Career

Dr. Holbrook

The steam engine. The telephone. Television. ATMs. The Internet. Smartphones. The 24/7 hospitalist program.

Perhaps the single most important innovation along the road to where we are now in HM has been the development of the hospital-sponsored, 24/7, on-site hospitalist program. And the father of this invention may be the most significant figure in HM you’ve never heard of: John Holbrook, MD, FACEP. An emergency-medicine physician since the mid-1970s, Dr. Holbrook did something in July 1993 that was considered off the wall, yet proved to be revolutionary: From nothing, he launched a 24/7 hospitalist program staffed with board-eligible and board-certified internists at Mercy Hospital in Springfield, Mass. The inpatient physicians (this was before the word “hospitalist” came to be) were employed by a subsidiary of the hospital and worked in place of community primary-care physicians (PCPs), taking care of hospitalized patients who did not have a PCP, or whose PCP chose not to come to the hospital.

Of great significance, from the beginning, and perhaps by unintentional design, these physicians were agents of change and improvement for the hospital itself.

To be sure, in places like Southern California, 24/7, on-site hospitalist programs were in place in the late 1980s. Some claim those programs may have been the birthplace of the hospitalist model. However, such programs came to be in order to help medical groups manage full capitated risk delegated to them from HMOs on a population of patients, and were not supported by the hospital, per se. This is distinct from hospitalist programs—such as Mercy’s—sponsored by hospitals (whether employed or contracted) in predominantly fee-for-service markets, which then comprised the lion’s share of the U.S. market.

I had the extraordinary good fortune to happen along in July 1994, get hired by Dr. Holbrook, and soon after begin serving as medical director for the Mercy program, which I would do for the next decade. To this day, Dr. Holbrook is a mentor and trusted advisor to me. I caught up with him in recognition of the 20th anniversary of the Mercy Inpatient Medicine Service.

Dr. Holbrook

Question: What gave you the idea to launch what was, at the time, considered such an unconventional program?

Answer: Before the specialty of emergency medicine, a patient’s private physician would be called in most cases when a patient present in the ED: 25 or 50 doctors might be called over 24 hours, each to see one patient each. The inefficiency and disruption caused by this system was a natural and logical stimulus to develop the specialty of emergency medicine. I saw hospitalist medicine as an exact analogy.

Q: What were you observing in the healthcare environment that drove you to create the Mercy Inpatient Medicine Service?

A: Working for many years in the emergency department of a community hospital without a house staff, the ED docs would admit a patient at night or on the weekend and the attending physician would often plan to see the patient “in the morning.” When the patient would decompensate in the middle of the night, the ED doc would get a call to run to the floor to “Band-Aid” the situation.

Q: How did you convince the board of trustees to fund it?

A: The reasons were primarily economic. No. 1, the hospital was losing market share because local physicians would prefer to admit to the teaching hospital [a nearby competitor], where they were not required to come in during the middle of the night. No. 2, the cost of a hospitalization managed by a hospitalist was less expensive than either a hospital stay managed by house staff or managed over the telephone by a private attending at home.

Q: What was the most difficult operational challenge for the program?

A: Effective and timely communication with the community physicians was the most difficult operational challenge. Access to outpatient medical treatment immediately prior to a hospitalization and timely communication to the community physician were both challenges that we never adequately solved in the early days. I understand that these issues can still be problematic.

Q: How was it received by patients?

A: Overall, patients were very happy with the system. In the old system, with a typical four-physician practice, a patient had only a 1 in 4 chance of being admitted by the doctor who was familiar with the case. The fact that the hospitalist was available in the hospital made the improvement in quality apparent to most patients.

Q: How did you get the medical staff to buy into the program?

A: I personally visited every private physician who participated. Physicians were given the option of not participating, or of part-time participation—for example, on weekends or holidays only. The word spread. Physicians came up to me and told me that the program enabled them to continue practicing for another five years. Physicians’ spouses thanked me.

Q: Are you surprised HM as a field has grown so quickly?

A: I am not really that surprised. It is a better way to organize health care. I am surprised that it did not occur sooner. We talked about instituting this system for 10 years before 1993.

Q: What big challenges remain for hospital medicine? What are some solutions?

A: I believe that the biggest global challenge for hospital medicine remains communication with community-based providers, both before the hospitalization as well as during hospitalization and immediately after discharge. In the era of the EMR, the Internet, and the iPhone and Android, this should be easier. HIPAA has not helped.

The other growing challenge will become apparent as hospitalists age in the profession: Disruption of the diurnal sleep cycle becomes increasingly problematic for many physicians after the age of 50 and can easily lead to burnout. The early hospitalists were all in their 30s. The attractive lifestyle choice for the 30-year-old can lead to burnout for the 55-year-old. The emergency-medicine literature has noted a similar problem of shift work/sleep fragmentation.

Final Thoughts

I believe Dr. Holbrook’s assessments on the future of our specialty are on target. As HM continues to mature, we need to continue to focus on how we communicate with providers outside the four walls of the hospital and how to address barriers to making HM a sustainable career.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at [email protected].

(Editor's note: Updated July 12, 2013.)

Dr. Holbrook

The steam engine. The telephone. Television. ATMs. The Internet. Smartphones. The 24/7 hospitalist program.

Perhaps the single most important innovation along the road to where we are now in HM has been the development of the hospital-sponsored, 24/7, on-site hospitalist program. And the father of this invention may be the most significant figure in HM you’ve never heard of: John Holbrook, MD, FACEP. An emergency-medicine physician since the mid-1970s, Dr. Holbrook did something in July 1993 that was considered off the wall, yet proved to be revolutionary: From nothing, he launched a 24/7 hospitalist program staffed with board-eligible and board-certified internists at Mercy Hospital in Springfield, Mass. The inpatient physicians (this was before the word “hospitalist” came to be) were employed by a subsidiary of the hospital and worked in place of community primary-care physicians (PCPs), taking care of hospitalized patients who did not have a PCP, or whose PCP chose not to come to the hospital.

Of great significance, from the beginning, and perhaps by unintentional design, these physicians were agents of change and improvement for the hospital itself.

To be sure, in places like Southern California, 24/7, on-site hospitalist programs were in place in the late 1980s. Some claim those programs may have been the birthplace of the hospitalist model. However, such programs came to be in order to help medical groups manage full capitated risk delegated to them from HMOs on a population of patients, and were not supported by the hospital, per se. This is distinct from hospitalist programs—such as Mercy’s—sponsored by hospitals (whether employed or contracted) in predominantly fee-for-service markets, which then comprised the lion’s share of the U.S. market.

I had the extraordinary good fortune to happen along in July 1994, get hired by Dr. Holbrook, and soon after begin serving as medical director for the Mercy program, which I would do for the next decade. To this day, Dr. Holbrook is a mentor and trusted advisor to me. I caught up with him in recognition of the 20th anniversary of the Mercy Inpatient Medicine Service.

Dr. Holbrook

Question: What gave you the idea to launch what was, at the time, considered such an unconventional program?

Answer: Before the specialty of emergency medicine, a patient’s private physician would be called in most cases when a patient present in the ED: 25 or 50 doctors might be called over 24 hours, each to see one patient each. The inefficiency and disruption caused by this system was a natural and logical stimulus to develop the specialty of emergency medicine. I saw hospitalist medicine as an exact analogy.

Q: What were you observing in the healthcare environment that drove you to create the Mercy Inpatient Medicine Service?

A: Working for many years in the emergency department of a community hospital without a house staff, the ED docs would admit a patient at night or on the weekend and the attending physician would often plan to see the patient “in the morning.” When the patient would decompensate in the middle of the night, the ED doc would get a call to run to the floor to “Band-Aid” the situation.

Q: How did you convince the board of trustees to fund it?

A: The reasons were primarily economic. No. 1, the hospital was losing market share because local physicians would prefer to admit to the teaching hospital [a nearby competitor], where they were not required to come in during the middle of the night. No. 2, the cost of a hospitalization managed by a hospitalist was less expensive than either a hospital stay managed by house staff or managed over the telephone by a private attending at home.

Q: What was the most difficult operational challenge for the program?

A: Effective and timely communication with the community physicians was the most difficult operational challenge. Access to outpatient medical treatment immediately prior to a hospitalization and timely communication to the community physician were both challenges that we never adequately solved in the early days. I understand that these issues can still be problematic.

Q: How was it received by patients?

A: Overall, patients were very happy with the system. In the old system, with a typical four-physician practice, a patient had only a 1 in 4 chance of being admitted by the doctor who was familiar with the case. The fact that the hospitalist was available in the hospital made the improvement in quality apparent to most patients.

Q: How did you get the medical staff to buy into the program?

A: I personally visited every private physician who participated. Physicians were given the option of not participating, or of part-time participation—for example, on weekends or holidays only. The word spread. Physicians came up to me and told me that the program enabled them to continue practicing for another five years. Physicians’ spouses thanked me.

Q: Are you surprised HM as a field has grown so quickly?

A: I am not really that surprised. It is a better way to organize health care. I am surprised that it did not occur sooner. We talked about instituting this system for 10 years before 1993.

Q: What big challenges remain for hospital medicine? What are some solutions?

A: I believe that the biggest global challenge for hospital medicine remains communication with community-based providers, both before the hospitalization as well as during hospitalization and immediately after discharge. In the era of the EMR, the Internet, and the iPhone and Android, this should be easier. HIPAA has not helped.

The other growing challenge will become apparent as hospitalists age in the profession: Disruption of the diurnal sleep cycle becomes increasingly problematic for many physicians after the age of 50 and can easily lead to burnout. The early hospitalists were all in their 30s. The attractive lifestyle choice for the 30-year-old can lead to burnout for the 55-year-old. The emergency-medicine literature has noted a similar problem of shift work/sleep fragmentation.

Final Thoughts

I believe Dr. Holbrook’s assessments on the future of our specialty are on target. As HM continues to mature, we need to continue to focus on how we communicate with providers outside the four walls of the hospital and how to address barriers to making HM a sustainable career.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at [email protected].

(Editor's note: Updated July 12, 2013.)

Dr. Holbrook

The steam engine. The telephone. Television. ATMs. The Internet. Smartphones. The 24/7 hospitalist program.

Perhaps the single most important innovation along the road to where we are now in HM has been the development of the hospital-sponsored, 24/7, on-site hospitalist program. And the father of this invention may be the most significant figure in HM you’ve never heard of: John Holbrook, MD, FACEP. An emergency-medicine physician since the mid-1970s, Dr. Holbrook did something in July 1993 that was considered off the wall, yet proved to be revolutionary: From nothing, he launched a 24/7 hospitalist program staffed with board-eligible and board-certified internists at Mercy Hospital in Springfield, Mass. The inpatient physicians (this was before the word “hospitalist” came to be) were employed by a subsidiary of the hospital and worked in place of community primary-care physicians (PCPs), taking care of hospitalized patients who did not have a PCP, or whose PCP chose not to come to the hospital.

Of great significance, from the beginning, and perhaps by unintentional design, these physicians were agents of change and improvement for the hospital itself.

To be sure, in places like Southern California, 24/7, on-site hospitalist programs were in place in the late 1980s. Some claim those programs may have been the birthplace of the hospitalist model. However, such programs came to be in order to help medical groups manage full capitated risk delegated to them from HMOs on a population of patients, and were not supported by the hospital, per se. This is distinct from hospitalist programs—such as Mercy’s—sponsored by hospitals (whether employed or contracted) in predominantly fee-for-service markets, which then comprised the lion’s share of the U.S. market.

I had the extraordinary good fortune to happen along in July 1994, get hired by Dr. Holbrook, and soon after begin serving as medical director for the Mercy program, which I would do for the next decade. To this day, Dr. Holbrook is a mentor and trusted advisor to me. I caught up with him in recognition of the 20th anniversary of the Mercy Inpatient Medicine Service.

Dr. Holbrook

Question: What gave you the idea to launch what was, at the time, considered such an unconventional program?

Answer: Before the specialty of emergency medicine, a patient’s private physician would be called in most cases when a patient present in the ED: 25 or 50 doctors might be called over 24 hours, each to see one patient each. The inefficiency and disruption caused by this system was a natural and logical stimulus to develop the specialty of emergency medicine. I saw hospitalist medicine as an exact analogy.

Q: What were you observing in the healthcare environment that drove you to create the Mercy Inpatient Medicine Service?

A: Working for many years in the emergency department of a community hospital without a house staff, the ED docs would admit a patient at night or on the weekend and the attending physician would often plan to see the patient “in the morning.” When the patient would decompensate in the middle of the night, the ED doc would get a call to run to the floor to “Band-Aid” the situation.

Q: How did you convince the board of trustees to fund it?

A: The reasons were primarily economic. No. 1, the hospital was losing market share because local physicians would prefer to admit to the teaching hospital [a nearby competitor], where they were not required to come in during the middle of the night. No. 2, the cost of a hospitalization managed by a hospitalist was less expensive than either a hospital stay managed by house staff or managed over the telephone by a private attending at home.

Q: What was the most difficult operational challenge for the program?

A: Effective and timely communication with the community physicians was the most difficult operational challenge. Access to outpatient medical treatment immediately prior to a hospitalization and timely communication to the community physician were both challenges that we never adequately solved in the early days. I understand that these issues can still be problematic.

Q: How was it received by patients?

A: Overall, patients were very happy with the system. In the old system, with a typical four-physician practice, a patient had only a 1 in 4 chance of being admitted by the doctor who was familiar with the case. The fact that the hospitalist was available in the hospital made the improvement in quality apparent to most patients.

Q: How did you get the medical staff to buy into the program?

A: I personally visited every private physician who participated. Physicians were given the option of not participating, or of part-time participation—for example, on weekends or holidays only. The word spread. Physicians came up to me and told me that the program enabled them to continue practicing for another five years. Physicians’ spouses thanked me.

Q: Are you surprised HM as a field has grown so quickly?

A: I am not really that surprised. It is a better way to organize health care. I am surprised that it did not occur sooner. We talked about instituting this system for 10 years before 1993.

Q: What big challenges remain for hospital medicine? What are some solutions?

A: I believe that the biggest global challenge for hospital medicine remains communication with community-based providers, both before the hospitalization as well as during hospitalization and immediately after discharge. In the era of the EMR, the Internet, and the iPhone and Android, this should be easier. HIPAA has not helped.

The other growing challenge will become apparent as hospitalists age in the profession: Disruption of the diurnal sleep cycle becomes increasingly problematic for many physicians after the age of 50 and can easily lead to burnout. The early hospitalists were all in their 30s. The attractive lifestyle choice for the 30-year-old can lead to burnout for the 55-year-old. The emergency-medicine literature has noted a similar problem of shift work/sleep fragmentation.

Final Thoughts

I believe Dr. Holbrook’s assessments on the future of our specialty are on target. As HM continues to mature, we need to continue to focus on how we communicate with providers outside the four walls of the hospital and how to address barriers to making HM a sustainable career.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at [email protected].

(Editor's note: Updated July 12, 2013.)

The yearlong IPC-UCSF Fellowship for Hospitalist Leaders brings about 40 IPC: The Hospitalist Company group leaders together for a series of three-day training sessions and ongoing distance learning, executive coaching, and project mentoring.

The program emphasizes role plays and simulations, and even involves an acting coach to help participants learn to make more effective presentations, such as harnessing the power of storytelling, says Niraj L. Sehgal, MD, MPH, a hospitalist at the University of California at San Francisco (UCSF) who directs the fellowship through UCSF’s Center for Health Professions.

The first class graduated in November 2011, and the third is in session. Participants implement a mentored project in their home facility, with measurable results, as a vehicle for leadership development in such areas as quality improvement (QI), patient safety, or readmissions prevention. But the specific project is not as important as whether or not that project is well-designed to stretch the individual in areas where they weren’t comfortable before, Dr. Sehgal says.

Through her QI project, Jasmin Baleva, MD, of Memorial Hermann Memorial City Medical Center in Houston, a 2012 participant, found an alternate to the costly nocturnist model while maintaining the time it takes for the first hospitalist encounter with newly admitted patients. “I think the IPC-UCSF project gave my proposal a little more legitimacy,” she tells TH. “They also taught me how to present it in an effective package and to approach the C-suite feeling less intimidated.”

Larry Beresford is a freelance writer in Oakland, Calif.

References

1. Stobbe, M. Germ-zapping “robots”: Hospitals combat superbugs. Associated Press website. Available at: http://bigstory.ap.org/article/hospitals-see-surge-superbug-fighting-products. Accessed June 7, 2013.
2. Centers for Disease Control and Prevention. Vital Signs: Carbapenem-Resistant Enterobacteriaceae. Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6209a3.htm?s_cid=mm6209a3_w. Accessed June 7, 2013.
3. Wise ME, Scott RD, Baggs JM, et al. National estimates of central line-associated bloodstream infections in critical care patients. Infect Control Hosp Epidemiol, 2013;34(6):547-554.
4. Hsu E, Lin D, Evans SJ, et al. Doing well by doing good: assessing the cost savings of an intervention to reduce central line-associated bloodstream infections in a Hawaii hospital. Am J Med Qual, 2013 May 7 [Epub ahead of print].
5. Association of American Medical Colleges. Medical school enrollment on pace to reach 30 percent increase by 2017. Association of American Medical Colleges website. Available at: https://www.aamc.org/newsroom/newsreleases/ 335244/050213.html. Accessed June 7, 2013.

The yearlong IPC-UCSF Fellowship for Hospitalist Leaders brings about 40 IPC: The Hospitalist Company group leaders together for a series of three-day training sessions and ongoing distance learning, executive coaching, and project mentoring.

The program emphasizes role plays and simulations, and even involves an acting coach to help participants learn to make more effective presentations, such as harnessing the power of storytelling, says Niraj L. Sehgal, MD, MPH, a hospitalist at the University of California at San Francisco (UCSF) who directs the fellowship through UCSF’s Center for Health Professions.

The first class graduated in November 2011, and the third is in session. Participants implement a mentored project in their home facility, with measurable results, as a vehicle for leadership development in such areas as quality improvement (QI), patient safety, or readmissions prevention. But the specific project is not as important as whether or not that project is well-designed to stretch the individual in areas where they weren’t comfortable before, Dr. Sehgal says.

Through her QI project, Jasmin Baleva, MD, of Memorial Hermann Memorial City Medical Center in Houston, a 2012 participant, found an alternate to the costly nocturnist model while maintaining the time it takes for the first hospitalist encounter with newly admitted patients. “I think the IPC-UCSF project gave my proposal a little more legitimacy,” she tells TH. “They also taught me how to present it in an effective package and to approach the C-suite feeling less intimidated.”

Larry Beresford is a freelance writer in Oakland, Calif.

References

1. Stobbe, M. Germ-zapping “robots”: Hospitals combat superbugs. Associated Press website. Available at: http://bigstory.ap.org/article/hospitals-see-surge-superbug-fighting-products. Accessed June 7, 2013.
2. Centers for Disease Control and Prevention. Vital Signs: Carbapenem-Resistant Enterobacteriaceae. Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6209a3.htm?s_cid=mm6209a3_w. Accessed June 7, 2013.
3. Wise ME, Scott RD, Baggs JM, et al. National estimates of central line-associated bloodstream infections in critical care patients. Infect Control Hosp Epidemiol, 2013;34(6):547-554.
4. Hsu E, Lin D, Evans SJ, et al. Doing well by doing good: assessing the cost savings of an intervention to reduce central line-associated bloodstream infections in a Hawaii hospital. Am J Med Qual, 2013 May 7 [Epub ahead of print].
5. Association of American Medical Colleges. Medical school enrollment on pace to reach 30 percent increase by 2017. Association of American Medical Colleges website. Available at: https://www.aamc.org/newsroom/newsreleases/ 335244/050213.html. Accessed June 7, 2013.

The yearlong IPC-UCSF Fellowship for Hospitalist Leaders brings about 40 IPC: The Hospitalist Company group leaders together for a series of three-day training sessions and ongoing distance learning, executive coaching, and project mentoring.

The program emphasizes role plays and simulations, and even involves an acting coach to help participants learn to make more effective presentations, such as harnessing the power of storytelling, says Niraj L. Sehgal, MD, MPH, a hospitalist at the University of California at San Francisco (UCSF) who directs the fellowship through UCSF’s Center for Health Professions.

The first class graduated in November 2011, and the third is in session. Participants implement a mentored project in their home facility, with measurable results, as a vehicle for leadership development in such areas as quality improvement (QI), patient safety, or readmissions prevention. But the specific project is not as important as whether or not that project is well-designed to stretch the individual in areas where they weren’t comfortable before, Dr. Sehgal says.

Through her QI project, Jasmin Baleva, MD, of Memorial Hermann Memorial City Medical Center in Houston, a 2012 participant, found an alternate to the costly nocturnist model while maintaining the time it takes for the first hospitalist encounter with newly admitted patients. “I think the IPC-UCSF project gave my proposal a little more legitimacy,” she tells TH. “They also taught me how to present it in an effective package and to approach the C-suite feeling less intimidated.”

Larry Beresford is a freelance writer in Oakland, Calif.

References

1. Stobbe, M. Germ-zapping “robots”: Hospitals combat superbugs. Associated Press website. Available at: http://bigstory.ap.org/article/hospitals-see-surge-superbug-fighting-products. Accessed June 7, 2013.
2. Centers for Disease Control and Prevention. Vital Signs: Carbapenem-Resistant Enterobacteriaceae. Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6209a3.htm?s_cid=mm6209a3_w. Accessed June 7, 2013.
3. Wise ME, Scott RD, Baggs JM, et al. National estimates of central line-associated bloodstream infections in critical care patients. Infect Control Hosp Epidemiol, 2013;34(6):547-554.
4. Hsu E, Lin D, Evans SJ, et al. Doing well by doing good: assessing the cost savings of an intervention to reduce central line-associated bloodstream infections in a Hawaii hospital. Am J Med Qual, 2013 May 7 [Epub ahead of print].
5. Association of American Medical Colleges. Medical school enrollment on pace to reach 30 percent increase by 2017. Association of American Medical Colleges website. Available at: https://www.aamc.org/newsroom/newsreleases/ 335244/050213.html. Accessed June 7, 2013.

Job One during your first months as a working hospitalist is to acclimate to your hospital and HM group’s procedures. Increasingly, hospitalist teams include nurse practitioners (NPs) and physician assistants (PAs); for some new hospitalists, this will require another level of learning on the job. The 2012 State of Hospital Medicine report (www.hospitalmedicine.org/survey) noted that approximately half of HM groups serving adults and children utilized NPs and/or PAs. Although the report also acknowledged that identifying trends is difficult, the converging factors of aging U.S. demographics and the growing physician shortage indicate that NPs and PAs will become more prevalent in hospital medicine.

Physicians who have not worked alongside NPs or PAs often are unsure of how to approach the working relationship, says Jeanette Kalupa, DNP, ACNP-BC, SFHM, vice president of clinical operations at Hospitalists of Northern Michigan and a member of SHM’s Nurse Practitioner/Physician Assistant (NP/PA) Committee.

Roles and Scope of Practice

NPs and PAs perform myriad clinical and management responsibilities as hospitalists:

• Coordination of admissions and discharge planning;
• Patient histories, physical examinations, and diagnostic and therapeutic procedures (placing central lines, doing lumbar punctures, etc.);
• Medication orders; and
• Hospital committee work to improve processes of care.

Licensing requirements, physician oversight requirements, and scope of practice vary state to state and hospital to hospital. “If you’ve seen one hospital medicine group, you’ve seen one hospital medicine group”— coined by Mitchell Wilson, MD, SFHM, CMO at Atlanta-based Eagle Hospital Physicians—also applies to the way in which HM groups structure their use of NPs and PAs, says Tracy E. Cardin, ACNP-BC, of the University of Chicago Hospital and chair of the NP/PA Committee. SHM’s website offers information about the scope of practice and best ways to incorporate NPs and PAs into hospitalist practice.

Cardin

To hospitalists who express anxiety about an NP or PA overstepping bounds and putting the physician’s license at risk, Kalupa reminds them that she, too, has a license that is at risk. When roles are clearly delineated for tasks that NPs and PAs will perform, jeopardizing a license will not be an issue.

Literature supports equivalent outcomes in both primary care and inpatient settings when PAs and NPs are implemented to handle responsibilities within their scope of practice.^1,2 Using a PA or NP to handle uncomplicated pneumonia cases, to conduct a stress test, or assemble data for patient rounding, for example, can have a physician multiplier effect, says committee member David A. Friar, MD, SFHM, also a member of the NP/PA Committee. Dr. Friar, based in Traverse City, Mich., works daily with nurse practitioners and physician assistants as part of HNM.

“I think of the healthcare team as a toolbox with which we need to provide care for our patients,” he says. “A screwdriver is not half of a hammer, but it can be the best tool for a certain job. In addition, physicians are often seen as Swiss army knives—that we can do anything. We can make photocopies, but it doesn’t make sense for us to do that. So for cases of simple pneumonia or urinary tract infections, or for following people waiting for discharge, management by an NP or PA makes a lot of sense from an economic standpoint.”

Dr. Friar

Position Parity

Hospital leadership should set the tone for building a strong multidisciplinary team, Cardin says. Individual physicians can make a difference with the right approach to the working relationship. “If you are going to have successful collaborations with NPs and PAs,” she says, “you have to treat them like a doctor.” This does not mean that the pay structure will be the same, but in areas such as continuing medical education and group socializing, every member of the team should be treated as an equal. That approach makes sense to Dr. Friar, who makes it a point to call every person on the HM team a hospitalist.

He and Kalupa also point out that NPs and PAs can successfully fill team leadership roles. “Physicians need to be willing to accept that the personality traits that made them great clinicians are often not those that one would desire in a team leader,” Dr. Friar says. Using a football analogy, he notes that an important part of being a good team member is to play to other members’ strengths and protect them from their weaknesses. “You don’t have the linebacker run the ball, or the quarterback kick the field goal attempt; you use people’s strengths where they will be most effective for the care of your patients.”

When Conflicts Arise

Successful working relationships between physicians and NP/PAs hinge on clear expectations and the willingness to have difficult conversations, Cardin says. She has practiced as a hospitalist for seven years and prior to that worked in the acute-care setting. As a result, she says, she is quite comfortable seeing patients independently.

Hospitalists new to the group or those who have not worked with NPs before may bristle at that idea, she notes. If a problem arises, such as a perceived encroachment on one’s scope of practice, be willing to address it openly. All relationships are constantly evolving, and it’s important not to overreact.

It’s “just like driving a car,” she says. “If you overcorrect when a wheel comes off the road, you will wreck the car. Sometimes all that’s needed is a small adjustment to manage the problem.”

Gretchen Henkel is a freelance writer in California.

What’s in a Name?

Dr. Kalupa

When Jeanette Kalupa, DNP, ACNP-BC, SFHM, vice president of clinical operations for Hospitalists of Northern Michigan, first joined SHM’s Nurse Practitioner/Physician Assistant Committee in 2003, it was called the “NP/PA Task Force.” The name was changed to the Nonphysician Provider (NPP) Committee to accommodate other allied professionals, such as pharmacists and case managers. She and her NP colleagues object to the NPP moniker “because it designates us as what we are not.”

The term “midlevel provider,” another common designation, is also problematic, she says, because it heightens awareness of a hierarchy. Just this past year, the committee name was changed to NP/PA Committee. “We’ve evolved over time,” Kalupa says. “I think rather than labeling someone as a ‘midlevel provider,’ it’s better to just call them what they are.”

—Gretchen Henkel

References

1. Iglesias B, Ramos F, Serrano B, et al. A randomized controlled trial of nurses vs. doctors in the resolution of acute disease of low complexity in primary care. J Adv Nurs. 2013 March 21. doi: 10.1111/jan.12120 [Epub ahead of print].
2. Hoffman LA, Tasota FJ, Zullo TG, et al. Outcomes of care managed by an acute care nurse practitioner/attending physician team in a subacute medical intensive care unit. Am J Crit Care. 2005;14(2):121-130; quiz 131-132.

Job One during your first months as a working hospitalist is to acclimate to your hospital and HM group’s procedures. Increasingly, hospitalist teams include nurse practitioners (NPs) and physician assistants (PAs); for some new hospitalists, this will require another level of learning on the job. The 2012 State of Hospital Medicine report (www.hospitalmedicine.org/survey) noted that approximately half of HM groups serving adults and children utilized NPs and/or PAs. Although the report also acknowledged that identifying trends is difficult, the converging factors of aging U.S. demographics and the growing physician shortage indicate that NPs and PAs will become more prevalent in hospital medicine.

Physicians who have not worked alongside NPs or PAs often are unsure of how to approach the working relationship, says Jeanette Kalupa, DNP, ACNP-BC, SFHM, vice president of clinical operations at Hospitalists of Northern Michigan and a member of SHM’s Nurse Practitioner/Physician Assistant (NP/PA) Committee.

Roles and Scope of Practice

NPs and PAs perform myriad clinical and management responsibilities as hospitalists:

• Coordination of admissions and discharge planning;
• Patient histories, physical examinations, and diagnostic and therapeutic procedures (placing central lines, doing lumbar punctures, etc.);
• Medication orders; and
• Hospital committee work to improve processes of care.

Licensing requirements, physician oversight requirements, and scope of practice vary state to state and hospital to hospital. “If you’ve seen one hospital medicine group, you’ve seen one hospital medicine group”— coined by Mitchell Wilson, MD, SFHM, CMO at Atlanta-based Eagle Hospital Physicians—also applies to the way in which HM groups structure their use of NPs and PAs, says Tracy E. Cardin, ACNP-BC, of the University of Chicago Hospital and chair of the NP/PA Committee. SHM’s website offers information about the scope of practice and best ways to incorporate NPs and PAs into hospitalist practice.

Cardin

To hospitalists who express anxiety about an NP or PA overstepping bounds and putting the physician’s license at risk, Kalupa reminds them that she, too, has a license that is at risk. When roles are clearly delineated for tasks that NPs and PAs will perform, jeopardizing a license will not be an issue.

Literature supports equivalent outcomes in both primary care and inpatient settings when PAs and NPs are implemented to handle responsibilities within their scope of practice.^1,2 Using a PA or NP to handle uncomplicated pneumonia cases, to conduct a stress test, or assemble data for patient rounding, for example, can have a physician multiplier effect, says committee member David A. Friar, MD, SFHM, also a member of the NP/PA Committee. Dr. Friar, based in Traverse City, Mich., works daily with nurse practitioners and physician assistants as part of HNM.

“I think of the healthcare team as a toolbox with which we need to provide care for our patients,” he says. “A screwdriver is not half of a hammer, but it can be the best tool for a certain job. In addition, physicians are often seen as Swiss army knives—that we can do anything. We can make photocopies, but it doesn’t make sense for us to do that. So for cases of simple pneumonia or urinary tract infections, or for following people waiting for discharge, management by an NP or PA makes a lot of sense from an economic standpoint.”

Dr. Friar

Position Parity

Hospital leadership should set the tone for building a strong multidisciplinary team, Cardin says. Individual physicians can make a difference with the right approach to the working relationship. “If you are going to have successful collaborations with NPs and PAs,” she says, “you have to treat them like a doctor.” This does not mean that the pay structure will be the same, but in areas such as continuing medical education and group socializing, every member of the team should be treated as an equal. That approach makes sense to Dr. Friar, who makes it a point to call every person on the HM team a hospitalist.

He and Kalupa also point out that NPs and PAs can successfully fill team leadership roles. “Physicians need to be willing to accept that the personality traits that made them great clinicians are often not those that one would desire in a team leader,” Dr. Friar says. Using a football analogy, he notes that an important part of being a good team member is to play to other members’ strengths and protect them from their weaknesses. “You don’t have the linebacker run the ball, or the quarterback kick the field goal attempt; you use people’s strengths where they will be most effective for the care of your patients.”

When Conflicts Arise

Successful working relationships between physicians and NP/PAs hinge on clear expectations and the willingness to have difficult conversations, Cardin says. She has practiced as a hospitalist for seven years and prior to that worked in the acute-care setting. As a result, she says, she is quite comfortable seeing patients independently.

Hospitalists new to the group or those who have not worked with NPs before may bristle at that idea, she notes. If a problem arises, such as a perceived encroachment on one’s scope of practice, be willing to address it openly. All relationships are constantly evolving, and it’s important not to overreact.

It’s “just like driving a car,” she says. “If you overcorrect when a wheel comes off the road, you will wreck the car. Sometimes all that’s needed is a small adjustment to manage the problem.”

Gretchen Henkel is a freelance writer in California.

What’s in a Name?

Dr. Kalupa

When Jeanette Kalupa, DNP, ACNP-BC, SFHM, vice president of clinical operations for Hospitalists of Northern Michigan, first joined SHM’s Nurse Practitioner/Physician Assistant Committee in 2003, it was called the “NP/PA Task Force.” The name was changed to the Nonphysician Provider (NPP) Committee to accommodate other allied professionals, such as pharmacists and case managers. She and her NP colleagues object to the NPP moniker “because it designates us as what we are not.”

The term “midlevel provider,” another common designation, is also problematic, she says, because it heightens awareness of a hierarchy. Just this past year, the committee name was changed to NP/PA Committee. “We’ve evolved over time,” Kalupa says. “I think rather than labeling someone as a ‘midlevel provider,’ it’s better to just call them what they are.”

—Gretchen Henkel

References

1. Iglesias B, Ramos F, Serrano B, et al. A randomized controlled trial of nurses vs. doctors in the resolution of acute disease of low complexity in primary care. J Adv Nurs. 2013 March 21. doi: 10.1111/jan.12120 [Epub ahead of print].
2. Hoffman LA, Tasota FJ, Zullo TG, et al. Outcomes of care managed by an acute care nurse practitioner/attending physician team in a subacute medical intensive care unit. Am J Crit Care. 2005;14(2):121-130; quiz 131-132.

Job One during your first months as a working hospitalist is to acclimate to your hospital and HM group’s procedures. Increasingly, hospitalist teams include nurse practitioners (NPs) and physician assistants (PAs); for some new hospitalists, this will require another level of learning on the job. The 2012 State of Hospital Medicine report (www.hospitalmedicine.org/survey) noted that approximately half of HM groups serving adults and children utilized NPs and/or PAs. Although the report also acknowledged that identifying trends is difficult, the converging factors of aging U.S. demographics and the growing physician shortage indicate that NPs and PAs will become more prevalent in hospital medicine.

Physicians who have not worked alongside NPs or PAs often are unsure of how to approach the working relationship, says Jeanette Kalupa, DNP, ACNP-BC, SFHM, vice president of clinical operations at Hospitalists of Northern Michigan and a member of SHM’s Nurse Practitioner/Physician Assistant (NP/PA) Committee.

Roles and Scope of Practice

NPs and PAs perform myriad clinical and management responsibilities as hospitalists:

• Coordination of admissions and discharge planning;
• Patient histories, physical examinations, and diagnostic and therapeutic procedures (placing central lines, doing lumbar punctures, etc.);
• Medication orders; and
• Hospital committee work to improve processes of care.

Licensing requirements, physician oversight requirements, and scope of practice vary state to state and hospital to hospital. “If you’ve seen one hospital medicine group, you’ve seen one hospital medicine group”— coined by Mitchell Wilson, MD, SFHM, CMO at Atlanta-based Eagle Hospital Physicians—also applies to the way in which HM groups structure their use of NPs and PAs, says Tracy E. Cardin, ACNP-BC, of the University of Chicago Hospital and chair of the NP/PA Committee. SHM’s website offers information about the scope of practice and best ways to incorporate NPs and PAs into hospitalist practice.

Cardin

To hospitalists who express anxiety about an NP or PA overstepping bounds and putting the physician’s license at risk, Kalupa reminds them that she, too, has a license that is at risk. When roles are clearly delineated for tasks that NPs and PAs will perform, jeopardizing a license will not be an issue.

Literature supports equivalent outcomes in both primary care and inpatient settings when PAs and NPs are implemented to handle responsibilities within their scope of practice.^1,2 Using a PA or NP to handle uncomplicated pneumonia cases, to conduct a stress test, or assemble data for patient rounding, for example, can have a physician multiplier effect, says committee member David A. Friar, MD, SFHM, also a member of the NP/PA Committee. Dr. Friar, based in Traverse City, Mich., works daily with nurse practitioners and physician assistants as part of HNM.

“I think of the healthcare team as a toolbox with which we need to provide care for our patients,” he says. “A screwdriver is not half of a hammer, but it can be the best tool for a certain job. In addition, physicians are often seen as Swiss army knives—that we can do anything. We can make photocopies, but it doesn’t make sense for us to do that. So for cases of simple pneumonia or urinary tract infections, or for following people waiting for discharge, management by an NP or PA makes a lot of sense from an economic standpoint.”

Dr. Friar

Position Parity

Hospital leadership should set the tone for building a strong multidisciplinary team, Cardin says. Individual physicians can make a difference with the right approach to the working relationship. “If you are going to have successful collaborations with NPs and PAs,” she says, “you have to treat them like a doctor.” This does not mean that the pay structure will be the same, but in areas such as continuing medical education and group socializing, every member of the team should be treated as an equal. That approach makes sense to Dr. Friar, who makes it a point to call every person on the HM team a hospitalist.

He and Kalupa also point out that NPs and PAs can successfully fill team leadership roles. “Physicians need to be willing to accept that the personality traits that made them great clinicians are often not those that one would desire in a team leader,” Dr. Friar says. Using a football analogy, he notes that an important part of being a good team member is to play to other members’ strengths and protect them from their weaknesses. “You don’t have the linebacker run the ball, or the quarterback kick the field goal attempt; you use people’s strengths where they will be most effective for the care of your patients.”

When Conflicts Arise

Successful working relationships between physicians and NP/PAs hinge on clear expectations and the willingness to have difficult conversations, Cardin says. She has practiced as a hospitalist for seven years and prior to that worked in the acute-care setting. As a result, she says, she is quite comfortable seeing patients independently.

Hospitalists new to the group or those who have not worked with NPs before may bristle at that idea, she notes. If a problem arises, such as a perceived encroachment on one’s scope of practice, be willing to address it openly. All relationships are constantly evolving, and it’s important not to overreact.

It’s “just like driving a car,” she says. “If you overcorrect when a wheel comes off the road, you will wreck the car. Sometimes all that’s needed is a small adjustment to manage the problem.”

Gretchen Henkel is a freelance writer in California.

What’s in a Name?

Dr. Kalupa

When Jeanette Kalupa, DNP, ACNP-BC, SFHM, vice president of clinical operations for Hospitalists of Northern Michigan, first joined SHM’s Nurse Practitioner/Physician Assistant Committee in 2003, it was called the “NP/PA Task Force.” The name was changed to the Nonphysician Provider (NPP) Committee to accommodate other allied professionals, such as pharmacists and case managers. She and her NP colleagues object to the NPP moniker “because it designates us as what we are not.”

The term “midlevel provider,” another common designation, is also problematic, she says, because it heightens awareness of a hierarchy. Just this past year, the committee name was changed to NP/PA Committee. “We’ve evolved over time,” Kalupa says. “I think rather than labeling someone as a ‘midlevel provider,’ it’s better to just call them what they are.”

—Gretchen Henkel

References

1. Iglesias B, Ramos F, Serrano B, et al. A randomized controlled trial of nurses vs. doctors in the resolution of acute disease of low complexity in primary care. J Adv Nurs. 2013 March 21. doi: 10.1111/jan.12120 [Epub ahead of print].
2. Hoffman LA, Tasota FJ, Zullo TG, et al. Outcomes of care managed by an acute care nurse practitioner/attending physician team in a subacute medical intensive care unit. Am J Crit Care. 2005;14(2):121-130; quiz 131-132.

Leaving a job is never an easy decision, whether it is made voluntarily or not. A physician terminating a relationship with an employer may face emotionally charged conversations, difficult financial considerations, and long-term legal consequences. As you plan your exit strategy, it is critical for you to be aware of these issues and address them proactively with your employer. This can minimize hard feelings and surprises down the road for you, your former employer, and your colleagues.

In today’s competitive climate, a physician might work for several employers during the length of his or her career. With the tighter financial medical market and pressures from managed care mounting, employers are less likely to tolerate a nonproductive employee. Interoffice or personality conflicts may become intolerable for an unhappy or stressed physician. Physician turnover is a more common occurrence, and if not handled properly, it can be disruptive for all parties involved.

The following steps are meant for physicians contemplating leaving their place of employment or who may be asked to leave in the near future.

Step 1: Consider the Employment Agreement

Ideally, physician-separation matters are addressed preemptively when the physician enters the employer-employee relationship and signs an employment agreement. Thus, before contemplating a move, you should always start by reviewing the terms of your current employment agreement. A well-drafted employment agreement should specify the grounds for termination, both for cause (i.e. a specific set of reasons for immediate termination) and without cause (i.e. either party may terminate voluntarily). The agreement should specify the parties’ rights and obligations following a termination. These rights and obligations likely will vary depending on the basis for termination.

Typically, an employer will provide malpractice insurance for its physicians during the term of employment. However, physicians may be responsible for the cost of “tail coverage” upon the termination of employment. This is designed to protect the departing physician’s professional acts after leaving the employ of an employer with claims-made coverage. Because the coverage can be quite costly, a well-drafted employment agreement often will set forth which party is responsible for the procurement and payment of tail coverage. It is prudent for a departing physician to review the employment agreement to identify who has the affirmative obligation to provide the tail coverage, as it can be a costly surprise at termination.

The employment agreement also must be reviewed to determine the proper method to provide notice of termination (such as first-class mail, overnight courier, or hand delivery). Often, employment agreements will include a clause titled “Notice” that outlines the delivery method for proper notice to the employer.

Step 2: Consider a Termination/Separation Agreement

Entering into a termination agreement (sometimes referred to as a separation agreement) between the departing physician and the employer may address and resolve many of the outstanding issues that are not otherwise addressed in the employment agreement. A termination agreement may avoid unnecessary problems down the road and potentially acrimonious and costly litigation.

The termination agreement can fill in the gaps where the employment agreement is silent (or if an employment agreement does not exist). The key elements of a termination agreement often include:

• The effective date of the separation as well as what exactly is ending (e.g. employment, co-ownership, board membership, medical staff privileges);
• Payment and buyout terms;
• The physician’s removal from any management or administrative position (e.g. member of the governing board);
• Deferred compensation payments or severance pay that may need to be calculated and distributed;
• Employer obligations (if any) to provide the departing physician’s fringe benefits and business expenses, including retirement-plan contributions, health insurance, life insurance, medical dues, etc.; and
• Unused vacation days, bonuses, or expenses due.

If previously addressed in the employment agreement, the parties should reaffirm their respective rights and obligations regarding medical records, confidential information, noncompetition and nonsolicitation provisions. Otherwise, the termination agreement should identify the physician’s competitive and solicitation activities post-termination.

A noncompetition provision should include the geographic territory in which and the time period during which the departing physician cannot compete with the former employer. It is important to remember courts will render these provisions as unenforceable and invalid if improperly drafted or overly broad. It is common to see nondisparagement provisions, whereby each party agrees to refrain from making any negative or false statements regarding the other. Nondisclosure provisions are common as well with regards to what may be disclosed to third parties.

The separation agreement also should address the return of company property, including office key, credit card, computer, cell phone, and beeper. Patient records and charts should be completed and returned to the employer. Often, the departing physician will still be allowed reasonable access to patient records post-termination for certain authorized purposes (e.g. defending disciplinary actions, malpractice claims, and billing/payer claims and audits), usually at the physician’s own expense.

The termination agreement may also outline how patients will be notified about the physician’s departure. If a patient wishes to continue treatment with the departing physician, the former employer must be ready to transition the patient.

A well-written termination agreement will provide for mutual releases. However, there are often exclusions from the mutual releases, such as pre-termination date liabilities; medical malpractice claims resulting from the physician’s misconduct; or taxes, interests, and penalties covering the pre-termination date.

Step 3: Severance Pay

Depending on the circumstances surrounding the termination and employment agreements, a physician may be entitled to severance payments beginning on the date of termination and/or for a period of time post-termination. The departing physician should determine whether severance is appropriate and whether he or she is willing to forego severance payments in exchange for other benefits. Depending on the dollar amount and the physician’s career objectives, it may be worthwhile to sacrifice severance payments for a less onerous noncompete provision, for example.

Step 4: Take the High Road

Because you never know when your paths might cross with former coworkers or employers, it is always sensible to remain discreet and level-headed during this trying period. Although it is natural to discuss an impending move with others, a prudent physician will avoid water-cooler gossip.

In the event conflicts arise, limit the public disclosure of these disputes. Neither side wins the public relations battle, and often, both sides lose. This is a circumstance where experienced legal counsel can be invaluable as you navigate these potentially rocky waters. You would be well served to seek legal advice to discuss your intentions before making an actual move.

As always, remember conversations you have with counsel are typically protected by attorney-client privilege. It is always advisable to secure legal counsel to review the terms of an employment agreement, negotiate a fair termination/separation agreement, and serve as an advocate during this challenging career move.

Steven M. Harris, Esq., is a nationally recognized healthcare attorney and a member of the law firm McDonald Hopkins LLC in Chicago. Write to him at [email protected].

Leaving a job is never an easy decision, whether it is made voluntarily or not. A physician terminating a relationship with an employer may face emotionally charged conversations, difficult financial considerations, and long-term legal consequences. As you plan your exit strategy, it is critical for you to be aware of these issues and address them proactively with your employer. This can minimize hard feelings and surprises down the road for you, your former employer, and your colleagues.

In today’s competitive climate, a physician might work for several employers during the length of his or her career. With the tighter financial medical market and pressures from managed care mounting, employers are less likely to tolerate a nonproductive employee. Interoffice or personality conflicts may become intolerable for an unhappy or stressed physician. Physician turnover is a more common occurrence, and if not handled properly, it can be disruptive for all parties involved.

The following steps are meant for physicians contemplating leaving their place of employment or who may be asked to leave in the near future.

Step 1: Consider the Employment Agreement

Ideally, physician-separation matters are addressed preemptively when the physician enters the employer-employee relationship and signs an employment agreement. Thus, before contemplating a move, you should always start by reviewing the terms of your current employment agreement. A well-drafted employment agreement should specify the grounds for termination, both for cause (i.e. a specific set of reasons for immediate termination) and without cause (i.e. either party may terminate voluntarily). The agreement should specify the parties’ rights and obligations following a termination. These rights and obligations likely will vary depending on the basis for termination.

Typically, an employer will provide malpractice insurance for its physicians during the term of employment. However, physicians may be responsible for the cost of “tail coverage” upon the termination of employment. This is designed to protect the departing physician’s professional acts after leaving the employ of an employer with claims-made coverage. Because the coverage can be quite costly, a well-drafted employment agreement often will set forth which party is responsible for the procurement and payment of tail coverage. It is prudent for a departing physician to review the employment agreement to identify who has the affirmative obligation to provide the tail coverage, as it can be a costly surprise at termination.

The employment agreement also must be reviewed to determine the proper method to provide notice of termination (such as first-class mail, overnight courier, or hand delivery). Often, employment agreements will include a clause titled “Notice” that outlines the delivery method for proper notice to the employer.

Step 2: Consider a Termination/Separation Agreement

Entering into a termination agreement (sometimes referred to as a separation agreement) between the departing physician and the employer may address and resolve many of the outstanding issues that are not otherwise addressed in the employment agreement. A termination agreement may avoid unnecessary problems down the road and potentially acrimonious and costly litigation.

The termination agreement can fill in the gaps where the employment agreement is silent (or if an employment agreement does not exist). The key elements of a termination agreement often include:

• The effective date of the separation as well as what exactly is ending (e.g. employment, co-ownership, board membership, medical staff privileges);
• Payment and buyout terms;
• The physician’s removal from any management or administrative position (e.g. member of the governing board);
• Deferred compensation payments or severance pay that may need to be calculated and distributed;
• Employer obligations (if any) to provide the departing physician’s fringe benefits and business expenses, including retirement-plan contributions, health insurance, life insurance, medical dues, etc.; and
• Unused vacation days, bonuses, or expenses due.

If previously addressed in the employment agreement, the parties should reaffirm their respective rights and obligations regarding medical records, confidential information, noncompetition and nonsolicitation provisions. Otherwise, the termination agreement should identify the physician’s competitive and solicitation activities post-termination.

A noncompetition provision should include the geographic territory in which and the time period during which the departing physician cannot compete with the former employer. It is important to remember courts will render these provisions as unenforceable and invalid if improperly drafted or overly broad. It is common to see nondisparagement provisions, whereby each party agrees to refrain from making any negative or false statements regarding the other. Nondisclosure provisions are common as well with regards to what may be disclosed to third parties.

The separation agreement also should address the return of company property, including office key, credit card, computer, cell phone, and beeper. Patient records and charts should be completed and returned to the employer. Often, the departing physician will still be allowed reasonable access to patient records post-termination for certain authorized purposes (e.g. defending disciplinary actions, malpractice claims, and billing/payer claims and audits), usually at the physician’s own expense.

The termination agreement may also outline how patients will be notified about the physician’s departure. If a patient wishes to continue treatment with the departing physician, the former employer must be ready to transition the patient.

A well-written termination agreement will provide for mutual releases. However, there are often exclusions from the mutual releases, such as pre-termination date liabilities; medical malpractice claims resulting from the physician’s misconduct; or taxes, interests, and penalties covering the pre-termination date.

Step 3: Severance Pay

Depending on the circumstances surrounding the termination and employment agreements, a physician may be entitled to severance payments beginning on the date of termination and/or for a period of time post-termination. The departing physician should determine whether severance is appropriate and whether he or she is willing to forego severance payments in exchange for other benefits. Depending on the dollar amount and the physician’s career objectives, it may be worthwhile to sacrifice severance payments for a less onerous noncompete provision, for example.

Step 4: Take the High Road

Because you never know when your paths might cross with former coworkers or employers, it is always sensible to remain discreet and level-headed during this trying period. Although it is natural to discuss an impending move with others, a prudent physician will avoid water-cooler gossip.

In the event conflicts arise, limit the public disclosure of these disputes. Neither side wins the public relations battle, and often, both sides lose. This is a circumstance where experienced legal counsel can be invaluable as you navigate these potentially rocky waters. You would be well served to seek legal advice to discuss your intentions before making an actual move.

As always, remember conversations you have with counsel are typically protected by attorney-client privilege. It is always advisable to secure legal counsel to review the terms of an employment agreement, negotiate a fair termination/separation agreement, and serve as an advocate during this challenging career move.

Steven M. Harris, Esq., is a nationally recognized healthcare attorney and a member of the law firm McDonald Hopkins LLC in Chicago. Write to him at [email protected].

Leaving a job is never an easy decision, whether it is made voluntarily or not. A physician terminating a relationship with an employer may face emotionally charged conversations, difficult financial considerations, and long-term legal consequences. As you plan your exit strategy, it is critical for you to be aware of these issues and address them proactively with your employer. This can minimize hard feelings and surprises down the road for you, your former employer, and your colleagues.

In today’s competitive climate, a physician might work for several employers during the length of his or her career. With the tighter financial medical market and pressures from managed care mounting, employers are less likely to tolerate a nonproductive employee. Interoffice or personality conflicts may become intolerable for an unhappy or stressed physician. Physician turnover is a more common occurrence, and if not handled properly, it can be disruptive for all parties involved.

The following steps are meant for physicians contemplating leaving their place of employment or who may be asked to leave in the near future.

Step 1: Consider the Employment Agreement

Ideally, physician-separation matters are addressed preemptively when the physician enters the employer-employee relationship and signs an employment agreement. Thus, before contemplating a move, you should always start by reviewing the terms of your current employment agreement. A well-drafted employment agreement should specify the grounds for termination, both for cause (i.e. a specific set of reasons for immediate termination) and without cause (i.e. either party may terminate voluntarily). The agreement should specify the parties’ rights and obligations following a termination. These rights and obligations likely will vary depending on the basis for termination.

Typically, an employer will provide malpractice insurance for its physicians during the term of employment. However, physicians may be responsible for the cost of “tail coverage” upon the termination of employment. This is designed to protect the departing physician’s professional acts after leaving the employ of an employer with claims-made coverage. Because the coverage can be quite costly, a well-drafted employment agreement often will set forth which party is responsible for the procurement and payment of tail coverage. It is prudent for a departing physician to review the employment agreement to identify who has the affirmative obligation to provide the tail coverage, as it can be a costly surprise at termination.

The employment agreement also must be reviewed to determine the proper method to provide notice of termination (such as first-class mail, overnight courier, or hand delivery). Often, employment agreements will include a clause titled “Notice” that outlines the delivery method for proper notice to the employer.

Step 2: Consider a Termination/Separation Agreement

Entering into a termination agreement (sometimes referred to as a separation agreement) between the departing physician and the employer may address and resolve many of the outstanding issues that are not otherwise addressed in the employment agreement. A termination agreement may avoid unnecessary problems down the road and potentially acrimonious and costly litigation.

The termination agreement can fill in the gaps where the employment agreement is silent (or if an employment agreement does not exist). The key elements of a termination agreement often include:

• The effective date of the separation as well as what exactly is ending (e.g. employment, co-ownership, board membership, medical staff privileges);
• Payment and buyout terms;
• The physician’s removal from any management or administrative position (e.g. member of the governing board);
• Deferred compensation payments or severance pay that may need to be calculated and distributed;
• Employer obligations (if any) to provide the departing physician’s fringe benefits and business expenses, including retirement-plan contributions, health insurance, life insurance, medical dues, etc.; and
• Unused vacation days, bonuses, or expenses due.

If previously addressed in the employment agreement, the parties should reaffirm their respective rights and obligations regarding medical records, confidential information, noncompetition and nonsolicitation provisions. Otherwise, the termination agreement should identify the physician’s competitive and solicitation activities post-termination.

A noncompetition provision should include the geographic territory in which and the time period during which the departing physician cannot compete with the former employer. It is important to remember courts will render these provisions as unenforceable and invalid if improperly drafted or overly broad. It is common to see nondisparagement provisions, whereby each party agrees to refrain from making any negative or false statements regarding the other. Nondisclosure provisions are common as well with regards to what may be disclosed to third parties.

The separation agreement also should address the return of company property, including office key, credit card, computer, cell phone, and beeper. Patient records and charts should be completed and returned to the employer. Often, the departing physician will still be allowed reasonable access to patient records post-termination for certain authorized purposes (e.g. defending disciplinary actions, malpractice claims, and billing/payer claims and audits), usually at the physician’s own expense.

The termination agreement may also outline how patients will be notified about the physician’s departure. If a patient wishes to continue treatment with the departing physician, the former employer must be ready to transition the patient.

A well-written termination agreement will provide for mutual releases. However, there are often exclusions from the mutual releases, such as pre-termination date liabilities; medical malpractice claims resulting from the physician’s misconduct; or taxes, interests, and penalties covering the pre-termination date.

Step 3: Severance Pay

Depending on the circumstances surrounding the termination and employment agreements, a physician may be entitled to severance payments beginning on the date of termination and/or for a period of time post-termination. The departing physician should determine whether severance is appropriate and whether he or she is willing to forego severance payments in exchange for other benefits. Depending on the dollar amount and the physician’s career objectives, it may be worthwhile to sacrifice severance payments for a less onerous noncompete provision, for example.

Step 4: Take the High Road

Because you never know when your paths might cross with former coworkers or employers, it is always sensible to remain discreet and level-headed during this trying period. Although it is natural to discuss an impending move with others, a prudent physician will avoid water-cooler gossip.

In the event conflicts arise, limit the public disclosure of these disputes. Neither side wins the public relations battle, and often, both sides lose. This is a circumstance where experienced legal counsel can be invaluable as you navigate these potentially rocky waters. You would be well served to seek legal advice to discuss your intentions before making an actual move.

As always, remember conversations you have with counsel are typically protected by attorney-client privilege. It is always advisable to secure legal counsel to review the terms of an employment agreement, negotiate a fair termination/separation agreement, and serve as an advocate during this challenging career move.

Steven M. Harris, Esq., is a nationally recognized healthcare attorney and a member of the law firm McDonald Hopkins LLC in Chicago. Write to him at [email protected].

Empathy: ability to understand and share the feelings of another.

In today’s increasingly hyper-measured healthcare world, we are looking more and more at measures of patient outcomes. The Institute for Healthcare Improvement (IHI) touts the Triple Aim principle as the lens through which we should be approaching our work. The Triple Aim is the three-part goal and simultaneous focus of improving the health of the community and our patients, improving affordability of care, and finally and perhaps most elusively, improving the patient experience. Who wouldn’t want to hit on these admirable goals? How do we do it?

In approaching the health aspect of the Triple Aim, we, as hospitalists, have tried-and-true frameworks of process improvement. Clinical research and peer-reviewed publication advance the knowledge of what medicines and procedures can improve care. Although powerful and generally truthful, this system results in a slow diffusion of practice improvement, not to mention idiosyncratic and nonstandardized care. This has led to a new toolkit of improvement techniques: continuous quality improvement, Lean, and Six Sigma. We learn and adopt these and watch our scores go up at a steady pace.

Improving affordability has its challenges, some huge, like our basic cultural ethos that “more is better.” Yet affordability is still something we can grasp. It is rooted in systems we are all familiar with, from basic personal finance to resource allocation to generally accepted accounting principles. We all can grasp that the current system of pay for widgets is teetering at the edge, just waiting for a shove from CMS to send it to its doom. Once this happens, affordability likely will become something we can start to make serious headway against.

Improving the experience of patients and families is perhaps the toughest of the three and where I would like to focus.

Patients First

First, a question: Are experience scores reflective of the true experience of a patient?

Two weeks after discharge, when patients receive their HCAHPS questionnaire in the mail, do they remember the details of their stay? And who was their doctor anyway? The cardiologist who placed a stent? The on-call doctor? The hospitalist who visited them every morning? If all we focus on is the scores, and we lack faith that the scores represent the true experience of patients, then how can we ever truly create a more satisfying experience for our patients?

I believe that the answer lies with empathy. What’s unique about this part of the Triple Aim is that many of the answers are within us. Gaining empathy with our patients requires us to ask questions of them and also to ask questions of ourselves. It requires us to invoke ancient methods of learning and thinking, like walking in another’s shoes for a day or using the Golden Rule. Experience doesn’t lend itself to being taught by PowerPoint. It must be lived and channeled back and out through our emotional selves as empathy.

Using the wisdom of patients themselves is one way to understand their needs and develop the empathy to motivate us to change how we do things in health care. Many organizations around the country have used some form of patient focus group to help learn from patients. Park Nicollet, a large health system in Minnesota, has incorporated family councils in nearly every clinic and care area. They usually are patients or caregivers from the area, bound together by a common disease or location. They dedicate their time, often meeting monthly, to share their stories, give opinions on care processes, and even to shape the design of a care area. Currently, there are more than 100 patient councils in the system, and the number continues to grow.

Film, when done skillfully, is a powerful tool in helping us gain empathy. The Cleveland Clinic has produced an amazing short film called “Empathy: The Human Connection to Patient Care.” It follows patients, families, and staff through the care system. As the camera focuses on each person, floating text appears near them, explaining their situation, inner thoughts, or fears, all overlaid by an emotional piano score. Tears will flow. Understanding follows.

Jim Merlino, MD, Cleveland Clinic’s chief experience officer, explains, “We need to understand that being on the other side of health care is frightening, and our job, our responsibility as people responsible for other people, is to help ease that fear.” Cleveland Clinic has done a remarkable job in reminding us why we went in to health care.

Morgan Spurlock of “Super Size Me” fame produced a reality series called “30 Days.” In each episode, a participant spent 30 days in the shoes of another. In the “Life in a Wheelchair” episode, Super Bowl-winning football player Ray Crockett lives in a wheelchair for 30 days and explores what it is like going through recovery and the healthcare system. He meets several rehabbing paraplegics and quadriplegics and accompanies them through their daily lives at home and the hospital. Viewers gain empathy directly in seeing these patients struggle to get better and work with the healthcare system. We also gain empathy watching Crockett gain empathy. The combination is powerful.

In Patients’ Shoes

In addition to listening and observation, we can begin to literally walk in the shoes of our patients.

I recently attended IHI’s International Forum in London. The National Health Service (NHS) in England is using a new tool to help providers understand what it is like for geriatric patients who must navigate the healthcare system with diminished senses and capabilities. Providers put on an age-simulation suit (www.age-simulation-suit.com) that mimics the impairments of aging. Special goggles fog the vision and narrow the visual field. Head mobility is reduced so that it becomes difficult to see beyond the field cuts. Earmuffs reduce high-frequency hearing and the ability to understand speech clearly. The overall suit impedes motion and reduces strength. Thick gloves make it difficult to coordinate fine motions. Wearing this suit and trying to go through a hospital or clinic setting instantly makes the wearer gain empathy for our patients’ needs.

Most important, be a patient. SHM immediate past president Shaun Frost, MD, SFHM, whose personal mission during his tenure was to help the society understand patient experience, explained it best to me. “In one episode in the hospital with a family member, I learned more about patient experience than all the reading and self-educating I have been doing for the last year.”

I think any of us who have been a patient in the hospital, or accompanied a loved one, comes out frustrated that the healthcare system is so convoluted and lacking in clarity for patients. Then there is often a sense of renewal, hopefully,followed by evangelism to spread their newfound empathy to others in the system.

In our busy work lives as hospitalists, it isn’t easy turning our daily focus away from efficiency and productivity. Yet we must always remain mindful of that core idea every one of us wrote down as the heart of our personal statements on our applications to medical school. Do you remember writing something like this? “I want to help people and relieve suffering in their time of need.”

Empathy is the start of our work.

Dr. Kealey is medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn. He is an SHM board member and SHM president-elect.

Empathy: ability to understand and share the feelings of another.

In today’s increasingly hyper-measured healthcare world, we are looking more and more at measures of patient outcomes. The Institute for Healthcare Improvement (IHI) touts the Triple Aim principle as the lens through which we should be approaching our work. The Triple Aim is the three-part goal and simultaneous focus of improving the health of the community and our patients, improving affordability of care, and finally and perhaps most elusively, improving the patient experience. Who wouldn’t want to hit on these admirable goals? How do we do it?

In approaching the health aspect of the Triple Aim, we, as hospitalists, have tried-and-true frameworks of process improvement. Clinical research and peer-reviewed publication advance the knowledge of what medicines and procedures can improve care. Although powerful and generally truthful, this system results in a slow diffusion of practice improvement, not to mention idiosyncratic and nonstandardized care. This has led to a new toolkit of improvement techniques: continuous quality improvement, Lean, and Six Sigma. We learn and adopt these and watch our scores go up at a steady pace.

Improving affordability has its challenges, some huge, like our basic cultural ethos that “more is better.” Yet affordability is still something we can grasp. It is rooted in systems we are all familiar with, from basic personal finance to resource allocation to generally accepted accounting principles. We all can grasp that the current system of pay for widgets is teetering at the edge, just waiting for a shove from CMS to send it to its doom. Once this happens, affordability likely will become something we can start to make serious headway against.

Improving the experience of patients and families is perhaps the toughest of the three and where I would like to focus.

Patients First

First, a question: Are experience scores reflective of the true experience of a patient?

Two weeks after discharge, when patients receive their HCAHPS questionnaire in the mail, do they remember the details of their stay? And who was their doctor anyway? The cardiologist who placed a stent? The on-call doctor? The hospitalist who visited them every morning? If all we focus on is the scores, and we lack faith that the scores represent the true experience of patients, then how can we ever truly create a more satisfying experience for our patients?

I believe that the answer lies with empathy. What’s unique about this part of the Triple Aim is that many of the answers are within us. Gaining empathy with our patients requires us to ask questions of them and also to ask questions of ourselves. It requires us to invoke ancient methods of learning and thinking, like walking in another’s shoes for a day or using the Golden Rule. Experience doesn’t lend itself to being taught by PowerPoint. It must be lived and channeled back and out through our emotional selves as empathy.

Using the wisdom of patients themselves is one way to understand their needs and develop the empathy to motivate us to change how we do things in health care. Many organizations around the country have used some form of patient focus group to help learn from patients. Park Nicollet, a large health system in Minnesota, has incorporated family councils in nearly every clinic and care area. They usually are patients or caregivers from the area, bound together by a common disease or location. They dedicate their time, often meeting monthly, to share their stories, give opinions on care processes, and even to shape the design of a care area. Currently, there are more than 100 patient councils in the system, and the number continues to grow.

Film, when done skillfully, is a powerful tool in helping us gain empathy. The Cleveland Clinic has produced an amazing short film called “Empathy: The Human Connection to Patient Care.” It follows patients, families, and staff through the care system. As the camera focuses on each person, floating text appears near them, explaining their situation, inner thoughts, or fears, all overlaid by an emotional piano score. Tears will flow. Understanding follows.

Jim Merlino, MD, Cleveland Clinic’s chief experience officer, explains, “We need to understand that being on the other side of health care is frightening, and our job, our responsibility as people responsible for other people, is to help ease that fear.” Cleveland Clinic has done a remarkable job in reminding us why we went in to health care.

Morgan Spurlock of “Super Size Me” fame produced a reality series called “30 Days.” In each episode, a participant spent 30 days in the shoes of another. In the “Life in a Wheelchair” episode, Super Bowl-winning football player Ray Crockett lives in a wheelchair for 30 days and explores what it is like going through recovery and the healthcare system. He meets several rehabbing paraplegics and quadriplegics and accompanies them through their daily lives at home and the hospital. Viewers gain empathy directly in seeing these patients struggle to get better and work with the healthcare system. We also gain empathy watching Crockett gain empathy. The combination is powerful.

In Patients’ Shoes

In addition to listening and observation, we can begin to literally walk in the shoes of our patients.

I recently attended IHI’s International Forum in London. The National Health Service (NHS) in England is using a new tool to help providers understand what it is like for geriatric patients who must navigate the healthcare system with diminished senses and capabilities. Providers put on an age-simulation suit (www.age-simulation-suit.com) that mimics the impairments of aging. Special goggles fog the vision and narrow the visual field. Head mobility is reduced so that it becomes difficult to see beyond the field cuts. Earmuffs reduce high-frequency hearing and the ability to understand speech clearly. The overall suit impedes motion and reduces strength. Thick gloves make it difficult to coordinate fine motions. Wearing this suit and trying to go through a hospital or clinic setting instantly makes the wearer gain empathy for our patients’ needs.

Most important, be a patient. SHM immediate past president Shaun Frost, MD, SFHM, whose personal mission during his tenure was to help the society understand patient experience, explained it best to me. “In one episode in the hospital with a family member, I learned more about patient experience than all the reading and self-educating I have been doing for the last year.”

I think any of us who have been a patient in the hospital, or accompanied a loved one, comes out frustrated that the healthcare system is so convoluted and lacking in clarity for patients. Then there is often a sense of renewal, hopefully,followed by evangelism to spread their newfound empathy to others in the system.

In our busy work lives as hospitalists, it isn’t easy turning our daily focus away from efficiency and productivity. Yet we must always remain mindful of that core idea every one of us wrote down as the heart of our personal statements on our applications to medical school. Do you remember writing something like this? “I want to help people and relieve suffering in their time of need.”

Empathy is the start of our work.

Dr. Kealey is medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn. He is an SHM board member and SHM president-elect.

Empathy: ability to understand and share the feelings of another.

In today’s increasingly hyper-measured healthcare world, we are looking more and more at measures of patient outcomes. The Institute for Healthcare Improvement (IHI) touts the Triple Aim principle as the lens through which we should be approaching our work. The Triple Aim is the three-part goal and simultaneous focus of improving the health of the community and our patients, improving affordability of care, and finally and perhaps most elusively, improving the patient experience. Who wouldn’t want to hit on these admirable goals? How do we do it?

In approaching the health aspect of the Triple Aim, we, as hospitalists, have tried-and-true frameworks of process improvement. Clinical research and peer-reviewed publication advance the knowledge of what medicines and procedures can improve care. Although powerful and generally truthful, this system results in a slow diffusion of practice improvement, not to mention idiosyncratic and nonstandardized care. This has led to a new toolkit of improvement techniques: continuous quality improvement, Lean, and Six Sigma. We learn and adopt these and watch our scores go up at a steady pace.

Improving affordability has its challenges, some huge, like our basic cultural ethos that “more is better.” Yet affordability is still something we can grasp. It is rooted in systems we are all familiar with, from basic personal finance to resource allocation to generally accepted accounting principles. We all can grasp that the current system of pay for widgets is teetering at the edge, just waiting for a shove from CMS to send it to its doom. Once this happens, affordability likely will become something we can start to make serious headway against.

Improving the experience of patients and families is perhaps the toughest of the three and where I would like to focus.

Patients First

First, a question: Are experience scores reflective of the true experience of a patient?

Two weeks after discharge, when patients receive their HCAHPS questionnaire in the mail, do they remember the details of their stay? And who was their doctor anyway? The cardiologist who placed a stent? The on-call doctor? The hospitalist who visited them every morning? If all we focus on is the scores, and we lack faith that the scores represent the true experience of patients, then how can we ever truly create a more satisfying experience for our patients?

I believe that the answer lies with empathy. What’s unique about this part of the Triple Aim is that many of the answers are within us. Gaining empathy with our patients requires us to ask questions of them and also to ask questions of ourselves. It requires us to invoke ancient methods of learning and thinking, like walking in another’s shoes for a day or using the Golden Rule. Experience doesn’t lend itself to being taught by PowerPoint. It must be lived and channeled back and out through our emotional selves as empathy.

Using the wisdom of patients themselves is one way to understand their needs and develop the empathy to motivate us to change how we do things in health care. Many organizations around the country have used some form of patient focus group to help learn from patients. Park Nicollet, a large health system in Minnesota, has incorporated family councils in nearly every clinic and care area. They usually are patients or caregivers from the area, bound together by a common disease or location. They dedicate their time, often meeting monthly, to share their stories, give opinions on care processes, and even to shape the design of a care area. Currently, there are more than 100 patient councils in the system, and the number continues to grow.

Film, when done skillfully, is a powerful tool in helping us gain empathy. The Cleveland Clinic has produced an amazing short film called “Empathy: The Human Connection to Patient Care.” It follows patients, families, and staff through the care system. As the camera focuses on each person, floating text appears near them, explaining their situation, inner thoughts, or fears, all overlaid by an emotional piano score. Tears will flow. Understanding follows.

Jim Merlino, MD, Cleveland Clinic’s chief experience officer, explains, “We need to understand that being on the other side of health care is frightening, and our job, our responsibility as people responsible for other people, is to help ease that fear.” Cleveland Clinic has done a remarkable job in reminding us why we went in to health care.

Morgan Spurlock of “Super Size Me” fame produced a reality series called “30 Days.” In each episode, a participant spent 30 days in the shoes of another. In the “Life in a Wheelchair” episode, Super Bowl-winning football player Ray Crockett lives in a wheelchair for 30 days and explores what it is like going through recovery and the healthcare system. He meets several rehabbing paraplegics and quadriplegics and accompanies them through their daily lives at home and the hospital. Viewers gain empathy directly in seeing these patients struggle to get better and work with the healthcare system. We also gain empathy watching Crockett gain empathy. The combination is powerful.

In Patients’ Shoes

In addition to listening and observation, we can begin to literally walk in the shoes of our patients.

I recently attended IHI’s International Forum in London. The National Health Service (NHS) in England is using a new tool to help providers understand what it is like for geriatric patients who must navigate the healthcare system with diminished senses and capabilities. Providers put on an age-simulation suit (www.age-simulation-suit.com) that mimics the impairments of aging. Special goggles fog the vision and narrow the visual field. Head mobility is reduced so that it becomes difficult to see beyond the field cuts. Earmuffs reduce high-frequency hearing and the ability to understand speech clearly. The overall suit impedes motion and reduces strength. Thick gloves make it difficult to coordinate fine motions. Wearing this suit and trying to go through a hospital or clinic setting instantly makes the wearer gain empathy for our patients’ needs.

Most important, be a patient. SHM immediate past president Shaun Frost, MD, SFHM, whose personal mission during his tenure was to help the society understand patient experience, explained it best to me. “In one episode in the hospital with a family member, I learned more about patient experience than all the reading and self-educating I have been doing for the last year.”

I think any of us who have been a patient in the hospital, or accompanied a loved one, comes out frustrated that the healthcare system is so convoluted and lacking in clarity for patients. Then there is often a sense of renewal, hopefully,followed by evangelism to spread their newfound empathy to others in the system.

In our busy work lives as hospitalists, it isn’t easy turning our daily focus away from efficiency and productivity. Yet we must always remain mindful of that core idea every one of us wrote down as the heart of our personal statements on our applications to medical school. Do you remember writing something like this? “I want to help people and relieve suffering in their time of need.”

Empathy is the start of our work.

Dr. Kealey is medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn. He is an SHM board member and SHM president-elect.

The Centers for Medicare & Medicaid Services (CMS) recently released a few Fact Sheets on how they anticipate funding changes on a few of their programs that were implemented (or sustained) under the Affordable Care Act. As a background, CMS pays most acute-care hospitals by prospectively determining payment based on a patient’s diagnosis and the severity of illness within that diagnosis (e.g. “MS-DRG”). These payment amounts are updated annually after evaluating several factors, including the costs associated with the delivery of care.

One of the most major changes described in the Fact Sheet that will affect hospitalists is how CMS will review inpatient stays based on the number of nights in the hospital. CMS has proposed that any patient who stays in the hospital for two or more “midnights” should be appropriate for payment under Medicare Part A. For those who stay in the hospital for only one (or zero) midnights, payment under Medicare Part A will only be appropriate if:

1. There is sufficient documentation at the time of admission that the anticipated length of stay is two or more nights; and.
2. Further documentation that circumstances changed, and the hospital stay ended prematurely because of those changes.

Overall for hospitalists, this should substantially simplify the admitting process, whereby most inpatients being admitted with the anticipation of two or more nights should qualify for an inpatient stay. This also reduces the administrative burden of correcting the “inpatient” versus “observation” designation, which keeps many hospital staffs entirely too busy. This change also should relieve a significant burden from the patients and their families, who if kept in observation for a period of time, may have to pay substantially out of pocket to make up for the difference between the cost of the stay and the reimbursement from CMS for observation status. So this is one of the moves that CMS is making to simplify (and not complicate) an already too-complicated payment system. This should go into effect October 2013 and will be a sigh of much relief from many of us.

A few other anticipated changes that will affect hospitalists include:

Payments for Unfunded Care

Another major change that will go into affect October 2013 is the amount of monies received by hospitals that care for unfunded patients. These payments historically have been made to “Disproportionate Share Hospitals” (DSH), which are hospitals that care for a higher percentage of unfunded patients. Under the Affordable Care Act, only 25% of these payments will be distributed to DSH hospitals; the remaining 75% will be reduced based on the number of uninsured in the U.S., then redistributed to DSH hospitals based on their portion of uninsured care delivered.

Most DSH hospitals should expect a decrease in DSH payments, the amount of which will depend on their share of unfunded patients.

Any reduction in the “bottom line” to the hospital can affect hospitalists, especially those who are directly employed by the hospital.

Hospital-Acquired Conditions

CMS has long had the Hospital-Acquired Condition (HAC) program in effect, which has the ability to reduce the amount of payment for inpatients who acquire a HAC during their hospital stay. Starting in October 2014, CMS will impose additional financial penalties for hospitals with high HAC rates.

Specifically, those hospitals in the highest 25th percentile of HAC rates will be penalized 1% of their overall CMS payments. Another proposed change is that the following be included in the HAC reduction plan (two “domains” of measures):

• Domain No. 1: Six of the AHRQ Patient Safety Indicators (PSIs), including pressure ulcers, foreign bodies left in after surgery, iatrogenic pneumothorax, postoperative physiologic or metabolic derangements, postoperative VTE, and accidental puncture/laceration.
• Domain No. 2: Central-line-associated bloodstream infections (CLABSI) and catheter-associated urinary tract infections (CAUTIs).

The domains will be weighted equally, and an average score will determine the total score. There will be some methodology for risk adjustment, and hospitals will be given a review and comment period to validate their own scores.

Most hospitalists have at least indirect control over many of these HACs,and all need to pay very close attention to their hospital’s rates of these now and in the future.

Readmissions

As we all know, the Hospital Readmission Reduction program went into effect October 2012; it placed 1% of CMS payments at risk. This will increase to 2% of payments as of October 2013. CMS will continue to use AMI, CHF, and pneumonia as the three conditions under which the readmissions are measured but will put in some methodology to account for planned readmissions.

In addition, in October 2014, they plan to add readmission rates for COPD and for hip/knee arthroplasty.

Hospitalists will continue to need to progress their transitions of care programs, at least for these five patients conditions but more likely (and more effectively) for all hospital discharges.

Quality Measures

Currently more than 99% of acute-care hospitals participate in the pay-for-reporting quality program through CMS, the results of which have been displayed on the Hospital Compare website (www.hospitalcompare.hhs.gov) for years. The program started in 2004 with 10 quality metrics and now includes 57 metrics. These include process and outcome measures for AMI, CHF, and pneumonia, as well as process measures for surgical care, HACs, and patient-satisfaction surveys, among others.

This program will continue to expand over time, including hospital-acquired MRSA and Clostridium difficile rates. The few hospitals not participating will have their CMS annual payments reduced by 2%.

EHR Incentives

CMS is evaluating ways to reduce the burden of reporting by aligning EHR incentives with the Inpatient Quality Reporting program.

Summary

After an open commentary period, the Final Rule will be published Aug. 1, and will become effective for discharges on or after Oct. 1. Although CMS will continue to expand the total number of measures that need to be reported, and the penalties for non-reporting or low performance will continue to escalate, CMS is at least attempting to reduce the overall burden of reporting by combining measures and programs over time and using EHRs to facilitate the bulk of reporting over time.

The global message to hospitalists is: Continue to focus on reducing the burden of HACs, enhance throughput, and carefully and thoughtfully transition patients to the next provider after their hospital discharge. All in all, although at times this can feel overwhelming, these changes represent the right direction to move for high-quality and safe patient care.

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

Reference

1. Centers for Medicare & Medicaid. Fact Sheets: CMS proposals to improve quality of care during hospital inpatient stays. Centers for Medicare & Medicaid website. Available at: www.cms.gov/apps/media/press/factsheet.asp?Counter=4586&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=6&intPage=&showAll=&pYear=&year=&desc=&cboOrder=date. Accessed May 1, 2013.

The Centers for Medicare & Medicaid Services (CMS) recently released a few Fact Sheets on how they anticipate funding changes on a few of their programs that were implemented (or sustained) under the Affordable Care Act. As a background, CMS pays most acute-care hospitals by prospectively determining payment based on a patient’s diagnosis and the severity of illness within that diagnosis (e.g. “MS-DRG”). These payment amounts are updated annually after evaluating several factors, including the costs associated with the delivery of care.

One of the most major changes described in the Fact Sheet that will affect hospitalists is how CMS will review inpatient stays based on the number of nights in the hospital. CMS has proposed that any patient who stays in the hospital for two or more “midnights” should be appropriate for payment under Medicare Part A. For those who stay in the hospital for only one (or zero) midnights, payment under Medicare Part A will only be appropriate if:

1. There is sufficient documentation at the time of admission that the anticipated length of stay is two or more nights; and.
2. Further documentation that circumstances changed, and the hospital stay ended prematurely because of those changes.

Overall for hospitalists, this should substantially simplify the admitting process, whereby most inpatients being admitted with the anticipation of two or more nights should qualify for an inpatient stay. This also reduces the administrative burden of correcting the “inpatient” versus “observation” designation, which keeps many hospital staffs entirely too busy. This change also should relieve a significant burden from the patients and their families, who if kept in observation for a period of time, may have to pay substantially out of pocket to make up for the difference between the cost of the stay and the reimbursement from CMS for observation status. So this is one of the moves that CMS is making to simplify (and not complicate) an already too-complicated payment system. This should go into effect October 2013 and will be a sigh of much relief from many of us.

A few other anticipated changes that will affect hospitalists include:

Payments for Unfunded Care

Another major change that will go into affect October 2013 is the amount of monies received by hospitals that care for unfunded patients. These payments historically have been made to “Disproportionate Share Hospitals” (DSH), which are hospitals that care for a higher percentage of unfunded patients. Under the Affordable Care Act, only 25% of these payments will be distributed to DSH hospitals; the remaining 75% will be reduced based on the number of uninsured in the U.S., then redistributed to DSH hospitals based on their portion of uninsured care delivered.

Most DSH hospitals should expect a decrease in DSH payments, the amount of which will depend on their share of unfunded patients.

Any reduction in the “bottom line” to the hospital can affect hospitalists, especially those who are directly employed by the hospital.

Hospital-Acquired Conditions

CMS has long had the Hospital-Acquired Condition (HAC) program in effect, which has the ability to reduce the amount of payment for inpatients who acquire a HAC during their hospital stay. Starting in October 2014, CMS will impose additional financial penalties for hospitals with high HAC rates.

Specifically, those hospitals in the highest 25th percentile of HAC rates will be penalized 1% of their overall CMS payments. Another proposed change is that the following be included in the HAC reduction plan (two “domains” of measures):

• Domain No. 1: Six of the AHRQ Patient Safety Indicators (PSIs), including pressure ulcers, foreign bodies left in after surgery, iatrogenic pneumothorax, postoperative physiologic or metabolic derangements, postoperative VTE, and accidental puncture/laceration.
• Domain No. 2: Central-line-associated bloodstream infections (CLABSI) and catheter-associated urinary tract infections (CAUTIs).

The domains will be weighted equally, and an average score will determine the total score. There will be some methodology for risk adjustment, and hospitals will be given a review and comment period to validate their own scores.

Most hospitalists have at least indirect control over many of these HACs,and all need to pay very close attention to their hospital’s rates of these now and in the future.

Readmissions

As we all know, the Hospital Readmission Reduction program went into effect October 2012; it placed 1% of CMS payments at risk. This will increase to 2% of payments as of October 2013. CMS will continue to use AMI, CHF, and pneumonia as the three conditions under which the readmissions are measured but will put in some methodology to account for planned readmissions.

In addition, in October 2014, they plan to add readmission rates for COPD and for hip/knee arthroplasty.

Hospitalists will continue to need to progress their transitions of care programs, at least for these five patients conditions but more likely (and more effectively) for all hospital discharges.

Quality Measures

Currently more than 99% of acute-care hospitals participate in the pay-for-reporting quality program through CMS, the results of which have been displayed on the Hospital Compare website (www.hospitalcompare.hhs.gov) for years. The program started in 2004 with 10 quality metrics and now includes 57 metrics. These include process and outcome measures for AMI, CHF, and pneumonia, as well as process measures for surgical care, HACs, and patient-satisfaction surveys, among others.

This program will continue to expand over time, including hospital-acquired MRSA and Clostridium difficile rates. The few hospitals not participating will have their CMS annual payments reduced by 2%.

EHR Incentives

CMS is evaluating ways to reduce the burden of reporting by aligning EHR incentives with the Inpatient Quality Reporting program.

Summary

After an open commentary period, the Final Rule will be published Aug. 1, and will become effective for discharges on or after Oct. 1. Although CMS will continue to expand the total number of measures that need to be reported, and the penalties for non-reporting or low performance will continue to escalate, CMS is at least attempting to reduce the overall burden of reporting by combining measures and programs over time and using EHRs to facilitate the bulk of reporting over time.

The global message to hospitalists is: Continue to focus on reducing the burden of HACs, enhance throughput, and carefully and thoughtfully transition patients to the next provider after their hospital discharge. All in all, although at times this can feel overwhelming, these changes represent the right direction to move for high-quality and safe patient care.

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

Reference

1. Centers for Medicare & Medicaid. Fact Sheets: CMS proposals to improve quality of care during hospital inpatient stays. Centers for Medicare & Medicaid website. Available at: www.cms.gov/apps/media/press/factsheet.asp?Counter=4586&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=6&intPage=&showAll=&pYear=&year=&desc=&cboOrder=date. Accessed May 1, 2013.

The Centers for Medicare & Medicaid Services (CMS) recently released a few Fact Sheets on how they anticipate funding changes on a few of their programs that were implemented (or sustained) under the Affordable Care Act. As a background, CMS pays most acute-care hospitals by prospectively determining payment based on a patient’s diagnosis and the severity of illness within that diagnosis (e.g. “MS-DRG”). These payment amounts are updated annually after evaluating several factors, including the costs associated with the delivery of care.

One of the most major changes described in the Fact Sheet that will affect hospitalists is how CMS will review inpatient stays based on the number of nights in the hospital. CMS has proposed that any patient who stays in the hospital for two or more “midnights” should be appropriate for payment under Medicare Part A. For those who stay in the hospital for only one (or zero) midnights, payment under Medicare Part A will only be appropriate if:

1. There is sufficient documentation at the time of admission that the anticipated length of stay is two or more nights; and.
2. Further documentation that circumstances changed, and the hospital stay ended prematurely because of those changes.

Overall for hospitalists, this should substantially simplify the admitting process, whereby most inpatients being admitted with the anticipation of two or more nights should qualify for an inpatient stay. This also reduces the administrative burden of correcting the “inpatient” versus “observation” designation, which keeps many hospital staffs entirely too busy. This change also should relieve a significant burden from the patients and their families, who if kept in observation for a period of time, may have to pay substantially out of pocket to make up for the difference between the cost of the stay and the reimbursement from CMS for observation status. So this is one of the moves that CMS is making to simplify (and not complicate) an already too-complicated payment system. This should go into effect October 2013 and will be a sigh of much relief from many of us.

A few other anticipated changes that will affect hospitalists include:

Payments for Unfunded Care

Another major change that will go into affect October 2013 is the amount of monies received by hospitals that care for unfunded patients. These payments historically have been made to “Disproportionate Share Hospitals” (DSH), which are hospitals that care for a higher percentage of unfunded patients. Under the Affordable Care Act, only 25% of these payments will be distributed to DSH hospitals; the remaining 75% will be reduced based on the number of uninsured in the U.S., then redistributed to DSH hospitals based on their portion of uninsured care delivered.

Most DSH hospitals should expect a decrease in DSH payments, the amount of which will depend on their share of unfunded patients.

Any reduction in the “bottom line” to the hospital can affect hospitalists, especially those who are directly employed by the hospital.

Hospital-Acquired Conditions

CMS has long had the Hospital-Acquired Condition (HAC) program in effect, which has the ability to reduce the amount of payment for inpatients who acquire a HAC during their hospital stay. Starting in October 2014, CMS will impose additional financial penalties for hospitals with high HAC rates.

Specifically, those hospitals in the highest 25th percentile of HAC rates will be penalized 1% of their overall CMS payments. Another proposed change is that the following be included in the HAC reduction plan (two “domains” of measures):

• Domain No. 1: Six of the AHRQ Patient Safety Indicators (PSIs), including pressure ulcers, foreign bodies left in after surgery, iatrogenic pneumothorax, postoperative physiologic or metabolic derangements, postoperative VTE, and accidental puncture/laceration.
• Domain No. 2: Central-line-associated bloodstream infections (CLABSI) and catheter-associated urinary tract infections (CAUTIs).

The domains will be weighted equally, and an average score will determine the total score. There will be some methodology for risk adjustment, and hospitals will be given a review and comment period to validate their own scores.

Most hospitalists have at least indirect control over many of these HACs,and all need to pay very close attention to their hospital’s rates of these now and in the future.

Readmissions

As we all know, the Hospital Readmission Reduction program went into effect October 2012; it placed 1% of CMS payments at risk. This will increase to 2% of payments as of October 2013. CMS will continue to use AMI, CHF, and pneumonia as the three conditions under which the readmissions are measured but will put in some methodology to account for planned readmissions.

In addition, in October 2014, they plan to add readmission rates for COPD and for hip/knee arthroplasty.

Hospitalists will continue to need to progress their transitions of care programs, at least for these five patients conditions but more likely (and more effectively) for all hospital discharges.

Quality Measures

Currently more than 99% of acute-care hospitals participate in the pay-for-reporting quality program through CMS, the results of which have been displayed on the Hospital Compare website (www.hospitalcompare.hhs.gov) for years. The program started in 2004 with 10 quality metrics and now includes 57 metrics. These include process and outcome measures for AMI, CHF, and pneumonia, as well as process measures for surgical care, HACs, and patient-satisfaction surveys, among others.

This program will continue to expand over time, including hospital-acquired MRSA and Clostridium difficile rates. The few hospitals not participating will have their CMS annual payments reduced by 2%.

EHR Incentives

CMS is evaluating ways to reduce the burden of reporting by aligning EHR incentives with the Inpatient Quality Reporting program.

Summary

After an open commentary period, the Final Rule will be published Aug. 1, and will become effective for discharges on or after Oct. 1. Although CMS will continue to expand the total number of measures that need to be reported, and the penalties for non-reporting or low performance will continue to escalate, CMS is at least attempting to reduce the overall burden of reporting by combining measures and programs over time and using EHRs to facilitate the bulk of reporting over time.

The global message to hospitalists is: Continue to focus on reducing the burden of HACs, enhance throughput, and carefully and thoughtfully transition patients to the next provider after their hospital discharge. All in all, although at times this can feel overwhelming, these changes represent the right direction to move for high-quality and safe patient care.

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

Reference

1. Centers for Medicare & Medicaid. Fact Sheets: CMS proposals to improve quality of care during hospital inpatient stays. Centers for Medicare & Medicaid website. Available at: www.cms.gov/apps/media/press/factsheet.asp?Counter=4586&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=6&intPage=&showAll=&pYear=&year=&desc=&cboOrder=date. Accessed May 1, 2013.

Dr. Hospitalist

I am a third-year internal-medicine resident and currently looking for a nocturnist opportunity. I have no experience in negotiating a job or salary. When I interview for a job, should I negotiate for salary? How do I know that the salary is correct and what others in the same group are getting? Thanks for the help.

–Santhosh Mannem, New York City

Dr. Hospitalist responds:

Salary discussions are always intriguing, mainly because you won’t really know what everyone else is getting paid. There are several places to get some information. To begin, find out the general salary range for the market in which you want to work. Just because an annual salary might be $240,000 in Emporia, Kan., doesn’t mean a thing if you are looking for a job in Salt Lake City or Seattle. You can use the online resources through SHM (www.hospitalmedicine.org/survey) to paint a pretty good picture of salary by region, but remember that these are ranges only.

When I think of job offers, I like to take total compensation and break it down by category. For example, benefits are not negotiable—your employer cannot vary the health insurance coverage they provide by physician. Still, you need to consider benefits as an important part of the package. A good health insurance plan won’t mean as much to a single physician as it would to one with a family, so consider your individual needs. I strongly encourage you to make a line item for every potential benefit: health, dental, disability, life, continuing medical education (CME), professional dues, retirement plans (potentially with an employer match), malpractice insurance costs, and so on. A job with a “salary” of $300,000 but no benefits would pale in comparison to a job paying $250,000 with full benefits.

Don’t discount the value of benefits; get the numbers and assign a dollar amount. If the group is not being transparent on benefits, walk away.

With strict regard to salary, you probably will get little to no information as to what the rest of the group members are paid. Feel free to ask, but expect some vague answers. Most often, there is a fairly tight convergence of salaries within a given market, and it’s always better to interview for more than one job in the same location. You mentioned that you’d like to work as a nocturnist, which is good. These positions are recruited heavily and tend to command a higher initial salary.

Overall, your ability to negotiate a higher salary is going to be rather limited. However, there is another calculation worth mentioning: You need to find out how much you are being paid per unit of work so you can compare jobs. Here are some of the items to help you figure out a formula that works for you: annual salary, contracted shifts per year/month, pay per shift, admits/census per shift, number of weekends, and potential bonus thresholds. Use these numbers (metrics) to more accurately compare different jobs. There is no magic formula; it just depends on what is important to you, but you will get a much better picture if you combine these metrics with your benefit analysis.

As a nocturnist, I would not expect to hit any productivity metrics. If you are that busy, it’s probably a miserable job. In a business sense, nights almost always lose money.

One thing that can always be negotiated: a signing bonus and/or loan forgiveness. Often, a practice won’t want to continually offer higher starting salaries since eventually this causes wage creep across the practice. However, they can be much more flexible when it comes to “one-time” payments. This keeps the overall salary structure for the practice intact and is usually much more agreeable for your employer. As always, it’s a supply-and-demand issue, but if you are a nocturnist looking at a high-demand area, I would negotiate hard for a signing bonus and maybe even a contract-renewal bonus after your first year.

It never hurts to get creative, either. I remember negotiating my first job; I offered to sign a two-year contract (instead of one) if they would let me take off six months the first year. They said yes, I did some traveling that first year on my new salary, and I stayed with the practice for 11 years. Don’t get so caught up in salary numbers that you lose sight of what’s really important to you and whether the job would be the right fit.

Good luck and welcome to hospital medicine. You’ll love it.

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

Dr. Hospitalist

I am a third-year internal-medicine resident and currently looking for a nocturnist opportunity. I have no experience in negotiating a job or salary. When I interview for a job, should I negotiate for salary? How do I know that the salary is correct and what others in the same group are getting? Thanks for the help.

–Santhosh Mannem, New York City

Dr. Hospitalist responds:

Salary discussions are always intriguing, mainly because you won’t really know what everyone else is getting paid. There are several places to get some information. To begin, find out the general salary range for the market in which you want to work. Just because an annual salary might be $240,000 in Emporia, Kan., doesn’t mean a thing if you are looking for a job in Salt Lake City or Seattle. You can use the online resources through SHM (www.hospitalmedicine.org/survey) to paint a pretty good picture of salary by region, but remember that these are ranges only.

When I think of job offers, I like to take total compensation and break it down by category. For example, benefits are not negotiable—your employer cannot vary the health insurance coverage they provide by physician. Still, you need to consider benefits as an important part of the package. A good health insurance plan won’t mean as much to a single physician as it would to one with a family, so consider your individual needs. I strongly encourage you to make a line item for every potential benefit: health, dental, disability, life, continuing medical education (CME), professional dues, retirement plans (potentially with an employer match), malpractice insurance costs, and so on. A job with a “salary” of $300,000 but no benefits would pale in comparison to a job paying $250,000 with full benefits.

Don’t discount the value of benefits; get the numbers and assign a dollar amount. If the group is not being transparent on benefits, walk away.

With strict regard to salary, you probably will get little to no information as to what the rest of the group members are paid. Feel free to ask, but expect some vague answers. Most often, there is a fairly tight convergence of salaries within a given market, and it’s always better to interview for more than one job in the same location. You mentioned that you’d like to work as a nocturnist, which is good. These positions are recruited heavily and tend to command a higher initial salary.

Overall, your ability to negotiate a higher salary is going to be rather limited. However, there is another calculation worth mentioning: You need to find out how much you are being paid per unit of work so you can compare jobs. Here are some of the items to help you figure out a formula that works for you: annual salary, contracted shifts per year/month, pay per shift, admits/census per shift, number of weekends, and potential bonus thresholds. Use these numbers (metrics) to more accurately compare different jobs. There is no magic formula; it just depends on what is important to you, but you will get a much better picture if you combine these metrics with your benefit analysis.

As a nocturnist, I would not expect to hit any productivity metrics. If you are that busy, it’s probably a miserable job. In a business sense, nights almost always lose money.

One thing that can always be negotiated: a signing bonus and/or loan forgiveness. Often, a practice won’t want to continually offer higher starting salaries since eventually this causes wage creep across the practice. However, they can be much more flexible when it comes to “one-time” payments. This keeps the overall salary structure for the practice intact and is usually much more agreeable for your employer. As always, it’s a supply-and-demand issue, but if you are a nocturnist looking at a high-demand area, I would negotiate hard for a signing bonus and maybe even a contract-renewal bonus after your first year.

It never hurts to get creative, either. I remember negotiating my first job; I offered to sign a two-year contract (instead of one) if they would let me take off six months the first year. They said yes, I did some traveling that first year on my new salary, and I stayed with the practice for 11 years. Don’t get so caught up in salary numbers that you lose sight of what’s really important to you and whether the job would be the right fit.

Good luck and welcome to hospital medicine. You’ll love it.

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

Dr. Hospitalist

I am a third-year internal-medicine resident and currently looking for a nocturnist opportunity. I have no experience in negotiating a job or salary. When I interview for a job, should I negotiate for salary? How do I know that the salary is correct and what others in the same group are getting? Thanks for the help.

–Santhosh Mannem, New York City

Dr. Hospitalist responds:

Salary discussions are always intriguing, mainly because you won’t really know what everyone else is getting paid. There are several places to get some information. To begin, find out the general salary range for the market in which you want to work. Just because an annual salary might be $240,000 in Emporia, Kan., doesn’t mean a thing if you are looking for a job in Salt Lake City or Seattle. You can use the online resources through SHM (www.hospitalmedicine.org/survey) to paint a pretty good picture of salary by region, but remember that these are ranges only.

When I think of job offers, I like to take total compensation and break it down by category. For example, benefits are not negotiable—your employer cannot vary the health insurance coverage they provide by physician. Still, you need to consider benefits as an important part of the package. A good health insurance plan won’t mean as much to a single physician as it would to one with a family, so consider your individual needs. I strongly encourage you to make a line item for every potential benefit: health, dental, disability, life, continuing medical education (CME), professional dues, retirement plans (potentially with an employer match), malpractice insurance costs, and so on. A job with a “salary” of $300,000 but no benefits would pale in comparison to a job paying $250,000 with full benefits.

Don’t discount the value of benefits; get the numbers and assign a dollar amount. If the group is not being transparent on benefits, walk away.

With strict regard to salary, you probably will get little to no information as to what the rest of the group members are paid. Feel free to ask, but expect some vague answers. Most often, there is a fairly tight convergence of salaries within a given market, and it’s always better to interview for more than one job in the same location. You mentioned that you’d like to work as a nocturnist, which is good. These positions are recruited heavily and tend to command a higher initial salary.

Overall, your ability to negotiate a higher salary is going to be rather limited. However, there is another calculation worth mentioning: You need to find out how much you are being paid per unit of work so you can compare jobs. Here are some of the items to help you figure out a formula that works for you: annual salary, contracted shifts per year/month, pay per shift, admits/census per shift, number of weekends, and potential bonus thresholds. Use these numbers (metrics) to more accurately compare different jobs. There is no magic formula; it just depends on what is important to you, but you will get a much better picture if you combine these metrics with your benefit analysis.

As a nocturnist, I would not expect to hit any productivity metrics. If you are that busy, it’s probably a miserable job. In a business sense, nights almost always lose money.

One thing that can always be negotiated: a signing bonus and/or loan forgiveness. Often, a practice won’t want to continually offer higher starting salaries since eventually this causes wage creep across the practice. However, they can be much more flexible when it comes to “one-time” payments. This keeps the overall salary structure for the practice intact and is usually much more agreeable for your employer. As always, it’s a supply-and-demand issue, but if you are a nocturnist looking at a high-demand area, I would negotiate hard for a signing bonus and maybe even a contract-renewal bonus after your first year.

It never hurts to get creative, either. I remember negotiating my first job; I offered to sign a two-year contract (instead of one) if they would let me take off six months the first year. They said yes, I did some traveling that first year on my new salary, and I stayed with the practice for 11 years. Don’t get so caught up in salary numbers that you lose sight of what’s really important to you and whether the job would be the right fit.

Good luck and welcome to hospital medicine. You’ll love it.

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

A new study shows that hospitalized patients who were more engaged in their own care produced higher costs and longer lengths of stay (LOS).

The report, "Association of Patient Preferences for Participation in Decision Making With Length of Stay and Costs Among Hospitalized Patients," published in JAMA Internal Medicine, used a survey of 21,754 patients in one academic setting to determine their preferences on shared decision-making. The information was later linked to administrative data.

Patients who said they preferred to participate in decision-making with their physicians had a 0.26-day (95% CI, 0.06-0.47 day) longer LOS (P=0.01) and incurred an average of $865 (95% CI, $155-$1,575) in higher total hospitalization costs (P=0.02). Patients with higher education levels and private health insurance were more likely than others to want to participate in decision-making with doctors, the authors noted.

Lead author Hyo Jung Tak, PhD, of the department of medicine at the University of Chicago says that while the results don't mean that patient-centered care directly drives up costs, it is important not to accept at face value that engaged patients lead to reduced health-care-delivery costs.

“These days,” she adds, “many researchers and policymakers expect that patient-centered care could help to reduce medical utilization as it could prevent costly interventions that patients may not want, but I think people should be more careful in terms of how it really applies in the clinical setting.”

Dr. Tak cautions that many variables could affect how a similar study would work at other hospitals, including an institution’s payor mix and the socioeconomic status of its service area. She said a potentially larger issue is why some patients strongly disagree with the idea of leaving medical decisions up to their physicians.

“If we can find that answer, that could help to improve patient-centered care in the future,” Dr. Tak adds. “That could be the ultimate question in this study.”

Visit our website for more information on patient-centered care.

A new study shows that hospitalized patients who were more engaged in their own care produced higher costs and longer lengths of stay (LOS).

The report, "Association of Patient Preferences for Participation in Decision Making With Length of Stay and Costs Among Hospitalized Patients," published in JAMA Internal Medicine, used a survey of 21,754 patients in one academic setting to determine their preferences on shared decision-making. The information was later linked to administrative data.

Patients who said they preferred to participate in decision-making with their physicians had a 0.26-day (95% CI, 0.06-0.47 day) longer LOS (P=0.01) and incurred an average of $865 (95% CI, $155-$1,575) in higher total hospitalization costs (P=0.02). Patients with higher education levels and private health insurance were more likely than others to want to participate in decision-making with doctors, the authors noted.

Lead author Hyo Jung Tak, PhD, of the department of medicine at the University of Chicago says that while the results don't mean that patient-centered care directly drives up costs, it is important not to accept at face value that engaged patients lead to reduced health-care-delivery costs.

“These days,” she adds, “many researchers and policymakers expect that patient-centered care could help to reduce medical utilization as it could prevent costly interventions that patients may not want, but I think people should be more careful in terms of how it really applies in the clinical setting.”

Dr. Tak cautions that many variables could affect how a similar study would work at other hospitals, including an institution’s payor mix and the socioeconomic status of its service area. She said a potentially larger issue is why some patients strongly disagree with the idea of leaving medical decisions up to their physicians.

“If we can find that answer, that could help to improve patient-centered care in the future,” Dr. Tak adds. “That could be the ultimate question in this study.”

Visit our website for more information on patient-centered care.

A new study shows that hospitalized patients who were more engaged in their own care produced higher costs and longer lengths of stay (LOS).

The report, "Association of Patient Preferences for Participation in Decision Making With Length of Stay and Costs Among Hospitalized Patients," published in JAMA Internal Medicine, used a survey of 21,754 patients in one academic setting to determine their preferences on shared decision-making. The information was later linked to administrative data.

Patients who said they preferred to participate in decision-making with their physicians had a 0.26-day (95% CI, 0.06-0.47 day) longer LOS (P=0.01) and incurred an average of $865 (95% CI, $155-$1,575) in higher total hospitalization costs (P=0.02). Patients with higher education levels and private health insurance were more likely than others to want to participate in decision-making with doctors, the authors noted.

Lead author Hyo Jung Tak, PhD, of the department of medicine at the University of Chicago says that while the results don't mean that patient-centered care directly drives up costs, it is important not to accept at face value that engaged patients lead to reduced health-care-delivery costs.

“These days,” she adds, “many researchers and policymakers expect that patient-centered care could help to reduce medical utilization as it could prevent costly interventions that patients may not want, but I think people should be more careful in terms of how it really applies in the clinical setting.”

Dr. Tak cautions that many variables could affect how a similar study would work at other hospitals, including an institution’s payor mix and the socioeconomic status of its service area. She said a potentially larger issue is why some patients strongly disagree with the idea of leaving medical decisions up to their physicians.

“If we can find that answer, that could help to improve patient-centered care in the future,” Dr. Tak adds. “That could be the ultimate question in this study.”

Visit our website for more information on patient-centered care.

Clinical question: Are patients able to select health-care providers based on price of service?

Background: With health-care costs rising, patients are encouraged to take a more active role in cost containment. Many initiatives call for greater pricing transparency in the health-care system. This study evaluated price availability for a common surgical procedure.

Study design: Telephone inquiries with standardized interview script.

Setting: Twenty top-ranked orthopedic hospitals and 102 non-top-ranked U.S. hospitals.

Synopsis: Hospitals were contacted by phone with a standardized, scripted request for the price of an elective total hip arthroplasty. The script described the patient as a 62-year-old grandmother without insurance who is able to pay out of pocket and wishes to compare hospital prices. On the first or second attempt, 40% of top-ranked and 32% of non-top-ranked hospitals were able to provide their price; after five attempts, authors were unable to obtain full pricing information (both hospital and physician fee) from 40% of top-ranked and 37% of non-top-ranked hospitals. Neither fee was made available by 15% of top-ranked and 16% of non-top-ranked hospitals. Wide variation in pricing was found across hospitals. The authors commented on the difficulties they encountered, such as the transfer of calls between departments and the uncertainty of representatives on how to assist.

Bottom line: For individual patients, applying basic economic principles as a consumer might be tiresome and often impossible, with no major differences between top-ranked and non-top-ranked hospitals.

Citation: Rosenthal JA, Lu X, Cram P. Availability of consumer prices from US hospitals for a common surgical procedure. JAMA Intern Med. 2013;173(6):427-432.

Visit our website for more physician reviews of recent HM-relevant literature.

Clinical question: Are patients able to select health-care providers based on price of service?

Background: With health-care costs rising, patients are encouraged to take a more active role in cost containment. Many initiatives call for greater pricing transparency in the health-care system. This study evaluated price availability for a common surgical procedure.

Study design: Telephone inquiries with standardized interview script.

Setting: Twenty top-ranked orthopedic hospitals and 102 non-top-ranked U.S. hospitals.

Synopsis: Hospitals were contacted by phone with a standardized, scripted request for the price of an elective total hip arthroplasty. The script described the patient as a 62-year-old grandmother without insurance who is able to pay out of pocket and wishes to compare hospital prices. On the first or second attempt, 40% of top-ranked and 32% of non-top-ranked hospitals were able to provide their price; after five attempts, authors were unable to obtain full pricing information (both hospital and physician fee) from 40% of top-ranked and 37% of non-top-ranked hospitals. Neither fee was made available by 15% of top-ranked and 16% of non-top-ranked hospitals. Wide variation in pricing was found across hospitals. The authors commented on the difficulties they encountered, such as the transfer of calls between departments and the uncertainty of representatives on how to assist.

Bottom line: For individual patients, applying basic economic principles as a consumer might be tiresome and often impossible, with no major differences between top-ranked and non-top-ranked hospitals.

Citation: Rosenthal JA, Lu X, Cram P. Availability of consumer prices from US hospitals for a common surgical procedure. JAMA Intern Med. 2013;173(6):427-432.

Visit our website for more physician reviews of recent HM-relevant literature.

Clinical question: Are patients able to select health-care providers based on price of service?

Background: With health-care costs rising, patients are encouraged to take a more active role in cost containment. Many initiatives call for greater pricing transparency in the health-care system. This study evaluated price availability for a common surgical procedure.

Study design: Telephone inquiries with standardized interview script.

Setting: Twenty top-ranked orthopedic hospitals and 102 non-top-ranked U.S. hospitals.

Synopsis: Hospitals were contacted by phone with a standardized, scripted request for the price of an elective total hip arthroplasty. The script described the patient as a 62-year-old grandmother without insurance who is able to pay out of pocket and wishes to compare hospital prices. On the first or second attempt, 40% of top-ranked and 32% of non-top-ranked hospitals were able to provide their price; after five attempts, authors were unable to obtain full pricing information (both hospital and physician fee) from 40% of top-ranked and 37% of non-top-ranked hospitals. Neither fee was made available by 15% of top-ranked and 16% of non-top-ranked hospitals. Wide variation in pricing was found across hospitals. The authors commented on the difficulties they encountered, such as the transfer of calls between departments and the uncertainty of representatives on how to assist.

Bottom line: For individual patients, applying basic economic principles as a consumer might be tiresome and often impossible, with no major differences between top-ranked and non-top-ranked hospitals.

Citation: Rosenthal JA, Lu X, Cram P. Availability of consumer prices from US hospitals for a common surgical procedure. JAMA Intern Med. 2013;173(6):427-432.

Visit our website for more physician reviews of recent HM-relevant literature.

Many hospitalists are anxious about looming changes to the American Board of Medicine’s (ABIM) Maintenance of Certification (MOC) process, but hospital medicine leaders say the effect will be positive.

In January, ABIM and the American Board of Medical Specialties (ABMS) will begin reporting on whether hospitalists and other physicians are meeting MOC requirements. To do so, physicians need to complete 20 ABIM MOC points by December 2015, and every two years after that. Physicians also need to earn 100 ABIM MOC points by December 2018, and every five years after that.

Previously, physicians had to amass a total of 100 points every 10 years between secure exams. The new rules are aimed at keeping “pace with the changes in the science of medicine and assessment,” ABIM says on its website.

“I think the anxiety is coming out of it being misunderstood,” says Jeff Wiese, MD, MHM, professor of medicine and associate dean for graduate medical education at Tulane University Health Sciences Center in New Orleans. “It’s not that big of a deal when you put it in the context of what you do for CME now.”

Dr. Wiese emphasizes the secure exam will still be taken every 10 years, but increasing the frequency of learning via practice-improvement modules (PIMs) and other vehicles should serve to improve hospitalists’ efficiency and care delivery.

Ethan Cumbler, MD, FACP, of the University of Colorado at Denver, an annual faculty member for the ABIM’s MOC pre-course at SHM’s annual meetings, says that codifying additional learning is a good thing for the specialty. “If the point of this is to actually improve how we’re practicing as doctors, then we do want to be practicing this in an ongoing fashion,” Dr. Cumbler says.

Visit our website for more information on CME.

Many hospitalists are anxious about looming changes to the American Board of Medicine’s (ABIM) Maintenance of Certification (MOC) process, but hospital medicine leaders say the effect will be positive.

In January, ABIM and the American Board of Medical Specialties (ABMS) will begin reporting on whether hospitalists and other physicians are meeting MOC requirements. To do so, physicians need to complete 20 ABIM MOC points by December 2015, and every two years after that. Physicians also need to earn 100 ABIM MOC points by December 2018, and every five years after that.

Previously, physicians had to amass a total of 100 points every 10 years between secure exams. The new rules are aimed at keeping “pace with the changes in the science of medicine and assessment,” ABIM says on its website.

“I think the anxiety is coming out of it being misunderstood,” says Jeff Wiese, MD, MHM, professor of medicine and associate dean for graduate medical education at Tulane University Health Sciences Center in New Orleans. “It’s not that big of a deal when you put it in the context of what you do for CME now.”

Dr. Wiese emphasizes the secure exam will still be taken every 10 years, but increasing the frequency of learning via practice-improvement modules (PIMs) and other vehicles should serve to improve hospitalists’ efficiency and care delivery.

Ethan Cumbler, MD, FACP, of the University of Colorado at Denver, an annual faculty member for the ABIM’s MOC pre-course at SHM’s annual meetings, says that codifying additional learning is a good thing for the specialty. “If the point of this is to actually improve how we’re practicing as doctors, then we do want to be practicing this in an ongoing fashion,” Dr. Cumbler says.

Visit our website for more information on CME.

Many hospitalists are anxious about looming changes to the American Board of Medicine’s (ABIM) Maintenance of Certification (MOC) process, but hospital medicine leaders say the effect will be positive.

In January, ABIM and the American Board of Medical Specialties (ABMS) will begin reporting on whether hospitalists and other physicians are meeting MOC requirements. To do so, physicians need to complete 20 ABIM MOC points by December 2015, and every two years after that. Physicians also need to earn 100 ABIM MOC points by December 2018, and every five years after that.

Previously, physicians had to amass a total of 100 points every 10 years between secure exams. The new rules are aimed at keeping “pace with the changes in the science of medicine and assessment,” ABIM says on its website.

“I think the anxiety is coming out of it being misunderstood,” says Jeff Wiese, MD, MHM, professor of medicine and associate dean for graduate medical education at Tulane University Health Sciences Center in New Orleans. “It’s not that big of a deal when you put it in the context of what you do for CME now.”

Dr. Wiese emphasizes the secure exam will still be taken every 10 years, but increasing the frequency of learning via practice-improvement modules (PIMs) and other vehicles should serve to improve hospitalists’ efficiency and care delivery.

Ethan Cumbler, MD, FACP, of the University of Colorado at Denver, an annual faculty member for the ABIM’s MOC pre-course at SHM’s annual meetings, says that codifying additional learning is a good thing for the specialty. “If the point of this is to actually improve how we’re practicing as doctors, then we do want to be practicing this in an ongoing fashion,” Dr. Cumbler says.

Visit our website for more information on CME.