Managing Your Practice

A recent survey of nearly 1,000 students from three medical schools found that just 15% planned to become primary-care physicians, including 11.2% of first-year students.¹

That startlingly low number might not be reflective of the whole country, and other national surveys have suggested significantly higher rates. But the responses underscore some important contributors beyond financial concerns that include a more negative overall view of PCPs’ work life compared to that of specialists. “Our data suggest that although medical school does not create these negative views of primary-care work life, it may reinforce them,” the authors write.

Conversely, the results suggest that time spent observing physicians could help break negative stereotypes about the ability to develop good relationships with patients, and that career plans might not be based on perceptions, but rather on values and goals. “The study reinforces the importance of admitting students with primary-care-oriented values and primary-care interest and reinforcing those values over the course of medical school,” the authors conclude.

“Maybe we’re not selecting medical students in the optimal way for what society needs,” says Elbert Huang, MD, associate professor of medicine at the University of Chicago. By emphasizing GPA and test scores, “maybe when you do that, you end with people who don’t want to actually take care of patients in primary care.”

Other studies suggest he’s on to something. Research conducted by the Washington, D.C.-based Robert Graham Center found that students in rural medical schools are significantly more likely to go into rural healthcare and primary care than students in urban medical schools.

“The problem there is that we’ve cut the number of people from rural areas going to medical school by half over the last 20 years,” center director Robert Phillips, MD, MSPH, says. “A lot of students just don’t have the background to make them competitive.” Many students in minority communities face similar challenges.

Ed Salsberg, director of the National Center for Health Workforce Analysis in the Health Resources and Services Administration, says many newer osteopathic schools are positioning themselves in rural communities, helping them attract students who might not have gone to medical school otherwise.

Reaching back even earlier into the pipeline to help mentor elementary and high school students might be another way to help build capacity. Medical organizations also seem to be getting the message. New MCAT recommendations by the Association of American Medical Colleges, for example, place less emphasis on scientific knowledge in favor of a more holistic assessment of critical analysis and reasoning skills. The association also is encouraging medical schools to pay more attention to such personal characteristics as integrity and service orientation.

“That’s more of a long-term strategy, but I think it has an impact on who gets recruited to medical school,” Salsberg says.

Reference

1. Phillips J, Weismantel D, Gold K, Schwenk T. How do medical students view the work life of primary care and specialty physicians? Fam Med. 2012;44(1):7-13.

A recent survey of nearly 1,000 students from three medical schools found that just 15% planned to become primary-care physicians, including 11.2% of first-year students.¹

That startlingly low number might not be reflective of the whole country, and other national surveys have suggested significantly higher rates. But the responses underscore some important contributors beyond financial concerns that include a more negative overall view of PCPs’ work life compared to that of specialists. “Our data suggest that although medical school does not create these negative views of primary-care work life, it may reinforce them,” the authors write.

Conversely, the results suggest that time spent observing physicians could help break negative stereotypes about the ability to develop good relationships with patients, and that career plans might not be based on perceptions, but rather on values and goals. “The study reinforces the importance of admitting students with primary-care-oriented values and primary-care interest and reinforcing those values over the course of medical school,” the authors conclude.

“Maybe we’re not selecting medical students in the optimal way for what society needs,” says Elbert Huang, MD, associate professor of medicine at the University of Chicago. By emphasizing GPA and test scores, “maybe when you do that, you end with people who don’t want to actually take care of patients in primary care.”

Other studies suggest he’s on to something. Research conducted by the Washington, D.C.-based Robert Graham Center found that students in rural medical schools are significantly more likely to go into rural healthcare and primary care than students in urban medical schools.

“The problem there is that we’ve cut the number of people from rural areas going to medical school by half over the last 20 years,” center director Robert Phillips, MD, MSPH, says. “A lot of students just don’t have the background to make them competitive.” Many students in minority communities face similar challenges.

Ed Salsberg, director of the National Center for Health Workforce Analysis in the Health Resources and Services Administration, says many newer osteopathic schools are positioning themselves in rural communities, helping them attract students who might not have gone to medical school otherwise.

Reaching back even earlier into the pipeline to help mentor elementary and high school students might be another way to help build capacity. Medical organizations also seem to be getting the message. New MCAT recommendations by the Association of American Medical Colleges, for example, place less emphasis on scientific knowledge in favor of a more holistic assessment of critical analysis and reasoning skills. The association also is encouraging medical schools to pay more attention to such personal characteristics as integrity and service orientation.

“That’s more of a long-term strategy, but I think it has an impact on who gets recruited to medical school,” Salsberg says.

Reference

1. Phillips J, Weismantel D, Gold K, Schwenk T. How do medical students view the work life of primary care and specialty physicians? Fam Med. 2012;44(1):7-13.

A recent survey of nearly 1,000 students from three medical schools found that just 15% planned to become primary-care physicians, including 11.2% of first-year students.¹

That startlingly low number might not be reflective of the whole country, and other national surveys have suggested significantly higher rates. But the responses underscore some important contributors beyond financial concerns that include a more negative overall view of PCPs’ work life compared to that of specialists. “Our data suggest that although medical school does not create these negative views of primary-care work life, it may reinforce them,” the authors write.

Conversely, the results suggest that time spent observing physicians could help break negative stereotypes about the ability to develop good relationships with patients, and that career plans might not be based on perceptions, but rather on values and goals. “The study reinforces the importance of admitting students with primary-care-oriented values and primary-care interest and reinforcing those values over the course of medical school,” the authors conclude.

“Maybe we’re not selecting medical students in the optimal way for what society needs,” says Elbert Huang, MD, associate professor of medicine at the University of Chicago. By emphasizing GPA and test scores, “maybe when you do that, you end with people who don’t want to actually take care of patients in primary care.”

Other studies suggest he’s on to something. Research conducted by the Washington, D.C.-based Robert Graham Center found that students in rural medical schools are significantly more likely to go into rural healthcare and primary care than students in urban medical schools.

“The problem there is that we’ve cut the number of people from rural areas going to medical school by half over the last 20 years,” center director Robert Phillips, MD, MSPH, says. “A lot of students just don’t have the background to make them competitive.” Many students in minority communities face similar challenges.

Ed Salsberg, director of the National Center for Health Workforce Analysis in the Health Resources and Services Administration, says many newer osteopathic schools are positioning themselves in rural communities, helping them attract students who might not have gone to medical school otherwise.

Reaching back even earlier into the pipeline to help mentor elementary and high school students might be another way to help build capacity. Medical organizations also seem to be getting the message. New MCAT recommendations by the Association of American Medical Colleges, for example, place less emphasis on scientific knowledge in favor of a more holistic assessment of critical analysis and reasoning skills. The association also is encouraging medical schools to pay more attention to such personal characteristics as integrity and service orientation.

“That’s more of a long-term strategy, but I think it has an impact on who gets recruited to medical school,” Salsberg says.

Reference

1. Phillips J, Weismantel D, Gold K, Schwenk T. How do medical students view the work life of primary care and specialty physicians? Fam Med. 2012;44(1):7-13.

Click here to listen to Dr. Arora

Click here to listen to Dr. Arora

Click here to listen to Dr. Arora

Hospitalist Jason Adelman, MD, MS, believes computerized physician order-entry (CPOE) systems improve workflow and help prevent many mistakes, but the automation also causes mistakes as physicians toggle back and forth between screens in the system interface.

Dr. Adelman, patient safety officer at Montefiore Medical Center in the Bronx, N.Y., and colleagues developed an automated method for measuring wrong-patient electronic orders. They found that systems that compel physicians to re-enter certain information reduced errors.

CPOE systems have "certainly prevented errors," he says, "but they've unintentionally caused errors, and the name of the game is to keep working on ways to prevent more and more errors and minimize those errors unintentionally caused by these systems."

The researchers hypothesized that some wrong-patient orders are recognized by the orderer shortly after entry, promptly retracted, then re-entered on the correct patient. Their study results, published in the Journal of the American Medical Informatics Association, used a "retract and reorder" measurement tool that flagged any orders placed on a patient that were quickly retracted and replaced with a new order set.

Using the tool, Dr. Adleman and his research team estimated that 5,246 orders were placed on the wrong patients in 2009 at Montefiore.

The study also showed that interventions helped lower the odds of wrong-patient errors. One method made physicians click on a link to verify a patient’s identity, while another required the physician to manually input information to confirm the patient’s identity. Potential other interventions included using photo identification to ensure that physicians entered orders correctly.

"I think the goal is to try to get perfection," Dr. Adelman says. "I don't know if you could ever get totally there ... but you try."

Hospitalist Jason Adelman, MD, MS, believes computerized physician order-entry (CPOE) systems improve workflow and help prevent many mistakes, but the automation also causes mistakes as physicians toggle back and forth between screens in the system interface.

Dr. Adelman, patient safety officer at Montefiore Medical Center in the Bronx, N.Y., and colleagues developed an automated method for measuring wrong-patient electronic orders. They found that systems that compel physicians to re-enter certain information reduced errors.

CPOE systems have "certainly prevented errors," he says, "but they've unintentionally caused errors, and the name of the game is to keep working on ways to prevent more and more errors and minimize those errors unintentionally caused by these systems."

The researchers hypothesized that some wrong-patient orders are recognized by the orderer shortly after entry, promptly retracted, then re-entered on the correct patient. Their study results, published in the Journal of the American Medical Informatics Association, used a "retract and reorder" measurement tool that flagged any orders placed on a patient that were quickly retracted and replaced with a new order set.

Using the tool, Dr. Adleman and his research team estimated that 5,246 orders were placed on the wrong patients in 2009 at Montefiore.

The study also showed that interventions helped lower the odds of wrong-patient errors. One method made physicians click on a link to verify a patient’s identity, while another required the physician to manually input information to confirm the patient’s identity. Potential other interventions included using photo identification to ensure that physicians entered orders correctly.

"I think the goal is to try to get perfection," Dr. Adelman says. "I don't know if you could ever get totally there ... but you try."

Hospitalist Jason Adelman, MD, MS, believes computerized physician order-entry (CPOE) systems improve workflow and help prevent many mistakes, but the automation also causes mistakes as physicians toggle back and forth between screens in the system interface.

Dr. Adelman, patient safety officer at Montefiore Medical Center in the Bronx, N.Y., and colleagues developed an automated method for measuring wrong-patient electronic orders. They found that systems that compel physicians to re-enter certain information reduced errors.

CPOE systems have "certainly prevented errors," he says, "but they've unintentionally caused errors, and the name of the game is to keep working on ways to prevent more and more errors and minimize those errors unintentionally caused by these systems."

The researchers hypothesized that some wrong-patient orders are recognized by the orderer shortly after entry, promptly retracted, then re-entered on the correct patient. Their study results, published in the Journal of the American Medical Informatics Association, used a "retract and reorder" measurement tool that flagged any orders placed on a patient that were quickly retracted and replaced with a new order set.

Using the tool, Dr. Adleman and his research team estimated that 5,246 orders were placed on the wrong patients in 2009 at Montefiore.

The study also showed that interventions helped lower the odds of wrong-patient errors. One method made physicians click on a link to verify a patient’s identity, while another required the physician to manually input information to confirm the patient’s identity. Potential other interventions included using photo identification to ensure that physicians entered orders correctly.

"I think the goal is to try to get perfection," Dr. Adelman says. "I don't know if you could ever get totally there ... but you try."

Unpublished data from a British study of dedicated psychiatric hospitalists shows clear improvements in 17 of 23 measured outcomes, according to the study's lead researcher.

Julian Beezhold, MD, a consultant in emergency psychiatry at Norfolk and Suffolk NHS Foundation Trust (formerly Norfolk and Waveney Mental Health Foundation Trust) presented the data at the annual meeting of the American Psychiatric Association in May in Philadelphia.

The researchers investigated 5,000 patients over nearly eight years. By switching coverage from 13 consultant psychiatrists to dedicated-unit psychiatric hospitalists, the study showed lengths of stay on two inpatient psychiatry units cut in half (just over 11 days from nearly 22 days). Researchers also found reductions in violent episodes and self-harm. Demand for beds on the units declined steadily during the study, resulting in consolidation down to one unit.

"We found overwhelming, robust evidence showing clear benefit from a hospitalist model of care," Dr. Beezhold says. "We found that dedicated doctors are able to achieve better quality of care simply because they are there, able to respond to crises and to change treatment plans more quickly when that is needed."

Psychiatry practice differs from most specialty practice in the United Kingdom, he adds, but the recent trend has been toward a larger division between office-based and hospital-based practices.

In the U.S., models of coverage for acute psychiatric patients include specialized psychiatric hospitals, dedicated psychiatric units within general hospitals, and patients admitted to general hospital units whose psychiatric care is managed by consultation-liaison psychiatrists, says Abigail Donovan, MD, a psychiatrist at Massachusetts General Hospital in Boston.

"At Mass General, we have access to all of these approaches," she says, adding that the new data "reinforces the way we've been doing things with dedicated psychiatric hospitalists—showing the tangible results of this model."

Unpublished data from a British study of dedicated psychiatric hospitalists shows clear improvements in 17 of 23 measured outcomes, according to the study's lead researcher.

Julian Beezhold, MD, a consultant in emergency psychiatry at Norfolk and Suffolk NHS Foundation Trust (formerly Norfolk and Waveney Mental Health Foundation Trust) presented the data at the annual meeting of the American Psychiatric Association in May in Philadelphia.

The researchers investigated 5,000 patients over nearly eight years. By switching coverage from 13 consultant psychiatrists to dedicated-unit psychiatric hospitalists, the study showed lengths of stay on two inpatient psychiatry units cut in half (just over 11 days from nearly 22 days). Researchers also found reductions in violent episodes and self-harm. Demand for beds on the units declined steadily during the study, resulting in consolidation down to one unit.

"We found overwhelming, robust evidence showing clear benefit from a hospitalist model of care," Dr. Beezhold says. "We found that dedicated doctors are able to achieve better quality of care simply because they are there, able to respond to crises and to change treatment plans more quickly when that is needed."

Psychiatry practice differs from most specialty practice in the United Kingdom, he adds, but the recent trend has been toward a larger division between office-based and hospital-based practices.

In the U.S., models of coverage for acute psychiatric patients include specialized psychiatric hospitals, dedicated psychiatric units within general hospitals, and patients admitted to general hospital units whose psychiatric care is managed by consultation-liaison psychiatrists, says Abigail Donovan, MD, a psychiatrist at Massachusetts General Hospital in Boston.

"At Mass General, we have access to all of these approaches," she says, adding that the new data "reinforces the way we've been doing things with dedicated psychiatric hospitalists—showing the tangible results of this model."

Unpublished data from a British study of dedicated psychiatric hospitalists shows clear improvements in 17 of 23 measured outcomes, according to the study's lead researcher.

Julian Beezhold, MD, a consultant in emergency psychiatry at Norfolk and Suffolk NHS Foundation Trust (formerly Norfolk and Waveney Mental Health Foundation Trust) presented the data at the annual meeting of the American Psychiatric Association in May in Philadelphia.

The researchers investigated 5,000 patients over nearly eight years. By switching coverage from 13 consultant psychiatrists to dedicated-unit psychiatric hospitalists, the study showed lengths of stay on two inpatient psychiatry units cut in half (just over 11 days from nearly 22 days). Researchers also found reductions in violent episodes and self-harm. Demand for beds on the units declined steadily during the study, resulting in consolidation down to one unit.

"We found overwhelming, robust evidence showing clear benefit from a hospitalist model of care," Dr. Beezhold says. "We found that dedicated doctors are able to achieve better quality of care simply because they are there, able to respond to crises and to change treatment plans more quickly when that is needed."

Psychiatry practice differs from most specialty practice in the United Kingdom, he adds, but the recent trend has been toward a larger division between office-based and hospital-based practices.

In the U.S., models of coverage for acute psychiatric patients include specialized psychiatric hospitals, dedicated psychiatric units within general hospitals, and patients admitted to general hospital units whose psychiatric care is managed by consultation-liaison psychiatrists, says Abigail Donovan, MD, a psychiatrist at Massachusetts General Hospital in Boston.

"At Mass General, we have access to all of these approaches," she says, adding that the new data "reinforces the way we've been doing things with dedicated psychiatric hospitalists—showing the tangible results of this model."

Now that the Supreme Court has upheld the constitutionality of most of the Affordable Care Act, it behooves us to take a closer look at that law’s potential impact on physicians.

Last year I wrote that most physicians would see few changes in the near term, largely because the essential changes sought by physicians – tort reform, and revision of the ill-conceived Medicare compensation rules that threaten to cut payments by 25% every few months – were never addressed.

That said, many of the law’s provisions did favor physicians in the short term. As of last year, insurers could no longer cancel policies already issued, nor could they exclude applicants who were previously uninsurable because of chronic ailments. This provision indirectly triggered the Supreme Court’s involvement, since insurers cannot afford to cover patients with existing conditions without a mandate that all individuals purchase coverage. (Without that, healthy people would have no reason to buy insurance until they got sick, the equivalent of waiting to buy fire insurance until your house was aflame.) The case before the court centered on the constitutionality of the individual mandate, which was upheld.

Other highlights of the Affordable Care Act include prohibition of lifetime coverage limits and guaranteed coverage of dependents on their parents’ policies until they are 26 years old. Early retirees do not have to risk going uninsured until they qualify for Medicare, and Medicare’s infamous "doughnut hole" is gradually closing. Small businesses now receive tax-credit incentives to insure their workers.

All of this adds up to more paying patients, with better insurance. However, as additional provisions come online this year, the long-range potential impact on private practitioners becomes more uncertain, and more ominous.

"Physician payment reforms" will begin to appear. Although no one yet knows exactly what that means, the law mandates the formation of "accountable care organizations" to "improve quality and efficiency of care." The buzzword will be outcomes – the better your measurable results, the higher your reimbursements. This is supposed to reward quality of care over volume of procedures, but the result could be exactly the opposite if less-motivated providers cherry pick the quick, easy, least-risky cases and refer anything time consuming or complex to tertiary centers.

In 2013, Medicare will introduce a national program of payment bundling. A single hospital admission, for example, will be paid with a single bundled payment that will have to be divided among the hospital and treating physicians. The idea, ostensibly, is to encourage physicians and hospitals to work together to "better coordinate patient care," but arguments over how to divide the pie could, once again, have the opposite effect.

And it won’t take long for hospitals to figure out that they can keep the whole pie if the partnering physicians are their employees. So look for more private offices to be absorbed by hospitals, which already employ almost a third of all physicians.

By 2014, states will have to set up "SHOP Exchanges" (Small Business Health Options Programs), allowing small businesses (defined as 100 employees or less) to pool their resources to buy health insurance. Most people will, by then, be required to have health insurance coverage or pay a fine if they don’t. Employers not offering coverage will face fines and other penalties, and health insurance companies will begin paying a fee based on their market share, which will no doubt be passed along to those they insure, nullifying some of the savings garnered by the SHOP Exchanges, which are already predicted to be marginal.

The big Medicaid expansion will be in place by 2014 as well, but few physicians are likely to accept more Medicaid patients unless compensation increases. That is unlikely to happen without substantial reductions in the states’ woeful budget deficits – and probably not even then, since state governments already complain about their Medicaid budgets. Hospitals, with their deeper pockets, will get most of the new Medicaid patients and will hire even more physicians away from private practice to treat them.

If this sounds like a potential problem for private practice as we know it, it is. Then again, it’s too early for reliable predictions: The recent Supreme Court decision notwithstanding, there is a lot of potential leeway in the new law’s future specifications; and a lot can happen between now and full implementation, from modifications and amendments to outright repeal. Only time will tell.

Dr. Joseph S. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. To respond to this column, email him at our editorial offices at [email protected].

Now that the Supreme Court has upheld the constitutionality of most of the Affordable Care Act, it behooves us to take a closer look at that law’s potential impact on physicians.

Last year I wrote that most physicians would see few changes in the near term, largely because the essential changes sought by physicians – tort reform, and revision of the ill-conceived Medicare compensation rules that threaten to cut payments by 25% every few months – were never addressed.

That said, many of the law’s provisions did favor physicians in the short term. As of last year, insurers could no longer cancel policies already issued, nor could they exclude applicants who were previously uninsurable because of chronic ailments. This provision indirectly triggered the Supreme Court’s involvement, since insurers cannot afford to cover patients with existing conditions without a mandate that all individuals purchase coverage. (Without that, healthy people would have no reason to buy insurance until they got sick, the equivalent of waiting to buy fire insurance until your house was aflame.) The case before the court centered on the constitutionality of the individual mandate, which was upheld.

Other highlights of the Affordable Care Act include prohibition of lifetime coverage limits and guaranteed coverage of dependents on their parents’ policies until they are 26 years old. Early retirees do not have to risk going uninsured until they qualify for Medicare, and Medicare’s infamous "doughnut hole" is gradually closing. Small businesses now receive tax-credit incentives to insure their workers.

All of this adds up to more paying patients, with better insurance. However, as additional provisions come online this year, the long-range potential impact on private practitioners becomes more uncertain, and more ominous.

"Physician payment reforms" will begin to appear. Although no one yet knows exactly what that means, the law mandates the formation of "accountable care organizations" to "improve quality and efficiency of care." The buzzword will be outcomes – the better your measurable results, the higher your reimbursements. This is supposed to reward quality of care over volume of procedures, but the result could be exactly the opposite if less-motivated providers cherry pick the quick, easy, least-risky cases and refer anything time consuming or complex to tertiary centers.

In 2013, Medicare will introduce a national program of payment bundling. A single hospital admission, for example, will be paid with a single bundled payment that will have to be divided among the hospital and treating physicians. The idea, ostensibly, is to encourage physicians and hospitals to work together to "better coordinate patient care," but arguments over how to divide the pie could, once again, have the opposite effect.

And it won’t take long for hospitals to figure out that they can keep the whole pie if the partnering physicians are their employees. So look for more private offices to be absorbed by hospitals, which already employ almost a third of all physicians.

By 2014, states will have to set up "SHOP Exchanges" (Small Business Health Options Programs), allowing small businesses (defined as 100 employees or less) to pool their resources to buy health insurance. Most people will, by then, be required to have health insurance coverage or pay a fine if they don’t. Employers not offering coverage will face fines and other penalties, and health insurance companies will begin paying a fee based on their market share, which will no doubt be passed along to those they insure, nullifying some of the savings garnered by the SHOP Exchanges, which are already predicted to be marginal.

The big Medicaid expansion will be in place by 2014 as well, but few physicians are likely to accept more Medicaid patients unless compensation increases. That is unlikely to happen without substantial reductions in the states’ woeful budget deficits – and probably not even then, since state governments already complain about their Medicaid budgets. Hospitals, with their deeper pockets, will get most of the new Medicaid patients and will hire even more physicians away from private practice to treat them.

If this sounds like a potential problem for private practice as we know it, it is. Then again, it’s too early for reliable predictions: The recent Supreme Court decision notwithstanding, there is a lot of potential leeway in the new law’s future specifications; and a lot can happen between now and full implementation, from modifications and amendments to outright repeal. Only time will tell.

Dr. Joseph S. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. To respond to this column, email him at our editorial offices at [email protected].

Now that the Supreme Court has upheld the constitutionality of most of the Affordable Care Act, it behooves us to take a closer look at that law’s potential impact on physicians.

Last year I wrote that most physicians would see few changes in the near term, largely because the essential changes sought by physicians – tort reform, and revision of the ill-conceived Medicare compensation rules that threaten to cut payments by 25% every few months – were never addressed.

That said, many of the law’s provisions did favor physicians in the short term. As of last year, insurers could no longer cancel policies already issued, nor could they exclude applicants who were previously uninsurable because of chronic ailments. This provision indirectly triggered the Supreme Court’s involvement, since insurers cannot afford to cover patients with existing conditions without a mandate that all individuals purchase coverage. (Without that, healthy people would have no reason to buy insurance until they got sick, the equivalent of waiting to buy fire insurance until your house was aflame.) The case before the court centered on the constitutionality of the individual mandate, which was upheld.

Other highlights of the Affordable Care Act include prohibition of lifetime coverage limits and guaranteed coverage of dependents on their parents’ policies until they are 26 years old. Early retirees do not have to risk going uninsured until they qualify for Medicare, and Medicare’s infamous "doughnut hole" is gradually closing. Small businesses now receive tax-credit incentives to insure their workers.

All of this adds up to more paying patients, with better insurance. However, as additional provisions come online this year, the long-range potential impact on private practitioners becomes more uncertain, and more ominous.

"Physician payment reforms" will begin to appear. Although no one yet knows exactly what that means, the law mandates the formation of "accountable care organizations" to "improve quality and efficiency of care." The buzzword will be outcomes – the better your measurable results, the higher your reimbursements. This is supposed to reward quality of care over volume of procedures, but the result could be exactly the opposite if less-motivated providers cherry pick the quick, easy, least-risky cases and refer anything time consuming or complex to tertiary centers.

In 2013, Medicare will introduce a national program of payment bundling. A single hospital admission, for example, will be paid with a single bundled payment that will have to be divided among the hospital and treating physicians. The idea, ostensibly, is to encourage physicians and hospitals to work together to "better coordinate patient care," but arguments over how to divide the pie could, once again, have the opposite effect.

And it won’t take long for hospitals to figure out that they can keep the whole pie if the partnering physicians are their employees. So look for more private offices to be absorbed by hospitals, which already employ almost a third of all physicians.

By 2014, states will have to set up "SHOP Exchanges" (Small Business Health Options Programs), allowing small businesses (defined as 100 employees or less) to pool their resources to buy health insurance. Most people will, by then, be required to have health insurance coverage or pay a fine if they don’t. Employers not offering coverage will face fines and other penalties, and health insurance companies will begin paying a fee based on their market share, which will no doubt be passed along to those they insure, nullifying some of the savings garnered by the SHOP Exchanges, which are already predicted to be marginal.

The big Medicaid expansion will be in place by 2014 as well, but few physicians are likely to accept more Medicaid patients unless compensation increases. That is unlikely to happen without substantial reductions in the states’ woeful budget deficits – and probably not even then, since state governments already complain about their Medicaid budgets. Hospitals, with their deeper pockets, will get most of the new Medicaid patients and will hire even more physicians away from private practice to treat them.

If this sounds like a potential problem for private practice as we know it, it is. Then again, it’s too early for reliable predictions: The recent Supreme Court decision notwithstanding, there is a lot of potential leeway in the new law’s future specifications; and a lot can happen between now and full implementation, from modifications and amendments to outright repeal. Only time will tell.

Dr. Joseph S. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. To respond to this column, email him at our editorial offices at [email protected].

Picture this likely scenario: You’re a hospitalist in a remote setting, and a patient with stroke symptoms is rushed in by ambulance. Numbness has overcome one side of his body. Dizziness disrupts his balance, his speech becomes slurred, and his vision is blurred. Treatment must be started swiftly to halt irreversible brain damage. The nearest neurologist is located hours away, but thanks to advanced video technology, you’re able to instantly consult face to face with that specialist to help ensure optimal recovery for the patient.

Such applications of telemedicine are becoming more mainstream and affordable, facilitating discussions and decisions between healthcare providers while improving patient access to specialty care in emergencies and other situations.

Remote hospitalist services include videoconferencing for patient monitoring and assessment of various clinical services, says Jona

Advantages and Challenges

Remote patient monitoring in ICUs is on the upswing, filling gaps in the shortage of physicians specializing in critical care. Some unit administrators have established off-site command centers for these specialists to follow multiple facilities with the assistance of video technology and to intervene at urgent times.¹

In a neonatal ICU, this type of live-feed technology allows for a face-to-face interaction with a pediatric pulmonologist, for example, when a premature infant is exhibiting symptoms of respiratory distress in the middle of the night, says David Cattell-Gordon, MSW, director of the Office of Telemedicine at the University of Virginia in Charlottesville.

Similarly, in rural areas where women don’t have immediate access to high-risk obstetricians, telemedicine makes it possible to consult with maternal-fetal medicine specialists from a distance, boosting the chances for pregnant mothers with complex conditions to carry healthy babies to term, says Cattell-Gordon. “Our approach has been to bring telemedicine to hospitals and clinics in communities where that resource [specialists] otherwise is unavailable,” he adds.

Compared with telephone conversations, the advantages of video consultations are multifold: They display a patient’s facial expressions, gestures, and other body language, which might assist with the diagnosis and prescribed treatment, says Kerry Weiner, MD, chief clinical officer for IPC: The Hospitalist Company in North Hollywood, Calif., which has a presence in about 900 facilities in 25 states.

When the strength of that assessment depends on visual inspection, the technology can be particularly helpful. “The weak part of it is when you need to touch” to guide that assessment, Dr. Weiner says. That’s when the technology isn’t as useful. Still, he adds, “We use teleconferencing all over the place in a Skype-like manner, only more sophisticated. It’s more encrypted.”

Interacting within a secure network is crucial to protect privacy, says Peter Kragel, MD, clinical director of the Telemedicine Center at East Carolina University’s Brody School of Medicine in Greenville, N.C. As with any form of communication that transmits identifiable patient information, healthcare providers must comply with HIPAA guidelines when employing videoconferencing services similar to Skype.

“Because of concerns about compliance with encryption and confidentiality regulations, we do not use [videoconferencing] here,” Dr. Kragel says.

Additionally, “telemedicine isn’t always appropriate for patient care,” Linkous says. “All of this depends on the circumstances and needs of the patient. Obviously, surgery requires a direct physician-patient interaction, except for robotic surgery.” For hospitals that don’t have any neurology coverage, telemedicine robots can assist with outside consults for time-sensitive stroke care.

Videoconferencing isn’t necessary for all telemedicine encounters, Linkous says. Teledermatology and retinal screening use “store and forward” communication of images, which allows for the electronic transmission of images and documents in non-emergent situations in which immediate video isn’t necessary.

“As a society, we’ve become more comfortable with the technology,” says Matthew Harbison, MD, medical director of Sound Physicians hospitalist services at Memorial Hermann-Texas Medical Center in Houston. “And as the technology continues to develop, ultimately there will be [more of] a role, but how large that will be is difficult to predict.” He adds that “the advantages are obviously in low-staffed places or staffing-challenged sites.”

Moving Ahead

As experts continue to iron out the kinks and as communities obtain greater access to broadband signals, telemedicine equipment is moving to advanced high-definition platforms. Meanwhile, the expense has come down considerably since its inception in the mid-1990s. A high-definition setup that once cost upward of $130,000 is now available for less than $10,000, Cattell-Gordon says.

The digital transmission also can assist in patient follow-up after discharge from the hospital and in monitoring various chronic diseases from home. It’s an effective tool for medical staff meetings and training purposes as well.

IPC's hospitalists have been using the technology to communicate with each other, brainstorming across regions of the country. “Because we’re a national company,” Dr. Weiner says, “this has changed the game in terms of being able to collaborate.”

Susan Kreimer is a freelance medical writer based in New York.

Reference

1. Thomas EJ, Lucke JF, Wueste L, Weavind L, Patel B. Association of telemedicine for remote monitoring of intensive care patients with mortality, complications, and length of stay. JAMA. 2009;302:2671-2678.

Picture this likely scenario: You’re a hospitalist in a remote setting, and a patient with stroke symptoms is rushed in by ambulance. Numbness has overcome one side of his body. Dizziness disrupts his balance, his speech becomes slurred, and his vision is blurred. Treatment must be started swiftly to halt irreversible brain damage. The nearest neurologist is located hours away, but thanks to advanced video technology, you’re able to instantly consult face to face with that specialist to help ensure optimal recovery for the patient.

Such applications of telemedicine are becoming more mainstream and affordable, facilitating discussions and decisions between healthcare providers while improving patient access to specialty care in emergencies and other situations.

Remote hospitalist services include videoconferencing for patient monitoring and assessment of various clinical services, says Jona

Advantages and Challenges

Remote patient monitoring in ICUs is on the upswing, filling gaps in the shortage of physicians specializing in critical care. Some unit administrators have established off-site command centers for these specialists to follow multiple facilities with the assistance of video technology and to intervene at urgent times.¹

In a neonatal ICU, this type of live-feed technology allows for a face-to-face interaction with a pediatric pulmonologist, for example, when a premature infant is exhibiting symptoms of respiratory distress in the middle of the night, says David Cattell-Gordon, MSW, director of the Office of Telemedicine at the University of Virginia in Charlottesville.

Similarly, in rural areas where women don’t have immediate access to high-risk obstetricians, telemedicine makes it possible to consult with maternal-fetal medicine specialists from a distance, boosting the chances for pregnant mothers with complex conditions to carry healthy babies to term, says Cattell-Gordon. “Our approach has been to bring telemedicine to hospitals and clinics in communities where that resource [specialists] otherwise is unavailable,” he adds.

Compared with telephone conversations, the advantages of video consultations are multifold: They display a patient’s facial expressions, gestures, and other body language, which might assist with the diagnosis and prescribed treatment, says Kerry Weiner, MD, chief clinical officer for IPC: The Hospitalist Company in North Hollywood, Calif., which has a presence in about 900 facilities in 25 states.

When the strength of that assessment depends on visual inspection, the technology can be particularly helpful. “The weak part of it is when you need to touch” to guide that assessment, Dr. Weiner says. That’s when the technology isn’t as useful. Still, he adds, “We use teleconferencing all over the place in a Skype-like manner, only more sophisticated. It’s more encrypted.”

Interacting within a secure network is crucial to protect privacy, says Peter Kragel, MD, clinical director of the Telemedicine Center at East Carolina University’s Brody School of Medicine in Greenville, N.C. As with any form of communication that transmits identifiable patient information, healthcare providers must comply with HIPAA guidelines when employing videoconferencing services similar to Skype.

“Because of concerns about compliance with encryption and confidentiality regulations, we do not use [videoconferencing] here,” Dr. Kragel says.

Additionally, “telemedicine isn’t always appropriate for patient care,” Linkous says. “All of this depends on the circumstances and needs of the patient. Obviously, surgery requires a direct physician-patient interaction, except for robotic surgery.” For hospitals that don’t have any neurology coverage, telemedicine robots can assist with outside consults for time-sensitive stroke care.

Videoconferencing isn’t necessary for all telemedicine encounters, Linkous says. Teledermatology and retinal screening use “store and forward” communication of images, which allows for the electronic transmission of images and documents in non-emergent situations in which immediate video isn’t necessary.

“As a society, we’ve become more comfortable with the technology,” says Matthew Harbison, MD, medical director of Sound Physicians hospitalist services at Memorial Hermann-Texas Medical Center in Houston. “And as the technology continues to develop, ultimately there will be [more of] a role, but how large that will be is difficult to predict.” He adds that “the advantages are obviously in low-staffed places or staffing-challenged sites.”

Moving Ahead

As experts continue to iron out the kinks and as communities obtain greater access to broadband signals, telemedicine equipment is moving to advanced high-definition platforms. Meanwhile, the expense has come down considerably since its inception in the mid-1990s. A high-definition setup that once cost upward of $130,000 is now available for less than $10,000, Cattell-Gordon says.

The digital transmission also can assist in patient follow-up after discharge from the hospital and in monitoring various chronic diseases from home. It’s an effective tool for medical staff meetings and training purposes as well.

IPC's hospitalists have been using the technology to communicate with each other, brainstorming across regions of the country. “Because we’re a national company,” Dr. Weiner says, “this has changed the game in terms of being able to collaborate.”

Susan Kreimer is a freelance medical writer based in New York.

Reference

1. Thomas EJ, Lucke JF, Wueste L, Weavind L, Patel B. Association of telemedicine for remote monitoring of intensive care patients with mortality, complications, and length of stay. JAMA. 2009;302:2671-2678.

Picture this likely scenario: You’re a hospitalist in a remote setting, and a patient with stroke symptoms is rushed in by ambulance. Numbness has overcome one side of his body. Dizziness disrupts his balance, his speech becomes slurred, and his vision is blurred. Treatment must be started swiftly to halt irreversible brain damage. The nearest neurologist is located hours away, but thanks to advanced video technology, you’re able to instantly consult face to face with that specialist to help ensure optimal recovery for the patient.

Such applications of telemedicine are becoming more mainstream and affordable, facilitating discussions and decisions between healthcare providers while improving patient access to specialty care in emergencies and other situations.

Remote hospitalist services include videoconferencing for patient monitoring and assessment of various clinical services, says Jona

Advantages and Challenges

Remote patient monitoring in ICUs is on the upswing, filling gaps in the shortage of physicians specializing in critical care. Some unit administrators have established off-site command centers for these specialists to follow multiple facilities with the assistance of video technology and to intervene at urgent times.¹

In a neonatal ICU, this type of live-feed technology allows for a face-to-face interaction with a pediatric pulmonologist, for example, when a premature infant is exhibiting symptoms of respiratory distress in the middle of the night, says David Cattell-Gordon, MSW, director of the Office of Telemedicine at the University of Virginia in Charlottesville.

Similarly, in rural areas where women don’t have immediate access to high-risk obstetricians, telemedicine makes it possible to consult with maternal-fetal medicine specialists from a distance, boosting the chances for pregnant mothers with complex conditions to carry healthy babies to term, says Cattell-Gordon. “Our approach has been to bring telemedicine to hospitals and clinics in communities where that resource [specialists] otherwise is unavailable,” he adds.

Compared with telephone conversations, the advantages of video consultations are multifold: They display a patient’s facial expressions, gestures, and other body language, which might assist with the diagnosis and prescribed treatment, says Kerry Weiner, MD, chief clinical officer for IPC: The Hospitalist Company in North Hollywood, Calif., which has a presence in about 900 facilities in 25 states.

When the strength of that assessment depends on visual inspection, the technology can be particularly helpful. “The weak part of it is when you need to touch” to guide that assessment, Dr. Weiner says. That’s when the technology isn’t as useful. Still, he adds, “We use teleconferencing all over the place in a Skype-like manner, only more sophisticated. It’s more encrypted.”

Interacting within a secure network is crucial to protect privacy, says Peter Kragel, MD, clinical director of the Telemedicine Center at East Carolina University’s Brody School of Medicine in Greenville, N.C. As with any form of communication that transmits identifiable patient information, healthcare providers must comply with HIPAA guidelines when employing videoconferencing services similar to Skype.

“Because of concerns about compliance with encryption and confidentiality regulations, we do not use [videoconferencing] here,” Dr. Kragel says.

Additionally, “telemedicine isn’t always appropriate for patient care,” Linkous says. “All of this depends on the circumstances and needs of the patient. Obviously, surgery requires a direct physician-patient interaction, except for robotic surgery.” For hospitals that don’t have any neurology coverage, telemedicine robots can assist with outside consults for time-sensitive stroke care.

Videoconferencing isn’t necessary for all telemedicine encounters, Linkous says. Teledermatology and retinal screening use “store and forward” communication of images, which allows for the electronic transmission of images and documents in non-emergent situations in which immediate video isn’t necessary.

“As a society, we’ve become more comfortable with the technology,” says Matthew Harbison, MD, medical director of Sound Physicians hospitalist services at Memorial Hermann-Texas Medical Center in Houston. “And as the technology continues to develop, ultimately there will be [more of] a role, but how large that will be is difficult to predict.” He adds that “the advantages are obviously in low-staffed places or staffing-challenged sites.”

Moving Ahead

As experts continue to iron out the kinks and as communities obtain greater access to broadband signals, telemedicine equipment is moving to advanced high-definition platforms. Meanwhile, the expense has come down considerably since its inception in the mid-1990s. A high-definition setup that once cost upward of $130,000 is now available for less than $10,000, Cattell-Gordon says.

The digital transmission also can assist in patient follow-up after discharge from the hospital and in monitoring various chronic diseases from home. It’s an effective tool for medical staff meetings and training purposes as well.

IPC's hospitalists have been using the technology to communicate with each other, brainstorming across regions of the country. “Because we’re a national company,” Dr. Weiner says, “this has changed the game in terms of being able to collaborate.”

Susan Kreimer is a freelance medical writer based in New York.

Reference

1. Thomas EJ, Lucke JF, Wueste L, Weavind L, Patel B. Association of telemedicine for remote monitoring of intensive care patients with mortality, complications, and length of stay. JAMA. 2009;302:2671-2678.

A hospitalist was recently offered a lucrative position in his community and was concerned that his previous employment agreement would prohibit him from accepting the new job opportunity. His former employment contract contained a noncompetition clause that made him and his prospective employer rightfully concerned. Upon a comprehensive review of his former employment contract, the noncompetition provision was not as restrictive as he and his prospective employer had previously thought. As it turned out, in his case, and in many others, the noncompetition clause was penetrable, and the physician accepted the new employment offer knowing he was not in violation of his previous contract.

What Is a Noncompetition Clause?

A noncompetition clause, also known as a covenant not to compete or a restrictive covenant, is a provision in a contract that precludes one party from engaging in competition with another party by working 1) in a particular field, 2) within a specific geographic area, and 3) for a stated period of time. A well-written noncompetition provision will prevent a physician from practicing within a certain geographical area surrounding the employer or the employer’s hospital relationships and for a prescribed period of time after the termination of the physician’s employment.

Often, the physician will be permitted to practice within the parameters of the restricted geographical area or time period if they (or the prospective employer) “buy out” of the clause. This is an especially good option when the reasonableness of the noncompetition is not black and white, and both parties want to avoid the expense of litigating the enforceability of the noncompetition clause. Otherwise, in the event the physician breaches the noncompetition clause, the former employer will usually first seek injunctive relief that prohibits the physician’s new employment, then follow with a request for monetary damages arising from the physician’s breach.

In states where noncompetition clauses for physicians are enforceable, the provision must: 1) protect the employer’s legitimate business interest, 2) be specific in geographical scope, and 3) have a narrowly tailored durational scope. Each of these factors is described below. If the language in the clause is vague or does not clearly describe the exact terms of the restrictions on practice, the clause might be unenforceable or open to greater interpretation than either party anticipated.

Do Employers Have a Legitimate Business Interest to Protect?

In order for a noncompetition clause to be enforceable, it must protect the employer’s legitimate business interest. Some examples of a legitimate business interest in the HM context are the employer’s goodwill and the retention of the employer’s clients (hospitals and medical practices). Moreover, since noncompetition clauses are not looked upon with favor by courts because they operate as a restraint of trade, the language needs to be narrowly tailored in order to protect the employer’s legitimate interests.

Is Geographical Scope Reasonable?

Noncompetition clauses must also specify the restricted geographical area where the physician is prohibited from practicing. However, whether a geographical scope is overly broad will not only depend on state law, but also the location of the employer and the surrounding community.

Typically, contracts will provide a radius in miles surrounding the employer’s location or locations as the restricted territory. But whether a geographic limitation is “reasonable” is a relative term. A five-mile radius in an urban area like New York City might be home to millions of people, whereas a five-mile radius in a suburb of New York might only be home to a few thousand people. For hospitalists, the geographic restriction might prohibit the physician from practicing at or for the employer’s clients (e.g. hospitals).

Although the following might seem obviously overly broad to some, a review of contracts with the following geographic restrictions should be considered red flags:

• Prohibition to practice anywhere in the U.S.;
• Prohibition to practice anywhere in a specific state;
• Prohibition to practice in a territory comprised of excessive miles from the employer’s location; and
• Prohibition to practice in certain counties.

Please note that exclusion to practice in certain counties might be overly broad in some situations but might be acceptable in others. For example, a hospitalist sold his ownership stake in his practice, and part of the deal required him to agree not to practice in Los Angeles County. This particular county restriction would be difficult, if not impossible, to enforce because Los Angeles County includes more than 80 cities and covers more than 4,000 square miles.

Is Durational Scope Reasonable?

A noncompetition clause should identify the length of time in which the physician is prohibited from practicing within the restricted geographic area. Whether the durational scope is reasonable will vary from state to state. As a general rule of thumb, if the restricted time frame is two years or less after termination of the contract, the time restriction will likely be considered “reasonable.” However, state laws vary on whether time restraints in excess of two years are enforceable.

A common pitfall with time restrictions is excessiveness based on the state’s laws and the specific circumstances of the physician and the employer. In negotiating the restricted length of time in a noncompetition clause, it is more common to have a longer time restriction when a physician is selling an ownership interest in a practice than for a physician entering into an employment relationship.

Prospective Employers: What You Need to Know

Great care must be taken when hiring a physician. States recognize the legal theory of interference with a contract. If an employer is recruiting a hospitalist who is subject to an employment agreement with a noncompetition clause, the prospective employer must be very careful in the recruiting process. It is recommended that the employment agreement include a representation by the physician-employee that he or she is not subject to any other agreement that would prohibit the physician from entering into the new employment relationship.

If a prospective employer is aware of an existing employment contract that contains practice restrictions on a recruited physician, the prospective employer could be held responsible for damages if a dispute arises between the parties.

It’s All in the Words

Although it might seem like semantics, a few words can change your future. Before you put pen to paper, be sure to have any contract containing a noncompetition clause reviewed by a lawyer who is well-versed in your state’s laws. If you have already signed an agreement with a noncompetition clause and you are considering your next career move, a lawyer can shed some light on a seemingly impenetrable clause.

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].

A hospitalist was recently offered a lucrative position in his community and was concerned that his previous employment agreement would prohibit him from accepting the new job opportunity. His former employment contract contained a noncompetition clause that made him and his prospective employer rightfully concerned. Upon a comprehensive review of his former employment contract, the noncompetition provision was not as restrictive as he and his prospective employer had previously thought. As it turned out, in his case, and in many others, the noncompetition clause was penetrable, and the physician accepted the new employment offer knowing he was not in violation of his previous contract.

What Is a Noncompetition Clause?

A noncompetition clause, also known as a covenant not to compete or a restrictive covenant, is a provision in a contract that precludes one party from engaging in competition with another party by working 1) in a particular field, 2) within a specific geographic area, and 3) for a stated period of time. A well-written noncompetition provision will prevent a physician from practicing within a certain geographical area surrounding the employer or the employer’s hospital relationships and for a prescribed period of time after the termination of the physician’s employment.

Often, the physician will be permitted to practice within the parameters of the restricted geographical area or time period if they (or the prospective employer) “buy out” of the clause. This is an especially good option when the reasonableness of the noncompetition is not black and white, and both parties want to avoid the expense of litigating the enforceability of the noncompetition clause. Otherwise, in the event the physician breaches the noncompetition clause, the former employer will usually first seek injunctive relief that prohibits the physician’s new employment, then follow with a request for monetary damages arising from the physician’s breach.

In states where noncompetition clauses for physicians are enforceable, the provision must: 1) protect the employer’s legitimate business interest, 2) be specific in geographical scope, and 3) have a narrowly tailored durational scope. Each of these factors is described below. If the language in the clause is vague or does not clearly describe the exact terms of the restrictions on practice, the clause might be unenforceable or open to greater interpretation than either party anticipated.

Do Employers Have a Legitimate Business Interest to Protect?

In order for a noncompetition clause to be enforceable, it must protect the employer’s legitimate business interest. Some examples of a legitimate business interest in the HM context are the employer’s goodwill and the retention of the employer’s clients (hospitals and medical practices). Moreover, since noncompetition clauses are not looked upon with favor by courts because they operate as a restraint of trade, the language needs to be narrowly tailored in order to protect the employer’s legitimate interests.

Is Geographical Scope Reasonable?

Noncompetition clauses must also specify the restricted geographical area where the physician is prohibited from practicing. However, whether a geographical scope is overly broad will not only depend on state law, but also the location of the employer and the surrounding community.

Typically, contracts will provide a radius in miles surrounding the employer’s location or locations as the restricted territory. But whether a geographic limitation is “reasonable” is a relative term. A five-mile radius in an urban area like New York City might be home to millions of people, whereas a five-mile radius in a suburb of New York might only be home to a few thousand people. For hospitalists, the geographic restriction might prohibit the physician from practicing at or for the employer’s clients (e.g. hospitals).

Although the following might seem obviously overly broad to some, a review of contracts with the following geographic restrictions should be considered red flags:

• Prohibition to practice anywhere in the U.S.;
• Prohibition to practice anywhere in a specific state;
• Prohibition to practice in a territory comprised of excessive miles from the employer’s location; and
• Prohibition to practice in certain counties.

Please note that exclusion to practice in certain counties might be overly broad in some situations but might be acceptable in others. For example, a hospitalist sold his ownership stake in his practice, and part of the deal required him to agree not to practice in Los Angeles County. This particular county restriction would be difficult, if not impossible, to enforce because Los Angeles County includes more than 80 cities and covers more than 4,000 square miles.

Is Durational Scope Reasonable?

A noncompetition clause should identify the length of time in which the physician is prohibited from practicing within the restricted geographic area. Whether the durational scope is reasonable will vary from state to state. As a general rule of thumb, if the restricted time frame is two years or less after termination of the contract, the time restriction will likely be considered “reasonable.” However, state laws vary on whether time restraints in excess of two years are enforceable.

A common pitfall with time restrictions is excessiveness based on the state’s laws and the specific circumstances of the physician and the employer. In negotiating the restricted length of time in a noncompetition clause, it is more common to have a longer time restriction when a physician is selling an ownership interest in a practice than for a physician entering into an employment relationship.

Prospective Employers: What You Need to Know

Great care must be taken when hiring a physician. States recognize the legal theory of interference with a contract. If an employer is recruiting a hospitalist who is subject to an employment agreement with a noncompetition clause, the prospective employer must be very careful in the recruiting process. It is recommended that the employment agreement include a representation by the physician-employee that he or she is not subject to any other agreement that would prohibit the physician from entering into the new employment relationship.

If a prospective employer is aware of an existing employment contract that contains practice restrictions on a recruited physician, the prospective employer could be held responsible for damages if a dispute arises between the parties.

It’s All in the Words

Although it might seem like semantics, a few words can change your future. Before you put pen to paper, be sure to have any contract containing a noncompetition clause reviewed by a lawyer who is well-versed in your state’s laws. If you have already signed an agreement with a noncompetition clause and you are considering your next career move, a lawyer can shed some light on a seemingly impenetrable clause.

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].

A hospitalist was recently offered a lucrative position in his community and was concerned that his previous employment agreement would prohibit him from accepting the new job opportunity. His former employment contract contained a noncompetition clause that made him and his prospective employer rightfully concerned. Upon a comprehensive review of his former employment contract, the noncompetition provision was not as restrictive as he and his prospective employer had previously thought. As it turned out, in his case, and in many others, the noncompetition clause was penetrable, and the physician accepted the new employment offer knowing he was not in violation of his previous contract.

What Is a Noncompetition Clause?

A noncompetition clause, also known as a covenant not to compete or a restrictive covenant, is a provision in a contract that precludes one party from engaging in competition with another party by working 1) in a particular field, 2) within a specific geographic area, and 3) for a stated period of time. A well-written noncompetition provision will prevent a physician from practicing within a certain geographical area surrounding the employer or the employer’s hospital relationships and for a prescribed period of time after the termination of the physician’s employment.

Often, the physician will be permitted to practice within the parameters of the restricted geographical area or time period if they (or the prospective employer) “buy out” of the clause. This is an especially good option when the reasonableness of the noncompetition is not black and white, and both parties want to avoid the expense of litigating the enforceability of the noncompetition clause. Otherwise, in the event the physician breaches the noncompetition clause, the former employer will usually first seek injunctive relief that prohibits the physician’s new employment, then follow with a request for monetary damages arising from the physician’s breach.

In states where noncompetition clauses for physicians are enforceable, the provision must: 1) protect the employer’s legitimate business interest, 2) be specific in geographical scope, and 3) have a narrowly tailored durational scope. Each of these factors is described below. If the language in the clause is vague or does not clearly describe the exact terms of the restrictions on practice, the clause might be unenforceable or open to greater interpretation than either party anticipated.

Do Employers Have a Legitimate Business Interest to Protect?

In order for a noncompetition clause to be enforceable, it must protect the employer’s legitimate business interest. Some examples of a legitimate business interest in the HM context are the employer’s goodwill and the retention of the employer’s clients (hospitals and medical practices). Moreover, since noncompetition clauses are not looked upon with favor by courts because they operate as a restraint of trade, the language needs to be narrowly tailored in order to protect the employer’s legitimate interests.

Is Geographical Scope Reasonable?

Noncompetition clauses must also specify the restricted geographical area where the physician is prohibited from practicing. However, whether a geographical scope is overly broad will not only depend on state law, but also the location of the employer and the surrounding community.

Typically, contracts will provide a radius in miles surrounding the employer’s location or locations as the restricted territory. But whether a geographic limitation is “reasonable” is a relative term. A five-mile radius in an urban area like New York City might be home to millions of people, whereas a five-mile radius in a suburb of New York might only be home to a few thousand people. For hospitalists, the geographic restriction might prohibit the physician from practicing at or for the employer’s clients (e.g. hospitals).

Although the following might seem obviously overly broad to some, a review of contracts with the following geographic restrictions should be considered red flags:

• Prohibition to practice anywhere in the U.S.;
• Prohibition to practice anywhere in a specific state;
• Prohibition to practice in a territory comprised of excessive miles from the employer’s location; and
• Prohibition to practice in certain counties.

Please note that exclusion to practice in certain counties might be overly broad in some situations but might be acceptable in others. For example, a hospitalist sold his ownership stake in his practice, and part of the deal required him to agree not to practice in Los Angeles County. This particular county restriction would be difficult, if not impossible, to enforce because Los Angeles County includes more than 80 cities and covers more than 4,000 square miles.

Is Durational Scope Reasonable?

A noncompetition clause should identify the length of time in which the physician is prohibited from practicing within the restricted geographic area. Whether the durational scope is reasonable will vary from state to state. As a general rule of thumb, if the restricted time frame is two years or less after termination of the contract, the time restriction will likely be considered “reasonable.” However, state laws vary on whether time restraints in excess of two years are enforceable.

A common pitfall with time restrictions is excessiveness based on the state’s laws and the specific circumstances of the physician and the employer. In negotiating the restricted length of time in a noncompetition clause, it is more common to have a longer time restriction when a physician is selling an ownership interest in a practice than for a physician entering into an employment relationship.

Prospective Employers: What You Need to Know

Great care must be taken when hiring a physician. States recognize the legal theory of interference with a contract. If an employer is recruiting a hospitalist who is subject to an employment agreement with a noncompetition clause, the prospective employer must be very careful in the recruiting process. It is recommended that the employment agreement include a representation by the physician-employee that he or she is not subject to any other agreement that would prohibit the physician from entering into the new employment relationship.

If a prospective employer is aware of an existing employment contract that contains practice restrictions on a recruited physician, the prospective employer could be held responsible for damages if a dispute arises between the parties.

It’s All in the Words

Although it might seem like semantics, a few words can change your future. Before you put pen to paper, be sure to have any contract containing a noncompetition clause reviewed by a lawyer who is well-versed in your state’s laws. If you have already signed an agreement with a noncompetition clause and you are considering your next career move, a lawyer can shed some light on a seemingly impenetrable clause.

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].

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The adult inpatient medicine service at Presbyterian Medical Group (PMG) in Albuquerque, N.M, has been utilizing a unit-based care model (UBCM) with multidisciplinary rounding for the past two years. Due to the positive results, what initially started on two medicine floors telemetry and non-telemetry quickly spread to all of the medicine floors. With implementation of Unit Base 4 in April, all of the medicine beds at Presbyterian will be run using a UBCM.

Set within an inner-city hospital, the medicine service is one of the largest single-site HM programs in the country. The group has 46 FTE requirements and performed more than 15,000 admissions and consults in 2011.

Background

In early 2010, however, the HM service was in crisis. Daily starting census on a typical rounding team was 18 to 20 patients per day, and the average length of stay (LOS) for the group was close to five days. Morale among the hospitalists was low, mainly due to the patient load and multiple throughput issues. Simply stated, the program was at a tipping point.

It was at this time that a Lean Six Sigma Project was initiated to examine the throughput issues. This project expanded rapidly, with input from physicians, nurses, care coordinators, and ancillary staff, and eventually morphed into the UBCM.

The original UBCM premise was to have four geographically isolated hospitalists staff a telemetry floor, and four unit-based hospitalists staff a non-telemetry floor. The isolation guaranteed a lower starting average census for the rounding hospitalists. Each hospitalist on the UBCM would be assigned one specific care coordinator. The multidisciplinary round then occurred at the whiteboard with the hospitalists, nurses, care coordinators, and ancillary staff. The whiteboard had the floor’s census and pertinent care coordination information. The UBCM utilized several tools: visual management (white board), dedicated workspace for the hospitalist team members, standardization of work for team members, and self-regulating governance.

UBCM does not focus specifically on standardization of management of specific disease processes but on standardization of communication and interaction between various team members. For example, at multidisciplinary rounds, the charge nurses and care coordinators ask specific questions regarding estimated discharge date, level of care issues (i.e. observation vs. admission), downgrade to telemetry, and discharge issues. The new practice model had these original goals:

• Reduce average LOS, thereby increasing patient encounters through backfill;
• Improve patient satisfaction; and
• Improve financial outcomes.

The Financial Case for UBCM

The UBCM team worked closely with the finance department to create a business model with a net present value proposal for each unit-base rollout. This included the cost of hiring an additional FTE for each UBCM, but it meant each UBCM rounding team had a lower starting census.

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The results have been very exciting.

The average LOS dropped to 4.6 days from 5.06 days in 2011; in 2012, the group’s LOS is at 4.40 days. By lowering average LOS with available backfill population, the group was able to increase patient discharges 15% (to 14,411 in 2011 from 12,503 in 2010).

The financial modeling for Unit Base 1 was based on the addition of PMG’s inpatient medicine service to the contribution margin by increasing patient encounters; the model for Unit Base 2 was based on savings through variable expenditures by decreasing average LOS. After 21 months, Unit Base 1 added $2.2 million to the contribution margin; after 15 months, Unit Base 2 lowered variable expenditure of $1.3 million.

The significant drop in average LOS has allowed the hospital to close a nine-bed temporary holding floor, which was created in 2009 to relieve ED congestion. This was a realized savings of $800,000 of a fixed cost.

Other Key Measures

Patient satisfaction scores have been encouraging; however, the group is realizing that the same hospitalists are scoring lower on the medicine floor with the older physical plant than on the floor with the newer physical plant. The percentage of downgrades from telemetry to non-telemetry significantly improved.

Additionally, there was initially skepticism among the hospitalists and the nursing staff. The biggest concern was that multidisciplinary rounding could not be successfully implemented on a busy medicine or telemetry floor during one of the busiest times of the day, at 9 a.m. However, team members quickly discovered that multidisciplinary rounds were an efficient way of communicating and prioritizing their time and resources. They also quickly realized the benefit to their daily workflow, and now leverage this tool to increase efficiency.

Having hospitalists geographically isolated and creating an environment that encourages communication has changed the culture of the inpatient workplace. The relationship between the hospitalists, nurses, ancillary staff, and care coordinators has improved significantly.

Try It for Yourself

Having practiced traditional internal medicine for nine years prior to becoming a hospitalist, I realize that many hospitalists are still rounding based on traditional models. But with such a system, ask yourself:

• Does a busy hospitalist always communicate the plan of care with the nurse?
• Does a hospitalist communicate with the care coordinator or physical therapist for each patient?
• Does a hospitalist leverage the fact that he or she is hospital-based to the maximum efficiency?

The answer in the vast majority of HM groups is “no.” With a UBCM approach, the efficiencies, the quality, and the communication improvements are baked into the process. We did not admonish our staff to perform “quality,” nor did we “improve communication.” We feel that we have found the holy grail of hospital medicine. The UBCM approach solves many of our problems, allows us to hire more hospitalists, and benefits our hospital’s bottom line.

Dr. Yu is medical director of the adult inpatient medicine service at Presbyterian Medical Group, Albuquerque, N.M. He is a former member of Team Hospitalist.

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The adult inpatient medicine service at Presbyterian Medical Group (PMG) in Albuquerque, N.M, has been utilizing a unit-based care model (UBCM) with multidisciplinary rounding for the past two years. Due to the positive results, what initially started on two medicine floors telemetry and non-telemetry quickly spread to all of the medicine floors. With implementation of Unit Base 4 in April, all of the medicine beds at Presbyterian will be run using a UBCM.

Set within an inner-city hospital, the medicine service is one of the largest single-site HM programs in the country. The group has 46 FTE requirements and performed more than 15,000 admissions and consults in 2011.

Background

In early 2010, however, the HM service was in crisis. Daily starting census on a typical rounding team was 18 to 20 patients per day, and the average length of stay (LOS) for the group was close to five days. Morale among the hospitalists was low, mainly due to the patient load and multiple throughput issues. Simply stated, the program was at a tipping point.

It was at this time that a Lean Six Sigma Project was initiated to examine the throughput issues. This project expanded rapidly, with input from physicians, nurses, care coordinators, and ancillary staff, and eventually morphed into the UBCM.

The original UBCM premise was to have four geographically isolated hospitalists staff a telemetry floor, and four unit-based hospitalists staff a non-telemetry floor. The isolation guaranteed a lower starting average census for the rounding hospitalists. Each hospitalist on the UBCM would be assigned one specific care coordinator. The multidisciplinary round then occurred at the whiteboard with the hospitalists, nurses, care coordinators, and ancillary staff. The whiteboard had the floor’s census and pertinent care coordination information. The UBCM utilized several tools: visual management (white board), dedicated workspace for the hospitalist team members, standardization of work for team members, and self-regulating governance.

UBCM does not focus specifically on standardization of management of specific disease processes but on standardization of communication and interaction between various team members. For example, at multidisciplinary rounds, the charge nurses and care coordinators ask specific questions regarding estimated discharge date, level of care issues (i.e. observation vs. admission), downgrade to telemetry, and discharge issues. The new practice model had these original goals:

• Reduce average LOS, thereby increasing patient encounters through backfill;
• Improve patient satisfaction; and
• Improve financial outcomes.

The Financial Case for UBCM

The UBCM team worked closely with the finance department to create a business model with a net present value proposal for each unit-base rollout. This included the cost of hiring an additional FTE for each UBCM, but it meant each UBCM rounding team had a lower starting census.

click for large version

The results have been very exciting.

The average LOS dropped to 4.6 days from 5.06 days in 2011; in 2012, the group’s LOS is at 4.40 days. By lowering average LOS with available backfill population, the group was able to increase patient discharges 15% (to 14,411 in 2011 from 12,503 in 2010).

The financial modeling for Unit Base 1 was based on the addition of PMG’s inpatient medicine service to the contribution margin by increasing patient encounters; the model for Unit Base 2 was based on savings through variable expenditures by decreasing average LOS. After 21 months, Unit Base 1 added $2.2 million to the contribution margin; after 15 months, Unit Base 2 lowered variable expenditure of $1.3 million.

The significant drop in average LOS has allowed the hospital to close a nine-bed temporary holding floor, which was created in 2009 to relieve ED congestion. This was a realized savings of $800,000 of a fixed cost.

Other Key Measures

Patient satisfaction scores have been encouraging; however, the group is realizing that the same hospitalists are scoring lower on the medicine floor with the older physical plant than on the floor with the newer physical plant. The percentage of downgrades from telemetry to non-telemetry significantly improved.

Additionally, there was initially skepticism among the hospitalists and the nursing staff. The biggest concern was that multidisciplinary rounding could not be successfully implemented on a busy medicine or telemetry floor during one of the busiest times of the day, at 9 a.m. However, team members quickly discovered that multidisciplinary rounds were an efficient way of communicating and prioritizing their time and resources. They also quickly realized the benefit to their daily workflow, and now leverage this tool to increase efficiency.

Having hospitalists geographically isolated and creating an environment that encourages communication has changed the culture of the inpatient workplace. The relationship between the hospitalists, nurses, ancillary staff, and care coordinators has improved significantly.

Try It for Yourself

Having practiced traditional internal medicine for nine years prior to becoming a hospitalist, I realize that many hospitalists are still rounding based on traditional models. But with such a system, ask yourself:

• Does a busy hospitalist always communicate the plan of care with the nurse?
• Does a hospitalist communicate with the care coordinator or physical therapist for each patient?
• Does a hospitalist leverage the fact that he or she is hospital-based to the maximum efficiency?

The answer in the vast majority of HM groups is “no.” With a UBCM approach, the efficiencies, the quality, and the communication improvements are baked into the process. We did not admonish our staff to perform “quality,” nor did we “improve communication.” We feel that we have found the holy grail of hospital medicine. The UBCM approach solves many of our problems, allows us to hire more hospitalists, and benefits our hospital’s bottom line.

Dr. Yu is medical director of the adult inpatient medicine service at Presbyterian Medical Group, Albuquerque, N.M. He is a former member of Team Hospitalist.

click for large version

The adult inpatient medicine service at Presbyterian Medical Group (PMG) in Albuquerque, N.M, has been utilizing a unit-based care model (UBCM) with multidisciplinary rounding for the past two years. Due to the positive results, what initially started on two medicine floors telemetry and non-telemetry quickly spread to all of the medicine floors. With implementation of Unit Base 4 in April, all of the medicine beds at Presbyterian will be run using a UBCM.

Set within an inner-city hospital, the medicine service is one of the largest single-site HM programs in the country. The group has 46 FTE requirements and performed more than 15,000 admissions and consults in 2011.

Background

In early 2010, however, the HM service was in crisis. Daily starting census on a typical rounding team was 18 to 20 patients per day, and the average length of stay (LOS) for the group was close to five days. Morale among the hospitalists was low, mainly due to the patient load and multiple throughput issues. Simply stated, the program was at a tipping point.

It was at this time that a Lean Six Sigma Project was initiated to examine the throughput issues. This project expanded rapidly, with input from physicians, nurses, care coordinators, and ancillary staff, and eventually morphed into the UBCM.

The original UBCM premise was to have four geographically isolated hospitalists staff a telemetry floor, and four unit-based hospitalists staff a non-telemetry floor. The isolation guaranteed a lower starting average census for the rounding hospitalists. Each hospitalist on the UBCM would be assigned one specific care coordinator. The multidisciplinary round then occurred at the whiteboard with the hospitalists, nurses, care coordinators, and ancillary staff. The whiteboard had the floor’s census and pertinent care coordination information. The UBCM utilized several tools: visual management (white board), dedicated workspace for the hospitalist team members, standardization of work for team members, and self-regulating governance.

UBCM does not focus specifically on standardization of management of specific disease processes but on standardization of communication and interaction between various team members. For example, at multidisciplinary rounds, the charge nurses and care coordinators ask specific questions regarding estimated discharge date, level of care issues (i.e. observation vs. admission), downgrade to telemetry, and discharge issues. The new practice model had these original goals:

• Reduce average LOS, thereby increasing patient encounters through backfill;
• Improve patient satisfaction; and
• Improve financial outcomes.

The Financial Case for UBCM

The UBCM team worked closely with the finance department to create a business model with a net present value proposal for each unit-base rollout. This included the cost of hiring an additional FTE for each UBCM, but it meant each UBCM rounding team had a lower starting census.

click for large version

The results have been very exciting.

The average LOS dropped to 4.6 days from 5.06 days in 2011; in 2012, the group’s LOS is at 4.40 days. By lowering average LOS with available backfill population, the group was able to increase patient discharges 15% (to 14,411 in 2011 from 12,503 in 2010).

The financial modeling for Unit Base 1 was based on the addition of PMG’s inpatient medicine service to the contribution margin by increasing patient encounters; the model for Unit Base 2 was based on savings through variable expenditures by decreasing average LOS. After 21 months, Unit Base 1 added $2.2 million to the contribution margin; after 15 months, Unit Base 2 lowered variable expenditure of $1.3 million.

The significant drop in average LOS has allowed the hospital to close a nine-bed temporary holding floor, which was created in 2009 to relieve ED congestion. This was a realized savings of $800,000 of a fixed cost.

Other Key Measures

Patient satisfaction scores have been encouraging; however, the group is realizing that the same hospitalists are scoring lower on the medicine floor with the older physical plant than on the floor with the newer physical plant. The percentage of downgrades from telemetry to non-telemetry significantly improved.

Additionally, there was initially skepticism among the hospitalists and the nursing staff. The biggest concern was that multidisciplinary rounding could not be successfully implemented on a busy medicine or telemetry floor during one of the busiest times of the day, at 9 a.m. However, team members quickly discovered that multidisciplinary rounds were an efficient way of communicating and prioritizing their time and resources. They also quickly realized the benefit to their daily workflow, and now leverage this tool to increase efficiency.

Having hospitalists geographically isolated and creating an environment that encourages communication has changed the culture of the inpatient workplace. The relationship between the hospitalists, nurses, ancillary staff, and care coordinators has improved significantly.

Try It for Yourself

Having practiced traditional internal medicine for nine years prior to becoming a hospitalist, I realize that many hospitalists are still rounding based on traditional models. But with such a system, ask yourself:

• Does a busy hospitalist always communicate the plan of care with the nurse?
• Does a hospitalist communicate with the care coordinator or physical therapist for each patient?
• Does a hospitalist leverage the fact that he or she is hospital-based to the maximum efficiency?

The answer in the vast majority of HM groups is “no.” With a UBCM approach, the efficiencies, the quality, and the communication improvements are baked into the process. We did not admonish our staff to perform “quality,” nor did we “improve communication.” We feel that we have found the holy grail of hospital medicine. The UBCM approach solves many of our problems, allows us to hire more hospitalists, and benefits our hospital’s bottom line.

Dr. Yu is medical director of the adult inpatient medicine service at Presbyterian Medical Group, Albuquerque, N.M. He is a former member of Team Hospitalist.

Danielle Scheurer, MD, MSCR, SFHM

Let’s be honest. How many times in the past (insert any timeline here; month, week, day, minute) have you heard a disparaging comment about a hospital regulatory agency? They usually sound something like, “Well, I’ll be darned if I am going to let CMS tell me how to practice medicine” or “So is this another Joint Commission thing?”

I understand the frustration. The healthcare industry is incredibly regulated. So much so that I, and countless others in hospital administration offices around the country, relinquish an inordinate amount of time figuring out what it is we are supposed to be complying with, then figuring how we are actually going to do it. It often has been equated to Whac-a-Mole, a game that requires more eyeballs and arm strength than an extraterrestrial possesses. There are many reasons that underlie the frustration and lead to the disparaging comments:

• Some requirements are not perfectly evidence-based. Not all process measures actually correlate with any outcomes; just because someone checks an oxygen saturation on every pneumonia patient doesn’t mean anything else improves for the patient.
• Some requirements are poorly implemented. I think we can all agree that counseling patients to stop smoking is a laudable goal. However, “smoking cessation counseling” is often relegated to uttering a short phrase (“you know you should really quit smoking”) while holding the exit-door handle, then checking the box for documentation. This “counseling session” is probably as effective as declaring every day a Great American Smokeout.
• Some regulations result in unintended consequences when implemented into large, complicated organizations. An obvious example is the time to first antibiotic in pneumonia patients, which resulted in frequent and unnecessary antibiotic utilization in patients who did not have pneumonia.
• Some are just extremely difficult to accomplish with high reliability. An example here is time to PCI for heart attacks. It’s clearly the right thing to do, and clearly very difficult to get it completed, on time, on every single patient. And 99% compliance is just not good enough, because the 1% matters.

And as a result of these imperfections, “noncompliance” leads to lots of emails, rework, restructuring, and at times downright bickering—hence, the disparaging comments.

Regulatory Origins and Missions

But let’s back up for a minute and think about why healthcare regulations exist: Many local, state, and federal agencies have enhanced the scrutiny of healthcare over time because, quite frankly, the healthcare industry did not regulate itself very well. We insisted for decades that patients were each too unique to be “cook-booked,” that medicine was an art as much as it was a science, and that “it’s just complicated.”

It took a few (too many) high-profile deaths and a few common-sense publications to incense the public, our payors, and our regulators. Who is not familiar with the 98,000-preventable-deaths-a-year statistic? Not only is that figure sobering, but it also is quite difficult to untether from our reputation. Henceforth, over the course of decades, a multitude of moles have emerged, littering the landscape and sparing no area of the healthcare industry.

So let’s back up another minute and think about what these agencies are trying to do: Could it be that most regulatory agencies really do want to leverage large-scale improvements in patient outcomes, at the best value?

Take this vision statement, as an example: “All people always experience the safest, highest-quality, best-value healthcare across all settings.”

Sounds like the kind of healthcare I want for my kids and my mom. That is the vision statement of the Joint Commission.

How about this vision statement: “CMS is a major force and a trustworthy partner for the continual improvement of health and healthcare for all Americans.”

Not too shabby.

So why do we view regulators like moles? Why do we arm ourselves with big, black mallets ready to strike when we see them emerge from the corner of our eye?

HM-Mole Alliance

Whac-a-Mole is an unwinnable game. No player has ever whacked all the moles. If you have not been to your local arcade lately, the game starts out slow, such that most players can keep pace; it then accelerates, such that several moles are outside the holes simultaneously, and their time above ground becomes consecutively shorter. You can add mallets, even add players, but generally they end up getting in each other’s way, communication breaks down, and one mole gets whacked twice, while another exits unscathed, only to break the soil elsewhere.

Danielle Scheurer, MD, MSCR, SFHM

Maybe a better strategy is to have a strategy—to work with our “trustworthy partners” to align our vision statements, anticipate the vermin’s approach, and fill the holes (or chasms) before anything has a chance to squeeze through. Maybe we should tell them where the moles are, because we actually already know what they look like and where they dwell. Why don’t we tell them which moles are the most dangerous, the most annoying, or are the most likely to tear up the topsoil into an irreparable state?

What about all the issues that no one is telling us we have to comply with—for example, a universal allergy list across the spectrum of care, or a perfectly reliable system to ensure that a patient with an epidural catheter cannot be anticoagulated? Such a list is endless, and no one is telling us we have to address the majority of the items on the list.

It comes down to this: What kind of healthcare do you want for yourself, your family, and the patients who trust you? I’d rather not have a reactive, frantic race to obliterate the next torrid creature that has arisen. I suggest a proactive, strategic pathway of tilling the soil.

In anticipation of a universal vote for the latter, join me in congratulating the healthcare industry in holding ourselves accountable, embracing a new era of transparency and collaboration, and routinely going beyond the expectations of our regulators. And leaving the mallet in the arcade.

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].

Danielle Scheurer, MD, MSCR, SFHM

Let’s be honest. How many times in the past (insert any timeline here; month, week, day, minute) have you heard a disparaging comment about a hospital regulatory agency? They usually sound something like, “Well, I’ll be darned if I am going to let CMS tell me how to practice medicine” or “So is this another Joint Commission thing?”

I understand the frustration. The healthcare industry is incredibly regulated. So much so that I, and countless others in hospital administration offices around the country, relinquish an inordinate amount of time figuring out what it is we are supposed to be complying with, then figuring how we are actually going to do it. It often has been equated to Whac-a-Mole, a game that requires more eyeballs and arm strength than an extraterrestrial possesses. There are many reasons that underlie the frustration and lead to the disparaging comments:

• Some requirements are not perfectly evidence-based. Not all process measures actually correlate with any outcomes; just because someone checks an oxygen saturation on every pneumonia patient doesn’t mean anything else improves for the patient.
• Some requirements are poorly implemented. I think we can all agree that counseling patients to stop smoking is a laudable goal. However, “smoking cessation counseling” is often relegated to uttering a short phrase (“you know you should really quit smoking”) while holding the exit-door handle, then checking the box for documentation. This “counseling session” is probably as effective as declaring every day a Great American Smokeout.
• Some regulations result in unintended consequences when implemented into large, complicated organizations. An obvious example is the time to first antibiotic in pneumonia patients, which resulted in frequent and unnecessary antibiotic utilization in patients who did not have pneumonia.
• Some are just extremely difficult to accomplish with high reliability. An example here is time to PCI for heart attacks. It’s clearly the right thing to do, and clearly very difficult to get it completed, on time, on every single patient. And 99% compliance is just not good enough, because the 1% matters.

And as a result of these imperfections, “noncompliance” leads to lots of emails, rework, restructuring, and at times downright bickering—hence, the disparaging comments.

Regulatory Origins and Missions

But let’s back up for a minute and think about why healthcare regulations exist: Many local, state, and federal agencies have enhanced the scrutiny of healthcare over time because, quite frankly, the healthcare industry did not regulate itself very well. We insisted for decades that patients were each too unique to be “cook-booked,” that medicine was an art as much as it was a science, and that “it’s just complicated.”

It took a few (too many) high-profile deaths and a few common-sense publications to incense the public, our payors, and our regulators. Who is not familiar with the 98,000-preventable-deaths-a-year statistic? Not only is that figure sobering, but it also is quite difficult to untether from our reputation. Henceforth, over the course of decades, a multitude of moles have emerged, littering the landscape and sparing no area of the healthcare industry.

So let’s back up another minute and think about what these agencies are trying to do: Could it be that most regulatory agencies really do want to leverage large-scale improvements in patient outcomes, at the best value?

Take this vision statement, as an example: “All people always experience the safest, highest-quality, best-value healthcare across all settings.”

Sounds like the kind of healthcare I want for my kids and my mom. That is the vision statement of the Joint Commission.

How about this vision statement: “CMS is a major force and a trustworthy partner for the continual improvement of health and healthcare for all Americans.”

Not too shabby.

So why do we view regulators like moles? Why do we arm ourselves with big, black mallets ready to strike when we see them emerge from the corner of our eye?

HM-Mole Alliance

Whac-a-Mole is an unwinnable game. No player has ever whacked all the moles. If you have not been to your local arcade lately, the game starts out slow, such that most players can keep pace; it then accelerates, such that several moles are outside the holes simultaneously, and their time above ground becomes consecutively shorter. You can add mallets, even add players, but generally they end up getting in each other’s way, communication breaks down, and one mole gets whacked twice, while another exits unscathed, only to break the soil elsewhere.

Danielle Scheurer, MD, MSCR, SFHM

Maybe a better strategy is to have a strategy—to work with our “trustworthy partners” to align our vision statements, anticipate the vermin’s approach, and fill the holes (or chasms) before anything has a chance to squeeze through. Maybe we should tell them where the moles are, because we actually already know what they look like and where they dwell. Why don’t we tell them which moles are the most dangerous, the most annoying, or are the most likely to tear up the topsoil into an irreparable state?

What about all the issues that no one is telling us we have to comply with—for example, a universal allergy list across the spectrum of care, or a perfectly reliable system to ensure that a patient with an epidural catheter cannot be anticoagulated? Such a list is endless, and no one is telling us we have to address the majority of the items on the list.

It comes down to this: What kind of healthcare do you want for yourself, your family, and the patients who trust you? I’d rather not have a reactive, frantic race to obliterate the next torrid creature that has arisen. I suggest a proactive, strategic pathway of tilling the soil.

In anticipation of a universal vote for the latter, join me in congratulating the healthcare industry in holding ourselves accountable, embracing a new era of transparency and collaboration, and routinely going beyond the expectations of our regulators. And leaving the mallet in the arcade.

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].

Danielle Scheurer, MD, MSCR, SFHM

Let’s be honest. How many times in the past (insert any timeline here; month, week, day, minute) have you heard a disparaging comment about a hospital regulatory agency? They usually sound something like, “Well, I’ll be darned if I am going to let CMS tell me how to practice medicine” or “So is this another Joint Commission thing?”

I understand the frustration. The healthcare industry is incredibly regulated. So much so that I, and countless others in hospital administration offices around the country, relinquish an inordinate amount of time figuring out what it is we are supposed to be complying with, then figuring how we are actually going to do it. It often has been equated to Whac-a-Mole, a game that requires more eyeballs and arm strength than an extraterrestrial possesses. There are many reasons that underlie the frustration and lead to the disparaging comments:

• Some requirements are not perfectly evidence-based. Not all process measures actually correlate with any outcomes; just because someone checks an oxygen saturation on every pneumonia patient doesn’t mean anything else improves for the patient.
• Some requirements are poorly implemented. I think we can all agree that counseling patients to stop smoking is a laudable goal. However, “smoking cessation counseling” is often relegated to uttering a short phrase (“you know you should really quit smoking”) while holding the exit-door handle, then checking the box for documentation. This “counseling session” is probably as effective as declaring every day a Great American Smokeout.
• Some regulations result in unintended consequences when implemented into large, complicated organizations. An obvious example is the time to first antibiotic in pneumonia patients, which resulted in frequent and unnecessary antibiotic utilization in patients who did not have pneumonia.
• Some are just extremely difficult to accomplish with high reliability. An example here is time to PCI for heart attacks. It’s clearly the right thing to do, and clearly very difficult to get it completed, on time, on every single patient. And 99% compliance is just not good enough, because the 1% matters.

And as a result of these imperfections, “noncompliance” leads to lots of emails, rework, restructuring, and at times downright bickering—hence, the disparaging comments.

Regulatory Origins and Missions

But let’s back up for a minute and think about why healthcare regulations exist: Many local, state, and federal agencies have enhanced the scrutiny of healthcare over time because, quite frankly, the healthcare industry did not regulate itself very well. We insisted for decades that patients were each too unique to be “cook-booked,” that medicine was an art as much as it was a science, and that “it’s just complicated.”

It took a few (too many) high-profile deaths and a few common-sense publications to incense the public, our payors, and our regulators. Who is not familiar with the 98,000-preventable-deaths-a-year statistic? Not only is that figure sobering, but it also is quite difficult to untether from our reputation. Henceforth, over the course of decades, a multitude of moles have emerged, littering the landscape and sparing no area of the healthcare industry.

So let’s back up another minute and think about what these agencies are trying to do: Could it be that most regulatory agencies really do want to leverage large-scale improvements in patient outcomes, at the best value?

Take this vision statement, as an example: “All people always experience the safest, highest-quality, best-value healthcare across all settings.”

Sounds like the kind of healthcare I want for my kids and my mom. That is the vision statement of the Joint Commission.

How about this vision statement: “CMS is a major force and a trustworthy partner for the continual improvement of health and healthcare for all Americans.”

Not too shabby.

So why do we view regulators like moles? Why do we arm ourselves with big, black mallets ready to strike when we see them emerge from the corner of our eye?

HM-Mole Alliance

Whac-a-Mole is an unwinnable game. No player has ever whacked all the moles. If you have not been to your local arcade lately, the game starts out slow, such that most players can keep pace; it then accelerates, such that several moles are outside the holes simultaneously, and their time above ground becomes consecutively shorter. You can add mallets, even add players, but generally they end up getting in each other’s way, communication breaks down, and one mole gets whacked twice, while another exits unscathed, only to break the soil elsewhere.

Danielle Scheurer, MD, MSCR, SFHM

Maybe a better strategy is to have a strategy—to work with our “trustworthy partners” to align our vision statements, anticipate the vermin’s approach, and fill the holes (or chasms) before anything has a chance to squeeze through. Maybe we should tell them where the moles are, because we actually already know what they look like and where they dwell. Why don’t we tell them which moles are the most dangerous, the most annoying, or are the most likely to tear up the topsoil into an irreparable state?

What about all the issues that no one is telling us we have to comply with—for example, a universal allergy list across the spectrum of care, or a perfectly reliable system to ensure that a patient with an epidural catheter cannot be anticoagulated? Such a list is endless, and no one is telling us we have to address the majority of the items on the list.

It comes down to this: What kind of healthcare do you want for yourself, your family, and the patients who trust you? I’d rather not have a reactive, frantic race to obliterate the next torrid creature that has arisen. I suggest a proactive, strategic pathway of tilling the soil.

In anticipation of a universal vote for the latter, join me in congratulating the healthcare industry in holding ourselves accountable, embracing a new era of transparency and collaboration, and routinely going beyond the expectations of our regulators. And leaving the mallet in the arcade.

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].

Louis O’Boyle, DO, FACP, FHM, says hospitalists with an entrepreneurial bent can use flexibility and creativity to design HM programs that meet the unique needs of small or rural hospitals. He owns a hospitalist practice, Advanced Inpatient Medicine, which serves 98-bed Wayne Memorial Hospital in Honesdale, Pa., population 4,874.

“In 2006, the largest group of community physicians locally said they were not going to do hospital coverage or take unassigned hospitalized patients anymore,” Dr. O’Boyle says. The hospital first brought in an out-of-town consultant to provide hospitalist services, but in 2009, Dr. O’Boyle seized the opportunity to fill the need. He formed his own company, which employs five hospitalists providing 24/7 coverage (clinicians rotate between 8 a.m.-to-4 p.m. shifts and 4 p.m.-to-8 a.m. shifts). The hospitalist on duty can often go home after the ED slows down, he says, although hiring a sixth hospitalist would make it easier to provide a 24-hour presence.

Dr. O'Boyle

“Our hospitalists see an average of 12 patients a day, so we’re not running too hard. You can take time to do a good job, and still have supper with your kids some workdays. In a rural area, you can still get away with that,” Dr. O’Boyle says. “We have a good salary, work schedule, and caseload. We have a great team, with everyone on board with what we’re trying to do.”

Members of Dr. O’Boyle’s group sit on all of the hospital’s committees. Many have a say in changes that go on at the hospital. The group is active in quality and safety projects and research on readmission rates. The program has been so successful that he is negotiating to cover several other hospitals in the region.

“Another key to the success of this program is our fiscal responsibility, demonstrating the value we bring to the hospital,” he says. “We align our goals with the hospital’s goals. We have cut length of stay by an average of three-quarters of a day. We were very involved with the IT department in setting up EHR and CPOE to our specifications. There is a whole list of things we do to justify our worth, and our subsidy payment from the hospital is particularly low.”

Dr. O’Boyle, in addition to his practice-management responsibilities, works alongside his colleagues. “It’s not like I’m the boss—more like I’m first among equals,” he says. “We meet as a team once a month.”

Louis O’Boyle, DO, FACP, FHM, says hospitalists with an entrepreneurial bent can use flexibility and creativity to design HM programs that meet the unique needs of small or rural hospitals. He owns a hospitalist practice, Advanced Inpatient Medicine, which serves 98-bed Wayne Memorial Hospital in Honesdale, Pa., population 4,874.

“In 2006, the largest group of community physicians locally said they were not going to do hospital coverage or take unassigned hospitalized patients anymore,” Dr. O’Boyle says. The hospital first brought in an out-of-town consultant to provide hospitalist services, but in 2009, Dr. O’Boyle seized the opportunity to fill the need. He formed his own company, which employs five hospitalists providing 24/7 coverage (clinicians rotate between 8 a.m.-to-4 p.m. shifts and 4 p.m.-to-8 a.m. shifts). The hospitalist on duty can often go home after the ED slows down, he says, although hiring a sixth hospitalist would make it easier to provide a 24-hour presence.

Dr. O'Boyle

“Our hospitalists see an average of 12 patients a day, so we’re not running too hard. You can take time to do a good job, and still have supper with your kids some workdays. In a rural area, you can still get away with that,” Dr. O’Boyle says. “We have a good salary, work schedule, and caseload. We have a great team, with everyone on board with what we’re trying to do.”

Members of Dr. O’Boyle’s group sit on all of the hospital’s committees. Many have a say in changes that go on at the hospital. The group is active in quality and safety projects and research on readmission rates. The program has been so successful that he is negotiating to cover several other hospitals in the region.

“Another key to the success of this program is our fiscal responsibility, demonstrating the value we bring to the hospital,” he says. “We align our goals with the hospital’s goals. We have cut length of stay by an average of three-quarters of a day. We were very involved with the IT department in setting up EHR and CPOE to our specifications. There is a whole list of things we do to justify our worth, and our subsidy payment from the hospital is particularly low.”

Dr. O’Boyle, in addition to his practice-management responsibilities, works alongside his colleagues. “It’s not like I’m the boss—more like I’m first among equals,” he says. “We meet as a team once a month.”

Louis O’Boyle, DO, FACP, FHM, says hospitalists with an entrepreneurial bent can use flexibility and creativity to design HM programs that meet the unique needs of small or rural hospitals. He owns a hospitalist practice, Advanced Inpatient Medicine, which serves 98-bed Wayne Memorial Hospital in Honesdale, Pa., population 4,874.

“In 2006, the largest group of community physicians locally said they were not going to do hospital coverage or take unassigned hospitalized patients anymore,” Dr. O’Boyle says. The hospital first brought in an out-of-town consultant to provide hospitalist services, but in 2009, Dr. O’Boyle seized the opportunity to fill the need. He formed his own company, which employs five hospitalists providing 24/7 coverage (clinicians rotate between 8 a.m.-to-4 p.m. shifts and 4 p.m.-to-8 a.m. shifts). The hospitalist on duty can often go home after the ED slows down, he says, although hiring a sixth hospitalist would make it easier to provide a 24-hour presence.

Dr. O'Boyle

“Our hospitalists see an average of 12 patients a day, so we’re not running too hard. You can take time to do a good job, and still have supper with your kids some workdays. In a rural area, you can still get away with that,” Dr. O’Boyle says. “We have a good salary, work schedule, and caseload. We have a great team, with everyone on board with what we’re trying to do.”

Members of Dr. O’Boyle’s group sit on all of the hospital’s committees. Many have a say in changes that go on at the hospital. The group is active in quality and safety projects and research on readmission rates. The program has been so successful that he is negotiating to cover several other hospitals in the region.

“Another key to the success of this program is our fiscal responsibility, demonstrating the value we bring to the hospital,” he says. “We align our goals with the hospital’s goals. We have cut length of stay by an average of three-quarters of a day. We were very involved with the IT department in setting up EHR and CPOE to our specifications. There is a whole list of things we do to justify our worth, and our subsidy payment from the hospital is particularly low.”

Dr. O’Boyle, in addition to his practice-management responsibilities, works alongside his colleagues. “It’s not like I’m the boss—more like I’m first among equals,” he says. “We meet as a team once a month.”