Background: Concerned about the impact of house officer (HO) fatigue on education and the quality of patient care, the ACGME instituted work restrictions for HOs effective July 1, 2003. Proponents believe HO fatigue contributes to in-hospital errors. Opponents argue that decreasing HO work hours will increase errors due to patient handoffs and HO cross-coverage. We surveyed internal medicine faculty and HOs to understand clinician perceptions of the impact of the ACGME regulations.

Methods: We created a written survey instrument based on a literature review, expert opinion, and focus groups of HOs, staff internists, and nurses. The survey asked respondents to recall types of errors and contributing factors that occurred in the 3 months prior to work-hour restrictions,and to predict how the restrictions would affect patient care and HO education. We administered the survey in July and August 2003 via email and in person to PGY2/3 medical HOs and medical ward and ICU attending physicians at Beth Israel Deaconess Medical Center. Responses were scored on the Likert scale. We calculated the percentage of respondents who agreed/strongly agreed or disagreed/strongly disagreed with statements and used the rank sum test to compare HO and attending physician responses.

Results: We received completed surveys from 81 of 95 HOs and 40 of 104 attending physicians, including all 11 staff hospitalists who, together, accounted for approximately 65% of inpatient medical admissions. HOs were more likely than attendings to attribute errors to high census (70% vs. 22%, p=0.001) and fatigue (52% vs. 38%, p=0.02); HOs were less likely than attendings to attribute errors to cross-coverage (53% vs. 79%, p<0.001) and lack of experience or knowledge (54% vs. 68%, p=0.03).

Fifty-two percent of HOs and 22% of attending physicians agreed that fatigue contributed to HO errors in the previous 3 months, but only 20% of HOs and 10% of attendings predicted that fatigue would contribute to errors after implementing work-hour restrictions. Despite this expected reduction in HO fatigue, a majority of HOs and attendings disagreed that quality of care (55% and 69%) and continuity of care (89% and 89%) would improve. Ninetyfive percent of HOs and 98% of attendings predicted that in the new system errors would occur as a result of cross-coverage, compared with 53% and 79%, respectively, at baseline. Half the HOs (55%) and attendings (50%) believed that HO errors would increase overall after the change.

Conclusion: Clinicians were skeptical that ACGME work-hour restrictions would improve care or decrease errors. Instead, many HOs and attendings predicted that the new regulations would change the underlying cause of error from fatigue to cross-coverage, and that the total number of errors would increase. If academic medical centers and their patients are to reap the intended benefits of work-hour restrictions, residency directors will need to develop and implement skill-building initiatives focused on cross-coverage.

Dr. Kripalani can be contacted at [email protected].

Background: Concerned about the impact of house officer (HO) fatigue on education and the quality of patient care, the ACGME instituted work restrictions for HOs effective July 1, 2003. Proponents believe HO fatigue contributes to in-hospital errors. Opponents argue that decreasing HO work hours will increase errors due to patient handoffs and HO cross-coverage. We surveyed internal medicine faculty and HOs to understand clinician perceptions of the impact of the ACGME regulations.

Methods: We created a written survey instrument based on a literature review, expert opinion, and focus groups of HOs, staff internists, and nurses. The survey asked respondents to recall types of errors and contributing factors that occurred in the 3 months prior to work-hour restrictions,and to predict how the restrictions would affect patient care and HO education. We administered the survey in July and August 2003 via email and in person to PGY2/3 medical HOs and medical ward and ICU attending physicians at Beth Israel Deaconess Medical Center. Responses were scored on the Likert scale. We calculated the percentage of respondents who agreed/strongly agreed or disagreed/strongly disagreed with statements and used the rank sum test to compare HO and attending physician responses.

Results: We received completed surveys from 81 of 95 HOs and 40 of 104 attending physicians, including all 11 staff hospitalists who, together, accounted for approximately 65% of inpatient medical admissions. HOs were more likely than attendings to attribute errors to high census (70% vs. 22%, p=0.001) and fatigue (52% vs. 38%, p=0.02); HOs were less likely than attendings to attribute errors to cross-coverage (53% vs. 79%, p<0.001) and lack of experience or knowledge (54% vs. 68%, p=0.03).

Fifty-two percent of HOs and 22% of attending physicians agreed that fatigue contributed to HO errors in the previous 3 months, but only 20% of HOs and 10% of attendings predicted that fatigue would contribute to errors after implementing work-hour restrictions. Despite this expected reduction in HO fatigue, a majority of HOs and attendings disagreed that quality of care (55% and 69%) and continuity of care (89% and 89%) would improve. Ninetyfive percent of HOs and 98% of attendings predicted that in the new system errors would occur as a result of cross-coverage, compared with 53% and 79%, respectively, at baseline. Half the HOs (55%) and attendings (50%) believed that HO errors would increase overall after the change.

Conclusion: Clinicians were skeptical that ACGME work-hour restrictions would improve care or decrease errors. Instead, many HOs and attendings predicted that the new regulations would change the underlying cause of error from fatigue to cross-coverage, and that the total number of errors would increase. If academic medical centers and their patients are to reap the intended benefits of work-hour restrictions, residency directors will need to develop and implement skill-building initiatives focused on cross-coverage.

Dr. Kripalani can be contacted at [email protected].

Background: Concerned about the impact of house officer (HO) fatigue on education and the quality of patient care, the ACGME instituted work restrictions for HOs effective July 1, 2003. Proponents believe HO fatigue contributes to in-hospital errors. Opponents argue that decreasing HO work hours will increase errors due to patient handoffs and HO cross-coverage. We surveyed internal medicine faculty and HOs to understand clinician perceptions of the impact of the ACGME regulations.

Methods: We created a written survey instrument based on a literature review, expert opinion, and focus groups of HOs, staff internists, and nurses. The survey asked respondents to recall types of errors and contributing factors that occurred in the 3 months prior to work-hour restrictions,and to predict how the restrictions would affect patient care and HO education. We administered the survey in July and August 2003 via email and in person to PGY2/3 medical HOs and medical ward and ICU attending physicians at Beth Israel Deaconess Medical Center. Responses were scored on the Likert scale. We calculated the percentage of respondents who agreed/strongly agreed or disagreed/strongly disagreed with statements and used the rank sum test to compare HO and attending physician responses.

Results: We received completed surveys from 81 of 95 HOs and 40 of 104 attending physicians, including all 11 staff hospitalists who, together, accounted for approximately 65% of inpatient medical admissions. HOs were more likely than attendings to attribute errors to high census (70% vs. 22%, p=0.001) and fatigue (52% vs. 38%, p=0.02); HOs were less likely than attendings to attribute errors to cross-coverage (53% vs. 79%, p<0.001) and lack of experience or knowledge (54% vs. 68%, p=0.03).

Fifty-two percent of HOs and 22% of attending physicians agreed that fatigue contributed to HO errors in the previous 3 months, but only 20% of HOs and 10% of attendings predicted that fatigue would contribute to errors after implementing work-hour restrictions. Despite this expected reduction in HO fatigue, a majority of HOs and attendings disagreed that quality of care (55% and 69%) and continuity of care (89% and 89%) would improve. Ninetyfive percent of HOs and 98% of attendings predicted that in the new system errors would occur as a result of cross-coverage, compared with 53% and 79%, respectively, at baseline. Half the HOs (55%) and attendings (50%) believed that HO errors would increase overall after the change.

Conclusion: Clinicians were skeptical that ACGME work-hour restrictions would improve care or decrease errors. Instead, many HOs and attendings predicted that the new regulations would change the underlying cause of error from fatigue to cross-coverage, and that the total number of errors would increase. If academic medical centers and their patients are to reap the intended benefits of work-hour restrictions, residency directors will need to develop and implement skill-building initiatives focused on cross-coverage.

Dr. Kripalani can be contacted at [email protected].

A 57-year-old woman with no previous medical history was admitted with weakness. The patient complained of 2 months of ascending bilateral lower extremity weakness followed by subjective “numbness” of both legs. She had a normal lumbosacral MRI as an outpatient and presented to the ED with progressive symptoms. She denied back pain, bowel or bladder problems, diplopia, ataxia, or confusion. As well, there were no fevers, chills, muscle pain, or weight loss. She had no risk factors for HIV and no toxic exposures.

On admission, her vital signs were normal and her general physical exam was unremarkable. Her neurologic exam was notable for diffuse symmetric 3/5 bilateral lower extremity weakness and symmetric bilateral sensory loss in a “stocking” distribution. She had bilateral lower extremity hyperreflexia and plantar reflexes were extensor bilaterally. She had normal upper extremities, cranial nerves, and mental status. Screening laboratories including fasting glucose, B12, RPR, TSH, HIV, SPEP, and UPEP were negative. A repeat lumbosacral MRI and a lumbar puncture were nondiagnostic.

While hospitalized, the patient suffered progressive ascending weakness involving the upper extremities and the diaphragm, necessitating intubation. She was treated with high-dose steroids, IVIG, and plasmapheresis for the possibility of Guillain-Barre or transverse myelitis; there was no change in her symptoms. With no clear diagnosis, on hospital day 10, she complained of diplopia and was found to have right eye chemosis, proptosis, right abducens nerve palsy, and a loud bruit over the right eye. A CT scan revealed dilated right ophthalmic veins and an engorged cavernous sinus (Figure 1). A cerebral angiogram was performed and showed a distal right vertebral arteriovenous fistula (Figure 2), and an MRI showed increased signal in the entire cord secondary to venous hypertension.

What is the diagnosis?

Vertebral Arterio-Venous Fistula (AVF) with arterialized venous drainage to the cavernous sinus, ophthalmic veins, and the cervical epidural veins leading to her ocular symptoms and a cervical myelopathy.

She had no history of trauma and the AVF was thought to be spontaneous. She underwent successful transarterial embolization of the right vertebral artery (see Figure 3). Her ocular symptoms rapidly improved and she was transferred to a rehabilitation facility with improving motor and sensory function.

Discussion: Vertebral arteriovenous fistulas (AVFs) are rare vascular malformations characterized by abnormal shunting between the extracranial vertebral artery and a neighboring vein. Vertebral AVFs are most often secondary to trauma including penetrating gunshot or stab wounds to the neck. Fibromuscular dysplasia and neurofibromatosis are predisposing conditions but vertebral AVFs can be spontaneous as in this case. Patients with vertebral AVFs may present with tinnitus, but frequently they have no symptoms and their fistulas are discovered as cervical bruits on routine auscultation. Neurologic syndromes in the setting of a vertebral AVF are rare and typically secondary to arterialization of venous drainage leading to local ischemia and nerve damage. There are case reports of vertigo and vertebrobasilar insufficiency, cervical radiculopathy related to nerve-root compression from engorged vertebral veins, and cervical myelopathy from venous hypertension similar to this patient. As well, there is only one case report of a vertebral AVF leading to exophthalmos, chemosis, and a bruit, mimicking a carotid-cavernous fistula. This is the first reported case of a vertebral AVF leading to both cervical cord and ocular pathology.

Vertebral AVFs can be suspected based on CT and MRI findings, but angiography is the gold standard for diagnosis. Transarterial embolization is the safest and most effective treatment, allowing for occlusion of the fistula while maintaining patency of the vertebral artery. If treated expediently, most patients experience total recovery.

Dr. Baudendistel can be contacted at [email protected].

References

1. Ammirati M, Mirzai S, Samii M. Vertebral arteriovenous fistulae: report of two cases and review of the literature. Acta Neurochir. 1989;99:122-6.
2. Gobin YP, Duckwiler GR, Vinuela F. Direct arteriovenous fistulas: diagnosis and intervention. Neuroimaging Clin North Am. 1998;8:425-43.
3. Halbach VV, Higashida RT, Hieshima GB. Treatment of vertebral arteriovenous fistulas. AJR. 1988;150:405-12.

A 57-year-old woman with no previous medical history was admitted with weakness. The patient complained of 2 months of ascending bilateral lower extremity weakness followed by subjective “numbness” of both legs. She had a normal lumbosacral MRI as an outpatient and presented to the ED with progressive symptoms. She denied back pain, bowel or bladder problems, diplopia, ataxia, or confusion. As well, there were no fevers, chills, muscle pain, or weight loss. She had no risk factors for HIV and no toxic exposures.

On admission, her vital signs were normal and her general physical exam was unremarkable. Her neurologic exam was notable for diffuse symmetric 3/5 bilateral lower extremity weakness and symmetric bilateral sensory loss in a “stocking” distribution. She had bilateral lower extremity hyperreflexia and plantar reflexes were extensor bilaterally. She had normal upper extremities, cranial nerves, and mental status. Screening laboratories including fasting glucose, B12, RPR, TSH, HIV, SPEP, and UPEP were negative. A repeat lumbosacral MRI and a lumbar puncture were nondiagnostic.

While hospitalized, the patient suffered progressive ascending weakness involving the upper extremities and the diaphragm, necessitating intubation. She was treated with high-dose steroids, IVIG, and plasmapheresis for the possibility of Guillain-Barre or transverse myelitis; there was no change in her symptoms. With no clear diagnosis, on hospital day 10, she complained of diplopia and was found to have right eye chemosis, proptosis, right abducens nerve palsy, and a loud bruit over the right eye. A CT scan revealed dilated right ophthalmic veins and an engorged cavernous sinus (Figure 1). A cerebral angiogram was performed and showed a distal right vertebral arteriovenous fistula (Figure 2), and an MRI showed increased signal in the entire cord secondary to venous hypertension.

What is the diagnosis?

Vertebral Arterio-Venous Fistula (AVF) with arterialized venous drainage to the cavernous sinus, ophthalmic veins, and the cervical epidural veins leading to her ocular symptoms and a cervical myelopathy.

She had no history of trauma and the AVF was thought to be spontaneous. She underwent successful transarterial embolization of the right vertebral artery (see Figure 3). Her ocular symptoms rapidly improved and she was transferred to a rehabilitation facility with improving motor and sensory function.

Discussion: Vertebral arteriovenous fistulas (AVFs) are rare vascular malformations characterized by abnormal shunting between the extracranial vertebral artery and a neighboring vein. Vertebral AVFs are most often secondary to trauma including penetrating gunshot or stab wounds to the neck. Fibromuscular dysplasia and neurofibromatosis are predisposing conditions but vertebral AVFs can be spontaneous as in this case. Patients with vertebral AVFs may present with tinnitus, but frequently they have no symptoms and their fistulas are discovered as cervical bruits on routine auscultation. Neurologic syndromes in the setting of a vertebral AVF are rare and typically secondary to arterialization of venous drainage leading to local ischemia and nerve damage. There are case reports of vertigo and vertebrobasilar insufficiency, cervical radiculopathy related to nerve-root compression from engorged vertebral veins, and cervical myelopathy from venous hypertension similar to this patient. As well, there is only one case report of a vertebral AVF leading to exophthalmos, chemosis, and a bruit, mimicking a carotid-cavernous fistula. This is the first reported case of a vertebral AVF leading to both cervical cord and ocular pathology.

Vertebral AVFs can be suspected based on CT and MRI findings, but angiography is the gold standard for diagnosis. Transarterial embolization is the safest and most effective treatment, allowing for occlusion of the fistula while maintaining patency of the vertebral artery. If treated expediently, most patients experience total recovery.

Dr. Baudendistel can be contacted at [email protected].

References

1. Ammirati M, Mirzai S, Samii M. Vertebral arteriovenous fistulae: report of two cases and review of the literature. Acta Neurochir. 1989;99:122-6.
2. Gobin YP, Duckwiler GR, Vinuela F. Direct arteriovenous fistulas: diagnosis and intervention. Neuroimaging Clin North Am. 1998;8:425-43.
3. Halbach VV, Higashida RT, Hieshima GB. Treatment of vertebral arteriovenous fistulas. AJR. 1988;150:405-12.

A 57-year-old woman with no previous medical history was admitted with weakness. The patient complained of 2 months of ascending bilateral lower extremity weakness followed by subjective “numbness” of both legs. She had a normal lumbosacral MRI as an outpatient and presented to the ED with progressive symptoms. She denied back pain, bowel or bladder problems, diplopia, ataxia, or confusion. As well, there were no fevers, chills, muscle pain, or weight loss. She had no risk factors for HIV and no toxic exposures.

On admission, her vital signs were normal and her general physical exam was unremarkable. Her neurologic exam was notable for diffuse symmetric 3/5 bilateral lower extremity weakness and symmetric bilateral sensory loss in a “stocking” distribution. She had bilateral lower extremity hyperreflexia and plantar reflexes were extensor bilaterally. She had normal upper extremities, cranial nerves, and mental status. Screening laboratories including fasting glucose, B12, RPR, TSH, HIV, SPEP, and UPEP were negative. A repeat lumbosacral MRI and a lumbar puncture were nondiagnostic.

While hospitalized, the patient suffered progressive ascending weakness involving the upper extremities and the diaphragm, necessitating intubation. She was treated with high-dose steroids, IVIG, and plasmapheresis for the possibility of Guillain-Barre or transverse myelitis; there was no change in her symptoms. With no clear diagnosis, on hospital day 10, she complained of diplopia and was found to have right eye chemosis, proptosis, right abducens nerve palsy, and a loud bruit over the right eye. A CT scan revealed dilated right ophthalmic veins and an engorged cavernous sinus (Figure 1). A cerebral angiogram was performed and showed a distal right vertebral arteriovenous fistula (Figure 2), and an MRI showed increased signal in the entire cord secondary to venous hypertension.

What is the diagnosis?

Vertebral Arterio-Venous Fistula (AVF) with arterialized venous drainage to the cavernous sinus, ophthalmic veins, and the cervical epidural veins leading to her ocular symptoms and a cervical myelopathy.

She had no history of trauma and the AVF was thought to be spontaneous. She underwent successful transarterial embolization of the right vertebral artery (see Figure 3). Her ocular symptoms rapidly improved and she was transferred to a rehabilitation facility with improving motor and sensory function.

Discussion: Vertebral arteriovenous fistulas (AVFs) are rare vascular malformations characterized by abnormal shunting between the extracranial vertebral artery and a neighboring vein. Vertebral AVFs are most often secondary to trauma including penetrating gunshot or stab wounds to the neck. Fibromuscular dysplasia and neurofibromatosis are predisposing conditions but vertebral AVFs can be spontaneous as in this case. Patients with vertebral AVFs may present with tinnitus, but frequently they have no symptoms and their fistulas are discovered as cervical bruits on routine auscultation. Neurologic syndromes in the setting of a vertebral AVF are rare and typically secondary to arterialization of venous drainage leading to local ischemia and nerve damage. There are case reports of vertigo and vertebrobasilar insufficiency, cervical radiculopathy related to nerve-root compression from engorged vertebral veins, and cervical myelopathy from venous hypertension similar to this patient. As well, there is only one case report of a vertebral AVF leading to exophthalmos, chemosis, and a bruit, mimicking a carotid-cavernous fistula. This is the first reported case of a vertebral AVF leading to both cervical cord and ocular pathology.

Vertebral AVFs can be suspected based on CT and MRI findings, but angiography is the gold standard for diagnosis. Transarterial embolization is the safest and most effective treatment, allowing for occlusion of the fistula while maintaining patency of the vertebral artery. If treated expediently, most patients experience total recovery.

Dr. Baudendistel can be contacted at [email protected].

References

1. Ammirati M, Mirzai S, Samii M. Vertebral arteriovenous fistulae: report of two cases and review of the literature. Acta Neurochir. 1989;99:122-6.
2. Gobin YP, Duckwiler GR, Vinuela F. Direct arteriovenous fistulas: diagnosis and intervention. Neuroimaging Clin North Am. 1998;8:425-43.
3. Halbach VV, Higashida RT, Hieshima GB. Treatment of vertebral arteriovenous fistulas. AJR. 1988;150:405-12.

Introduction

Hospitalists often have questions related to coding for consultative services and subsequent hospital visits, especially when other specialists are managing the patient “concurrently.” If the hospitalist is practicing in a teaching hospital the guidelines can be yet more confusing, due to the need to apply Medicare’s teaching physician guidelines. Even after reading informative articles or attending educational sessions, hospitalists may encounter unique scenarios that can frustrate the most experienced physician and/or coder. The goal of this article is to present some basic principles regarding coding for consultations and concurrent care, and to provide several case scenarios that can be applied in clinical practice as a guide.

Objectives of the article include answering the following questions:

• Is it appropriate as a hospitalist to bill a consultation code when requested by a surgeon who really wants you to manage the patient’s chronic medical conditions?
• Can a hospitalist charge for services provided to a postoperative patient at the request of the surgeon, even though there are no real medical conditions or complications?
• Can two internists (different subspecialties) treat and bill the same patient on the same day and get paid?
• Can two internists (same specialty) treat and bill the same patient on the same day?
• What if my group performs preoperative evaluations and will also be managing the patient postoperatively for his/her medical conditions? When the surgeon requests a “consult” may I use the consultation codes?

Consultations

An inpatient consultation is a service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem(s) is requested by another physician. There has been a tremendous amount of confusion in interpreting the rules regarding consultations in general, and this is particularly true for hospitalists given frequent blurring of the distinction between classic consultation and co-management. In August of 1999, Medicare clarified for its carriers when an encounter qualified as a consultation. Here’s what the manual states:

Consultation followed by treatment: “…Payment for a consultation may be made regardless of treatment initiation UNLESS A TRANSFER OF CARE OCCURS. A transfer of care occurs when the referring physician transfers the responsibility for the patient’s complete care to the receiving physician at the time of referral and the receiving physician documents approval of the transfer of care in advance. “ (reference MCM 15506 B.)

Inpatient consultant services are coded using initial consult codes (99251-99255).

Scenario # 1

A psychiatrist asks you to see a 36-year-old man for “uncontrolled hypertension” who was admitted with a manic episode. The patient stopped taking his anti-hypertensive medications 6 weeks before, and his systolic blood pressure has been consistently running 160–170 since admission. You perform an in-depth review of his medical records, along with a thorough history and physical examination (made challenging by his poorly controlled mania) and review of his laboratory studies. After your evaluation, you agree to manage the patient’s hypertension problem.

Question # 1: Should this be coded as a consultation or a subsequent visit?

Answer: Since a request was made to evaluate a patient for a problem and you did not in advance of the consultation (in writing) accept transfer of the patient’s medical care, a consultation may be coded as long as all of the criteria have been met. The fact that you decide to manage the patient’s hypertension subsequent to the initial consult does not impact your ability to use the initial consult code for this patient. Remember the requirements for a consultation—

• Request for consult. (A written order by the psychiatrist should be documented in the record and the consulting physician should document “Consult requested by Dr. Smith for evaluation of patient’s uncontrolled hypertension.”)
• Written report of his or her findings in the inpatient medical record. (The note may serve as a “report” and should clearly define the recommendations made by you, the consultant.)

Question # 2: Can the degree of complexity be considered higher than a typical patient with “uncontrolled hypertension” due to the difficulties in obtaining the information for this patient?

Answer: The complexity of data reviewed can have an impact on the level of service billed. The uncontrolled nature of the underlying problem, and the summarizing of the patient’s history from the record when the patient is unable to provide the information would be indicative of moderate complexity decision-making. Note that in situations where the level of service is much lower than the time spent with the patient due to extenuating circumstances such as these, it may be appropriate to consider “prolonged care” codes as long as the time thresholds are met and time is documented in the record.

Scenario # 2

A patient with stable hypertension and diabetes has been seen by one of the other members of your group and specialty for a preoperative consultation. The consultation was performed and the patient was deemed to be medically optimized. After the surgery, you are asked to co-manage the patient’s SAME medical conditions.

Question: Can I code an initial consult?

Answer: This is a situation where Medicare has a special rule for those physicians (same specialty and in the same group practice) who perform pre-operative consultations. A consult code (either initial or follow up) should not be used but rather a subsequent visit code should be used. An assumption is made that the physician who performed the preoperative consult will have developed a treatment plan for that problem and will have assumed responsibility for any postoperative care requested by the surgeon. HOWEVER, if a new problem has arisen and a consult is requested by the physician postoperatively, then an initial consult code may be used.

Postoperative Management of Medical Problems

According to Medicare’s carrier manual, “If a surgeon asks a physician to take responsibility for the management of an aspect of the patient’s condition during the postoperative period, the physician may not bill a consultation because the surgeon is not asking the physician’s opinion or advice for the surgeon’s use in treating the patient. The physician’s services would constitute concurrent care and should be billed using the appropriate level subsequent visit codes.” (MCM 15506 G) This often is reflected by an order from the surgeon that says “notify Dr. X of patient’s transfer to RNF” or perhaps a telephone call to place a patient on the hospitalist’s schedule. So what is “concurrent care”?

Concurrent Care

Concurrent care exists where services “more extensive than consultative services are rendered by more than one physician during a period of time” (MCM 2020E). Basically this means that more than one physician has primary responsibility for managing a portion of the patient’s care (concurrently) during the patient’s inpatient stay. For Medicare and other payers, this is considered appropriate when these “concurrent” services are “reasonable and necessary.”

• The condition(s) or diagnoses warrant the service and the specialty or expertise of the other physician(s) and at a reasonable frequency or duration.
• Duplicate services (i.e., services provided by two different providers of the same specialty for the same or similar conditions) will typically not be considered necessary unless a special circumstance is noted. For many payers, the internist and subspecialist who co-manage the same problem may have services performed on the same day denied, and documentation would need to show there were “special circumstances.” However, if the hospitalist is treating additional issues, then there should be no problem with separate payment. Medicare does recognize the endocrinology and internal medicine specialties separately and would probably pay both even if for the same condition. But if both are really “co-managing” the same problem without any additional issues daily, most payers are going to question this, either at the time of billing or retrospectively through audits.

Inpatient Concurrent care then is coded with subsequent hospital codes in the hospital setting (Codes 99231 through 99233).

Scenario # 3

A 73-year-old man with a past medical history notable for chronic renal insufficiency, hypertension, and Alzheimer’s type dementia undergoes a right open nephrectomy for renal cell carcinoma. His early postoperative course is marked by hypotension in the post-anesthesia care unit, and he is admitted to the SICU. His course there is significant for worsening of his baseline creatinine of 1.9 to 3.8, the development of delirium, and labile blood pressure. He is transferred from the SICU to a regular nursing floor on postoperative day 2, and the attending urologist requests that you assume management of the patient’s hypertension, delirium, and acute renal failure.

Question: Does this meet the definition of appropriate concurrent care or a consultation?

Answer: Although this constitutes something of a gray area, the request as worded indicates that the hospitalist will be providing concurrent care, and the initial visit should thus be billed as a Level 3 subsequent visit (99233). If the hospitalist’s role is, rather, to provide recommendations regarding management of these problems, the initial visit should be billed as an initial inpatient consult at the appropriate level.

Scenario # 4

A 66-year-old woman with a history of coronary artery disease 3 years after stenting of the left anterior descending coronary artery, moderate aortic stenosis, well-controlled diabetes mellitus, and hyperlipidemia undergoes a left modified radical mastectomy. On the morning of her first postoperative day, she experiences substernal chest pain, with T wave inversions in the inferior leads of her ECG. Her breast surgeon consults cardiology for her chest pain, endocrinology for “diabetic control,” and the hospitalist to “oversee the medical issues.”

Question: Can the hospitalist successfully bill in this setting? If so, what needs to be done to allow this?

Answer: Because of the various specialists who are treating this patient’s medical conditions, it will be difficult to demonstrate to a payer that an additional physician should be managing the patient’s care on a daily basis for the same medical problems. Such billing would probably be considered “duplicate care” and one of the physicians’ charges will be appropriately denied. However, if the specialists have been consulted only and have not assumed management for these medical conditions, then the hospitalist who has assumed management may bill for these services. As with scenario #3, the surgeon’s request as worded in this scenario indicates the hospitalist is providing concurrent care and a consultation is not being requested.

Scenario #5:

The hospital medicine consult team is asked to see a 31-year-old woman who is postoperative day 3 after a total proctocolectomy for refractory ulcerative colitis. Her past medical history is remarkable for iron-deficiency anemia, steroid-induced diabetes, and depression. You are asked to evaluate the patient for shortness of breath that began that day. The PGY-3 resident working with you evaluates the patient initially, reviews all available records from this admission as well as the past, performs an exhaustive history and physical, personally reviews the ECG and chest X-ray that have just been completed, and documents all of the above. You then discuss the case with the resident, and personally confirm critical portions of the history and examination. You agree with the resident’s assessment that the patient has most likely sustained a pulmonary embolism, as well as her recommendation for empiric anticoagulation and an urgent V/Q scan.

Question #1: What must be done documentation-wise by the attending physician to ensure that the optimum billing level is captured for this patient? What is not acceptable in this setting?

Answer: Redocumentation by the teaching physician is relatively minimal since CMS revised its guidelines [Transmittal 1780 dated 11/22/02], which allows substantial reference to the resident’s note in addition to a personal note, however, documentation must clearly demonstrate that the teaching physician was physically present during the key portions of the service billed. Examples of documentation provided by CMS are:

“I performed a history and examination of the patient and discussed his management with the resident. I reviewed the resident’s note and agree with the documented findings and plan of care.”

Or

“I saw and evaluated the patient. I agree with the findings and plan of care documented in the resident’s note.”

Or

“I saw and evaluated the patient. I agree w/ the resident’s note except…” while noting the difference in plan, etc.

Question #2: If the hospitalist/medical resident write the orders for the heparin and V/Q scan, does this constitute comanagement and prevent billing this as a consult?

Answer: A consultant may initiate treatment at the conclusion of his evaluation and still bill a consultation code as long as the other requirements have been met (i.e., a request for opinion regarding evaluation and treatment and no advance transfer of care). There are no specific rules related to medical residents in this scenario, so if the teaching physician is performing the consult in a timely manner with the resident, a consultation could still be coded appropriately.

Summary

Although efforts have been made by Medicare to clarify the vagaries of coding for consultative work, existing guidelines remain complex and not necessarily intuitive. This article has attempted to shed light on some of the more commonly encountered situations with which hospitalists grapple, but is unable to address all of the questions that may arise. Hospitalists and hospital medicine groups are encouraged to familiarize themselves with current coding guidelines and to establish and maintain strong relationships with local coding professionals. Future issues of The Hospitalist will tackle additional coding questions.

Dr. Pfeiffer can be contacted at [email protected].

Introduction

Hospitalists often have questions related to coding for consultative services and subsequent hospital visits, especially when other specialists are managing the patient “concurrently.” If the hospitalist is practicing in a teaching hospital the guidelines can be yet more confusing, due to the need to apply Medicare’s teaching physician guidelines. Even after reading informative articles or attending educational sessions, hospitalists may encounter unique scenarios that can frustrate the most experienced physician and/or coder. The goal of this article is to present some basic principles regarding coding for consultations and concurrent care, and to provide several case scenarios that can be applied in clinical practice as a guide.

Objectives of the article include answering the following questions:

• Is it appropriate as a hospitalist to bill a consultation code when requested by a surgeon who really wants you to manage the patient’s chronic medical conditions?
• Can a hospitalist charge for services provided to a postoperative patient at the request of the surgeon, even though there are no real medical conditions or complications?
• Can two internists (different subspecialties) treat and bill the same patient on the same day and get paid?
• Can two internists (same specialty) treat and bill the same patient on the same day?
• What if my group performs preoperative evaluations and will also be managing the patient postoperatively for his/her medical conditions? When the surgeon requests a “consult” may I use the consultation codes?

Consultations

An inpatient consultation is a service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem(s) is requested by another physician. There has been a tremendous amount of confusion in interpreting the rules regarding consultations in general, and this is particularly true for hospitalists given frequent blurring of the distinction between classic consultation and co-management. In August of 1999, Medicare clarified for its carriers when an encounter qualified as a consultation. Here’s what the manual states:

Consultation followed by treatment: “…Payment for a consultation may be made regardless of treatment initiation UNLESS A TRANSFER OF CARE OCCURS. A transfer of care occurs when the referring physician transfers the responsibility for the patient’s complete care to the receiving physician at the time of referral and the receiving physician documents approval of the transfer of care in advance. “ (reference MCM 15506 B.)

Inpatient consultant services are coded using initial consult codes (99251-99255).

Scenario # 1

A psychiatrist asks you to see a 36-year-old man for “uncontrolled hypertension” who was admitted with a manic episode. The patient stopped taking his anti-hypertensive medications 6 weeks before, and his systolic blood pressure has been consistently running 160–170 since admission. You perform an in-depth review of his medical records, along with a thorough history and physical examination (made challenging by his poorly controlled mania) and review of his laboratory studies. After your evaluation, you agree to manage the patient’s hypertension problem.

Question # 1: Should this be coded as a consultation or a subsequent visit?

Answer: Since a request was made to evaluate a patient for a problem and you did not in advance of the consultation (in writing) accept transfer of the patient’s medical care, a consultation may be coded as long as all of the criteria have been met. The fact that you decide to manage the patient’s hypertension subsequent to the initial consult does not impact your ability to use the initial consult code for this patient. Remember the requirements for a consultation—

• Request for consult. (A written order by the psychiatrist should be documented in the record and the consulting physician should document “Consult requested by Dr. Smith for evaluation of patient’s uncontrolled hypertension.”)
• Written report of his or her findings in the inpatient medical record. (The note may serve as a “report” and should clearly define the recommendations made by you, the consultant.)

Question # 2: Can the degree of complexity be considered higher than a typical patient with “uncontrolled hypertension” due to the difficulties in obtaining the information for this patient?

Answer: The complexity of data reviewed can have an impact on the level of service billed. The uncontrolled nature of the underlying problem, and the summarizing of the patient’s history from the record when the patient is unable to provide the information would be indicative of moderate complexity decision-making. Note that in situations where the level of service is much lower than the time spent with the patient due to extenuating circumstances such as these, it may be appropriate to consider “prolonged care” codes as long as the time thresholds are met and time is documented in the record.

Scenario # 2

A patient with stable hypertension and diabetes has been seen by one of the other members of your group and specialty for a preoperative consultation. The consultation was performed and the patient was deemed to be medically optimized. After the surgery, you are asked to co-manage the patient’s SAME medical conditions.

Question: Can I code an initial consult?

Answer: This is a situation where Medicare has a special rule for those physicians (same specialty and in the same group practice) who perform pre-operative consultations. A consult code (either initial or follow up) should not be used but rather a subsequent visit code should be used. An assumption is made that the physician who performed the preoperative consult will have developed a treatment plan for that problem and will have assumed responsibility for any postoperative care requested by the surgeon. HOWEVER, if a new problem has arisen and a consult is requested by the physician postoperatively, then an initial consult code may be used.

Postoperative Management of Medical Problems

According to Medicare’s carrier manual, “If a surgeon asks a physician to take responsibility for the management of an aspect of the patient’s condition during the postoperative period, the physician may not bill a consultation because the surgeon is not asking the physician’s opinion or advice for the surgeon’s use in treating the patient. The physician’s services would constitute concurrent care and should be billed using the appropriate level subsequent visit codes.” (MCM 15506 G) This often is reflected by an order from the surgeon that says “notify Dr. X of patient’s transfer to RNF” or perhaps a telephone call to place a patient on the hospitalist’s schedule. So what is “concurrent care”?

Concurrent Care

Concurrent care exists where services “more extensive than consultative services are rendered by more than one physician during a period of time” (MCM 2020E). Basically this means that more than one physician has primary responsibility for managing a portion of the patient’s care (concurrently) during the patient’s inpatient stay. For Medicare and other payers, this is considered appropriate when these “concurrent” services are “reasonable and necessary.”

• The condition(s) or diagnoses warrant the service and the specialty or expertise of the other physician(s) and at a reasonable frequency or duration.
• Duplicate services (i.e., services provided by two different providers of the same specialty for the same or similar conditions) will typically not be considered necessary unless a special circumstance is noted. For many payers, the internist and subspecialist who co-manage the same problem may have services performed on the same day denied, and documentation would need to show there were “special circumstances.” However, if the hospitalist is treating additional issues, then there should be no problem with separate payment. Medicare does recognize the endocrinology and internal medicine specialties separately and would probably pay both even if for the same condition. But if both are really “co-managing” the same problem without any additional issues daily, most payers are going to question this, either at the time of billing or retrospectively through audits.

Inpatient Concurrent care then is coded with subsequent hospital codes in the hospital setting (Codes 99231 through 99233).

Scenario # 3

A 73-year-old man with a past medical history notable for chronic renal insufficiency, hypertension, and Alzheimer’s type dementia undergoes a right open nephrectomy for renal cell carcinoma. His early postoperative course is marked by hypotension in the post-anesthesia care unit, and he is admitted to the SICU. His course there is significant for worsening of his baseline creatinine of 1.9 to 3.8, the development of delirium, and labile blood pressure. He is transferred from the SICU to a regular nursing floor on postoperative day 2, and the attending urologist requests that you assume management of the patient’s hypertension, delirium, and acute renal failure.

Question: Does this meet the definition of appropriate concurrent care or a consultation?

Answer: Although this constitutes something of a gray area, the request as worded indicates that the hospitalist will be providing concurrent care, and the initial visit should thus be billed as a Level 3 subsequent visit (99233). If the hospitalist’s role is, rather, to provide recommendations regarding management of these problems, the initial visit should be billed as an initial inpatient consult at the appropriate level.

Scenario # 4

A 66-year-old woman with a history of coronary artery disease 3 years after stenting of the left anterior descending coronary artery, moderate aortic stenosis, well-controlled diabetes mellitus, and hyperlipidemia undergoes a left modified radical mastectomy. On the morning of her first postoperative day, she experiences substernal chest pain, with T wave inversions in the inferior leads of her ECG. Her breast surgeon consults cardiology for her chest pain, endocrinology for “diabetic control,” and the hospitalist to “oversee the medical issues.”

Question: Can the hospitalist successfully bill in this setting? If so, what needs to be done to allow this?

Answer: Because of the various specialists who are treating this patient’s medical conditions, it will be difficult to demonstrate to a payer that an additional physician should be managing the patient’s care on a daily basis for the same medical problems. Such billing would probably be considered “duplicate care” and one of the physicians’ charges will be appropriately denied. However, if the specialists have been consulted only and have not assumed management for these medical conditions, then the hospitalist who has assumed management may bill for these services. As with scenario #3, the surgeon’s request as worded in this scenario indicates the hospitalist is providing concurrent care and a consultation is not being requested.

Scenario #5:

The hospital medicine consult team is asked to see a 31-year-old woman who is postoperative day 3 after a total proctocolectomy for refractory ulcerative colitis. Her past medical history is remarkable for iron-deficiency anemia, steroid-induced diabetes, and depression. You are asked to evaluate the patient for shortness of breath that began that day. The PGY-3 resident working with you evaluates the patient initially, reviews all available records from this admission as well as the past, performs an exhaustive history and physical, personally reviews the ECG and chest X-ray that have just been completed, and documents all of the above. You then discuss the case with the resident, and personally confirm critical portions of the history and examination. You agree with the resident’s assessment that the patient has most likely sustained a pulmonary embolism, as well as her recommendation for empiric anticoagulation and an urgent V/Q scan.

Question #1: What must be done documentation-wise by the attending physician to ensure that the optimum billing level is captured for this patient? What is not acceptable in this setting?

Answer: Redocumentation by the teaching physician is relatively minimal since CMS revised its guidelines [Transmittal 1780 dated 11/22/02], which allows substantial reference to the resident’s note in addition to a personal note, however, documentation must clearly demonstrate that the teaching physician was physically present during the key portions of the service billed. Examples of documentation provided by CMS are:

“I performed a history and examination of the patient and discussed his management with the resident. I reviewed the resident’s note and agree with the documented findings and plan of care.”

Or

“I saw and evaluated the patient. I agree with the findings and plan of care documented in the resident’s note.”

Or

“I saw and evaluated the patient. I agree w/ the resident’s note except…” while noting the difference in plan, etc.

Question #2: If the hospitalist/medical resident write the orders for the heparin and V/Q scan, does this constitute comanagement and prevent billing this as a consult?

Answer: A consultant may initiate treatment at the conclusion of his evaluation and still bill a consultation code as long as the other requirements have been met (i.e., a request for opinion regarding evaluation and treatment and no advance transfer of care). There are no specific rules related to medical residents in this scenario, so if the teaching physician is performing the consult in a timely manner with the resident, a consultation could still be coded appropriately.

Summary

Although efforts have been made by Medicare to clarify the vagaries of coding for consultative work, existing guidelines remain complex and not necessarily intuitive. This article has attempted to shed light on some of the more commonly encountered situations with which hospitalists grapple, but is unable to address all of the questions that may arise. Hospitalists and hospital medicine groups are encouraged to familiarize themselves with current coding guidelines and to establish and maintain strong relationships with local coding professionals. Future issues of The Hospitalist will tackle additional coding questions.

Dr. Pfeiffer can be contacted at [email protected].

Introduction

Hospitalists often have questions related to coding for consultative services and subsequent hospital visits, especially when other specialists are managing the patient “concurrently.” If the hospitalist is practicing in a teaching hospital the guidelines can be yet more confusing, due to the need to apply Medicare’s teaching physician guidelines. Even after reading informative articles or attending educational sessions, hospitalists may encounter unique scenarios that can frustrate the most experienced physician and/or coder. The goal of this article is to present some basic principles regarding coding for consultations and concurrent care, and to provide several case scenarios that can be applied in clinical practice as a guide.

Objectives of the article include answering the following questions:

• Is it appropriate as a hospitalist to bill a consultation code when requested by a surgeon who really wants you to manage the patient’s chronic medical conditions?
• Can a hospitalist charge for services provided to a postoperative patient at the request of the surgeon, even though there are no real medical conditions or complications?
• Can two internists (different subspecialties) treat and bill the same patient on the same day and get paid?
• Can two internists (same specialty) treat and bill the same patient on the same day?
• What if my group performs preoperative evaluations and will also be managing the patient postoperatively for his/her medical conditions? When the surgeon requests a “consult” may I use the consultation codes?

Consultations

An inpatient consultation is a service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem(s) is requested by another physician. There has been a tremendous amount of confusion in interpreting the rules regarding consultations in general, and this is particularly true for hospitalists given frequent blurring of the distinction between classic consultation and co-management. In August of 1999, Medicare clarified for its carriers when an encounter qualified as a consultation. Here’s what the manual states:

Consultation followed by treatment: “…Payment for a consultation may be made regardless of treatment initiation UNLESS A TRANSFER OF CARE OCCURS. A transfer of care occurs when the referring physician transfers the responsibility for the patient’s complete care to the receiving physician at the time of referral and the receiving physician documents approval of the transfer of care in advance. “ (reference MCM 15506 B.)

Inpatient consultant services are coded using initial consult codes (99251-99255).

Scenario # 1

A psychiatrist asks you to see a 36-year-old man for “uncontrolled hypertension” who was admitted with a manic episode. The patient stopped taking his anti-hypertensive medications 6 weeks before, and his systolic blood pressure has been consistently running 160–170 since admission. You perform an in-depth review of his medical records, along with a thorough history and physical examination (made challenging by his poorly controlled mania) and review of his laboratory studies. After your evaluation, you agree to manage the patient’s hypertension problem.

Question # 1: Should this be coded as a consultation or a subsequent visit?

Answer: Since a request was made to evaluate a patient for a problem and you did not in advance of the consultation (in writing) accept transfer of the patient’s medical care, a consultation may be coded as long as all of the criteria have been met. The fact that you decide to manage the patient’s hypertension subsequent to the initial consult does not impact your ability to use the initial consult code for this patient. Remember the requirements for a consultation—

• Request for consult. (A written order by the psychiatrist should be documented in the record and the consulting physician should document “Consult requested by Dr. Smith for evaluation of patient’s uncontrolled hypertension.”)
• Written report of his or her findings in the inpatient medical record. (The note may serve as a “report” and should clearly define the recommendations made by you, the consultant.)

Question # 2: Can the degree of complexity be considered higher than a typical patient with “uncontrolled hypertension” due to the difficulties in obtaining the information for this patient?

Answer: The complexity of data reviewed can have an impact on the level of service billed. The uncontrolled nature of the underlying problem, and the summarizing of the patient’s history from the record when the patient is unable to provide the information would be indicative of moderate complexity decision-making. Note that in situations where the level of service is much lower than the time spent with the patient due to extenuating circumstances such as these, it may be appropriate to consider “prolonged care” codes as long as the time thresholds are met and time is documented in the record.

Scenario # 2

A patient with stable hypertension and diabetes has been seen by one of the other members of your group and specialty for a preoperative consultation. The consultation was performed and the patient was deemed to be medically optimized. After the surgery, you are asked to co-manage the patient’s SAME medical conditions.

Question: Can I code an initial consult?

Answer: This is a situation where Medicare has a special rule for those physicians (same specialty and in the same group practice) who perform pre-operative consultations. A consult code (either initial or follow up) should not be used but rather a subsequent visit code should be used. An assumption is made that the physician who performed the preoperative consult will have developed a treatment plan for that problem and will have assumed responsibility for any postoperative care requested by the surgeon. HOWEVER, if a new problem has arisen and a consult is requested by the physician postoperatively, then an initial consult code may be used.

Postoperative Management of Medical Problems

According to Medicare’s carrier manual, “If a surgeon asks a physician to take responsibility for the management of an aspect of the patient’s condition during the postoperative period, the physician may not bill a consultation because the surgeon is not asking the physician’s opinion or advice for the surgeon’s use in treating the patient. The physician’s services would constitute concurrent care and should be billed using the appropriate level subsequent visit codes.” (MCM 15506 G) This often is reflected by an order from the surgeon that says “notify Dr. X of patient’s transfer to RNF” or perhaps a telephone call to place a patient on the hospitalist’s schedule. So what is “concurrent care”?

Concurrent Care

Concurrent care exists where services “more extensive than consultative services are rendered by more than one physician during a period of time” (MCM 2020E). Basically this means that more than one physician has primary responsibility for managing a portion of the patient’s care (concurrently) during the patient’s inpatient stay. For Medicare and other payers, this is considered appropriate when these “concurrent” services are “reasonable and necessary.”

• The condition(s) or diagnoses warrant the service and the specialty or expertise of the other physician(s) and at a reasonable frequency or duration.
• Duplicate services (i.e., services provided by two different providers of the same specialty for the same or similar conditions) will typically not be considered necessary unless a special circumstance is noted. For many payers, the internist and subspecialist who co-manage the same problem may have services performed on the same day denied, and documentation would need to show there were “special circumstances.” However, if the hospitalist is treating additional issues, then there should be no problem with separate payment. Medicare does recognize the endocrinology and internal medicine specialties separately and would probably pay both even if for the same condition. But if both are really “co-managing” the same problem without any additional issues daily, most payers are going to question this, either at the time of billing or retrospectively through audits.

Inpatient Concurrent care then is coded with subsequent hospital codes in the hospital setting (Codes 99231 through 99233).

Scenario # 3

A 73-year-old man with a past medical history notable for chronic renal insufficiency, hypertension, and Alzheimer’s type dementia undergoes a right open nephrectomy for renal cell carcinoma. His early postoperative course is marked by hypotension in the post-anesthesia care unit, and he is admitted to the SICU. His course there is significant for worsening of his baseline creatinine of 1.9 to 3.8, the development of delirium, and labile blood pressure. He is transferred from the SICU to a regular nursing floor on postoperative day 2, and the attending urologist requests that you assume management of the patient’s hypertension, delirium, and acute renal failure.

Question: Does this meet the definition of appropriate concurrent care or a consultation?

Answer: Although this constitutes something of a gray area, the request as worded indicates that the hospitalist will be providing concurrent care, and the initial visit should thus be billed as a Level 3 subsequent visit (99233). If the hospitalist’s role is, rather, to provide recommendations regarding management of these problems, the initial visit should be billed as an initial inpatient consult at the appropriate level.

Scenario # 4

A 66-year-old woman with a history of coronary artery disease 3 years after stenting of the left anterior descending coronary artery, moderate aortic stenosis, well-controlled diabetes mellitus, and hyperlipidemia undergoes a left modified radical mastectomy. On the morning of her first postoperative day, she experiences substernal chest pain, with T wave inversions in the inferior leads of her ECG. Her breast surgeon consults cardiology for her chest pain, endocrinology for “diabetic control,” and the hospitalist to “oversee the medical issues.”

Question: Can the hospitalist successfully bill in this setting? If so, what needs to be done to allow this?

Answer: Because of the various specialists who are treating this patient’s medical conditions, it will be difficult to demonstrate to a payer that an additional physician should be managing the patient’s care on a daily basis for the same medical problems. Such billing would probably be considered “duplicate care” and one of the physicians’ charges will be appropriately denied. However, if the specialists have been consulted only and have not assumed management for these medical conditions, then the hospitalist who has assumed management may bill for these services. As with scenario #3, the surgeon’s request as worded in this scenario indicates the hospitalist is providing concurrent care and a consultation is not being requested.

Scenario #5:

The hospital medicine consult team is asked to see a 31-year-old woman who is postoperative day 3 after a total proctocolectomy for refractory ulcerative colitis. Her past medical history is remarkable for iron-deficiency anemia, steroid-induced diabetes, and depression. You are asked to evaluate the patient for shortness of breath that began that day. The PGY-3 resident working with you evaluates the patient initially, reviews all available records from this admission as well as the past, performs an exhaustive history and physical, personally reviews the ECG and chest X-ray that have just been completed, and documents all of the above. You then discuss the case with the resident, and personally confirm critical portions of the history and examination. You agree with the resident’s assessment that the patient has most likely sustained a pulmonary embolism, as well as her recommendation for empiric anticoagulation and an urgent V/Q scan.

Question #1: What must be done documentation-wise by the attending physician to ensure that the optimum billing level is captured for this patient? What is not acceptable in this setting?

Answer: Redocumentation by the teaching physician is relatively minimal since CMS revised its guidelines [Transmittal 1780 dated 11/22/02], which allows substantial reference to the resident’s note in addition to a personal note, however, documentation must clearly demonstrate that the teaching physician was physically present during the key portions of the service billed. Examples of documentation provided by CMS are:

“I performed a history and examination of the patient and discussed his management with the resident. I reviewed the resident’s note and agree with the documented findings and plan of care.”

Or

“I saw and evaluated the patient. I agree with the findings and plan of care documented in the resident’s note.”

Or

“I saw and evaluated the patient. I agree w/ the resident’s note except…” while noting the difference in plan, etc.

Question #2: If the hospitalist/medical resident write the orders for the heparin and V/Q scan, does this constitute comanagement and prevent billing this as a consult?

Answer: A consultant may initiate treatment at the conclusion of his evaluation and still bill a consultation code as long as the other requirements have been met (i.e., a request for opinion regarding evaluation and treatment and no advance transfer of care). There are no specific rules related to medical residents in this scenario, so if the teaching physician is performing the consult in a timely manner with the resident, a consultation could still be coded appropriately.

Summary

Although efforts have been made by Medicare to clarify the vagaries of coding for consultative work, existing guidelines remain complex and not necessarily intuitive. This article has attempted to shed light on some of the more commonly encountered situations with which hospitalists grapple, but is unable to address all of the questions that may arise. Hospitalists and hospital medicine groups are encouraged to familiarize themselves with current coding guidelines and to establish and maintain strong relationships with local coding professionals. Future issues of The Hospitalist will tackle additional coding questions.

Dr. Pfeiffer can be contacted at [email protected].

Today’s hospitals must address a variety of challenges stemming from the expectation to provide more services and better quality with fewer financial, material, and human resources. According to the annual survey conducted by the American Hospital Association (AHA) in 2003, total expenses for all U.S. community hospitals were more than $450 billion. In managing these expenditures, hospitals face the following pressures:

• Cost increases in medical supplies and pharmaceuticals.
• Record shortages of nurses, pharmacists, and technicians.
• A growing uncompensated patient pool.
• Annual potential reductions in Medicare and Medicaid reimbursements.
• Rising bad debt resulting from greater patient responsibilityfor the cost of care.
• The diversion of more profitable cases to specialty and freestanding ambulatory care facilities and surgery centers.
• Soaring costs associated with adequately serving high-risk conditions, such as cancer, heart disease, and HIV/AIDS.
• Discounted reimbursement rates with insurers.
• Increasing pressure to commit financial resources to clinical information technology.
• The need to fund infrastructure improvements and physical plant renovations as well as expansions to address increasing demand (1).

To overcome these challenges, hospitals must find innovative ways to balance revenues and expenses, fund necessary capital investments, and satisfy the public’s demand for quality, safety, and accessibility.

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Hospitalist Programs: A Good Investment

One solution to the above-mentioned situations is a hospitalist program, which, in its short history, has already had a profound impact on inpatient care. Robert M. Wachter, MD, associate chair in the department of medicine at the University of California, San Francisco (UCSF) and medical service chief at Moffitt-Long Hospitals, coined the term hospitalist in an article in the New England Journal of Medicine in 1996 (15). At the 2002 annual meeting of the Society of Hospital Medicine (SHM), Wachter presented findings from a study conducted at his institution. The results demonstrate a significant return on investment (ROI) of 5.8: 1 when a hospitalist program is utilized (See Table 1 for details) (14).

How do hospitalists reduce length of stay (LOS) and cost per stay? William David Rifkin, MD, associate director of the Yale Primary Care Residency Program, offers three basic reasons why hospitalist programs contribute to effective and efficient use of resources. Since hospitalists are physically onsite, they are better able to react to condition changes and requests for consultations in a timely manner, he asserts. Also, being familiar with the hospital’s systems of care, the hospitalist knows who to call and how to utilize the services of social workers and other contingency staff when arranging for post-discharge care. Third, Rifkin indicates that inpatients today are sicker than they were in past years, a fact well known and understood by hospitalists. “There is an increased level of acuity,” he says. “Hospitalists are used to seeing these kinds of patients. They are more comfortable taking care of these patients and will see more of them with any given diagnosis” (11).

In one of his studies, Rifkin noted a reduction in LOS for inpatients with a pneumonia diagnosis. “The hospitalist had switched the patient from IV (intravenous) to oral antibiotics,” he says. Reacting quickly to indications that the patient was ready for a change in treatment modality facilitated an earlier discharge (12).

L. Craig Miller, MD, senior vice president of medical affairs at Baptist Health Care, reports that his hospital saved $2.56 million in 2 years as a direct result of its inpatient management program (7). Although attention to technical and clinical details is important, Miller emphasizes the critical role the human factor plays, specifically the impact of teamwork, on achieving resource utilization savings. “Hospitalists work as a team, collaborating with physicians and ED doctors,” he says. This cooperative spirit enables the efficient use of manpower in patient care. Miller adds that at Baptist, as is the case at most hospitals, the medical complexity of patients dictates a need for cooperation in order to successfully treat illness. The presence of hospitalists facilitates the team effort, causing a positive trickle down effect regarding LOS, readmission and mortality rates, he affirms. “The hospitalist provides focused leadership to utilization resource management,” says Miller (9).

In the role of inpatient leader, the hospitalist also facilitates emergency department (ED) throughput, which results in another area of cost savings for the hospital. Paola Coppola, MD, ED director at Brookhaven Memorial Hospital Medical Center, says, “From an ER perspective, a call to the hospitalist replaces multiple calls to specialists. In general, hospitalists feel much more comfortable treating a wide array of conditions including infectious disease, pneumonias, strokes ,and chest pain without the intervention of specialists in that field. Hence, hospital consumption of resources decreases, which in turn lowers length of stay.” He echoes Rifkin’s thoughts on quick response time. “Hospitalists provide an immediately available service, thus saving ER physicians valuable time. This ensures faster turnover, better throughput, makes more ER beds available and services more patients, eventually helping the hospital’s bottom line,” says Coppola (2).

In addition to teamwork, 24/7 availability is vital to the wise utilization of resources, according to Anthony Shallash, MD, vice president of medical affairs at Brookhaven. “The fact of 24/7 presence allows rapid responses to patient condition and problems. Continuous and close monitoring of patients allows them to be upgraded or downgraded as needed,” he says. “As such, LOS is decreased and quite favorable as compared to peer practitioners for similar disease severity. Resources consumed and tests ordered also show a favorable trend” (13).

A recently published study (6) by researchers at Dartmouth Medical School documents the variation in the volume and cost of services that academic medical centers use in treating patients. Hospitals were categorized as low- and high-intensity, with significant differences in cost per case. For example, the high-intensity hospitals spent up to 47% more on care for acute myocardial infarction. In an interview in Today’s Hospitalist (17), the lead author, Elliott S. Fisher, MD, professor of medicine and community and family medicine at Dartmouth Medical School, described the importance of coordination in achieving efficient care. Fisher says, “I think there’s a real opportunity for hospitalists to improve the care of patients in both high- and low-intensity hospitals. Having ten doctors involved in a given patient’s care may not be a good thing, unless someone [i.e., the hospitalist] is doing a really good job of coordinating that care.”

Hospitalists focus only on inpatient medicine. They are familiar with managing the most common medical diagnoses, such as community acquired pneumonia, diabetes, and congestive heart failure. Hospitalist programs often develop uniform and consistent ways of treating these patients. Cogent Healthcare, a national hospitalist management company, has implemented the “Cogent Care Guides,” best practice guidelines for high-volume hospital diagnoses. Ron Greeno, MD, FCCP and Cogent’s chief medical officer, says “The Cogent Care Guides ensure best practices are implemented at critical points in the patient’s care… decreasing the variability of care that results in inefficiencies.” Greeno added, “The care guidelines (also) support the timely notification of the primary care physician of nine critical landmark events related to patient status that can affect outcomes” (5).

Stacy Goldsholl, Director of the Covenant Health-Care Hospital Medicine Program in Saginaw, MI, suggests other ways that hospitalists can generate utilization savings for their hospitals. “Hospitalists often eliminate unnecessary admissions and shift work-ups to the ambulatory setting. For example, I recently arranged an outpatient colonoscopy for a pneumonia patient with a stable hemoglobin and heme positive stool. Because of my experience treating patients with pneumonia, I was able to determine that the circumstances did not require an inpatient stay.” In addition, Dr. Goldsholl has found that the hospitalists in her program are quite effective in classifying “observation” patients, eliminating reimbursement conflicts with Medicare, Medicaid, and other insurers.

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Finally, because they are always in the hospital rather than sharing time between the office and hospital, hospitalists can improve inpatient continuity of care, resulting in lower costs and better outcomes. Adrienne Bennett, MD, chief of the hospital medicine service at Newton-Wellesley Hospital near Boston, examined cases managed by hospitalists and nonhospitalist community physicians, comparing the number of “handoffs” of responsibility that occur among attending physicians. Community physicians share inpatient responsibility in their practices and sometimes their partners round on their patients. Every time another physician assumes responsibility for a patient, there is the potential for a loss of information and a discontinuity of care. At Newton-Wellesley Hospital, the hospitalists work a schedule of 14 days on, followed by 7 days off. “We found that hospitalists averaged less than half the number of handoffs as the community physicians,” says Bennett. “This may be one of the reasons that hospitalists have better case mix adjusted utilization performance.”

Stakeholder Analysis

Anecdotal evidence, as well as documented studies, has demonstrated that hospitalists provide value to a wide range of stakeholders involved in the inpatient care process. With regard to resource utilization savings, the hospitalist provides the following benefits to each of the listed stakeholder (Table 2).

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Published Research Results

Dozens of studies demonstrate the positive effects hospitalist programs have on resource utilization. Observational, retrospective and prospective data analysis have been conducted at community-based hospitals as well as at academic medical institutions. Findings consistently indicate that hospitalist programs result in resource savings for patients, physicians, and hospital medicine. The following studies represent the most recent efforts at tracking hospitalist programs and their effects on resource utilization (Table 3).

Conclusion

According to the AHA’s 2003 survey of healthcare trends, the fiscal health of the nation’s hospitals will most likely remain fragile and variable in the coming years. The survey cites declining operating margins, a continued decrease in reimbursement, labor shortages, and rising insurance and pharmaceutical costs, as well as the need to invest in technology and facility maintenance and upkeep as key factors. However, hospitalists have proven time and again in clinical studies that they can bring value to the operation of a healthcare facility. With reduced lengths of stay, decreased overall hospital costs, and equivalent—if not superior—quality, hospitalists can contribute significantly to a hospital’s healthy bottom line.

Dr. Syed can be contacted at [email protected].

References

1. ACP Research Center, Environmental Assessment: Trends in hospital financing. 2003. www.aha.org
2. Coppola P. Email interview, December 15, 2004.
3. Everett GD, Anton MP, Jackson BK, Swigert C, Uddin N. “Comparison of hospital costs and length of stay associated with general internists and hospitalist physicians at a community hospital.” Am J Manag Care. 2004;10:626-30.
4. Gregory D, Baigelman W, Wilson IB. Hospital economics of the hospitalist. Health Services Research. 2003:38(3): 905-18; discussion 919-22.
5. Greeno, Ron, MD, FCCP, chief medical officer, Cogent Healthcare, Irvine, California. Telephone interview, December 16, 2004.
6. Healthaffairs.org, “Use of Medicare claims data to monitor provider-specific performance among patients with severe chronic illness.” 10.1377/hlthaff.var.5. Posting date: October 7, 2004.
7. “Hospitalists save $2.5 million and decrease LOS.” Healthcare Benchmarks and Quality Improvement, May 2004.
8. Kaboli PJ, Barnett MJ, Rosenthal GE. Associations with reduced length of stay and costs on an academic hospitalist service. Am J Manag Care. 2004;10: 561-8.
9. Miller LC. Telephone interview, November 16, 2004.
10. Palmer HC, Armistead NS, Elnicki DM, et al. The effect of a hospitalist service with nurse discharge planner on patient care in an academic teaching hospital. Am J Med. 2001;111: 627-632.
11. Rifkin WD. Telephone interview. December 15, 2004.
12. Rifkin WD, Conner D, Silver A, Eichorn A. Comparison of processes and outcomes of pneumonia care between hospitalists and community-based primary care physicians. Mayo Clin Proc. 2002;77:1053-8.
13. Shallash A. Email interview, December 17, 2004.
14. Wachter RM. Presentation, Society of Hospital Medicine (SHM) annual meeting 2002.
15. Wachter RM and Goldman L. The emerging role of “hospitalists” in the American health care system. N Engl J Med. 1996;335:514-7
16. Wachter RM and Goldman L. “The hospitalist movement five years later.” J Am Med Assoc. 2002;287:0487-94.
17. “Why less really can be more when it comes to teaching hospitals.” Today’s Hospitalist. 2004 December

Today’s hospitals must address a variety of challenges stemming from the expectation to provide more services and better quality with fewer financial, material, and human resources. According to the annual survey conducted by the American Hospital Association (AHA) in 2003, total expenses for all U.S. community hospitals were more than $450 billion. In managing these expenditures, hospitals face the following pressures:

• Cost increases in medical supplies and pharmaceuticals.
• Record shortages of nurses, pharmacists, and technicians.
• A growing uncompensated patient pool.
• Annual potential reductions in Medicare and Medicaid reimbursements.
• Rising bad debt resulting from greater patient responsibilityfor the cost of care.
• The diversion of more profitable cases to specialty and freestanding ambulatory care facilities and surgery centers.
• Soaring costs associated with adequately serving high-risk conditions, such as cancer, heart disease, and HIV/AIDS.
• Discounted reimbursement rates with insurers.
• Increasing pressure to commit financial resources to clinical information technology.
• The need to fund infrastructure improvements and physical plant renovations as well as expansions to address increasing demand (1).

To overcome these challenges, hospitals must find innovative ways to balance revenues and expenses, fund necessary capital investments, and satisfy the public’s demand for quality, safety, and accessibility.

click for large version

Hospitalist Programs: A Good Investment

One solution to the above-mentioned situations is a hospitalist program, which, in its short history, has already had a profound impact on inpatient care. Robert M. Wachter, MD, associate chair in the department of medicine at the University of California, San Francisco (UCSF) and medical service chief at Moffitt-Long Hospitals, coined the term hospitalist in an article in the New England Journal of Medicine in 1996 (15). At the 2002 annual meeting of the Society of Hospital Medicine (SHM), Wachter presented findings from a study conducted at his institution. The results demonstrate a significant return on investment (ROI) of 5.8: 1 when a hospitalist program is utilized (See Table 1 for details) (14).

How do hospitalists reduce length of stay (LOS) and cost per stay? William David Rifkin, MD, associate director of the Yale Primary Care Residency Program, offers three basic reasons why hospitalist programs contribute to effective and efficient use of resources. Since hospitalists are physically onsite, they are better able to react to condition changes and requests for consultations in a timely manner, he asserts. Also, being familiar with the hospital’s systems of care, the hospitalist knows who to call and how to utilize the services of social workers and other contingency staff when arranging for post-discharge care. Third, Rifkin indicates that inpatients today are sicker than they were in past years, a fact well known and understood by hospitalists. “There is an increased level of acuity,” he says. “Hospitalists are used to seeing these kinds of patients. They are more comfortable taking care of these patients and will see more of them with any given diagnosis” (11).

In one of his studies, Rifkin noted a reduction in LOS for inpatients with a pneumonia diagnosis. “The hospitalist had switched the patient from IV (intravenous) to oral antibiotics,” he says. Reacting quickly to indications that the patient was ready for a change in treatment modality facilitated an earlier discharge (12).

L. Craig Miller, MD, senior vice president of medical affairs at Baptist Health Care, reports that his hospital saved $2.56 million in 2 years as a direct result of its inpatient management program (7). Although attention to technical and clinical details is important, Miller emphasizes the critical role the human factor plays, specifically the impact of teamwork, on achieving resource utilization savings. “Hospitalists work as a team, collaborating with physicians and ED doctors,” he says. This cooperative spirit enables the efficient use of manpower in patient care. Miller adds that at Baptist, as is the case at most hospitals, the medical complexity of patients dictates a need for cooperation in order to successfully treat illness. The presence of hospitalists facilitates the team effort, causing a positive trickle down effect regarding LOS, readmission and mortality rates, he affirms. “The hospitalist provides focused leadership to utilization resource management,” says Miller (9).

In the role of inpatient leader, the hospitalist also facilitates emergency department (ED) throughput, which results in another area of cost savings for the hospital. Paola Coppola, MD, ED director at Brookhaven Memorial Hospital Medical Center, says, “From an ER perspective, a call to the hospitalist replaces multiple calls to specialists. In general, hospitalists feel much more comfortable treating a wide array of conditions including infectious disease, pneumonias, strokes ,and chest pain without the intervention of specialists in that field. Hence, hospital consumption of resources decreases, which in turn lowers length of stay.” He echoes Rifkin’s thoughts on quick response time. “Hospitalists provide an immediately available service, thus saving ER physicians valuable time. This ensures faster turnover, better throughput, makes more ER beds available and services more patients, eventually helping the hospital’s bottom line,” says Coppola (2).

In addition to teamwork, 24/7 availability is vital to the wise utilization of resources, according to Anthony Shallash, MD, vice president of medical affairs at Brookhaven. “The fact of 24/7 presence allows rapid responses to patient condition and problems. Continuous and close monitoring of patients allows them to be upgraded or downgraded as needed,” he says. “As such, LOS is decreased and quite favorable as compared to peer practitioners for similar disease severity. Resources consumed and tests ordered also show a favorable trend” (13).

A recently published study (6) by researchers at Dartmouth Medical School documents the variation in the volume and cost of services that academic medical centers use in treating patients. Hospitals were categorized as low- and high-intensity, with significant differences in cost per case. For example, the high-intensity hospitals spent up to 47% more on care for acute myocardial infarction. In an interview in Today’s Hospitalist (17), the lead author, Elliott S. Fisher, MD, professor of medicine and community and family medicine at Dartmouth Medical School, described the importance of coordination in achieving efficient care. Fisher says, “I think there’s a real opportunity for hospitalists to improve the care of patients in both high- and low-intensity hospitals. Having ten doctors involved in a given patient’s care may not be a good thing, unless someone [i.e., the hospitalist] is doing a really good job of coordinating that care.”

Hospitalists focus only on inpatient medicine. They are familiar with managing the most common medical diagnoses, such as community acquired pneumonia, diabetes, and congestive heart failure. Hospitalist programs often develop uniform and consistent ways of treating these patients. Cogent Healthcare, a national hospitalist management company, has implemented the “Cogent Care Guides,” best practice guidelines for high-volume hospital diagnoses. Ron Greeno, MD, FCCP and Cogent’s chief medical officer, says “The Cogent Care Guides ensure best practices are implemented at critical points in the patient’s care… decreasing the variability of care that results in inefficiencies.” Greeno added, “The care guidelines (also) support the timely notification of the primary care physician of nine critical landmark events related to patient status that can affect outcomes” (5).

Stacy Goldsholl, Director of the Covenant Health-Care Hospital Medicine Program in Saginaw, MI, suggests other ways that hospitalists can generate utilization savings for their hospitals. “Hospitalists often eliminate unnecessary admissions and shift work-ups to the ambulatory setting. For example, I recently arranged an outpatient colonoscopy for a pneumonia patient with a stable hemoglobin and heme positive stool. Because of my experience treating patients with pneumonia, I was able to determine that the circumstances did not require an inpatient stay.” In addition, Dr. Goldsholl has found that the hospitalists in her program are quite effective in classifying “observation” patients, eliminating reimbursement conflicts with Medicare, Medicaid, and other insurers.

click for large version

Finally, because they are always in the hospital rather than sharing time between the office and hospital, hospitalists can improve inpatient continuity of care, resulting in lower costs and better outcomes. Adrienne Bennett, MD, chief of the hospital medicine service at Newton-Wellesley Hospital near Boston, examined cases managed by hospitalists and nonhospitalist community physicians, comparing the number of “handoffs” of responsibility that occur among attending physicians. Community physicians share inpatient responsibility in their practices and sometimes their partners round on their patients. Every time another physician assumes responsibility for a patient, there is the potential for a loss of information and a discontinuity of care. At Newton-Wellesley Hospital, the hospitalists work a schedule of 14 days on, followed by 7 days off. “We found that hospitalists averaged less than half the number of handoffs as the community physicians,” says Bennett. “This may be one of the reasons that hospitalists have better case mix adjusted utilization performance.”

Stakeholder Analysis

Anecdotal evidence, as well as documented studies, has demonstrated that hospitalists provide value to a wide range of stakeholders involved in the inpatient care process. With regard to resource utilization savings, the hospitalist provides the following benefits to each of the listed stakeholder (Table 2).

click for large version

Published Research Results

Dozens of studies demonstrate the positive effects hospitalist programs have on resource utilization. Observational, retrospective and prospective data analysis have been conducted at community-based hospitals as well as at academic medical institutions. Findings consistently indicate that hospitalist programs result in resource savings for patients, physicians, and hospital medicine. The following studies represent the most recent efforts at tracking hospitalist programs and their effects on resource utilization (Table 3).

Conclusion

According to the AHA’s 2003 survey of healthcare trends, the fiscal health of the nation’s hospitals will most likely remain fragile and variable in the coming years. The survey cites declining operating margins, a continued decrease in reimbursement, labor shortages, and rising insurance and pharmaceutical costs, as well as the need to invest in technology and facility maintenance and upkeep as key factors. However, hospitalists have proven time and again in clinical studies that they can bring value to the operation of a healthcare facility. With reduced lengths of stay, decreased overall hospital costs, and equivalent—if not superior—quality, hospitalists can contribute significantly to a hospital’s healthy bottom line.

Dr. Syed can be contacted at [email protected].

References

1. ACP Research Center, Environmental Assessment: Trends in hospital financing. 2003. www.aha.org
2. Coppola P. Email interview, December 15, 2004.
3. Everett GD, Anton MP, Jackson BK, Swigert C, Uddin N. “Comparison of hospital costs and length of stay associated with general internists and hospitalist physicians at a community hospital.” Am J Manag Care. 2004;10:626-30.
4. Gregory D, Baigelman W, Wilson IB. Hospital economics of the hospitalist. Health Services Research. 2003:38(3): 905-18; discussion 919-22.
5. Greeno, Ron, MD, FCCP, chief medical officer, Cogent Healthcare, Irvine, California. Telephone interview, December 16, 2004.
6. Healthaffairs.org, “Use of Medicare claims data to monitor provider-specific performance among patients with severe chronic illness.” 10.1377/hlthaff.var.5. Posting date: October 7, 2004.
7. “Hospitalists save $2.5 million and decrease LOS.” Healthcare Benchmarks and Quality Improvement, May 2004.
8. Kaboli PJ, Barnett MJ, Rosenthal GE. Associations with reduced length of stay and costs on an academic hospitalist service. Am J Manag Care. 2004;10: 561-8.
9. Miller LC. Telephone interview, November 16, 2004.
10. Palmer HC, Armistead NS, Elnicki DM, et al. The effect of a hospitalist service with nurse discharge planner on patient care in an academic teaching hospital. Am J Med. 2001;111: 627-632.
11. Rifkin WD. Telephone interview. December 15, 2004.
12. Rifkin WD, Conner D, Silver A, Eichorn A. Comparison of processes and outcomes of pneumonia care between hospitalists and community-based primary care physicians. Mayo Clin Proc. 2002;77:1053-8.
13. Shallash A. Email interview, December 17, 2004.
14. Wachter RM. Presentation, Society of Hospital Medicine (SHM) annual meeting 2002.
15. Wachter RM and Goldman L. The emerging role of “hospitalists” in the American health care system. N Engl J Med. 1996;335:514-7
16. Wachter RM and Goldman L. “The hospitalist movement five years later.” J Am Med Assoc. 2002;287:0487-94.
17. “Why less really can be more when it comes to teaching hospitals.” Today’s Hospitalist. 2004 December

Today’s hospitals must address a variety of challenges stemming from the expectation to provide more services and better quality with fewer financial, material, and human resources. According to the annual survey conducted by the American Hospital Association (AHA) in 2003, total expenses for all U.S. community hospitals were more than $450 billion. In managing these expenditures, hospitals face the following pressures:

• Cost increases in medical supplies and pharmaceuticals.
• Record shortages of nurses, pharmacists, and technicians.
• A growing uncompensated patient pool.
• Annual potential reductions in Medicare and Medicaid reimbursements.
• Rising bad debt resulting from greater patient responsibilityfor the cost of care.
• The diversion of more profitable cases to specialty and freestanding ambulatory care facilities and surgery centers.
• Soaring costs associated with adequately serving high-risk conditions, such as cancer, heart disease, and HIV/AIDS.
• Discounted reimbursement rates with insurers.
• Increasing pressure to commit financial resources to clinical information technology.
• The need to fund infrastructure improvements and physical plant renovations as well as expansions to address increasing demand (1).

To overcome these challenges, hospitals must find innovative ways to balance revenues and expenses, fund necessary capital investments, and satisfy the public’s demand for quality, safety, and accessibility.

click for large version

Hospitalist Programs: A Good Investment

One solution to the above-mentioned situations is a hospitalist program, which, in its short history, has already had a profound impact on inpatient care. Robert M. Wachter, MD, associate chair in the department of medicine at the University of California, San Francisco (UCSF) and medical service chief at Moffitt-Long Hospitals, coined the term hospitalist in an article in the New England Journal of Medicine in 1996 (15). At the 2002 annual meeting of the Society of Hospital Medicine (SHM), Wachter presented findings from a study conducted at his institution. The results demonstrate a significant return on investment (ROI) of 5.8: 1 when a hospitalist program is utilized (See Table 1 for details) (14).

How do hospitalists reduce length of stay (LOS) and cost per stay? William David Rifkin, MD, associate director of the Yale Primary Care Residency Program, offers three basic reasons why hospitalist programs contribute to effective and efficient use of resources. Since hospitalists are physically onsite, they are better able to react to condition changes and requests for consultations in a timely manner, he asserts. Also, being familiar with the hospital’s systems of care, the hospitalist knows who to call and how to utilize the services of social workers and other contingency staff when arranging for post-discharge care. Third, Rifkin indicates that inpatients today are sicker than they were in past years, a fact well known and understood by hospitalists. “There is an increased level of acuity,” he says. “Hospitalists are used to seeing these kinds of patients. They are more comfortable taking care of these patients and will see more of them with any given diagnosis” (11).

In one of his studies, Rifkin noted a reduction in LOS for inpatients with a pneumonia diagnosis. “The hospitalist had switched the patient from IV (intravenous) to oral antibiotics,” he says. Reacting quickly to indications that the patient was ready for a change in treatment modality facilitated an earlier discharge (12).

L. Craig Miller, MD, senior vice president of medical affairs at Baptist Health Care, reports that his hospital saved $2.56 million in 2 years as a direct result of its inpatient management program (7). Although attention to technical and clinical details is important, Miller emphasizes the critical role the human factor plays, specifically the impact of teamwork, on achieving resource utilization savings. “Hospitalists work as a team, collaborating with physicians and ED doctors,” he says. This cooperative spirit enables the efficient use of manpower in patient care. Miller adds that at Baptist, as is the case at most hospitals, the medical complexity of patients dictates a need for cooperation in order to successfully treat illness. The presence of hospitalists facilitates the team effort, causing a positive trickle down effect regarding LOS, readmission and mortality rates, he affirms. “The hospitalist provides focused leadership to utilization resource management,” says Miller (9).

In the role of inpatient leader, the hospitalist also facilitates emergency department (ED) throughput, which results in another area of cost savings for the hospital. Paola Coppola, MD, ED director at Brookhaven Memorial Hospital Medical Center, says, “From an ER perspective, a call to the hospitalist replaces multiple calls to specialists. In general, hospitalists feel much more comfortable treating a wide array of conditions including infectious disease, pneumonias, strokes ,and chest pain without the intervention of specialists in that field. Hence, hospital consumption of resources decreases, which in turn lowers length of stay.” He echoes Rifkin’s thoughts on quick response time. “Hospitalists provide an immediately available service, thus saving ER physicians valuable time. This ensures faster turnover, better throughput, makes more ER beds available and services more patients, eventually helping the hospital’s bottom line,” says Coppola (2).

In addition to teamwork, 24/7 availability is vital to the wise utilization of resources, according to Anthony Shallash, MD, vice president of medical affairs at Brookhaven. “The fact of 24/7 presence allows rapid responses to patient condition and problems. Continuous and close monitoring of patients allows them to be upgraded or downgraded as needed,” he says. “As such, LOS is decreased and quite favorable as compared to peer practitioners for similar disease severity. Resources consumed and tests ordered also show a favorable trend” (13).

A recently published study (6) by researchers at Dartmouth Medical School documents the variation in the volume and cost of services that academic medical centers use in treating patients. Hospitals were categorized as low- and high-intensity, with significant differences in cost per case. For example, the high-intensity hospitals spent up to 47% more on care for acute myocardial infarction. In an interview in Today’s Hospitalist (17), the lead author, Elliott S. Fisher, MD, professor of medicine and community and family medicine at Dartmouth Medical School, described the importance of coordination in achieving efficient care. Fisher says, “I think there’s a real opportunity for hospitalists to improve the care of patients in both high- and low-intensity hospitals. Having ten doctors involved in a given patient’s care may not be a good thing, unless someone [i.e., the hospitalist] is doing a really good job of coordinating that care.”

Hospitalists focus only on inpatient medicine. They are familiar with managing the most common medical diagnoses, such as community acquired pneumonia, diabetes, and congestive heart failure. Hospitalist programs often develop uniform and consistent ways of treating these patients. Cogent Healthcare, a national hospitalist management company, has implemented the “Cogent Care Guides,” best practice guidelines for high-volume hospital diagnoses. Ron Greeno, MD, FCCP and Cogent’s chief medical officer, says “The Cogent Care Guides ensure best practices are implemented at critical points in the patient’s care… decreasing the variability of care that results in inefficiencies.” Greeno added, “The care guidelines (also) support the timely notification of the primary care physician of nine critical landmark events related to patient status that can affect outcomes” (5).

Stacy Goldsholl, Director of the Covenant Health-Care Hospital Medicine Program in Saginaw, MI, suggests other ways that hospitalists can generate utilization savings for their hospitals. “Hospitalists often eliminate unnecessary admissions and shift work-ups to the ambulatory setting. For example, I recently arranged an outpatient colonoscopy for a pneumonia patient with a stable hemoglobin and heme positive stool. Because of my experience treating patients with pneumonia, I was able to determine that the circumstances did not require an inpatient stay.” In addition, Dr. Goldsholl has found that the hospitalists in her program are quite effective in classifying “observation” patients, eliminating reimbursement conflicts with Medicare, Medicaid, and other insurers.

click for large version

Finally, because they are always in the hospital rather than sharing time between the office and hospital, hospitalists can improve inpatient continuity of care, resulting in lower costs and better outcomes. Adrienne Bennett, MD, chief of the hospital medicine service at Newton-Wellesley Hospital near Boston, examined cases managed by hospitalists and nonhospitalist community physicians, comparing the number of “handoffs” of responsibility that occur among attending physicians. Community physicians share inpatient responsibility in their practices and sometimes their partners round on their patients. Every time another physician assumes responsibility for a patient, there is the potential for a loss of information and a discontinuity of care. At Newton-Wellesley Hospital, the hospitalists work a schedule of 14 days on, followed by 7 days off. “We found that hospitalists averaged less than half the number of handoffs as the community physicians,” says Bennett. “This may be one of the reasons that hospitalists have better case mix adjusted utilization performance.”

Stakeholder Analysis

Anecdotal evidence, as well as documented studies, has demonstrated that hospitalists provide value to a wide range of stakeholders involved in the inpatient care process. With regard to resource utilization savings, the hospitalist provides the following benefits to each of the listed stakeholder (Table 2).

click for large version

Published Research Results

Dozens of studies demonstrate the positive effects hospitalist programs have on resource utilization. Observational, retrospective and prospective data analysis have been conducted at community-based hospitals as well as at academic medical institutions. Findings consistently indicate that hospitalist programs result in resource savings for patients, physicians, and hospital medicine. The following studies represent the most recent efforts at tracking hospitalist programs and their effects on resource utilization (Table 3).

Conclusion

According to the AHA’s 2003 survey of healthcare trends, the fiscal health of the nation’s hospitals will most likely remain fragile and variable in the coming years. The survey cites declining operating margins, a continued decrease in reimbursement, labor shortages, and rising insurance and pharmaceutical costs, as well as the need to invest in technology and facility maintenance and upkeep as key factors. However, hospitalists have proven time and again in clinical studies that they can bring value to the operation of a healthcare facility. With reduced lengths of stay, decreased overall hospital costs, and equivalent—if not superior—quality, hospitalists can contribute significantly to a hospital’s healthy bottom line.

Dr. Syed can be contacted at [email protected].

References

1. ACP Research Center, Environmental Assessment: Trends in hospital financing. 2003. www.aha.org
2. Coppola P. Email interview, December 15, 2004.
3. Everett GD, Anton MP, Jackson BK, Swigert C, Uddin N. “Comparison of hospital costs and length of stay associated with general internists and hospitalist physicians at a community hospital.” Am J Manag Care. 2004;10:626-30.
4. Gregory D, Baigelman W, Wilson IB. Hospital economics of the hospitalist. Health Services Research. 2003:38(3): 905-18; discussion 919-22.
5. Greeno, Ron, MD, FCCP, chief medical officer, Cogent Healthcare, Irvine, California. Telephone interview, December 16, 2004.
6. Healthaffairs.org, “Use of Medicare claims data to monitor provider-specific performance among patients with severe chronic illness.” 10.1377/hlthaff.var.5. Posting date: October 7, 2004.
7. “Hospitalists save $2.5 million and decrease LOS.” Healthcare Benchmarks and Quality Improvement, May 2004.
8. Kaboli PJ, Barnett MJ, Rosenthal GE. Associations with reduced length of stay and costs on an academic hospitalist service. Am J Manag Care. 2004;10: 561-8.
9. Miller LC. Telephone interview, November 16, 2004.
10. Palmer HC, Armistead NS, Elnicki DM, et al. The effect of a hospitalist service with nurse discharge planner on patient care in an academic teaching hospital. Am J Med. 2001;111: 627-632.
11. Rifkin WD. Telephone interview. December 15, 2004.
12. Rifkin WD, Conner D, Silver A, Eichorn A. Comparison of processes and outcomes of pneumonia care between hospitalists and community-based primary care physicians. Mayo Clin Proc. 2002;77:1053-8.
13. Shallash A. Email interview, December 17, 2004.
14. Wachter RM. Presentation, Society of Hospital Medicine (SHM) annual meeting 2002.
15. Wachter RM and Goldman L. The emerging role of “hospitalists” in the American health care system. N Engl J Med. 1996;335:514-7
16. Wachter RM and Goldman L. “The hospitalist movement five years later.” J Am Med Assoc. 2002;287:0487-94.
17. “Why less really can be more when it comes to teaching hospitals.” Today’s Hospitalist. 2004 December

When Robert Lee, MD, an internist affiliated with Iowa Health Physicians, a multi-specialty group in Des Moines, was called to the hospital to see one of his patients, he faced a 50-minute round trip plus additional time to find a parking place and catch an elevator before reaching the inpatient unit. In the time it took for him to see a couple of his patients in the hospital, he could have treated five patients in the office (1).

David McAtee, MD, an osteopath at Murdock Family Medicine, a group practice of eight family physicians in Port Charlotte, Florida, estimates its doctors were spending 30% of their time at the hospital caring for only 5% of their patients (2).

With an eye toward enhancing their office practices and offering patients efficient and effective inpatient treatment, both the Des Moines and Port Charlotte medical groups pursued a growing trend in the health care industry: they turned to hospitalists. Lee notes that the change allows him to enjoy a more normal lifestyle with his family and enhances his income (1). The Murdock group’s decision to contract with hospitalists in 2003 resulted in an expansion of office hours. With more available time, the group is in the process of developing a series of programs targeting various diseases as a means of educating patients in better self-care. Additionally, McAtee expresses the hope that medical malpractice insurance premiums will decrease as a result of less time spent on inpatient care (2).

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Hospitalist Impact on Primary Care Physicians

Primary care physicians (PCPs) do have reservations regarding the involvement of hospitalists in the care of their patients. Some PCPs voice concerns about the potential reduction in income if they opt to use hospitalists. According to one estimate, primary care doctors may incur an average annual decrease in income of $25,000 by forgoing hospital rounds. However, studies indicate that PCPs have the potential to earn as much as $50,000 more by spending time in the office instead of seeing inpatients (3). Hospitalist programs that offer on-site, 24-hour availability provide other benefits. When a crisis strikes, PCPs may be difficult to reach as they are seeing office patients. The hurricanes that hit Florida in September and October 2004 clearly demonstrated the value of having continuous inpatient care by qualified physicians already at the hospital. Treacherous weather conditions prevented PCPs from driving to the hospital to see their patients. Although the hospital was unable to perform lab tests, surgeries, or diagnostic imaging procedures owing to power outages, hospitalists were already on-site and stabilized patients with their basic clinical skills (3). Patients who may not have heard of the term “hospitalist” were pleased that a physician was available to answer questions, address unexpected medical issues, and offer immediate support and comfort.

Admittedly, not all PCPs have embraced the hospitalist model. The perception that they might lose skill and prestige by giving up inpatient visits might prevent them from utilizing hospitalist services. In some cases, PCPs might perceive a reduction in continuity of care. These concerns are valid and warrant consideration. However, a well-run hospitalist program will keep communication lines open between hospitalists and PCPs, so that patients receive optimal care as both inpatients and outpatients.

Hospitalists and Surgeons/Specialists

Robert T. Trousdale, MD, orthopedic surgeon at the Mayo Clinic in Rochester, Minnesota, spends most of his day in the operating room or evaluating patients for surgery. An expert in hip and knee surgery, he admits that many orthopedic surgeons have insufficient knowledge when it comes to treating some of the common medical problems that may occur postoperatively. “Hospitalists help us co-manage patients in this area. They bring an increased level of experience to the management of the patient,” he says. Trousdale notes the added benefits of time and hospitalist availability.

“I am in the operating room for 5 hours at a time. If a nurse calls to report that one of my patients has developed post-op dizziness or chest pain, I might not be able to see him for 2 hours,” he says. Hospitalists have both the expertise and the availability to address medical issues in a timelier manner and expedite recovery time.

Additionally, Trousdale admits that, although he is quite familiar with the intricacies of the musculoskeletal system, he is less certain of the necessary tests a patient might need post-operatively. “We might take a ‘shotgun’ approach and order 15 expensive tests, which is an unnecessary use of the hospital’s resources,” he says (4).

Jeanne Huddleston, MD, director of the Inpatient Internal Medicine Program at Mayo Clinic and assistant professor of medicine at the Mayo College of Medicine, led a study to determine the impact hospitalists have on the co-management of patients having hip and knee surgery. The findings, published in 2004, reveal that of 526 patients in the study, more of those managed by hospitalist-orthopedic teams were discharged with no complications (61.6% for hospitalist-orthopedic teams vs. 48.8% for traditional orthopedic surgical teams). Only 30.2% of patients co-managed by hospitalists experienced minor complications, while 44.3% of patients managed by traditional orthopedic surgical teams had similar difficulties. Huddleston notes also that most orthopedic surgeons and nurses responding to a satisfaction survey preferred the hospitalist orthopedic model (5).

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Hospitalists and Emergency Department Physicians

Brent R. Asplin, MD, MPH, research director in the department of emergency medicine at Regions Hospital in St. Paul, Minnesota, cites three ways in which hospitalists positively affect the emergency department (ED): through extraordinary availability, consistent and reliable care, and their focus on the hospital. “Hospitalists are available 24 hours a day,” he says. “It’s nice to know when you send a patient to the floor, there is an experienced physician in-house to take care of them. You do not have to try to reach a PCP on the phone.” He reports that capacity is a major problem for EDs. Bottlenecks result when there are patients who are ready to be admitted from the ED but must wait for other patients to be discharged. Hospitalists are always available to maintain a smooth patient flow and facilitate throughput, according to Asplin.

As a group, hospitalists adhere to a consistent approach to patient care. Once a patient is admitted, efficient, reliable in-house care will ensure a quick recovery and discharge. Asplin says, “Hospitalists are more likely to embrace clinical pathways for the most common clinical diagnoses. This reduces variability across the board and increases patient outcome and flow.” Also, hospitalists focus exclusively on inpatient care, enabling them to devote all their attention to servicing the patient while they are hospitalized without the distractions that might divert a PCP’s concentration. Asplin says, “Regarding clinical care, operations, and quality improvement, it helps to have a group dedicated and focused on the hospital” (6).

In teaching hospitals, residents also benefit from the presence of hospitalists. According to Barbara LeTourneau, MD, an ED physician and professional physician executive consultant also based at Regions, residents have the continuous supervision of experienced practitioners who can answer questions and teach on an ongoing basis. “With hospitalists there is much quicker and better patient care,” she says.

In her role as administrator, LeTourneau has an historical perspective on the delivery of inpatient care at her hospital. Prior to the implementation of hospital medicine programs, positive changes took a longer period of time to reach agreement and execution, she reports. “Having hospitalists here provides one group of experienced physicians who see a large percentage of patients,” says LeTourneau. Managing a significant caseload enables the hospitalist to understand the system in depth. “Hospitalists can provide good feedback and make it easier to implement necessary changes,” LeTourneau says (7) (Table 1, page 26).

Stakeholder Analysis

Studies reveal that hospitalists improve the practices of physicians and several subspecialties in a number of ways. Not only do PCPs benefit from the presence of hospitalists, but other medical specialists, patients, families, and medical facilities gain advantages as well.

Research Studies

Since 1996 when the term “hospitalist” was first used, a number of studies have been conducted to evaluate the benefits they bring to PCPs and other physicians. In the past decade, the number of hospitalists has increased dramatically, lending credence to their value in an inpatient medical setting. In 2005, the Society of Hospital Medicine (SHM) estimates that there are 12,000 hospitalists in the U.S.

In a survey by Mitretek Healthcare , researchers asked hospital leaders to rate a number of strategies that affect hospital–medical staff relations. Sixty-two percent of the leaders surveyed gave hospitalist programs a high rating pertaining to hospital-physician alignment (8). Other studies also support the growing belief that hospitalists can effectively and efficiently enhance physician practices (Table 2).

Conclusion

Joseph Li, MD, director of the hospitalist program at Beth Israel Deaconess Medical Center in Boston, hopes to build a career based on the belief that hospitalists are leading the way in “preventing medical errors and hospital-acquired infections, managing the complex hospital environment, finding the right transition to home care or rehabilitation, and providing palliative and end-of-life care” (9). As hospital medicine programs become more prevalent and accepted, more and more PCPs are seeing the value in their presence. A major national hospitalist management company surveyed PCPs in five markets on their experiences with hospitalists. The responses revealed a 100% satisfaction rating on the quality of inpatient care (10). In the future, hospitalists like Li will strive to maintain that rating while they help improve physician practices and enhance patient care.

Dr. Kealey can be contact at [email protected].

References

1. Jackson C. Doctors find hospitalists save time, money: primary care physicians are seeing that turning over their hospital business allows them to make more income. Amednews.com, February 19, 2001.
2. Trendy hospital medicine comes to Charlotte. Sunherald.com, February 13, 2004.
3. Landro L. Medicine’s fastest-growing specialty: hospitalbound doctors take the place of your physician; effort to reduce costs, errors. The Wall Street Journal Online, October 6, 2004.
4. Trousdale RT. Department of Orthopedics, Mayo Clinic, Rochester, MN. Telephone interview, January 3, 2005.
5. Huddleston JM, Long KH, Naessens JM, et al. Medical and surgical comanagement after elective hip and knee arthroplasty: a randomized controlled trial. Ann Intern Med. 2004;141:28-38.
6. Asplin BR. research director, Department of Emergency Medicine, Regions Hospital, St. Paul, MN. Telephone interview, January 5, 2005.
7. LeTourneau B. Emergency department physician, professional physician executive consultant, Regions Hospital, St. Paul, MN. Telephone interview, January 7, 2005.
8. McGowan RA. Strengthening hospital-physician relationships. Healthcare Financial Management Association. December 2004. www.hfma.org/publications/HFMMagazine/business.htm
9. Barnard A. Medical profession, patients have warmed to the ‘hospitalist’. The Boston Globe. January 30, 2002.
10. PCPs and hospitalists: a new attitude? Cogent Quarterly. 1;4:Fall 2001.
11. Auerbach AD, Aronson MD, Davis RB, Phillips RS. How physicians perceive hospitalist services after implementation: anticipation vs. reality. Arch Intern Med. 2003;163:2330-6.
12. Auerbach AD, Nelson EA, Lindenauer PK, Pantilat SZ, Katz PP, Wachter RM. Physician attitudes toward and prevalence of the hospitalist model of care: results of a national survey. Am J Med. 2000;109(8):648-53.
13. Halpert AP, Pearson SD, LeWine HE, et al. The impact of an inpatient physician program on quality, utilization, and satisfaction. Am J Manag Care. 2000;6:549-55.
14. Fernandez A, Grumbach K, Goetein L, et al. Friend or foe? How primary care physicians perceive hospitalists. Arch Intern Med. 2000;160:2902-8.

When Robert Lee, MD, an internist affiliated with Iowa Health Physicians, a multi-specialty group in Des Moines, was called to the hospital to see one of his patients, he faced a 50-minute round trip plus additional time to find a parking place and catch an elevator before reaching the inpatient unit. In the time it took for him to see a couple of his patients in the hospital, he could have treated five patients in the office (1).

David McAtee, MD, an osteopath at Murdock Family Medicine, a group practice of eight family physicians in Port Charlotte, Florida, estimates its doctors were spending 30% of their time at the hospital caring for only 5% of their patients (2).

With an eye toward enhancing their office practices and offering patients efficient and effective inpatient treatment, both the Des Moines and Port Charlotte medical groups pursued a growing trend in the health care industry: they turned to hospitalists. Lee notes that the change allows him to enjoy a more normal lifestyle with his family and enhances his income (1). The Murdock group’s decision to contract with hospitalists in 2003 resulted in an expansion of office hours. With more available time, the group is in the process of developing a series of programs targeting various diseases as a means of educating patients in better self-care. Additionally, McAtee expresses the hope that medical malpractice insurance premiums will decrease as a result of less time spent on inpatient care (2).

click for large version

Hospitalist Impact on Primary Care Physicians

Primary care physicians (PCPs) do have reservations regarding the involvement of hospitalists in the care of their patients. Some PCPs voice concerns about the potential reduction in income if they opt to use hospitalists. According to one estimate, primary care doctors may incur an average annual decrease in income of $25,000 by forgoing hospital rounds. However, studies indicate that PCPs have the potential to earn as much as $50,000 more by spending time in the office instead of seeing inpatients (3). Hospitalist programs that offer on-site, 24-hour availability provide other benefits. When a crisis strikes, PCPs may be difficult to reach as they are seeing office patients. The hurricanes that hit Florida in September and October 2004 clearly demonstrated the value of having continuous inpatient care by qualified physicians already at the hospital. Treacherous weather conditions prevented PCPs from driving to the hospital to see their patients. Although the hospital was unable to perform lab tests, surgeries, or diagnostic imaging procedures owing to power outages, hospitalists were already on-site and stabilized patients with their basic clinical skills (3). Patients who may not have heard of the term “hospitalist” were pleased that a physician was available to answer questions, address unexpected medical issues, and offer immediate support and comfort.

Admittedly, not all PCPs have embraced the hospitalist model. The perception that they might lose skill and prestige by giving up inpatient visits might prevent them from utilizing hospitalist services. In some cases, PCPs might perceive a reduction in continuity of care. These concerns are valid and warrant consideration. However, a well-run hospitalist program will keep communication lines open between hospitalists and PCPs, so that patients receive optimal care as both inpatients and outpatients.

Hospitalists and Surgeons/Specialists

Robert T. Trousdale, MD, orthopedic surgeon at the Mayo Clinic in Rochester, Minnesota, spends most of his day in the operating room or evaluating patients for surgery. An expert in hip and knee surgery, he admits that many orthopedic surgeons have insufficient knowledge when it comes to treating some of the common medical problems that may occur postoperatively. “Hospitalists help us co-manage patients in this area. They bring an increased level of experience to the management of the patient,” he says. Trousdale notes the added benefits of time and hospitalist availability.

“I am in the operating room for 5 hours at a time. If a nurse calls to report that one of my patients has developed post-op dizziness or chest pain, I might not be able to see him for 2 hours,” he says. Hospitalists have both the expertise and the availability to address medical issues in a timelier manner and expedite recovery time.

Additionally, Trousdale admits that, although he is quite familiar with the intricacies of the musculoskeletal system, he is less certain of the necessary tests a patient might need post-operatively. “We might take a ‘shotgun’ approach and order 15 expensive tests, which is an unnecessary use of the hospital’s resources,” he says (4).

Jeanne Huddleston, MD, director of the Inpatient Internal Medicine Program at Mayo Clinic and assistant professor of medicine at the Mayo College of Medicine, led a study to determine the impact hospitalists have on the co-management of patients having hip and knee surgery. The findings, published in 2004, reveal that of 526 patients in the study, more of those managed by hospitalist-orthopedic teams were discharged with no complications (61.6% for hospitalist-orthopedic teams vs. 48.8% for traditional orthopedic surgical teams). Only 30.2% of patients co-managed by hospitalists experienced minor complications, while 44.3% of patients managed by traditional orthopedic surgical teams had similar difficulties. Huddleston notes also that most orthopedic surgeons and nurses responding to a satisfaction survey preferred the hospitalist orthopedic model (5).

click for large version

Hospitalists and Emergency Department Physicians

Brent R. Asplin, MD, MPH, research director in the department of emergency medicine at Regions Hospital in St. Paul, Minnesota, cites three ways in which hospitalists positively affect the emergency department (ED): through extraordinary availability, consistent and reliable care, and their focus on the hospital. “Hospitalists are available 24 hours a day,” he says. “It’s nice to know when you send a patient to the floor, there is an experienced physician in-house to take care of them. You do not have to try to reach a PCP on the phone.” He reports that capacity is a major problem for EDs. Bottlenecks result when there are patients who are ready to be admitted from the ED but must wait for other patients to be discharged. Hospitalists are always available to maintain a smooth patient flow and facilitate throughput, according to Asplin.

As a group, hospitalists adhere to a consistent approach to patient care. Once a patient is admitted, efficient, reliable in-house care will ensure a quick recovery and discharge. Asplin says, “Hospitalists are more likely to embrace clinical pathways for the most common clinical diagnoses. This reduces variability across the board and increases patient outcome and flow.” Also, hospitalists focus exclusively on inpatient care, enabling them to devote all their attention to servicing the patient while they are hospitalized without the distractions that might divert a PCP’s concentration. Asplin says, “Regarding clinical care, operations, and quality improvement, it helps to have a group dedicated and focused on the hospital” (6).

In teaching hospitals, residents also benefit from the presence of hospitalists. According to Barbara LeTourneau, MD, an ED physician and professional physician executive consultant also based at Regions, residents have the continuous supervision of experienced practitioners who can answer questions and teach on an ongoing basis. “With hospitalists there is much quicker and better patient care,” she says.

In her role as administrator, LeTourneau has an historical perspective on the delivery of inpatient care at her hospital. Prior to the implementation of hospital medicine programs, positive changes took a longer period of time to reach agreement and execution, she reports. “Having hospitalists here provides one group of experienced physicians who see a large percentage of patients,” says LeTourneau. Managing a significant caseload enables the hospitalist to understand the system in depth. “Hospitalists can provide good feedback and make it easier to implement necessary changes,” LeTourneau says (7) (Table 1, page 26).

Stakeholder Analysis

Studies reveal that hospitalists improve the practices of physicians and several subspecialties in a number of ways. Not only do PCPs benefit from the presence of hospitalists, but other medical specialists, patients, families, and medical facilities gain advantages as well.

Research Studies

Since 1996 when the term “hospitalist” was first used, a number of studies have been conducted to evaluate the benefits they bring to PCPs and other physicians. In the past decade, the number of hospitalists has increased dramatically, lending credence to their value in an inpatient medical setting. In 2005, the Society of Hospital Medicine (SHM) estimates that there are 12,000 hospitalists in the U.S.

In a survey by Mitretek Healthcare , researchers asked hospital leaders to rate a number of strategies that affect hospital–medical staff relations. Sixty-two percent of the leaders surveyed gave hospitalist programs a high rating pertaining to hospital-physician alignment (8). Other studies also support the growing belief that hospitalists can effectively and efficiently enhance physician practices (Table 2).

Conclusion

Joseph Li, MD, director of the hospitalist program at Beth Israel Deaconess Medical Center in Boston, hopes to build a career based on the belief that hospitalists are leading the way in “preventing medical errors and hospital-acquired infections, managing the complex hospital environment, finding the right transition to home care or rehabilitation, and providing palliative and end-of-life care” (9). As hospital medicine programs become more prevalent and accepted, more and more PCPs are seeing the value in their presence. A major national hospitalist management company surveyed PCPs in five markets on their experiences with hospitalists. The responses revealed a 100% satisfaction rating on the quality of inpatient care (10). In the future, hospitalists like Li will strive to maintain that rating while they help improve physician practices and enhance patient care.

Dr. Kealey can be contact at [email protected].

References

1. Jackson C. Doctors find hospitalists save time, money: primary care physicians are seeing that turning over their hospital business allows them to make more income. Amednews.com, February 19, 2001.
2. Trendy hospital medicine comes to Charlotte. Sunherald.com, February 13, 2004.
3. Landro L. Medicine’s fastest-growing specialty: hospitalbound doctors take the place of your physician; effort to reduce costs, errors. The Wall Street Journal Online, October 6, 2004.
4. Trousdale RT. Department of Orthopedics, Mayo Clinic, Rochester, MN. Telephone interview, January 3, 2005.
5. Huddleston JM, Long KH, Naessens JM, et al. Medical and surgical comanagement after elective hip and knee arthroplasty: a randomized controlled trial. Ann Intern Med. 2004;141:28-38.
6. Asplin BR. research director, Department of Emergency Medicine, Regions Hospital, St. Paul, MN. Telephone interview, January 5, 2005.
7. LeTourneau B. Emergency department physician, professional physician executive consultant, Regions Hospital, St. Paul, MN. Telephone interview, January 7, 2005.
8. McGowan RA. Strengthening hospital-physician relationships. Healthcare Financial Management Association. December 2004. www.hfma.org/publications/HFMMagazine/business.htm
9. Barnard A. Medical profession, patients have warmed to the ‘hospitalist’. The Boston Globe. January 30, 2002.
10. PCPs and hospitalists: a new attitude? Cogent Quarterly. 1;4:Fall 2001.
11. Auerbach AD, Aronson MD, Davis RB, Phillips RS. How physicians perceive hospitalist services after implementation: anticipation vs. reality. Arch Intern Med. 2003;163:2330-6.
12. Auerbach AD, Nelson EA, Lindenauer PK, Pantilat SZ, Katz PP, Wachter RM. Physician attitudes toward and prevalence of the hospitalist model of care: results of a national survey. Am J Med. 2000;109(8):648-53.
13. Halpert AP, Pearson SD, LeWine HE, et al. The impact of an inpatient physician program on quality, utilization, and satisfaction. Am J Manag Care. 2000;6:549-55.
14. Fernandez A, Grumbach K, Goetein L, et al. Friend or foe? How primary care physicians perceive hospitalists. Arch Intern Med. 2000;160:2902-8.

When Robert Lee, MD, an internist affiliated with Iowa Health Physicians, a multi-specialty group in Des Moines, was called to the hospital to see one of his patients, he faced a 50-minute round trip plus additional time to find a parking place and catch an elevator before reaching the inpatient unit. In the time it took for him to see a couple of his patients in the hospital, he could have treated five patients in the office (1).

David McAtee, MD, an osteopath at Murdock Family Medicine, a group practice of eight family physicians in Port Charlotte, Florida, estimates its doctors were spending 30% of their time at the hospital caring for only 5% of their patients (2).

With an eye toward enhancing their office practices and offering patients efficient and effective inpatient treatment, both the Des Moines and Port Charlotte medical groups pursued a growing trend in the health care industry: they turned to hospitalists. Lee notes that the change allows him to enjoy a more normal lifestyle with his family and enhances his income (1). The Murdock group’s decision to contract with hospitalists in 2003 resulted in an expansion of office hours. With more available time, the group is in the process of developing a series of programs targeting various diseases as a means of educating patients in better self-care. Additionally, McAtee expresses the hope that medical malpractice insurance premiums will decrease as a result of less time spent on inpatient care (2).

click for large version

Hospitalist Impact on Primary Care Physicians

Primary care physicians (PCPs) do have reservations regarding the involvement of hospitalists in the care of their patients. Some PCPs voice concerns about the potential reduction in income if they opt to use hospitalists. According to one estimate, primary care doctors may incur an average annual decrease in income of $25,000 by forgoing hospital rounds. However, studies indicate that PCPs have the potential to earn as much as $50,000 more by spending time in the office instead of seeing inpatients (3). Hospitalist programs that offer on-site, 24-hour availability provide other benefits. When a crisis strikes, PCPs may be difficult to reach as they are seeing office patients. The hurricanes that hit Florida in September and October 2004 clearly demonstrated the value of having continuous inpatient care by qualified physicians already at the hospital. Treacherous weather conditions prevented PCPs from driving to the hospital to see their patients. Although the hospital was unable to perform lab tests, surgeries, or diagnostic imaging procedures owing to power outages, hospitalists were already on-site and stabilized patients with their basic clinical skills (3). Patients who may not have heard of the term “hospitalist” were pleased that a physician was available to answer questions, address unexpected medical issues, and offer immediate support and comfort.

Admittedly, not all PCPs have embraced the hospitalist model. The perception that they might lose skill and prestige by giving up inpatient visits might prevent them from utilizing hospitalist services. In some cases, PCPs might perceive a reduction in continuity of care. These concerns are valid and warrant consideration. However, a well-run hospitalist program will keep communication lines open between hospitalists and PCPs, so that patients receive optimal care as both inpatients and outpatients.

Hospitalists and Surgeons/Specialists

Robert T. Trousdale, MD, orthopedic surgeon at the Mayo Clinic in Rochester, Minnesota, spends most of his day in the operating room or evaluating patients for surgery. An expert in hip and knee surgery, he admits that many orthopedic surgeons have insufficient knowledge when it comes to treating some of the common medical problems that may occur postoperatively. “Hospitalists help us co-manage patients in this area. They bring an increased level of experience to the management of the patient,” he says. Trousdale notes the added benefits of time and hospitalist availability.

“I am in the operating room for 5 hours at a time. If a nurse calls to report that one of my patients has developed post-op dizziness or chest pain, I might not be able to see him for 2 hours,” he says. Hospitalists have both the expertise and the availability to address medical issues in a timelier manner and expedite recovery time.

Additionally, Trousdale admits that, although he is quite familiar with the intricacies of the musculoskeletal system, he is less certain of the necessary tests a patient might need post-operatively. “We might take a ‘shotgun’ approach and order 15 expensive tests, which is an unnecessary use of the hospital’s resources,” he says (4).

Jeanne Huddleston, MD, director of the Inpatient Internal Medicine Program at Mayo Clinic and assistant professor of medicine at the Mayo College of Medicine, led a study to determine the impact hospitalists have on the co-management of patients having hip and knee surgery. The findings, published in 2004, reveal that of 526 patients in the study, more of those managed by hospitalist-orthopedic teams were discharged with no complications (61.6% for hospitalist-orthopedic teams vs. 48.8% for traditional orthopedic surgical teams). Only 30.2% of patients co-managed by hospitalists experienced minor complications, while 44.3% of patients managed by traditional orthopedic surgical teams had similar difficulties. Huddleston notes also that most orthopedic surgeons and nurses responding to a satisfaction survey preferred the hospitalist orthopedic model (5).

click for large version

Hospitalists and Emergency Department Physicians

Brent R. Asplin, MD, MPH, research director in the department of emergency medicine at Regions Hospital in St. Paul, Minnesota, cites three ways in which hospitalists positively affect the emergency department (ED): through extraordinary availability, consistent and reliable care, and their focus on the hospital. “Hospitalists are available 24 hours a day,” he says. “It’s nice to know when you send a patient to the floor, there is an experienced physician in-house to take care of them. You do not have to try to reach a PCP on the phone.” He reports that capacity is a major problem for EDs. Bottlenecks result when there are patients who are ready to be admitted from the ED but must wait for other patients to be discharged. Hospitalists are always available to maintain a smooth patient flow and facilitate throughput, according to Asplin.

As a group, hospitalists adhere to a consistent approach to patient care. Once a patient is admitted, efficient, reliable in-house care will ensure a quick recovery and discharge. Asplin says, “Hospitalists are more likely to embrace clinical pathways for the most common clinical diagnoses. This reduces variability across the board and increases patient outcome and flow.” Also, hospitalists focus exclusively on inpatient care, enabling them to devote all their attention to servicing the patient while they are hospitalized without the distractions that might divert a PCP’s concentration. Asplin says, “Regarding clinical care, operations, and quality improvement, it helps to have a group dedicated and focused on the hospital” (6).

In teaching hospitals, residents also benefit from the presence of hospitalists. According to Barbara LeTourneau, MD, an ED physician and professional physician executive consultant also based at Regions, residents have the continuous supervision of experienced practitioners who can answer questions and teach on an ongoing basis. “With hospitalists there is much quicker and better patient care,” she says.

In her role as administrator, LeTourneau has an historical perspective on the delivery of inpatient care at her hospital. Prior to the implementation of hospital medicine programs, positive changes took a longer period of time to reach agreement and execution, she reports. “Having hospitalists here provides one group of experienced physicians who see a large percentage of patients,” says LeTourneau. Managing a significant caseload enables the hospitalist to understand the system in depth. “Hospitalists can provide good feedback and make it easier to implement necessary changes,” LeTourneau says (7) (Table 1, page 26).

Stakeholder Analysis

Studies reveal that hospitalists improve the practices of physicians and several subspecialties in a number of ways. Not only do PCPs benefit from the presence of hospitalists, but other medical specialists, patients, families, and medical facilities gain advantages as well.

Research Studies

Since 1996 when the term “hospitalist” was first used, a number of studies have been conducted to evaluate the benefits they bring to PCPs and other physicians. In the past decade, the number of hospitalists has increased dramatically, lending credence to their value in an inpatient medical setting. In 2005, the Society of Hospital Medicine (SHM) estimates that there are 12,000 hospitalists in the U.S.

In a survey by Mitretek Healthcare , researchers asked hospital leaders to rate a number of strategies that affect hospital–medical staff relations. Sixty-two percent of the leaders surveyed gave hospitalist programs a high rating pertaining to hospital-physician alignment (8). Other studies also support the growing belief that hospitalists can effectively and efficiently enhance physician practices (Table 2).

Conclusion

Joseph Li, MD, director of the hospitalist program at Beth Israel Deaconess Medical Center in Boston, hopes to build a career based on the belief that hospitalists are leading the way in “preventing medical errors and hospital-acquired infections, managing the complex hospital environment, finding the right transition to home care or rehabilitation, and providing palliative and end-of-life care” (9). As hospital medicine programs become more prevalent and accepted, more and more PCPs are seeing the value in their presence. A major national hospitalist management company surveyed PCPs in five markets on their experiences with hospitalists. The responses revealed a 100% satisfaction rating on the quality of inpatient care (10). In the future, hospitalists like Li will strive to maintain that rating while they help improve physician practices and enhance patient care.

Dr. Kealey can be contact at [email protected].

References

1. Jackson C. Doctors find hospitalists save time, money: primary care physicians are seeing that turning over their hospital business allows them to make more income. Amednews.com, February 19, 2001.
2. Trendy hospital medicine comes to Charlotte. Sunherald.com, February 13, 2004.
3. Landro L. Medicine’s fastest-growing specialty: hospitalbound doctors take the place of your physician; effort to reduce costs, errors. The Wall Street Journal Online, October 6, 2004.
4. Trousdale RT. Department of Orthopedics, Mayo Clinic, Rochester, MN. Telephone interview, January 3, 2005.
5. Huddleston JM, Long KH, Naessens JM, et al. Medical and surgical comanagement after elective hip and knee arthroplasty: a randomized controlled trial. Ann Intern Med. 2004;141:28-38.
6. Asplin BR. research director, Department of Emergency Medicine, Regions Hospital, St. Paul, MN. Telephone interview, January 5, 2005.
7. LeTourneau B. Emergency department physician, professional physician executive consultant, Regions Hospital, St. Paul, MN. Telephone interview, January 7, 2005.
8. McGowan RA. Strengthening hospital-physician relationships. Healthcare Financial Management Association. December 2004. www.hfma.org/publications/HFMMagazine/business.htm
9. Barnard A. Medical profession, patients have warmed to the ‘hospitalist’. The Boston Globe. January 30, 2002.
10. PCPs and hospitalists: a new attitude? Cogent Quarterly. 1;4:Fall 2001.
11. Auerbach AD, Aronson MD, Davis RB, Phillips RS. How physicians perceive hospitalist services after implementation: anticipation vs. reality. Arch Intern Med. 2003;163:2330-6.
12. Auerbach AD, Nelson EA, Lindenauer PK, Pantilat SZ, Katz PP, Wachter RM. Physician attitudes toward and prevalence of the hospitalist model of care: results of a national survey. Am J Med. 2000;109(8):648-53.
13. Halpert AP, Pearson SD, LeWine HE, et al. The impact of an inpatient physician program on quality, utilization, and satisfaction. Am J Manag Care. 2000;6:549-55.
14. Fernandez A, Grumbach K, Goetein L, et al. Friend or foe? How primary care physicians perceive hospitalists. Arch Intern Med. 2000;160:2902-8.

What would prompt someone to exclaim “fantastic, inspirational, and motivational,” and trigger adults to hug each other when it is time to say goodbye? The first-ever SHM Leadership Academy welcomed 110 hospitalist leaders to the Westin La Paloma Resort in Tucson, AZ on January 10–13, 2005. A resounding success, the Leadership Academy offered instruction in leading change, communicating effectively, handling conflict and negotiation, strategic planning, and interpreting hospital business drivers. Two years in the making, this course combined an outstanding national faculty with small group learning exercises to begin the process of training hospitalists who will lead important initiatives as we shape the hospital of the future.

At the 2003 SHM Annual Meeting in San Diego, a standing room crowd of about 200 hospitalists at the Leadership Forum expressed their need for advanced leadership training. Responding to obvious demand, SHM developed a successful, soldout 1-day Leadership Pre-Course held in New Orleans at the 2004 SHM Annual Meeting. Building on this pre-course and again reacting to the requests of SHM members, Co-Directors Russell Holman and Mark Williams designed the Leadership Academy to provide more in-depth training over 4 days. Assisted by Tina Budnitz, SHM Senior Advisor for Planning and Development, this course was developed to address the leadership training needs of hospitalists. As an example of its resounding success, one participant made the following comment. “Even with 18 years of clinical/administrative experience as well as an MBA, this course was a learning experience and I gained and reinforced critical areas of thinking and actions.”

Credit for this success deservedly should be attributed to the outstanding faculty. SHM’s CEO Larry Wellikson led the first day, eloquently delineating the leadership challenges in hospital medicine. The audience appreciated how hospital medicine is evolving rapidly, still defining itself, and how hospitalists will be developing metrics for success. The remainder of the first day allowed participants to evaluate their own strengths and assess how their unique styles impact interactions with others. Using the Strength Deployment Inventory®, David Javitch, PhD explored how “reds,” “greens,” and “blues” approach situations and communicate with their colleagues. Javitch, an organizational psychologist from Harvard, demonstrated how individual styles of communication and interaction influence success at management and leadership. SHM Member Eric Howell, MD moderated a discussion featuring a movie capturing common hospital-based examples of conflict and led participants through techniques for conflict resolution and negotiation.

On the second day, Michael Guthrie, MD, MBA identified business drivers for hospital survival and success. Guthrie currently serves as a senior executive for a large national health alliance and has experience as a health system CEO, medical director, and consultant on performance improvement. Guthrie finished the morning by helping attendees interpret hospital performance reports and associated metrics and determine how such measures should guide leadership planning and decision making.

The next day was highlighted by sessions led by Jack Silversin, DMD, DrPH from Harvard, using table exercises and real world examples to demonstrate how to lead change. A nationally recognized expert in change management and co-author of “Leading Physicians through Change: How to Achieve and Sustain Results,” Dr. Silversin actively stimulated attendees to appraise their situations at home. He showed participants how to develop shared organizational vision, strengthen leadership, and accelerate implementation of change. Afterwards, Holman and Williams coordinated a series of sessions on strategic planning. They used multiple examples and exercises to aid attendees in developing vision and mission statements, as well as “SMART” goals.

The final day focused on communication. An experienced educator, Kathleen Miner, PhD, MPH, MEd, reviewed communication theory and how it applies to our everyday conversations and interactions. Miner, an Associate Dean for Public Health at Emory University, brought decades of experience to her presentation. The course ended with Holman recapping how to use what we learned to achieve success as a leader.

Overall, the course was structured to facilitate interaction and small group exercises. The interactive sessions provided opportunities for participants to apply concepts.

Use of facilitators greatly augmented the impact of this training. Participants in the course sat ten to a table, and each table was led by an experienced hospitalist leader trained to be a facilitator. We were extraordinarily fortunate to have leaders in hospital medicine as facilitators including: Mary Jo Gorman, Bill Atchley, Pat Cawley, Lisa Kettering, Alpesh Amin, Ron Greeno, Burke Kealey, Eric Siegal, Stacy Goldsholl, and Eric Howell.

The impact of the meeting was powerfully described by a facilitator, “I’ve never before experienced such sustained energy and enthusiasm at a meeting. People literally spent hours after the didactic sessions talking, sharing ideas, and commiserating. Speaks to the pent-up need for this, and the effectiveness of the curriculum in galvanizing the group.”

No meeting can be such a success without tremendous support from SHM staff. Angela Musial and Erica Pearson deserve our sincere thanks for handling all the logistical issues and guaranteeing a terrific time for everyone who attended. They ensured that everything worked without a hitch including two wonderful receptions, which fostered networking and opportunities to share challenges and success stories.

The Society of Hospital Medicine will hold another Leadership Academy this Fall: September 12–15 in Vail, Colorado. The learning objectives for the Leadership Academy highlight the skills hospitalists can gain by attending.

• Evaluate personal leadership strengths and weaknesses and apply them to everyday leadership and management challenges
• Effectively advocate the value of their Hospital Medicine program
• Predict and plan for the near-term challenges affecting the viability of their Hospital Medicine program
• Improve patient outcomes through successful planning, allocation of resources, collaboration, teamwork, and execution
• Create and execute a communication strategy for all key constituencies
• Interpret key hospital drivers
• Examine how hospital performance metrics are derived and how hospital medicine practices can influence and impact these metrics
• Implement methods of effective change through leadership, shared vision, and managing the organizational culture
• Utilize strategic planning to define a vision for their program, prioritize efforts, and achieve designated goals

Registration will again be limited to 100 hospitalist leaders and we expect this to fill quickly. The first Leadership Academy was sold out months before it was held, and interest in the September 2005 Leadership Academy in Vail is equally as strong after the rousing success of the January meeting in Tucson. If you are interested in attending, registration information can be found on page 19, at the SHM Web site at www.hospitalmedicine.org, or by calling SHM at 800-843-3360. We look forward to seeing you there.

What would prompt someone to exclaim “fantastic, inspirational, and motivational,” and trigger adults to hug each other when it is time to say goodbye? The first-ever SHM Leadership Academy welcomed 110 hospitalist leaders to the Westin La Paloma Resort in Tucson, AZ on January 10–13, 2005. A resounding success, the Leadership Academy offered instruction in leading change, communicating effectively, handling conflict and negotiation, strategic planning, and interpreting hospital business drivers. Two years in the making, this course combined an outstanding national faculty with small group learning exercises to begin the process of training hospitalists who will lead important initiatives as we shape the hospital of the future.

At the 2003 SHM Annual Meeting in San Diego, a standing room crowd of about 200 hospitalists at the Leadership Forum expressed their need for advanced leadership training. Responding to obvious demand, SHM developed a successful, soldout 1-day Leadership Pre-Course held in New Orleans at the 2004 SHM Annual Meeting. Building on this pre-course and again reacting to the requests of SHM members, Co-Directors Russell Holman and Mark Williams designed the Leadership Academy to provide more in-depth training over 4 days. Assisted by Tina Budnitz, SHM Senior Advisor for Planning and Development, this course was developed to address the leadership training needs of hospitalists. As an example of its resounding success, one participant made the following comment. “Even with 18 years of clinical/administrative experience as well as an MBA, this course was a learning experience and I gained and reinforced critical areas of thinking and actions.”

Credit for this success deservedly should be attributed to the outstanding faculty. SHM’s CEO Larry Wellikson led the first day, eloquently delineating the leadership challenges in hospital medicine. The audience appreciated how hospital medicine is evolving rapidly, still defining itself, and how hospitalists will be developing metrics for success. The remainder of the first day allowed participants to evaluate their own strengths and assess how their unique styles impact interactions with others. Using the Strength Deployment Inventory®, David Javitch, PhD explored how “reds,” “greens,” and “blues” approach situations and communicate with their colleagues. Javitch, an organizational psychologist from Harvard, demonstrated how individual styles of communication and interaction influence success at management and leadership. SHM Member Eric Howell, MD moderated a discussion featuring a movie capturing common hospital-based examples of conflict and led participants through techniques for conflict resolution and negotiation.

On the second day, Michael Guthrie, MD, MBA identified business drivers for hospital survival and success. Guthrie currently serves as a senior executive for a large national health alliance and has experience as a health system CEO, medical director, and consultant on performance improvement. Guthrie finished the morning by helping attendees interpret hospital performance reports and associated metrics and determine how such measures should guide leadership planning and decision making.

The next day was highlighted by sessions led by Jack Silversin, DMD, DrPH from Harvard, using table exercises and real world examples to demonstrate how to lead change. A nationally recognized expert in change management and co-author of “Leading Physicians through Change: How to Achieve and Sustain Results,” Dr. Silversin actively stimulated attendees to appraise their situations at home. He showed participants how to develop shared organizational vision, strengthen leadership, and accelerate implementation of change. Afterwards, Holman and Williams coordinated a series of sessions on strategic planning. They used multiple examples and exercises to aid attendees in developing vision and mission statements, as well as “SMART” goals.

The final day focused on communication. An experienced educator, Kathleen Miner, PhD, MPH, MEd, reviewed communication theory and how it applies to our everyday conversations and interactions. Miner, an Associate Dean for Public Health at Emory University, brought decades of experience to her presentation. The course ended with Holman recapping how to use what we learned to achieve success as a leader.

Overall, the course was structured to facilitate interaction and small group exercises. The interactive sessions provided opportunities for participants to apply concepts.

Use of facilitators greatly augmented the impact of this training. Participants in the course sat ten to a table, and each table was led by an experienced hospitalist leader trained to be a facilitator. We were extraordinarily fortunate to have leaders in hospital medicine as facilitators including: Mary Jo Gorman, Bill Atchley, Pat Cawley, Lisa Kettering, Alpesh Amin, Ron Greeno, Burke Kealey, Eric Siegal, Stacy Goldsholl, and Eric Howell.

The impact of the meeting was powerfully described by a facilitator, “I’ve never before experienced such sustained energy and enthusiasm at a meeting. People literally spent hours after the didactic sessions talking, sharing ideas, and commiserating. Speaks to the pent-up need for this, and the effectiveness of the curriculum in galvanizing the group.”

No meeting can be such a success without tremendous support from SHM staff. Angela Musial and Erica Pearson deserve our sincere thanks for handling all the logistical issues and guaranteeing a terrific time for everyone who attended. They ensured that everything worked without a hitch including two wonderful receptions, which fostered networking and opportunities to share challenges and success stories.

The Society of Hospital Medicine will hold another Leadership Academy this Fall: September 12–15 in Vail, Colorado. The learning objectives for the Leadership Academy highlight the skills hospitalists can gain by attending.

• Evaluate personal leadership strengths and weaknesses and apply them to everyday leadership and management challenges
• Effectively advocate the value of their Hospital Medicine program
• Predict and plan for the near-term challenges affecting the viability of their Hospital Medicine program
• Improve patient outcomes through successful planning, allocation of resources, collaboration, teamwork, and execution
• Create and execute a communication strategy for all key constituencies
• Interpret key hospital drivers
• Examine how hospital performance metrics are derived and how hospital medicine practices can influence and impact these metrics
• Implement methods of effective change through leadership, shared vision, and managing the organizational culture
• Utilize strategic planning to define a vision for their program, prioritize efforts, and achieve designated goals

Registration will again be limited to 100 hospitalist leaders and we expect this to fill quickly. The first Leadership Academy was sold out months before it was held, and interest in the September 2005 Leadership Academy in Vail is equally as strong after the rousing success of the January meeting in Tucson. If you are interested in attending, registration information can be found on page 19, at the SHM Web site at www.hospitalmedicine.org, or by calling SHM at 800-843-3360. We look forward to seeing you there.

What would prompt someone to exclaim “fantastic, inspirational, and motivational,” and trigger adults to hug each other when it is time to say goodbye? The first-ever SHM Leadership Academy welcomed 110 hospitalist leaders to the Westin La Paloma Resort in Tucson, AZ on January 10–13, 2005. A resounding success, the Leadership Academy offered instruction in leading change, communicating effectively, handling conflict and negotiation, strategic planning, and interpreting hospital business drivers. Two years in the making, this course combined an outstanding national faculty with small group learning exercises to begin the process of training hospitalists who will lead important initiatives as we shape the hospital of the future.

At the 2003 SHM Annual Meeting in San Diego, a standing room crowd of about 200 hospitalists at the Leadership Forum expressed their need for advanced leadership training. Responding to obvious demand, SHM developed a successful, soldout 1-day Leadership Pre-Course held in New Orleans at the 2004 SHM Annual Meeting. Building on this pre-course and again reacting to the requests of SHM members, Co-Directors Russell Holman and Mark Williams designed the Leadership Academy to provide more in-depth training over 4 days. Assisted by Tina Budnitz, SHM Senior Advisor for Planning and Development, this course was developed to address the leadership training needs of hospitalists. As an example of its resounding success, one participant made the following comment. “Even with 18 years of clinical/administrative experience as well as an MBA, this course was a learning experience and I gained and reinforced critical areas of thinking and actions.”

Credit for this success deservedly should be attributed to the outstanding faculty. SHM’s CEO Larry Wellikson led the first day, eloquently delineating the leadership challenges in hospital medicine. The audience appreciated how hospital medicine is evolving rapidly, still defining itself, and how hospitalists will be developing metrics for success. The remainder of the first day allowed participants to evaluate their own strengths and assess how their unique styles impact interactions with others. Using the Strength Deployment Inventory®, David Javitch, PhD explored how “reds,” “greens,” and “blues” approach situations and communicate with their colleagues. Javitch, an organizational psychologist from Harvard, demonstrated how individual styles of communication and interaction influence success at management and leadership. SHM Member Eric Howell, MD moderated a discussion featuring a movie capturing common hospital-based examples of conflict and led participants through techniques for conflict resolution and negotiation.

On the second day, Michael Guthrie, MD, MBA identified business drivers for hospital survival and success. Guthrie currently serves as a senior executive for a large national health alliance and has experience as a health system CEO, medical director, and consultant on performance improvement. Guthrie finished the morning by helping attendees interpret hospital performance reports and associated metrics and determine how such measures should guide leadership planning and decision making.

The next day was highlighted by sessions led by Jack Silversin, DMD, DrPH from Harvard, using table exercises and real world examples to demonstrate how to lead change. A nationally recognized expert in change management and co-author of “Leading Physicians through Change: How to Achieve and Sustain Results,” Dr. Silversin actively stimulated attendees to appraise their situations at home. He showed participants how to develop shared organizational vision, strengthen leadership, and accelerate implementation of change. Afterwards, Holman and Williams coordinated a series of sessions on strategic planning. They used multiple examples and exercises to aid attendees in developing vision and mission statements, as well as “SMART” goals.

The final day focused on communication. An experienced educator, Kathleen Miner, PhD, MPH, MEd, reviewed communication theory and how it applies to our everyday conversations and interactions. Miner, an Associate Dean for Public Health at Emory University, brought decades of experience to her presentation. The course ended with Holman recapping how to use what we learned to achieve success as a leader.

Overall, the course was structured to facilitate interaction and small group exercises. The interactive sessions provided opportunities for participants to apply concepts.

Use of facilitators greatly augmented the impact of this training. Participants in the course sat ten to a table, and each table was led by an experienced hospitalist leader trained to be a facilitator. We were extraordinarily fortunate to have leaders in hospital medicine as facilitators including: Mary Jo Gorman, Bill Atchley, Pat Cawley, Lisa Kettering, Alpesh Amin, Ron Greeno, Burke Kealey, Eric Siegal, Stacy Goldsholl, and Eric Howell.

The impact of the meeting was powerfully described by a facilitator, “I’ve never before experienced such sustained energy and enthusiasm at a meeting. People literally spent hours after the didactic sessions talking, sharing ideas, and commiserating. Speaks to the pent-up need for this, and the effectiveness of the curriculum in galvanizing the group.”

No meeting can be such a success without tremendous support from SHM staff. Angela Musial and Erica Pearson deserve our sincere thanks for handling all the logistical issues and guaranteeing a terrific time for everyone who attended. They ensured that everything worked without a hitch including two wonderful receptions, which fostered networking and opportunities to share challenges and success stories.

The Society of Hospital Medicine will hold another Leadership Academy this Fall: September 12–15 in Vail, Colorado. The learning objectives for the Leadership Academy highlight the skills hospitalists can gain by attending.

• Evaluate personal leadership strengths and weaknesses and apply them to everyday leadership and management challenges
• Effectively advocate the value of their Hospital Medicine program
• Predict and plan for the near-term challenges affecting the viability of their Hospital Medicine program
• Improve patient outcomes through successful planning, allocation of resources, collaboration, teamwork, and execution
• Create and execute a communication strategy for all key constituencies
• Interpret key hospital drivers
• Examine how hospital performance metrics are derived and how hospital medicine practices can influence and impact these metrics
• Implement methods of effective change through leadership, shared vision, and managing the organizational culture
• Utilize strategic planning to define a vision for their program, prioritize efforts, and achieve designated goals

Registration will again be limited to 100 hospitalist leaders and we expect this to fill quickly. The first Leadership Academy was sold out months before it was held, and interest in the September 2005 Leadership Academy in Vail is equally as strong after the rousing success of the January meeting in Tucson. If you are interested in attending, registration information can be found on page 19, at the SHM Web site at www.hospitalmedicine.org, or by calling SHM at 800-843-3360. We look forward to seeing you there.

SHM has elected Scott A. Flanders, MD, Alpesh Amin, MD, MBA, and Stacy Goldsholl, MD, to serve a 3-year term on the board of directors, beginning April 29, 2005. The new board members replace outgoing board members Jeff Dichter, MD, David Zipes, MD, and Peter Lindenauer, MD.

“Our new board members are all accomplished physicians who have consistently demonstrated their commitment to the field of hospital medicine,” said SHM president Jeanne Huddleston, MD. “Each of these new board members brings a vast range of experience, leadership, and passion to the Board that is sure to stimulate new thinking and new goals that will strengthen the role of hospitalists. We look forward to their insights and vision as we continue to expand the role of hospitalists as leaders and change agents in transforming patient care and quality.”

Scott A. Flanders, MD, FACP was a founding member of SHM’s Board of Directors in 1997 and served on the board for 6 years. He has since served on many of SHM’s committees and was editor of the organization’s newsletter, The Hospitalist, from 1997 through 2003.

Dr. Flanders currently is a clinical associate professor in the Division of General Internal Medicine at the University of Michigan in Ann Arbor, where he also serves as associate division chief of General Medicine for Inpatient Programs and associate director of Inpatient Programs for the Department of Internal Medicine. He is the director of the University of Michigan’s Hospitalist Program. He was formerly an associate professor of medicine at the University of California, San Francisco and director of the Hospitalist Residency Track there . Dr. Flanders, in collaboration with other University of California faculty, developed the content for the nation’s first Hospitalist Residency Track. This track has become a model that has been widely disseminated to other academic centers starting similar programs and formed the basis of a recent chapter for the Association of Program Directors in Internal Medicine (APDIM) Manual. Dr. Flanders regularly consults with both academic and community hospitals on issues related to curriculum development in the inpatient setting.

In addition to these activities, Dr. Flanders has been active in guideline development, quality improvement, and patient safety both at the University of Michigan and the University of California, San Francisco. His research interests are related to hospitalists, dissemination of patient safety practices, and the diagnosis and treatment of lower respiratory infections. He speaks regularly at national conferences on the topics of hospitalists and community-acquired and nosocomial pneumonia. He served as associate editor of AHRQ’s Web M&M online journal of patient safety from its inception until 2004.

Dr. Flanders earned his medical degree from the University of Chicago in 1993 and completed his residency training in Internal Medicine at the University of California, San Francisco.

Alpesh Amin, MD, MBA, FACP became a charter member of SHM in 1998 and also serves as chair of SHM’s Education Committee. Under his leadership, the committee developed three task forces: the Core Curricuum, Leadership, and Geriatrics. Dr. Amin serves as a member of each of these (as well as the SHM Journal Task Force), where he provides guidance in developing education curriculum to improve SHM member skills in these areas. Dr. Amin also is one of the co-authors of the first Core Curriculum for Hospital Medicine, soon to be published. He also served on the 2004 Annual Program Committee and will be the program director for the 2006 Annual Meeting.

Dr. Amin is the executive director for the Hospitalist Program at the University of California Irvine Medical Center in Irvine, a program he started in June 1998. Over the last 7 years, he has grown the program to 15 academic hospitalists. He is also vice-chair for Clinical Affairs, associate program director for the Internal Medicine Residency Program, and clerkship director for the Medicine Clerkship at the University of California, Irvine. Through these different roles, he has been involved in clinical care, administrative and hospital based committee work, and curriculum development. He has also been involved in developing the Hospitalist/Consultative Curriculum, Palliative & Hospice Care Curriculum, and Business of Medicine Curriculum at UCI.

Dr. Amin’s research interests are related to the field of hospital medicine, patient safety and quality, and medical education. He is an invited speaker at national conferences on community acquired and hospital acquired pneumonia, deep vein thrombosis and venous thromboembolism, and heart failure.

Dr. Amin earned his medical degree from Northwestern University Medical School, Chicago, IL in 1994. He did his residency training in Internal Medicine at the University of California, Irvine, and went on to earn an MBA in Health Care from that school in 2000.

Stacy Goldsholl, MD, BC, IM has been a practicing hospitalist for 10 years and is a charter member of SHM. Since joining SHM, she has participated as SHM’s Michigan State Regional Councilor, a member of the Practice Management Committee, and faculty for the Midwest Regional Meeting. Currently she is the 2004/5 Chair of the Benchmarks and Productivity Task Force, a faculty member for the 2004/5 Annual Meeting Committee, and facilitator for the 2005 SHM Leadership Academy.

Dr. Goldsholl is currently national medical director for Cogent Healthcare and is the owner of Catalyst Inpatient Solutions, LLC, a consulting firm she founded in 2002 for hospital medicine program development and education.

Dr. Goldsholl began her career in hospital medicine at a community hospital in Atlanta, where she served as a physician advisor for medical management and utilization review. In 2000, she initiated a hospitalist division for a large multi-specialty group in Wilmington, North Carolina. She has spent the last 4 years implementing hospital medicine programs for two large (700 bed) non-profit hospitals and establishing Catalyst Inpatient Solutions to serve the needs of various hospitals, including for-profit and critical access hospital designations, ranging in size from 75 to 700 beds.

Dr. Goldsholl’s clinical interests include partnering Palliative Medicine and Pastoral Services with care of the hospitalized patient, and she participated as a faculty scholar with the 2004 Harvard Medical School’s Program in Palliative Care Education and Practice.

In addition to Dr. Goldsholl’s clinical practice, she served as co-author for “The Hospitalist Program Management Guide” (HCPro), as well as consultant to the Clinical Advisory Board of the Advisory Board Company for the publication “Second Generation Hospitalist Programs.”

Dr. Goldsholl earned her MD at the University of North Carolina at Chapel Hill in 1992 and went on to complete her residency training there. She earned a Bachelor of Science degree in Biology from York College of Pennsylvania in 1985 and attended a Medical Scholars Program at the University of Illinois in Urbana from 1986-1990. She is Board Certified in Internal Medicine and a member of the American College of Physician Executives.

Please join us in congratulating all of the new board members, and also in thanking our outgoing board members for their dedication and service.

SHM has elected Scott A. Flanders, MD, Alpesh Amin, MD, MBA, and Stacy Goldsholl, MD, to serve a 3-year term on the board of directors, beginning April 29, 2005. The new board members replace outgoing board members Jeff Dichter, MD, David Zipes, MD, and Peter Lindenauer, MD.

“Our new board members are all accomplished physicians who have consistently demonstrated their commitment to the field of hospital medicine,” said SHM president Jeanne Huddleston, MD. “Each of these new board members brings a vast range of experience, leadership, and passion to the Board that is sure to stimulate new thinking and new goals that will strengthen the role of hospitalists. We look forward to their insights and vision as we continue to expand the role of hospitalists as leaders and change agents in transforming patient care and quality.”

Scott A. Flanders, MD, FACP was a founding member of SHM’s Board of Directors in 1997 and served on the board for 6 years. He has since served on many of SHM’s committees and was editor of the organization’s newsletter, The Hospitalist, from 1997 through 2003.

Dr. Flanders currently is a clinical associate professor in the Division of General Internal Medicine at the University of Michigan in Ann Arbor, where he also serves as associate division chief of General Medicine for Inpatient Programs and associate director of Inpatient Programs for the Department of Internal Medicine. He is the director of the University of Michigan’s Hospitalist Program. He was formerly an associate professor of medicine at the University of California, San Francisco and director of the Hospitalist Residency Track there . Dr. Flanders, in collaboration with other University of California faculty, developed the content for the nation’s first Hospitalist Residency Track. This track has become a model that has been widely disseminated to other academic centers starting similar programs and formed the basis of a recent chapter for the Association of Program Directors in Internal Medicine (APDIM) Manual. Dr. Flanders regularly consults with both academic and community hospitals on issues related to curriculum development in the inpatient setting.

In addition to these activities, Dr. Flanders has been active in guideline development, quality improvement, and patient safety both at the University of Michigan and the University of California, San Francisco. His research interests are related to hospitalists, dissemination of patient safety practices, and the diagnosis and treatment of lower respiratory infections. He speaks regularly at national conferences on the topics of hospitalists and community-acquired and nosocomial pneumonia. He served as associate editor of AHRQ’s Web M&M online journal of patient safety from its inception until 2004.

Dr. Flanders earned his medical degree from the University of Chicago in 1993 and completed his residency training in Internal Medicine at the University of California, San Francisco.

Alpesh Amin, MD, MBA, FACP became a charter member of SHM in 1998 and also serves as chair of SHM’s Education Committee. Under his leadership, the committee developed three task forces: the Core Curricuum, Leadership, and Geriatrics. Dr. Amin serves as a member of each of these (as well as the SHM Journal Task Force), where he provides guidance in developing education curriculum to improve SHM member skills in these areas. Dr. Amin also is one of the co-authors of the first Core Curriculum for Hospital Medicine, soon to be published. He also served on the 2004 Annual Program Committee and will be the program director for the 2006 Annual Meeting.

Dr. Amin is the executive director for the Hospitalist Program at the University of California Irvine Medical Center in Irvine, a program he started in June 1998. Over the last 7 years, he has grown the program to 15 academic hospitalists. He is also vice-chair for Clinical Affairs, associate program director for the Internal Medicine Residency Program, and clerkship director for the Medicine Clerkship at the University of California, Irvine. Through these different roles, he has been involved in clinical care, administrative and hospital based committee work, and curriculum development. He has also been involved in developing the Hospitalist/Consultative Curriculum, Palliative & Hospice Care Curriculum, and Business of Medicine Curriculum at UCI.

Dr. Amin’s research interests are related to the field of hospital medicine, patient safety and quality, and medical education. He is an invited speaker at national conferences on community acquired and hospital acquired pneumonia, deep vein thrombosis and venous thromboembolism, and heart failure.

Dr. Amin earned his medical degree from Northwestern University Medical School, Chicago, IL in 1994. He did his residency training in Internal Medicine at the University of California, Irvine, and went on to earn an MBA in Health Care from that school in 2000.

Stacy Goldsholl, MD, BC, IM has been a practicing hospitalist for 10 years and is a charter member of SHM. Since joining SHM, she has participated as SHM’s Michigan State Regional Councilor, a member of the Practice Management Committee, and faculty for the Midwest Regional Meeting. Currently she is the 2004/5 Chair of the Benchmarks and Productivity Task Force, a faculty member for the 2004/5 Annual Meeting Committee, and facilitator for the 2005 SHM Leadership Academy.

Dr. Goldsholl is currently national medical director for Cogent Healthcare and is the owner of Catalyst Inpatient Solutions, LLC, a consulting firm she founded in 2002 for hospital medicine program development and education.

Dr. Goldsholl began her career in hospital medicine at a community hospital in Atlanta, where she served as a physician advisor for medical management and utilization review. In 2000, she initiated a hospitalist division for a large multi-specialty group in Wilmington, North Carolina. She has spent the last 4 years implementing hospital medicine programs for two large (700 bed) non-profit hospitals and establishing Catalyst Inpatient Solutions to serve the needs of various hospitals, including for-profit and critical access hospital designations, ranging in size from 75 to 700 beds.

Dr. Goldsholl’s clinical interests include partnering Palliative Medicine and Pastoral Services with care of the hospitalized patient, and she participated as a faculty scholar with the 2004 Harvard Medical School’s Program in Palliative Care Education and Practice.

In addition to Dr. Goldsholl’s clinical practice, she served as co-author for “The Hospitalist Program Management Guide” (HCPro), as well as consultant to the Clinical Advisory Board of the Advisory Board Company for the publication “Second Generation Hospitalist Programs.”

Dr. Goldsholl earned her MD at the University of North Carolina at Chapel Hill in 1992 and went on to complete her residency training there. She earned a Bachelor of Science degree in Biology from York College of Pennsylvania in 1985 and attended a Medical Scholars Program at the University of Illinois in Urbana from 1986-1990. She is Board Certified in Internal Medicine and a member of the American College of Physician Executives.

Please join us in congratulating all of the new board members, and also in thanking our outgoing board members for their dedication and service.

SHM has elected Scott A. Flanders, MD, Alpesh Amin, MD, MBA, and Stacy Goldsholl, MD, to serve a 3-year term on the board of directors, beginning April 29, 2005. The new board members replace outgoing board members Jeff Dichter, MD, David Zipes, MD, and Peter Lindenauer, MD.

“Our new board members are all accomplished physicians who have consistently demonstrated their commitment to the field of hospital medicine,” said SHM president Jeanne Huddleston, MD. “Each of these new board members brings a vast range of experience, leadership, and passion to the Board that is sure to stimulate new thinking and new goals that will strengthen the role of hospitalists. We look forward to their insights and vision as we continue to expand the role of hospitalists as leaders and change agents in transforming patient care and quality.”

Scott A. Flanders, MD, FACP was a founding member of SHM’s Board of Directors in 1997 and served on the board for 6 years. He has since served on many of SHM’s committees and was editor of the organization’s newsletter, The Hospitalist, from 1997 through 2003.

Dr. Flanders currently is a clinical associate professor in the Division of General Internal Medicine at the University of Michigan in Ann Arbor, where he also serves as associate division chief of General Medicine for Inpatient Programs and associate director of Inpatient Programs for the Department of Internal Medicine. He is the director of the University of Michigan’s Hospitalist Program. He was formerly an associate professor of medicine at the University of California, San Francisco and director of the Hospitalist Residency Track there . Dr. Flanders, in collaboration with other University of California faculty, developed the content for the nation’s first Hospitalist Residency Track. This track has become a model that has been widely disseminated to other academic centers starting similar programs and formed the basis of a recent chapter for the Association of Program Directors in Internal Medicine (APDIM) Manual. Dr. Flanders regularly consults with both academic and community hospitals on issues related to curriculum development in the inpatient setting.

In addition to these activities, Dr. Flanders has been active in guideline development, quality improvement, and patient safety both at the University of Michigan and the University of California, San Francisco. His research interests are related to hospitalists, dissemination of patient safety practices, and the diagnosis and treatment of lower respiratory infections. He speaks regularly at national conferences on the topics of hospitalists and community-acquired and nosocomial pneumonia. He served as associate editor of AHRQ’s Web M&M online journal of patient safety from its inception until 2004.

Dr. Flanders earned his medical degree from the University of Chicago in 1993 and completed his residency training in Internal Medicine at the University of California, San Francisco.

Alpesh Amin, MD, MBA, FACP became a charter member of SHM in 1998 and also serves as chair of SHM’s Education Committee. Under his leadership, the committee developed three task forces: the Core Curricuum, Leadership, and Geriatrics. Dr. Amin serves as a member of each of these (as well as the SHM Journal Task Force), where he provides guidance in developing education curriculum to improve SHM member skills in these areas. Dr. Amin also is one of the co-authors of the first Core Curriculum for Hospital Medicine, soon to be published. He also served on the 2004 Annual Program Committee and will be the program director for the 2006 Annual Meeting.

Dr. Amin is the executive director for the Hospitalist Program at the University of California Irvine Medical Center in Irvine, a program he started in June 1998. Over the last 7 years, he has grown the program to 15 academic hospitalists. He is also vice-chair for Clinical Affairs, associate program director for the Internal Medicine Residency Program, and clerkship director for the Medicine Clerkship at the University of California, Irvine. Through these different roles, he has been involved in clinical care, administrative and hospital based committee work, and curriculum development. He has also been involved in developing the Hospitalist/Consultative Curriculum, Palliative & Hospice Care Curriculum, and Business of Medicine Curriculum at UCI.

Dr. Amin’s research interests are related to the field of hospital medicine, patient safety and quality, and medical education. He is an invited speaker at national conferences on community acquired and hospital acquired pneumonia, deep vein thrombosis and venous thromboembolism, and heart failure.

Dr. Amin earned his medical degree from Northwestern University Medical School, Chicago, IL in 1994. He did his residency training in Internal Medicine at the University of California, Irvine, and went on to earn an MBA in Health Care from that school in 2000.

Stacy Goldsholl, MD, BC, IM has been a practicing hospitalist for 10 years and is a charter member of SHM. Since joining SHM, she has participated as SHM’s Michigan State Regional Councilor, a member of the Practice Management Committee, and faculty for the Midwest Regional Meeting. Currently she is the 2004/5 Chair of the Benchmarks and Productivity Task Force, a faculty member for the 2004/5 Annual Meeting Committee, and facilitator for the 2005 SHM Leadership Academy.

Dr. Goldsholl is currently national medical director for Cogent Healthcare and is the owner of Catalyst Inpatient Solutions, LLC, a consulting firm she founded in 2002 for hospital medicine program development and education.

Dr. Goldsholl began her career in hospital medicine at a community hospital in Atlanta, where she served as a physician advisor for medical management and utilization review. In 2000, she initiated a hospitalist division for a large multi-specialty group in Wilmington, North Carolina. She has spent the last 4 years implementing hospital medicine programs for two large (700 bed) non-profit hospitals and establishing Catalyst Inpatient Solutions to serve the needs of various hospitals, including for-profit and critical access hospital designations, ranging in size from 75 to 700 beds.

Dr. Goldsholl’s clinical interests include partnering Palliative Medicine and Pastoral Services with care of the hospitalized patient, and she participated as a faculty scholar with the 2004 Harvard Medical School’s Program in Palliative Care Education and Practice.

In addition to Dr. Goldsholl’s clinical practice, she served as co-author for “The Hospitalist Program Management Guide” (HCPro), as well as consultant to the Clinical Advisory Board of the Advisory Board Company for the publication “Second Generation Hospitalist Programs.”

Dr. Goldsholl earned her MD at the University of North Carolina at Chapel Hill in 1992 and went on to complete her residency training there. She earned a Bachelor of Science degree in Biology from York College of Pennsylvania in 1985 and attended a Medical Scholars Program at the University of Illinois in Urbana from 1986-1990. She is Board Certified in Internal Medicine and a member of the American College of Physician Executives.

Please join us in congratulating all of the new board members, and also in thanking our outgoing board members for their dedication and service.

This chapter looks at work generated by the surveyed hospitalists. Overall, the median charges per year for physician hospitalists are $288,242 and the median collections are $160,000 (a 56% collection rate). The typical surveyed physician had a median of 2,259 encounters, 468 admissions and consultations, and 3,000 RVUs. The analyses below examine these measures from the following perspectives: region, employment model, specialty/provider type, and compensation model.

• Consistent with the compensation and productivity input measures, academic hospitalists have low median collections ($110,000 vs. $160,000 overall), low encounters (1,600 vs. 2,259 overall), low admissions and consults (371 vs. 468). However, academic hospitalists generate an equivalent number of RVUs (3,000) indicating that they are delivering more complex services. NOTE: At 40% ($110,000/$278,122), the median collection rate for academic groups is the lowest of all employment categories. This may be explained by the payer mix at academic medical centers.



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• Hospitalist-only groups, both local and multi-state, generate the most work output. With regard to median charges generated, local groups are 21% higher ($350,000 vs. $288,242) and multi-state groups are 4% higher ($300,988 vs. $288,242). Hospitalists in multi-state groups have remarkable performance with regard to collections, achieving a 95% collection rate compared to a overall average of 56%. These hospitalist-only groups also have much higher encounters, admissions/consults, and RVUs.
• As in the Productivity Inputs, Eastern hospitalists have the lowest measures of Productivity Outputs. Hospitalists in the Southern region generate the most work in all five categories of outputs.
• Compared with adult medicine hospitalists, pediatricians generate fewer charges ($203,554 vs. $290,000), collections ($111,000 vs. $160,100), encounters (1,300 vs. 2,340), admissions/consults (441 vs. 470), and RVUs (1,990 vs. 3,000).
• Non-physicians generate about half the charges, collections, admissions/consults, and RVUs of physician hospitalists.
• Productivity–based compensation appears to have a positive impact on Productivity Output (the incentives appear to work).
• Compared with hospitalists with a 100% salary model, hospitalists that have a 100% productivity model have median charges 65% higher ($385,200 vs. $233,251), median collections that are 56% higher ($200,000 vs. $128,063), encounters that are 64% higher (3,000 vs. 1,831), admissions/consults that are 44% higher (575 vs. 400), and more than twice the median number of RVUs (4,967 vs. 2,395). In all cases hospitalists with a mixed compensation model fall in the middle of the two medians.

This chapter looks at work generated by the surveyed hospitalists. Overall, the median charges per year for physician hospitalists are $288,242 and the median collections are $160,000 (a 56% collection rate). The typical surveyed physician had a median of 2,259 encounters, 468 admissions and consultations, and 3,000 RVUs. The analyses below examine these measures from the following perspectives: region, employment model, specialty/provider type, and compensation model.

• Consistent with the compensation and productivity input measures, academic hospitalists have low median collections ($110,000 vs. $160,000 overall), low encounters (1,600 vs. 2,259 overall), low admissions and consults (371 vs. 468). However, academic hospitalists generate an equivalent number of RVUs (3,000) indicating that they are delivering more complex services. NOTE: At 40% ($110,000/$278,122), the median collection rate for academic groups is the lowest of all employment categories. This may be explained by the payer mix at academic medical centers.



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• Hospitalist-only groups, both local and multi-state, generate the most work output. With regard to median charges generated, local groups are 21% higher ($350,000 vs. $288,242) and multi-state groups are 4% higher ($300,988 vs. $288,242). Hospitalists in multi-state groups have remarkable performance with regard to collections, achieving a 95% collection rate compared to a overall average of 56%. These hospitalist-only groups also have much higher encounters, admissions/consults, and RVUs.
• As in the Productivity Inputs, Eastern hospitalists have the lowest measures of Productivity Outputs. Hospitalists in the Southern region generate the most work in all five categories of outputs.
• Compared with adult medicine hospitalists, pediatricians generate fewer charges ($203,554 vs. $290,000), collections ($111,000 vs. $160,100), encounters (1,300 vs. 2,340), admissions/consults (441 vs. 470), and RVUs (1,990 vs. 3,000).
• Non-physicians generate about half the charges, collections, admissions/consults, and RVUs of physician hospitalists.
• Productivity–based compensation appears to have a positive impact on Productivity Output (the incentives appear to work).
• Compared with hospitalists with a 100% salary model, hospitalists that have a 100% productivity model have median charges 65% higher ($385,200 vs. $233,251), median collections that are 56% higher ($200,000 vs. $128,063), encounters that are 64% higher (3,000 vs. 1,831), admissions/consults that are 44% higher (575 vs. 400), and more than twice the median number of RVUs (4,967 vs. 2,395). In all cases hospitalists with a mixed compensation model fall in the middle of the two medians.

This chapter looks at work generated by the surveyed hospitalists. Overall, the median charges per year for physician hospitalists are $288,242 and the median collections are $160,000 (a 56% collection rate). The typical surveyed physician had a median of 2,259 encounters, 468 admissions and consultations, and 3,000 RVUs. The analyses below examine these measures from the following perspectives: region, employment model, specialty/provider type, and compensation model.

• Consistent with the compensation and productivity input measures, academic hospitalists have low median collections ($110,000 vs. $160,000 overall), low encounters (1,600 vs. 2,259 overall), low admissions and consults (371 vs. 468). However, academic hospitalists generate an equivalent number of RVUs (3,000) indicating that they are delivering more complex services. NOTE: At 40% ($110,000/$278,122), the median collection rate for academic groups is the lowest of all employment categories. This may be explained by the payer mix at academic medical centers.



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• Hospitalist-only groups, both local and multi-state, generate the most work output. With regard to median charges generated, local groups are 21% higher ($350,000 vs. $288,242) and multi-state groups are 4% higher ($300,988 vs. $288,242). Hospitalists in multi-state groups have remarkable performance with regard to collections, achieving a 95% collection rate compared to a overall average of 56%. These hospitalist-only groups also have much higher encounters, admissions/consults, and RVUs.
• As in the Productivity Inputs, Eastern hospitalists have the lowest measures of Productivity Outputs. Hospitalists in the Southern region generate the most work in all five categories of outputs.
• Compared with adult medicine hospitalists, pediatricians generate fewer charges ($203,554 vs. $290,000), collections ($111,000 vs. $160,100), encounters (1,300 vs. 2,340), admissions/consults (441 vs. 470), and RVUs (1,990 vs. 3,000).
• Non-physicians generate about half the charges, collections, admissions/consults, and RVUs of physician hospitalists.
• Productivity–based compensation appears to have a positive impact on Productivity Output (the incentives appear to work).
• Compared with hospitalists with a 100% salary model, hospitalists that have a 100% productivity model have median charges 65% higher ($385,200 vs. $233,251), median collections that are 56% higher ($200,000 vs. $128,063), encounters that are 64% higher (3,000 vs. 1,831), admissions/consults that are 44% higher (575 vs. 400), and more than twice the median number of RVUs (4,967 vs. 2,395). In all cases hospitalists with a mixed compensation model fall in the middle of the two medians.

The next Annual Meeting is near. This means that the year, serving as your President, has nearly come to an end. As a result, this will be my last column. It is a good time for reflection.

First, I must thank the thousands of hospitalists who have joined SHM, filled out surveys, and attended meetings (either nationally or locally). You see, SHM’s data on hospitalists—where they are, what they do, and numbers in practice—is the source of information people outside the profession are using to understand and make decisions about our growing specialty. There is strength in numbers and your participation at every level infuses the energy necessary for us to continue the journey of becoming a legitimate specialty. Thank you.

As an organization, we have made significant progress toward our mission of making quality and safety core to what it means to practice hospital medicine. We have joined a number of other organizations, associations, and foundations to create various initiatives aimed at improving the quality and safety of care delivered in our hospitals. Specific areas of focus to date have been in the care of geriatric, diabetic, cardiac, and critically ill patients. We have also begun to address key preventative strategies such as antibiotic resistance and thromboembolic disease prophylaxis. These national partnerships SHM has formed with such organizations as the American College of Chest Physicians, American Association of Critical Care Nurses, American Hospital Association, Hartford Foundation, American College of Cardiology, Institute of Health Care Improvement, Joint Commission, and many others, demonstrate the breadth of teamwork that is necessary to care for patients across the continuum. Hospitalists are a crucial part of that team as more and more of our nation’s patients are cared for by hospitalists during their acute illnesses.

It has been an amazing year of watching this organization grow and mature. But what do I worry about as I leave my post? What is the kernel of concern that I must ensure is passed on with this next “transition of care” of our organization? It is that which defines us. I mentioned in my speech at lunch last year that we (the Society of Hospital Medicine) would fail if what hospitalists became known as were simply those pediatricians or internists who spent more time than their peers in the hospital. I don’t know about you, but at least once each month someone will approach me and say “I spend 25% of my time seeing patients in the hospital—So I must be a hospitalist!” (Quoting the original work of Drs. Robert Wachter and Lee Goldman in their 1996 New England Journal of Medicine article.) Well, as time has passed and the field has clearly evolved with more than 10,000 hospitalists practicing, the definition has clearly evolved.

But is our defi nition of what we do still based on time in the hospital? Or is it a more substantial definition? Is it about one’s professional focus? Is it about where one’s passion for medicine lies? What one wakes up in the middle of the night worrying about? What is a hospitalist?

The definition set forth by the Society of Hospital Medicine (adopted in the spring of 2000) is the following: Hospitalists are doctors whose primary professional focus is the general medical care of hospitalized patients. Their activities may include patient care, teaching, research, and leadership related to hospital care. Hospital medicine is a specialty organized around a site of care (the hospital) rather than an organ (like cardiology), a disease (like oncology), or a patient’s age (like pediatrics).

It seems silly to be asking this question of what defines us after writing about the burgeoning specialty. But as was pointed out in February’s JGIM issue, “varied employment relationships create diverse practice structures, priorities and roles.” Our practices have each grown so quickly out of local market pressures and individual hospital needs that we have evolved in slightly different directions. This is a natural consequence of such rapid growth. Just like any other specialty, practice structures and employment models will differ across the country. But I would challenge us to ensure that our higher priorities do not differ.

The American health care system needs an entire army of physicians and other providers to give whole heartedly and completely of their professional time, creativity, and energy to the hospital… to fix current system problems. It is no different than the cardiologists of today spending their energy and time discovering at the molecular level what causes ventricular dysfunction and then translating that knowledge to bedside care. Hospitalists, are specialists of in hospital medicine, and must do for the hospital what cardiologists do to the heart. We must study and learn what causes the health care delivered by the hospital to fail. Then we must translate that knowledge to the care of all patients in the hospital by improving the systems of care delivery.

According to Dr. Charles Mayo, “The definition of a specialist as one who ‘knows more and more about less and less. Its truth makes essential that the specialist, to do efficient work, must have some association with others who, taken altogether, represent the whole of which the specialty is only a part.” Our generalist colleagues care about the hospital as much as we do but do not necessarily have the time to concentrate specifically on hospital systems. There are so many other things that require their attention at the same time, but we need them to be there.

So we are only a part of what is needed to deliver the best care to all patients. But we have become a critical part of that team in the hospital. It is the hospitalists who, through their chosen focus on one aspect of medicine, will need to give the energy, creativity, and time to improving our systems of health care delivery in the hospital and across key transitions of care. Regardless of where we practice or how our practice is structured, our higher calling as a specialty is to determine the root causes of what ails the hospitals of this country. Then, as a specialty we must discover new mechanisms that would provide care at the level of quality called for by our patients. If we as hospitalists are truly specialists… If we are experts at delivering hospital based care… Then we have a vested interest in addressing these higher priorities. The improvements in health care that will be achieved, because a group of providers have dedicated their careers to making the hospital a better place for our patients, will ultimately make the definition of a hospitalist quite clear.

The next Annual Meeting is near. This means that the year, serving as your President, has nearly come to an end. As a result, this will be my last column. It is a good time for reflection.

First, I must thank the thousands of hospitalists who have joined SHM, filled out surveys, and attended meetings (either nationally or locally). You see, SHM’s data on hospitalists—where they are, what they do, and numbers in practice—is the source of information people outside the profession are using to understand and make decisions about our growing specialty. There is strength in numbers and your participation at every level infuses the energy necessary for us to continue the journey of becoming a legitimate specialty. Thank you.

As an organization, we have made significant progress toward our mission of making quality and safety core to what it means to practice hospital medicine. We have joined a number of other organizations, associations, and foundations to create various initiatives aimed at improving the quality and safety of care delivered in our hospitals. Specific areas of focus to date have been in the care of geriatric, diabetic, cardiac, and critically ill patients. We have also begun to address key preventative strategies such as antibiotic resistance and thromboembolic disease prophylaxis. These national partnerships SHM has formed with such organizations as the American College of Chest Physicians, American Association of Critical Care Nurses, American Hospital Association, Hartford Foundation, American College of Cardiology, Institute of Health Care Improvement, Joint Commission, and many others, demonstrate the breadth of teamwork that is necessary to care for patients across the continuum. Hospitalists are a crucial part of that team as more and more of our nation’s patients are cared for by hospitalists during their acute illnesses.

It has been an amazing year of watching this organization grow and mature. But what do I worry about as I leave my post? What is the kernel of concern that I must ensure is passed on with this next “transition of care” of our organization? It is that which defines us. I mentioned in my speech at lunch last year that we (the Society of Hospital Medicine) would fail if what hospitalists became known as were simply those pediatricians or internists who spent more time than their peers in the hospital. I don’t know about you, but at least once each month someone will approach me and say “I spend 25% of my time seeing patients in the hospital—So I must be a hospitalist!” (Quoting the original work of Drs. Robert Wachter and Lee Goldman in their 1996 New England Journal of Medicine article.) Well, as time has passed and the field has clearly evolved with more than 10,000 hospitalists practicing, the definition has clearly evolved.

But is our defi nition of what we do still based on time in the hospital? Or is it a more substantial definition? Is it about one’s professional focus? Is it about where one’s passion for medicine lies? What one wakes up in the middle of the night worrying about? What is a hospitalist?

The definition set forth by the Society of Hospital Medicine (adopted in the spring of 2000) is the following: Hospitalists are doctors whose primary professional focus is the general medical care of hospitalized patients. Their activities may include patient care, teaching, research, and leadership related to hospital care. Hospital medicine is a specialty organized around a site of care (the hospital) rather than an organ (like cardiology), a disease (like oncology), or a patient’s age (like pediatrics).

It seems silly to be asking this question of what defines us after writing about the burgeoning specialty. But as was pointed out in February’s JGIM issue, “varied employment relationships create diverse practice structures, priorities and roles.” Our practices have each grown so quickly out of local market pressures and individual hospital needs that we have evolved in slightly different directions. This is a natural consequence of such rapid growth. Just like any other specialty, practice structures and employment models will differ across the country. But I would challenge us to ensure that our higher priorities do not differ.

The American health care system needs an entire army of physicians and other providers to give whole heartedly and completely of their professional time, creativity, and energy to the hospital… to fix current system problems. It is no different than the cardiologists of today spending their energy and time discovering at the molecular level what causes ventricular dysfunction and then translating that knowledge to bedside care. Hospitalists, are specialists of in hospital medicine, and must do for the hospital what cardiologists do to the heart. We must study and learn what causes the health care delivered by the hospital to fail. Then we must translate that knowledge to the care of all patients in the hospital by improving the systems of care delivery.

According to Dr. Charles Mayo, “The definition of a specialist as one who ‘knows more and more about less and less. Its truth makes essential that the specialist, to do efficient work, must have some association with others who, taken altogether, represent the whole of which the specialty is only a part.” Our generalist colleagues care about the hospital as much as we do but do not necessarily have the time to concentrate specifically on hospital systems. There are so many other things that require their attention at the same time, but we need them to be there.

So we are only a part of what is needed to deliver the best care to all patients. But we have become a critical part of that team in the hospital. It is the hospitalists who, through their chosen focus on one aspect of medicine, will need to give the energy, creativity, and time to improving our systems of health care delivery in the hospital and across key transitions of care. Regardless of where we practice or how our practice is structured, our higher calling as a specialty is to determine the root causes of what ails the hospitals of this country. Then, as a specialty we must discover new mechanisms that would provide care at the level of quality called for by our patients. If we as hospitalists are truly specialists… If we are experts at delivering hospital based care… Then we have a vested interest in addressing these higher priorities. The improvements in health care that will be achieved, because a group of providers have dedicated their careers to making the hospital a better place for our patients, will ultimately make the definition of a hospitalist quite clear.

The next Annual Meeting is near. This means that the year, serving as your President, has nearly come to an end. As a result, this will be my last column. It is a good time for reflection.

First, I must thank the thousands of hospitalists who have joined SHM, filled out surveys, and attended meetings (either nationally or locally). You see, SHM’s data on hospitalists—where they are, what they do, and numbers in practice—is the source of information people outside the profession are using to understand and make decisions about our growing specialty. There is strength in numbers and your participation at every level infuses the energy necessary for us to continue the journey of becoming a legitimate specialty. Thank you.

As an organization, we have made significant progress toward our mission of making quality and safety core to what it means to practice hospital medicine. We have joined a number of other organizations, associations, and foundations to create various initiatives aimed at improving the quality and safety of care delivered in our hospitals. Specific areas of focus to date have been in the care of geriatric, diabetic, cardiac, and critically ill patients. We have also begun to address key preventative strategies such as antibiotic resistance and thromboembolic disease prophylaxis. These national partnerships SHM has formed with such organizations as the American College of Chest Physicians, American Association of Critical Care Nurses, American Hospital Association, Hartford Foundation, American College of Cardiology, Institute of Health Care Improvement, Joint Commission, and many others, demonstrate the breadth of teamwork that is necessary to care for patients across the continuum. Hospitalists are a crucial part of that team as more and more of our nation’s patients are cared for by hospitalists during their acute illnesses.

It has been an amazing year of watching this organization grow and mature. But what do I worry about as I leave my post? What is the kernel of concern that I must ensure is passed on with this next “transition of care” of our organization? It is that which defines us. I mentioned in my speech at lunch last year that we (the Society of Hospital Medicine) would fail if what hospitalists became known as were simply those pediatricians or internists who spent more time than their peers in the hospital. I don’t know about you, but at least once each month someone will approach me and say “I spend 25% of my time seeing patients in the hospital—So I must be a hospitalist!” (Quoting the original work of Drs. Robert Wachter and Lee Goldman in their 1996 New England Journal of Medicine article.) Well, as time has passed and the field has clearly evolved with more than 10,000 hospitalists practicing, the definition has clearly evolved.

But is our defi nition of what we do still based on time in the hospital? Or is it a more substantial definition? Is it about one’s professional focus? Is it about where one’s passion for medicine lies? What one wakes up in the middle of the night worrying about? What is a hospitalist?

The definition set forth by the Society of Hospital Medicine (adopted in the spring of 2000) is the following: Hospitalists are doctors whose primary professional focus is the general medical care of hospitalized patients. Their activities may include patient care, teaching, research, and leadership related to hospital care. Hospital medicine is a specialty organized around a site of care (the hospital) rather than an organ (like cardiology), a disease (like oncology), or a patient’s age (like pediatrics).

It seems silly to be asking this question of what defines us after writing about the burgeoning specialty. But as was pointed out in February’s JGIM issue, “varied employment relationships create diverse practice structures, priorities and roles.” Our practices have each grown so quickly out of local market pressures and individual hospital needs that we have evolved in slightly different directions. This is a natural consequence of such rapid growth. Just like any other specialty, practice structures and employment models will differ across the country. But I would challenge us to ensure that our higher priorities do not differ.

The American health care system needs an entire army of physicians and other providers to give whole heartedly and completely of their professional time, creativity, and energy to the hospital… to fix current system problems. It is no different than the cardiologists of today spending their energy and time discovering at the molecular level what causes ventricular dysfunction and then translating that knowledge to bedside care. Hospitalists, are specialists of in hospital medicine, and must do for the hospital what cardiologists do to the heart. We must study and learn what causes the health care delivered by the hospital to fail. Then we must translate that knowledge to the care of all patients in the hospital by improving the systems of care delivery.

According to Dr. Charles Mayo, “The definition of a specialist as one who ‘knows more and more about less and less. Its truth makes essential that the specialist, to do efficient work, must have some association with others who, taken altogether, represent the whole of which the specialty is only a part.” Our generalist colleagues care about the hospital as much as we do but do not necessarily have the time to concentrate specifically on hospital systems. There are so many other things that require their attention at the same time, but we need them to be there.

So we are only a part of what is needed to deliver the best care to all patients. But we have become a critical part of that team in the hospital. It is the hospitalists who, through their chosen focus on one aspect of medicine, will need to give the energy, creativity, and time to improving our systems of health care delivery in the hospital and across key transitions of care. Regardless of where we practice or how our practice is structured, our higher calling as a specialty is to determine the root causes of what ails the hospitals of this country. Then, as a specialty we must discover new mechanisms that would provide care at the level of quality called for by our patients. If we as hospitalists are truly specialists… If we are experts at delivering hospital based care… Then we have a vested interest in addressing these higher priorities. The improvements in health care that will be achieved, because a group of providers have dedicated their careers to making the hospital a better place for our patients, will ultimately make the definition of a hospitalist quite clear.