Managing Your Practice

Doctors shouldn’t have to worry about financial issues. The welfare of our patients should be our only concern.

We should be able to devote our full attention to studying how best to serve the needs of the people we care for. We shouldn’t need to spend time learning about healthcare reform or things like ICD-9 (or ICD-10!)—things that don’t help us provide better care to patients.

But these are pie-in-the-sky dreams. As far as I can tell, all healthcare systems require caregivers to attend to economics and data management that aren’t directly tied to clinical care. Our system depends on all caregivers devoting some time to learn how the system is organized, and keeping up with how it evolves. And the crisis in runaway costs in U.S. healthcare only increases the need for all who work in healthcare to devote significant time (too much) to the operational (nonclinical side) of healthcare.

Hospitalist practice is a much simpler business to manage and operate than most forms of clinical practice. There usually is no building to rent, few nonclinical employees to manage, and a comparatively simple financial model. And if employed by a hospital or other large entity, nonclinicians handle most of the “business management.” So when it comes to the number of brain cells diverted to business rather than clinical concerns, hospitalists start with an advantage over most other specialties.

Still, we have a lot of nonclinical stuff to keep up with. Consider the concept of “managing to Medicare reimbursement.” This means managing a practice or hospital in a way that minimizes the failure to capture all appropriate Medicare reimbursement dollars. Even if you’ve never heard of this concept before, there are probably a lot of people at your hospital who have this as their main responsibility, and clinicians should know something about it.

So in an effort to distract the fewest brain cells away from clinical matters, here is a very simple overview of some components of managing to Medicare reimbursement relevant to hospitalists. This isn’t a comprehensive list, only some hospitalist-relevant highlights.

Medicare Reimbursement Today

Accurate determination of inpatient vs. observation status. Wow, this can get complicated. Most hospitals have people who devote significant time to doing this for patients every day, and even those experts sometimes disagree on the appropriate status. But all hospitalists should have a basic understanding of how this works and a willingness to answer questions from the hospital’s experts, and, when appropriate, write additional information in the chart to clarify the appropriate status.

Optimal resource utilization, including length of stay. Because Medicare pays an essentially fixed amount based on the diagnoses for each inpatient admission, managing costs is critical to a hospital’s financial well-being. Hospitalists have a huge role in this. And regardless of how Medicare reimburses for services, there is clinical rationale for being careful about resources used and how long someone stays in a hospital. In many cases, more is not better—and it even could be worse—for the patient.

Optimal clinical documentation and accurate DRG assignment. Good documentation is important for clinical care, but beyond that, the precise way things are documented can have significant influence on Medicare reimbursement. Low potassium might in some cases lead to higher reimbursement, but a doctor must write “hypokalemia”; simply writing K+ means the hospital can’t include hypokalemia as a diagnosis. (A doctor, nurse practitioner, or physician assistant must write out “hypokalemia” only once for Medicare purposes; it would then be fine to use K+ in the chart every other time.)

Say you have a patient with a UTI and sepsis. Write only “urosepsis,” and the hospital must bill for cystitis—low reimbursement. Write “urinary tract infection with sepsis,” and the hospital can bill for higher reimbursement.

There should be people at your hospital who are experts at this, and all hospitalists should work with them to learn appropriate documentation language to describe illnesses correctly for billing purposes. Many hospitals use a system of “DRG queries,” which hospitalists should always respond to (though they should agree with the issue raised, such as “was the pneumonia likely due to aspiration?” only when clinically appropriate).

Change Is Coming

Don’t make the mistake of thinking Medicare reimbursement is a static phenomenon. It is undergoing rapid and significant evolution. For example, the Affordable Care Act, aka healthcare reform legislation, provides for a number of changes hospitalists need to understand.

I suggest that you make sure to understand your hospital’s or medical group’s position on accountable-care organizations (ACOs). It is a pretty complicated program that, in the first few years, has modest impact on reimbursement. If the ACO performs well, the additional reimbursement to an organization might pay for little more than the staff salaries of the staff that managed the considerable complexity of enrolling in and reporting for the program. And there is a risk the organization could lose money if it doesn’t perform well. So many organizations have decided not to pursue participation as an ACO, but they may decide to put in place most of the elements of an ACO without enrolling in the program. Some refer to this as an “aco” rather than an “ACO.”

Value-based purchasing (VBP) is set to influence hospital reimbursement rates starting in 2013 based on a hospital’s performance in 2012. SHM has a terrific VBP toolkit available online.

Bundled payments and financial penalties for readmissions also take effect in 2013. Now is the time ensure that you understand the implications of these programs; they are designed so that the financial impact to most organizations will be modest.

Reimbursement penalties for a specified list of hospital-acquired conditions (HACs) will begin in 2015. Conditions most relevant for hospitalists include vascular catheter-related bloodstream infections, catheter-related urinary infection, or manifestations of poor glycemic control (HONK, DKA, hypo-/hyperglycemia).

I plan to address some of these programs in greater detail in future practice management columns.

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is also course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.

Doctors shouldn’t have to worry about financial issues. The welfare of our patients should be our only concern.

We should be able to devote our full attention to studying how best to serve the needs of the people we care for. We shouldn’t need to spend time learning about healthcare reform or things like ICD-9 (or ICD-10!)—things that don’t help us provide better care to patients.

But these are pie-in-the-sky dreams. As far as I can tell, all healthcare systems require caregivers to attend to economics and data management that aren’t directly tied to clinical care. Our system depends on all caregivers devoting some time to learn how the system is organized, and keeping up with how it evolves. And the crisis in runaway costs in U.S. healthcare only increases the need for all who work in healthcare to devote significant time (too much) to the operational (nonclinical side) of healthcare.

Hospitalist practice is a much simpler business to manage and operate than most forms of clinical practice. There usually is no building to rent, few nonclinical employees to manage, and a comparatively simple financial model. And if employed by a hospital or other large entity, nonclinicians handle most of the “business management.” So when it comes to the number of brain cells diverted to business rather than clinical concerns, hospitalists start with an advantage over most other specialties.

Still, we have a lot of nonclinical stuff to keep up with. Consider the concept of “managing to Medicare reimbursement.” This means managing a practice or hospital in a way that minimizes the failure to capture all appropriate Medicare reimbursement dollars. Even if you’ve never heard of this concept before, there are probably a lot of people at your hospital who have this as their main responsibility, and clinicians should know something about it.

So in an effort to distract the fewest brain cells away from clinical matters, here is a very simple overview of some components of managing to Medicare reimbursement relevant to hospitalists. This isn’t a comprehensive list, only some hospitalist-relevant highlights.

Medicare Reimbursement Today

Accurate determination of inpatient vs. observation status. Wow, this can get complicated. Most hospitals have people who devote significant time to doing this for patients every day, and even those experts sometimes disagree on the appropriate status. But all hospitalists should have a basic understanding of how this works and a willingness to answer questions from the hospital’s experts, and, when appropriate, write additional information in the chart to clarify the appropriate status.

Optimal resource utilization, including length of stay. Because Medicare pays an essentially fixed amount based on the diagnoses for each inpatient admission, managing costs is critical to a hospital’s financial well-being. Hospitalists have a huge role in this. And regardless of how Medicare reimburses for services, there is clinical rationale for being careful about resources used and how long someone stays in a hospital. In many cases, more is not better—and it even could be worse—for the patient.

Optimal clinical documentation and accurate DRG assignment. Good documentation is important for clinical care, but beyond that, the precise way things are documented can have significant influence on Medicare reimbursement. Low potassium might in some cases lead to higher reimbursement, but a doctor must write “hypokalemia”; simply writing K+ means the hospital can’t include hypokalemia as a diagnosis. (A doctor, nurse practitioner, or physician assistant must write out “hypokalemia” only once for Medicare purposes; it would then be fine to use K+ in the chart every other time.)

Say you have a patient with a UTI and sepsis. Write only “urosepsis,” and the hospital must bill for cystitis—low reimbursement. Write “urinary tract infection with sepsis,” and the hospital can bill for higher reimbursement.

There should be people at your hospital who are experts at this, and all hospitalists should work with them to learn appropriate documentation language to describe illnesses correctly for billing purposes. Many hospitals use a system of “DRG queries,” which hospitalists should always respond to (though they should agree with the issue raised, such as “was the pneumonia likely due to aspiration?” only when clinically appropriate).

Change Is Coming

Don’t make the mistake of thinking Medicare reimbursement is a static phenomenon. It is undergoing rapid and significant evolution. For example, the Affordable Care Act, aka healthcare reform legislation, provides for a number of changes hospitalists need to understand.

I suggest that you make sure to understand your hospital’s or medical group’s position on accountable-care organizations (ACOs). It is a pretty complicated program that, in the first few years, has modest impact on reimbursement. If the ACO performs well, the additional reimbursement to an organization might pay for little more than the staff salaries of the staff that managed the considerable complexity of enrolling in and reporting for the program. And there is a risk the organization could lose money if it doesn’t perform well. So many organizations have decided not to pursue participation as an ACO, but they may decide to put in place most of the elements of an ACO without enrolling in the program. Some refer to this as an “aco” rather than an “ACO.”

Value-based purchasing (VBP) is set to influence hospital reimbursement rates starting in 2013 based on a hospital’s performance in 2012. SHM has a terrific VBP toolkit available online.

Bundled payments and financial penalties for readmissions also take effect in 2013. Now is the time ensure that you understand the implications of these programs; they are designed so that the financial impact to most organizations will be modest.

Reimbursement penalties for a specified list of hospital-acquired conditions (HACs) will begin in 2015. Conditions most relevant for hospitalists include vascular catheter-related bloodstream infections, catheter-related urinary infection, or manifestations of poor glycemic control (HONK, DKA, hypo-/hyperglycemia).

I plan to address some of these programs in greater detail in future practice management columns.

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is also course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.

Doctors shouldn’t have to worry about financial issues. The welfare of our patients should be our only concern.

We should be able to devote our full attention to studying how best to serve the needs of the people we care for. We shouldn’t need to spend time learning about healthcare reform or things like ICD-9 (or ICD-10!)—things that don’t help us provide better care to patients.

But these are pie-in-the-sky dreams. As far as I can tell, all healthcare systems require caregivers to attend to economics and data management that aren’t directly tied to clinical care. Our system depends on all caregivers devoting some time to learn how the system is organized, and keeping up with how it evolves. And the crisis in runaway costs in U.S. healthcare only increases the need for all who work in healthcare to devote significant time (too much) to the operational (nonclinical side) of healthcare.

Hospitalist practice is a much simpler business to manage and operate than most forms of clinical practice. There usually is no building to rent, few nonclinical employees to manage, and a comparatively simple financial model. And if employed by a hospital or other large entity, nonclinicians handle most of the “business management.” So when it comes to the number of brain cells diverted to business rather than clinical concerns, hospitalists start with an advantage over most other specialties.

Still, we have a lot of nonclinical stuff to keep up with. Consider the concept of “managing to Medicare reimbursement.” This means managing a practice or hospital in a way that minimizes the failure to capture all appropriate Medicare reimbursement dollars. Even if you’ve never heard of this concept before, there are probably a lot of people at your hospital who have this as their main responsibility, and clinicians should know something about it.

So in an effort to distract the fewest brain cells away from clinical matters, here is a very simple overview of some components of managing to Medicare reimbursement relevant to hospitalists. This isn’t a comprehensive list, only some hospitalist-relevant highlights.

Medicare Reimbursement Today

Accurate determination of inpatient vs. observation status. Wow, this can get complicated. Most hospitals have people who devote significant time to doing this for patients every day, and even those experts sometimes disagree on the appropriate status. But all hospitalists should have a basic understanding of how this works and a willingness to answer questions from the hospital’s experts, and, when appropriate, write additional information in the chart to clarify the appropriate status.

Optimal resource utilization, including length of stay. Because Medicare pays an essentially fixed amount based on the diagnoses for each inpatient admission, managing costs is critical to a hospital’s financial well-being. Hospitalists have a huge role in this. And regardless of how Medicare reimburses for services, there is clinical rationale for being careful about resources used and how long someone stays in a hospital. In many cases, more is not better—and it even could be worse—for the patient.

Optimal clinical documentation and accurate DRG assignment. Good documentation is important for clinical care, but beyond that, the precise way things are documented can have significant influence on Medicare reimbursement. Low potassium might in some cases lead to higher reimbursement, but a doctor must write “hypokalemia”; simply writing K+ means the hospital can’t include hypokalemia as a diagnosis. (A doctor, nurse practitioner, or physician assistant must write out “hypokalemia” only once for Medicare purposes; it would then be fine to use K+ in the chart every other time.)

Say you have a patient with a UTI and sepsis. Write only “urosepsis,” and the hospital must bill for cystitis—low reimbursement. Write “urinary tract infection with sepsis,” and the hospital can bill for higher reimbursement.

There should be people at your hospital who are experts at this, and all hospitalists should work with them to learn appropriate documentation language to describe illnesses correctly for billing purposes. Many hospitals use a system of “DRG queries,” which hospitalists should always respond to (though they should agree with the issue raised, such as “was the pneumonia likely due to aspiration?” only when clinically appropriate).

Change Is Coming

Don’t make the mistake of thinking Medicare reimbursement is a static phenomenon. It is undergoing rapid and significant evolution. For example, the Affordable Care Act, aka healthcare reform legislation, provides for a number of changes hospitalists need to understand.

I suggest that you make sure to understand your hospital’s or medical group’s position on accountable-care organizations (ACOs). It is a pretty complicated program that, in the first few years, has modest impact on reimbursement. If the ACO performs well, the additional reimbursement to an organization might pay for little more than the staff salaries of the staff that managed the considerable complexity of enrolling in and reporting for the program. And there is a risk the organization could lose money if it doesn’t perform well. So many organizations have decided not to pursue participation as an ACO, but they may decide to put in place most of the elements of an ACO without enrolling in the program. Some refer to this as an “aco” rather than an “ACO.”

Value-based purchasing (VBP) is set to influence hospital reimbursement rates starting in 2013 based on a hospital’s performance in 2012. SHM has a terrific VBP toolkit available online.

Bundled payments and financial penalties for readmissions also take effect in 2013. Now is the time ensure that you understand the implications of these programs; they are designed so that the financial impact to most organizations will be modest.

Reimbursement penalties for a specified list of hospital-acquired conditions (HACs) will begin in 2015. Conditions most relevant for hospitalists include vascular catheter-related bloodstream infections, catheter-related urinary infection, or manifestations of poor glycemic control (HONK, DKA, hypo-/hyperglycemia).

I plan to address some of these programs in greater detail in future practice management columns.

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is also course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.

Last month, we looked at the three main factors affecting workload variability across different HM practices and its relationship to compensation. This month we will examine how physician pay varies within a single site.

For the purposes of this discussion, we will ignore volume of encounters by physician. It goes without saying that if two physicians are working and producing an equal amount at the same site, their compensation will be similar. Outside of volume variability, then, what causes differences in compensation?

Leadership: This is a hugely important piece of the puzzle, and one that merits some attention. There always should be differential pay attached to those physicians willing to shoulder the leadership burden. In my honest opinion, local HM group leaders are horrifically, grotesquely, and shockingly underpaid. They tend to be very hard-working, almost servants to the other members of the group, and usually are vastly underappreciated.

Money isn’t necessarily the answer here; maybe the reward is a lighter schedule or lighter rounding load, but the bottom line is that there should be a substantial differential for leaders. Unfortunately, I think that still tends to be the exception rather than the rule. Hospitalist group leaders have a heck of a hard job trying to lead other physicians, and they should be paid accordingly.

At the same time, the best leaders are the ones that are still working a clinical schedule and, because of that, still understand the day-to-day demands of the job. I am always a bit skeptical of the folks who are in positions of power but aren’t experiencing the daily workload.

Experience: This is a little bit tricky. In their simplest form, physician practices tend to have partners and non-partners. The timeline from employment to partnership is about two to three years. Upon becoming partner, additional benefits accrue, generally in the form of higher compensation or the ability to work a reduced schedule.

However, “experience” prima facie will not vault one into the partnership level upon joining a new group. That experience only counts for the group you are in. (And the partner collections from the insurance payor system? No change in reimbursement. We have a payor system that, at this point, does not adequately recognize experience or quality. I always have fun trying to explain this to my friends outside of healthcare. They tend to just shake their head and sigh. Hopefully we can get somewhere new with value-based purchasing and ACOs.) Anyway, enough digressing...

Nights: A fair number of groups use a night shift model. These shifts, due to their timing, will generate a lower volume of encounters and require a commensurately higher pay. As a result, the inclusion of nocturnist compensation in a pay model will skew the numbers. In a practice with a large number of hospitals and night shifts, nocturnists are a sought-after commodity.

Quality: Here is where things are going to get interesting in the very near future. A lot of hospitalist groups have quality measures that play a part in compensation, but it’s mostly small numbers, maybe 10% of total compensation. These measures tend to be internal quality metrics for things like chart completion, citizenship, or meeting attendance. Now, with the Centers for Medicare & Medicaid Services (CMS) getting into the game, hospitals are starting to sit up and pay attention. That means administrators want hospitalists to pay attention, too. Exactly how data for each physician will be extracted from the group, which typically is extracted from the hospital as a whole, is a valid question. However, expect quality measures to persistently factor into the compensation equation.

The response I’ve laid out is meant to foster discussion, not serve as a final determination, and represents only one hospitalist’s view on the subject.

Last month, we looked at the three main factors affecting workload variability across different HM practices and its relationship to compensation. This month we will examine how physician pay varies within a single site.

For the purposes of this discussion, we will ignore volume of encounters by physician. It goes without saying that if two physicians are working and producing an equal amount at the same site, their compensation will be similar. Outside of volume variability, then, what causes differences in compensation?

Leadership: This is a hugely important piece of the puzzle, and one that merits some attention. There always should be differential pay attached to those physicians willing to shoulder the leadership burden. In my honest opinion, local HM group leaders are horrifically, grotesquely, and shockingly underpaid. They tend to be very hard-working, almost servants to the other members of the group, and usually are vastly underappreciated.

Money isn’t necessarily the answer here; maybe the reward is a lighter schedule or lighter rounding load, but the bottom line is that there should be a substantial differential for leaders. Unfortunately, I think that still tends to be the exception rather than the rule. Hospitalist group leaders have a heck of a hard job trying to lead other physicians, and they should be paid accordingly.

At the same time, the best leaders are the ones that are still working a clinical schedule and, because of that, still understand the day-to-day demands of the job. I am always a bit skeptical of the folks who are in positions of power but aren’t experiencing the daily workload.

Experience: This is a little bit tricky. In their simplest form, physician practices tend to have partners and non-partners. The timeline from employment to partnership is about two to three years. Upon becoming partner, additional benefits accrue, generally in the form of higher compensation or the ability to work a reduced schedule.

However, “experience” prima facie will not vault one into the partnership level upon joining a new group. That experience only counts for the group you are in. (And the partner collections from the insurance payor system? No change in reimbursement. We have a payor system that, at this point, does not adequately recognize experience or quality. I always have fun trying to explain this to my friends outside of healthcare. They tend to just shake their head and sigh. Hopefully we can get somewhere new with value-based purchasing and ACOs.) Anyway, enough digressing...

Nights: A fair number of groups use a night shift model. These shifts, due to their timing, will generate a lower volume of encounters and require a commensurately higher pay. As a result, the inclusion of nocturnist compensation in a pay model will skew the numbers. In a practice with a large number of hospitals and night shifts, nocturnists are a sought-after commodity.

Quality: Here is where things are going to get interesting in the very near future. A lot of hospitalist groups have quality measures that play a part in compensation, but it’s mostly small numbers, maybe 10% of total compensation. These measures tend to be internal quality metrics for things like chart completion, citizenship, or meeting attendance. Now, with the Centers for Medicare & Medicaid Services (CMS) getting into the game, hospitals are starting to sit up and pay attention. That means administrators want hospitalists to pay attention, too. Exactly how data for each physician will be extracted from the group, which typically is extracted from the hospital as a whole, is a valid question. However, expect quality measures to persistently factor into the compensation equation.

The response I’ve laid out is meant to foster discussion, not serve as a final determination, and represents only one hospitalist’s view on the subject.

Last month, we looked at the three main factors affecting workload variability across different HM practices and its relationship to compensation. This month we will examine how physician pay varies within a single site.

For the purposes of this discussion, we will ignore volume of encounters by physician. It goes without saying that if two physicians are working and producing an equal amount at the same site, their compensation will be similar. Outside of volume variability, then, what causes differences in compensation?

Leadership: This is a hugely important piece of the puzzle, and one that merits some attention. There always should be differential pay attached to those physicians willing to shoulder the leadership burden. In my honest opinion, local HM group leaders are horrifically, grotesquely, and shockingly underpaid. They tend to be very hard-working, almost servants to the other members of the group, and usually are vastly underappreciated.

Money isn’t necessarily the answer here; maybe the reward is a lighter schedule or lighter rounding load, but the bottom line is that there should be a substantial differential for leaders. Unfortunately, I think that still tends to be the exception rather than the rule. Hospitalist group leaders have a heck of a hard job trying to lead other physicians, and they should be paid accordingly.

At the same time, the best leaders are the ones that are still working a clinical schedule and, because of that, still understand the day-to-day demands of the job. I am always a bit skeptical of the folks who are in positions of power but aren’t experiencing the daily workload.

Experience: This is a little bit tricky. In their simplest form, physician practices tend to have partners and non-partners. The timeline from employment to partnership is about two to three years. Upon becoming partner, additional benefits accrue, generally in the form of higher compensation or the ability to work a reduced schedule.

However, “experience” prima facie will not vault one into the partnership level upon joining a new group. That experience only counts for the group you are in. (And the partner collections from the insurance payor system? No change in reimbursement. We have a payor system that, at this point, does not adequately recognize experience or quality. I always have fun trying to explain this to my friends outside of healthcare. They tend to just shake their head and sigh. Hopefully we can get somewhere new with value-based purchasing and ACOs.) Anyway, enough digressing...

Nights: A fair number of groups use a night shift model. These shifts, due to their timing, will generate a lower volume of encounters and require a commensurately higher pay. As a result, the inclusion of nocturnist compensation in a pay model will skew the numbers. In a practice with a large number of hospitals and night shifts, nocturnists are a sought-after commodity.

Quality: Here is where things are going to get interesting in the very near future. A lot of hospitalist groups have quality measures that play a part in compensation, but it’s mostly small numbers, maybe 10% of total compensation. These measures tend to be internal quality metrics for things like chart completion, citizenship, or meeting attendance. Now, with the Centers for Medicare & Medicaid Services (CMS) getting into the game, hospitals are starting to sit up and pay attention. That means administrators want hospitalists to pay attention, too. Exactly how data for each physician will be extracted from the group, which typically is extracted from the hospital as a whole, is a valid question. However, expect quality measures to persistently factor into the compensation equation.

The response I’ve laid out is meant to foster discussion, not serve as a final determination, and represents only one hospitalist’s view on the subject.

Some of the best companies in America started in a garage or a basement with an individual who had a great idea and the ability to grow it into a progressively larger business.

“It takes a leader with different capabilities to take a company to the next level,” says Martin Buser, MPH, FACHE, a partner with Hospitalist Management Resources LLC in San Diego, which has helped more than 350 HM programs nationwide in the past 15 years. “It’s an attitude of never stop learning, an ability to look at issues from 30,000 feet instead of ground zero so you can see the whole picture.”

Similarly, the most important predictor of an HM program’s success is its director, Buser says. If directors know how to communicate, innovate, facilitate, problem-solve, and inspire, they are much more likely to run a high-performing hospitalist program, says David Lee, MD, MBA, FACP, FHM, vice chairman of the Hospital Medicine Department at Ochsner Health System in New Orleans.

If group directors lack the skills and fail to adapt to change, the program’s outlook is far from certain. “We unfortunately get involved with these programs,” Buser says. “It’s painful to see.” Bad behavior is nothing new to the hospital setting, and HM is not immune to poor management. The following are common examples of bad behaviors and how groups can avoid the mishaps.

Scenario No. 1 : Great Clinician, Nice Person, Weak Advocate

Show that you understand the hospital’s issues. Certain things you want to compromise on, but other things you have to say, “If we do that, the ramifications are such that it’s just not going to work.”

—Martin Buser, MPH, FACHE, partner, Hospitalist Management Resources LLC, San Diego

The case: Earlier this year, medical center administrators asked the hospitalist program to do more with less, explaining the hospital was having a bad financial year. Administration approached the HM director, an exceptional, gregarious clinician who was named to the position years ago to help the program gain acceptance. The director agreed to indefinitely postpone two much-needed hirings, deciding it was better to share in the sacrifice than protest the cuts to the program’s budget. Hospitalists have since been working more shifts without a pay increase, and burnout symptoms have emerged with no signs of a thaw in the hiring freeze.

Expert advice: Buser says the “weak advocate” is a common issue among hospitalist groups, many of which he says are “going to hell” when he gets a rescue call. When a hospital is facing financial hardship, it is imperative that the HM director stand up for the program by explaining in detail the ramifications of each level of budget cuts. That’s because administrators might not realize the long-term damage that would result from such actions, he says. Being a strong, savvy advocate is even more important now since the financial future of many hospitals is ominous.

“With all of our hospitalist clients, we ask the CFO what is happening in the future…and the numbers are phenomenal,” says Buser. “They are seeing reductions of $10 million to $30 million off their bottom line.”

Administrators’ knee-jerk reaction is to cut costs. But there is another option: Grow the hospital out of its financial difficulties. It is up to the HM director to show administrators how the HM group has strategically gained them market share and how it will continue to do so. Good directors are in near constant contact with administrators, demonstrating the value their hospitalist program brings to the hospital, Buser says.

“You’re having regular meetings with the administrator, you’re producing the dashboard on a regular basis, you’re giving him trends that are going on,” he explains. “Show that you understand the hospital’s issues. Certain things you want to compromise on, but other things you have to say, ‘If we do that, the ramifications are such that it’s just not going to work.’”

Scenario No. 2 : Recruiting Roulette

A bad team fit is often worse than being short-staffed because it can literally destroy the team spirit.

—David Friar, MD, SFHM, CEO, Hospitalists of Northern Michigan, Traverse City

The case: The HM director felt pressure to hire. The program’s hospitalists were seeing two to three patients a day more than they should have been, and hospital administrators were worried the program was losing ground to the other hospitalist group in the community. Using an outside recruiter, the director hired two adept physicians with stellar CVs after an expedited review process that included a background check, a few phone interviews, and day of in-person interviews with some administrators and a hospitalist on the team. Now, nearly a year later, one of the physicians is about to leave because her family doesn’t like the community, and the other new hire’s abrasive personality has caused considerable damage to the team’s cohesion.

Expert advice: A big part of an HM program’s value is how it practices as a unified team, and directors need to recognize how vital the “team fit” is to hospitalists, says David Friar, MD, SFHM, CEO of Hospitalists of Northern Michigan in Traverse City.

“A bad team fit is often worse than being short-staffed because it can literally destroy the team spirit,” he says.

Directors should have a standardized recruitment process that includes a comprehensive background screening where references are closely checked, a round of interviews by people outside the HM program (nurses and referring physicians), and substantial time spent with hospitalists in the program, says Bryce Gartland, MD, FHM, associate director of the hospital medicine division and medical director of care coordination at Emory Healthcare in Atlanta.

“We put [candidates] with one of our physicians to actually go around the hospital,” he says. “It’s amazing to me the number of things you can pick up by that broader exposure that you may not pick up sitting in a room with a candidate across the table for an hour.”

If a recruitment service is used, the director must describe the HM program in detail to the recruiter and even have them meet hospitalists on the staff, Dr. Friar says.

“Sending them a memo saying ‘We need three new hospitalists ASAP’ isn’t helping them find you the perfect candidate,” he says. “Even the best recruiter can only do a great job for you if they really know your team and what it is you need in a candidate.”

A director also is well served to make recruiting a family event where spouses and even children are part of the interview process.

“By including the entire family and then supporting them after the move, we are much more likely to recruit providers that will stay good members of our team for years to come,” Dr. Friar says.

Scenario No. 3 : Amitte Diem

If you don’t get buy in from your staff, the change is doomed to fail from the beginning.

—John Bulger, DO, FACP, FHM, chief quality officer, director, hospital medicine service line, Geisinger Health System, Danville, Pa.

The case: For months, the medical center has been receiving an increased number of referrals from outlying hospitals, and no end is in sight. The extra patient load, much of it involving complex cases, has agitated the medical center’s staff, particularly the specialists, and they’ve begun to complain to hospital administrators. Seeking an ally, the specialists reach out to the HM director to present their case. Without doing independent analysis, the HM director sides with the specialists. Hospital administrators, facing growing resistance, work to decrease the referrals and are successful.

Expert advice: Consider working in the opposite direction, one that might turn a referral challenge into a profitable opportunity, Buser says. One of his firm’s clients, after thorough research, established a transfer center and set up an activation fee for the specialists who took the referrals. Hospitalists admitted about 90% of the cases, called consults, and named specialists so they received full fee-for-service at Medicare rates if they saw uninsured patients.

“That hospital is now making about $78 million a year, and the medical staff is saying, ‘How can we grow this?’” Buser says. “Here’s an example of how the hospital medicine director was key to turning the bad into something good.”

Because physicians tend to be reticent to change, it’s critical for hospitalist directors who want to seize an opportunity to thoroughly plan out how the change will occur and to prepare for potential obstacles along the way, says John Bulger, DO, FACP, FHM, chief quality officer and director of the hospital medicine service line for Geisinger Health System in Danville, Pa.

“You really need to be prepared with your rationale of why you’re doing it, if there’s data behind why you’re doing it, what the data is that’s driving it, and really what you hope to do with that change,” he says. “If you don’t get buy in from your staff, the change is doomed to fail from the beginning.”

Directors must embrace being a change agent if they want their HM programs to continue to be successful. In the minds of many hospital administrators, a program is only as good as its last achievement.

“It’s kind of like, ‘What have you done for me lately?’” Buser says. “You want to stay ahead of the curve and be alert to what’s going on and not be caught keeping your eyes off the ball and, as a result, not moving your program forward.”

Scenario No. 4 : Fumbling the Handoff

Notes and clinical information are submitted to this health information exchange and made available to any of the physicians who are caring for the patient almost immediately upon dictation and notation.

—Daniel Cusator, MD, MBA, vice president, Camden Group, El Segundo, Calif.

The case: The medical center’s monthly data for the past year has shown that hospitalists are taking care of their patients efficiently and getting them out of the hospital more quickly. However, mixed in with the positive numbers is a stubbornly high 30-day readmission rate. Indeed, some primary care groups and referring geriatricians have begun to grouse to the HM director about the discharge notes, complaining they aren’t as comprehensive as they would like.

Plus, the notes always arrive via office fax, which makes them more likely to get misplaced and harder to receive when doctors are out of the office.

Expert advice: Handoffs from discharge to pickup are where a lot of complications, errors, and safety issues arise, and poor handoffs are one of the largest drivers of readmission rates, especially in the elderly patient population, says Daniel Cusator, MD, MBA, vice president of the Camden Group, a healthcare consulting firm in El Segundo, Calif.

If the hospitalist director doesn’t provide the leadership and resources to help the HM team better coordinate with patients’ regular doctors, handoffs won’t be a priority throughout the group.

The HM director must recognize that the term “discharge note” is a misnomer.

What referring physicians really want is a care plan, which includes information about testing done in the hospital, testing that might be needed in the outpatient setting, medications the patient is on, complications the patient had in the hospital, potential problems to monitor, and any necessary follow-up, says Dr. Cusator, formerly the chief medical officer of clinical integration at Providence Health & Services in Southern California.

PCPs also want the care plan transmitted in their preferred method, whether that is text messaging, HIPAA-compliant email messaging, secure messaging, or fax.

“What I’ve seen some hospitalist groups do is create a menu capability for each of the physicians to choose their preferred method of notification of discharge of their patient,” Dr. Cusator says. Results suggest such a menu leads to improved physician satisfaction and reduced patient complications after discharge, he adds.

With today’s technological innovations, HM directors are unlimited in their ability to improve handoffs between their team and patients’ PCPs and specialists, Dr. Cusator says. Some HM directors, for example, are leading efforts to link electronic medical records systems to hospital-based health information exchange hubs that are accessible to physicians in the community.

“Notes and clinical information are submitted to this health information exchange and made available to any of the physicians who are caring for the patient almost immediately upon dictation and notation,” he says.

Scenario No. 5 : Protect Your Assets

There has to be a cohesiveness in order for your department to excel. You have to protect your assets in the group, which is your physicians.

—David Lee, MD, MBA, FACP, FHM, vice chairman, Hospital Medicine Department, Ochsner Health System, New Orleans.

The case: A physician isn’t sure she wants a career in hospital medicine. She finds the specialty rewarding but is looking for a different challenge, something beyond exclusively seeing patients. The HM director notices the physician has an aptitude for finding ways to do tasks more efficiently.

The director privately thinks the physician would be a good fit for a quality improvement project that’s about to start but doesn’t pursue it. The HM team just added a primary care group, and its patient census is quickly rising, requiring the hospitalists to devote their entire shifts to patient care. Within the year, the physician leaves the team for a fellowship program outside hospital medicine.

Expert advice: There are three communities in hospital medicine, Dr. Bulger says: people who want to be hospitalists, people who are passing through on their way to something else, and people who sit somewhere in the middle.

HM directors, he says, should do everything they can to develop not only the career hospitalists but also those on the fence.

“A lot of them you can turn into people who are going to be hospitalists if they are doing something that is rewarding for them,” Dr. Bulger says. “Many times rewarding for them is being involved more in the leadership of the group, being involved in quality improvement projects, really seeing how they can impact the care for populations of patients—and not just the patient who happens to be sitting in front of them.”

It’s incumbent on HM group leaders to link hospitalists with mentors and help them find a niche, Dr. Lee says. It keeps people interested and makes them feel part of a group.

“They need to feel they belong,” he says. “There has to be a cohesiveness in order for your department to excel. You have to protect your assets in the group, which is your physicians.”

Sending hospitalists to professional development training, such as SHM’s Leadership Academy (see “Leadership Academy Adds ‘Women in HM Issues’ to Schedule,” p. 9) or QI-focused webinars offered by SHM or the Institute of Healthcare Improvement, and following up with day-to-day coaching is a solid physician-development strategy, Dr. Gartland says. By virtue of their job, hospitalists are expected to lead and manage people in interactions with the ED, primary care, non-physician providers, nursing staff, and beyond, he says.

Directors also have to stop assuming that competent physicians are competent managers. “A lot of physicians don’t have those core skill sets, and we’ve got to pay conscious attention toward spending time dedicated to developing those,” Dr. Gartland says.

If directors don’t make professional development a priority or provide hospitalists with the flexibility to do non-clinical activities, retention may become an issue, Dr. Bulger says. “They could leave and go somewhere else,” he says, yet perhaps the more significant danger is losing hospitalists to programs and specialties outside hospital medicine.

Lisa Ryan is a freelance writer based in New Jersey.

THE FUNDAMENTALS

As hospitals position themselves for healthcare reform, they increasingly will turn to HM for strategies on how to provide high-quality patient care at a lower cost, Buser says. To meet hospitals’ needs and enhance the value of their programs, hospitalist directors should consider adopting these strategies recommended by HM leaders:

• Align compensation with the HM program’s goals. For example, if quality improvement is the priority, directors should financially reward hospitalists on quality performance, Dr. Lee says.
• Boost support staff and functions. For example, directors should ensure their team has access to the hospital’s case managers, who can handle discharge logistics so the hospitalist can focus on clinical issues, Dr. Cusator says.
• Control program growth. To borrow a popular line from the movie Field of Dreams: “If you build it, they will come.” Directors should be deliberate with group expansion and ensure enough staff is in place before adding to their referral base or adding a new service line, Dr. Bulger says. This reduces hospitalist burnout and preserves the group’s quality of patient care.
• Define two to three targets for success in the upcoming year and concentrate on accomplishing them. Start by consolidating what your team is working on, says Steven Deitelzweig, MD, SFHM, chairman of the Department of Hospital Medicine at Ochsner Health System in New Orleans. Pick too many things to master, and you end up excelling in none, he adds.
• Evaluate performance beyond a scorecard. Using constructive criticism grounded with examples, HM directors should provide feedback about what a physician is doing well and what can be done better so they can improve, Dr. Gartland says.
• Foster creative problem solving by including hospitalists in decisions. Directors should encourage the expression of different opinions and ideas, which helps the program avoid “group think” and allows innovation to occur, Dr. Lee says.
• Galvanize the new generation. To retain young physicians and make them feel part of the program, directors should learn how they communicate, how they work, and how they view work, Dr. Lee says.
• Help your hospital accurately measure reimbursement and mortality rates. Directors should make coding a priority and provide hospitalists with the tools they need to capture correct ICD-9 and CPT codes for their patients, Dr. Cusator says.
• Identify missing core capabilities and dedicate resources for it. For example, if HM programs have a high census of chronically ill and end-of-life patients, directors should assist the hospital in establishing a palliative care or hospice program, Dr. Cusator says.

Some of the best companies in America started in a garage or a basement with an individual who had a great idea and the ability to grow it into a progressively larger business.

“It takes a leader with different capabilities to take a company to the next level,” says Martin Buser, MPH, FACHE, a partner with Hospitalist Management Resources LLC in San Diego, which has helped more than 350 HM programs nationwide in the past 15 years. “It’s an attitude of never stop learning, an ability to look at issues from 30,000 feet instead of ground zero so you can see the whole picture.”

Similarly, the most important predictor of an HM program’s success is its director, Buser says. If directors know how to communicate, innovate, facilitate, problem-solve, and inspire, they are much more likely to run a high-performing hospitalist program, says David Lee, MD, MBA, FACP, FHM, vice chairman of the Hospital Medicine Department at Ochsner Health System in New Orleans.

If group directors lack the skills and fail to adapt to change, the program’s outlook is far from certain. “We unfortunately get involved with these programs,” Buser says. “It’s painful to see.” Bad behavior is nothing new to the hospital setting, and HM is not immune to poor management. The following are common examples of bad behaviors and how groups can avoid the mishaps.

Scenario No. 1 : Great Clinician, Nice Person, Weak Advocate

Show that you understand the hospital’s issues. Certain things you want to compromise on, but other things you have to say, “If we do that, the ramifications are such that it’s just not going to work.”

—Martin Buser, MPH, FACHE, partner, Hospitalist Management Resources LLC, San Diego

The case: Earlier this year, medical center administrators asked the hospitalist program to do more with less, explaining the hospital was having a bad financial year. Administration approached the HM director, an exceptional, gregarious clinician who was named to the position years ago to help the program gain acceptance. The director agreed to indefinitely postpone two much-needed hirings, deciding it was better to share in the sacrifice than protest the cuts to the program’s budget. Hospitalists have since been working more shifts without a pay increase, and burnout symptoms have emerged with no signs of a thaw in the hiring freeze.

Expert advice: Buser says the “weak advocate” is a common issue among hospitalist groups, many of which he says are “going to hell” when he gets a rescue call. When a hospital is facing financial hardship, it is imperative that the HM director stand up for the program by explaining in detail the ramifications of each level of budget cuts. That’s because administrators might not realize the long-term damage that would result from such actions, he says. Being a strong, savvy advocate is even more important now since the financial future of many hospitals is ominous.

“With all of our hospitalist clients, we ask the CFO what is happening in the future…and the numbers are phenomenal,” says Buser. “They are seeing reductions of $10 million to $30 million off their bottom line.”

Administrators’ knee-jerk reaction is to cut costs. But there is another option: Grow the hospital out of its financial difficulties. It is up to the HM director to show administrators how the HM group has strategically gained them market share and how it will continue to do so. Good directors are in near constant contact with administrators, demonstrating the value their hospitalist program brings to the hospital, Buser says.

“You’re having regular meetings with the administrator, you’re producing the dashboard on a regular basis, you’re giving him trends that are going on,” he explains. “Show that you understand the hospital’s issues. Certain things you want to compromise on, but other things you have to say, ‘If we do that, the ramifications are such that it’s just not going to work.’”

Scenario No. 2 : Recruiting Roulette

A bad team fit is often worse than being short-staffed because it can literally destroy the team spirit.

—David Friar, MD, SFHM, CEO, Hospitalists of Northern Michigan, Traverse City

The case: The HM director felt pressure to hire. The program’s hospitalists were seeing two to three patients a day more than they should have been, and hospital administrators were worried the program was losing ground to the other hospitalist group in the community. Using an outside recruiter, the director hired two adept physicians with stellar CVs after an expedited review process that included a background check, a few phone interviews, and day of in-person interviews with some administrators and a hospitalist on the team. Now, nearly a year later, one of the physicians is about to leave because her family doesn’t like the community, and the other new hire’s abrasive personality has caused considerable damage to the team’s cohesion.

Expert advice: A big part of an HM program’s value is how it practices as a unified team, and directors need to recognize how vital the “team fit” is to hospitalists, says David Friar, MD, SFHM, CEO of Hospitalists of Northern Michigan in Traverse City.

“A bad team fit is often worse than being short-staffed because it can literally destroy the team spirit,” he says.

Directors should have a standardized recruitment process that includes a comprehensive background screening where references are closely checked, a round of interviews by people outside the HM program (nurses and referring physicians), and substantial time spent with hospitalists in the program, says Bryce Gartland, MD, FHM, associate director of the hospital medicine division and medical director of care coordination at Emory Healthcare in Atlanta.

“We put [candidates] with one of our physicians to actually go around the hospital,” he says. “It’s amazing to me the number of things you can pick up by that broader exposure that you may not pick up sitting in a room with a candidate across the table for an hour.”

If a recruitment service is used, the director must describe the HM program in detail to the recruiter and even have them meet hospitalists on the staff, Dr. Friar says.

“Sending them a memo saying ‘We need three new hospitalists ASAP’ isn’t helping them find you the perfect candidate,” he says. “Even the best recruiter can only do a great job for you if they really know your team and what it is you need in a candidate.”

A director also is well served to make recruiting a family event where spouses and even children are part of the interview process.

“By including the entire family and then supporting them after the move, we are much more likely to recruit providers that will stay good members of our team for years to come,” Dr. Friar says.

Scenario No. 3 : Amitte Diem

If you don’t get buy in from your staff, the change is doomed to fail from the beginning.

—John Bulger, DO, FACP, FHM, chief quality officer, director, hospital medicine service line, Geisinger Health System, Danville, Pa.

The case: For months, the medical center has been receiving an increased number of referrals from outlying hospitals, and no end is in sight. The extra patient load, much of it involving complex cases, has agitated the medical center’s staff, particularly the specialists, and they’ve begun to complain to hospital administrators. Seeking an ally, the specialists reach out to the HM director to present their case. Without doing independent analysis, the HM director sides with the specialists. Hospital administrators, facing growing resistance, work to decrease the referrals and are successful.

Expert advice: Consider working in the opposite direction, one that might turn a referral challenge into a profitable opportunity, Buser says. One of his firm’s clients, after thorough research, established a transfer center and set up an activation fee for the specialists who took the referrals. Hospitalists admitted about 90% of the cases, called consults, and named specialists so they received full fee-for-service at Medicare rates if they saw uninsured patients.

“That hospital is now making about $78 million a year, and the medical staff is saying, ‘How can we grow this?’” Buser says. “Here’s an example of how the hospital medicine director was key to turning the bad into something good.”

Because physicians tend to be reticent to change, it’s critical for hospitalist directors who want to seize an opportunity to thoroughly plan out how the change will occur and to prepare for potential obstacles along the way, says John Bulger, DO, FACP, FHM, chief quality officer and director of the hospital medicine service line for Geisinger Health System in Danville, Pa.

“You really need to be prepared with your rationale of why you’re doing it, if there’s data behind why you’re doing it, what the data is that’s driving it, and really what you hope to do with that change,” he says. “If you don’t get buy in from your staff, the change is doomed to fail from the beginning.”

Directors must embrace being a change agent if they want their HM programs to continue to be successful. In the minds of many hospital administrators, a program is only as good as its last achievement.

“It’s kind of like, ‘What have you done for me lately?’” Buser says. “You want to stay ahead of the curve and be alert to what’s going on and not be caught keeping your eyes off the ball and, as a result, not moving your program forward.”

Scenario No. 4 : Fumbling the Handoff

Notes and clinical information are submitted to this health information exchange and made available to any of the physicians who are caring for the patient almost immediately upon dictation and notation.

—Daniel Cusator, MD, MBA, vice president, Camden Group, El Segundo, Calif.

The case: The medical center’s monthly data for the past year has shown that hospitalists are taking care of their patients efficiently and getting them out of the hospital more quickly. However, mixed in with the positive numbers is a stubbornly high 30-day readmission rate. Indeed, some primary care groups and referring geriatricians have begun to grouse to the HM director about the discharge notes, complaining they aren’t as comprehensive as they would like.

Plus, the notes always arrive via office fax, which makes them more likely to get misplaced and harder to receive when doctors are out of the office.

Expert advice: Handoffs from discharge to pickup are where a lot of complications, errors, and safety issues arise, and poor handoffs are one of the largest drivers of readmission rates, especially in the elderly patient population, says Daniel Cusator, MD, MBA, vice president of the Camden Group, a healthcare consulting firm in El Segundo, Calif.

If the hospitalist director doesn’t provide the leadership and resources to help the HM team better coordinate with patients’ regular doctors, handoffs won’t be a priority throughout the group.

The HM director must recognize that the term “discharge note” is a misnomer.

What referring physicians really want is a care plan, which includes information about testing done in the hospital, testing that might be needed in the outpatient setting, medications the patient is on, complications the patient had in the hospital, potential problems to monitor, and any necessary follow-up, says Dr. Cusator, formerly the chief medical officer of clinical integration at Providence Health & Services in Southern California.

PCPs also want the care plan transmitted in their preferred method, whether that is text messaging, HIPAA-compliant email messaging, secure messaging, or fax.

“What I’ve seen some hospitalist groups do is create a menu capability for each of the physicians to choose their preferred method of notification of discharge of their patient,” Dr. Cusator says. Results suggest such a menu leads to improved physician satisfaction and reduced patient complications after discharge, he adds.

With today’s technological innovations, HM directors are unlimited in their ability to improve handoffs between their team and patients’ PCPs and specialists, Dr. Cusator says. Some HM directors, for example, are leading efforts to link electronic medical records systems to hospital-based health information exchange hubs that are accessible to physicians in the community.

“Notes and clinical information are submitted to this health information exchange and made available to any of the physicians who are caring for the patient almost immediately upon dictation and notation,” he says.

Scenario No. 5 : Protect Your Assets

There has to be a cohesiveness in order for your department to excel. You have to protect your assets in the group, which is your physicians.

—David Lee, MD, MBA, FACP, FHM, vice chairman, Hospital Medicine Department, Ochsner Health System, New Orleans.

The case: A physician isn’t sure she wants a career in hospital medicine. She finds the specialty rewarding but is looking for a different challenge, something beyond exclusively seeing patients. The HM director notices the physician has an aptitude for finding ways to do tasks more efficiently.

The director privately thinks the physician would be a good fit for a quality improvement project that’s about to start but doesn’t pursue it. The HM team just added a primary care group, and its patient census is quickly rising, requiring the hospitalists to devote their entire shifts to patient care. Within the year, the physician leaves the team for a fellowship program outside hospital medicine.

Expert advice: There are three communities in hospital medicine, Dr. Bulger says: people who want to be hospitalists, people who are passing through on their way to something else, and people who sit somewhere in the middle.

HM directors, he says, should do everything they can to develop not only the career hospitalists but also those on the fence.

“A lot of them you can turn into people who are going to be hospitalists if they are doing something that is rewarding for them,” Dr. Bulger says. “Many times rewarding for them is being involved more in the leadership of the group, being involved in quality improvement projects, really seeing how they can impact the care for populations of patients—and not just the patient who happens to be sitting in front of them.”

It’s incumbent on HM group leaders to link hospitalists with mentors and help them find a niche, Dr. Lee says. It keeps people interested and makes them feel part of a group.

“They need to feel they belong,” he says. “There has to be a cohesiveness in order for your department to excel. You have to protect your assets in the group, which is your physicians.”

Sending hospitalists to professional development training, such as SHM’s Leadership Academy (see “Leadership Academy Adds ‘Women in HM Issues’ to Schedule,” p. 9) or QI-focused webinars offered by SHM or the Institute of Healthcare Improvement, and following up with day-to-day coaching is a solid physician-development strategy, Dr. Gartland says. By virtue of their job, hospitalists are expected to lead and manage people in interactions with the ED, primary care, non-physician providers, nursing staff, and beyond, he says.

Directors also have to stop assuming that competent physicians are competent managers. “A lot of physicians don’t have those core skill sets, and we’ve got to pay conscious attention toward spending time dedicated to developing those,” Dr. Gartland says.

If directors don’t make professional development a priority or provide hospitalists with the flexibility to do non-clinical activities, retention may become an issue, Dr. Bulger says. “They could leave and go somewhere else,” he says, yet perhaps the more significant danger is losing hospitalists to programs and specialties outside hospital medicine.

Lisa Ryan is a freelance writer based in New Jersey.

THE FUNDAMENTALS

As hospitals position themselves for healthcare reform, they increasingly will turn to HM for strategies on how to provide high-quality patient care at a lower cost, Buser says. To meet hospitals’ needs and enhance the value of their programs, hospitalist directors should consider adopting these strategies recommended by HM leaders:

• Align compensation with the HM program’s goals. For example, if quality improvement is the priority, directors should financially reward hospitalists on quality performance, Dr. Lee says.
• Boost support staff and functions. For example, directors should ensure their team has access to the hospital’s case managers, who can handle discharge logistics so the hospitalist can focus on clinical issues, Dr. Cusator says.
• Control program growth. To borrow a popular line from the movie Field of Dreams: “If you build it, they will come.” Directors should be deliberate with group expansion and ensure enough staff is in place before adding to their referral base or adding a new service line, Dr. Bulger says. This reduces hospitalist burnout and preserves the group’s quality of patient care.
• Define two to three targets for success in the upcoming year and concentrate on accomplishing them. Start by consolidating what your team is working on, says Steven Deitelzweig, MD, SFHM, chairman of the Department of Hospital Medicine at Ochsner Health System in New Orleans. Pick too many things to master, and you end up excelling in none, he adds.
• Evaluate performance beyond a scorecard. Using constructive criticism grounded with examples, HM directors should provide feedback about what a physician is doing well and what can be done better so they can improve, Dr. Gartland says.
• Foster creative problem solving by including hospitalists in decisions. Directors should encourage the expression of different opinions and ideas, which helps the program avoid “group think” and allows innovation to occur, Dr. Lee says.
• Galvanize the new generation. To retain young physicians and make them feel part of the program, directors should learn how they communicate, how they work, and how they view work, Dr. Lee says.
• Help your hospital accurately measure reimbursement and mortality rates. Directors should make coding a priority and provide hospitalists with the tools they need to capture correct ICD-9 and CPT codes for their patients, Dr. Cusator says.
• Identify missing core capabilities and dedicate resources for it. For example, if HM programs have a high census of chronically ill and end-of-life patients, directors should assist the hospital in establishing a palliative care or hospice program, Dr. Cusator says.

Some of the best companies in America started in a garage or a basement with an individual who had a great idea and the ability to grow it into a progressively larger business.

“It takes a leader with different capabilities to take a company to the next level,” says Martin Buser, MPH, FACHE, a partner with Hospitalist Management Resources LLC in San Diego, which has helped more than 350 HM programs nationwide in the past 15 years. “It’s an attitude of never stop learning, an ability to look at issues from 30,000 feet instead of ground zero so you can see the whole picture.”

Similarly, the most important predictor of an HM program’s success is its director, Buser says. If directors know how to communicate, innovate, facilitate, problem-solve, and inspire, they are much more likely to run a high-performing hospitalist program, says David Lee, MD, MBA, FACP, FHM, vice chairman of the Hospital Medicine Department at Ochsner Health System in New Orleans.

If group directors lack the skills and fail to adapt to change, the program’s outlook is far from certain. “We unfortunately get involved with these programs,” Buser says. “It’s painful to see.” Bad behavior is nothing new to the hospital setting, and HM is not immune to poor management. The following are common examples of bad behaviors and how groups can avoid the mishaps.

Scenario No. 1 : Great Clinician, Nice Person, Weak Advocate

Show that you understand the hospital’s issues. Certain things you want to compromise on, but other things you have to say, “If we do that, the ramifications are such that it’s just not going to work.”

—Martin Buser, MPH, FACHE, partner, Hospitalist Management Resources LLC, San Diego

The case: Earlier this year, medical center administrators asked the hospitalist program to do more with less, explaining the hospital was having a bad financial year. Administration approached the HM director, an exceptional, gregarious clinician who was named to the position years ago to help the program gain acceptance. The director agreed to indefinitely postpone two much-needed hirings, deciding it was better to share in the sacrifice than protest the cuts to the program’s budget. Hospitalists have since been working more shifts without a pay increase, and burnout symptoms have emerged with no signs of a thaw in the hiring freeze.

Expert advice: Buser says the “weak advocate” is a common issue among hospitalist groups, many of which he says are “going to hell” when he gets a rescue call. When a hospital is facing financial hardship, it is imperative that the HM director stand up for the program by explaining in detail the ramifications of each level of budget cuts. That’s because administrators might not realize the long-term damage that would result from such actions, he says. Being a strong, savvy advocate is even more important now since the financial future of many hospitals is ominous.

“With all of our hospitalist clients, we ask the CFO what is happening in the future…and the numbers are phenomenal,” says Buser. “They are seeing reductions of $10 million to $30 million off their bottom line.”

Administrators’ knee-jerk reaction is to cut costs. But there is another option: Grow the hospital out of its financial difficulties. It is up to the HM director to show administrators how the HM group has strategically gained them market share and how it will continue to do so. Good directors are in near constant contact with administrators, demonstrating the value their hospitalist program brings to the hospital, Buser says.

“You’re having regular meetings with the administrator, you’re producing the dashboard on a regular basis, you’re giving him trends that are going on,” he explains. “Show that you understand the hospital’s issues. Certain things you want to compromise on, but other things you have to say, ‘If we do that, the ramifications are such that it’s just not going to work.’”

Scenario No. 2 : Recruiting Roulette

A bad team fit is often worse than being short-staffed because it can literally destroy the team spirit.

—David Friar, MD, SFHM, CEO, Hospitalists of Northern Michigan, Traverse City

The case: The HM director felt pressure to hire. The program’s hospitalists were seeing two to three patients a day more than they should have been, and hospital administrators were worried the program was losing ground to the other hospitalist group in the community. Using an outside recruiter, the director hired two adept physicians with stellar CVs after an expedited review process that included a background check, a few phone interviews, and day of in-person interviews with some administrators and a hospitalist on the team. Now, nearly a year later, one of the physicians is about to leave because her family doesn’t like the community, and the other new hire’s abrasive personality has caused considerable damage to the team’s cohesion.

Expert advice: A big part of an HM program’s value is how it practices as a unified team, and directors need to recognize how vital the “team fit” is to hospitalists, says David Friar, MD, SFHM, CEO of Hospitalists of Northern Michigan in Traverse City.

“A bad team fit is often worse than being short-staffed because it can literally destroy the team spirit,” he says.

Directors should have a standardized recruitment process that includes a comprehensive background screening where references are closely checked, a round of interviews by people outside the HM program (nurses and referring physicians), and substantial time spent with hospitalists in the program, says Bryce Gartland, MD, FHM, associate director of the hospital medicine division and medical director of care coordination at Emory Healthcare in Atlanta.

“We put [candidates] with one of our physicians to actually go around the hospital,” he says. “It’s amazing to me the number of things you can pick up by that broader exposure that you may not pick up sitting in a room with a candidate across the table for an hour.”

If a recruitment service is used, the director must describe the HM program in detail to the recruiter and even have them meet hospitalists on the staff, Dr. Friar says.

“Sending them a memo saying ‘We need three new hospitalists ASAP’ isn’t helping them find you the perfect candidate,” he says. “Even the best recruiter can only do a great job for you if they really know your team and what it is you need in a candidate.”

A director also is well served to make recruiting a family event where spouses and even children are part of the interview process.

“By including the entire family and then supporting them after the move, we are much more likely to recruit providers that will stay good members of our team for years to come,” Dr. Friar says.

Scenario No. 3 : Amitte Diem

If you don’t get buy in from your staff, the change is doomed to fail from the beginning.

—John Bulger, DO, FACP, FHM, chief quality officer, director, hospital medicine service line, Geisinger Health System, Danville, Pa.

The case: For months, the medical center has been receiving an increased number of referrals from outlying hospitals, and no end is in sight. The extra patient load, much of it involving complex cases, has agitated the medical center’s staff, particularly the specialists, and they’ve begun to complain to hospital administrators. Seeking an ally, the specialists reach out to the HM director to present their case. Without doing independent analysis, the HM director sides with the specialists. Hospital administrators, facing growing resistance, work to decrease the referrals and are successful.

Expert advice: Consider working in the opposite direction, one that might turn a referral challenge into a profitable opportunity, Buser says. One of his firm’s clients, after thorough research, established a transfer center and set up an activation fee for the specialists who took the referrals. Hospitalists admitted about 90% of the cases, called consults, and named specialists so they received full fee-for-service at Medicare rates if they saw uninsured patients.

“That hospital is now making about $78 million a year, and the medical staff is saying, ‘How can we grow this?’” Buser says. “Here’s an example of how the hospital medicine director was key to turning the bad into something good.”

Because physicians tend to be reticent to change, it’s critical for hospitalist directors who want to seize an opportunity to thoroughly plan out how the change will occur and to prepare for potential obstacles along the way, says John Bulger, DO, FACP, FHM, chief quality officer and director of the hospital medicine service line for Geisinger Health System in Danville, Pa.

“You really need to be prepared with your rationale of why you’re doing it, if there’s data behind why you’re doing it, what the data is that’s driving it, and really what you hope to do with that change,” he says. “If you don’t get buy in from your staff, the change is doomed to fail from the beginning.”

Directors must embrace being a change agent if they want their HM programs to continue to be successful. In the minds of many hospital administrators, a program is only as good as its last achievement.

“It’s kind of like, ‘What have you done for me lately?’” Buser says. “You want to stay ahead of the curve and be alert to what’s going on and not be caught keeping your eyes off the ball and, as a result, not moving your program forward.”

Scenario No. 4 : Fumbling the Handoff

Notes and clinical information are submitted to this health information exchange and made available to any of the physicians who are caring for the patient almost immediately upon dictation and notation.

—Daniel Cusator, MD, MBA, vice president, Camden Group, El Segundo, Calif.

The case: The medical center’s monthly data for the past year has shown that hospitalists are taking care of their patients efficiently and getting them out of the hospital more quickly. However, mixed in with the positive numbers is a stubbornly high 30-day readmission rate. Indeed, some primary care groups and referring geriatricians have begun to grouse to the HM director about the discharge notes, complaining they aren’t as comprehensive as they would like.

Plus, the notes always arrive via office fax, which makes them more likely to get misplaced and harder to receive when doctors are out of the office.

Expert advice: Handoffs from discharge to pickup are where a lot of complications, errors, and safety issues arise, and poor handoffs are one of the largest drivers of readmission rates, especially in the elderly patient population, says Daniel Cusator, MD, MBA, vice president of the Camden Group, a healthcare consulting firm in El Segundo, Calif.

If the hospitalist director doesn’t provide the leadership and resources to help the HM team better coordinate with patients’ regular doctors, handoffs won’t be a priority throughout the group.

The HM director must recognize that the term “discharge note” is a misnomer.

What referring physicians really want is a care plan, which includes information about testing done in the hospital, testing that might be needed in the outpatient setting, medications the patient is on, complications the patient had in the hospital, potential problems to monitor, and any necessary follow-up, says Dr. Cusator, formerly the chief medical officer of clinical integration at Providence Health & Services in Southern California.

PCPs also want the care plan transmitted in their preferred method, whether that is text messaging, HIPAA-compliant email messaging, secure messaging, or fax.

“What I’ve seen some hospitalist groups do is create a menu capability for each of the physicians to choose their preferred method of notification of discharge of their patient,” Dr. Cusator says. Results suggest such a menu leads to improved physician satisfaction and reduced patient complications after discharge, he adds.

With today’s technological innovations, HM directors are unlimited in their ability to improve handoffs between their team and patients’ PCPs and specialists, Dr. Cusator says. Some HM directors, for example, are leading efforts to link electronic medical records systems to hospital-based health information exchange hubs that are accessible to physicians in the community.

“Notes and clinical information are submitted to this health information exchange and made available to any of the physicians who are caring for the patient almost immediately upon dictation and notation,” he says.

Scenario No. 5 : Protect Your Assets

There has to be a cohesiveness in order for your department to excel. You have to protect your assets in the group, which is your physicians.

—David Lee, MD, MBA, FACP, FHM, vice chairman, Hospital Medicine Department, Ochsner Health System, New Orleans.

The case: A physician isn’t sure she wants a career in hospital medicine. She finds the specialty rewarding but is looking for a different challenge, something beyond exclusively seeing patients. The HM director notices the physician has an aptitude for finding ways to do tasks more efficiently.

The director privately thinks the physician would be a good fit for a quality improvement project that’s about to start but doesn’t pursue it. The HM team just added a primary care group, and its patient census is quickly rising, requiring the hospitalists to devote their entire shifts to patient care. Within the year, the physician leaves the team for a fellowship program outside hospital medicine.

Expert advice: There are three communities in hospital medicine, Dr. Bulger says: people who want to be hospitalists, people who are passing through on their way to something else, and people who sit somewhere in the middle.

HM directors, he says, should do everything they can to develop not only the career hospitalists but also those on the fence.

“A lot of them you can turn into people who are going to be hospitalists if they are doing something that is rewarding for them,” Dr. Bulger says. “Many times rewarding for them is being involved more in the leadership of the group, being involved in quality improvement projects, really seeing how they can impact the care for populations of patients—and not just the patient who happens to be sitting in front of them.”

It’s incumbent on HM group leaders to link hospitalists with mentors and help them find a niche, Dr. Lee says. It keeps people interested and makes them feel part of a group.

“They need to feel they belong,” he says. “There has to be a cohesiveness in order for your department to excel. You have to protect your assets in the group, which is your physicians.”

Sending hospitalists to professional development training, such as SHM’s Leadership Academy (see “Leadership Academy Adds ‘Women in HM Issues’ to Schedule,” p. 9) or QI-focused webinars offered by SHM or the Institute of Healthcare Improvement, and following up with day-to-day coaching is a solid physician-development strategy, Dr. Gartland says. By virtue of their job, hospitalists are expected to lead and manage people in interactions with the ED, primary care, non-physician providers, nursing staff, and beyond, he says.

Directors also have to stop assuming that competent physicians are competent managers. “A lot of physicians don’t have those core skill sets, and we’ve got to pay conscious attention toward spending time dedicated to developing those,” Dr. Gartland says.

If directors don’t make professional development a priority or provide hospitalists with the flexibility to do non-clinical activities, retention may become an issue, Dr. Bulger says. “They could leave and go somewhere else,” he says, yet perhaps the more significant danger is losing hospitalists to programs and specialties outside hospital medicine.

Lisa Ryan is a freelance writer based in New Jersey.

THE FUNDAMENTALS

As hospitals position themselves for healthcare reform, they increasingly will turn to HM for strategies on how to provide high-quality patient care at a lower cost, Buser says. To meet hospitals’ needs and enhance the value of their programs, hospitalist directors should consider adopting these strategies recommended by HM leaders:

• Align compensation with the HM program’s goals. For example, if quality improvement is the priority, directors should financially reward hospitalists on quality performance, Dr. Lee says.
• Boost support staff and functions. For example, directors should ensure their team has access to the hospital’s case managers, who can handle discharge logistics so the hospitalist can focus on clinical issues, Dr. Cusator says.
• Control program growth. To borrow a popular line from the movie Field of Dreams: “If you build it, they will come.” Directors should be deliberate with group expansion and ensure enough staff is in place before adding to their referral base or adding a new service line, Dr. Bulger says. This reduces hospitalist burnout and preserves the group’s quality of patient care.
• Define two to three targets for success in the upcoming year and concentrate on accomplishing them. Start by consolidating what your team is working on, says Steven Deitelzweig, MD, SFHM, chairman of the Department of Hospital Medicine at Ochsner Health System in New Orleans. Pick too many things to master, and you end up excelling in none, he adds.
• Evaluate performance beyond a scorecard. Using constructive criticism grounded with examples, HM directors should provide feedback about what a physician is doing well and what can be done better so they can improve, Dr. Gartland says.
• Foster creative problem solving by including hospitalists in decisions. Directors should encourage the expression of different opinions and ideas, which helps the program avoid “group think” and allows innovation to occur, Dr. Lee says.
• Galvanize the new generation. To retain young physicians and make them feel part of the program, directors should learn how they communicate, how they work, and how they view work, Dr. Lee says.
• Help your hospital accurately measure reimbursement and mortality rates. Directors should make coding a priority and provide hospitalists with the tools they need to capture correct ICD-9 and CPT codes for their patients, Dr. Cusator says.
• Identify missing core capabilities and dedicate resources for it. For example, if HM programs have a high census of chronically ill and end-of-life patients, directors should assist the hospital in establishing a palliative care or hospice program, Dr. Cusator says.

I work with a number of health systems on determining full-market-value (FMV) compensation related to stipends paid to hospital-based specialists. What is your opinion on how compensation should be determined for the physicians to staff hospitals? Would you say that the busier the location, the higher the compensation? Would you say that the more hours the physician works (regardless of productivity), the more pay they receive? Would you say that the more years of experience that a physician has should result in higher compensation?

Curtis H. Bernstein, CPA/ABV, ASA, CVA, MBA,

director, valuation services,

Sinaiko Healthcare Consulting Inc.,

Los Angeles

Dr. Hospitalist responds:

The topic of physician compensation and workload comes up frequently, but this question frames it a bit differently. Namely, what are the external and internal factors at work in determining compensation? Let’s tackle the response in two parts: 1) How do you account for the variability across sites? and 2) How does physician pay vary within a single site? The crux of the first question comes down to trying to interpret physician workload across disparate locations. It’s not laden with quite the same complexity as Gordian’s knot, but it’s close. One could easily answer this question with a lot of “Yes, but ... ” in reference to the all the factors that go into determining compensation. Yes, a busier site would generate more encounters, thus more revenue, and thus more pay. However, that same site might also be so busy as to require more than one physician on at night. A higher-paid, but lower-volume, nocturnist would then skew the workload/pay scale. Same thing with the ICU; if it is fully staffed with intensivists (more likely in a higher-volume setting), then that would remove the single highest paying code for a hospitalist (the 99291: critical care time 35-74 minutes, 4.50 wRVU), and that has the potential to drop reimbursement. Practice management columnist John Nelson, MD, MHM, has written more than a few fantastic columns addressing just these sorts of issues, but let’s concentrate on just the key factors:

• Volume;
• Payor mix/collections;
• Ratio of day shifts to night shifts (optimal is 4:1), assuming that there are dedicated night shifts; and
• Value-added services.

Volume is fairly straightforward, with most hospitalists seeing around 15 patients per day. Now, an average is just that, and practices exist where the daily number is 10 and where the census is 25. Still, it’s an easy number to understand.

Payor mix is a little more complex but should not vary substantially quarter by quarter, though it could vary greatly year to year. (Note: This is independent of collection rate percentage, which is a completely artificial variable.) If Medicare pays $1 for a certain code and the charges are set at $1, then the collection rate is 100%. If the charges are set at $2, then the collection rate will be 50% but bring in the same amount of money. Arcane billing convention aside, from hospital to hospital and region to region, the payor mix and attendant collections will vary. Ratio of day shifts to night shifts posits that there is an optimal ratio of roughly four day shifts for every one night shift. Night shifts are more expensive, in general, so the more day shifts you have to cover your fixed cost of covering the nights, the better. The reason the ratio can’t be 10:1 is that 10 day-rounding hospitalists would generate a daily service of 150+ patients, and there is no way for one nocturnist to safely cross-cover all those folks, much less see new admissions.

Lastly, there are the value-added services that provide the raison d’être for hospitalists. We are fundamentally different from the procedure-based specialties in that our value comes not from increasing revenue (more procedures) but from decreasing costs. Initially, a lot of this focused on length of stay, and now it’s shifting to discussions of core measures, readmission rates, and other quality metrics. What a hospital is willing to pay for this service, which goes above and beyond taking call for unassigned patients, will go a long way toward determining the overall stipend and resultant physician compensation. (For more information on hospitalist compensation and productivity, check out the 2011 State of Hospital Medicine report, www.hospitalmedicine.org/survey)

Those are the basic underpinnings that will determine most of the variable compensation across disparate sites. Still, there can be other local factors (ancillary services, specialty support, EMRs, etc.) that come into play. Any practicing hospitalist can quickly discourse on what makes their job unique. And they are probably right—healthcare, like politics, is local.

I’ve run out of room to answer the second part of the question, which addresses the variable pay for physicians at the same site. Check back for that response next month.

I work with a number of health systems on determining full-market-value (FMV) compensation related to stipends paid to hospital-based specialists. What is your opinion on how compensation should be determined for the physicians to staff hospitals? Would you say that the busier the location, the higher the compensation? Would you say that the more hours the physician works (regardless of productivity), the more pay they receive? Would you say that the more years of experience that a physician has should result in higher compensation?

Curtis H. Bernstein, CPA/ABV, ASA, CVA, MBA,

director, valuation services,

Sinaiko Healthcare Consulting Inc.,

Los Angeles

Dr. Hospitalist responds:

The topic of physician compensation and workload comes up frequently, but this question frames it a bit differently. Namely, what are the external and internal factors at work in determining compensation? Let’s tackle the response in two parts: 1) How do you account for the variability across sites? and 2) How does physician pay vary within a single site? The crux of the first question comes down to trying to interpret physician workload across disparate locations. It’s not laden with quite the same complexity as Gordian’s knot, but it’s close. One could easily answer this question with a lot of “Yes, but ... ” in reference to the all the factors that go into determining compensation. Yes, a busier site would generate more encounters, thus more revenue, and thus more pay. However, that same site might also be so busy as to require more than one physician on at night. A higher-paid, but lower-volume, nocturnist would then skew the workload/pay scale. Same thing with the ICU; if it is fully staffed with intensivists (more likely in a higher-volume setting), then that would remove the single highest paying code for a hospitalist (the 99291: critical care time 35-74 minutes, 4.50 wRVU), and that has the potential to drop reimbursement. Practice management columnist John Nelson, MD, MHM, has written more than a few fantastic columns addressing just these sorts of issues, but let’s concentrate on just the key factors:

• Volume;
• Payor mix/collections;
• Ratio of day shifts to night shifts (optimal is 4:1), assuming that there are dedicated night shifts; and
• Value-added services.

Volume is fairly straightforward, with most hospitalists seeing around 15 patients per day. Now, an average is just that, and practices exist where the daily number is 10 and where the census is 25. Still, it’s an easy number to understand.

Payor mix is a little more complex but should not vary substantially quarter by quarter, though it could vary greatly year to year. (Note: This is independent of collection rate percentage, which is a completely artificial variable.) If Medicare pays $1 for a certain code and the charges are set at $1, then the collection rate is 100%. If the charges are set at $2, then the collection rate will be 50% but bring in the same amount of money. Arcane billing convention aside, from hospital to hospital and region to region, the payor mix and attendant collections will vary. Ratio of day shifts to night shifts posits that there is an optimal ratio of roughly four day shifts for every one night shift. Night shifts are more expensive, in general, so the more day shifts you have to cover your fixed cost of covering the nights, the better. The reason the ratio can’t be 10:1 is that 10 day-rounding hospitalists would generate a daily service of 150+ patients, and there is no way for one nocturnist to safely cross-cover all those folks, much less see new admissions.

Lastly, there are the value-added services that provide the raison d’être for hospitalists. We are fundamentally different from the procedure-based specialties in that our value comes not from increasing revenue (more procedures) but from decreasing costs. Initially, a lot of this focused on length of stay, and now it’s shifting to discussions of core measures, readmission rates, and other quality metrics. What a hospital is willing to pay for this service, which goes above and beyond taking call for unassigned patients, will go a long way toward determining the overall stipend and resultant physician compensation. (For more information on hospitalist compensation and productivity, check out the 2011 State of Hospital Medicine report, www.hospitalmedicine.org/survey)

Those are the basic underpinnings that will determine most of the variable compensation across disparate sites. Still, there can be other local factors (ancillary services, specialty support, EMRs, etc.) that come into play. Any practicing hospitalist can quickly discourse on what makes their job unique. And they are probably right—healthcare, like politics, is local.

I’ve run out of room to answer the second part of the question, which addresses the variable pay for physicians at the same site. Check back for that response next month.

I work with a number of health systems on determining full-market-value (FMV) compensation related to stipends paid to hospital-based specialists. What is your opinion on how compensation should be determined for the physicians to staff hospitals? Would you say that the busier the location, the higher the compensation? Would you say that the more hours the physician works (regardless of productivity), the more pay they receive? Would you say that the more years of experience that a physician has should result in higher compensation?

Curtis H. Bernstein, CPA/ABV, ASA, CVA, MBA,

director, valuation services,

Sinaiko Healthcare Consulting Inc.,

Los Angeles

Dr. Hospitalist responds:

The topic of physician compensation and workload comes up frequently, but this question frames it a bit differently. Namely, what are the external and internal factors at work in determining compensation? Let’s tackle the response in two parts: 1) How do you account for the variability across sites? and 2) How does physician pay vary within a single site? The crux of the first question comes down to trying to interpret physician workload across disparate locations. It’s not laden with quite the same complexity as Gordian’s knot, but it’s close. One could easily answer this question with a lot of “Yes, but ... ” in reference to the all the factors that go into determining compensation. Yes, a busier site would generate more encounters, thus more revenue, and thus more pay. However, that same site might also be so busy as to require more than one physician on at night. A higher-paid, but lower-volume, nocturnist would then skew the workload/pay scale. Same thing with the ICU; if it is fully staffed with intensivists (more likely in a higher-volume setting), then that would remove the single highest paying code for a hospitalist (the 99291: critical care time 35-74 minutes, 4.50 wRVU), and that has the potential to drop reimbursement. Practice management columnist John Nelson, MD, MHM, has written more than a few fantastic columns addressing just these sorts of issues, but let’s concentrate on just the key factors:

• Volume;
• Payor mix/collections;
• Ratio of day shifts to night shifts (optimal is 4:1), assuming that there are dedicated night shifts; and
• Value-added services.

Volume is fairly straightforward, with most hospitalists seeing around 15 patients per day. Now, an average is just that, and practices exist where the daily number is 10 and where the census is 25. Still, it’s an easy number to understand.

Payor mix is a little more complex but should not vary substantially quarter by quarter, though it could vary greatly year to year. (Note: This is independent of collection rate percentage, which is a completely artificial variable.) If Medicare pays $1 for a certain code and the charges are set at $1, then the collection rate is 100%. If the charges are set at $2, then the collection rate will be 50% but bring in the same amount of money. Arcane billing convention aside, from hospital to hospital and region to region, the payor mix and attendant collections will vary. Ratio of day shifts to night shifts posits that there is an optimal ratio of roughly four day shifts for every one night shift. Night shifts are more expensive, in general, so the more day shifts you have to cover your fixed cost of covering the nights, the better. The reason the ratio can’t be 10:1 is that 10 day-rounding hospitalists would generate a daily service of 150+ patients, and there is no way for one nocturnist to safely cross-cover all those folks, much less see new admissions.

Lastly, there are the value-added services that provide the raison d’être for hospitalists. We are fundamentally different from the procedure-based specialties in that our value comes not from increasing revenue (more procedures) but from decreasing costs. Initially, a lot of this focused on length of stay, and now it’s shifting to discussions of core measures, readmission rates, and other quality metrics. What a hospital is willing to pay for this service, which goes above and beyond taking call for unassigned patients, will go a long way toward determining the overall stipend and resultant physician compensation. (For more information on hospitalist compensation and productivity, check out the 2011 State of Hospital Medicine report, www.hospitalmedicine.org/survey)

Those are the basic underpinnings that will determine most of the variable compensation across disparate sites. Still, there can be other local factors (ancillary services, specialty support, EMRs, etc.) that come into play. Any practicing hospitalist can quickly discourse on what makes their job unique. And they are probably right—healthcare, like politics, is local.

I’ve run out of room to answer the second part of the question, which addresses the variable pay for physicians at the same site. Check back for that response next month.

One of the questions I am often asked is “What is the typical distribution of CPT codes for hospitalists?” Prior to publication of the 2011 State of Hospital Medicine report, no one could answer that question with any authority. The Centers for Medicare & Medicaid Services (CMS) publishes some Healthcare Procedure Code (HCPC) distribution information by specialty, but because CMS does not recognize HM as a specialty, the closest proxies are the reported distributions for internal medicine (or pediatrics). And hospitalists argue that because their patient population and the work they do are different, typical distributions for those specialties might not be applicable to hospitalists.

“Coding for hospitalists has to be different from other internists,” says SHM Practice Analysis Committee (PAC) member Rachel Lovins, MD, SFHM. “Because we take responsibility for unfamiliar patients that we hand back to other providers, our level of admission and discharge documentation in particular needs to be higher, in order to ensure excellent communication between hospitalists and PCPs.”

We finally have information about hospitalist coding practices, because both the academic and non-academic Hospital Medicine Supplements captured information about the distribution of inpatient admissions (CPT codes 99221, 99222, and 99223), subsequent visits (99231, 99232, and 99233), and discharges (99238 and 99239). Figure 1 shows the average CPT code distribution for non-academic HM groups serving adults only.

click for large version

The 2011 State of Hospital Medicine report also shows how CPT distribution varied based on some key practice characteristics. For example, HM practices that are not owned by hospitals/integrated delivery systems tend to code more of their services at higher service levels than do hospital-owned practices. And practices in the Western section of the country tend to code more services at higher levels than other parts of the country.

Other factors are certainly at play as well. “Whether a physician receives training in documentation and coding can have a tremendous impact on CPT distributions,” PAC member Beth Papetti says. “Historically, there has been a tendency for hospitalists to under-code, but through education and enhancements like electronic charge capture, hospitalists can more accurately substantiate the services they provided to the patient.”

Other committee members have speculated that a hospitalist’s compensation model might influence coding patterns, with those who receive less of their total compensation in the form of base salary (and more in the form of productivity and/or performance-based pay) tending to code more of their services at higher levels. But, in fact, the survey data don’t reveal any clear relationship between compensation structure and the average number of work RVUs (relative value units) per encounter.

Interestingly, coding patterns of academic HM practices were similar to those of non-academic practices for admissions and subsequent visits, but academic hospitalists tend to code a higher proportion of discharges at the <30-minute level (99238). PAC members speculate that residents and hospital support staff might perform a larger portion of the discharge coordination and paperwork in academic centers, and attendings can only bill based on their personal time, not time spent by others.

To contribute to a robust CPT distribution database, be sure to participate in the next State of Hospital Medicine survey, scheduled to launch in January 2012.

Leslie Flores, SHM senior advisor, practice management

One of the questions I am often asked is “What is the typical distribution of CPT codes for hospitalists?” Prior to publication of the 2011 State of Hospital Medicine report, no one could answer that question with any authority. The Centers for Medicare & Medicaid Services (CMS) publishes some Healthcare Procedure Code (HCPC) distribution information by specialty, but because CMS does not recognize HM as a specialty, the closest proxies are the reported distributions for internal medicine (or pediatrics). And hospitalists argue that because their patient population and the work they do are different, typical distributions for those specialties might not be applicable to hospitalists.

“Coding for hospitalists has to be different from other internists,” says SHM Practice Analysis Committee (PAC) member Rachel Lovins, MD, SFHM. “Because we take responsibility for unfamiliar patients that we hand back to other providers, our level of admission and discharge documentation in particular needs to be higher, in order to ensure excellent communication between hospitalists and PCPs.”

We finally have information about hospitalist coding practices, because both the academic and non-academic Hospital Medicine Supplements captured information about the distribution of inpatient admissions (CPT codes 99221, 99222, and 99223), subsequent visits (99231, 99232, and 99233), and discharges (99238 and 99239). Figure 1 shows the average CPT code distribution for non-academic HM groups serving adults only.

click for large version

The 2011 State of Hospital Medicine report also shows how CPT distribution varied based on some key practice characteristics. For example, HM practices that are not owned by hospitals/integrated delivery systems tend to code more of their services at higher service levels than do hospital-owned practices. And practices in the Western section of the country tend to code more services at higher levels than other parts of the country.

Other factors are certainly at play as well. “Whether a physician receives training in documentation and coding can have a tremendous impact on CPT distributions,” PAC member Beth Papetti says. “Historically, there has been a tendency for hospitalists to under-code, but through education and enhancements like electronic charge capture, hospitalists can more accurately substantiate the services they provided to the patient.”

Other committee members have speculated that a hospitalist’s compensation model might influence coding patterns, with those who receive less of their total compensation in the form of base salary (and more in the form of productivity and/or performance-based pay) tending to code more of their services at higher levels. But, in fact, the survey data don’t reveal any clear relationship between compensation structure and the average number of work RVUs (relative value units) per encounter.

Interestingly, coding patterns of academic HM practices were similar to those of non-academic practices for admissions and subsequent visits, but academic hospitalists tend to code a higher proportion of discharges at the <30-minute level (99238). PAC members speculate that residents and hospital support staff might perform a larger portion of the discharge coordination and paperwork in academic centers, and attendings can only bill based on their personal time, not time spent by others.

To contribute to a robust CPT distribution database, be sure to participate in the next State of Hospital Medicine survey, scheduled to launch in January 2012.

Leslie Flores, SHM senior advisor, practice management

One of the questions I am often asked is “What is the typical distribution of CPT codes for hospitalists?” Prior to publication of the 2011 State of Hospital Medicine report, no one could answer that question with any authority. The Centers for Medicare & Medicaid Services (CMS) publishes some Healthcare Procedure Code (HCPC) distribution information by specialty, but because CMS does not recognize HM as a specialty, the closest proxies are the reported distributions for internal medicine (or pediatrics). And hospitalists argue that because their patient population and the work they do are different, typical distributions for those specialties might not be applicable to hospitalists.

“Coding for hospitalists has to be different from other internists,” says SHM Practice Analysis Committee (PAC) member Rachel Lovins, MD, SFHM. “Because we take responsibility for unfamiliar patients that we hand back to other providers, our level of admission and discharge documentation in particular needs to be higher, in order to ensure excellent communication between hospitalists and PCPs.”

We finally have information about hospitalist coding practices, because both the academic and non-academic Hospital Medicine Supplements captured information about the distribution of inpatient admissions (CPT codes 99221, 99222, and 99223), subsequent visits (99231, 99232, and 99233), and discharges (99238 and 99239). Figure 1 shows the average CPT code distribution for non-academic HM groups serving adults only.

click for large version

The 2011 State of Hospital Medicine report also shows how CPT distribution varied based on some key practice characteristics. For example, HM practices that are not owned by hospitals/integrated delivery systems tend to code more of their services at higher service levels than do hospital-owned practices. And practices in the Western section of the country tend to code more services at higher levels than other parts of the country.

Other factors are certainly at play as well. “Whether a physician receives training in documentation and coding can have a tremendous impact on CPT distributions,” PAC member Beth Papetti says. “Historically, there has been a tendency for hospitalists to under-code, but through education and enhancements like electronic charge capture, hospitalists can more accurately substantiate the services they provided to the patient.”

Other committee members have speculated that a hospitalist’s compensation model might influence coding patterns, with those who receive less of their total compensation in the form of base salary (and more in the form of productivity and/or performance-based pay) tending to code more of their services at higher levels. But, in fact, the survey data don’t reveal any clear relationship between compensation structure and the average number of work RVUs (relative value units) per encounter.

Interestingly, coding patterns of academic HM practices were similar to those of non-academic practices for admissions and subsequent visits, but academic hospitalists tend to code a higher proportion of discharges at the <30-minute level (99238). PAC members speculate that residents and hospital support staff might perform a larger portion of the discharge coordination and paperwork in academic centers, and attendings can only bill based on their personal time, not time spent by others.

To contribute to a robust CPT distribution database, be sure to participate in the next State of Hospital Medicine survey, scheduled to launch in January 2012.

Leslie Flores, SHM senior advisor, practice management

I think 70% to 80% of U.S. hospitals now have a hospitalist practice. (Some have more than one hospitalist group operating within their walls.) I arrived at this estimate by relying on both my anecdotal experience and on the annual American Hospital Association survey, which in 2009 showed 58% of hospitals have hospitalists, with an ongoing rapid rate of adoption.

No regular reader of The Hospitalist should be surprised that most U.S. hospitals now have hospitalists, but some might be surprised that 20% to 30% don’t. There are about 5,800 hospitals in the U.S. (a ballpark figure), so that means about 1,100 to 1,800 don’t have hospitalists. What is unique about them?

For some hospitals, the answer is easy. For example, the U.S. has something like 450 psychiatric hospitals. They vary a lot, but many simply don’t accept patients with active medical problems, so these facilities would have little need for medical hospitalists.

Variations in how the term “hospitalist” is used probably account for some facilities reporting no hospitalists. For example, long-term acute-care hospitals (LTACs) might have dedicated inpatient providers but simply don’t call them hospitalists.

Even accounting for these things, there are still a lot of “med-surg” hospitals that say they don’t have hospitalists.

The Holdouts

My experience suggests the two most important reasons some hospitals have not yet developed a hospitalist practice are an oversupply of primary-care physicians (PCPs) and an attractive payor mix in the unassigned patient population. In fact, it is hard for me to imagine a hospital that enjoys both of these attributes ever being able to support hospitalists.

Although it isn’t a common problem, an excess of PCPs (or dearth of patients) removes the most universal and powerful stimulus to develop a hospitalist practice: the desire of PCPs to be relieved of hospital work. And in most cases, those PCPs can offset the loss of hospital work and its associated revenue, with more work in the office. This can mean a better lifestyle (e.g. no trips to the hospital on nights and weekends) and the same or higher income. But if there are too many PCPs in the community, they may be unwilling to give up the hospital work, as there might be no way to replace it in the office. End result: no hospitalists.

For the rare hospital that has an attractive ED-unassigned payor mix, PCPs are more likely to want to continue taking ED call and not support a proposal to develop a hospitalist practice. And access to the ED call roster can be important to new PCPs building a community practice. I have seen situations in which a hospital has addressed the poor reimbursement of unattached ED admissions by paying PCPs to provide that care. Even though that same hospital might want a hospitalist practice, the ED call payment it is providing to PCPs may create a barrier that can’t be overcome. Such a hospital will face the very difficult decision of terminating the payments for ED call and redirecting that money to a hospitalist practice—something that is likely to lead to a lot of frustration on the part of PCPs who depend on the pay-for-call arrangement. A common outcome: no hospitalists.

An occasional reason hospitals are late to the hospitalist party is one or two (rarely more than that) of its private PCPs have simply chosen to work heroic amounts, and in addition to office and hospital care of their private patients, they accept referrals from other PCPs. I have met a number of doctors like this. Some are terrific doctors who actively participate in hospital initiatives; many appear chronically tired and harried, and hospital staff express frustration that they do things like make rounds at 3 a.m., take hours to respond to urgent calls, refuse to use protocols, etc. But because they’ve responded to the PCPs’ desire to be relieved of hospital work, other doctors may rally to their support and prevent the hospital from moving forward with a hospitalist program.

Will Every Hospital Have Hospitalists Eventually?

It is really interesting to think about whether every hospital, outside narrow specialty hospitals, will have hospitalists in the future. I wonder what informed people in the 1970s and early 1980s were predicting for emergency medicine’s future. At that point it probably wasn’t clear that, in the future, dedicated ED doctors essentially would staff every ED in the country, but I think that is exactly what has happened. (I once worked with an approximately 100-bed rural hospital that didn’t have ED physicians until 1999. I wonder if they were the last adopter.)

I think hospitalists are critically important for nearly all med-surg hospitals; however, maybe there will always be a small number that either have PCPs continue to practice in the traditional model, working both outpatient and inpatient, or some other effective configuration that makes hospitalists less necessary. We’ll have to wait and see. But I’m pretty confident

that almost no institutions that have hospitalists will ever return to the pre-hospitalist model of care. It seems there is no going back.

For those hospitals without hospitalists currently who will at some future time have hospitalists, the right time for this to happen is dependent on a combination of local factors. It could be something like the departure (i.e. relocation or retirement) of some of the current doctors, or simply the arrival of someone who has a vision and energy to successfully navigate the obstacles to build one. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is also course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.</p>

I think 70% to 80% of U.S. hospitals now have a hospitalist practice. (Some have more than one hospitalist group operating within their walls.) I arrived at this estimate by relying on both my anecdotal experience and on the annual American Hospital Association survey, which in 2009 showed 58% of hospitals have hospitalists, with an ongoing rapid rate of adoption.

No regular reader of The Hospitalist should be surprised that most U.S. hospitals now have hospitalists, but some might be surprised that 20% to 30% don’t. There are about 5,800 hospitals in the U.S. (a ballpark figure), so that means about 1,100 to 1,800 don’t have hospitalists. What is unique about them?

For some hospitals, the answer is easy. For example, the U.S. has something like 450 psychiatric hospitals. They vary a lot, but many simply don’t accept patients with active medical problems, so these facilities would have little need for medical hospitalists.

Variations in how the term “hospitalist” is used probably account for some facilities reporting no hospitalists. For example, long-term acute-care hospitals (LTACs) might have dedicated inpatient providers but simply don’t call them hospitalists.

Even accounting for these things, there are still a lot of “med-surg” hospitals that say they don’t have hospitalists.

The Holdouts

My experience suggests the two most important reasons some hospitals have not yet developed a hospitalist practice are an oversupply of primary-care physicians (PCPs) and an attractive payor mix in the unassigned patient population. In fact, it is hard for me to imagine a hospital that enjoys both of these attributes ever being able to support hospitalists.

Although it isn’t a common problem, an excess of PCPs (or dearth of patients) removes the most universal and powerful stimulus to develop a hospitalist practice: the desire of PCPs to be relieved of hospital work. And in most cases, those PCPs can offset the loss of hospital work and its associated revenue, with more work in the office. This can mean a better lifestyle (e.g. no trips to the hospital on nights and weekends) and the same or higher income. But if there are too many PCPs in the community, they may be unwilling to give up the hospital work, as there might be no way to replace it in the office. End result: no hospitalists.

For the rare hospital that has an attractive ED-unassigned payor mix, PCPs are more likely to want to continue taking ED call and not support a proposal to develop a hospitalist practice. And access to the ED call roster can be important to new PCPs building a community practice. I have seen situations in which a hospital has addressed the poor reimbursement of unattached ED admissions by paying PCPs to provide that care. Even though that same hospital might want a hospitalist practice, the ED call payment it is providing to PCPs may create a barrier that can’t be overcome. Such a hospital will face the very difficult decision of terminating the payments for ED call and redirecting that money to a hospitalist practice—something that is likely to lead to a lot of frustration on the part of PCPs who depend on the pay-for-call arrangement. A common outcome: no hospitalists.

An occasional reason hospitals are late to the hospitalist party is one or two (rarely more than that) of its private PCPs have simply chosen to work heroic amounts, and in addition to office and hospital care of their private patients, they accept referrals from other PCPs. I have met a number of doctors like this. Some are terrific doctors who actively participate in hospital initiatives; many appear chronically tired and harried, and hospital staff express frustration that they do things like make rounds at 3 a.m., take hours to respond to urgent calls, refuse to use protocols, etc. But because they’ve responded to the PCPs’ desire to be relieved of hospital work, other doctors may rally to their support and prevent the hospital from moving forward with a hospitalist program.

Will Every Hospital Have Hospitalists Eventually?

It is really interesting to think about whether every hospital, outside narrow specialty hospitals, will have hospitalists in the future. I wonder what informed people in the 1970s and early 1980s were predicting for emergency medicine’s future. At that point it probably wasn’t clear that, in the future, dedicated ED doctors essentially would staff every ED in the country, but I think that is exactly what has happened. (I once worked with an approximately 100-bed rural hospital that didn’t have ED physicians until 1999. I wonder if they were the last adopter.)

I think hospitalists are critically important for nearly all med-surg hospitals; however, maybe there will always be a small number that either have PCPs continue to practice in the traditional model, working both outpatient and inpatient, or some other effective configuration that makes hospitalists less necessary. We’ll have to wait and see. But I’m pretty confident

that almost no institutions that have hospitalists will ever return to the pre-hospitalist model of care. It seems there is no going back.

For those hospitals without hospitalists currently who will at some future time have hospitalists, the right time for this to happen is dependent on a combination of local factors. It could be something like the departure (i.e. relocation or retirement) of some of the current doctors, or simply the arrival of someone who has a vision and energy to successfully navigate the obstacles to build one. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is also course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.</p>

I think 70% to 80% of U.S. hospitals now have a hospitalist practice. (Some have more than one hospitalist group operating within their walls.) I arrived at this estimate by relying on both my anecdotal experience and on the annual American Hospital Association survey, which in 2009 showed 58% of hospitals have hospitalists, with an ongoing rapid rate of adoption.

No regular reader of The Hospitalist should be surprised that most U.S. hospitals now have hospitalists, but some might be surprised that 20% to 30% don’t. There are about 5,800 hospitals in the U.S. (a ballpark figure), so that means about 1,100 to 1,800 don’t have hospitalists. What is unique about them?

For some hospitals, the answer is easy. For example, the U.S. has something like 450 psychiatric hospitals. They vary a lot, but many simply don’t accept patients with active medical problems, so these facilities would have little need for medical hospitalists.

Variations in how the term “hospitalist” is used probably account for some facilities reporting no hospitalists. For example, long-term acute-care hospitals (LTACs) might have dedicated inpatient providers but simply don’t call them hospitalists.

Even accounting for these things, there are still a lot of “med-surg” hospitals that say they don’t have hospitalists.

The Holdouts

My experience suggests the two most important reasons some hospitals have not yet developed a hospitalist practice are an oversupply of primary-care physicians (PCPs) and an attractive payor mix in the unassigned patient population. In fact, it is hard for me to imagine a hospital that enjoys both of these attributes ever being able to support hospitalists.

Although it isn’t a common problem, an excess of PCPs (or dearth of patients) removes the most universal and powerful stimulus to develop a hospitalist practice: the desire of PCPs to be relieved of hospital work. And in most cases, those PCPs can offset the loss of hospital work and its associated revenue, with more work in the office. This can mean a better lifestyle (e.g. no trips to the hospital on nights and weekends) and the same or higher income. But if there are too many PCPs in the community, they may be unwilling to give up the hospital work, as there might be no way to replace it in the office. End result: no hospitalists.

For the rare hospital that has an attractive ED-unassigned payor mix, PCPs are more likely to want to continue taking ED call and not support a proposal to develop a hospitalist practice. And access to the ED call roster can be important to new PCPs building a community practice. I have seen situations in which a hospital has addressed the poor reimbursement of unattached ED admissions by paying PCPs to provide that care. Even though that same hospital might want a hospitalist practice, the ED call payment it is providing to PCPs may create a barrier that can’t be overcome. Such a hospital will face the very difficult decision of terminating the payments for ED call and redirecting that money to a hospitalist practice—something that is likely to lead to a lot of frustration on the part of PCPs who depend on the pay-for-call arrangement. A common outcome: no hospitalists.

An occasional reason hospitals are late to the hospitalist party is one or two (rarely more than that) of its private PCPs have simply chosen to work heroic amounts, and in addition to office and hospital care of their private patients, they accept referrals from other PCPs. I have met a number of doctors like this. Some are terrific doctors who actively participate in hospital initiatives; many appear chronically tired and harried, and hospital staff express frustration that they do things like make rounds at 3 a.m., take hours to respond to urgent calls, refuse to use protocols, etc. But because they’ve responded to the PCPs’ desire to be relieved of hospital work, other doctors may rally to their support and prevent the hospital from moving forward with a hospitalist program.

Will Every Hospital Have Hospitalists Eventually?

It is really interesting to think about whether every hospital, outside narrow specialty hospitals, will have hospitalists in the future. I wonder what informed people in the 1970s and early 1980s were predicting for emergency medicine’s future. At that point it probably wasn’t clear that, in the future, dedicated ED doctors essentially would staff every ED in the country, but I think that is exactly what has happened. (I once worked with an approximately 100-bed rural hospital that didn’t have ED physicians until 1999. I wonder if they were the last adopter.)

I think hospitalists are critically important for nearly all med-surg hospitals; however, maybe there will always be a small number that either have PCPs continue to practice in the traditional model, working both outpatient and inpatient, or some other effective configuration that makes hospitalists less necessary. We’ll have to wait and see. But I’m pretty confident

that almost no institutions that have hospitalists will ever return to the pre-hospitalist model of care. It seems there is no going back.

For those hospitals without hospitalists currently who will at some future time have hospitalists, the right time for this to happen is dependent on a combination of local factors. It could be something like the departure (i.e. relocation or retirement) of some of the current doctors, or simply the arrival of someone who has a vision and energy to successfully navigate the obstacles to build one. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is also course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.</p>