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Excerpts from our interview with Team Hospitalist member David Weidig, MD, director of hospital medicine for Aurora Medical Group in West Allis, Wis., about best practices for multi-site hospital medicine.

[audio mp3="http://www.the-hospitalist.org/wp-content/uploads/2015/05/David-Weidig_HM15_FINAL_050215.mp3"][/audio]

Excerpts from our interview with Team Hospitalist member David Weidig, MD, director of hospital medicine for Aurora Medical Group in West Allis, Wis., about best practices for multi-site hospital medicine.

[audio mp3="http://www.the-hospitalist.org/wp-content/uploads/2015/05/David-Weidig_HM15_FINAL_050215.mp3"][/audio]

Excerpts from our interview with Team Hospitalist member David Weidig, MD, director of hospital medicine for Aurora Medical Group in West Allis, Wis., about best practices for multi-site hospital medicine.

[audio mp3="http://www.the-hospitalist.org/wp-content/uploads/2015/05/David-Weidig_HM15_FINAL_050215.mp3"][/audio]

SHM founder Win Whitcomb, MD, MHM, chief medical officer of Remedy Partners of Darien, Conn., talks about the annual practice management pre-course in an ever-changing healthcare landscape.

SHM founder Win Whitcomb, MD, MHM, chief medical officer of Remedy Partners of Darien, Conn., talks about the annual practice management pre-course in an ever-changing healthcare landscape.

SHM founder Win Whitcomb, MD, MHM, chief medical officer of Remedy Partners of Darien, Conn., talks about the annual practice management pre-course in an ever-changing healthcare landscape.

New SHM President Robert Harrington Jr., MD, SFHM, talks about his views on hospital medicine, the society and the value of diversity and teamwork.

New SHM President Robert Harrington Jr., MD, SFHM, talks about his views on hospital medicine, the society and the value of diversity and teamwork.

New SHM President Robert Harrington Jr., MD, SFHM, talks about his views on hospital medicine, the society and the value of diversity and teamwork.

The long awaited permanent repeal of the poorly designed Sustainable Growth Rate (SGR) came just in time to avert the 21.2% Medicare physician payment cut that would have taken effect on April 1st, 2015. The SGR formula was first enacted in the Balanced Budget Act of 1997 with the intent to control Medicare spending on physician services. The federal budget sequester in the Budget Control Act of 2011 led to heightened speculation of doom and gloom about the U.S. debt and, ultimately, the necessity of a massive reduction in Medicare payments. Over the past decade, lawmakers have managed to pass 17 various delays and adjustments to keep spending in line with the target SGR. In its place, Congress finally passed H.R. 2, the Medicare Access and CHIP Reauthorization Act (MACRA), which was signed into law by President Obama on April 16, 2015.

What physicians should expect:

(1) The bill includes a 0.5% physician pay increase per year for the next five years beginning July 1, 2015.

(2) It incentivizes physicians to use alternate payment models that focus on care coordination and preventive care.

(3) It consolidates the three existing Medicare quality reporting programs known as the Physician Quality Reporting System (PQRS), Meaningful Use of Electronic Health Records, and the Physician Value-Based Payment Modifier, as well as their associated penalties into a single value-based performance program called the Merit-based Incentive Payment System (MIPS) which starts in 2019.

Is this good for hospitalists? While hospitalists are now protected from the 21% pay cut, we are still faced with increasing burden of legislative mandates on quality metrics. This has created unique challenges for acute inpatient care. The current individual incentive programs will remain in effect until MIPS in 2019, mandating the reporting of PQRS and VBPMs in order to avoid penalties. As such, we will need to continue to focus our efforts on meeting these challenges by aligning our performance measures with that of our institutions. This includes helping to develop alternative payment mechanisms (APMs), such as accountable care organizations (ACOs), patient-centered medical homes, bundled-payment arrangements, and other models. Of note, physicians involved in APMs will not be subject to MIPS assessment and will receive an annual 5% increase from 2019-2024.

The legislation creates other concerns such as the planned enforcement of Medicare's “2-midnight” rule, the requirement of EHR to be interoperable by the end of 2018, and the uncertainty of fairness of CMS in assessing quality and incentive payments. And the question remains, will Congress shift its attention to lowering payments for hospitals and non-physician providers to offset the once expected Medicare cuts? Hospitalists are distinctively qualified to potentially make headway given our already very active involvement in hospital process improvements. It will be in our best interest to stay vocal at the hospital, local, and national level.

The long awaited permanent repeal of the poorly designed Sustainable Growth Rate (SGR) came just in time to avert the 21.2% Medicare physician payment cut that would have taken effect on April 1st, 2015. The SGR formula was first enacted in the Balanced Budget Act of 1997 with the intent to control Medicare spending on physician services. The federal budget sequester in the Budget Control Act of 2011 led to heightened speculation of doom and gloom about the U.S. debt and, ultimately, the necessity of a massive reduction in Medicare payments. Over the past decade, lawmakers have managed to pass 17 various delays and adjustments to keep spending in line with the target SGR. In its place, Congress finally passed H.R. 2, the Medicare Access and CHIP Reauthorization Act (MACRA), which was signed into law by President Obama on April 16, 2015.

What physicians should expect:

(1) The bill includes a 0.5% physician pay increase per year for the next five years beginning July 1, 2015.

(2) It incentivizes physicians to use alternate payment models that focus on care coordination and preventive care.

(3) It consolidates the three existing Medicare quality reporting programs known as the Physician Quality Reporting System (PQRS), Meaningful Use of Electronic Health Records, and the Physician Value-Based Payment Modifier, as well as their associated penalties into a single value-based performance program called the Merit-based Incentive Payment System (MIPS) which starts in 2019.

Is this good for hospitalists? While hospitalists are now protected from the 21% pay cut, we are still faced with increasing burden of legislative mandates on quality metrics. This has created unique challenges for acute inpatient care. The current individual incentive programs will remain in effect until MIPS in 2019, mandating the reporting of PQRS and VBPMs in order to avoid penalties. As such, we will need to continue to focus our efforts on meeting these challenges by aligning our performance measures with that of our institutions. This includes helping to develop alternative payment mechanisms (APMs), such as accountable care organizations (ACOs), patient-centered medical homes, bundled-payment arrangements, and other models. Of note, physicians involved in APMs will not be subject to MIPS assessment and will receive an annual 5% increase from 2019-2024.

The legislation creates other concerns such as the planned enforcement of Medicare's “2-midnight” rule, the requirement of EHR to be interoperable by the end of 2018, and the uncertainty of fairness of CMS in assessing quality and incentive payments. And the question remains, will Congress shift its attention to lowering payments for hospitals and non-physician providers to offset the once expected Medicare cuts? Hospitalists are distinctively qualified to potentially make headway given our already very active involvement in hospital process improvements. It will be in our best interest to stay vocal at the hospital, local, and national level.

The long awaited permanent repeal of the poorly designed Sustainable Growth Rate (SGR) came just in time to avert the 21.2% Medicare physician payment cut that would have taken effect on April 1st, 2015. The SGR formula was first enacted in the Balanced Budget Act of 1997 with the intent to control Medicare spending on physician services. The federal budget sequester in the Budget Control Act of 2011 led to heightened speculation of doom and gloom about the U.S. debt and, ultimately, the necessity of a massive reduction in Medicare payments. Over the past decade, lawmakers have managed to pass 17 various delays and adjustments to keep spending in line with the target SGR. In its place, Congress finally passed H.R. 2, the Medicare Access and CHIP Reauthorization Act (MACRA), which was signed into law by President Obama on April 16, 2015.

What physicians should expect:

(1) The bill includes a 0.5% physician pay increase per year for the next five years beginning July 1, 2015.

(2) It incentivizes physicians to use alternate payment models that focus on care coordination and preventive care.

(3) It consolidates the three existing Medicare quality reporting programs known as the Physician Quality Reporting System (PQRS), Meaningful Use of Electronic Health Records, and the Physician Value-Based Payment Modifier, as well as their associated penalties into a single value-based performance program called the Merit-based Incentive Payment System (MIPS) which starts in 2019.

Is this good for hospitalists? While hospitalists are now protected from the 21% pay cut, we are still faced with increasing burden of legislative mandates on quality metrics. This has created unique challenges for acute inpatient care. The current individual incentive programs will remain in effect until MIPS in 2019, mandating the reporting of PQRS and VBPMs in order to avoid penalties. As such, we will need to continue to focus our efforts on meeting these challenges by aligning our performance measures with that of our institutions. This includes helping to develop alternative payment mechanisms (APMs), such as accountable care organizations (ACOs), patient-centered medical homes, bundled-payment arrangements, and other models. Of note, physicians involved in APMs will not be subject to MIPS assessment and will receive an annual 5% increase from 2019-2024.

The legislation creates other concerns such as the planned enforcement of Medicare's “2-midnight” rule, the requirement of EHR to be interoperable by the end of 2018, and the uncertainty of fairness of CMS in assessing quality and incentive payments. And the question remains, will Congress shift its attention to lowering payments for hospitals and non-physician providers to offset the once expected Medicare cuts? Hospitalists are distinctively qualified to potentially make headway given our already very active involvement in hospital process improvements. It will be in our best interest to stay vocal at the hospital, local, and national level.

More than two-thirds of HM groups do not offer paid time off (PTO) to their hospitalists, but lack of vacation time isn’t a career deal breaker for aspiring hospitalists, say some HM leaders.

“Lack of separate PTO in general has not affected young hospitalists from choosing hospital medicine as their career, as hospital medicine offers many other positives,” says Bhavin Patel, MD, assistant professor in the department of internal medicine at the University of Minnesota Medical School in Duluth and a member of SHM’s Practice Analysis Committee. “Given there has not be any major push to either build PTO hours into scheduling or to offer it separately for many [hospital medicine groups], it may not be a major factor for many or most hospitalists.”

SHM surveyed HM groups about their PTO benefits and included the results in its 2014 State of Hospital Medicine Report. The survey examined HM groups that serve adults only and categorized the groups by geographic region, ownership/employment model, academic status, primary hospital graduate medical education program status, and practice size.

Results showed that larger groups were more likely to offer PTO benefits and more PTO hours than smaller groups. Only 21.1% of groups with four or fewer full-time equivalent hospitalists (FTE) offered PTO, with a median of 120 hours, and 45.9% of groups with 30 or more FTE offered PTO, with a median of 194 hours, according to the survey. The median amount of PTO among all groups was 160 hours per year.

Carolyn Sites, DO, FHM, senior medical director of hospitalist programs at Providence Health & Services in Oregon and also a member of SHM’s Practice Analysis Committee, says the difference in PTO between large and small groups is not surprising.

“Larger practice size offers more flexibility because you have enough staff to cover the hospital,” says Dr. Sites. “Hospital health systems may have a higher percentage of PTO offered due to their size and the need to offer similar benefits to all their employees. A small group is more challenged in being able to provide adequate coverage when a provider is absent. It usually means somebody has to work a lot more shifts to cover for the person who is absent.”

The survey also found that HM groups in the eastern U.S. and those employed by a hospital health system and/or academic groups were more likely to offer PTO and more hours. In the East, 50% of groups offered PTO, with a median amount of 200 hours annually. Similarly, 54.9% of groups with academic status as well as 47.4% of groups at university-based teaching hospitals offered PTO, with medians of 208 hours and 200 hours annually, respectively.

According to Dr. Sites, the overall 160-hour median amount of PTO is appropriate. “Assuming average shift lengths are 10 to 12 hours in length, this would convert to between 13 to 16 shifts off per year,” she notes. “This provides for two weeks break per year or several slightly shorter breaks per year.”

In terms of what research needs to be conducted to better analyze PTO patterns, Dr. Sites expresses that more “in-depth knowledge of the operational differences between groups that offer PTO and those that don’t” is necessary.

Visit our website for more information on PTO for hospitalists.

More than two-thirds of HM groups do not offer paid time off (PTO) to their hospitalists, but lack of vacation time isn’t a career deal breaker for aspiring hospitalists, say some HM leaders.

“Lack of separate PTO in general has not affected young hospitalists from choosing hospital medicine as their career, as hospital medicine offers many other positives,” says Bhavin Patel, MD, assistant professor in the department of internal medicine at the University of Minnesota Medical School in Duluth and a member of SHM’s Practice Analysis Committee. “Given there has not be any major push to either build PTO hours into scheduling or to offer it separately for many [hospital medicine groups], it may not be a major factor for many or most hospitalists.”

SHM surveyed HM groups about their PTO benefits and included the results in its 2014 State of Hospital Medicine Report. The survey examined HM groups that serve adults only and categorized the groups by geographic region, ownership/employment model, academic status, primary hospital graduate medical education program status, and practice size.

Results showed that larger groups were more likely to offer PTO benefits and more PTO hours than smaller groups. Only 21.1% of groups with four or fewer full-time equivalent hospitalists (FTE) offered PTO, with a median of 120 hours, and 45.9% of groups with 30 or more FTE offered PTO, with a median of 194 hours, according to the survey. The median amount of PTO among all groups was 160 hours per year.

Carolyn Sites, DO, FHM, senior medical director of hospitalist programs at Providence Health & Services in Oregon and also a member of SHM’s Practice Analysis Committee, says the difference in PTO between large and small groups is not surprising.

“Larger practice size offers more flexibility because you have enough staff to cover the hospital,” says Dr. Sites. “Hospital health systems may have a higher percentage of PTO offered due to their size and the need to offer similar benefits to all their employees. A small group is more challenged in being able to provide adequate coverage when a provider is absent. It usually means somebody has to work a lot more shifts to cover for the person who is absent.”

The survey also found that HM groups in the eastern U.S. and those employed by a hospital health system and/or academic groups were more likely to offer PTO and more hours. In the East, 50% of groups offered PTO, with a median amount of 200 hours annually. Similarly, 54.9% of groups with academic status as well as 47.4% of groups at university-based teaching hospitals offered PTO, with medians of 208 hours and 200 hours annually, respectively.

According to Dr. Sites, the overall 160-hour median amount of PTO is appropriate. “Assuming average shift lengths are 10 to 12 hours in length, this would convert to between 13 to 16 shifts off per year,” she notes. “This provides for two weeks break per year or several slightly shorter breaks per year.”

In terms of what research needs to be conducted to better analyze PTO patterns, Dr. Sites expresses that more “in-depth knowledge of the operational differences between groups that offer PTO and those that don’t” is necessary.

Visit our website for more information on PTO for hospitalists.

More than two-thirds of HM groups do not offer paid time off (PTO) to their hospitalists, but lack of vacation time isn’t a career deal breaker for aspiring hospitalists, say some HM leaders.

“Lack of separate PTO in general has not affected young hospitalists from choosing hospital medicine as their career, as hospital medicine offers many other positives,” says Bhavin Patel, MD, assistant professor in the department of internal medicine at the University of Minnesota Medical School in Duluth and a member of SHM’s Practice Analysis Committee. “Given there has not be any major push to either build PTO hours into scheduling or to offer it separately for many [hospital medicine groups], it may not be a major factor for many or most hospitalists.”

SHM surveyed HM groups about their PTO benefits and included the results in its 2014 State of Hospital Medicine Report. The survey examined HM groups that serve adults only and categorized the groups by geographic region, ownership/employment model, academic status, primary hospital graduate medical education program status, and practice size.

Results showed that larger groups were more likely to offer PTO benefits and more PTO hours than smaller groups. Only 21.1% of groups with four or fewer full-time equivalent hospitalists (FTE) offered PTO, with a median of 120 hours, and 45.9% of groups with 30 or more FTE offered PTO, with a median of 194 hours, according to the survey. The median amount of PTO among all groups was 160 hours per year.

Carolyn Sites, DO, FHM, senior medical director of hospitalist programs at Providence Health & Services in Oregon and also a member of SHM’s Practice Analysis Committee, says the difference in PTO between large and small groups is not surprising.

“Larger practice size offers more flexibility because you have enough staff to cover the hospital,” says Dr. Sites. “Hospital health systems may have a higher percentage of PTO offered due to their size and the need to offer similar benefits to all their employees. A small group is more challenged in being able to provide adequate coverage when a provider is absent. It usually means somebody has to work a lot more shifts to cover for the person who is absent.”

The survey also found that HM groups in the eastern U.S. and those employed by a hospital health system and/or academic groups were more likely to offer PTO and more hours. In the East, 50% of groups offered PTO, with a median amount of 200 hours annually. Similarly, 54.9% of groups with academic status as well as 47.4% of groups at university-based teaching hospitals offered PTO, with medians of 208 hours and 200 hours annually, respectively.

According to Dr. Sites, the overall 160-hour median amount of PTO is appropriate. “Assuming average shift lengths are 10 to 12 hours in length, this would convert to between 13 to 16 shifts off per year,” she notes. “This provides for two weeks break per year or several slightly shorter breaks per year.”

In terms of what research needs to be conducted to better analyze PTO patterns, Dr. Sites expresses that more “in-depth knowledge of the operational differences between groups that offer PTO and those that don’t” is necessary.

Visit our website for more information on PTO for hospitalists.

The process of determining outpatient and inpatient status for hospitalized Medicare beneficiaries needs reform, according to a recent article in the Journal of Hospital Medicine.

These status determinations, made by Recovery Audit Contractors (RACs), are a growing concern for hospitals as increasing numbers of Medicare patients are hospitalized as outpatients under observation status and are not covered by Medicare Part A hospital insurance and subject to uncapped out-of-pocket charges under Medicare Part B.

The paper’s lead author, Ann M. Sheehy, MD, MS, FHM, a hospitalist at the University of Wisconsin School of Medicine and Public Health in Madison and member of SHM’s Public Policy Committee, has testified before Congress on the issues of patient observation status and Medicare’s RAC program.

“The increase in RAC audits has prompted the growth, or at least been one of the factors in the growth, of observation care across the country,” Dr. Sheehy says.

The recent study by Dr. Sheehy and colleagues focused on Medicare Part A complex reviews at three academic hospitals between 2010 and 2013. All 8,110 RAC audits that occurred during the time period, from the more than 100,000 Medicare encounters at those institutions, all challenged billing status, never the care delivered. To manage these audits, each institution needed 5.1 full-time employees. “It’s very costly for hospitals and the government to manage this process,” Dr. Sheehy says.

The report also found that the mean duration for appeals of RAC decisions was 555 days. “It’s pretty easy to say that’s a failure of due process,” Dr. Sheehy says. “It’s hard for a hospital to have payments tied up for two or three years and still have enough money to take care of patients.”

Likewise, the RAC reporting was not transparent, Dr. Sheehy notes. Most successful hospital appeals were won during the discussion period, but because that is not part of the formal appeal period, the RACs didn’t report those numbers, meaning that most favorable decisions for hospitals did not appear in federal appeals reports. “We feel that any report of RAC accuracy is meaningless without reporting what happens in discussion, where most overturns are occurring,” Dr. Sheehy says.

“It is a process that’s flawed at this point,” Dr. Sheehy adds. “We hope this paper will contribute in some way to RAC reform, and that will help providers.”

Visit our website for more information on avoiding Medicare audits.

The process of determining outpatient and inpatient status for hospitalized Medicare beneficiaries needs reform, according to a recent article in the Journal of Hospital Medicine.

These status determinations, made by Recovery Audit Contractors (RACs), are a growing concern for hospitals as increasing numbers of Medicare patients are hospitalized as outpatients under observation status and are not covered by Medicare Part A hospital insurance and subject to uncapped out-of-pocket charges under Medicare Part B.

The paper’s lead author, Ann M. Sheehy, MD, MS, FHM, a hospitalist at the University of Wisconsin School of Medicine and Public Health in Madison and member of SHM’s Public Policy Committee, has testified before Congress on the issues of patient observation status and Medicare’s RAC program.

“The increase in RAC audits has prompted the growth, or at least been one of the factors in the growth, of observation care across the country,” Dr. Sheehy says.

The recent study by Dr. Sheehy and colleagues focused on Medicare Part A complex reviews at three academic hospitals between 2010 and 2013. All 8,110 RAC audits that occurred during the time period, from the more than 100,000 Medicare encounters at those institutions, all challenged billing status, never the care delivered. To manage these audits, each institution needed 5.1 full-time employees. “It’s very costly for hospitals and the government to manage this process,” Dr. Sheehy says.

The report also found that the mean duration for appeals of RAC decisions was 555 days. “It’s pretty easy to say that’s a failure of due process,” Dr. Sheehy says. “It’s hard for a hospital to have payments tied up for two or three years and still have enough money to take care of patients.”

Likewise, the RAC reporting was not transparent, Dr. Sheehy notes. Most successful hospital appeals were won during the discussion period, but because that is not part of the formal appeal period, the RACs didn’t report those numbers, meaning that most favorable decisions for hospitals did not appear in federal appeals reports. “We feel that any report of RAC accuracy is meaningless without reporting what happens in discussion, where most overturns are occurring,” Dr. Sheehy says.

“It is a process that’s flawed at this point,” Dr. Sheehy adds. “We hope this paper will contribute in some way to RAC reform, and that will help providers.”

Visit our website for more information on avoiding Medicare audits.

The process of determining outpatient and inpatient status for hospitalized Medicare beneficiaries needs reform, according to a recent article in the Journal of Hospital Medicine.

These status determinations, made by Recovery Audit Contractors (RACs), are a growing concern for hospitals as increasing numbers of Medicare patients are hospitalized as outpatients under observation status and are not covered by Medicare Part A hospital insurance and subject to uncapped out-of-pocket charges under Medicare Part B.

The paper’s lead author, Ann M. Sheehy, MD, MS, FHM, a hospitalist at the University of Wisconsin School of Medicine and Public Health in Madison and member of SHM’s Public Policy Committee, has testified before Congress on the issues of patient observation status and Medicare’s RAC program.

“The increase in RAC audits has prompted the growth, or at least been one of the factors in the growth, of observation care across the country,” Dr. Sheehy says.

The recent study by Dr. Sheehy and colleagues focused on Medicare Part A complex reviews at three academic hospitals between 2010 and 2013. All 8,110 RAC audits that occurred during the time period, from the more than 100,000 Medicare encounters at those institutions, all challenged billing status, never the care delivered. To manage these audits, each institution needed 5.1 full-time employees. “It’s very costly for hospitals and the government to manage this process,” Dr. Sheehy says.

The report also found that the mean duration for appeals of RAC decisions was 555 days. “It’s pretty easy to say that’s a failure of due process,” Dr. Sheehy says. “It’s hard for a hospital to have payments tied up for two or three years and still have enough money to take care of patients.”

Likewise, the RAC reporting was not transparent, Dr. Sheehy notes. Most successful hospital appeals were won during the discussion period, but because that is not part of the formal appeal period, the RACs didn’t report those numbers, meaning that most favorable decisions for hospitals did not appear in federal appeals reports. “We feel that any report of RAC accuracy is meaningless without reporting what happens in discussion, where most overturns are occurring,” Dr. Sheehy says.

“It is a process that’s flawed at this point,” Dr. Sheehy adds. “We hope this paper will contribute in some way to RAC reform, and that will help providers.”

Visit our website for more information on avoiding Medicare audits.

Three women hospitalists, Dr. Danielle Scheurer, chief quality officer at the Medical University of South Carolina; Dr. Sowmya Kanikkannan, hospital medicine director and assistant professor of medicine at Rowan University School of Osteopathic Medicine; and Dr. Vineet Arora, assistant dean at the University of Chicago School of Medicine, discuss the state of gender equity in hospital medicine and offer tips for women seeking careers in HM.

Three women hospitalists, Dr. Danielle Scheurer, chief quality officer at the Medical University of South Carolina; Dr. Sowmya Kanikkannan, hospital medicine director and assistant professor of medicine at Rowan University School of Osteopathic Medicine; and Dr. Vineet Arora, assistant dean at the University of Chicago School of Medicine, discuss the state of gender equity in hospital medicine and offer tips for women seeking careers in HM.

Three women hospitalists, Dr. Danielle Scheurer, chief quality officer at the Medical University of South Carolina; Dr. Sowmya Kanikkannan, hospital medicine director and assistant professor of medicine at Rowan University School of Osteopathic Medicine; and Dr. Vineet Arora, assistant dean at the University of Chicago School of Medicine, discuss the state of gender equity in hospital medicine and offer tips for women seeking careers in HM.

Session: Multi-site Hospitalist Leaders: Unique Challenges/What You Should Know

HM15 Presenter/Moderator: Scott Rissmiller, MD

Summation: This standing-room-only session was the result of a popular HMX e-community, which has become an active discussion board. As hospitals and health systems continue to consolidate across the country, there has been a rapid growth of multi-hospital systems. The role of the “Chief Hospitalist,” whose job is to lead multiple hospitalist groups within these systems, is evolving. These “Chief Hospitalists” are growing in number and they, as well as their followers, face unique challenges.

These points regarding organization structure were discussed, and as you look at your own organizational structure, these questions deserve your attention:

1. Purpose of your structure?
2. Is your structure centralized or decentralized?
3. How does your organizational structure support decision-making?
4. How does the structure ensure proper communication?
5. How are resources shared across geography?
6. What is your administrative support structure?
7. How is administrative time allocated for physician leaders?
8. How do you ensure engagement from all providers?
9. How does your organization structure create alignment with the healthcare system?

The following compensation issues were discussed, and can be used as a discussion outline for most groups:

1. How does your compensation (comp) plan align with the goals and values of the system?
2. How does your comp plan account for regional variances?
3. How does the comp plan encourage teamwork and sharing of resources?
4. How does comp plan account for differences in acuity, hospital size, night frequency, etc.?
5. Are goals and incentives group based, site based, or individual based?
6. How does the comp plan fairly reward “non-RVU” work? (teaching, committee service, etc.)
7. Should all site leaders receive the same comp regardless of group size?
8. Does the comp plan incorporate “minimum work standards”/social compact?

Key Points/HM Takeaways:

• Panel discussion was valuable and reassured attendees that there are multiple ways to make groups successful. One common variable of successful groups is open lines of communication at all levels.
• Physician on-boarding is critical and should be utilized to set clear expectations.
• HM Goals/expectations must be aligned with those of the hospital and health system.
• When multiple hospitals are part of a larger system, it is desirable for goals to be aligned across the health system.
• Two-way open communication is necessary for success.
• Try to take a walk in your colleague’s/stakeholder’s shoes:

  • How does my hospital administrative partner see this issue?
  • How does my regional director/system lead see this issue?
  • How does my bedside hospitalist physician/provider see this issue?
  • How would my patients view this issue?

• Issues facing different types of groups, academic vs. community and for profit vs. not for profit, are somewhat variable.
• The leadership Dyad consisting of a physician and practice management professional in partnership is an effective and well-proven management model.

Many thanks to Drs. T.J. Richardson and Dan Duzan for their input and assistance with this session summary. Dr. Richardson is a Regional Medical Director and Dr. Duzan is a Facility Medical Director, both work for TeamHealth.  

Julianna Lindsey is a hospitalist and physician leader based in the Dallas-Fort Worth Metroplex. Her focus is patient safety/quality and physician leadership. She is a member of TeamHospitalist.

Session: Multi-site Hospitalist Leaders: Unique Challenges/What You Should Know

HM15 Presenter/Moderator: Scott Rissmiller, MD

Summation: This standing-room-only session was the result of a popular HMX e-community, which has become an active discussion board. As hospitals and health systems continue to consolidate across the country, there has been a rapid growth of multi-hospital systems. The role of the “Chief Hospitalist,” whose job is to lead multiple hospitalist groups within these systems, is evolving. These “Chief Hospitalists” are growing in number and they, as well as their followers, face unique challenges.

These points regarding organization structure were discussed, and as you look at your own organizational structure, these questions deserve your attention:

1. Purpose of your structure?
2. Is your structure centralized or decentralized?
3. How does your organizational structure support decision-making?
4. How does the structure ensure proper communication?
5. How are resources shared across geography?
6. What is your administrative support structure?
7. How is administrative time allocated for physician leaders?
8. How do you ensure engagement from all providers?
9. How does your organization structure create alignment with the healthcare system?

The following compensation issues were discussed, and can be used as a discussion outline for most groups:

1. How does your compensation (comp) plan align with the goals and values of the system?
2. How does your comp plan account for regional variances?
3. How does the comp plan encourage teamwork and sharing of resources?
4. How does comp plan account for differences in acuity, hospital size, night frequency, etc.?
5. Are goals and incentives group based, site based, or individual based?
6. How does the comp plan fairly reward “non-RVU” work? (teaching, committee service, etc.)
7. Should all site leaders receive the same comp regardless of group size?
8. Does the comp plan incorporate “minimum work standards”/social compact?

Key Points/HM Takeaways:

• Panel discussion was valuable and reassured attendees that there are multiple ways to make groups successful. One common variable of successful groups is open lines of communication at all levels.
• Physician on-boarding is critical and should be utilized to set clear expectations.
• HM Goals/expectations must be aligned with those of the hospital and health system.
• When multiple hospitals are part of a larger system, it is desirable for goals to be aligned across the health system.
• Two-way open communication is necessary for success.
• Try to take a walk in your colleague’s/stakeholder’s shoes:

  • How does my hospital administrative partner see this issue?
  • How does my regional director/system lead see this issue?
  • How does my bedside hospitalist physician/provider see this issue?
  • How would my patients view this issue?

• Issues facing different types of groups, academic vs. community and for profit vs. not for profit, are somewhat variable.
• The leadership Dyad consisting of a physician and practice management professional in partnership is an effective and well-proven management model.

Many thanks to Drs. T.J. Richardson and Dan Duzan for their input and assistance with this session summary. Dr. Richardson is a Regional Medical Director and Dr. Duzan is a Facility Medical Director, both work for TeamHealth.  

Julianna Lindsey is a hospitalist and physician leader based in the Dallas-Fort Worth Metroplex. Her focus is patient safety/quality and physician leadership. She is a member of TeamHospitalist.

Session: Multi-site Hospitalist Leaders: Unique Challenges/What You Should Know

HM15 Presenter/Moderator: Scott Rissmiller, MD

Summation: This standing-room-only session was the result of a popular HMX e-community, which has become an active discussion board. As hospitals and health systems continue to consolidate across the country, there has been a rapid growth of multi-hospital systems. The role of the “Chief Hospitalist,” whose job is to lead multiple hospitalist groups within these systems, is evolving. These “Chief Hospitalists” are growing in number and they, as well as their followers, face unique challenges.

These points regarding organization structure were discussed, and as you look at your own organizational structure, these questions deserve your attention:

1. Purpose of your structure?
2. Is your structure centralized or decentralized?
3. How does your organizational structure support decision-making?
4. How does the structure ensure proper communication?
5. How are resources shared across geography?
6. What is your administrative support structure?
7. How is administrative time allocated for physician leaders?
8. How do you ensure engagement from all providers?
9. How does your organization structure create alignment with the healthcare system?

The following compensation issues were discussed, and can be used as a discussion outline for most groups:

1. How does your compensation (comp) plan align with the goals and values of the system?
2. How does your comp plan account for regional variances?
3. How does the comp plan encourage teamwork and sharing of resources?
4. How does comp plan account for differences in acuity, hospital size, night frequency, etc.?
5. Are goals and incentives group based, site based, or individual based?
6. How does the comp plan fairly reward “non-RVU” work? (teaching, committee service, etc.)
7. Should all site leaders receive the same comp regardless of group size?
8. Does the comp plan incorporate “minimum work standards”/social compact?

Key Points/HM Takeaways:

• Panel discussion was valuable and reassured attendees that there are multiple ways to make groups successful. One common variable of successful groups is open lines of communication at all levels.
• Physician on-boarding is critical and should be utilized to set clear expectations.
• HM Goals/expectations must be aligned with those of the hospital and health system.
• When multiple hospitals are part of a larger system, it is desirable for goals to be aligned across the health system.
• Two-way open communication is necessary for success.
• Try to take a walk in your colleague’s/stakeholder’s shoes:

  • How does my hospital administrative partner see this issue?
  • How does my regional director/system lead see this issue?
  • How does my bedside hospitalist physician/provider see this issue?
  • How would my patients view this issue?

• Issues facing different types of groups, academic vs. community and for profit vs. not for profit, are somewhat variable.
• The leadership Dyad consisting of a physician and practice management professional in partnership is an effective and well-proven management model.

Many thanks to Drs. T.J. Richardson and Dan Duzan for their input and assistance with this session summary. Dr. Richardson is a Regional Medical Director and Dr. Duzan is a Facility Medical Director, both work for TeamHealth.  

Julianna Lindsey is a hospitalist and physician leader based in the Dallas-Fort Worth Metroplex. Her focus is patient safety/quality and physician leadership. She is a member of TeamHospitalist.

Clinical question

Does barium impaction therapy using high-dose barium enemas prevent recurrent diverticular bleeding?

Bottom line

This small study demonstrates that barium impaction therapy using high-dose barium enemas is safe and effective at reducing the rate of recurrent diverticular bleeding. Note that this study was conducted in Japan, where the rate of rebleeding for patients with diverticulosis is much higher than in Western populations. (LOE = 1b-)

Reference: Nagata N, Niikura R, Shimbo T, et al. High-dose barium impaction therapy for the recurrence of colonic diverticular bleeding. Ann Surg 2015;261(2):269-275.

Study design: Randomized controlled trial (nonblinded)

Funding source: Government

Allocation: Concealed

Setting: Inpatient (any location)

Synopsis

A high-dose barium enema is thought to prevent recurrent diverticular bleeding through a physical tamponade of bleeding vessels, as well as by a direct hemostatic effect of the barium itself. Retained barium in colonic diverticula over time has previously been shown to be safe.

In this trial, patients hospitalized with diverticular bleeding who had spontaneous cessation of bleeding were randomized, using concealed allocation, to receive either barium impaction therapy (n = 27) or conservative treatment (n = 27). In the barium impaction therapy group, barium sulfate was administered by gastroenterologists via an enema bag at a concentration of 200 g barium per 100 mL tap water for a total volume of 400 mL. X-ray imaging confirmed filling of multiple colonic diverticula with barium and the patient was asked to rotate positions to ensure filling of all diverticula.

Baseline characteristics were similar in the 2 groups: the majority of patients were male, the average age was 70 years, and half had a prior history of diverticular bleeding. The severity of initial bleeding was also similar, as measured by number of units of blood transfused prior to randomization and the number of days until spontaneous cessation of bleeding.

For the primary outcome of recurrence of bleeding at the 1-year follow-up, the barium group fared better than the conservative treatment group (15% vs 43%; P = .04). You would have to treat 4 patients with barium impaction therapy to prevent 1 episode of recurrent bleeding. After adjusting for factors associated with recurrent bleeding, including hypertension, nonsteroidal anti-inflammatory drug use, and chronic renal failure, the risk of bleeding was decreased in the barium group (hazard ratio = 0.34, 95% CI 0.12-0.97). Barium impaction therapy did not result in any complications. Furthermore, over the course of the follow-up period, the barium group had a decreased number of re-hospitalizations, transfusions, and repeat colonoscopies.

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

Clinical question

Does barium impaction therapy using high-dose barium enemas prevent recurrent diverticular bleeding?

Bottom line

This small study demonstrates that barium impaction therapy using high-dose barium enemas is safe and effective at reducing the rate of recurrent diverticular bleeding. Note that this study was conducted in Japan, where the rate of rebleeding for patients with diverticulosis is much higher than in Western populations. (LOE = 1b-)

Reference: Nagata N, Niikura R, Shimbo T, et al. High-dose barium impaction therapy for the recurrence of colonic diverticular bleeding. Ann Surg 2015;261(2):269-275.

Study design: Randomized controlled trial (nonblinded)

Funding source: Government

Allocation: Concealed

Setting: Inpatient (any location)

Synopsis

A high-dose barium enema is thought to prevent recurrent diverticular bleeding through a physical tamponade of bleeding vessels, as well as by a direct hemostatic effect of the barium itself. Retained barium in colonic diverticula over time has previously been shown to be safe.

In this trial, patients hospitalized with diverticular bleeding who had spontaneous cessation of bleeding were randomized, using concealed allocation, to receive either barium impaction therapy (n = 27) or conservative treatment (n = 27). In the barium impaction therapy group, barium sulfate was administered by gastroenterologists via an enema bag at a concentration of 200 g barium per 100 mL tap water for a total volume of 400 mL. X-ray imaging confirmed filling of multiple colonic diverticula with barium and the patient was asked to rotate positions to ensure filling of all diverticula.

Baseline characteristics were similar in the 2 groups: the majority of patients were male, the average age was 70 years, and half had a prior history of diverticular bleeding. The severity of initial bleeding was also similar, as measured by number of units of blood transfused prior to randomization and the number of days until spontaneous cessation of bleeding.

For the primary outcome of recurrence of bleeding at the 1-year follow-up, the barium group fared better than the conservative treatment group (15% vs 43%; P = .04). You would have to treat 4 patients with barium impaction therapy to prevent 1 episode of recurrent bleeding. After adjusting for factors associated with recurrent bleeding, including hypertension, nonsteroidal anti-inflammatory drug use, and chronic renal failure, the risk of bleeding was decreased in the barium group (hazard ratio = 0.34, 95% CI 0.12-0.97). Barium impaction therapy did not result in any complications. Furthermore, over the course of the follow-up period, the barium group had a decreased number of re-hospitalizations, transfusions, and repeat colonoscopies.

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

Clinical question

Does barium impaction therapy using high-dose barium enemas prevent recurrent diverticular bleeding?

Bottom line

This small study demonstrates that barium impaction therapy using high-dose barium enemas is safe and effective at reducing the rate of recurrent diverticular bleeding. Note that this study was conducted in Japan, where the rate of rebleeding for patients with diverticulosis is much higher than in Western populations. (LOE = 1b-)

Reference: Nagata N, Niikura R, Shimbo T, et al. High-dose barium impaction therapy for the recurrence of colonic diverticular bleeding. Ann Surg 2015;261(2):269-275.

Study design: Randomized controlled trial (nonblinded)

Funding source: Government

Allocation: Concealed

Setting: Inpatient (any location)

Synopsis

A high-dose barium enema is thought to prevent recurrent diverticular bleeding through a physical tamponade of bleeding vessels, as well as by a direct hemostatic effect of the barium itself. Retained barium in colonic diverticula over time has previously been shown to be safe.

In this trial, patients hospitalized with diverticular bleeding who had spontaneous cessation of bleeding were randomized, using concealed allocation, to receive either barium impaction therapy (n = 27) or conservative treatment (n = 27). In the barium impaction therapy group, barium sulfate was administered by gastroenterologists via an enema bag at a concentration of 200 g barium per 100 mL tap water for a total volume of 400 mL. X-ray imaging confirmed filling of multiple colonic diverticula with barium and the patient was asked to rotate positions to ensure filling of all diverticula.

Baseline characteristics were similar in the 2 groups: the majority of patients were male, the average age was 70 years, and half had a prior history of diverticular bleeding. The severity of initial bleeding was also similar, as measured by number of units of blood transfused prior to randomization and the number of days until spontaneous cessation of bleeding.

For the primary outcome of recurrence of bleeding at the 1-year follow-up, the barium group fared better than the conservative treatment group (15% vs 43%; P = .04). You would have to treat 4 patients with barium impaction therapy to prevent 1 episode of recurrent bleeding. After adjusting for factors associated with recurrent bleeding, including hypertension, nonsteroidal anti-inflammatory drug use, and chronic renal failure, the risk of bleeding was decreased in the barium group (hazard ratio = 0.34, 95% CI 0.12-0.97). Barium impaction therapy did not result in any complications. Furthermore, over the course of the follow-up period, the barium group had a decreased number of re-hospitalizations, transfusions, and repeat colonoscopies.

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

Clinical question: Do steroids improve outcomes in patients with severe community-acquired pneumonia and a high inflammatory response?

Bottom line

In patients with severe community-acquired pneumonia (CAP) who have elevated levels of C-reactive protein (CRP), a short course of methylprednisolone decreases treatment failure, mainly by reducing radiographic progression of pulmonary infiltrates within 3 days to 5 days of treatment initiation. The patient population studied here represents a fraction of the patients with severe CAP, so this finding cannot be generalized. Moreover, this study was small and the findings require replication before they can be applied to this population.

Reference: Torres A, Sibila O, Ferrer M, et al. Effect of corticosteroids on treatment failure among hospitalized patients with severe community-acquired pneumonia and high inflammatory response. JAMA 2015;313(7):677-686.

Design: Randomized controlled trial (double-blinded); LOE: 1b

Setting: Inpatient (any location)

Synopsis

A previous meta-analysis of randomized controlled trials showed that the addition of steroids for treatment of community-acquired pneumonia decreases hospital length of stay but does not affect other clinical outcomes such as mortality or need for mechanical ventilation (J Hosp Med 2013;8:68-75).

In this study, investigators enrolled patients hospitalized with severe CAP (either risk class V by the Pneumonia Severity Index or as defined by American Thoracic Society) and a CRP level of greater than 15 mg/dL. Immunosuppressed patients or those with diabetes or recent major gastrointestinal bleeding were excluded.

Patients were randomized, using concealed allocation, to receive either methylprednisolone (0.5 mg per kg) every 12 hours (n = 61) or matching placebo (n = 59) for 5 days. The primary outcome was treatment failure. Early treatment failure was defined as clinical deterioration within 72 hours of treatment, whereas late failure was defined as radiographic progression of pulmonary infiltrates by more than 50%, respiratory failure, shock, or death between 3 days and 5 days.

Baseline characteristics were similar in the 2 groups, except for lower procalcitonin levels and less septic shock in the steroid group. Antibiotic treatment on admission was similar in both groups (most commonly ceftriaxone combined with either levofloxacin or azithromycin). The majority of patients were initially admitted to the intensive care unit. In the intention-to-treat analysis, the steroid group had less treatment failure than the placebo group (13% vs 31%; P = .02). This was driven by a higher rate of late treatment failure in the placebo group, primarily due to a greater incidence of radiographic progression of infiltrates. Results were similar after adjusting for potential confounders and imbalances in baseline characteristics (hazard ratio = 0.33, 95% CI 0.12 - 0.90; P = .03). There were no significant differences in length of stay, in-hospital mortality, or adverse events between the 2 groups.

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

Clinical question: Do steroids improve outcomes in patients with severe community-acquired pneumonia and a high inflammatory response?

Bottom line

In patients with severe community-acquired pneumonia (CAP) who have elevated levels of C-reactive protein (CRP), a short course of methylprednisolone decreases treatment failure, mainly by reducing radiographic progression of pulmonary infiltrates within 3 days to 5 days of treatment initiation. The patient population studied here represents a fraction of the patients with severe CAP, so this finding cannot be generalized. Moreover, this study was small and the findings require replication before they can be applied to this population.

Reference: Torres A, Sibila O, Ferrer M, et al. Effect of corticosteroids on treatment failure among hospitalized patients with severe community-acquired pneumonia and high inflammatory response. JAMA 2015;313(7):677-686.

Design: Randomized controlled trial (double-blinded); LOE: 1b

Setting: Inpatient (any location)

Synopsis

A previous meta-analysis of randomized controlled trials showed that the addition of steroids for treatment of community-acquired pneumonia decreases hospital length of stay but does not affect other clinical outcomes such as mortality or need for mechanical ventilation (J Hosp Med 2013;8:68-75).

In this study, investigators enrolled patients hospitalized with severe CAP (either risk class V by the Pneumonia Severity Index or as defined by American Thoracic Society) and a CRP level of greater than 15 mg/dL. Immunosuppressed patients or those with diabetes or recent major gastrointestinal bleeding were excluded.

Patients were randomized, using concealed allocation, to receive either methylprednisolone (0.5 mg per kg) every 12 hours (n = 61) or matching placebo (n = 59) for 5 days. The primary outcome was treatment failure. Early treatment failure was defined as clinical deterioration within 72 hours of treatment, whereas late failure was defined as radiographic progression of pulmonary infiltrates by more than 50%, respiratory failure, shock, or death between 3 days and 5 days.

Baseline characteristics were similar in the 2 groups, except for lower procalcitonin levels and less septic shock in the steroid group. Antibiotic treatment on admission was similar in both groups (most commonly ceftriaxone combined with either levofloxacin or azithromycin). The majority of patients were initially admitted to the intensive care unit. In the intention-to-treat analysis, the steroid group had less treatment failure than the placebo group (13% vs 31%; P = .02). This was driven by a higher rate of late treatment failure in the placebo group, primarily due to a greater incidence of radiographic progression of infiltrates. Results were similar after adjusting for potential confounders and imbalances in baseline characteristics (hazard ratio = 0.33, 95% CI 0.12 - 0.90; P = .03). There were no significant differences in length of stay, in-hospital mortality, or adverse events between the 2 groups.

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

Clinical question: Do steroids improve outcomes in patients with severe community-acquired pneumonia and a high inflammatory response?

Bottom line

In patients with severe community-acquired pneumonia (CAP) who have elevated levels of C-reactive protein (CRP), a short course of methylprednisolone decreases treatment failure, mainly by reducing radiographic progression of pulmonary infiltrates within 3 days to 5 days of treatment initiation. The patient population studied here represents a fraction of the patients with severe CAP, so this finding cannot be generalized. Moreover, this study was small and the findings require replication before they can be applied to this population.

Reference: Torres A, Sibila O, Ferrer M, et al. Effect of corticosteroids on treatment failure among hospitalized patients with severe community-acquired pneumonia and high inflammatory response. JAMA 2015;313(7):677-686.

Design: Randomized controlled trial (double-blinded); LOE: 1b

Setting: Inpatient (any location)

Synopsis

A previous meta-analysis of randomized controlled trials showed that the addition of steroids for treatment of community-acquired pneumonia decreases hospital length of stay but does not affect other clinical outcomes such as mortality or need for mechanical ventilation (J Hosp Med 2013;8:68-75).

In this study, investigators enrolled patients hospitalized with severe CAP (either risk class V by the Pneumonia Severity Index or as defined by American Thoracic Society) and a CRP level of greater than 15 mg/dL. Immunosuppressed patients or those with diabetes or recent major gastrointestinal bleeding were excluded.

Patients were randomized, using concealed allocation, to receive either methylprednisolone (0.5 mg per kg) every 12 hours (n = 61) or matching placebo (n = 59) for 5 days. The primary outcome was treatment failure. Early treatment failure was defined as clinical deterioration within 72 hours of treatment, whereas late failure was defined as radiographic progression of pulmonary infiltrates by more than 50%, respiratory failure, shock, or death between 3 days and 5 days.

Baseline characteristics were similar in the 2 groups, except for lower procalcitonin levels and less septic shock in the steroid group. Antibiotic treatment on admission was similar in both groups (most commonly ceftriaxone combined with either levofloxacin or azithromycin). The majority of patients were initially admitted to the intensive care unit. In the intention-to-treat analysis, the steroid group had less treatment failure than the placebo group (13% vs 31%; P = .02). This was driven by a higher rate of late treatment failure in the placebo group, primarily due to a greater incidence of radiographic progression of infiltrates. Results were similar after adjusting for potential confounders and imbalances in baseline characteristics (hazard ratio = 0.33, 95% CI 0.12 - 0.90; P = .03). There were no significant differences in length of stay, in-hospital mortality, or adverse events between the 2 groups.

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.