Practice Management

Michael Radzienda, MD, FHM, once worked in a hospitalist program in which physicians were scheduled 30 days straight on clinical duty and 30 days off clinical duty. Although it sounds harsh by today’s standards, that job was so satisfying, he says, the schedule never felt like a burden. Conversely, he’s seen hospitalists work five days on and five days off, and the job was treacherous.

His point: Work schedules are just one influential piece of the job satisfaction pie.

“Satisfaction has more to do with work relationships and opportunities for growth,” says Dr. Radzienda, chief of hospital medicine and director of hospital medicine service at Medical College of Wisconsin/Froedtert Memorial Lutheran General Hospital in Milwaukee.

Shift-based staffing has become the norm, as more than 70% of hospitalist groups use a shift-based staffing model, according to the State of Hospital Medicine: 2010 Report Based on 2009 Data.¹ That figure is up 40% from SHM’s 2005-2006 survey. Conversely, the number of HM groups employing call-based and hybrid (some shift, some call) coverage is declining—2.8% of groups employ call-based schedules, and 26.9% use a hybrid schedule. Those figures have dropped significantly from the 2005-2006 report, from 25% and 35%, respectively.

If you are going to make HM a career, you’ll need time to be with your family and pursue other interests, Dr. Radzienda says. As HM groups turn to more shift-based models, in which hospitalists work a set number of predetermined shifts and have no call responsibility, the challenge is setting a schedule that balances productivity and quality time off.

Fixed = Inflexible

The most popular way to schedule is through blocks of five days on/five days off (5/5) or seven days on/seven days off (7/7), in which hospitalists work 12 or 14 hours at a time, says Troy Ahlstrom, MD, FHM, a member of SHM’s Practice Analysis Committee and CFO of Hospitalists of Northern Michigan, a hospitalist-owned and -managed group based in Traverse City, Mich. Many HM groups employ this model because it’s easy to schedule and is attractive to residents who want a fixed schedule. But from a career satisfaction standpoint, the 5/5 and 7/7 schedule models present their own issues.

Fairness is the first potential pitfall. If all of the physicians in a group work the same schedule, they all have to log the same number of shifts and receive the same compensation. This leaves little to no wiggle room for hospitalists who want to make more money by picking up more shifts or those who want to work fewer shifts, Dr. Ahlstrom says. “People have different income goals,” he adds.

Second, physicians have to see the same number of patients throughout the day. This doesn’t take into consideration the reality that some hospitalists naturally work faster than others, thereby forcing the slower-paced doctors to keep up with an imposed patient load. “Invariably, no matter what you do, people are different,” Dr. Ahlstrom says.

Another consideration is that when physicians are working 12 to 14 hours a day, essentially they have no time for activities other than work and sleep, which doesn’t match the realities of life. Inevitably, things in personal lives crop up, which leads to swapping shifts that the group scheduler doesn’t know about or overloading the scheduler with shift-change requests, Dr. Ahlstrom explains.

Additionally, 7/7 schedules and their ilk squeeze a year’s worth of work into a compressed time frame, which can lead to intense stress and burnout, says John Nelson, MD, FACP, MHM, director of the hospitalist practice at Overlake Hospital in Bellevue, Wash., SHM co-founder, and practice management columnist for The Hospitalist. “Maximizing the number of days off is not the holy grail,” he says. “If you choose to shut your life down on days that you work, that is going to be toxic.”

Flexibility Equates to Fairness

Dr. Nelson has long advocated a flexible shift schedule that accommodates individual preferences by giving physicians in the group autonomy in deciding how much or how little they want to work. While the group as a whole has to get all the work done, the flexibility comes from one physician taking more shifts as another takes less.

Dr. Radzienda tries to create teams within his group by pairing hospitalists with similar scheduling preferences. For example, he might have a pair working 5/5 and another working 14/14. “Up front, it takes a lot of work, but once you template it out, it becomes a good strategy,” he says.

He also strives to build robust backup plans and jeopardy models (see “Surge Protection,” September 2010, p. 43) into the schedule for short-notice callouts, as you never know when a hospitalist will need to miss a day or two because of illness or a family emergency. “Psychologically, it helps to know that you don’t have to be a hero if you’re ill or emotionally strained,” Dr. Radzienda says.

Dr. Ahlstrom agrees that a flex-schedule strategy has a positive impact on hospitalists’ career satisfaction and longevity. He suggests hospitalists be allowed to specify how many patients they want to see and be compensated according to their workload through built-in bonuses for physicians who work more. Dr. Nelson suggests paying hospitalists per relative value unit (RVU) of work. “I think hospitalists would like it and find it liberating to be paid on production,” he says.

An added bonus to flexible work hours and patient load, according to Dr. Ahlstrom, is that pay difference “will lead to a far more collegial atmosphere, because physicians know they are getting compensated fairly for the amount of work done.”

Another advantage of a flexible schedule is hospitalists knowing they have the option of ramping up or scaling back the number of shifts they work, Dr. Ahlstrom says—for example, a physician who wants to reduce shifts in order to coach his daughter’s softball team or have Friday nights off to watch her son play high school football.

“You prevent burnout by allowing people to change their work schedule depending on what’s going on in their life,” Dr. Ahlstrom says. TH

Lisa Ryan is a freelance writer based in New Jersey.

Michael Radzienda, MD, FHM, once worked in a hospitalist program in which physicians were scheduled 30 days straight on clinical duty and 30 days off clinical duty. Although it sounds harsh by today’s standards, that job was so satisfying, he says, the schedule never felt like a burden. Conversely, he’s seen hospitalists work five days on and five days off, and the job was treacherous.

His point: Work schedules are just one influential piece of the job satisfaction pie.

“Satisfaction has more to do with work relationships and opportunities for growth,” says Dr. Radzienda, chief of hospital medicine and director of hospital medicine service at Medical College of Wisconsin/Froedtert Memorial Lutheran General Hospital in Milwaukee.

Shift-based staffing has become the norm, as more than 70% of hospitalist groups use a shift-based staffing model, according to the State of Hospital Medicine: 2010 Report Based on 2009 Data.¹ That figure is up 40% from SHM’s 2005-2006 survey. Conversely, the number of HM groups employing call-based and hybrid (some shift, some call) coverage is declining—2.8% of groups employ call-based schedules, and 26.9% use a hybrid schedule. Those figures have dropped significantly from the 2005-2006 report, from 25% and 35%, respectively.

If you are going to make HM a career, you’ll need time to be with your family and pursue other interests, Dr. Radzienda says. As HM groups turn to more shift-based models, in which hospitalists work a set number of predetermined shifts and have no call responsibility, the challenge is setting a schedule that balances productivity and quality time off.

Fixed = Inflexible

The most popular way to schedule is through blocks of five days on/five days off (5/5) or seven days on/seven days off (7/7), in which hospitalists work 12 or 14 hours at a time, says Troy Ahlstrom, MD, FHM, a member of SHM’s Practice Analysis Committee and CFO of Hospitalists of Northern Michigan, a hospitalist-owned and -managed group based in Traverse City, Mich. Many HM groups employ this model because it’s easy to schedule and is attractive to residents who want a fixed schedule. But from a career satisfaction standpoint, the 5/5 and 7/7 schedule models present their own issues.

Fairness is the first potential pitfall. If all of the physicians in a group work the same schedule, they all have to log the same number of shifts and receive the same compensation. This leaves little to no wiggle room for hospitalists who want to make more money by picking up more shifts or those who want to work fewer shifts, Dr. Ahlstrom says. “People have different income goals,” he adds.

Second, physicians have to see the same number of patients throughout the day. This doesn’t take into consideration the reality that some hospitalists naturally work faster than others, thereby forcing the slower-paced doctors to keep up with an imposed patient load. “Invariably, no matter what you do, people are different,” Dr. Ahlstrom says.

Another consideration is that when physicians are working 12 to 14 hours a day, essentially they have no time for activities other than work and sleep, which doesn’t match the realities of life. Inevitably, things in personal lives crop up, which leads to swapping shifts that the group scheduler doesn’t know about or overloading the scheduler with shift-change requests, Dr. Ahlstrom explains.

Additionally, 7/7 schedules and their ilk squeeze a year’s worth of work into a compressed time frame, which can lead to intense stress and burnout, says John Nelson, MD, FACP, MHM, director of the hospitalist practice at Overlake Hospital in Bellevue, Wash., SHM co-founder, and practice management columnist for The Hospitalist. “Maximizing the number of days off is not the holy grail,” he says. “If you choose to shut your life down on days that you work, that is going to be toxic.”

Flexibility Equates to Fairness

Dr. Nelson has long advocated a flexible shift schedule that accommodates individual preferences by giving physicians in the group autonomy in deciding how much or how little they want to work. While the group as a whole has to get all the work done, the flexibility comes from one physician taking more shifts as another takes less.

Dr. Radzienda tries to create teams within his group by pairing hospitalists with similar scheduling preferences. For example, he might have a pair working 5/5 and another working 14/14. “Up front, it takes a lot of work, but once you template it out, it becomes a good strategy,” he says.

He also strives to build robust backup plans and jeopardy models (see “Surge Protection,” September 2010, p. 43) into the schedule for short-notice callouts, as you never know when a hospitalist will need to miss a day or two because of illness or a family emergency. “Psychologically, it helps to know that you don’t have to be a hero if you’re ill or emotionally strained,” Dr. Radzienda says.

Dr. Ahlstrom agrees that a flex-schedule strategy has a positive impact on hospitalists’ career satisfaction and longevity. He suggests hospitalists be allowed to specify how many patients they want to see and be compensated according to their workload through built-in bonuses for physicians who work more. Dr. Nelson suggests paying hospitalists per relative value unit (RVU) of work. “I think hospitalists would like it and find it liberating to be paid on production,” he says.

An added bonus to flexible work hours and patient load, according to Dr. Ahlstrom, is that pay difference “will lead to a far more collegial atmosphere, because physicians know they are getting compensated fairly for the amount of work done.”

Another advantage of a flexible schedule is hospitalists knowing they have the option of ramping up or scaling back the number of shifts they work, Dr. Ahlstrom says—for example, a physician who wants to reduce shifts in order to coach his daughter’s softball team or have Friday nights off to watch her son play high school football.

“You prevent burnout by allowing people to change their work schedule depending on what’s going on in their life,” Dr. Ahlstrom says. TH

Lisa Ryan is a freelance writer based in New Jersey.

Michael Radzienda, MD, FHM, once worked in a hospitalist program in which physicians were scheduled 30 days straight on clinical duty and 30 days off clinical duty. Although it sounds harsh by today’s standards, that job was so satisfying, he says, the schedule never felt like a burden. Conversely, he’s seen hospitalists work five days on and five days off, and the job was treacherous.

His point: Work schedules are just one influential piece of the job satisfaction pie.

“Satisfaction has more to do with work relationships and opportunities for growth,” says Dr. Radzienda, chief of hospital medicine and director of hospital medicine service at Medical College of Wisconsin/Froedtert Memorial Lutheran General Hospital in Milwaukee.

Shift-based staffing has become the norm, as more than 70% of hospitalist groups use a shift-based staffing model, according to the State of Hospital Medicine: 2010 Report Based on 2009 Data.¹ That figure is up 40% from SHM’s 2005-2006 survey. Conversely, the number of HM groups employing call-based and hybrid (some shift, some call) coverage is declining—2.8% of groups employ call-based schedules, and 26.9% use a hybrid schedule. Those figures have dropped significantly from the 2005-2006 report, from 25% and 35%, respectively.

If you are going to make HM a career, you’ll need time to be with your family and pursue other interests, Dr. Radzienda says. As HM groups turn to more shift-based models, in which hospitalists work a set number of predetermined shifts and have no call responsibility, the challenge is setting a schedule that balances productivity and quality time off.

Fixed = Inflexible

The most popular way to schedule is through blocks of five days on/five days off (5/5) or seven days on/seven days off (7/7), in which hospitalists work 12 or 14 hours at a time, says Troy Ahlstrom, MD, FHM, a member of SHM’s Practice Analysis Committee and CFO of Hospitalists of Northern Michigan, a hospitalist-owned and -managed group based in Traverse City, Mich. Many HM groups employ this model because it’s easy to schedule and is attractive to residents who want a fixed schedule. But from a career satisfaction standpoint, the 5/5 and 7/7 schedule models present their own issues.

Fairness is the first potential pitfall. If all of the physicians in a group work the same schedule, they all have to log the same number of shifts and receive the same compensation. This leaves little to no wiggle room for hospitalists who want to make more money by picking up more shifts or those who want to work fewer shifts, Dr. Ahlstrom says. “People have different income goals,” he adds.

Second, physicians have to see the same number of patients throughout the day. This doesn’t take into consideration the reality that some hospitalists naturally work faster than others, thereby forcing the slower-paced doctors to keep up with an imposed patient load. “Invariably, no matter what you do, people are different,” Dr. Ahlstrom says.

Another consideration is that when physicians are working 12 to 14 hours a day, essentially they have no time for activities other than work and sleep, which doesn’t match the realities of life. Inevitably, things in personal lives crop up, which leads to swapping shifts that the group scheduler doesn’t know about or overloading the scheduler with shift-change requests, Dr. Ahlstrom explains.

Additionally, 7/7 schedules and their ilk squeeze a year’s worth of work into a compressed time frame, which can lead to intense stress and burnout, says John Nelson, MD, FACP, MHM, director of the hospitalist practice at Overlake Hospital in Bellevue, Wash., SHM co-founder, and practice management columnist for The Hospitalist. “Maximizing the number of days off is not the holy grail,” he says. “If you choose to shut your life down on days that you work, that is going to be toxic.”

Flexibility Equates to Fairness

Dr. Nelson has long advocated a flexible shift schedule that accommodates individual preferences by giving physicians in the group autonomy in deciding how much or how little they want to work. While the group as a whole has to get all the work done, the flexibility comes from one physician taking more shifts as another takes less.

Dr. Radzienda tries to create teams within his group by pairing hospitalists with similar scheduling preferences. For example, he might have a pair working 5/5 and another working 14/14. “Up front, it takes a lot of work, but once you template it out, it becomes a good strategy,” he says.

He also strives to build robust backup plans and jeopardy models (see “Surge Protection,” September 2010, p. 43) into the schedule for short-notice callouts, as you never know when a hospitalist will need to miss a day or two because of illness or a family emergency. “Psychologically, it helps to know that you don’t have to be a hero if you’re ill or emotionally strained,” Dr. Radzienda says.

Dr. Ahlstrom agrees that a flex-schedule strategy has a positive impact on hospitalists’ career satisfaction and longevity. He suggests hospitalists be allowed to specify how many patients they want to see and be compensated according to their workload through built-in bonuses for physicians who work more. Dr. Nelson suggests paying hospitalists per relative value unit (RVU) of work. “I think hospitalists would like it and find it liberating to be paid on production,” he says.

An added bonus to flexible work hours and patient load, according to Dr. Ahlstrom, is that pay difference “will lead to a far more collegial atmosphere, because physicians know they are getting compensated fairly for the amount of work done.”

Another advantage of a flexible schedule is hospitalists knowing they have the option of ramping up or scaling back the number of shifts they work, Dr. Ahlstrom says—for example, a physician who wants to reduce shifts in order to coach his daughter’s softball team or have Friday nights off to watch her son play high school football.

“You prevent burnout by allowing people to change their work schedule depending on what’s going on in their life,” Dr. Ahlstrom says. TH

Lisa Ryan is a freelance writer based in New Jersey.

Effective communication between a physician and their patient is critical to a successful treatment relationship. Even in the best of circumstances, however, we know that physicians and patients often have markedly different impressions of what is said during an interaction or the meaning of information provided. When a language barrier is present, or a patient has a hearing or visual impairment, these communication challenges multiply. How physicians address such challenges has multiple legal implications.

The ADA

Title III of the Americans with Disabilities Act (ADA) prohibits discrimination against visually impaired and deaf and hard-of-hearing people in places of public accommodation. Included within the definition of places of public accommodation is any “professional office of a healthcare provider,” regardless of the size of the office or number of employees. Thus, the ADA applies to doctors, dentists, psychiatrists and psychologists, hospitals, nursing homes and health clinics, and all other providers of mental and physical care. Accordingly, the ADA requires hospitals to provide effective means of communication for patients, family members, and hospital visitors who are visually impaired, deaf, or hard of hearing.

Public accommodations must comply with specific requirements related to effective communication with people with hearing, vision, or speech disabilities. Specifically, unless a hospital or physician can demonstrate that providing communication aids or services would fundamentally alter the nature of the goods or services offered, or would result in an undue burden, a hospital or physician must ensure that no individual with a disability is excluded, denied services, segregated, or otherwise treated differently than other individuals because of the absence of auxiliary aids and services.

Auxiliary aids and services relating to communications, in turn, include:

• Qualified interpreters;
• Note-takers;
• Transcription services;
• Written materials;
• Telephone handset amplifiers;
• Assistive listening devices;
• Assistive listening systems;
• Telephones compatible with hearing aids;
• Closed-caption decoders;
• Open and closed captioning;
• Telecommunications devices for deaf persons (TDDs);
• Videotext displays or other effective methods of making aurally delivered materials available to individuals with hearing impairments;
• Qualified readers;
• Taped texts;
• Audio recordings;
• Braille materials; and
• Large-print materials or other methods of making visually delivered materials available to individuals with visual impairments.

The U.S. Department of Justice (DOJ) has issued memorandums outlining the obligations of physicians and other healthcare providers to provide auxiliary aids or services to people with hearing impairments. The memo recommended that healthcare providers consult with patients about appropriate auxiliary aids and services. The memo noted, however, that private providers are not required to accede to a patient’s specific choice of auxiliary aid or service as long as the provider satisfies his or her obligation to ensure effective communication.

In comparison, healthcare providers working at public entities or hospitals must have a conversation with patients as part of a doctor’s process in providing effective communication, and physicians must give primary consideration to the patient’s choice (see “Americans with Disabilities Act Title II Requirements,” above).

The DOJ has indicated that in determining what constitutes an effective auxiliary aid or service, healthcare providers must consider, among other things, the length and complexity of the communication involved. For example, a note pad and written materials might be sufficient for some routine appointments, to discuss uncomplicated symptoms or minor injuries, or to complete insurance forms or medical history inquiries. When the information is lengthy or complex, however, such as a patient’s discussion of symptoms with medical personnel or a physician’s presentation of diagnosis and treatment options to patients or family members, it might be necessary to provide a qualified sign language interpreter or other interpreter; the use of handwritten notes might be inadequate.

The DOJ also has specified that hospitals should have arrangements in place to ensure that qualified interpreters are readily available on a scheduled basis, and on an unscheduled basis with minimal delay, including on-call arrangements for after-hours emergencies. Larger facilities can choose to have interpreters on staff. Hospitals should develop protocols and provide training to ensure that hospital staff know how to obtain interpreter services and other communication aids and services when needed.

The DOJ has recommended hospitals have signs and other types of notices to advise persons with disabilities that services and assistance are available, along with what they need to do to obtain them. A hospital must be prepared to make and receive relay system calls.

If telephones and televisions are provided in patient rooms, hospitals must provide patients who are deaf or hard of hearing comparable accessible equipment upon request, including TDDs, telephones that are hearing-aid compatible and have volume control, and televisions with closed captioning or decoders. For training or other educational services offered to patients or members of the public, additional aids and services (e.g. note-takers, captioned videos, assistive listening systems) might be necessary for effective communication.

Visual alarms are not required in patient rooms. However, evacuation procedures should include specific measures to ensure the safety of patients and visitors who are deaf or hard of hearing. Certain built-in communication features required for hospitals built or altered after the effective date of the ADA in 1992 include:

• Visual alarms, which must be provided in all public and common-use areas, including restrooms, where audible alarms are provided;
• TDDs, which must be provided at public pay phones serving emergency, recovery, or waiting rooms, and at least one TDD must be provided at other locations where there are four or more pay phones; and
• A certain percentage of public phones that must have other features, such as TDD plug-in capability, volume controls, and hearing-aid compatibility.

Also important: Hospitals and healthcare providers are not allowed to charge patients with a disability to cover the costs of providing auxiliary aids and services. Instead, the costs must be treated as overhead expenses that are passed on to all patients.

New Regulations

Effective March 15, amendments to the ADA regulations will take effect modifying both Title II and Title III. One of the relevant changes to the regulations include video remote interpreting (VRI) services as a kind of auxiliary aid, which could be used to provide effective communication. VRI is an interpreting service that delivers high-quality video images over dedicated lines or wireless technology.

The amended Title II regulations effective March 15 also expand on the explanation of an effective auxiliary aid and provide that “in order to be effective, auxiliary aids and services must be provided in accessible formats, in a timely manner, and in such a way as to protect the privacy and independence of the individual with a disability.” A public entity cannot require an individual with a disability to bring another individual to interpret for him or her, or rely on an adult accompanying an individual with a disability to interpret or facilitate communication, except in the case of an emergency or when the individual with a disability specifically requests that the accompanying adult interpret or facilitate communication, the accompanying adult agrees to provide such assistance, and reliance on that adult for such assistance is appropriate under the circumstances.

Similarly, a public entity cannot rely on a minor child to interpret or facilitate communication, except in an emergency involving an imminent threat to the safety or welfare of an individual or the public and no interpreter is available.

Title IV of Civil Rights Act

Individuals who do not speak English as their primary language and who have a limited ability to read, write, speak, or understand English might be eligible to receive language assistance with respect to particular services, benefits, or encounters.

Title VI and U.S. Department of Health and Human Services (HHS) regulations require recipients of federal financial assistance from HHS to take reasonable steps to provide meaningful access to limited-English-proficiency (LEP) persons. Recipients of HHS assistance might include hospitals, nursing homes, home health agencies, managed-care organizations, universities and other entities with health or social service research programs, and state, county, and local health agencies. It might also include Medicaid agencies, state, county, and local welfare agencies, programs for families, youth, and children, Head Start programs, public and private contractors, subcontractors, and vendors, and physicians and other providers who receive financial assistance from HHS.

HHS has indicated that the obligation to provide meaningful access is fact-dependent and starts with an individualized assessment that balances four factors:

• Number or proportion of LEP persons eligible to be served or likely to be encountered by the program or grantee;
• Frequency with which LEP individuals come into contact with the program;
• Nature and importance of the program, activity or service provided by the recipient to its beneficiaries; and
• Resources available to the grantee/recipient and the costs of interpretation/translation services.

HHS notes that there is no “one size fits all” solution for compliance with respect to LEP persons, and what constitutes “reasonable steps” for large providers might not be reasonable where small providers are concerned.

Use of family members or friends. HHS has indicated that some LEP persons feel more comfortable when a trusted family member or friend acts as an interpreter. When an LEP person attempts to access the services of a recipient of federal financial assistance, who upon application of the four factors is required to provide an interpreter, the recipient should make the LEP person aware that he or she has the option of having the recipient provide an interpreter for them without charge, or of using their own interpreter. Recipients also should consider special circumstances that might affect whether a family member or friend should serve as an interpreter, such as whether the situation is an emergency, and whether there are concerns over competency, confidentiality, privacy, or conflict of interest. Recipients cannot require LEP persons to use family members or friends as interpreters.

Vital documents. Recipients can use the four factors to determine if specific documents or portions of documents should be translated into the language of frequently encountered LEP groups eligible to be served or likely to be affected by the recipient’s program. Recipients should assess whether specific documents or portions of documents are “vital” to the program, information, encounter, or service involved, and the consequences to the LEP person if the information in question is not provided accurately or in a timely manner.

Compliance plans. HHS provides recipients with a “safe harbor” that, if undertaken, will be considered strong evidence that the recipient has satisfied its written translation obligations. If a recipient determines that it should provide language assistance services, a recipient might develop an implementation plan to address the identified needs of the LEP populations it serves. Recipients have considerable flexibility in developing this plan, but should: 1) identify LEP individuals who need language assistance; 2) identify language assistance measures (i.e. how staff can obtain services or respond to LEP callers); 3) train staff; 4) provide notice to LEP persons (e.g. posting signs); and 5) monitor and update the LEP plan.

Voluntary compliance efforts. The Office for Civil Rights and HHS have indicated they are committed to assisting recipients of HHS financial assistance in complying with their obligations under Title VI of the Civil Rights Act of 1964. HHS provides a variety of practical technical assistance to recipients to assist them in serving LEP persons so that they are in compliance with the Title VI regulations. The requirement to provide meaningful access to LEP persons is enforced and implemented by the HHS Office for Civil Rights through the procedures identified in the Title VI regulations. These procedures include complaint investigations, compliance reviews, efforts to secure voluntary compliance, and technical assistance.

Additionally, the American Medical Association has prepared the “Office Guide to Communicating with Limited English Proficient Patients” (download a PDF at www.ama-assn.org/ama1/pub/upload/mm/433/lep_booklet.pdf), which provides useful guidance to physicians.

Conclusion

The requirements for providing assistance to patients presenting with a language barrier, or patients who have hearing or visual impairments, are challenging. Advance planning for interacting with such patients can assist in successful physician-patient communications. Nonetheless, there is no “one size fits all” approach. Accordingly, if you have a question about a specific situation, consult the Office for Civil Rights (www.hhs.gov/ocr), the Department of Justice ADA Information Line (800-514-0301), or an attorney. TH

Carmen Decker is an attorney with Hershey Skinner, LLC, specializing in the representation of healthcare and licensed professionals. Kari Hershey is general counsel to the Colorado Medical Society and an instructor at the University of Colorado Law School.

Effective communication between a physician and their patient is critical to a successful treatment relationship. Even in the best of circumstances, however, we know that physicians and patients often have markedly different impressions of what is said during an interaction or the meaning of information provided. When a language barrier is present, or a patient has a hearing or visual impairment, these communication challenges multiply. How physicians address such challenges has multiple legal implications.

The ADA

Title III of the Americans with Disabilities Act (ADA) prohibits discrimination against visually impaired and deaf and hard-of-hearing people in places of public accommodation. Included within the definition of places of public accommodation is any “professional office of a healthcare provider,” regardless of the size of the office or number of employees. Thus, the ADA applies to doctors, dentists, psychiatrists and psychologists, hospitals, nursing homes and health clinics, and all other providers of mental and physical care. Accordingly, the ADA requires hospitals to provide effective means of communication for patients, family members, and hospital visitors who are visually impaired, deaf, or hard of hearing.

Public accommodations must comply with specific requirements related to effective communication with people with hearing, vision, or speech disabilities. Specifically, unless a hospital or physician can demonstrate that providing communication aids or services would fundamentally alter the nature of the goods or services offered, or would result in an undue burden, a hospital or physician must ensure that no individual with a disability is excluded, denied services, segregated, or otherwise treated differently than other individuals because of the absence of auxiliary aids and services.

Auxiliary aids and services relating to communications, in turn, include:

• Qualified interpreters;
• Note-takers;
• Transcription services;
• Written materials;
• Telephone handset amplifiers;
• Assistive listening devices;
• Assistive listening systems;
• Telephones compatible with hearing aids;
• Closed-caption decoders;
• Open and closed captioning;
• Telecommunications devices for deaf persons (TDDs);
• Videotext displays or other effective methods of making aurally delivered materials available to individuals with hearing impairments;
• Qualified readers;
• Taped texts;
• Audio recordings;
• Braille materials; and
• Large-print materials or other methods of making visually delivered materials available to individuals with visual impairments.

The U.S. Department of Justice (DOJ) has issued memorandums outlining the obligations of physicians and other healthcare providers to provide auxiliary aids or services to people with hearing impairments. The memo recommended that healthcare providers consult with patients about appropriate auxiliary aids and services. The memo noted, however, that private providers are not required to accede to a patient’s specific choice of auxiliary aid or service as long as the provider satisfies his or her obligation to ensure effective communication.

In comparison, healthcare providers working at public entities or hospitals must have a conversation with patients as part of a doctor’s process in providing effective communication, and physicians must give primary consideration to the patient’s choice (see “Americans with Disabilities Act Title II Requirements,” above).

The DOJ has indicated that in determining what constitutes an effective auxiliary aid or service, healthcare providers must consider, among other things, the length and complexity of the communication involved. For example, a note pad and written materials might be sufficient for some routine appointments, to discuss uncomplicated symptoms or minor injuries, or to complete insurance forms or medical history inquiries. When the information is lengthy or complex, however, such as a patient’s discussion of symptoms with medical personnel or a physician’s presentation of diagnosis and treatment options to patients or family members, it might be necessary to provide a qualified sign language interpreter or other interpreter; the use of handwritten notes might be inadequate.

The DOJ also has specified that hospitals should have arrangements in place to ensure that qualified interpreters are readily available on a scheduled basis, and on an unscheduled basis with minimal delay, including on-call arrangements for after-hours emergencies. Larger facilities can choose to have interpreters on staff. Hospitals should develop protocols and provide training to ensure that hospital staff know how to obtain interpreter services and other communication aids and services when needed.

The DOJ has recommended hospitals have signs and other types of notices to advise persons with disabilities that services and assistance are available, along with what they need to do to obtain them. A hospital must be prepared to make and receive relay system calls.

If telephones and televisions are provided in patient rooms, hospitals must provide patients who are deaf or hard of hearing comparable accessible equipment upon request, including TDDs, telephones that are hearing-aid compatible and have volume control, and televisions with closed captioning or decoders. For training or other educational services offered to patients or members of the public, additional aids and services (e.g. note-takers, captioned videos, assistive listening systems) might be necessary for effective communication.

Visual alarms are not required in patient rooms. However, evacuation procedures should include specific measures to ensure the safety of patients and visitors who are deaf or hard of hearing. Certain built-in communication features required for hospitals built or altered after the effective date of the ADA in 1992 include:

• Visual alarms, which must be provided in all public and common-use areas, including restrooms, where audible alarms are provided;
• TDDs, which must be provided at public pay phones serving emergency, recovery, or waiting rooms, and at least one TDD must be provided at other locations where there are four or more pay phones; and
• A certain percentage of public phones that must have other features, such as TDD plug-in capability, volume controls, and hearing-aid compatibility.

Also important: Hospitals and healthcare providers are not allowed to charge patients with a disability to cover the costs of providing auxiliary aids and services. Instead, the costs must be treated as overhead expenses that are passed on to all patients.

New Regulations

Effective March 15, amendments to the ADA regulations will take effect modifying both Title II and Title III. One of the relevant changes to the regulations include video remote interpreting (VRI) services as a kind of auxiliary aid, which could be used to provide effective communication. VRI is an interpreting service that delivers high-quality video images over dedicated lines or wireless technology.

The amended Title II regulations effective March 15 also expand on the explanation of an effective auxiliary aid and provide that “in order to be effective, auxiliary aids and services must be provided in accessible formats, in a timely manner, and in such a way as to protect the privacy and independence of the individual with a disability.” A public entity cannot require an individual with a disability to bring another individual to interpret for him or her, or rely on an adult accompanying an individual with a disability to interpret or facilitate communication, except in the case of an emergency or when the individual with a disability specifically requests that the accompanying adult interpret or facilitate communication, the accompanying adult agrees to provide such assistance, and reliance on that adult for such assistance is appropriate under the circumstances.

Similarly, a public entity cannot rely on a minor child to interpret or facilitate communication, except in an emergency involving an imminent threat to the safety or welfare of an individual or the public and no interpreter is available.

Title IV of Civil Rights Act

Individuals who do not speak English as their primary language and who have a limited ability to read, write, speak, or understand English might be eligible to receive language assistance with respect to particular services, benefits, or encounters.

Title VI and U.S. Department of Health and Human Services (HHS) regulations require recipients of federal financial assistance from HHS to take reasonable steps to provide meaningful access to limited-English-proficiency (LEP) persons. Recipients of HHS assistance might include hospitals, nursing homes, home health agencies, managed-care organizations, universities and other entities with health or social service research programs, and state, county, and local health agencies. It might also include Medicaid agencies, state, county, and local welfare agencies, programs for families, youth, and children, Head Start programs, public and private contractors, subcontractors, and vendors, and physicians and other providers who receive financial assistance from HHS.

HHS has indicated that the obligation to provide meaningful access is fact-dependent and starts with an individualized assessment that balances four factors:

• Number or proportion of LEP persons eligible to be served or likely to be encountered by the program or grantee;
• Frequency with which LEP individuals come into contact with the program;
• Nature and importance of the program, activity or service provided by the recipient to its beneficiaries; and
• Resources available to the grantee/recipient and the costs of interpretation/translation services.

HHS notes that there is no “one size fits all” solution for compliance with respect to LEP persons, and what constitutes “reasonable steps” for large providers might not be reasonable where small providers are concerned.

Use of family members or friends. HHS has indicated that some LEP persons feel more comfortable when a trusted family member or friend acts as an interpreter. When an LEP person attempts to access the services of a recipient of federal financial assistance, who upon application of the four factors is required to provide an interpreter, the recipient should make the LEP person aware that he or she has the option of having the recipient provide an interpreter for them without charge, or of using their own interpreter. Recipients also should consider special circumstances that might affect whether a family member or friend should serve as an interpreter, such as whether the situation is an emergency, and whether there are concerns over competency, confidentiality, privacy, or conflict of interest. Recipients cannot require LEP persons to use family members or friends as interpreters.

Vital documents. Recipients can use the four factors to determine if specific documents or portions of documents should be translated into the language of frequently encountered LEP groups eligible to be served or likely to be affected by the recipient’s program. Recipients should assess whether specific documents or portions of documents are “vital” to the program, information, encounter, or service involved, and the consequences to the LEP person if the information in question is not provided accurately or in a timely manner.

Compliance plans. HHS provides recipients with a “safe harbor” that, if undertaken, will be considered strong evidence that the recipient has satisfied its written translation obligations. If a recipient determines that it should provide language assistance services, a recipient might develop an implementation plan to address the identified needs of the LEP populations it serves. Recipients have considerable flexibility in developing this plan, but should: 1) identify LEP individuals who need language assistance; 2) identify language assistance measures (i.e. how staff can obtain services or respond to LEP callers); 3) train staff; 4) provide notice to LEP persons (e.g. posting signs); and 5) monitor and update the LEP plan.

Voluntary compliance efforts. The Office for Civil Rights and HHS have indicated they are committed to assisting recipients of HHS financial assistance in complying with their obligations under Title VI of the Civil Rights Act of 1964. HHS provides a variety of practical technical assistance to recipients to assist them in serving LEP persons so that they are in compliance with the Title VI regulations. The requirement to provide meaningful access to LEP persons is enforced and implemented by the HHS Office for Civil Rights through the procedures identified in the Title VI regulations. These procedures include complaint investigations, compliance reviews, efforts to secure voluntary compliance, and technical assistance.

Additionally, the American Medical Association has prepared the “Office Guide to Communicating with Limited English Proficient Patients” (download a PDF at www.ama-assn.org/ama1/pub/upload/mm/433/lep_booklet.pdf), which provides useful guidance to physicians.

Conclusion

The requirements for providing assistance to patients presenting with a language barrier, or patients who have hearing or visual impairments, are challenging. Advance planning for interacting with such patients can assist in successful physician-patient communications. Nonetheless, there is no “one size fits all” approach. Accordingly, if you have a question about a specific situation, consult the Office for Civil Rights (www.hhs.gov/ocr), the Department of Justice ADA Information Line (800-514-0301), or an attorney. TH

Carmen Decker is an attorney with Hershey Skinner, LLC, specializing in the representation of healthcare and licensed professionals. Kari Hershey is general counsel to the Colorado Medical Society and an instructor at the University of Colorado Law School.

Effective communication between a physician and their patient is critical to a successful treatment relationship. Even in the best of circumstances, however, we know that physicians and patients often have markedly different impressions of what is said during an interaction or the meaning of information provided. When a language barrier is present, or a patient has a hearing or visual impairment, these communication challenges multiply. How physicians address such challenges has multiple legal implications.

The ADA

Title III of the Americans with Disabilities Act (ADA) prohibits discrimination against visually impaired and deaf and hard-of-hearing people in places of public accommodation. Included within the definition of places of public accommodation is any “professional office of a healthcare provider,” regardless of the size of the office or number of employees. Thus, the ADA applies to doctors, dentists, psychiatrists and psychologists, hospitals, nursing homes and health clinics, and all other providers of mental and physical care. Accordingly, the ADA requires hospitals to provide effective means of communication for patients, family members, and hospital visitors who are visually impaired, deaf, or hard of hearing.

Public accommodations must comply with specific requirements related to effective communication with people with hearing, vision, or speech disabilities. Specifically, unless a hospital or physician can demonstrate that providing communication aids or services would fundamentally alter the nature of the goods or services offered, or would result in an undue burden, a hospital or physician must ensure that no individual with a disability is excluded, denied services, segregated, or otherwise treated differently than other individuals because of the absence of auxiliary aids and services.

Auxiliary aids and services relating to communications, in turn, include:

• Qualified interpreters;
• Note-takers;
• Transcription services;
• Written materials;
• Telephone handset amplifiers;
• Assistive listening devices;
• Assistive listening systems;
• Telephones compatible with hearing aids;
• Closed-caption decoders;
• Open and closed captioning;
• Telecommunications devices for deaf persons (TDDs);
• Videotext displays or other effective methods of making aurally delivered materials available to individuals with hearing impairments;
• Qualified readers;
• Taped texts;
• Audio recordings;
• Braille materials; and
• Large-print materials or other methods of making visually delivered materials available to individuals with visual impairments.

The U.S. Department of Justice (DOJ) has issued memorandums outlining the obligations of physicians and other healthcare providers to provide auxiliary aids or services to people with hearing impairments. The memo recommended that healthcare providers consult with patients about appropriate auxiliary aids and services. The memo noted, however, that private providers are not required to accede to a patient’s specific choice of auxiliary aid or service as long as the provider satisfies his or her obligation to ensure effective communication.

In comparison, healthcare providers working at public entities or hospitals must have a conversation with patients as part of a doctor’s process in providing effective communication, and physicians must give primary consideration to the patient’s choice (see “Americans with Disabilities Act Title II Requirements,” above).

The DOJ has indicated that in determining what constitutes an effective auxiliary aid or service, healthcare providers must consider, among other things, the length and complexity of the communication involved. For example, a note pad and written materials might be sufficient for some routine appointments, to discuss uncomplicated symptoms or minor injuries, or to complete insurance forms or medical history inquiries. When the information is lengthy or complex, however, such as a patient’s discussion of symptoms with medical personnel or a physician’s presentation of diagnosis and treatment options to patients or family members, it might be necessary to provide a qualified sign language interpreter or other interpreter; the use of handwritten notes might be inadequate.

The DOJ also has specified that hospitals should have arrangements in place to ensure that qualified interpreters are readily available on a scheduled basis, and on an unscheduled basis with minimal delay, including on-call arrangements for after-hours emergencies. Larger facilities can choose to have interpreters on staff. Hospitals should develop protocols and provide training to ensure that hospital staff know how to obtain interpreter services and other communication aids and services when needed.

The DOJ has recommended hospitals have signs and other types of notices to advise persons with disabilities that services and assistance are available, along with what they need to do to obtain them. A hospital must be prepared to make and receive relay system calls.

If telephones and televisions are provided in patient rooms, hospitals must provide patients who are deaf or hard of hearing comparable accessible equipment upon request, including TDDs, telephones that are hearing-aid compatible and have volume control, and televisions with closed captioning or decoders. For training or other educational services offered to patients or members of the public, additional aids and services (e.g. note-takers, captioned videos, assistive listening systems) might be necessary for effective communication.

Visual alarms are not required in patient rooms. However, evacuation procedures should include specific measures to ensure the safety of patients and visitors who are deaf or hard of hearing. Certain built-in communication features required for hospitals built or altered after the effective date of the ADA in 1992 include:

• Visual alarms, which must be provided in all public and common-use areas, including restrooms, where audible alarms are provided;
• TDDs, which must be provided at public pay phones serving emergency, recovery, or waiting rooms, and at least one TDD must be provided at other locations where there are four or more pay phones; and
• A certain percentage of public phones that must have other features, such as TDD plug-in capability, volume controls, and hearing-aid compatibility.

Also important: Hospitals and healthcare providers are not allowed to charge patients with a disability to cover the costs of providing auxiliary aids and services. Instead, the costs must be treated as overhead expenses that are passed on to all patients.

New Regulations

Effective March 15, amendments to the ADA regulations will take effect modifying both Title II and Title III. One of the relevant changes to the regulations include video remote interpreting (VRI) services as a kind of auxiliary aid, which could be used to provide effective communication. VRI is an interpreting service that delivers high-quality video images over dedicated lines or wireless technology.

The amended Title II regulations effective March 15 also expand on the explanation of an effective auxiliary aid and provide that “in order to be effective, auxiliary aids and services must be provided in accessible formats, in a timely manner, and in such a way as to protect the privacy and independence of the individual with a disability.” A public entity cannot require an individual with a disability to bring another individual to interpret for him or her, or rely on an adult accompanying an individual with a disability to interpret or facilitate communication, except in the case of an emergency or when the individual with a disability specifically requests that the accompanying adult interpret or facilitate communication, the accompanying adult agrees to provide such assistance, and reliance on that adult for such assistance is appropriate under the circumstances.

Similarly, a public entity cannot rely on a minor child to interpret or facilitate communication, except in an emergency involving an imminent threat to the safety or welfare of an individual or the public and no interpreter is available.

Title IV of Civil Rights Act

Individuals who do not speak English as their primary language and who have a limited ability to read, write, speak, or understand English might be eligible to receive language assistance with respect to particular services, benefits, or encounters.

Title VI and U.S. Department of Health and Human Services (HHS) regulations require recipients of federal financial assistance from HHS to take reasonable steps to provide meaningful access to limited-English-proficiency (LEP) persons. Recipients of HHS assistance might include hospitals, nursing homes, home health agencies, managed-care organizations, universities and other entities with health or social service research programs, and state, county, and local health agencies. It might also include Medicaid agencies, state, county, and local welfare agencies, programs for families, youth, and children, Head Start programs, public and private contractors, subcontractors, and vendors, and physicians and other providers who receive financial assistance from HHS.

HHS has indicated that the obligation to provide meaningful access is fact-dependent and starts with an individualized assessment that balances four factors:

• Number or proportion of LEP persons eligible to be served or likely to be encountered by the program or grantee;
• Frequency with which LEP individuals come into contact with the program;
• Nature and importance of the program, activity or service provided by the recipient to its beneficiaries; and
• Resources available to the grantee/recipient and the costs of interpretation/translation services.

HHS notes that there is no “one size fits all” solution for compliance with respect to LEP persons, and what constitutes “reasonable steps” for large providers might not be reasonable where small providers are concerned.

Use of family members or friends. HHS has indicated that some LEP persons feel more comfortable when a trusted family member or friend acts as an interpreter. When an LEP person attempts to access the services of a recipient of federal financial assistance, who upon application of the four factors is required to provide an interpreter, the recipient should make the LEP person aware that he or she has the option of having the recipient provide an interpreter for them without charge, or of using their own interpreter. Recipients also should consider special circumstances that might affect whether a family member or friend should serve as an interpreter, such as whether the situation is an emergency, and whether there are concerns over competency, confidentiality, privacy, or conflict of interest. Recipients cannot require LEP persons to use family members or friends as interpreters.

Vital documents. Recipients can use the four factors to determine if specific documents or portions of documents should be translated into the language of frequently encountered LEP groups eligible to be served or likely to be affected by the recipient’s program. Recipients should assess whether specific documents or portions of documents are “vital” to the program, information, encounter, or service involved, and the consequences to the LEP person if the information in question is not provided accurately or in a timely manner.

Compliance plans. HHS provides recipients with a “safe harbor” that, if undertaken, will be considered strong evidence that the recipient has satisfied its written translation obligations. If a recipient determines that it should provide language assistance services, a recipient might develop an implementation plan to address the identified needs of the LEP populations it serves. Recipients have considerable flexibility in developing this plan, but should: 1) identify LEP individuals who need language assistance; 2) identify language assistance measures (i.e. how staff can obtain services or respond to LEP callers); 3) train staff; 4) provide notice to LEP persons (e.g. posting signs); and 5) monitor and update the LEP plan.

Voluntary compliance efforts. The Office for Civil Rights and HHS have indicated they are committed to assisting recipients of HHS financial assistance in complying with their obligations under Title VI of the Civil Rights Act of 1964. HHS provides a variety of practical technical assistance to recipients to assist them in serving LEP persons so that they are in compliance with the Title VI regulations. The requirement to provide meaningful access to LEP persons is enforced and implemented by the HHS Office for Civil Rights through the procedures identified in the Title VI regulations. These procedures include complaint investigations, compliance reviews, efforts to secure voluntary compliance, and technical assistance.

Additionally, the American Medical Association has prepared the “Office Guide to Communicating with Limited English Proficient Patients” (download a PDF at www.ama-assn.org/ama1/pub/upload/mm/433/lep_booklet.pdf), which provides useful guidance to physicians.

Conclusion

The requirements for providing assistance to patients presenting with a language barrier, or patients who have hearing or visual impairments, are challenging. Advance planning for interacting with such patients can assist in successful physician-patient communications. Nonetheless, there is no “one size fits all” approach. Accordingly, if you have a question about a specific situation, consult the Office for Civil Rights (www.hhs.gov/ocr), the Department of Justice ADA Information Line (800-514-0301), or an attorney. TH

Carmen Decker is an attorney with Hershey Skinner, LLC, specializing in the representation of healthcare and licensed professionals. Kari Hershey is general counsel to the Colorado Medical Society and an instructor at the University of Colorado Law School.

What is value-based purchasing (VBP) and why should I care? Well, for starters, your hospital’s CFO might not know that starting in 2013 (just two years from now), the Centers for Medicare & Medicaid Services (CMS) will be withholding at least 1% of all Medicare payments, but CMS is giving your hospital a chance to get some or all of that money back. For a busy hospital, the withholding will easily be $1 million; for many hospitals, that figure is more like $2 million to $3 million.

SHM thinks hospitalists are uniquely positioned to be champions for the C-suite, helping the hospital’s balance sheet, aiding in staff retention, and providing better care for our patients. And that’s where VBP comes in.

In March 2010, Congress passed the Patient Protection and Affordable Care Act (see “Health Reform Turns 1,” p. 16). This law includes a provision that establishes a VBP program for hospital payments beginning with discharges on Oct. 1, 2012. Payment will be based on hospital performance on quality measures determined by Health and Human Services (HHS). The VBP program will pay hospitals for their actual performance on quality measures, rather than for just reporting those measures, starting in 2013.

This is a null-set game, in which the funding for the best performers is clearly coming out of the hide of low-performing hospitals. Funding will be phased in from 2013 through 2017. Hospitals will have their payments for all Medicare DRGs reduced by 1% in 2013, 1.25% in 2014, 1.5% in 2015, 1.75% in 2016, and 2% in 2017 and beyond. Just ask your CFO what this means at your hospital and see his or her brow furrow.

The good news (i.e. carrot) is that a hospital that meets or exceeds the performance standards will be eligible to earn back all the Medicare money that was withheld and even earn a bonus of as much as 2%.

VBP Metrics

So just what performance will be measured in the new VBP program? While physicians might see quality in clinical terms, the VBP program defines performance more broadly; that means it includes the patient experience. In fact, about 70% of the quality measures will be based on clinical performance, and a full 30% will come from scores on post-discharge patient satisfaction questionnaires (e.g. HCAHPS). To understand the importance of the patient satisfaction part of the VBP equation, just note that Press Ganey, the largest private company helping hospitals understand what their customers are thinking, is jumping into the VBP arena with both feet. Your hospital’s CFO (and lead hospitalist) should contact Press Ganey and run your current performance numbers through their VBP calculator to see if you are on the hilltop or in a deep hole.

The clinical measures will be selected from those used in the current Medicare pay-for-reporting program and likely will include measures for myocardial infarction, heart failure, pneumonia, and surgical care. In addition, HHS is mandated to include measures of efficiency, looking at ways to assess the spending per Medicare beneficiary. This is the real value equation: value = outcomes ÷ cost.

HM to the Rescue

No one in the hospital community sits more at the nexus of clinical care on these measures, efficiency, and the patient experience than hospitalists. This is an opportunity and a risk for hospitalists; that is why SHM is actively planning strategies to help hospitalists assist their hospitals in assessing how their current performance would play out in the payment world post-2013. In addition, SHM will have tools to assist hospitalists in creating change to help their institutions be in the top half of the nation’s hospitals—those who will get their millions of withheld dollars back.

SHM’s board of directors recently passed the following position statement on value-based purchasing:

“SHM supports the Affordable Care Act (ACA) Section 3001 directing the Secretary of HHS to establish a value-based purchasing program under the hospital inpatient prospective payment system. We believe that the Medicare reimbursement system must be changed to promote value, and we strongly support policies that link quality measurement to performance-based payment. We are pleased that under ACA the Secretary will establish performance standards that reward hospitals based on either attaining a certain performance standard or making improvements relative to a previous performance period. Hospitalists, who care for more hospitalized patients than any other physician group and lead system change and quality improvement efforts, will be critical to improving the performance of hospitals under this program.”

As mentioned above, the VBP program poses some risks to hospitalists. We cannot improve our hospital’s performance by ourselves, no matter how well motivated and trained we are. Hospitalists tend to attract a group of patients who traditionally have less satisfaction with their hospital experience (e.g. acutely ill patients admitted through the ED). But for more than a decade, hospitalists have been touting our goal to change the system for the better and to strive to be rewarded for value and performance, not simply for the doing.

In some ways, hospitals’ financial support of hospitalist groups has been predicated on the value we currently provide in efficiency (e.g. decreased length of stay, better use of resources) and effectiveness (e.g. improved measurable quality). The VBP program in ACA is just a first big step for the largest payor of hospital care—CMS—to change the ground rules.

Well-prepared hospitalists can provide leadership and help deliver their institutions to the top half of hospitals (those that will receive bonus payment) and, at the same time, begin to change the culture of their hospital to provide their patients with a better clinical outcome and a better patient experience.

Congress and President Obama are our allies here. A million dollars should get your hospital executives’ attention. Now is the time for hospitalists—with SHM’s help—to step up and show what we can do. TH

Dr. Wellikson is CEO of SHM.

What is value-based purchasing (VBP) and why should I care? Well, for starters, your hospital’s CFO might not know that starting in 2013 (just two years from now), the Centers for Medicare & Medicaid Services (CMS) will be withholding at least 1% of all Medicare payments, but CMS is giving your hospital a chance to get some or all of that money back. For a busy hospital, the withholding will easily be $1 million; for many hospitals, that figure is more like $2 million to $3 million.

SHM thinks hospitalists are uniquely positioned to be champions for the C-suite, helping the hospital’s balance sheet, aiding in staff retention, and providing better care for our patients. And that’s where VBP comes in.

In March 2010, Congress passed the Patient Protection and Affordable Care Act (see “Health Reform Turns 1,” p. 16). This law includes a provision that establishes a VBP program for hospital payments beginning with discharges on Oct. 1, 2012. Payment will be based on hospital performance on quality measures determined by Health and Human Services (HHS). The VBP program will pay hospitals for their actual performance on quality measures, rather than for just reporting those measures, starting in 2013.

This is a null-set game, in which the funding for the best performers is clearly coming out of the hide of low-performing hospitals. Funding will be phased in from 2013 through 2017. Hospitals will have their payments for all Medicare DRGs reduced by 1% in 2013, 1.25% in 2014, 1.5% in 2015, 1.75% in 2016, and 2% in 2017 and beyond. Just ask your CFO what this means at your hospital and see his or her brow furrow.

The good news (i.e. carrot) is that a hospital that meets or exceeds the performance standards will be eligible to earn back all the Medicare money that was withheld and even earn a bonus of as much as 2%.

VBP Metrics

So just what performance will be measured in the new VBP program? While physicians might see quality in clinical terms, the VBP program defines performance more broadly; that means it includes the patient experience. In fact, about 70% of the quality measures will be based on clinical performance, and a full 30% will come from scores on post-discharge patient satisfaction questionnaires (e.g. HCAHPS). To understand the importance of the patient satisfaction part of the VBP equation, just note that Press Ganey, the largest private company helping hospitals understand what their customers are thinking, is jumping into the VBP arena with both feet. Your hospital’s CFO (and lead hospitalist) should contact Press Ganey and run your current performance numbers through their VBP calculator to see if you are on the hilltop or in a deep hole.

The clinical measures will be selected from those used in the current Medicare pay-for-reporting program and likely will include measures for myocardial infarction, heart failure, pneumonia, and surgical care. In addition, HHS is mandated to include measures of efficiency, looking at ways to assess the spending per Medicare beneficiary. This is the real value equation: value = outcomes ÷ cost.

HM to the Rescue

No one in the hospital community sits more at the nexus of clinical care on these measures, efficiency, and the patient experience than hospitalists. This is an opportunity and a risk for hospitalists; that is why SHM is actively planning strategies to help hospitalists assist their hospitals in assessing how their current performance would play out in the payment world post-2013. In addition, SHM will have tools to assist hospitalists in creating change to help their institutions be in the top half of the nation’s hospitals—those who will get their millions of withheld dollars back.

SHM’s board of directors recently passed the following position statement on value-based purchasing:

“SHM supports the Affordable Care Act (ACA) Section 3001 directing the Secretary of HHS to establish a value-based purchasing program under the hospital inpatient prospective payment system. We believe that the Medicare reimbursement system must be changed to promote value, and we strongly support policies that link quality measurement to performance-based payment. We are pleased that under ACA the Secretary will establish performance standards that reward hospitals based on either attaining a certain performance standard or making improvements relative to a previous performance period. Hospitalists, who care for more hospitalized patients than any other physician group and lead system change and quality improvement efforts, will be critical to improving the performance of hospitals under this program.”

As mentioned above, the VBP program poses some risks to hospitalists. We cannot improve our hospital’s performance by ourselves, no matter how well motivated and trained we are. Hospitalists tend to attract a group of patients who traditionally have less satisfaction with their hospital experience (e.g. acutely ill patients admitted through the ED). But for more than a decade, hospitalists have been touting our goal to change the system for the better and to strive to be rewarded for value and performance, not simply for the doing.

In some ways, hospitals’ financial support of hospitalist groups has been predicated on the value we currently provide in efficiency (e.g. decreased length of stay, better use of resources) and effectiveness (e.g. improved measurable quality). The VBP program in ACA is just a first big step for the largest payor of hospital care—CMS—to change the ground rules.

Well-prepared hospitalists can provide leadership and help deliver their institutions to the top half of hospitals (those that will receive bonus payment) and, at the same time, begin to change the culture of their hospital to provide their patients with a better clinical outcome and a better patient experience.

Congress and President Obama are our allies here. A million dollars should get your hospital executives’ attention. Now is the time for hospitalists—with SHM’s help—to step up and show what we can do. TH

Dr. Wellikson is CEO of SHM.

What is value-based purchasing (VBP) and why should I care? Well, for starters, your hospital’s CFO might not know that starting in 2013 (just two years from now), the Centers for Medicare & Medicaid Services (CMS) will be withholding at least 1% of all Medicare payments, but CMS is giving your hospital a chance to get some or all of that money back. For a busy hospital, the withholding will easily be $1 million; for many hospitals, that figure is more like $2 million to $3 million.

SHM thinks hospitalists are uniquely positioned to be champions for the C-suite, helping the hospital’s balance sheet, aiding in staff retention, and providing better care for our patients. And that’s where VBP comes in.

In March 2010, Congress passed the Patient Protection and Affordable Care Act (see “Health Reform Turns 1,” p. 16). This law includes a provision that establishes a VBP program for hospital payments beginning with discharges on Oct. 1, 2012. Payment will be based on hospital performance on quality measures determined by Health and Human Services (HHS). The VBP program will pay hospitals for their actual performance on quality measures, rather than for just reporting those measures, starting in 2013.

This is a null-set game, in which the funding for the best performers is clearly coming out of the hide of low-performing hospitals. Funding will be phased in from 2013 through 2017. Hospitals will have their payments for all Medicare DRGs reduced by 1% in 2013, 1.25% in 2014, 1.5% in 2015, 1.75% in 2016, and 2% in 2017 and beyond. Just ask your CFO what this means at your hospital and see his or her brow furrow.

The good news (i.e. carrot) is that a hospital that meets or exceeds the performance standards will be eligible to earn back all the Medicare money that was withheld and even earn a bonus of as much as 2%.

VBP Metrics

So just what performance will be measured in the new VBP program? While physicians might see quality in clinical terms, the VBP program defines performance more broadly; that means it includes the patient experience. In fact, about 70% of the quality measures will be based on clinical performance, and a full 30% will come from scores on post-discharge patient satisfaction questionnaires (e.g. HCAHPS). To understand the importance of the patient satisfaction part of the VBP equation, just note that Press Ganey, the largest private company helping hospitals understand what their customers are thinking, is jumping into the VBP arena with both feet. Your hospital’s CFO (and lead hospitalist) should contact Press Ganey and run your current performance numbers through their VBP calculator to see if you are on the hilltop or in a deep hole.

The clinical measures will be selected from those used in the current Medicare pay-for-reporting program and likely will include measures for myocardial infarction, heart failure, pneumonia, and surgical care. In addition, HHS is mandated to include measures of efficiency, looking at ways to assess the spending per Medicare beneficiary. This is the real value equation: value = outcomes ÷ cost.

HM to the Rescue

No one in the hospital community sits more at the nexus of clinical care on these measures, efficiency, and the patient experience than hospitalists. This is an opportunity and a risk for hospitalists; that is why SHM is actively planning strategies to help hospitalists assist their hospitals in assessing how their current performance would play out in the payment world post-2013. In addition, SHM will have tools to assist hospitalists in creating change to help their institutions be in the top half of the nation’s hospitals—those who will get their millions of withheld dollars back.

SHM’s board of directors recently passed the following position statement on value-based purchasing:

“SHM supports the Affordable Care Act (ACA) Section 3001 directing the Secretary of HHS to establish a value-based purchasing program under the hospital inpatient prospective payment system. We believe that the Medicare reimbursement system must be changed to promote value, and we strongly support policies that link quality measurement to performance-based payment. We are pleased that under ACA the Secretary will establish performance standards that reward hospitals based on either attaining a certain performance standard or making improvements relative to a previous performance period. Hospitalists, who care for more hospitalized patients than any other physician group and lead system change and quality improvement efforts, will be critical to improving the performance of hospitals under this program.”

As mentioned above, the VBP program poses some risks to hospitalists. We cannot improve our hospital’s performance by ourselves, no matter how well motivated and trained we are. Hospitalists tend to attract a group of patients who traditionally have less satisfaction with their hospital experience (e.g. acutely ill patients admitted through the ED). But for more than a decade, hospitalists have been touting our goal to change the system for the better and to strive to be rewarded for value and performance, not simply for the doing.

In some ways, hospitals’ financial support of hospitalist groups has been predicated on the value we currently provide in efficiency (e.g. decreased length of stay, better use of resources) and effectiveness (e.g. improved measurable quality). The VBP program in ACA is just a first big step for the largest payor of hospital care—CMS—to change the ground rules.

Well-prepared hospitalists can provide leadership and help deliver their institutions to the top half of hospitals (those that will receive bonus payment) and, at the same time, begin to change the culture of their hospital to provide their patients with a better clinical outcome and a better patient experience.

Congress and President Obama are our allies here. A million dollars should get your hospital executives’ attention. Now is the time for hospitalists—with SHM’s help—to step up and show what we can do. TH

Dr. Wellikson is CEO of SHM.

I’m often asked about the attributes associated with high-functioning practices, so I thought I’d offer a list of them in this column. I’ve written entire columns about some of them in prior issues of The Hospitalist, so I will provide only brief commentary about each of them here.

I think this list can serve as a valuable frame of reference for any hospitalist practice, though it is geared more toward nonacademic settings. It is based on my own career as a hospitalist, which spans more than 20 years, and 15 years’ work as a consultant with nearly 300 institutions around the country. While I think my experience has given me a valuable perspective, others might reasonably omit some attributes listed here or add others.

I believe the single most important measure of a practice is excellent outcomes for its patients. That said, all of the attributes I describe here have more to do with excellent operational, or business, performance. It is possible for a practice to have all of these attributes and still provide disappointing clinical quality for its patients, but that seems really unlikely to me. And even a practice that provides superior clinical care probably won’t be able to do so for long without high-functioning business operations.

I think each of these attributes might be a cause of a practice’s excellent performance, but it is possible that some are a result of it. They are listed in no particular order.

A culture of practice ownership. The most important attribute associated with a high-functioning practice is that the providers in the group maintain a mindset of practice ownership. Even if you are employees of a hospital or other organization, you should think of yourselves as owners of the practice’s performance. When problems arise, you shouldn’t simply assume it is up to the practice leader alone, or an administrator outside of the practice to solve it. Instead, each doctor should always be thinking about how to improve the practice and taking action to make it happen. For more, see “Foster Ownership Culture” in the August 2008 issue, or visit my website and take a quiz (http://nelsonflores.com/html/quiz.html) to assess your ownership culture.

An effective group leader. All groups need a leader who takes the role seriously and doesn’t just view the job description as making the work schedule and attending more meetings than the other hospitalists. (Unfortunately, my experience is that this is precisely what a lot of leaders think.) Of the many markers that effective leaders display, one that seems pretty reliable to me is whether the group has routinely scheduled meetings, with an agenda provided in advance and minutes circulated a few days later. I wrote about effective group leaders in a June 2008 column titled “Follow the Money.”

Autonomy in making decisions. Even when you are an employee of a larger entity, the practice should be structured so that hospitalists have as much autonomy in decision-making as possible. For example, you should always be able to adjust the group’s work schedule (e.g. when shifts start and stop). You also should have a lot of say about your staffing and workload. The latter typically requires that the group is connected to the financial consequences of its choices, which usually means a compensation system based, to a significant degree, on productivity.

While still common for hospitalists, when the largest salary component is fixed, it will always follow that someone outside the group (e.g. an administrator at the hospital) will end up deciding how hard you will have to work to justify the promised salary. And the hospitalists will almost always find fault with that person’s decision—a recipe for constant frustration that inhibits the development of an ownership culture, among other things.

Each doctor sees the job as more than just providing care to patients. In addition to providing quality care for your patients, each hospitalist in the group must work to improve the performance of the hospital. This means work on clinical protocols, medical staff functions (e.g. credentials committee), documentation and coding for both CPT and DRG billing, etc.

Strong social connections. Every high-performing practice I’ve worked with is notable for the social connections between the hospitalists themselves, as well as between hospitalists and other physicians, nursing staff, and administrators. This shouldn’t be taken lightly. Social connections matter—a lot. And while the hospitalists in most groups feel reasonably connected with one another, too often they feel isolated from the other doctors and administrators at the hospital. I wrote some more thoughts about this in a June 2010 column, “Square Peg, Square Hole.”

Hospitalists actively involved in recruiting for their practice. The hospitalists themselves—at a minimum, the group leader—should be very involved in recruiting new members for the group. Professional recruiters are very valuable but can be a lot more effective if the hospitalists themselves participate in the process. The group will land better candidates that way. For more, see “We’re Hiring,” from July 2008.

Hospitalists know data about their performance. Too many practices fail to provide routine data about each provider’s clinical and financial performance. Make sure your group isn’t in this category. Develop a routine report of key metrics for your practice. Usually it is fine, and best, to provide to the whole group unblinded performance data about each individual hospitalist. For more information, check out “Measuring Hospitalist Performance: Metrics, Reports, and Dashboards” on the SHM website.

Don’t rely solely on consensus-based decision-making. Relying on consensus is reasonable for most decisions, if a group has about eight to 10 members. Larger groups need to decide how they’ll make decisions if consensus can’t be reached easily. And they need to have the discipline to stick to their agreed upon process, usually a vote. For more on this subject, see “Play by the Rules” in the December 2007 issue. 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.

I’m often asked about the attributes associated with high-functioning practices, so I thought I’d offer a list of them in this column. I’ve written entire columns about some of them in prior issues of The Hospitalist, so I will provide only brief commentary about each of them here.

I think this list can serve as a valuable frame of reference for any hospitalist practice, though it is geared more toward nonacademic settings. It is based on my own career as a hospitalist, which spans more than 20 years, and 15 years’ work as a consultant with nearly 300 institutions around the country. While I think my experience has given me a valuable perspective, others might reasonably omit some attributes listed here or add others.

I believe the single most important measure of a practice is excellent outcomes for its patients. That said, all of the attributes I describe here have more to do with excellent operational, or business, performance. It is possible for a practice to have all of these attributes and still provide disappointing clinical quality for its patients, but that seems really unlikely to me. And even a practice that provides superior clinical care probably won’t be able to do so for long without high-functioning business operations.

I think each of these attributes might be a cause of a practice’s excellent performance, but it is possible that some are a result of it. They are listed in no particular order.

A culture of practice ownership. The most important attribute associated with a high-functioning practice is that the providers in the group maintain a mindset of practice ownership. Even if you are employees of a hospital or other organization, you should think of yourselves as owners of the practice’s performance. When problems arise, you shouldn’t simply assume it is up to the practice leader alone, or an administrator outside of the practice to solve it. Instead, each doctor should always be thinking about how to improve the practice and taking action to make it happen. For more, see “Foster Ownership Culture” in the August 2008 issue, or visit my website and take a quiz (http://nelsonflores.com/html/quiz.html) to assess your ownership culture.

An effective group leader. All groups need a leader who takes the role seriously and doesn’t just view the job description as making the work schedule and attending more meetings than the other hospitalists. (Unfortunately, my experience is that this is precisely what a lot of leaders think.) Of the many markers that effective leaders display, one that seems pretty reliable to me is whether the group has routinely scheduled meetings, with an agenda provided in advance and minutes circulated a few days later. I wrote about effective group leaders in a June 2008 column titled “Follow the Money.”

Autonomy in making decisions. Even when you are an employee of a larger entity, the practice should be structured so that hospitalists have as much autonomy in decision-making as possible. For example, you should always be able to adjust the group’s work schedule (e.g. when shifts start and stop). You also should have a lot of say about your staffing and workload. The latter typically requires that the group is connected to the financial consequences of its choices, which usually means a compensation system based, to a significant degree, on productivity.

While still common for hospitalists, when the largest salary component is fixed, it will always follow that someone outside the group (e.g. an administrator at the hospital) will end up deciding how hard you will have to work to justify the promised salary. And the hospitalists will almost always find fault with that person’s decision—a recipe for constant frustration that inhibits the development of an ownership culture, among other things.

Each doctor sees the job as more than just providing care to patients. In addition to providing quality care for your patients, each hospitalist in the group must work to improve the performance of the hospital. This means work on clinical protocols, medical staff functions (e.g. credentials committee), documentation and coding for both CPT and DRG billing, etc.

Strong social connections. Every high-performing practice I’ve worked with is notable for the social connections between the hospitalists themselves, as well as between hospitalists and other physicians, nursing staff, and administrators. This shouldn’t be taken lightly. Social connections matter—a lot. And while the hospitalists in most groups feel reasonably connected with one another, too often they feel isolated from the other doctors and administrators at the hospital. I wrote some more thoughts about this in a June 2010 column, “Square Peg, Square Hole.”

Hospitalists actively involved in recruiting for their practice. The hospitalists themselves—at a minimum, the group leader—should be very involved in recruiting new members for the group. Professional recruiters are very valuable but can be a lot more effective if the hospitalists themselves participate in the process. The group will land better candidates that way. For more, see “We’re Hiring,” from July 2008.

Hospitalists know data about their performance. Too many practices fail to provide routine data about each provider’s clinical and financial performance. Make sure your group isn’t in this category. Develop a routine report of key metrics for your practice. Usually it is fine, and best, to provide to the whole group unblinded performance data about each individual hospitalist. For more information, check out “Measuring Hospitalist Performance: Metrics, Reports, and Dashboards” on the SHM website.

Don’t rely solely on consensus-based decision-making. Relying on consensus is reasonable for most decisions, if a group has about eight to 10 members. Larger groups need to decide how they’ll make decisions if consensus can’t be reached easily. And they need to have the discipline to stick to their agreed upon process, usually a vote. For more on this subject, see “Play by the Rules” in the December 2007 issue. 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.

I’m often asked about the attributes associated with high-functioning practices, so I thought I’d offer a list of them in this column. I’ve written entire columns about some of them in prior issues of The Hospitalist, so I will provide only brief commentary about each of them here.

I think this list can serve as a valuable frame of reference for any hospitalist practice, though it is geared more toward nonacademic settings. It is based on my own career as a hospitalist, which spans more than 20 years, and 15 years’ work as a consultant with nearly 300 institutions around the country. While I think my experience has given me a valuable perspective, others might reasonably omit some attributes listed here or add others.

I believe the single most important measure of a practice is excellent outcomes for its patients. That said, all of the attributes I describe here have more to do with excellent operational, or business, performance. It is possible for a practice to have all of these attributes and still provide disappointing clinical quality for its patients, but that seems really unlikely to me. And even a practice that provides superior clinical care probably won’t be able to do so for long without high-functioning business operations.

I think each of these attributes might be a cause of a practice’s excellent performance, but it is possible that some are a result of it. They are listed in no particular order.

A culture of practice ownership. The most important attribute associated with a high-functioning practice is that the providers in the group maintain a mindset of practice ownership. Even if you are employees of a hospital or other organization, you should think of yourselves as owners of the practice’s performance. When problems arise, you shouldn’t simply assume it is up to the practice leader alone, or an administrator outside of the practice to solve it. Instead, each doctor should always be thinking about how to improve the practice and taking action to make it happen. For more, see “Foster Ownership Culture” in the August 2008 issue, or visit my website and take a quiz (http://nelsonflores.com/html/quiz.html) to assess your ownership culture.

An effective group leader. All groups need a leader who takes the role seriously and doesn’t just view the job description as making the work schedule and attending more meetings than the other hospitalists. (Unfortunately, my experience is that this is precisely what a lot of leaders think.) Of the many markers that effective leaders display, one that seems pretty reliable to me is whether the group has routinely scheduled meetings, with an agenda provided in advance and minutes circulated a few days later. I wrote about effective group leaders in a June 2008 column titled “Follow the Money.”

Autonomy in making decisions. Even when you are an employee of a larger entity, the practice should be structured so that hospitalists have as much autonomy in decision-making as possible. For example, you should always be able to adjust the group’s work schedule (e.g. when shifts start and stop). You also should have a lot of say about your staffing and workload. The latter typically requires that the group is connected to the financial consequences of its choices, which usually means a compensation system based, to a significant degree, on productivity.

While still common for hospitalists, when the largest salary component is fixed, it will always follow that someone outside the group (e.g. an administrator at the hospital) will end up deciding how hard you will have to work to justify the promised salary. And the hospitalists will almost always find fault with that person’s decision—a recipe for constant frustration that inhibits the development of an ownership culture, among other things.

Each doctor sees the job as more than just providing care to patients. In addition to providing quality care for your patients, each hospitalist in the group must work to improve the performance of the hospital. This means work on clinical protocols, medical staff functions (e.g. credentials committee), documentation and coding for both CPT and DRG billing, etc.

Strong social connections. Every high-performing practice I’ve worked with is notable for the social connections between the hospitalists themselves, as well as between hospitalists and other physicians, nursing staff, and administrators. This shouldn’t be taken lightly. Social connections matter—a lot. And while the hospitalists in most groups feel reasonably connected with one another, too often they feel isolated from the other doctors and administrators at the hospital. I wrote some more thoughts about this in a June 2010 column, “Square Peg, Square Hole.”

Hospitalists actively involved in recruiting for their practice. The hospitalists themselves—at a minimum, the group leader—should be very involved in recruiting new members for the group. Professional recruiters are very valuable but can be a lot more effective if the hospitalists themselves participate in the process. The group will land better candidates that way. For more, see “We’re Hiring,” from July 2008.

Hospitalists know data about their performance. Too many practices fail to provide routine data about each provider’s clinical and financial performance. Make sure your group isn’t in this category. Develop a routine report of key metrics for your practice. Usually it is fine, and best, to provide to the whole group unblinded performance data about each individual hospitalist. For more information, check out “Measuring Hospitalist Performance: Metrics, Reports, and Dashboards” on the SHM website.

Don’t rely solely on consensus-based decision-making. Relying on consensus is reasonable for most decisions, if a group has about eight to 10 members. Larger groups need to decide how they’ll make decisions if consensus can’t be reached easily. And they need to have the discipline to stick to their agreed upon process, usually a vote. For more on this subject, see “Play by the Rules” in the December 2007 issue. 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.

I am leaving my current hospitalist company, and they are telling me that I have to pay them back the $10,000 sign-on/relocation bonus that was originally given to me. When I looked at the contract that I was given at the onset of our interview meetings, there was no clause stating a timeframe or any mention of me paying this back if I left the company. However, when I stated that I was giving my three-month notice, they said that their reasoning was based on a clause in the contract that says if I left before the end of the first year, then I would need to return the bonus.

I have worked for this company for nine months and moved to this city specifically for the purpose of this job. I didn’t believe what they were saying because I had read over the initial contract very well ... but then I compared that initial contract and the one that I actually signed. They changed some things that we never talked about; for instance, they changed the insurance from occurrence type to claims made, and they added a sentence at the end of the paragraph discussing the bonus.

I just think this was not very honest of them. Do I have any recourse? I wouldn’t even mind paying back a portion of it, but it makes me so mad that they obviously were being sneaky in changing the 14-page contract.

Cindy Nichols, MD

Austin, Texas

Dr. Hospitalist responds: I am sorry to hear of the troubles. When I read your note, I thought unfortunately of the English playwright Noel Coward, who once said, “It is discouraging to think how many people are shocked by honesty and how few by deceit.” Unfortunately, this happens all too commonly. Sounds like you are the unfortunate victim of nothing more than a bait-and-switch. I am not a lawyer and am not offering legal advice, but I suggest you contact a healthcare attorney familiar with employment contracts in Texas. But it would seem to me that since you did sign the contract, I suspect you have little recourse.

Although you are going to be out some money, I actually think this is more damaging to your employer than it is to you. You might have to repay the $10,000, but this could cost your employer much more. In today’s environment, in which anyone who has access to the Internet or a smartphone, one’s reputation can be reviled or revered at the whim of one’s keystroke. It does not seem to me that it makes much sense to engage in business in such a deceitful manner. Word can spread easily about a dishonest employer, even though the contract handed to you could have been the action of a single dishonest employee, rather than a corporate strategy. If the company is fortunate, you will take the time to let someone senior in the company know what happened to you. With this information, they can review their practice and assure that it doesn’t happen to another employee.

More likely, I expect that you are not likely to waste your time speaking with anyone else in the company, but that instead you will tell friends and colleagues about how you were victimized by this employer. It is a small world and this company’s image will suffer immeasurably from these water-cooler discussions. But I encourage you to take the high road: Contact a higher-up in the company and hold a professional discussion with them.

Best-case scenario: They respect your feedback and honor the original contract. Worst-case scenario: You walk away from people you really don’t want to work with, and you walk away with your dignity intact. TH

I am leaving my current hospitalist company, and they are telling me that I have to pay them back the $10,000 sign-on/relocation bonus that was originally given to me. When I looked at the contract that I was given at the onset of our interview meetings, there was no clause stating a timeframe or any mention of me paying this back if I left the company. However, when I stated that I was giving my three-month notice, they said that their reasoning was based on a clause in the contract that says if I left before the end of the first year, then I would need to return the bonus.

I have worked for this company for nine months and moved to this city specifically for the purpose of this job. I didn’t believe what they were saying because I had read over the initial contract very well ... but then I compared that initial contract and the one that I actually signed. They changed some things that we never talked about; for instance, they changed the insurance from occurrence type to claims made, and they added a sentence at the end of the paragraph discussing the bonus.

I just think this was not very honest of them. Do I have any recourse? I wouldn’t even mind paying back a portion of it, but it makes me so mad that they obviously were being sneaky in changing the 14-page contract.

Cindy Nichols, MD

Austin, Texas

Dr. Hospitalist responds: I am sorry to hear of the troubles. When I read your note, I thought unfortunately of the English playwright Noel Coward, who once said, “It is discouraging to think how many people are shocked by honesty and how few by deceit.” Unfortunately, this happens all too commonly. Sounds like you are the unfortunate victim of nothing more than a bait-and-switch. I am not a lawyer and am not offering legal advice, but I suggest you contact a healthcare attorney familiar with employment contracts in Texas. But it would seem to me that since you did sign the contract, I suspect you have little recourse.

Although you are going to be out some money, I actually think this is more damaging to your employer than it is to you. You might have to repay the $10,000, but this could cost your employer much more. In today’s environment, in which anyone who has access to the Internet or a smartphone, one’s reputation can be reviled or revered at the whim of one’s keystroke. It does not seem to me that it makes much sense to engage in business in such a deceitful manner. Word can spread easily about a dishonest employer, even though the contract handed to you could have been the action of a single dishonest employee, rather than a corporate strategy. If the company is fortunate, you will take the time to let someone senior in the company know what happened to you. With this information, they can review their practice and assure that it doesn’t happen to another employee.

More likely, I expect that you are not likely to waste your time speaking with anyone else in the company, but that instead you will tell friends and colleagues about how you were victimized by this employer. It is a small world and this company’s image will suffer immeasurably from these water-cooler discussions. But I encourage you to take the high road: Contact a higher-up in the company and hold a professional discussion with them.

Best-case scenario: They respect your feedback and honor the original contract. Worst-case scenario: You walk away from people you really don’t want to work with, and you walk away with your dignity intact. TH

I am leaving my current hospitalist company, and they are telling me that I have to pay them back the $10,000 sign-on/relocation bonus that was originally given to me. When I looked at the contract that I was given at the onset of our interview meetings, there was no clause stating a timeframe or any mention of me paying this back if I left the company. However, when I stated that I was giving my three-month notice, they said that their reasoning was based on a clause in the contract that says if I left before the end of the first year, then I would need to return the bonus.

I have worked for this company for nine months and moved to this city specifically for the purpose of this job. I didn’t believe what they were saying because I had read over the initial contract very well ... but then I compared that initial contract and the one that I actually signed. They changed some things that we never talked about; for instance, they changed the insurance from occurrence type to claims made, and they added a sentence at the end of the paragraph discussing the bonus.

I just think this was not very honest of them. Do I have any recourse? I wouldn’t even mind paying back a portion of it, but it makes me so mad that they obviously were being sneaky in changing the 14-page contract.

Cindy Nichols, MD

Austin, Texas

Dr. Hospitalist responds: I am sorry to hear of the troubles. When I read your note, I thought unfortunately of the English playwright Noel Coward, who once said, “It is discouraging to think how many people are shocked by honesty and how few by deceit.” Unfortunately, this happens all too commonly. Sounds like you are the unfortunate victim of nothing more than a bait-and-switch. I am not a lawyer and am not offering legal advice, but I suggest you contact a healthcare attorney familiar with employment contracts in Texas. But it would seem to me that since you did sign the contract, I suspect you have little recourse.

Although you are going to be out some money, I actually think this is more damaging to your employer than it is to you. You might have to repay the $10,000, but this could cost your employer much more. In today’s environment, in which anyone who has access to the Internet or a smartphone, one’s reputation can be reviled or revered at the whim of one’s keystroke. It does not seem to me that it makes much sense to engage in business in such a deceitful manner. Word can spread easily about a dishonest employer, even though the contract handed to you could have been the action of a single dishonest employee, rather than a corporate strategy. If the company is fortunate, you will take the time to let someone senior in the company know what happened to you. With this information, they can review their practice and assure that it doesn’t happen to another employee.

More likely, I expect that you are not likely to waste your time speaking with anyone else in the company, but that instead you will tell friends and colleagues about how you were victimized by this employer. It is a small world and this company’s image will suffer immeasurably from these water-cooler discussions. But I encourage you to take the high road: Contact a higher-up in the company and hold a professional discussion with them.

Best-case scenario: They respect your feedback and honor the original contract. Worst-case scenario: You walk away from people you really don’t want to work with, and you walk away with your dignity intact. TH

Necessity, as they say, is the mother of invention, and the growing focus on the need for high-quality and cost-effective care is bringing a host of new innovations to light. One that hospitalists are likely to hear about far more about is the evolving role of an “extensivist,” an inpatient provider who ventures to outpatient settings to assist with care transitions.

In many ways, the expanding discussion of what extensivists are and do reflects the success of hospitalists in coordinating inpatient care and improving such metrics as length of stay (LOS). Why should that coordination end upon discharge? healthcare experts have wondered. Instead of a pure hospitalist system, could the experience and training of hospitalists be extended to include transitional or interim settings that provide a safety net between the hospital and a primary-care physician (PCP)? Might that improved inpatient-outpatient coordination help with other metrics, such as reduced rehospitalizations (see “All Aboard,” p. 1)?

We write an order of discharge to a skilled nursing facility, and patients go off into the community and we have no idea where they’re going, who they’re going to, what’s the quality of care out there, what’s the capacity of care.—Adam Singer, MD, CEO, IPC: The Hospitalist Co., North Hollywood, Calif.

One tangible result of those questions has been the growth of high-risk clinics. Hospitalist programs can provide clinic referrals for discharged patients who still require hands-on care, while PCPs can likewise refer some of their more complex patients. The clinic, then, becomes an alternative to hospitalization, or a preventive measure to avoid rehospitalization.

Philip Sanger, MD, founder and former CEO of Houston-based Inpatient Medical Services (now Intercede Health), is credited with one of the first uses of the term “extensivist.” Initially, it only described a hospitalist or other care provider who sees high-risk patients in an outpatient clinic.

Writing in Managed Healthcare Executive in 2002, Dr. Sanger explained: “To move from generally sick to generally well, high-risk patients need something extra—more attention than a busy PCP can offer [and] more individualized care than most protocol-driven disease management programs can provide. A high-risk clinic system is one way to fill this care gap. Also referred to as transitional-care clinics, these outpatient clinics focus on preventing hospital admissions and stabilizing high-risk patients.”¹

Measured Improvements

Adam Singer, MD, CEO of North Hollywood, Calif.-based IPC: The Hospitalist Co., says this extensivist model provides a respite for hospitalists, who typically spend a month at a time in these transitional clinics before heading back into the fray of the hospital. As hospitals, independent physician associations, and managed-care organizations try out new models of care, though, the definition of an extensivist has broadened to include providers in a range of outpatient settings, such as skilled nursing facilities, assistant living communities, and even home health services. California’s CareMore Medicare Advantage plan, in particular, has been cited by the Agency for Healthcare Research and Quality (AHRQ) for using hospitalists as extensivists in both outpatient clinics and skilled nursing facilities to reduce hospital readmission rates, LOS, and inpatient resource use.

The CareMore model reduces the caseload of its hospitalists to about six or eight patients per half-day, giving doctors more time to talk to patients and their family members. Based on those conversations, the extensivist works with a case manager to provide needed resources to each patient after discharge. The doctors also spend roughly half of each day in clinics seeing their own recently discharged patients, and one or two days each week in a skilled nursing facility to visit patients transferred from the hospital (for more details, visit www.innovations.ahrq.gov/content.aspx?id=2903).

Average inpatient LOS among the plan’s 44,000 members dipped to 3.2 days, compared with 5.8 days for Medicare fee-for-service providers and 4.5 days for traditional HM programs in the state. Last April, CareMore’s 30-day readmission rate averaged 13.4%, compared with a 19.6% rate for Medicare.

Baltimore-based Bravo Health has begun opening its own transitional advanced-care centers for members of its Medicare Advantage program, offering case management for complex conditions and immediate care when a PCP is unavailable. Another model has been advanced through team approaches practiced by the likes of Kaiser Permanente, though hospitalists aren’t necessarily the ones providing outpatient follow-up care. No matter what the model is called, Dr. Singer says, the main point is the same: “trying to connect the dots so that we get patients continuing to get better along the continuum without having to be readmitted.”

In December, IPC did some more dot-connecting of its own with its announced acquisition of Senior Care of Colorado, which operates more than 200 geriatric-care facilities in the Denver area. Don Murphy, MD, IPC’s practice group leader for Senior Care of Colorado, says the model emphasizes a continuum of care and information flow from hospitalists in the hospital to affiliated providers in skilled nursing facilities and other outpatient settings. “We think that model, where we tie everything together, will be one of the best that we can do,” Dr. Murphy says.

From Dr. Singer’s perspective, the growing opportunities have sprung from efforts to address a persistent challenge. “We write an order of discharge to a skilled nursing facility, and patients go off into the community and we have no idea where they’re going, who they’re going to, what’s the quality of care out there, what’s the capacity of care,” he says. One of the central ideas of healthcare reform—creating true accountability around an episode of care—will require doctors to be linked “not just during what used to be the episode of care in the hospital,” he adds, “but throughout the continuum until that patient is really returned healthy back to wherever they’re going to be living.”

With a new emphasis on avoidable hospitalizations, hospitals will increasingly need to team up with other providers to avoid fragmentation of care. Using extensivists to help avoid gaps might be a good fit for accountable-care organizations, and Dr. Murphy says the process may be easier for big systems, such as Ochsner in New Orleans or the Cleveland Clinic, which are working in a confined geographic area with a defined patient population.

“The real challenge will be those of us out there in larger metropolitan areas where we’re not under the roof of one big conglomerate but still having to work together creatively and effectively to smooth the continuum,” Dr. Singer says.

Emerging Trends

Other trends are making inpatient-outpatient partnerships, whether formal or informal, an increasingly necessary part of providing high-quality healthcare. “We are seeing folks come out of the hospitals who 30 years ago clearly would have been in the hospital for a prolonged stay,” Dr. Murphy says. “A lot of these [patients], instead of going to SNFs, are going back to their homes and to assisted living with additional services; they require a lot of follow-up.”

Dr. Singer says he’s seeing another trend in which PCPs are likewise transitioning to newly created extensivist roles in sub-acute settings such as nursing homes. The position, he says, offers the attraction of a high-impact, longer-term relationship with patients without the high overhead of standalone clinics. The blurring of lines between outpatient and inpatient providers has created questions for hospitalists, too. For example, at what point does a hospitalist working much of the time in an outpatient clinic or skilled nursing facility no longer fit the traditional definition of a hospitalist? Does that detract from the doctor’s hospital duties? TH

Bryn Nelson is a freelance medical writer based in Seattle.

Reference

1. Sanger, P. Health plans juggle precarious patients. Managed Healthcare Executive. 2002:40-41.

Necessity, as they say, is the mother of invention, and the growing focus on the need for high-quality and cost-effective care is bringing a host of new innovations to light. One that hospitalists are likely to hear about far more about is the evolving role of an “extensivist,” an inpatient provider who ventures to outpatient settings to assist with care transitions.

In many ways, the expanding discussion of what extensivists are and do reflects the success of hospitalists in coordinating inpatient care and improving such metrics as length of stay (LOS). Why should that coordination end upon discharge? healthcare experts have wondered. Instead of a pure hospitalist system, could the experience and training of hospitalists be extended to include transitional or interim settings that provide a safety net between the hospital and a primary-care physician (PCP)? Might that improved inpatient-outpatient coordination help with other metrics, such as reduced rehospitalizations (see “All Aboard,” p. 1)?

We write an order of discharge to a skilled nursing facility, and patients go off into the community and we have no idea where they’re going, who they’re going to, what’s the quality of care out there, what’s the capacity of care.—Adam Singer, MD, CEO, IPC: The Hospitalist Co., North Hollywood, Calif.

One tangible result of those questions has been the growth of high-risk clinics. Hospitalist programs can provide clinic referrals for discharged patients who still require hands-on care, while PCPs can likewise refer some of their more complex patients. The clinic, then, becomes an alternative to hospitalization, or a preventive measure to avoid rehospitalization.

Philip Sanger, MD, founder and former CEO of Houston-based Inpatient Medical Services (now Intercede Health), is credited with one of the first uses of the term “extensivist.” Initially, it only described a hospitalist or other care provider who sees high-risk patients in an outpatient clinic.

Writing in Managed Healthcare Executive in 2002, Dr. Sanger explained: “To move from generally sick to generally well, high-risk patients need something extra—more attention than a busy PCP can offer [and] more individualized care than most protocol-driven disease management programs can provide. A high-risk clinic system is one way to fill this care gap. Also referred to as transitional-care clinics, these outpatient clinics focus on preventing hospital admissions and stabilizing high-risk patients.”¹

Measured Improvements

Adam Singer, MD, CEO of North Hollywood, Calif.-based IPC: The Hospitalist Co., says this extensivist model provides a respite for hospitalists, who typically spend a month at a time in these transitional clinics before heading back into the fray of the hospital. As hospitals, independent physician associations, and managed-care organizations try out new models of care, though, the definition of an extensivist has broadened to include providers in a range of outpatient settings, such as skilled nursing facilities, assistant living communities, and even home health services. California’s CareMore Medicare Advantage plan, in particular, has been cited by the Agency for Healthcare Research and Quality (AHRQ) for using hospitalists as extensivists in both outpatient clinics and skilled nursing facilities to reduce hospital readmission rates, LOS, and inpatient resource use.

The CareMore model reduces the caseload of its hospitalists to about six or eight patients per half-day, giving doctors more time to talk to patients and their family members. Based on those conversations, the extensivist works with a case manager to provide needed resources to each patient after discharge. The doctors also spend roughly half of each day in clinics seeing their own recently discharged patients, and one or two days each week in a skilled nursing facility to visit patients transferred from the hospital (for more details, visit www.innovations.ahrq.gov/content.aspx?id=2903).

Average inpatient LOS among the plan’s 44,000 members dipped to 3.2 days, compared with 5.8 days for Medicare fee-for-service providers and 4.5 days for traditional HM programs in the state. Last April, CareMore’s 30-day readmission rate averaged 13.4%, compared with a 19.6% rate for Medicare.

Baltimore-based Bravo Health has begun opening its own transitional advanced-care centers for members of its Medicare Advantage program, offering case management for complex conditions and immediate care when a PCP is unavailable. Another model has been advanced through team approaches practiced by the likes of Kaiser Permanente, though hospitalists aren’t necessarily the ones providing outpatient follow-up care. No matter what the model is called, Dr. Singer says, the main point is the same: “trying to connect the dots so that we get patients continuing to get better along the continuum without having to be readmitted.”

In December, IPC did some more dot-connecting of its own with its announced acquisition of Senior Care of Colorado, which operates more than 200 geriatric-care facilities in the Denver area. Don Murphy, MD, IPC’s practice group leader for Senior Care of Colorado, says the model emphasizes a continuum of care and information flow from hospitalists in the hospital to affiliated providers in skilled nursing facilities and other outpatient settings. “We think that model, where we tie everything together, will be one of the best that we can do,” Dr. Murphy says.

From Dr. Singer’s perspective, the growing opportunities have sprung from efforts to address a persistent challenge. “We write an order of discharge to a skilled nursing facility, and patients go off into the community and we have no idea where they’re going, who they’re going to, what’s the quality of care out there, what’s the capacity of care,” he says. One of the central ideas of healthcare reform—creating true accountability around an episode of care—will require doctors to be linked “not just during what used to be the episode of care in the hospital,” he adds, “but throughout the continuum until that patient is really returned healthy back to wherever they’re going to be living.”

With a new emphasis on avoidable hospitalizations, hospitals will increasingly need to team up with other providers to avoid fragmentation of care. Using extensivists to help avoid gaps might be a good fit for accountable-care organizations, and Dr. Murphy says the process may be easier for big systems, such as Ochsner in New Orleans or the Cleveland Clinic, which are working in a confined geographic area with a defined patient population.

“The real challenge will be those of us out there in larger metropolitan areas where we’re not under the roof of one big conglomerate but still having to work together creatively and effectively to smooth the continuum,” Dr. Singer says.

Emerging Trends

Other trends are making inpatient-outpatient partnerships, whether formal or informal, an increasingly necessary part of providing high-quality healthcare. “We are seeing folks come out of the hospitals who 30 years ago clearly would have been in the hospital for a prolonged stay,” Dr. Murphy says. “A lot of these [patients], instead of going to SNFs, are going back to their homes and to assisted living with additional services; they require a lot of follow-up.”

Dr. Singer says he’s seeing another trend in which PCPs are likewise transitioning to newly created extensivist roles in sub-acute settings such as nursing homes. The position, he says, offers the attraction of a high-impact, longer-term relationship with patients without the high overhead of standalone clinics. The blurring of lines between outpatient and inpatient providers has created questions for hospitalists, too. For example, at what point does a hospitalist working much of the time in an outpatient clinic or skilled nursing facility no longer fit the traditional definition of a hospitalist? Does that detract from the doctor’s hospital duties? TH

Bryn Nelson is a freelance medical writer based in Seattle.

Reference

1. Sanger, P. Health plans juggle precarious patients. Managed Healthcare Executive. 2002:40-41.

Necessity, as they say, is the mother of invention, and the growing focus on the need for high-quality and cost-effective care is bringing a host of new innovations to light. One that hospitalists are likely to hear about far more about is the evolving role of an “extensivist,” an inpatient provider who ventures to outpatient settings to assist with care transitions.

In many ways, the expanding discussion of what extensivists are and do reflects the success of hospitalists in coordinating inpatient care and improving such metrics as length of stay (LOS). Why should that coordination end upon discharge? healthcare experts have wondered. Instead of a pure hospitalist system, could the experience and training of hospitalists be extended to include transitional or interim settings that provide a safety net between the hospital and a primary-care physician (PCP)? Might that improved inpatient-outpatient coordination help with other metrics, such as reduced rehospitalizations (see “All Aboard,” p. 1)?

We write an order of discharge to a skilled nursing facility, and patients go off into the community and we have no idea where they’re going, who they’re going to, what’s the quality of care out there, what’s the capacity of care.—Adam Singer, MD, CEO, IPC: The Hospitalist Co., North Hollywood, Calif.

One tangible result of those questions has been the growth of high-risk clinics. Hospitalist programs can provide clinic referrals for discharged patients who still require hands-on care, while PCPs can likewise refer some of their more complex patients. The clinic, then, becomes an alternative to hospitalization, or a preventive measure to avoid rehospitalization.

Philip Sanger, MD, founder and former CEO of Houston-based Inpatient Medical Services (now Intercede Health), is credited with one of the first uses of the term “extensivist.” Initially, it only described a hospitalist or other care provider who sees high-risk patients in an outpatient clinic.

Writing in Managed Healthcare Executive in 2002, Dr. Sanger explained: “To move from generally sick to generally well, high-risk patients need something extra—more attention than a busy PCP can offer [and] more individualized care than most protocol-driven disease management programs can provide. A high-risk clinic system is one way to fill this care gap. Also referred to as transitional-care clinics, these outpatient clinics focus on preventing hospital admissions and stabilizing high-risk patients.”¹

Measured Improvements

Adam Singer, MD, CEO of North Hollywood, Calif.-based IPC: The Hospitalist Co., says this extensivist model provides a respite for hospitalists, who typically spend a month at a time in these transitional clinics before heading back into the fray of the hospital. As hospitals, independent physician associations, and managed-care organizations try out new models of care, though, the definition of an extensivist has broadened to include providers in a range of outpatient settings, such as skilled nursing facilities, assistant living communities, and even home health services. California’s CareMore Medicare Advantage plan, in particular, has been cited by the Agency for Healthcare Research and Quality (AHRQ) for using hospitalists as extensivists in both outpatient clinics and skilled nursing facilities to reduce hospital readmission rates, LOS, and inpatient resource use.

The CareMore model reduces the caseload of its hospitalists to about six or eight patients per half-day, giving doctors more time to talk to patients and their family members. Based on those conversations, the extensivist works with a case manager to provide needed resources to each patient after discharge. The doctors also spend roughly half of each day in clinics seeing their own recently discharged patients, and one or two days each week in a skilled nursing facility to visit patients transferred from the hospital (for more details, visit www.innovations.ahrq.gov/content.aspx?id=2903).

Average inpatient LOS among the plan’s 44,000 members dipped to 3.2 days, compared with 5.8 days for Medicare fee-for-service providers and 4.5 days for traditional HM programs in the state. Last April, CareMore’s 30-day readmission rate averaged 13.4%, compared with a 19.6% rate for Medicare.

Baltimore-based Bravo Health has begun opening its own transitional advanced-care centers for members of its Medicare Advantage program, offering case management for complex conditions and immediate care when a PCP is unavailable. Another model has been advanced through team approaches practiced by the likes of Kaiser Permanente, though hospitalists aren’t necessarily the ones providing outpatient follow-up care. No matter what the model is called, Dr. Singer says, the main point is the same: “trying to connect the dots so that we get patients continuing to get better along the continuum without having to be readmitted.”

In December, IPC did some more dot-connecting of its own with its announced acquisition of Senior Care of Colorado, which operates more than 200 geriatric-care facilities in the Denver area. Don Murphy, MD, IPC’s practice group leader for Senior Care of Colorado, says the model emphasizes a continuum of care and information flow from hospitalists in the hospital to affiliated providers in skilled nursing facilities and other outpatient settings. “We think that model, where we tie everything together, will be one of the best that we can do,” Dr. Murphy says.

From Dr. Singer’s perspective, the growing opportunities have sprung from efforts to address a persistent challenge. “We write an order of discharge to a skilled nursing facility, and patients go off into the community and we have no idea where they’re going, who they’re going to, what’s the quality of care out there, what’s the capacity of care,” he says. One of the central ideas of healthcare reform—creating true accountability around an episode of care—will require doctors to be linked “not just during what used to be the episode of care in the hospital,” he adds, “but throughout the continuum until that patient is really returned healthy back to wherever they’re going to be living.”

With a new emphasis on avoidable hospitalizations, hospitals will increasingly need to team up with other providers to avoid fragmentation of care. Using extensivists to help avoid gaps might be a good fit for accountable-care organizations, and Dr. Murphy says the process may be easier for big systems, such as Ochsner in New Orleans or the Cleveland Clinic, which are working in a confined geographic area with a defined patient population.

“The real challenge will be those of us out there in larger metropolitan areas where we’re not under the roof of one big conglomerate but still having to work together creatively and effectively to smooth the continuum,” Dr. Singer says.

Emerging Trends

Other trends are making inpatient-outpatient partnerships, whether formal or informal, an increasingly necessary part of providing high-quality healthcare. “We are seeing folks come out of the hospitals who 30 years ago clearly would have been in the hospital for a prolonged stay,” Dr. Murphy says. “A lot of these [patients], instead of going to SNFs, are going back to their homes and to assisted living with additional services; they require a lot of follow-up.”

Dr. Singer says he’s seeing another trend in which PCPs are likewise transitioning to newly created extensivist roles in sub-acute settings such as nursing homes. The position, he says, offers the attraction of a high-impact, longer-term relationship with patients without the high overhead of standalone clinics. The blurring of lines between outpatient and inpatient providers has created questions for hospitalists, too. For example, at what point does a hospitalist working much of the time in an outpatient clinic or skilled nursing facility no longer fit the traditional definition of a hospitalist? Does that detract from the doctor’s hospital duties? TH

Bryn Nelson is a freelance medical writer based in Seattle.

Reference

1. Sanger, P. Health plans juggle precarious patients. Managed Healthcare Executive. 2002:40-41.

I like to ask laypeople what they think “hospitalist” means. For years, I was confident that they had never heard the term, but now my question is more often met with an accurate response.

A hotel desk clerk in 1998 actually made one of the cleverest guesses I’ve ever heard. For the whole day, she and her colleagues had in front of them a sign that read “Hospitalist Meeting in the Ballroom,” which got them talking about what in the world a hospitalist is. Seeing from my badge that I was attending that meeting, she asked me what the term meant, but she first gamely provided her best guess: “Someone who makes lists of hospitals.”

There seems to be no end to the number of healthcare-related nouns and verbs to which someone attaches the suffix “ist.” Some days I request so many consults that I’m just a “referralist” (one who refers patients; surely this is a term we can do without). But don’t let the headline of this column confuse you: I really am addressing the lists used to determine which doctor to refer patients to.

Hospitalist Referrals

The first of two common referral lists for hospitalists is a directory of primary-care physicians (PCPs) and clinics, as well as some other providers that refer patients to the hospitalist. Nearly all hospitalist groups maintain such a list, and they might apply a variety of terms such as “subscriber” (which refers to hospitalists) and “nonsubscriber” physicians.

Because most HM groups care for patients who come from all or nearly all of the PCPs in an area, it is often simpler to just create a short list of those providers who don’t refer to the hospitalists. In many hospitals, there are just four or five providers on that list. ED providers are the ones who most often access this list. When visiting other hospitals, I often see a paper copy of the list taped up at the provider workstations in the ED.

Consult Who?

The other, and much less common, type of referral list governs which doctors the hospitalists are to consult. There are two strategies that come up when thinking about this kind of list.

Do what the ED doctors do. ED physicians typically are constrained by the list of on-call physicians for each specialty, and are to always consult that doctor rather than another. For example, the ED doctor is required to consult Dr. Taylor for any patient in need of a general surgeon and doesn’t have a prior relationship with one. Tomorrow, the ED doctor is required to consult Dr. Simon. Dr. Taylor and Dr. Simon are to be contacted because they are the ones on call for the ED those days. Even if the ED doctor would rather consult Dr. Simon today (maybe she is more able, affable, and available than Dr. Taylor), that isn’t an option, because it is Dr. Taylor’s name on the ED on-call roster today.

Each PCP creates a referral list for hospitalists to follow. New hospitalist practices often agree to follow the consulting patterns of each referring PCP. This can increase PCP acceptance of the HM model, and after all, the GI doctor consulted by the hospitalist during the few days in the hospital is the same one who will be working with the PCP when the patient has outpatient issues requiring GI specialty care. This usually means that the hospitalist carries a list of each PCP, and which GI doctor, orthopedist, etc., that particular PCP likes to consult. When the hospitalist needs an ortho consult, she first verifies the PCP this patient sees, then pulls out the list to see the orthopedist(s) that PCP prefers.

In most settings, either form of a mandated referral list is a poor system for hospitalists and is best avoided. Instead, the hospitalists should be free to deviate from the ED call list as they see fit. And while they should be attentive to the consulting preferences of each PCP, it is best not to promise the PCPs that their preference will always be followed. Providing the hospitalists this latitude means they can tailor the choice of consultant to the patient’s needs and the level of service (i.e. able, affable, available) each provides. And, at least in theory, when there are competing providers in a given specialty, they will have an incentive to provide better service to the hospitalist as a way of ensuring future referrals.

Practical Considerations

Even though I think it is optimal for hospitalists to have a lot of latitude in which doctors they consult, there are some practical considerations to keep in mind. For example, if the patient’s PCP is in a group that also has surgeons, it will be best to call one of them, and not a competing surgeon, when the patient has surgical needs. And the hospitalists as a group should usually make some effort to avoid never consulting a particular provider or group, as that could lead the “blackballed” doctor or group to complain enough that the medical staff or hospital leadership might force the hospitalists to follow the ED call roster when choosing referrals.

The number of physicians seeking hospital employment, which is steadily increasing these days, will in many settings increase sensitivities around referral patterns. For example, if your hospital has had three competing general surgery groups and one chooses to become hospital-employed, then the other two groups are likely to worry a lot that the hospitalists might be directed by the hospital to preferentially refer to the newly employed surgeons. Even if your hospitalist group has never had any sort of encouragement to do this, it could be very hard to convince the non-hospital-employed surgeons of this. This could become such a sensitive issue that it might be necessary to carefully track the number of referrals to each surgical group.

And to prevent arguments like “You just consult us on the bad or uninsured patients,” you might also need to track the nature of the patient’s problem and insurance status, and whether the referral led to a procedure. The best approach will be to try to prevent these sorts of things from coming up by maintaining good communication and relations with other physician groups and thinking deliberately about your referral patterns. 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 course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program.” This column represents his views and is not intended to reflect an official position of SHM.

I like to ask laypeople what they think “hospitalist” means. For years, I was confident that they had never heard the term, but now my question is more often met with an accurate response.

A hotel desk clerk in 1998 actually made one of the cleverest guesses I’ve ever heard. For the whole day, she and her colleagues had in front of them a sign that read “Hospitalist Meeting in the Ballroom,” which got them talking about what in the world a hospitalist is. Seeing from my badge that I was attending that meeting, she asked me what the term meant, but she first gamely provided her best guess: “Someone who makes lists of hospitals.”

There seems to be no end to the number of healthcare-related nouns and verbs to which someone attaches the suffix “ist.” Some days I request so many consults that I’m just a “referralist” (one who refers patients; surely this is a term we can do without). But don’t let the headline of this column confuse you: I really am addressing the lists used to determine which doctor to refer patients to.

Hospitalist Referrals

The first of two common referral lists for hospitalists is a directory of primary-care physicians (PCPs) and clinics, as well as some other providers that refer patients to the hospitalist. Nearly all hospitalist groups maintain such a list, and they might apply a variety of terms such as “subscriber” (which refers to hospitalists) and “nonsubscriber” physicians.

Because most HM groups care for patients who come from all or nearly all of the PCPs in an area, it is often simpler to just create a short list of those providers who don’t refer to the hospitalists. In many hospitals, there are just four or five providers on that list. ED providers are the ones who most often access this list. When visiting other hospitals, I often see a paper copy of the list taped up at the provider workstations in the ED.

Consult Who?

The other, and much less common, type of referral list governs which doctors the hospitalists are to consult. There are two strategies that come up when thinking about this kind of list.

Do what the ED doctors do. ED physicians typically are constrained by the list of on-call physicians for each specialty, and are to always consult that doctor rather than another. For example, the ED doctor is required to consult Dr. Taylor for any patient in need of a general surgeon and doesn’t have a prior relationship with one. Tomorrow, the ED doctor is required to consult Dr. Simon. Dr. Taylor and Dr. Simon are to be contacted because they are the ones on call for the ED those days. Even if the ED doctor would rather consult Dr. Simon today (maybe she is more able, affable, and available than Dr. Taylor), that isn’t an option, because it is Dr. Taylor’s name on the ED on-call roster today.

Each PCP creates a referral list for hospitalists to follow. New hospitalist practices often agree to follow the consulting patterns of each referring PCP. This can increase PCP acceptance of the HM model, and after all, the GI doctor consulted by the hospitalist during the few days in the hospital is the same one who will be working with the PCP when the patient has outpatient issues requiring GI specialty care. This usually means that the hospitalist carries a list of each PCP, and which GI doctor, orthopedist, etc., that particular PCP likes to consult. When the hospitalist needs an ortho consult, she first verifies the PCP this patient sees, then pulls out the list to see the orthopedist(s) that PCP prefers.

In most settings, either form of a mandated referral list is a poor system for hospitalists and is best avoided. Instead, the hospitalists should be free to deviate from the ED call list as they see fit. And while they should be attentive to the consulting preferences of each PCP, it is best not to promise the PCPs that their preference will always be followed. Providing the hospitalists this latitude means they can tailor the choice of consultant to the patient’s needs and the level of service (i.e. able, affable, available) each provides. And, at least in theory, when there are competing providers in a given specialty, they will have an incentive to provide better service to the hospitalist as a way of ensuring future referrals.

Practical Considerations

Even though I think it is optimal for hospitalists to have a lot of latitude in which doctors they consult, there are some practical considerations to keep in mind. For example, if the patient’s PCP is in a group that also has surgeons, it will be best to call one of them, and not a competing surgeon, when the patient has surgical needs. And the hospitalists as a group should usually make some effort to avoid never consulting a particular provider or group, as that could lead the “blackballed” doctor or group to complain enough that the medical staff or hospital leadership might force the hospitalists to follow the ED call roster when choosing referrals.

The number of physicians seeking hospital employment, which is steadily increasing these days, will in many settings increase sensitivities around referral patterns. For example, if your hospital has had three competing general surgery groups and one chooses to become hospital-employed, then the other two groups are likely to worry a lot that the hospitalists might be directed by the hospital to preferentially refer to the newly employed surgeons. Even if your hospitalist group has never had any sort of encouragement to do this, it could be very hard to convince the non-hospital-employed surgeons of this. This could become such a sensitive issue that it might be necessary to carefully track the number of referrals to each surgical group.

And to prevent arguments like “You just consult us on the bad or uninsured patients,” you might also need to track the nature of the patient’s problem and insurance status, and whether the referral led to a procedure. The best approach will be to try to prevent these sorts of things from coming up by maintaining good communication and relations with other physician groups and thinking deliberately about your referral patterns. 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 course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program.” This column represents his views and is not intended to reflect an official position of SHM.

I like to ask laypeople what they think “hospitalist” means. For years, I was confident that they had never heard the term, but now my question is more often met with an accurate response.

A hotel desk clerk in 1998 actually made one of the cleverest guesses I’ve ever heard. For the whole day, she and her colleagues had in front of them a sign that read “Hospitalist Meeting in the Ballroom,” which got them talking about what in the world a hospitalist is. Seeing from my badge that I was attending that meeting, she asked me what the term meant, but she first gamely provided her best guess: “Someone who makes lists of hospitals.”

There seems to be no end to the number of healthcare-related nouns and verbs to which someone attaches the suffix “ist.” Some days I request so many consults that I’m just a “referralist” (one who refers patients; surely this is a term we can do without). But don’t let the headline of this column confuse you: I really am addressing the lists used to determine which doctor to refer patients to.

Hospitalist Referrals

The first of two common referral lists for hospitalists is a directory of primary-care physicians (PCPs) and clinics, as well as some other providers that refer patients to the hospitalist. Nearly all hospitalist groups maintain such a list, and they might apply a variety of terms such as “subscriber” (which refers to hospitalists) and “nonsubscriber” physicians.

Because most HM groups care for patients who come from all or nearly all of the PCPs in an area, it is often simpler to just create a short list of those providers who don’t refer to the hospitalists. In many hospitals, there are just four or five providers on that list. ED providers are the ones who most often access this list. When visiting other hospitals, I often see a paper copy of the list taped up at the provider workstations in the ED.

Consult Who?

The other, and much less common, type of referral list governs which doctors the hospitalists are to consult. There are two strategies that come up when thinking about this kind of list.

Do what the ED doctors do. ED physicians typically are constrained by the list of on-call physicians for each specialty, and are to always consult that doctor rather than another. For example, the ED doctor is required to consult Dr. Taylor for any patient in need of a general surgeon and doesn’t have a prior relationship with one. Tomorrow, the ED doctor is required to consult Dr. Simon. Dr. Taylor and Dr. Simon are to be contacted because they are the ones on call for the ED those days. Even if the ED doctor would rather consult Dr. Simon today (maybe she is more able, affable, and available than Dr. Taylor), that isn’t an option, because it is Dr. Taylor’s name on the ED on-call roster today.

Each PCP creates a referral list for hospitalists to follow. New hospitalist practices often agree to follow the consulting patterns of each referring PCP. This can increase PCP acceptance of the HM model, and after all, the GI doctor consulted by the hospitalist during the few days in the hospital is the same one who will be working with the PCP when the patient has outpatient issues requiring GI specialty care. This usually means that the hospitalist carries a list of each PCP, and which GI doctor, orthopedist, etc., that particular PCP likes to consult. When the hospitalist needs an ortho consult, she first verifies the PCP this patient sees, then pulls out the list to see the orthopedist(s) that PCP prefers.

In most settings, either form of a mandated referral list is a poor system for hospitalists and is best avoided. Instead, the hospitalists should be free to deviate from the ED call list as they see fit. And while they should be attentive to the consulting preferences of each PCP, it is best not to promise the PCPs that their preference will always be followed. Providing the hospitalists this latitude means they can tailor the choice of consultant to the patient’s needs and the level of service (i.e. able, affable, available) each provides. And, at least in theory, when there are competing providers in a given specialty, they will have an incentive to provide better service to the hospitalist as a way of ensuring future referrals.

Practical Considerations

Even though I think it is optimal for hospitalists to have a lot of latitude in which doctors they consult, there are some practical considerations to keep in mind. For example, if the patient’s PCP is in a group that also has surgeons, it will be best to call one of them, and not a competing surgeon, when the patient has surgical needs. And the hospitalists as a group should usually make some effort to avoid never consulting a particular provider or group, as that could lead the “blackballed” doctor or group to complain enough that the medical staff or hospital leadership might force the hospitalists to follow the ED call roster when choosing referrals.

The number of physicians seeking hospital employment, which is steadily increasing these days, will in many settings increase sensitivities around referral patterns. For example, if your hospital has had three competing general surgery groups and one chooses to become hospital-employed, then the other two groups are likely to worry a lot that the hospitalists might be directed by the hospital to preferentially refer to the newly employed surgeons. Even if your hospitalist group has never had any sort of encouragement to do this, it could be very hard to convince the non-hospital-employed surgeons of this. This could become such a sensitive issue that it might be necessary to carefully track the number of referrals to each surgical group.

And to prevent arguments like “You just consult us on the bad or uninsured patients,” you might also need to track the nature of the patient’s problem and insurance status, and whether the referral led to a procedure. The best approach will be to try to prevent these sorts of things from coming up by maintaining good communication and relations with other physician groups and thinking deliberately about your referral patterns. 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 course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program.” This column represents his views and is not intended to reflect an official position of SHM.

I heard that there are new resident work-hour rules that preclude interns from spending the night in the hospital. Tell me this isn’t true! I am an old-timer.

Thad Horton, MD

St. Louis

Dr. Hospitalist responds: On Sept. 26, 2010, the Accreditation Council for Graduate Medical Education (ACGME) approved new resident duty-hours and supervision standards; the new rules go into effect July 1. ACGME accredits more than 8,800 medical residency programs in the U.S. in more than 130 specialties and subspecialties. More than 111,000 residents and fellows train in these programs annually. ACGME first instituted duty-hour regulations in 2003; those led to a dramatic decrease in resident work-hours.

Basically, the highlights of the new rules are:

• Residents are limited to 80 hours weekly, averaged over a four-week period, and inclusive of all in-house call activities and moonlighting;
• Residents must be allowed one day free of duty every week (at-home call cannot be assigned on these free days);
• PGY-1 residents cannot work more than 16 hours daily, and residents beyond their PGY-1 year cannot work more than 24 hours daily;
• Residents must have at least eight hours off between shifts, and residents who work a 24-hour shift must have a minimum of 14 hours off before starting another shift;
• Residents cannot work more than six consecutive nights as night float; and
• Residents cannot be scheduled for in-house call more frequently than every third night.

I have not seen any specific prohibition on interns working overnight in the hospital. However, the new rules restrict interns to working no more than 16 hours daily, so that will mean interns who stay overnight in the hospital, until 7 or 8 a.m., cannot begin that overnight shift until 3 or 4 p.m. the day before. That means programs planning to keep their interns in-house overnight will have to be creative in their scheduling.

The demand for innovative scheduling won’t be the only implication of these new regulations. A number of forces have driven the rapid expansion of HM over the past decade. We have seen the development of sizable hospitalist programs at a number of teaching hospitals across the country. Hospitalists at teaching hospitals are not only supervising the care provided by residents, but they are also caring for patients without resident involvement. Since the original ACGME duty-hours cutback in 2002, we have seen the development and expansion of hospitalist-staffed, non-resident-covered medical services at most teaching hospitals across the country. Any further restriction in resident work-hours likely will result in the need to hire additional hospitalists to care for patients.

Virtually all HM programs require financial support to make ends meet. The most recent SHM/MGMA compensation and productivity survey found that the average hospitalist full-time equivalent (FTE) requires a little more than $100,000 of support annually. Regardless of the employer, much of that support comes from the hospital. So it appears that hospitals with teaching programs will end up footing the bill for the new resident regulations. I expect HM programs at teaching hospitals will face pushback from hospital administrators, but hiring additional hospitalists is a cost-effective proposition—and not complying with the ACGME rules is not an option, unless your program wants to risk losing its accreditation.

If you are a hospitalist program leader at a teaching hospital, I encourage you to plan accordingly and discuss the impact of these revisions in duty-hours with your teaching program director and your hospital administration.

Communication, Comfort Zone Key to Managing Hypertensive Emergencies

I just saw a patient in our urgent-care clinic sent from an ophthalmologist’s office with newly diagnosed retinal hemorrhages in both eyes and repeated BPs of 170/115. She had no history of hypertension (HTN) and no other symptoms. Does this qualify as an emergency? I couldn’t find any literature in this regard. My sense was it was an emergency, as her vision seemed to be at risk, so I sent her to the ED for IV meds in a controlled environment. Did I overreact?

Dennis Swanson, MD

Grand Rapids, Mich.

Dr. Hospitalist responds: Thank you for your question. There are numerous potential causes of retinal hemorrhages. Aside from trauma, we most commonly see retinal hemorrhages in patients with diabetic retinopathy and/or HTN. As you know, the retina is the only part of the vasculature that we can visualize noninvasively. This is a good example of why it is always important for providers to perform a fundoscopy on every patient with newly discovered HTN.

Retinal hemorrhage is one of several ocular diseases directly related to HTN. Based on your description, it sounds as if the ophthalmologist discovered the retinal hemorrhages and sent the patient to you, given the concern that uncontrolled HTN was the cause of the hemorrhages. You stated that you sent the patient to the ED because you were concerned the patient’s vision “seemed to be at risk.” Most retinal hemorrhages are asymptomatic unless the macular is affected, in which case the patient experiences a change in their visual acuity. Progressive microvascular changes in the retina can cause a loss of visual acuity. Aside from addressing the underlying problem causing the hemorrhages, laser surgery is the typical treatment of retinal hemorrhages. The laser seals off the abnormally bleeding vessels in the retina.

It would be useful to know about any communication that occurred between you and the ophthalmologist. I imagine the ophthalmologist was going to perform laser surgery but sent the patient to the hospital to address the HTN. If you did not feel comfortable managing the patient’s HTN in the urgent-care clinic, you did the right thing by sending the patient to the ED. It also is important to note that patients with hypertensive retinopathy often have other microvascular diseases, including in the kidneys. This patient should be evaluated for any evidence of proteinuria, which can suggest progressive microvascular renal disease, also as a result of uncontrolled HTN. TH

I heard that there are new resident work-hour rules that preclude interns from spending the night in the hospital. Tell me this isn’t true! I am an old-timer.

Thad Horton, MD

St. Louis

Dr. Hospitalist responds: On Sept. 26, 2010, the Accreditation Council for Graduate Medical Education (ACGME) approved new resident duty-hours and supervision standards; the new rules go into effect July 1. ACGME accredits more than 8,800 medical residency programs in the U.S. in more than 130 specialties and subspecialties. More than 111,000 residents and fellows train in these programs annually. ACGME first instituted duty-hour regulations in 2003; those led to a dramatic decrease in resident work-hours.

Basically, the highlights of the new rules are:

• Residents are limited to 80 hours weekly, averaged over a four-week period, and inclusive of all in-house call activities and moonlighting;
• Residents must be allowed one day free of duty every week (at-home call cannot be assigned on these free days);
• PGY-1 residents cannot work more than 16 hours daily, and residents beyond their PGY-1 year cannot work more than 24 hours daily;
• Residents must have at least eight hours off between shifts, and residents who work a 24-hour shift must have a minimum of 14 hours off before starting another shift;
• Residents cannot work more than six consecutive nights as night float; and
• Residents cannot be scheduled for in-house call more frequently than every third night.

I have not seen any specific prohibition on interns working overnight in the hospital. However, the new rules restrict interns to working no more than 16 hours daily, so that will mean interns who stay overnight in the hospital, until 7 or 8 a.m., cannot begin that overnight shift until 3 or 4 p.m. the day before. That means programs planning to keep their interns in-house overnight will have to be creative in their scheduling.

The demand for innovative scheduling won’t be the only implication of these new regulations. A number of forces have driven the rapid expansion of HM over the past decade. We have seen the development of sizable hospitalist programs at a number of teaching hospitals across the country. Hospitalists at teaching hospitals are not only supervising the care provided by residents, but they are also caring for patients without resident involvement. Since the original ACGME duty-hours cutback in 2002, we have seen the development and expansion of hospitalist-staffed, non-resident-covered medical services at most teaching hospitals across the country. Any further restriction in resident work-hours likely will result in the need to hire additional hospitalists to care for patients.

Virtually all HM programs require financial support to make ends meet. The most recent SHM/MGMA compensation and productivity survey found that the average hospitalist full-time equivalent (FTE) requires a little more than $100,000 of support annually. Regardless of the employer, much of that support comes from the hospital. So it appears that hospitals with teaching programs will end up footing the bill for the new resident regulations. I expect HM programs at teaching hospitals will face pushback from hospital administrators, but hiring additional hospitalists is a cost-effective proposition—and not complying with the ACGME rules is not an option, unless your program wants to risk losing its accreditation.

If you are a hospitalist program leader at a teaching hospital, I encourage you to plan accordingly and discuss the impact of these revisions in duty-hours with your teaching program director and your hospital administration.

Communication, Comfort Zone Key to Managing Hypertensive Emergencies

I just saw a patient in our urgent-care clinic sent from an ophthalmologist’s office with newly diagnosed retinal hemorrhages in both eyes and repeated BPs of 170/115. She had no history of hypertension (HTN) and no other symptoms. Does this qualify as an emergency? I couldn’t find any literature in this regard. My sense was it was an emergency, as her vision seemed to be at risk, so I sent her to the ED for IV meds in a controlled environment. Did I overreact?

Dennis Swanson, MD

Grand Rapids, Mich.

Dr. Hospitalist responds: Thank you for your question. There are numerous potential causes of retinal hemorrhages. Aside from trauma, we most commonly see retinal hemorrhages in patients with diabetic retinopathy and/or HTN. As you know, the retina is the only part of the vasculature that we can visualize noninvasively. This is a good example of why it is always important for providers to perform a fundoscopy on every patient with newly discovered HTN.

Retinal hemorrhage is one of several ocular diseases directly related to HTN. Based on your description, it sounds as if the ophthalmologist discovered the retinal hemorrhages and sent the patient to you, given the concern that uncontrolled HTN was the cause of the hemorrhages. You stated that you sent the patient to the ED because you were concerned the patient’s vision “seemed to be at risk.” Most retinal hemorrhages are asymptomatic unless the macular is affected, in which case the patient experiences a change in their visual acuity. Progressive microvascular changes in the retina can cause a loss of visual acuity. Aside from addressing the underlying problem causing the hemorrhages, laser surgery is the typical treatment of retinal hemorrhages. The laser seals off the abnormally bleeding vessels in the retina.

It would be useful to know about any communication that occurred between you and the ophthalmologist. I imagine the ophthalmologist was going to perform laser surgery but sent the patient to the hospital to address the HTN. If you did not feel comfortable managing the patient’s HTN in the urgent-care clinic, you did the right thing by sending the patient to the ED. It also is important to note that patients with hypertensive retinopathy often have other microvascular diseases, including in the kidneys. This patient should be evaluated for any evidence of proteinuria, which can suggest progressive microvascular renal disease, also as a result of uncontrolled HTN. TH

I heard that there are new resident work-hour rules that preclude interns from spending the night in the hospital. Tell me this isn’t true! I am an old-timer.

Thad Horton, MD

St. Louis

Dr. Hospitalist responds: On Sept. 26, 2010, the Accreditation Council for Graduate Medical Education (ACGME) approved new resident duty-hours and supervision standards; the new rules go into effect July 1. ACGME accredits more than 8,800 medical residency programs in the U.S. in more than 130 specialties and subspecialties. More than 111,000 residents and fellows train in these programs annually. ACGME first instituted duty-hour regulations in 2003; those led to a dramatic decrease in resident work-hours.

Basically, the highlights of the new rules are:

• Residents are limited to 80 hours weekly, averaged over a four-week period, and inclusive of all in-house call activities and moonlighting;
• Residents must be allowed one day free of duty every week (at-home call cannot be assigned on these free days);
• PGY-1 residents cannot work more than 16 hours daily, and residents beyond their PGY-1 year cannot work more than 24 hours daily;
• Residents must have at least eight hours off between shifts, and residents who work a 24-hour shift must have a minimum of 14 hours off before starting another shift;
• Residents cannot work more than six consecutive nights as night float; and
• Residents cannot be scheduled for in-house call more frequently than every third night.

I have not seen any specific prohibition on interns working overnight in the hospital. However, the new rules restrict interns to working no more than 16 hours daily, so that will mean interns who stay overnight in the hospital, until 7 or 8 a.m., cannot begin that overnight shift until 3 or 4 p.m. the day before. That means programs planning to keep their interns in-house overnight will have to be creative in their scheduling.

The demand for innovative scheduling won’t be the only implication of these new regulations. A number of forces have driven the rapid expansion of HM over the past decade. We have seen the development of sizable hospitalist programs at a number of teaching hospitals across the country. Hospitalists at teaching hospitals are not only supervising the care provided by residents, but they are also caring for patients without resident involvement. Since the original ACGME duty-hours cutback in 2002, we have seen the development and expansion of hospitalist-staffed, non-resident-covered medical services at most teaching hospitals across the country. Any further restriction in resident work-hours likely will result in the need to hire additional hospitalists to care for patients.

Virtually all HM programs require financial support to make ends meet. The most recent SHM/MGMA compensation and productivity survey found that the average hospitalist full-time equivalent (FTE) requires a little more than $100,000 of support annually. Regardless of the employer, much of that support comes from the hospital. So it appears that hospitals with teaching programs will end up footing the bill for the new resident regulations. I expect HM programs at teaching hospitals will face pushback from hospital administrators, but hiring additional hospitalists is a cost-effective proposition—and not complying with the ACGME rules is not an option, unless your program wants to risk losing its accreditation.

If you are a hospitalist program leader at a teaching hospital, I encourage you to plan accordingly and discuss the impact of these revisions in duty-hours with your teaching program director and your hospital administration.

Communication, Comfort Zone Key to Managing Hypertensive Emergencies

I just saw a patient in our urgent-care clinic sent from an ophthalmologist’s office with newly diagnosed retinal hemorrhages in both eyes and repeated BPs of 170/115. She had no history of hypertension (HTN) and no other symptoms. Does this qualify as an emergency? I couldn’t find any literature in this regard. My sense was it was an emergency, as her vision seemed to be at risk, so I sent her to the ED for IV meds in a controlled environment. Did I overreact?

Dennis Swanson, MD

Grand Rapids, Mich.

Dr. Hospitalist responds: Thank you for your question. There are numerous potential causes of retinal hemorrhages. Aside from trauma, we most commonly see retinal hemorrhages in patients with diabetic retinopathy and/or HTN. As you know, the retina is the only part of the vasculature that we can visualize noninvasively. This is a good example of why it is always important for providers to perform a fundoscopy on every patient with newly discovered HTN.

Retinal hemorrhage is one of several ocular diseases directly related to HTN. Based on your description, it sounds as if the ophthalmologist discovered the retinal hemorrhages and sent the patient to you, given the concern that uncontrolled HTN was the cause of the hemorrhages. You stated that you sent the patient to the ED because you were concerned the patient’s vision “seemed to be at risk.” Most retinal hemorrhages are asymptomatic unless the macular is affected, in which case the patient experiences a change in their visual acuity. Progressive microvascular changes in the retina can cause a loss of visual acuity. Aside from addressing the underlying problem causing the hemorrhages, laser surgery is the typical treatment of retinal hemorrhages. The laser seals off the abnormally bleeding vessels in the retina.

It would be useful to know about any communication that occurred between you and the ophthalmologist. I imagine the ophthalmologist was going to perform laser surgery but sent the patient to the hospital to address the HTN. If you did not feel comfortable managing the patient’s HTN in the urgent-care clinic, you did the right thing by sending the patient to the ED. It also is important to note that patients with hypertensive retinopathy often have other microvascular diseases, including in the kidneys. This patient should be evaluated for any evidence of proteinuria, which can suggest progressive microvascular renal disease, also as a result of uncontrolled HTN. TH

In response to internal and external pressures to minimize length of stay, adhere to limitations on the maximum number of admitted patients, focus on evidence-based care, and improve outcomes of care, hospitalists have incorporated nonphysician providers (NPPs), such as acute-care nurse practitioners (ACNPs), into their group practices.¹ HM groups employing these practitioners must be aware of state and federal regulations, as well as billing and documentation standards surrounding NPP services.

Consider the following common hospitalist scenario: A nurse practitioner evaluates a 67-year-old patient admitted for chronic obstructive bronchitis and progressing shortness of breath. The nurse practitioner documents the service and provides the attending physician with an update on the patient’s status. Later in the day, the physician makes rounds and concurs with the patient’s current plan of care.

The above scenario represents a shared/split service in which two providers from the same group perform a service for the same patient on the same calendar day. The Centers for Medicare & Medicaid Services (CMS) allows these visits to be combined and reported under a single provider’s name if the shared/split billing criteria are met and appropriately documented.

Eligible Providers

The shared/split billing option only applies to services rendered by the attending physician and specified NPPs: nurse practitioners, physician assistants, clinical nurse specialists, and certified nurse-midwives. Both the attending physician and the NPP must be part of the same group practice, either through direct employment or a leased arrangement that contractually links the two individuals. The “leased” relationship often occurs when the facility directly employs the NPP but arranges for the NPP to provide services exclusively for the physician group. It is imperative that the bills for the NPP services are captured and reported by one entity—the hospitalist group.

Several other NPPs (e.g. clinical psychologists or certified registered nurse anesthetists) are recognized by CMS but are ineligible for shared/split billing and must report their services under a different Medicare billing option. Additionally, shared/split services do not apply to physicians in training (interns, residents, fellows) or students.

Qualifying Services

Medicare reimburses services that are considered reasonable and necessary and not otherwise excluded from coverage. From a clinical perspective, NPPs might provide any service permitted by the state scope of practice and performed under the appropriate level of supervision or collaboration as depicted in licensure requirements. These typically comprise visits or procedures rendered by ancillary staff or considered a “physician” service.

Alternatively, shared/split billing regulations limit the types of services that can be reported under this methodology, recognizing only evaluation and management (E/M) services provided in explicit facility-based settings: EDs, outpatient hospital clinics, or inpatient hospitals. Critical-care services and procedures are excluded.

Physician Involvement

The NPP and the physician must have a face-to-face encounter with the same patient on the same calendar day, and there are no constraints on which provider should perform the initial encounter of the day.²

The extent of each provider’s involvement is left to provider discretion and/or local Medicare contractor requirements. Some contractors refer to the physician performing a “substantive” service but do not elaborate with specific service parameters, leaving the physician to determine the critical or key portion of his/her service. A corresponding, detailed notation alleviates any misconceptions of physician involvement.

Documentation by the attending physician should include an attestation that unequivocally demonstrates their personal encounter with the patient—for example, “Patient seen and examined by me.” Additionally, both the NPP and the physician should document the name of the individual with whom the service is shared/split—for example, “Agree with note by ____.” This allows for better charge capture; alerts coders, auditors, and payor representatives to consider both notes in support of the billed service; and ensures that the correct notes are sent to the payor in the event of claim denial and subsequent appeal.

Each provider must document their portion of the rendered service, date and legibly sign their corresponding note, and select the visit level supported by the cumulative encounter—for example, “Pulse oximetry 94% on room air. Audible rhonchi at bilateral lung bases. Start O2 2L nasal cannula. Obtain CXR.”

Only one claim can be submitted for a shared/split service. The services might either be reported with the physician’s NPI or the NPP’s NPI. Reimbursement is dependent upon this designation. The physician NPI generates 100% of the Medicare allowable rate; the NPP NPI limits reimbursement to 85% of the allowable physician rate.

Non-Medicare Claims

The shared/split billing policy only applies to Medicare beneficiaries. Due to excessive costs of NPP credentialing and enrollment, most non-Medicare insurers do not issue NPP provider numbers.

Effective June 1, 2010, Aetna began to enroll and reimburse NPP services, but it has not yet outlined a policy that parallels Medicare’s shared/split billing policy. However, lack of payor policy does not preclude payment for shared NPP services; it necessitates additional—and initial—efforts to obtain recognition and corresponding reimbursement.

After determining which insurers have applicable shared/split billing policies, develop a reasonable guideline to offer those payors who do not recognize the billing option. Alert the payor, in writing, that policy implementation will take place in a predetermined timeframe unless the payor can provide an alternate billing option. Some experts suggest physician groups outline the following key issues when structuring a billing option:

• Types of NPP involved in patient care;
• Category of services provided (e.g. E/M, procedures);
• Service location(s) (ED, inpatient, or outpatient hospital);
• Physician involvement;
• Mechanism for reporting services; and
• Documentation requirements.

This can be performed for any of the NPP billing options and is not limited to shared/split billing. Be sure to obtain payor response before initiating the shared/split billing process.

Summary

NPPs are involved in numerous services within the hospital, and often share/split services with hospitalists. Successful reporting requires understanding of and adherence to federal, state, and billing guidelines.

It is important to identify NPP employment relationships, the NPP’s role in the provision of services, the state supervisory or collaborative rules, and local payor interpretations to prevent misrepresentations, misunderstandings, or erroneous reporting. TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

1. Howie JN, Erickson M. Acute care nurse practitioners: creating and implementing a model of care for an inpatient general medical service. Am J Crit Care. 2002; 11(5):448-458.
2. Medicare Claims Processing Manual: Chapter 12, Section 30.6.1B. Centers for Medicare and Medicaid Services website. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed Nov. 14, 2010.
3. Pohlig, C. Nonphysician providers in your practice. In: Coding for Chest Medicine 2009. Northbrook, Ill.: American College of Chest Physicians; 2010.
4. Medicare Benefit Policy Manual: Chapter 15, Section 190-200. CMS website. Available at: www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf. Accessed Nov. 14, 2010.

In response to internal and external pressures to minimize length of stay, adhere to limitations on the maximum number of admitted patients, focus on evidence-based care, and improve outcomes of care, hospitalists have incorporated nonphysician providers (NPPs), such as acute-care nurse practitioners (ACNPs), into their group practices.¹ HM groups employing these practitioners must be aware of state and federal regulations, as well as billing and documentation standards surrounding NPP services.

Consider the following common hospitalist scenario: A nurse practitioner evaluates a 67-year-old patient admitted for chronic obstructive bronchitis and progressing shortness of breath. The nurse practitioner documents the service and provides the attending physician with an update on the patient’s status. Later in the day, the physician makes rounds and concurs with the patient’s current plan of care.

The above scenario represents a shared/split service in which two providers from the same group perform a service for the same patient on the same calendar day. The Centers for Medicare & Medicaid Services (CMS) allows these visits to be combined and reported under a single provider’s name if the shared/split billing criteria are met and appropriately documented.

Eligible Providers

The shared/split billing option only applies to services rendered by the attending physician and specified NPPs: nurse practitioners, physician assistants, clinical nurse specialists, and certified nurse-midwives. Both the attending physician and the NPP must be part of the same group practice, either through direct employment or a leased arrangement that contractually links the two individuals. The “leased” relationship often occurs when the facility directly employs the NPP but arranges for the NPP to provide services exclusively for the physician group. It is imperative that the bills for the NPP services are captured and reported by one entity—the hospitalist group.

Several other NPPs (e.g. clinical psychologists or certified registered nurse anesthetists) are recognized by CMS but are ineligible for shared/split billing and must report their services under a different Medicare billing option. Additionally, shared/split services do not apply to physicians in training (interns, residents, fellows) or students.

Qualifying Services

Medicare reimburses services that are considered reasonable and necessary and not otherwise excluded from coverage. From a clinical perspective, NPPs might provide any service permitted by the state scope of practice and performed under the appropriate level of supervision or collaboration as depicted in licensure requirements. These typically comprise visits or procedures rendered by ancillary staff or considered a “physician” service.

Alternatively, shared/split billing regulations limit the types of services that can be reported under this methodology, recognizing only evaluation and management (E/M) services provided in explicit facility-based settings: EDs, outpatient hospital clinics, or inpatient hospitals. Critical-care services and procedures are excluded.

Physician Involvement

The NPP and the physician must have a face-to-face encounter with the same patient on the same calendar day, and there are no constraints on which provider should perform the initial encounter of the day.²

The extent of each provider’s involvement is left to provider discretion and/or local Medicare contractor requirements. Some contractors refer to the physician performing a “substantive” service but do not elaborate with specific service parameters, leaving the physician to determine the critical or key portion of his/her service. A corresponding, detailed notation alleviates any misconceptions of physician involvement.

Documentation by the attending physician should include an attestation that unequivocally demonstrates their personal encounter with the patient—for example, “Patient seen and examined by me.” Additionally, both the NPP and the physician should document the name of the individual with whom the service is shared/split—for example, “Agree with note by ____.” This allows for better charge capture; alerts coders, auditors, and payor representatives to consider both notes in support of the billed service; and ensures that the correct notes are sent to the payor in the event of claim denial and subsequent appeal.

Each provider must document their portion of the rendered service, date and legibly sign their corresponding note, and select the visit level supported by the cumulative encounter—for example, “Pulse oximetry 94% on room air. Audible rhonchi at bilateral lung bases. Start O2 2L nasal cannula. Obtain CXR.”

Only one claim can be submitted for a shared/split service. The services might either be reported with the physician’s NPI or the NPP’s NPI. Reimbursement is dependent upon this designation. The physician NPI generates 100% of the Medicare allowable rate; the NPP NPI limits reimbursement to 85% of the allowable physician rate.

Non-Medicare Claims

The shared/split billing policy only applies to Medicare beneficiaries. Due to excessive costs of NPP credentialing and enrollment, most non-Medicare insurers do not issue NPP provider numbers.

Effective June 1, 2010, Aetna began to enroll and reimburse NPP services, but it has not yet outlined a policy that parallels Medicare’s shared/split billing policy. However, lack of payor policy does not preclude payment for shared NPP services; it necessitates additional—and initial—efforts to obtain recognition and corresponding reimbursement.

After determining which insurers have applicable shared/split billing policies, develop a reasonable guideline to offer those payors who do not recognize the billing option. Alert the payor, in writing, that policy implementation will take place in a predetermined timeframe unless the payor can provide an alternate billing option. Some experts suggest physician groups outline the following key issues when structuring a billing option:

• Types of NPP involved in patient care;
• Category of services provided (e.g. E/M, procedures);
• Service location(s) (ED, inpatient, or outpatient hospital);
• Physician involvement;
• Mechanism for reporting services; and
• Documentation requirements.

This can be performed for any of the NPP billing options and is not limited to shared/split billing. Be sure to obtain payor response before initiating the shared/split billing process.

Summary

NPPs are involved in numerous services within the hospital, and often share/split services with hospitalists. Successful reporting requires understanding of and adherence to federal, state, and billing guidelines.

It is important to identify NPP employment relationships, the NPP’s role in the provision of services, the state supervisory or collaborative rules, and local payor interpretations to prevent misrepresentations, misunderstandings, or erroneous reporting. TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

1. Howie JN, Erickson M. Acute care nurse practitioners: creating and implementing a model of care for an inpatient general medical service. Am J Crit Care. 2002; 11(5):448-458.
2. Medicare Claims Processing Manual: Chapter 12, Section 30.6.1B. Centers for Medicare and Medicaid Services website. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed Nov. 14, 2010.
3. Pohlig, C. Nonphysician providers in your practice. In: Coding for Chest Medicine 2009. Northbrook, Ill.: American College of Chest Physicians; 2010.
4. Medicare Benefit Policy Manual: Chapter 15, Section 190-200. CMS website. Available at: www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf. Accessed Nov. 14, 2010.

In response to internal and external pressures to minimize length of stay, adhere to limitations on the maximum number of admitted patients, focus on evidence-based care, and improve outcomes of care, hospitalists have incorporated nonphysician providers (NPPs), such as acute-care nurse practitioners (ACNPs), into their group practices.¹ HM groups employing these practitioners must be aware of state and federal regulations, as well as billing and documentation standards surrounding NPP services.

Consider the following common hospitalist scenario: A nurse practitioner evaluates a 67-year-old patient admitted for chronic obstructive bronchitis and progressing shortness of breath. The nurse practitioner documents the service and provides the attending physician with an update on the patient’s status. Later in the day, the physician makes rounds and concurs with the patient’s current plan of care.

The above scenario represents a shared/split service in which two providers from the same group perform a service for the same patient on the same calendar day. The Centers for Medicare & Medicaid Services (CMS) allows these visits to be combined and reported under a single provider’s name if the shared/split billing criteria are met and appropriately documented.

Eligible Providers

The shared/split billing option only applies to services rendered by the attending physician and specified NPPs: nurse practitioners, physician assistants, clinical nurse specialists, and certified nurse-midwives. Both the attending physician and the NPP must be part of the same group practice, either through direct employment or a leased arrangement that contractually links the two individuals. The “leased” relationship often occurs when the facility directly employs the NPP but arranges for the NPP to provide services exclusively for the physician group. It is imperative that the bills for the NPP services are captured and reported by one entity—the hospitalist group.

Several other NPPs (e.g. clinical psychologists or certified registered nurse anesthetists) are recognized by CMS but are ineligible for shared/split billing and must report their services under a different Medicare billing option. Additionally, shared/split services do not apply to physicians in training (interns, residents, fellows) or students.

Qualifying Services

Medicare reimburses services that are considered reasonable and necessary and not otherwise excluded from coverage. From a clinical perspective, NPPs might provide any service permitted by the state scope of practice and performed under the appropriate level of supervision or collaboration as depicted in licensure requirements. These typically comprise visits or procedures rendered by ancillary staff or considered a “physician” service.

Alternatively, shared/split billing regulations limit the types of services that can be reported under this methodology, recognizing only evaluation and management (E/M) services provided in explicit facility-based settings: EDs, outpatient hospital clinics, or inpatient hospitals. Critical-care services and procedures are excluded.

Physician Involvement

The NPP and the physician must have a face-to-face encounter with the same patient on the same calendar day, and there are no constraints on which provider should perform the initial encounter of the day.²

The extent of each provider’s involvement is left to provider discretion and/or local Medicare contractor requirements. Some contractors refer to the physician performing a “substantive” service but do not elaborate with specific service parameters, leaving the physician to determine the critical or key portion of his/her service. A corresponding, detailed notation alleviates any misconceptions of physician involvement.

Documentation by the attending physician should include an attestation that unequivocally demonstrates their personal encounter with the patient—for example, “Patient seen and examined by me.” Additionally, both the NPP and the physician should document the name of the individual with whom the service is shared/split—for example, “Agree with note by ____.” This allows for better charge capture; alerts coders, auditors, and payor representatives to consider both notes in support of the billed service; and ensures that the correct notes are sent to the payor in the event of claim denial and subsequent appeal.

Each provider must document their portion of the rendered service, date and legibly sign their corresponding note, and select the visit level supported by the cumulative encounter—for example, “Pulse oximetry 94% on room air. Audible rhonchi at bilateral lung bases. Start O2 2L nasal cannula. Obtain CXR.”

Only one claim can be submitted for a shared/split service. The services might either be reported with the physician’s NPI or the NPP’s NPI. Reimbursement is dependent upon this designation. The physician NPI generates 100% of the Medicare allowable rate; the NPP NPI limits reimbursement to 85% of the allowable physician rate.

Non-Medicare Claims

The shared/split billing policy only applies to Medicare beneficiaries. Due to excessive costs of NPP credentialing and enrollment, most non-Medicare insurers do not issue NPP provider numbers.

Effective June 1, 2010, Aetna began to enroll and reimburse NPP services, but it has not yet outlined a policy that parallels Medicare’s shared/split billing policy. However, lack of payor policy does not preclude payment for shared NPP services; it necessitates additional—and initial—efforts to obtain recognition and corresponding reimbursement.

After determining which insurers have applicable shared/split billing policies, develop a reasonable guideline to offer those payors who do not recognize the billing option. Alert the payor, in writing, that policy implementation will take place in a predetermined timeframe unless the payor can provide an alternate billing option. Some experts suggest physician groups outline the following key issues when structuring a billing option:

• Types of NPP involved in patient care;
• Category of services provided (e.g. E/M, procedures);
• Service location(s) (ED, inpatient, or outpatient hospital);
• Physician involvement;
• Mechanism for reporting services; and
• Documentation requirements.

This can be performed for any of the NPP billing options and is not limited to shared/split billing. Be sure to obtain payor response before initiating the shared/split billing process.

Summary

NPPs are involved in numerous services within the hospital, and often share/split services with hospitalists. Successful reporting requires understanding of and adherence to federal, state, and billing guidelines.

It is important to identify NPP employment relationships, the NPP’s role in the provision of services, the state supervisory or collaborative rules, and local payor interpretations to prevent misrepresentations, misunderstandings, or erroneous reporting. TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

1. Howie JN, Erickson M. Acute care nurse practitioners: creating and implementing a model of care for an inpatient general medical service. Am J Crit Care. 2002; 11(5):448-458.
2. Medicare Claims Processing Manual: Chapter 12, Section 30.6.1B. Centers for Medicare and Medicaid Services website. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed Nov. 14, 2010.
3. Pohlig, C. Nonphysician providers in your practice. In: Coding for Chest Medicine 2009. Northbrook, Ill.: American College of Chest Physicians; 2010.
4. Medicare Benefit Policy Manual: Chapter 15, Section 190-200. CMS website. Available at: www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf. Accessed Nov. 14, 2010.

Every clinician in HM depends on a smooth-running hospitalist program to ensure the best possible patient care and efficiency. Even though they might not be visible to hospitalized patients, practice administration issues (e.g. compensation and incentives, reporting return on investment, or the Physician’s Quality Reporting System) are vital components to effectively running an HM group. And that’s what explains the growing popularity of SHM’s new resources for administrators.

In 2010, SHM presented five free online discussions for hospitalist practice leaders. Each session in the Practice Administrators’ Roundtable Series began with a formal presentation and was followed with open discussion from administrators and leaders from around the country.

SHM will continue the program in 2011 with such topics as Hospitalist Recruitment, Retention, & Orientation (Feb. 24) and Patient Satisfaction (May 26).

“The response to new programs for hospitalist administrators has been very positive,” says Kim Dickinson, MA, regional COO for Cogent Healthcare and a member of SHM’s Administrators’ Task Force, which has taken the lead on planning the roundtables. “As hospital medicine programs continue to evolve, there will be a growing need to address their administrative issues, too.”

The program will break new ground in 2011 with the first SHM Award for Excellence in Hospital Medicine. The new award, to be presented at HM11, will recognize a physician assistant, nurse practitioner, RN, pharmacist, administrator, case manager, or a nonphysician member of SHM.

“Hospital medicine groups depend on effective leadership, communication and administration,” says SHM president Jeff Wiese, MD, SFHM. “That’s why these new programs are so critical to improving quality, safety, and efficiency in hospital care. It is appropriate then that the best of the best should be recognized in this regard. I am personally excited to present the first SHM Award for Excellence in Hospital Medicine at the SHM annual meeting in Dallas.”

All of the roundtable discussions are archived in SHM’s Practice Management Institute (www.hospitalmedicine.org/practiceresources).

Every clinician in HM depends on a smooth-running hospitalist program to ensure the best possible patient care and efficiency. Even though they might not be visible to hospitalized patients, practice administration issues (e.g. compensation and incentives, reporting return on investment, or the Physician’s Quality Reporting System) are vital components to effectively running an HM group. And that’s what explains the growing popularity of SHM’s new resources for administrators.

In 2010, SHM presented five free online discussions for hospitalist practice leaders. Each session in the Practice Administrators’ Roundtable Series began with a formal presentation and was followed with open discussion from administrators and leaders from around the country.

SHM will continue the program in 2011 with such topics as Hospitalist Recruitment, Retention, & Orientation (Feb. 24) and Patient Satisfaction (May 26).

“The response to new programs for hospitalist administrators has been very positive,” says Kim Dickinson, MA, regional COO for Cogent Healthcare and a member of SHM’s Administrators’ Task Force, which has taken the lead on planning the roundtables. “As hospital medicine programs continue to evolve, there will be a growing need to address their administrative issues, too.”

The program will break new ground in 2011 with the first SHM Award for Excellence in Hospital Medicine. The new award, to be presented at HM11, will recognize a physician assistant, nurse practitioner, RN, pharmacist, administrator, case manager, or a nonphysician member of SHM.

“Hospital medicine groups depend on effective leadership, communication and administration,” says SHM president Jeff Wiese, MD, SFHM. “That’s why these new programs are so critical to improving quality, safety, and efficiency in hospital care. It is appropriate then that the best of the best should be recognized in this regard. I am personally excited to present the first SHM Award for Excellence in Hospital Medicine at the SHM annual meeting in Dallas.”

All of the roundtable discussions are archived in SHM’s Practice Management Institute (www.hospitalmedicine.org/practiceresources).

Every clinician in HM depends on a smooth-running hospitalist program to ensure the best possible patient care and efficiency. Even though they might not be visible to hospitalized patients, practice administration issues (e.g. compensation and incentives, reporting return on investment, or the Physician’s Quality Reporting System) are vital components to effectively running an HM group. And that’s what explains the growing popularity of SHM’s new resources for administrators.

In 2010, SHM presented five free online discussions for hospitalist practice leaders. Each session in the Practice Administrators’ Roundtable Series began with a formal presentation and was followed with open discussion from administrators and leaders from around the country.

SHM will continue the program in 2011 with such topics as Hospitalist Recruitment, Retention, & Orientation (Feb. 24) and Patient Satisfaction (May 26).

“The response to new programs for hospitalist administrators has been very positive,” says Kim Dickinson, MA, regional COO for Cogent Healthcare and a member of SHM’s Administrators’ Task Force, which has taken the lead on planning the roundtables. “As hospital medicine programs continue to evolve, there will be a growing need to address their administrative issues, too.”

The program will break new ground in 2011 with the first SHM Award for Excellence in Hospital Medicine. The new award, to be presented at HM11, will recognize a physician assistant, nurse practitioner, RN, pharmacist, administrator, case manager, or a nonphysician member of SHM.

“Hospital medicine groups depend on effective leadership, communication and administration,” says SHM president Jeff Wiese, MD, SFHM. “That’s why these new programs are so critical to improving quality, safety, and efficiency in hospital care. It is appropriate then that the best of the best should be recognized in this regard. I am personally excited to present the first SHM Award for Excellence in Hospital Medicine at the SHM annual meeting in Dallas.”

All of the roundtable discussions are archived in SHM’s Practice Management Institute (www.hospitalmedicine.org/practiceresources).