.gov/eohhs/docs/dhcfp/pc/final-report/final-report.pdf) that proposed that Massachusetts phase out fee-for-service reimbursement and replace it with an accountable-care approach that incorporated a global payment model combining elements of risk-adjusted capitation, pay-for-performance, evidence-based guidelines, and medical-home-style care coordination. Although a bill to accelerate statewide implementation of the model awaits a vote in the state legislature, the private health insurance market is well into the game.

Blue Cross Blue Shield of Massachusetts has been using a version of the model (known as the “alternative quality contract”) since 2009, with the goal of reducing healthcare cost growth by half over five years by holding providers accountable for cost and quality, and encouraging the most appropriate treatments by the right kind of providers in the most appropriate settings. Participating hospital and physician groups receive a monthly global fee for each patient (adjusted annually for patient health status and inflation) in return for providing them with all the preventive, primary, specialty, hospital, and follow-up care they need. Providers have the incentive to reduce inefficiencies, and they can earn additional incentive payments for meeting or exceeding clinical performance measures tied to process, outcomes, and patient care experience.

More than a third of the insurer’s provider network is participating in this alternative quality contract program, and early results are promising. A recent Harvard Medical School study found that medical spending at the end of the first year was nearly 2% lower among physicians and hospitals participating in the program compared with those working under traditional fee-for-service contracts, largely the result of physicians changing referral patterns and shifting care to lower-cost facilities.² Quality of care among participants was significantly higher than that of non-participants in the insurer’s network, especially for adults with chronic illness and for children.

Several major healthcare delivery systems in Massachusetts are taking the accountable-care model to the next level this year by participating in the Pioneer Accountable Care Organizations (ACO) initiative, which also replaces fee-for-service with global revenue sharing plus quality and care-coordination incentives.

Part of the reason that providers in Massachusetts and around the country have a genuine interest in testing global payments and other value-based models is that they fear the day when the government and private sectors say “We just don’t have the money” and exert draconian fee-for-service rate control, Altman maintains.

Hospitalist Impacts

Hospitalists could find their referral patterns shifted slightly under global payment arrangements—potentially seeing fewer consults for low-risk patients and seeing greater demand for their services for more medically complex patients, Dr. Whitcomb says. HM likely will be the most heavily involved in ACOs that cover the Medicare population, whose patients are of higher acuity and more frequently hospitalized.

When fee-for-service reimbursement ultimately does give way to alternative reimbursement models, such as global payments, effective team-based care will become paramount to ensure effective hospital discharges and that preventable readmissions are minimized, Dr. Li says. He urges hospitalists to prepare their programs to manage a sicker patient population, and to cultivate the strongest possible coordination and alignment with PCPs, discharge planning professionals, and outpatient providers of all sorts. That way, hospitalists will be positioned to leverage their value in a healthcare system that requires value.

Christopher Guadagnino is a freelance medical writer based in Philadelphia.

For SHM’s official position on issues like healthcare reform, value-based purchasing, and medical errors, visit www.hospitalmedicine.org/advocacy

Next month marks the sixth anniversary of former Massachusetts governor Mitt Romney’s signing into law a health insurance reform bill that brought near-universal coverage to the state’s residents. The Massachusetts experience represents a microcosm of what might be expected on a national scale with the Affordable Care Act (ACA): success in covering the uninsured, but persistent access and cost challenges that can only be overcome with fundamental payment reform.

“There is more going on in Massachusetts than anywhere else in the country, by far—in terms of coverage, delivery, and finance reform of healthcare,” says Stuart H. Altman, PhD, professor of national health policy at Brandeis University in Waltham, Mass. “The state’s example sends the positive message that the healthcare delivery system can be improved, but it takes time. Massachusetts is ahead of most states.”

Positives & Negatives

The Massachusetts law expands Medicaid enrollment to those earning up to 300% of the federal poverty level; offers state-subsidized commercial health insurance coverage to all other uninsured citizens; and allows young adults to remain on a parent’s plan until age 25. The law also mandates that employers with more than 10 employees offer subsidized health insurance coverage, and that every state resident over 18 purchase coverage or face tax penalties.

There is more going on in Massachusetts than anywhere else in the country, by far—in terms of coverage, delivery, and finance reform of healthcare.

—Stuart H. Altman, PhD, professor of national health policy, Brandeis University, Waltham, Mass.

The law has brought coverage to nearly 412,000 previously uninsured residents (as of December 2010, the latest figures available), and less than 2% of residents remain uninsured—down from about 10% before the law was enacted.¹

The law has not constrained the cost of healthcare in Massachusetts, which remains among the most expensive in the nation, and which current Massachusetts Gov. Deval Patrick acknowledges is continuing to rise at an unsustainable rate. A bill before the state legislature would give the governor the authority to review reimbursement contracts, to determine whether the fees paid by insurers to providers are appropriate, before approving insurance premium rates.

More surprising are the serious healthcare access challenges that persist in the state despite nearly universal health insurance coverage. The Massachusetts Medical Society outlined these challenges in a December 2011 white paper (see “Access Problems Persist Despite Insurance,” left).¹

One of the biggest challenges the state faces is a dearth of primary-care physicians (PCPs). “One of the biggest lessons learned is that insurance expansion did not lead to better access,” observes Winthrop F. Whitcomb, MD, MHM, medical director of Healthcare Quality at Baystate Medical Center in Springfield, Mass., and co-founder of SHM. “Medicaid is a loss-leader and does not pay enough to cover the cost of running a medical practice. Expanding Medicaid may actually make access worse if primary-care physicians opt out of it.”

Insurance reform has not made it any easier for a hospitalist to find a PCP for a patient who comes to the hospital without one, Dr. Whitcomb says, or to discharge a patient to a long-term or post-acute-care setting that their insurance covers inadequately, if at all.

“We do continue to see ED visits and hospital admissions that would have been preventable had the patient seen a PCP first,” says SHM President Joseph Ming Wah Li, MD, SFHM, director of hospital medicine at Beth Israel Deaconess Medical Center in Boston.

Dr. Li says his group has experienced difficulties getting patients hooked up with timely and appropriate post-discharge follow-up care because of packed PCP schedules. In response, they developed a hospitalist-run, post-discharge clinic for outpatients to fill in the gap and provide their patients with the follow-up care they need.

“My hospitalists will manage the patient through their episode of care, regardless of whether they are an inpatient or outpatient, until their PCP is available,” Dr. Li says. “I would love to see our hospitalist-run, post-discharge clinic made obsolete by PCPs with available appointments.”

Fundamental Payment Reform

Access and cost problems like these have serious national implications, as Medicaid eligibility under the ACA is expected to grow by 16 million people by 2019, or roughly 25%. The Massachusetts experience suggests that decreasing financial barriers to care can raise other barriers, such as inadequate physician availability, and does nothing to address the 800-pound gorilla of spiraling costs.

Critics who dismiss the Massachusetts experiment as “doing nothing to control costs” miss the larger picture of innovation occurring in the state, however. Insurance reform was never intended to be the end of the story.

In response to a mandate to investigate reforming and restructuring the payment system as the next step in statewide healthcare reform, a Special Commission on the Health Care Payment System released recommendations in July 2009 (www.mass.gov/eohhs/docs/dhcfp/pc/final-report/final-report.pdf) that proposed that Massachusetts phase out fee-for-service reimbursement and replace it with an accountable-care approach that incorporated a global payment model combining elements of risk-adjusted capitation, pay-for-performance, evidence-based guidelines, and medical-home-style care coordination. Although a bill to accelerate statewide implementation of the model awaits a vote in the state legislature, the private health insurance market is well into the game.

Blue Cross Blue Shield of Massachusetts has been using a version of the model (known as the “alternative quality contract”) since 2009, with the goal of reducing healthcare cost growth by half over five years by holding providers accountable for cost and quality, and encouraging the most appropriate treatments by the right kind of providers in the most appropriate settings. Participating hospital and physician groups receive a monthly global fee for each patient (adjusted annually for patient health status and inflation) in return for providing them with all the preventive, primary, specialty, hospital, and follow-up care they need. Providers have the incentive to reduce inefficiencies, and they can earn additional incentive payments for meeting or exceeding clinical performance measures tied to process, outcomes, and patient care experience.

More than a third of the insurer’s provider network is participating in this alternative quality contract program, and early results are promising. A recent Harvard Medical School study found that medical spending at the end of the first year was nearly 2% lower among physicians and hospitals participating in the program compared with those working under traditional fee-for-service contracts, largely the result of physicians changing referral patterns and shifting care to lower-cost facilities.² Quality of care among participants was significantly higher than that of non-participants in the insurer’s network, especially for adults with chronic illness and for children.

Several major healthcare delivery systems in Massachusetts are taking the accountable-care model to the next level this year by participating in the Pioneer Accountable Care Organizations (ACO) initiative, which also replaces fee-for-service with global revenue sharing plus quality and care-coordination incentives.

Part of the reason that providers in Massachusetts and around the country have a genuine interest in testing global payments and other value-based models is that they fear the day when the government and private sectors say “We just don’t have the money” and exert draconian fee-for-service rate control, Altman maintains.

Hospitalist Impacts

Hospitalists could find their referral patterns shifted slightly under global payment arrangements—potentially seeing fewer consults for low-risk patients and seeing greater demand for their services for more medically complex patients, Dr. Whitcomb says. HM likely will be the most heavily involved in ACOs that cover the Medicare population, whose patients are of higher acuity and more frequently hospitalized.

When fee-for-service reimbursement ultimately does give way to alternative reimbursement models, such as global payments, effective team-based care will become paramount to ensure effective hospital discharges and that preventable readmissions are minimized, Dr. Li says. He urges hospitalists to prepare their programs to manage a sicker patient population, and to cultivate the strongest possible coordination and alignment with PCPs, discharge planning professionals, and outpatient providers of all sorts. That way, hospitalists will be positioned to leverage their value in a healthcare system that requires value.

Christopher Guadagnino is a freelance medical writer based in Philadelphia.

For SHM’s official position on issues like healthcare reform, value-based purchasing, and medical errors, visit www.hospitalmedicine.org/advocacy

When Ahmad Nooristani, MD, became a physician, part of his motivation was to help his native country. “I wanted to become a physician so that I could give back,” says Dr. Nooristani, who emigrated to the U.S. from Afghanistan in 1981. He graduated medical school in 2008.

His opportunity to give back arrived in a different scenario, however. As a hospitalist with San Luis Hospitalists AMC, which provides coverage to Sierra Vista Regional Medical Center and French Hospital Medical Center in San Luis Obispo, Calif., Dr. Nooristani saw firsthand the downstream effects of uninsured patients without access to care for their chronic conditions.

One way to address preventive care for the uninsured, he reasoned, was to open a free clinic. In 2009, in addition to his seven-on/seven-off duties as a hospitalist, Dr. Nooristani began work on establishing a clinic for uninsured patients in his new hometown. Almost three years and countless fundraising events later, the Noor Foundation Clinic (www.slonoorfoundation.org) opened its doors in October 2011, offering not just primary care but ophthalmologic examinations, nutrition counseling, physical therapy, and point-of-service testing, too. For now, the clinic is open Friday and Saturday afternoons; all care is free.

Dr. Nooristani has worked 20 hours a week on the project. He’s recruited 400 volunteers, ranging from high-level administrators from the county’s hospitals to community fundraisers to off-duty nurses and physician colleagues.

“He’s a hard-working guy and is always looking for ways to improve things,” says hospitalist colleague Christian Voge, MD, medical director and president of San Luis Hospitalists. “I think he saw a need and is trying to give back.”

A Gap to Fill

Located on the central coast of California, San Luis Obispo County has a population of 269,637, according to 2010 U.S. Census figures. County public health officer Penny A. Borenstein, MD, MPH, says that figures from such surveys as the California Health Interview Survey and the Census Bureau indicate that approximately 35,000 of the county’s residents had no health insurance at some point in the last 12 months. The number of those who are underinsured (i.e. who carry minimal catastrophic insurance with high deductibles) is harder to quantify.

Although other clinic options exist in the county, through Medi-Cal and the County Medical Services Program, Dr. Borenstein believes that the Noor Foundation Clinic will help address gaps. “Even a sliding scale fee [such as those charged by community health centers] can sometimes be a deterrent to people,” she notes. “I give [Dr. Nooristani] many kudos for taking the bull by the horn and saying, ‘Let’s at least try to put something together to help fill the gaps in a very imperfect healthcare system.’”

New Skills Acquired

During an interview just days after the clinic opened its doors, Dr. Nooristani voiced some amazement about the long permitting process. “The hoops you have to jump through—it’s unbelievable,” he said.

Subject to federal, state, and county regulations, the clinic had to be retrofitted with a $25,000 air filtration and ducting system, among other upgrades. As a result, the foundation was paying rent for two years before the clinic opened its doors. “I could have seen a few thousand patients,” Dr. Nooristani says. “I mean, think about the complications I could have prevented.”

Still, he’s philosophical about the process. “On the flipside, I’m glad I did it this way. As tedious and time-consuming as it was, it served the purpose of bringing the whole community together,” he says.

Fundraising events for the foundation, as well as private donations, raised a total of $80,000 in a two-year period. Just before the clinic opened, the San Luis Obispo County Board of Supervisors approved a $75,000 grant to the Noor Foundation to cover the annual costs of point-of-service testing. And a broad swath of the county’s office holders, healthcare administrators, and community leaders attended the clinic’s grand opening.

Geared to the Patient

Keeping in mind his patient population, Dr. Nooristani plans to incorporate patient education on managing chronic illnesses. An ophthalmologist has volunteered one day a month. A separate optometric examination room is outfitted with all the requisite equipment, and eyeglasses have been donated.

Furnished tastefully throughout, the clinic does not have the stark quality sometimes associated with free clinics. Dr. Nooristani also is respectful of patients’ time: “I don’t want anybody sitting in the waiting room for more than 30 minutes,” he says.

That’s why the appointment calendar is structured to accommodate future appointments, and he currently staffs each clinic day with two physicians and additional providers. He’s also savvy about his use of volunteers, limiting their hours to avoid burnout.

Catching Fire

Dr. Nooristani already has his sights set on more clinics, hopefully in his home country. In the meantime, though, he says, “people need care here.”

Like the meaning of the clinic name (“noor” means hope, and his name translates to “land of hope”), he hopes to inspire others to follow his lead. “Any community, big or small, can do this,” he says, enthusiasm in his voice. “You just have to keep your eyes on the prize.”

Gretchen Henkel is a freelance writer based in California.

When Ahmad Nooristani, MD, became a physician, part of his motivation was to help his native country. “I wanted to become a physician so that I could give back,” says Dr. Nooristani, who emigrated to the U.S. from Afghanistan in 1981. He graduated medical school in 2008.

His opportunity to give back arrived in a different scenario, however. As a hospitalist with San Luis Hospitalists AMC, which provides coverage to Sierra Vista Regional Medical Center and French Hospital Medical Center in San Luis Obispo, Calif., Dr. Nooristani saw firsthand the downstream effects of uninsured patients without access to care for their chronic conditions.

One way to address preventive care for the uninsured, he reasoned, was to open a free clinic. In 2009, in addition to his seven-on/seven-off duties as a hospitalist, Dr. Nooristani began work on establishing a clinic for uninsured patients in his new hometown. Almost three years and countless fundraising events later, the Noor Foundation Clinic (www.slonoorfoundation.org) opened its doors in October 2011, offering not just primary care but ophthalmologic examinations, nutrition counseling, physical therapy, and point-of-service testing, too. For now, the clinic is open Friday and Saturday afternoons; all care is free.

Dr. Nooristani has worked 20 hours a week on the project. He’s recruited 400 volunteers, ranging from high-level administrators from the county’s hospitals to community fundraisers to off-duty nurses and physician colleagues.

“He’s a hard-working guy and is always looking for ways to improve things,” says hospitalist colleague Christian Voge, MD, medical director and president of San Luis Hospitalists. “I think he saw a need and is trying to give back.”

A Gap to Fill

Located on the central coast of California, San Luis Obispo County has a population of 269,637, according to 2010 U.S. Census figures. County public health officer Penny A. Borenstein, MD, MPH, says that figures from such surveys as the California Health Interview Survey and the Census Bureau indicate that approximately 35,000 of the county’s residents had no health insurance at some point in the last 12 months. The number of those who are underinsured (i.e. who carry minimal catastrophic insurance with high deductibles) is harder to quantify.

Although other clinic options exist in the county, through Medi-Cal and the County Medical Services Program, Dr. Borenstein believes that the Noor Foundation Clinic will help address gaps. “Even a sliding scale fee [such as those charged by community health centers] can sometimes be a deterrent to people,” she notes. “I give [Dr. Nooristani] many kudos for taking the bull by the horn and saying, ‘Let’s at least try to put something together to help fill the gaps in a very imperfect healthcare system.’”

New Skills Acquired

During an interview just days after the clinic opened its doors, Dr. Nooristani voiced some amazement about the long permitting process. “The hoops you have to jump through—it’s unbelievable,” he said.

Subject to federal, state, and county regulations, the clinic had to be retrofitted with a $25,000 air filtration and ducting system, among other upgrades. As a result, the foundation was paying rent for two years before the clinic opened its doors. “I could have seen a few thousand patients,” Dr. Nooristani says. “I mean, think about the complications I could have prevented.”

Still, he’s philosophical about the process. “On the flipside, I’m glad I did it this way. As tedious and time-consuming as it was, it served the purpose of bringing the whole community together,” he says.

Fundraising events for the foundation, as well as private donations, raised a total of $80,000 in a two-year period. Just before the clinic opened, the San Luis Obispo County Board of Supervisors approved a $75,000 grant to the Noor Foundation to cover the annual costs of point-of-service testing. And a broad swath of the county’s office holders, healthcare administrators, and community leaders attended the clinic’s grand opening.

Geared to the Patient

Keeping in mind his patient population, Dr. Nooristani plans to incorporate patient education on managing chronic illnesses. An ophthalmologist has volunteered one day a month. A separate optometric examination room is outfitted with all the requisite equipment, and eyeglasses have been donated.

Furnished tastefully throughout, the clinic does not have the stark quality sometimes associated with free clinics. Dr. Nooristani also is respectful of patients’ time: “I don’t want anybody sitting in the waiting room for more than 30 minutes,” he says.

That’s why the appointment calendar is structured to accommodate future appointments, and he currently staffs each clinic day with two physicians and additional providers. He’s also savvy about his use of volunteers, limiting their hours to avoid burnout.

Catching Fire

Dr. Nooristani already has his sights set on more clinics, hopefully in his home country. In the meantime, though, he says, “people need care here.”

Like the meaning of the clinic name (“noor” means hope, and his name translates to “land of hope”), he hopes to inspire others to follow his lead. “Any community, big or small, can do this,” he says, enthusiasm in his voice. “You just have to keep your eyes on the prize.”

Gretchen Henkel is a freelance writer based in California.

When Ahmad Nooristani, MD, became a physician, part of his motivation was to help his native country. “I wanted to become a physician so that I could give back,” says Dr. Nooristani, who emigrated to the U.S. from Afghanistan in 1981. He graduated medical school in 2008.

His opportunity to give back arrived in a different scenario, however. As a hospitalist with San Luis Hospitalists AMC, which provides coverage to Sierra Vista Regional Medical Center and French Hospital Medical Center in San Luis Obispo, Calif., Dr. Nooristani saw firsthand the downstream effects of uninsured patients without access to care for their chronic conditions.

One way to address preventive care for the uninsured, he reasoned, was to open a free clinic. In 2009, in addition to his seven-on/seven-off duties as a hospitalist, Dr. Nooristani began work on establishing a clinic for uninsured patients in his new hometown. Almost three years and countless fundraising events later, the Noor Foundation Clinic (www.slonoorfoundation.org) opened its doors in October 2011, offering not just primary care but ophthalmologic examinations, nutrition counseling, physical therapy, and point-of-service testing, too. For now, the clinic is open Friday and Saturday afternoons; all care is free.

Dr. Nooristani has worked 20 hours a week on the project. He’s recruited 400 volunteers, ranging from high-level administrators from the county’s hospitals to community fundraisers to off-duty nurses and physician colleagues.

“He’s a hard-working guy and is always looking for ways to improve things,” says hospitalist colleague Christian Voge, MD, medical director and president of San Luis Hospitalists. “I think he saw a need and is trying to give back.”

A Gap to Fill

Located on the central coast of California, San Luis Obispo County has a population of 269,637, according to 2010 U.S. Census figures. County public health officer Penny A. Borenstein, MD, MPH, says that figures from such surveys as the California Health Interview Survey and the Census Bureau indicate that approximately 35,000 of the county’s residents had no health insurance at some point in the last 12 months. The number of those who are underinsured (i.e. who carry minimal catastrophic insurance with high deductibles) is harder to quantify.

Although other clinic options exist in the county, through Medi-Cal and the County Medical Services Program, Dr. Borenstein believes that the Noor Foundation Clinic will help address gaps. “Even a sliding scale fee [such as those charged by community health centers] can sometimes be a deterrent to people,” she notes. “I give [Dr. Nooristani] many kudos for taking the bull by the horn and saying, ‘Let’s at least try to put something together to help fill the gaps in a very imperfect healthcare system.’”

New Skills Acquired

During an interview just days after the clinic opened its doors, Dr. Nooristani voiced some amazement about the long permitting process. “The hoops you have to jump through—it’s unbelievable,” he said.

Subject to federal, state, and county regulations, the clinic had to be retrofitted with a $25,000 air filtration and ducting system, among other upgrades. As a result, the foundation was paying rent for two years before the clinic opened its doors. “I could have seen a few thousand patients,” Dr. Nooristani says. “I mean, think about the complications I could have prevented.”

Still, he’s philosophical about the process. “On the flipside, I’m glad I did it this way. As tedious and time-consuming as it was, it served the purpose of bringing the whole community together,” he says.

Fundraising events for the foundation, as well as private donations, raised a total of $80,000 in a two-year period. Just before the clinic opened, the San Luis Obispo County Board of Supervisors approved a $75,000 grant to the Noor Foundation to cover the annual costs of point-of-service testing. And a broad swath of the county’s office holders, healthcare administrators, and community leaders attended the clinic’s grand opening.

Geared to the Patient

Keeping in mind his patient population, Dr. Nooristani plans to incorporate patient education on managing chronic illnesses. An ophthalmologist has volunteered one day a month. A separate optometric examination room is outfitted with all the requisite equipment, and eyeglasses have been donated.

Furnished tastefully throughout, the clinic does not have the stark quality sometimes associated with free clinics. Dr. Nooristani also is respectful of patients’ time: “I don’t want anybody sitting in the waiting room for more than 30 minutes,” he says.

That’s why the appointment calendar is structured to accommodate future appointments, and he currently staffs each clinic day with two physicians and additional providers. He’s also savvy about his use of volunteers, limiting their hours to avoid burnout.

Catching Fire

Dr. Nooristani already has his sights set on more clinics, hopefully in his home country. In the meantime, though, he says, “people need care here.”

Like the meaning of the clinic name (“noor” means hope, and his name translates to “land of hope”), he hopes to inspire others to follow his lead. “Any community, big or small, can do this,” he says, enthusiasm in his voice. “You just have to keep your eyes on the prize.”

Gretchen Henkel is a freelance writer based in California.