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Scheduling patterns in hospital medicine
For years, the Society of Hospital Medicine has been asking hospital medicine programs about operational metrics in order to understand and catalog how they are functioning and evolving. After compensation, the scheduling patterns that hospital medicine groups (HMGs) are using is the most reviewed item in the report.
When hospital medicine first started, 7 days working followed by 7 days off (7-on-7-off) quickly became vogue. No one really knows how this happened, but it was most likely due to the fact that hospital medicine most closely resembled emergency medicine and scheduling similar to emergency medicine seemed to make sense (that is, 14 shifts per month). That along with the assumption that continuity of care was critical in inpatient care and would improve quality most likely resulted in the popularity of the 7-on-7-off schedule.
In the most recent survey in 2016, HMGs were once again asked to comment on how they schedule. Groups were able to choose from five scheduling options:
1. Seven days on followed by 7 days off
2. Other fixed rotation block schedules (such as 5-on 5-off; or 10-on 5-off)
3. Monday to Friday with rotating weekend coverage
4. Variable schedule
5. Other
Looking at HMG programs that serve only adult populations, a majority of them (48%) follow a fixed rotating schedule either 7 days on followed by 7 days off, or some other fixed schedule, while 31% of programs that responded stated that they used a Monday to Friday schedule. Looking at the programs as a whole, it would seem that the 7-on-7-off schedule was quickly losing popularity while the Monday to Friday schedule was increasingly being used. However, this broad generalization doesn’t really give you the full picture.
Upon analyzing the data further, we see some distinct differences arise based on program size. Small programs (fewer than 10 full-time employees [FTEs]) are much more likely to schedule a Monday to Friday schedule than any other model, whereas only a handful of large programs (greater than 20 FTEs) schedule in this way, rather choosing to use a 7-on-7-off schedule.
The last survey was done in 2014 and a lot has changed since then. Significantly more programs responded in 2016, compared with 2014 (530 vs. 355) and the majority of this increase was made of up smaller programs (fewer than 10 FTEs). Programs with four or fewer FTEs, compared with the prior survey, increased by over 400% (37 programs in 2014 vs. 151 programs in 2016). Overall, programs with fewer than 10 FTEs constituted over 50% of the total programs that responded in 2016 (whereas they made up only a third in 2014). This was particularly significant since size of the program was the one variable that determined how a program might schedule – other factors like geographic region, academic status, or primary hospital GME status did not show significant variance in how groups scheduled.
The second major change that occurred is that these same small programs (those with fewer than 10 FTEs) moved overwhelmingly to a Monday to Friday schedule. In 2014, only 3% of small programs scheduled using a Monday to Friday pattern, but in 2016 almost 50% of small programs reported scheduling in this way. This change in the overall composition of programs, with small programs now making up over 50% of the programs that reported, and the specific change in how small programs schedule results in a noteworthy decrease of programs using a 7 days on followed by 7 days off (7-on-7-off) schedule (53.8% in 2014 and only 38.1% in 2016), and a corresponding increase in the number of programs that schedule using a Monday to Friday schedule (4% in 2014 to 31% in 2016).
In distinct contrast to programs with fewer than 10 FTEs, a very similar number of programs with greater than 20 FTEs reported in 2016 as in 2014 – there was no increase in this subgroup. I’m not clear at this time if this is because there is truly no increase in the number of large programs nationally, or if there is another factor causing larger programs to under-report. The large programs that did report data in 2016 continue to utilize a 7-on-7-off schedule or another fixed rotating block schedule more than 50% of the time. In fact, the utilization of one of these two scheduling patterns increased slightly from 2014 to 2016 (from 52% to 58%). Those that did not use one of the prior mentioned scheduling patterns were most likely to schedule with a variable schedule. A Monday to Friday schedule was almost never used in programs of this size and showed no significant change from 2014 to 2016.
This snapshot highlights the changing landscape in hospital medicine. Hospital medicine is penetrating more and more into smaller and smaller hospitals, and has even made it into critical access hospitals. As recently as 5-10 years ago, it was felt that these hospitals were too small to have a hospital medicine program. This is likely one of the reasons for the increase in programs with four or fewer FTEs. There has also been increasing discontent with the 7-on-7-off schedule, which many feel is leading to burnout. Dr. Bob Wachter famously said during the closing plenary of the 2016 Society of Hospital Medicine Annual Meeting that the 7-on-7-off schedule was “a mistake.” Despite this brewing discontent, larger programs have not changed their scheduling patterns, likely because finding a another scheduling pattern that is effective, supports high-quality care, and is sustainable for such a large group is challenging.
Many people will say that there are as many different types of hospital medicine programs as there are hospital medicine programs. This is true for scheduling as for other aspects of hospital medicine operations. As we continue to grow and evolve as an industry, scheduling patterns will continue to change and evolve as well. For now, two patterns are emerging – smaller programs are utilizing a Monday to Friday schedule and larger programs are utilizing a 7-on-7-off schedule. Only time will tell if these scheduling patterns persist or continue to evolve.
Dr. George is a board certified internal medicine physician and practicing hospitalist with over 15 years of experience in hospital medicine. She has been actively involved in the Society of Hospital Medicine and has participated in and chaired multiple committees and task forces. She is currently executive vice president and chief medical officer of Hospital Medicine at Schumacher Clinical Partners, a national provider of emergency medicine and hospital medicine services. She lives in the northwest suburbs of Chicago with her family.
For years, the Society of Hospital Medicine has been asking hospital medicine programs about operational metrics in order to understand and catalog how they are functioning and evolving. After compensation, the scheduling patterns that hospital medicine groups (HMGs) are using is the most reviewed item in the report.
When hospital medicine first started, 7 days working followed by 7 days off (7-on-7-off) quickly became vogue. No one really knows how this happened, but it was most likely due to the fact that hospital medicine most closely resembled emergency medicine and scheduling similar to emergency medicine seemed to make sense (that is, 14 shifts per month). That along with the assumption that continuity of care was critical in inpatient care and would improve quality most likely resulted in the popularity of the 7-on-7-off schedule.
In the most recent survey in 2016, HMGs were once again asked to comment on how they schedule. Groups were able to choose from five scheduling options:
1. Seven days on followed by 7 days off
2. Other fixed rotation block schedules (such as 5-on 5-off; or 10-on 5-off)
3. Monday to Friday with rotating weekend coverage
4. Variable schedule
5. Other
Looking at HMG programs that serve only adult populations, a majority of them (48%) follow a fixed rotating schedule either 7 days on followed by 7 days off, or some other fixed schedule, while 31% of programs that responded stated that they used a Monday to Friday schedule. Looking at the programs as a whole, it would seem that the 7-on-7-off schedule was quickly losing popularity while the Monday to Friday schedule was increasingly being used. However, this broad generalization doesn’t really give you the full picture.
Upon analyzing the data further, we see some distinct differences arise based on program size. Small programs (fewer than 10 full-time employees [FTEs]) are much more likely to schedule a Monday to Friday schedule than any other model, whereas only a handful of large programs (greater than 20 FTEs) schedule in this way, rather choosing to use a 7-on-7-off schedule.
The last survey was done in 2014 and a lot has changed since then. Significantly more programs responded in 2016, compared with 2014 (530 vs. 355) and the majority of this increase was made of up smaller programs (fewer than 10 FTEs). Programs with four or fewer FTEs, compared with the prior survey, increased by over 400% (37 programs in 2014 vs. 151 programs in 2016). Overall, programs with fewer than 10 FTEs constituted over 50% of the total programs that responded in 2016 (whereas they made up only a third in 2014). This was particularly significant since size of the program was the one variable that determined how a program might schedule – other factors like geographic region, academic status, or primary hospital GME status did not show significant variance in how groups scheduled.
The second major change that occurred is that these same small programs (those with fewer than 10 FTEs) moved overwhelmingly to a Monday to Friday schedule. In 2014, only 3% of small programs scheduled using a Monday to Friday pattern, but in 2016 almost 50% of small programs reported scheduling in this way. This change in the overall composition of programs, with small programs now making up over 50% of the programs that reported, and the specific change in how small programs schedule results in a noteworthy decrease of programs using a 7 days on followed by 7 days off (7-on-7-off) schedule (53.8% in 2014 and only 38.1% in 2016), and a corresponding increase in the number of programs that schedule using a Monday to Friday schedule (4% in 2014 to 31% in 2016).
In distinct contrast to programs with fewer than 10 FTEs, a very similar number of programs with greater than 20 FTEs reported in 2016 as in 2014 – there was no increase in this subgroup. I’m not clear at this time if this is because there is truly no increase in the number of large programs nationally, or if there is another factor causing larger programs to under-report. The large programs that did report data in 2016 continue to utilize a 7-on-7-off schedule or another fixed rotating block schedule more than 50% of the time. In fact, the utilization of one of these two scheduling patterns increased slightly from 2014 to 2016 (from 52% to 58%). Those that did not use one of the prior mentioned scheduling patterns were most likely to schedule with a variable schedule. A Monday to Friday schedule was almost never used in programs of this size and showed no significant change from 2014 to 2016.
This snapshot highlights the changing landscape in hospital medicine. Hospital medicine is penetrating more and more into smaller and smaller hospitals, and has even made it into critical access hospitals. As recently as 5-10 years ago, it was felt that these hospitals were too small to have a hospital medicine program. This is likely one of the reasons for the increase in programs with four or fewer FTEs. There has also been increasing discontent with the 7-on-7-off schedule, which many feel is leading to burnout. Dr. Bob Wachter famously said during the closing plenary of the 2016 Society of Hospital Medicine Annual Meeting that the 7-on-7-off schedule was “a mistake.” Despite this brewing discontent, larger programs have not changed their scheduling patterns, likely because finding a another scheduling pattern that is effective, supports high-quality care, and is sustainable for such a large group is challenging.
Many people will say that there are as many different types of hospital medicine programs as there are hospital medicine programs. This is true for scheduling as for other aspects of hospital medicine operations. As we continue to grow and evolve as an industry, scheduling patterns will continue to change and evolve as well. For now, two patterns are emerging – smaller programs are utilizing a Monday to Friday schedule and larger programs are utilizing a 7-on-7-off schedule. Only time will tell if these scheduling patterns persist or continue to evolve.
Dr. George is a board certified internal medicine physician and practicing hospitalist with over 15 years of experience in hospital medicine. She has been actively involved in the Society of Hospital Medicine and has participated in and chaired multiple committees and task forces. She is currently executive vice president and chief medical officer of Hospital Medicine at Schumacher Clinical Partners, a national provider of emergency medicine and hospital medicine services. She lives in the northwest suburbs of Chicago with her family.
For years, the Society of Hospital Medicine has been asking hospital medicine programs about operational metrics in order to understand and catalog how they are functioning and evolving. After compensation, the scheduling patterns that hospital medicine groups (HMGs) are using is the most reviewed item in the report.
When hospital medicine first started, 7 days working followed by 7 days off (7-on-7-off) quickly became vogue. No one really knows how this happened, but it was most likely due to the fact that hospital medicine most closely resembled emergency medicine and scheduling similar to emergency medicine seemed to make sense (that is, 14 shifts per month). That along with the assumption that continuity of care was critical in inpatient care and would improve quality most likely resulted in the popularity of the 7-on-7-off schedule.
In the most recent survey in 2016, HMGs were once again asked to comment on how they schedule. Groups were able to choose from five scheduling options:
1. Seven days on followed by 7 days off
2. Other fixed rotation block schedules (such as 5-on 5-off; or 10-on 5-off)
3. Monday to Friday with rotating weekend coverage
4. Variable schedule
5. Other
Looking at HMG programs that serve only adult populations, a majority of them (48%) follow a fixed rotating schedule either 7 days on followed by 7 days off, or some other fixed schedule, while 31% of programs that responded stated that they used a Monday to Friday schedule. Looking at the programs as a whole, it would seem that the 7-on-7-off schedule was quickly losing popularity while the Monday to Friday schedule was increasingly being used. However, this broad generalization doesn’t really give you the full picture.
Upon analyzing the data further, we see some distinct differences arise based on program size. Small programs (fewer than 10 full-time employees [FTEs]) are much more likely to schedule a Monday to Friday schedule than any other model, whereas only a handful of large programs (greater than 20 FTEs) schedule in this way, rather choosing to use a 7-on-7-off schedule.
The last survey was done in 2014 and a lot has changed since then. Significantly more programs responded in 2016, compared with 2014 (530 vs. 355) and the majority of this increase was made of up smaller programs (fewer than 10 FTEs). Programs with four or fewer FTEs, compared with the prior survey, increased by over 400% (37 programs in 2014 vs. 151 programs in 2016). Overall, programs with fewer than 10 FTEs constituted over 50% of the total programs that responded in 2016 (whereas they made up only a third in 2014). This was particularly significant since size of the program was the one variable that determined how a program might schedule – other factors like geographic region, academic status, or primary hospital GME status did not show significant variance in how groups scheduled.
The second major change that occurred is that these same small programs (those with fewer than 10 FTEs) moved overwhelmingly to a Monday to Friday schedule. In 2014, only 3% of small programs scheduled using a Monday to Friday pattern, but in 2016 almost 50% of small programs reported scheduling in this way. This change in the overall composition of programs, with small programs now making up over 50% of the programs that reported, and the specific change in how small programs schedule results in a noteworthy decrease of programs using a 7 days on followed by 7 days off (7-on-7-off) schedule (53.8% in 2014 and only 38.1% in 2016), and a corresponding increase in the number of programs that schedule using a Monday to Friday schedule (4% in 2014 to 31% in 2016).
In distinct contrast to programs with fewer than 10 FTEs, a very similar number of programs with greater than 20 FTEs reported in 2016 as in 2014 – there was no increase in this subgroup. I’m not clear at this time if this is because there is truly no increase in the number of large programs nationally, or if there is another factor causing larger programs to under-report. The large programs that did report data in 2016 continue to utilize a 7-on-7-off schedule or another fixed rotating block schedule more than 50% of the time. In fact, the utilization of one of these two scheduling patterns increased slightly from 2014 to 2016 (from 52% to 58%). Those that did not use one of the prior mentioned scheduling patterns were most likely to schedule with a variable schedule. A Monday to Friday schedule was almost never used in programs of this size and showed no significant change from 2014 to 2016.
This snapshot highlights the changing landscape in hospital medicine. Hospital medicine is penetrating more and more into smaller and smaller hospitals, and has even made it into critical access hospitals. As recently as 5-10 years ago, it was felt that these hospitals were too small to have a hospital medicine program. This is likely one of the reasons for the increase in programs with four or fewer FTEs. There has also been increasing discontent with the 7-on-7-off schedule, which many feel is leading to burnout. Dr. Bob Wachter famously said during the closing plenary of the 2016 Society of Hospital Medicine Annual Meeting that the 7-on-7-off schedule was “a mistake.” Despite this brewing discontent, larger programs have not changed their scheduling patterns, likely because finding a another scheduling pattern that is effective, supports high-quality care, and is sustainable for such a large group is challenging.
Many people will say that there are as many different types of hospital medicine programs as there are hospital medicine programs. This is true for scheduling as for other aspects of hospital medicine operations. As we continue to grow and evolve as an industry, scheduling patterns will continue to change and evolve as well. For now, two patterns are emerging – smaller programs are utilizing a Monday to Friday schedule and larger programs are utilizing a 7-on-7-off schedule. Only time will tell if these scheduling patterns persist or continue to evolve.
Dr. George is a board certified internal medicine physician and practicing hospitalist with over 15 years of experience in hospital medicine. She has been actively involved in the Society of Hospital Medicine and has participated in and chaired multiple committees and task forces. She is currently executive vice president and chief medical officer of Hospital Medicine at Schumacher Clinical Partners, a national provider of emergency medicine and hospital medicine services. She lives in the northwest suburbs of Chicago with her family.
VIDEO: How to manage surgical pain in opioid addiction treatment
NEW ORLEANS – How do you manage surgical pain when someone is in treatment for opioid addiction? And how do you manage chronic pain?
It is possible to give patients opioids for post-op pain without increasing the risk of relapse, according to Margaret Chaplin, MD, a staff psychiatrist at Community Mental Health Affiliates in New Britain, Conn.
Dr. Chaplin generally uses buprenorphine and naloxone (Suboxone) for opioid use disorder, and she likes to keep her patients on it for surgery. That often means, however, talking with skeptical surgeons and anesthesiologists beforehand, and reminding them that buprenorphine itself has analgesic effects. Meanwhile, when her patients have chronic pain, sometimes they need help understanding that aspirin and acetaminophen help, even if they don’t give patients a warm, fuzzy feeling.
Dr. Chaplin shared those tips and more about pain management in opioid addiction in an interview at the American Psychiatric Association’s Institute on Psychiatric Services.
NEW ORLEANS – How do you manage surgical pain when someone is in treatment for opioid addiction? And how do you manage chronic pain?
It is possible to give patients opioids for post-op pain without increasing the risk of relapse, according to Margaret Chaplin, MD, a staff psychiatrist at Community Mental Health Affiliates in New Britain, Conn.
Dr. Chaplin generally uses buprenorphine and naloxone (Suboxone) for opioid use disorder, and she likes to keep her patients on it for surgery. That often means, however, talking with skeptical surgeons and anesthesiologists beforehand, and reminding them that buprenorphine itself has analgesic effects. Meanwhile, when her patients have chronic pain, sometimes they need help understanding that aspirin and acetaminophen help, even if they don’t give patients a warm, fuzzy feeling.
Dr. Chaplin shared those tips and more about pain management in opioid addiction in an interview at the American Psychiatric Association’s Institute on Psychiatric Services.
NEW ORLEANS – How do you manage surgical pain when someone is in treatment for opioid addiction? And how do you manage chronic pain?
It is possible to give patients opioids for post-op pain without increasing the risk of relapse, according to Margaret Chaplin, MD, a staff psychiatrist at Community Mental Health Affiliates in New Britain, Conn.
Dr. Chaplin generally uses buprenorphine and naloxone (Suboxone) for opioid use disorder, and she likes to keep her patients on it for surgery. That often means, however, talking with skeptical surgeons and anesthesiologists beforehand, and reminding them that buprenorphine itself has analgesic effects. Meanwhile, when her patients have chronic pain, sometimes they need help understanding that aspirin and acetaminophen help, even if they don’t give patients a warm, fuzzy feeling.
Dr. Chaplin shared those tips and more about pain management in opioid addiction in an interview at the American Psychiatric Association’s Institute on Psychiatric Services.
AT IPS 2017
Firearms’ injury toll of $3 billion just ‘a drop in the bucket’
SAN DIEGO – The true impact of firearms injuries may be greatly underestimated, according to a study presented at the American College of Surgeons Clinical Congress.
An analysis released earlier this month estimated that firearms injuries cost nearly $3 billion a year in emergency department and inpatient treatment costs. The real cost is likely to be 10-20 times higher, said the lead author of the study, Faiz Gani, MD, a research fellow with the Johns Hopkins Surgery Center for Outcomes Research, Baltimore.
“This is just a drop in the bucket,” Dr. Gani said in an interview at the annual clinical congress of the American College of Surgeons. 
Dr. Gani and his colleagues launched their study (Health Affairs 2017;36[10]:1729-38) to better understand the cost of firearms injuries, including nonfatal and accidental injuries.
Most estimates of the cost of firearm injuries are outdated or focused on states or single trauma centers, he said. “Contemporary [costs] for emergency rooms are unknown,” he said. “Also, the numbers come down and shoot up. It’s important to continually study this.”
The statistics are especially important to surgeons, who handle these injuries. “A lot of times the surgeon is the primary health care provider if the patient is injured severely. It’s important that we as surgeons know what’s going on.”
The researchers retrospectively analyzed data from the Nationwide Emergency Department Sample of the Healthcare Cost and Utilization Project for the years 2006-2014. They identified 150,930 patients who appeared alive in emergency departments over that period with firearms injuries, and they estimated the total weighted number at 704,916.
They found that the incidence of firearms injury admissions actually fell during 2006-2013 (from 27.9 visits per 100,000 people to 21.5, P < .001) but bumped up by 23.7% to 26.6 during 2013-2014 (P < .001).
Not surprisingly, more men were injured than women: 45.8 firearms-injured men per 100,000 patients presenting at emergency departments, compared with 5.5 firearms-injured women. Assaults (49.5%) and accidents (35.3%) accounted for most cases, followed by attempted suicides (5.3%) and legal intervention (2.4%).
Those who were assaulted had a higher likelihood of being poor, while those who tried to kill themselves were more likely to have the highest incomes among firearms-injured patients.
The average costs of emergency and inpatient care for patients injured by firearms were $5,254 and $95,887, respectively, collectively amounting to about $2.8 billion each year.
Dr. Gani mentioned that the estimation of the cost and impact of firearms injuries don’t account for people who died of firearms injuries before reaching the emergency department, he says, including patients who committed suicide and died at home.
The cost estimates also don’t take follow-up care, rehabilitation, and lifelong disability into account. The surgical portion of the cost is likely to be much higher because the study doesn’t take future surgical procedures into account, he said.
Based on estimates by the Centers for Disease Control and Prevention of the impact of the injuries, Dr. Gani argued that the true annual cost could be 10 or 20 times the nearly $3 billion estimated by the study.
Discussant Elliott R. Haut, MD, FACS, a trauma surgeon at Johns Hopkins Medicine in Baltimore, agreed that the study estimates of cost and impact estimated in the study represent a small part of a larger toll. Some families and individuals can pay those costs more than once. He recalls hearing from family members of firearm victims who recognize him because they’ve been at the hospital for other shooting incidents. “We’ve all heard someone say, ‘You were here the last time when my brother/cousin/uncle was shot,’ ” he said.
Future research should focus on better understanding the long-term cost of firearm injuries and the influence of socioeconomics and demographics, Dr. Gani said.
Dr. Gani and Dr. Haut reported no relevant disclosures.
SAN DIEGO – The true impact of firearms injuries may be greatly underestimated, according to a study presented at the American College of Surgeons Clinical Congress.
An analysis released earlier this month estimated that firearms injuries cost nearly $3 billion a year in emergency department and inpatient treatment costs. The real cost is likely to be 10-20 times higher, said the lead author of the study, Faiz Gani, MD, a research fellow with the Johns Hopkins Surgery Center for Outcomes Research, Baltimore.
“This is just a drop in the bucket,” Dr. Gani said in an interview at the annual clinical congress of the American College of Surgeons.
Dr. Gani and his colleagues launched their study (Health Affairs 2017;36[10]:1729-38) to better understand the cost of firearms injuries, including nonfatal and accidental injuries.
Most estimates of the cost of firearm injuries are outdated or focused on states or single trauma centers, he said. “Contemporary [costs] for emergency rooms are unknown,” he said. “Also, the numbers come down and shoot up. It’s important to continually study this.”
The statistics are especially important to surgeons, who handle these injuries. “A lot of times the surgeon is the primary health care provider if the patient is injured severely. It’s important that we as surgeons know what’s going on.”
The researchers retrospectively analyzed data from the Nationwide Emergency Department Sample of the Healthcare Cost and Utilization Project for the years 2006-2014. They identified 150,930 patients who appeared alive in emergency departments over that period with firearms injuries, and they estimated the total weighted number at 704,916.
They found that the incidence of firearms injury admissions actually fell during 2006-2013 (from 27.9 visits per 100,000 people to 21.5, P < .001) but bumped up by 23.7% to 26.6 during 2013-2014 (P < .001).
Not surprisingly, more men were injured than women: 45.8 firearms-injured men per 100,000 patients presenting at emergency departments, compared with 5.5 firearms-injured women. Assaults (49.5%) and accidents (35.3%) accounted for most cases, followed by attempted suicides (5.3%) and legal intervention (2.4%).
Those who were assaulted had a higher likelihood of being poor, while those who tried to kill themselves were more likely to have the highest incomes among firearms-injured patients.
The average costs of emergency and inpatient care for patients injured by firearms were $5,254 and $95,887, respectively, collectively amounting to about $2.8 billion each year.
Dr. Gani mentioned that the estimation of the cost and impact of firearms injuries don’t account for people who died of firearms injuries before reaching the emergency department, he says, including patients who committed suicide and died at home.
The cost estimates also don’t take follow-up care, rehabilitation, and lifelong disability into account. The surgical portion of the cost is likely to be much higher because the study doesn’t take future surgical procedures into account, he said.
Based on estimates by the Centers for Disease Control and Prevention of the impact of the injuries, Dr. Gani argued that the true annual cost could be 10 or 20 times the nearly $3 billion estimated by the study.
Discussant Elliott R. Haut, MD, FACS, a trauma surgeon at Johns Hopkins Medicine in Baltimore, agreed that the study estimates of cost and impact estimated in the study represent a small part of a larger toll. Some families and individuals can pay those costs more than once. He recalls hearing from family members of firearm victims who recognize him because they’ve been at the hospital for other shooting incidents. “We’ve all heard someone say, ‘You were here the last time when my brother/cousin/uncle was shot,’ ” he said.
Future research should focus on better understanding the long-term cost of firearm injuries and the influence of socioeconomics and demographics, Dr. Gani said.
Dr. Gani and Dr. Haut reported no relevant disclosures.
SAN DIEGO – The true impact of firearms injuries may be greatly underestimated, according to a study presented at the American College of Surgeons Clinical Congress.
An analysis released earlier this month estimated that firearms injuries cost nearly $3 billion a year in emergency department and inpatient treatment costs. The real cost is likely to be 10-20 times higher, said the lead author of the study, Faiz Gani, MD, a research fellow with the Johns Hopkins Surgery Center for Outcomes Research, Baltimore.
“This is just a drop in the bucket,” Dr. Gani said in an interview at the annual clinical congress of the American College of Surgeons.
Dr. Gani and his colleagues launched their study (Health Affairs 2017;36[10]:1729-38) to better understand the cost of firearms injuries, including nonfatal and accidental injuries.
Most estimates of the cost of firearm injuries are outdated or focused on states or single trauma centers, he said. “Contemporary [costs] for emergency rooms are unknown,” he said. “Also, the numbers come down and shoot up. It’s important to continually study this.”
The statistics are especially important to surgeons, who handle these injuries. “A lot of times the surgeon is the primary health care provider if the patient is injured severely. It’s important that we as surgeons know what’s going on.”
The researchers retrospectively analyzed data from the Nationwide Emergency Department Sample of the Healthcare Cost and Utilization Project for the years 2006-2014. They identified 150,930 patients who appeared alive in emergency departments over that period with firearms injuries, and they estimated the total weighted number at 704,916.
They found that the incidence of firearms injury admissions actually fell during 2006-2013 (from 27.9 visits per 100,000 people to 21.5, P < .001) but bumped up by 23.7% to 26.6 during 2013-2014 (P < .001).
Not surprisingly, more men were injured than women: 45.8 firearms-injured men per 100,000 patients presenting at emergency departments, compared with 5.5 firearms-injured women. Assaults (49.5%) and accidents (35.3%) accounted for most cases, followed by attempted suicides (5.3%) and legal intervention (2.4%).
Those who were assaulted had a higher likelihood of being poor, while those who tried to kill themselves were more likely to have the highest incomes among firearms-injured patients.
The average costs of emergency and inpatient care for patients injured by firearms were $5,254 and $95,887, respectively, collectively amounting to about $2.8 billion each year.
Dr. Gani mentioned that the estimation of the cost and impact of firearms injuries don’t account for people who died of firearms injuries before reaching the emergency department, he says, including patients who committed suicide and died at home.
The cost estimates also don’t take follow-up care, rehabilitation, and lifelong disability into account. The surgical portion of the cost is likely to be much higher because the study doesn’t take future surgical procedures into account, he said.
Based on estimates by the Centers for Disease Control and Prevention of the impact of the injuries, Dr. Gani argued that the true annual cost could be 10 or 20 times the nearly $3 billion estimated by the study.
Discussant Elliott R. Haut, MD, FACS, a trauma surgeon at Johns Hopkins Medicine in Baltimore, agreed that the study estimates of cost and impact estimated in the study represent a small part of a larger toll. Some families and individuals can pay those costs more than once. He recalls hearing from family members of firearm victims who recognize him because they’ve been at the hospital for other shooting incidents. “We’ve all heard someone say, ‘You were here the last time when my brother/cousin/uncle was shot,’ ” he said.
Future research should focus on better understanding the long-term cost of firearm injuries and the influence of socioeconomics and demographics, Dr. Gani said.
Dr. Gani and Dr. Haut reported no relevant disclosures.
AT THE ACS CLINICAL CONGRESS
Study: EHR malpractice claims rising
Malpractice claims involving the use of electronic health records (EHRs) are on the rise, according to data from The Doctors Company.
Cases in which EHRs were a factor grew from 2 claims during 2007-2010 to 161 claims from 2011 to December 2016, according an analysis published Oct. 16 by The Doctors Company, a national medical malpractice insurer.
The majority of EHR-related claims during 2014-2016 stemmed from incidents in a doctor’s office or a hospital clinic (35%), while the second most common location was a patient’s room. Malpractice claims involving EHRs were most commonly alleged against ob.gyns, followed by family physicians, and orthopedists. Diagnosis errors and improper medication management were the top most frequent allegations associated with EHR claims.
The analysis shows that while digitization of medicine has improved patient safety, it also has a dark side – as evidenced by the emergence of new kinds of errors, said Robert M. Wachter, MD, a professor at the University of California, San Francisco, and a member of the board of governors for The Doctors Company.
“This study makes an important contribution by chronicling actual errors, such as wrong medications selected from an autopick list, and helps point the way to changes ranging from physician education to EHR software design,” Dr. Wachter said in a statement.
[email protected]
On Twitter @legal_med
Malpractice claims involving the use of electronic health records (EHRs) are on the rise, according to data from The Doctors Company.
Cases in which EHRs were a factor grew from 2 claims during 2007-2010 to 161 claims from 2011 to December 2016, according an analysis published Oct. 16 by The Doctors Company, a national medical malpractice insurer.
The majority of EHR-related claims during 2014-2016 stemmed from incidents in a doctor’s office or a hospital clinic (35%), while the second most common location was a patient’s room. Malpractice claims involving EHRs were most commonly alleged against ob.gyns, followed by family physicians, and orthopedists. Diagnosis errors and improper medication management were the top most frequent allegations associated with EHR claims.
The analysis shows that while digitization of medicine has improved patient safety, it also has a dark side – as evidenced by the emergence of new kinds of errors, said Robert M. Wachter, MD, a professor at the University of California, San Francisco, and a member of the board of governors for The Doctors Company.
“This study makes an important contribution by chronicling actual errors, such as wrong medications selected from an autopick list, and helps point the way to changes ranging from physician education to EHR software design,” Dr. Wachter said in a statement.
[email protected]
On Twitter @legal_med
Malpractice claims involving the use of electronic health records (EHRs) are on the rise, according to data from The Doctors Company.
Cases in which EHRs were a factor grew from 2 claims during 2007-2010 to 161 claims from 2011 to December 2016, according an analysis published Oct. 16 by The Doctors Company, a national medical malpractice insurer.
The majority of EHR-related claims during 2014-2016 stemmed from incidents in a doctor’s office or a hospital clinic (35%), while the second most common location was a patient’s room. Malpractice claims involving EHRs were most commonly alleged against ob.gyns, followed by family physicians, and orthopedists. Diagnosis errors and improper medication management were the top most frequent allegations associated with EHR claims.
The analysis shows that while digitization of medicine has improved patient safety, it also has a dark side – as evidenced by the emergence of new kinds of errors, said Robert M. Wachter, MD, a professor at the University of California, San Francisco, and a member of the board of governors for The Doctors Company.
“This study makes an important contribution by chronicling actual errors, such as wrong medications selected from an autopick list, and helps point the way to changes ranging from physician education to EHR software design,” Dr. Wachter said in a statement.
[email protected]
On Twitter @legal_med
Key clinical point:
Major finding: Cases in which EHRs were a factor grew from 2 claims during 2007-2010 to 161 claims from 2011 to December 2016
Data source: Review of 163 claims from 2007 to 2016 in The Doctors Company database.
Disclosures: The study was funded by The Doctors Company.
Thinking about productivity: Survey data 2017
The 2017 MGMA survey data on compensation and productivity were released last June. While the numbers aren’t surprising, reviewing them always gets me thinking about factors that influence reasonable expectations for compensation and productivity in any individual hospitalist group.
The data were collected in early 2017, reflecting work done in 2016, and show a national median hospitalist compensation for internal medicine physicians of $284,000, up from $278,500 the year before. Since MGMA added a hospitalist category to the survey, compensation has been growing significantly faster than inflation, even though productivity has been essentially flat. I’ve always thought that the high demand for hospitalists, which isn’t letting up much, in the face of a limited supply is probably the most significant force causing hospitalist compensation to rise faster than in most other specialties.
The survey shows a median of 2,114 billed encounters and 4,159 wRVUs (work relative value units) generated per internal medicine hospitalist annually (family medicine hospitalists are reported separately). These numbers have been pretty stable for many years.
Whether it is reasonable to expect hospitalists in your group to produce at this level is a question that can unspool into a lengthy conversation. Below are several assertions I regularly hear others make about productivity, and following each is my commentary.
“Surveys show only what is most typical, not what is optimal. Our field suffers from concerning levels of burnout, essentially proving that median levels of productivity shown in surveys is too high.”
I share this concern, but this is a complicated issue. You’ll have to make up your own mind regarding how significantly workload influences hospitalist burnout. But the modest amount of published research on this topic suggests that workload itself isn’t as strongly associated with burnout as you might think. I’m certain workload does play a role, but other factors such as “occupational solidarity” seem to matter more. Lowering workload in some settings might be appropriate, but without other interventions may not influence work-related stress and burnout as much as might be hoped.
“Surveys don’t capture unbillable activities (‘unbillable wRVUs’), so are a poor frame of reference when thinking about productivity expectations in our own group.”
It’s true that hospitalists do a lot of work that isn’t captured in wRVUs. My work with many groups around the country suggests the amount and difficulty of this unbillable work is reasonably similar across most groups. We all spend time with handoffs, managing paperwork such as charge capture and completing forms, responding to a rapid response call that doesn’t lead to a billable charge, etc. The average amount of this sort of work is built into the survey. Clearly some groups are outliers with meaningfully more unbillable work than elsewhere, but that can be a difficult or impossible thing to prove.
“My hospital has unique barriers to efficiency/productivity, so it’s more difficult to achieve levels of productivity shown in surveys.”
This is another way of expressing the previous issue. To support this assertion hospitalists will mention that it is tougher to be productive at their hospital because they’re a referral center with unusually sick and complicated patients; they teach trainees in addition to clinical care; and/or their patients and families are unusually demanding, so they take much more time than at other places.
Yet for each of these issues I also hear the reverse argument regularly. Hospitalists point out that because they’re a small hospital (not a referral center) they lack the support of other specialties so must manage all aspects of care themselves; they don’t have residents to help do some of the work; and their patients are unsophisticated and lack social support. For these reasons, the argument goes, they shouldn’t be expected to achieve levels of productivity shown in surveys.
I have worked with hospitalist groups that I am convinced do face unusual barriers to efficiency that are meaningful enough that unless the barriers can be addressed, I think productivity expectations should be lower than survey benchmarks. For example, in most academic medical centers and a very small number of nonacademic hospitals, only the attending physician writes orders; consulting doctors don’t. This means that the attending hospitalist must check a patient’s chart repeatedly through the day just to see if the consultant proposed even small things like ordering a routine lab test, advancing the diet, etc., that the hospitalist must order.
A separate daytime admitter shift is a modest barrier to efficiency that is so common it is clearly factored into survey results. Most hospitalist groups with more than about five doctors working daily have one doctor (or more than one in large groups) manage admissions while the rest round and are protected from admissions. While this may have a number of benefits, overall hospitalist efficiency isn’t one of them. It means that all patients, not just those admitted at night, will have a handoff from the admitting provider to a new attending for the first rounding visit. This new attending will spend additional time becoming familiar with the patient – time that wouldn’t be necessary had that doctor performed the admission visit herself.
“Our hospitalist group is always being asked to take on more duties, such as managing med reconciliation, taking referrals from an additional PCP group, or serving as admitting and attending physician for patients previously admitted by a different specialty (which now serves in the consultant role). For this reason, it’s necessary to steadily lower hospitalist productivity expectations over time.”
A hospitalist today probably spends a quarter of the day doing things I didn’t have to do at the outset of my career in the 1980s. So my impulse is to agree that as the breadth of our responsibilities expands, expected wRVU productivity should fall. But surveys over the last 15-20 years don’t show this happening, and the pressure to maintain productivity levels isn’t likely to let up. Rather than generating fewer wRVUs (seeing fewer patients), hospital medicine, like health care as a whole, faces the challenge of continually improving our efficiency.
“Surveys are only one frame of reference for determining expectations at my particular hospitalist group. There are other factors to consider as well.”
This is absolutely true. There may be many reasons for your group to set expectations that are meaningfully different from survey figures. Just make sure your rationale for doing so is well considered and effectively communicated to other stakeholders, such as those in finance and organizational leadership at your organization.
Dr. Nelson has had a career in clinical practice as a hospitalist starting in 1988. He is cofounder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is codirector for SHM’s practice management courses. [email protected]
The 2017 MGMA survey data on compensation and productivity were released last June. While the numbers aren’t surprising, reviewing them always gets me thinking about factors that influence reasonable expectations for compensation and productivity in any individual hospitalist group.
The data were collected in early 2017, reflecting work done in 2016, and show a national median hospitalist compensation for internal medicine physicians of $284,000, up from $278,500 the year before. Since MGMA added a hospitalist category to the survey, compensation has been growing significantly faster than inflation, even though productivity has been essentially flat. I’ve always thought that the high demand for hospitalists, which isn’t letting up much, in the face of a limited supply is probably the most significant force causing hospitalist compensation to rise faster than in most other specialties.
The survey shows a median of 2,114 billed encounters and 4,159 wRVUs (work relative value units) generated per internal medicine hospitalist annually (family medicine hospitalists are reported separately). These numbers have been pretty stable for many years.
Whether it is reasonable to expect hospitalists in your group to produce at this level is a question that can unspool into a lengthy conversation. Below are several assertions I regularly hear others make about productivity, and following each is my commentary.
“Surveys show only what is most typical, not what is optimal. Our field suffers from concerning levels of burnout, essentially proving that median levels of productivity shown in surveys is too high.”
I share this concern, but this is a complicated issue. You’ll have to make up your own mind regarding how significantly workload influences hospitalist burnout. But the modest amount of published research on this topic suggests that workload itself isn’t as strongly associated with burnout as you might think. I’m certain workload does play a role, but other factors such as “occupational solidarity” seem to matter more. Lowering workload in some settings might be appropriate, but without other interventions may not influence work-related stress and burnout as much as might be hoped.
“Surveys don’t capture unbillable activities (‘unbillable wRVUs’), so are a poor frame of reference when thinking about productivity expectations in our own group.”
It’s true that hospitalists do a lot of work that isn’t captured in wRVUs. My work with many groups around the country suggests the amount and difficulty of this unbillable work is reasonably similar across most groups. We all spend time with handoffs, managing paperwork such as charge capture and completing forms, responding to a rapid response call that doesn’t lead to a billable charge, etc. The average amount of this sort of work is built into the survey. Clearly some groups are outliers with meaningfully more unbillable work than elsewhere, but that can be a difficult or impossible thing to prove.
“My hospital has unique barriers to efficiency/productivity, so it’s more difficult to achieve levels of productivity shown in surveys.”
This is another way of expressing the previous issue. To support this assertion hospitalists will mention that it is tougher to be productive at their hospital because they’re a referral center with unusually sick and complicated patients; they teach trainees in addition to clinical care; and/or their patients and families are unusually demanding, so they take much more time than at other places.
Yet for each of these issues I also hear the reverse argument regularly. Hospitalists point out that because they’re a small hospital (not a referral center) they lack the support of other specialties so must manage all aspects of care themselves; they don’t have residents to help do some of the work; and their patients are unsophisticated and lack social support. For these reasons, the argument goes, they shouldn’t be expected to achieve levels of productivity shown in surveys.
I have worked with hospitalist groups that I am convinced do face unusual barriers to efficiency that are meaningful enough that unless the barriers can be addressed, I think productivity expectations should be lower than survey benchmarks. For example, in most academic medical centers and a very small number of nonacademic hospitals, only the attending physician writes orders; consulting doctors don’t. This means that the attending hospitalist must check a patient’s chart repeatedly through the day just to see if the consultant proposed even small things like ordering a routine lab test, advancing the diet, etc., that the hospitalist must order.
A separate daytime admitter shift is a modest barrier to efficiency that is so common it is clearly factored into survey results. Most hospitalist groups with more than about five doctors working daily have one doctor (or more than one in large groups) manage admissions while the rest round and are protected from admissions. While this may have a number of benefits, overall hospitalist efficiency isn’t one of them. It means that all patients, not just those admitted at night, will have a handoff from the admitting provider to a new attending for the first rounding visit. This new attending will spend additional time becoming familiar with the patient – time that wouldn’t be necessary had that doctor performed the admission visit herself.
“Our hospitalist group is always being asked to take on more duties, such as managing med reconciliation, taking referrals from an additional PCP group, or serving as admitting and attending physician for patients previously admitted by a different specialty (which now serves in the consultant role). For this reason, it’s necessary to steadily lower hospitalist productivity expectations over time.”
A hospitalist today probably spends a quarter of the day doing things I didn’t have to do at the outset of my career in the 1980s. So my impulse is to agree that as the breadth of our responsibilities expands, expected wRVU productivity should fall. But surveys over the last 15-20 years don’t show this happening, and the pressure to maintain productivity levels isn’t likely to let up. Rather than generating fewer wRVUs (seeing fewer patients), hospital medicine, like health care as a whole, faces the challenge of continually improving our efficiency.
“Surveys are only one frame of reference for determining expectations at my particular hospitalist group. There are other factors to consider as well.”
This is absolutely true. There may be many reasons for your group to set expectations that are meaningfully different from survey figures. Just make sure your rationale for doing so is well considered and effectively communicated to other stakeholders, such as those in finance and organizational leadership at your organization.
Dr. Nelson has had a career in clinical practice as a hospitalist starting in 1988. He is cofounder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is codirector for SHM’s practice management courses. [email protected]
The 2017 MGMA survey data on compensation and productivity were released last June. While the numbers aren’t surprising, reviewing them always gets me thinking about factors that influence reasonable expectations for compensation and productivity in any individual hospitalist group.
The data were collected in early 2017, reflecting work done in 2016, and show a national median hospitalist compensation for internal medicine physicians of $284,000, up from $278,500 the year before. Since MGMA added a hospitalist category to the survey, compensation has been growing significantly faster than inflation, even though productivity has been essentially flat. I’ve always thought that the high demand for hospitalists, which isn’t letting up much, in the face of a limited supply is probably the most significant force causing hospitalist compensation to rise faster than in most other specialties.
The survey shows a median of 2,114 billed encounters and 4,159 wRVUs (work relative value units) generated per internal medicine hospitalist annually (family medicine hospitalists are reported separately). These numbers have been pretty stable for many years.
Whether it is reasonable to expect hospitalists in your group to produce at this level is a question that can unspool into a lengthy conversation. Below are several assertions I regularly hear others make about productivity, and following each is my commentary.
“Surveys show only what is most typical, not what is optimal. Our field suffers from concerning levels of burnout, essentially proving that median levels of productivity shown in surveys is too high.”
I share this concern, but this is a complicated issue. You’ll have to make up your own mind regarding how significantly workload influences hospitalist burnout. But the modest amount of published research on this topic suggests that workload itself isn’t as strongly associated with burnout as you might think. I’m certain workload does play a role, but other factors such as “occupational solidarity” seem to matter more. Lowering workload in some settings might be appropriate, but without other interventions may not influence work-related stress and burnout as much as might be hoped.
“Surveys don’t capture unbillable activities (‘unbillable wRVUs’), so are a poor frame of reference when thinking about productivity expectations in our own group.”
It’s true that hospitalists do a lot of work that isn’t captured in wRVUs. My work with many groups around the country suggests the amount and difficulty of this unbillable work is reasonably similar across most groups. We all spend time with handoffs, managing paperwork such as charge capture and completing forms, responding to a rapid response call that doesn’t lead to a billable charge, etc. The average amount of this sort of work is built into the survey. Clearly some groups are outliers with meaningfully more unbillable work than elsewhere, but that can be a difficult or impossible thing to prove.
“My hospital has unique barriers to efficiency/productivity, so it’s more difficult to achieve levels of productivity shown in surveys.”
This is another way of expressing the previous issue. To support this assertion hospitalists will mention that it is tougher to be productive at their hospital because they’re a referral center with unusually sick and complicated patients; they teach trainees in addition to clinical care; and/or their patients and families are unusually demanding, so they take much more time than at other places.
Yet for each of these issues I also hear the reverse argument regularly. Hospitalists point out that because they’re a small hospital (not a referral center) they lack the support of other specialties so must manage all aspects of care themselves; they don’t have residents to help do some of the work; and their patients are unsophisticated and lack social support. For these reasons, the argument goes, they shouldn’t be expected to achieve levels of productivity shown in surveys.
I have worked with hospitalist groups that I am convinced do face unusual barriers to efficiency that are meaningful enough that unless the barriers can be addressed, I think productivity expectations should be lower than survey benchmarks. For example, in most academic medical centers and a very small number of nonacademic hospitals, only the attending physician writes orders; consulting doctors don’t. This means that the attending hospitalist must check a patient’s chart repeatedly through the day just to see if the consultant proposed even small things like ordering a routine lab test, advancing the diet, etc., that the hospitalist must order.
A separate daytime admitter shift is a modest barrier to efficiency that is so common it is clearly factored into survey results. Most hospitalist groups with more than about five doctors working daily have one doctor (or more than one in large groups) manage admissions while the rest round and are protected from admissions. While this may have a number of benefits, overall hospitalist efficiency isn’t one of them. It means that all patients, not just those admitted at night, will have a handoff from the admitting provider to a new attending for the first rounding visit. This new attending will spend additional time becoming familiar with the patient – time that wouldn’t be necessary had that doctor performed the admission visit herself.
“Our hospitalist group is always being asked to take on more duties, such as managing med reconciliation, taking referrals from an additional PCP group, or serving as admitting and attending physician for patients previously admitted by a different specialty (which now serves in the consultant role). For this reason, it’s necessary to steadily lower hospitalist productivity expectations over time.”
A hospitalist today probably spends a quarter of the day doing things I didn’t have to do at the outset of my career in the 1980s. So my impulse is to agree that as the breadth of our responsibilities expands, expected wRVU productivity should fall. But surveys over the last 15-20 years don’t show this happening, and the pressure to maintain productivity levels isn’t likely to let up. Rather than generating fewer wRVUs (seeing fewer patients), hospital medicine, like health care as a whole, faces the challenge of continually improving our efficiency.
“Surveys are only one frame of reference for determining expectations at my particular hospitalist group. There are other factors to consider as well.”
This is absolutely true. There may be many reasons for your group to set expectations that are meaningfully different from survey figures. Just make sure your rationale for doing so is well considered and effectively communicated to other stakeholders, such as those in finance and organizational leadership at your organization.
Dr. Nelson has had a career in clinical practice as a hospitalist starting in 1988. He is cofounder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is codirector for SHM’s practice management courses. [email protected]
SHM pushes to protect patients from ‘surprise’ out-of-network expenses
Patients entering a hospital should not be on the hook for costs related to out-of-network insurance coverage when that hospital is in-network, according to the Society of Hospital Medicine and other major medical societies, especially if it is an emergency situation and the patient is unable to make an informed choice regarding who is administering care to them.
“We want to see it come to a resolution that does not put patients in jeopardy for paying these extra costs when they are going a hospital that is in-network, and they assume that the physicians are in-network,” Ron Greeno, MD, FCCP, MHM, president of the Society of Hospital Medicine, said in an interview.
Other groups signing onto the resolution include the American College of Emergency Physicians, the American Academy of Orthopedic Surgeons, the American College of Radiology, the American Society of Anesthesiologists, the College of American Pathologists, the American Association of Neurological Surgeons, and the Congress of Neurological Surgeons.
“States are tackling this on a state-by-state basis and creating laws that are meant to protect patients from being placed in legal jeopardy,” Dr. Greeno said. “But you still want to maintain the rights of the health plan and the physicians to negotiate in good faith. That is basically the stance we take.”
According to Dr. Greeno, the joint resolution passed at the AMA meeting was “designed to make recommendations to states who are considering such laws.” The medical societies want to provide guidance on what to include in those laws that will make the process fair. “If you have a law that says ‘out of network doctors cannot balance bill at a hospital that is in-network,’ then the health plans have no reason to negotiate in good faith,” he said. “They will just pay those doctors whatever they feel like paying them.”
Ultimately, though, the resolution was about medical societies affirming their desire to protect patients from burdensome, unexpected bills.
“We want to make sure whatever laws are passed that they actually protect the patients while maintaining the ability of physicians and health plans to negotiate in good faith to a mutual resolution,” Dr. Greeno said.
Patients entering a hospital should not be on the hook for costs related to out-of-network insurance coverage when that hospital is in-network, according to the Society of Hospital Medicine and other major medical societies, especially if it is an emergency situation and the patient is unable to make an informed choice regarding who is administering care to them.
“We want to see it come to a resolution that does not put patients in jeopardy for paying these extra costs when they are going a hospital that is in-network, and they assume that the physicians are in-network,” Ron Greeno, MD, FCCP, MHM, president of the Society of Hospital Medicine, said in an interview.
Other groups signing onto the resolution include the American College of Emergency Physicians, the American Academy of Orthopedic Surgeons, the American College of Radiology, the American Society of Anesthesiologists, the College of American Pathologists, the American Association of Neurological Surgeons, and the Congress of Neurological Surgeons.
“States are tackling this on a state-by-state basis and creating laws that are meant to protect patients from being placed in legal jeopardy,” Dr. Greeno said. “But you still want to maintain the rights of the health plan and the physicians to negotiate in good faith. That is basically the stance we take.”
According to Dr. Greeno, the joint resolution passed at the AMA meeting was “designed to make recommendations to states who are considering such laws.” The medical societies want to provide guidance on what to include in those laws that will make the process fair. “If you have a law that says ‘out of network doctors cannot balance bill at a hospital that is in-network,’ then the health plans have no reason to negotiate in good faith,” he said. “They will just pay those doctors whatever they feel like paying them.”
Ultimately, though, the resolution was about medical societies affirming their desire to protect patients from burdensome, unexpected bills.
“We want to make sure whatever laws are passed that they actually protect the patients while maintaining the ability of physicians and health plans to negotiate in good faith to a mutual resolution,” Dr. Greeno said.
Patients entering a hospital should not be on the hook for costs related to out-of-network insurance coverage when that hospital is in-network, according to the Society of Hospital Medicine and other major medical societies, especially if it is an emergency situation and the patient is unable to make an informed choice regarding who is administering care to them.
“We want to see it come to a resolution that does not put patients in jeopardy for paying these extra costs when they are going a hospital that is in-network, and they assume that the physicians are in-network,” Ron Greeno, MD, FCCP, MHM, president of the Society of Hospital Medicine, said in an interview.
Other groups signing onto the resolution include the American College of Emergency Physicians, the American Academy of Orthopedic Surgeons, the American College of Radiology, the American Society of Anesthesiologists, the College of American Pathologists, the American Association of Neurological Surgeons, and the Congress of Neurological Surgeons.
“States are tackling this on a state-by-state basis and creating laws that are meant to protect patients from being placed in legal jeopardy,” Dr. Greeno said. “But you still want to maintain the rights of the health plan and the physicians to negotiate in good faith. That is basically the stance we take.”
According to Dr. Greeno, the joint resolution passed at the AMA meeting was “designed to make recommendations to states who are considering such laws.” The medical societies want to provide guidance on what to include in those laws that will make the process fair. “If you have a law that says ‘out of network doctors cannot balance bill at a hospital that is in-network,’ then the health plans have no reason to negotiate in good faith,” he said. “They will just pay those doctors whatever they feel like paying them.”
Ultimately, though, the resolution was about medical societies affirming their desire to protect patients from burdensome, unexpected bills.
“We want to make sure whatever laws are passed that they actually protect the patients while maintaining the ability of physicians and health plans to negotiate in good faith to a mutual resolution,” Dr. Greeno said.
Advance care planning benefit presents challenges
When Donna Sweet, MD, sees patients for routine exams, death and dying are often the furthest thing from their minds. Regardless of age or health status, however, Dr. Sweet regularly asks patients about end-of-life care and whether they’ve considered their options.
In the past, physicians had to be creative in how they coded for such conversations, but Medicare’s newish advance care planning benefit is changing that.
Staring in 2016, the Centers for Medicare & Medicaid Services began reimbursing physicians for advance care planning discussions with the approval of two new codes: 99497 and 99498. The codes pay about $86 for the first 30-minutes of a face-to-face conversation with a patient, family member, and/or surrogate and about $75 for additional sessions. Services can be furnished in both inpatient and ambulatory settings, and payment is not limited to particular physician specialties.
Dr. Sweet said that she uses these codes a couple times a week when patients visit for reasons such as routine hypertension or diabetes exams or annual Medicare wellness visits. To broach the subject, Dr. Sweet said it helps to have literature about advance care planning in the room that patients can review.
“It’s just a matter of bringing it up,” she said. “Considering some of the other codes, the advance care planning code is really pretty simple.”
However, doctors like Dr. Sweet appear to be in the minority when it comes to providing this service. Of the nearly 57 million beneficiaries enrolled in Medicare at the end of 2016, only about 1% received advance care planning sessions, according to analysis of Medicare data posted by Kaiser Health News. Nationwide, health providers submitted about $93 million in charges, of which $43 million was paid by Medicare.
Challenges deter conversations
During a recent visit with a 72-year-old cancer patient, Bridget Fahy, MD, a surgical oncologist at the University of New Mexico, Albuquerque, spent time discussing advance directives and the importance of naming a surrogate decision maker. Dr. Fahy had treated the patient for two different cancers over the course of 4 years, and he was now diagnosed with a third, she recalled during an interview. Figuring out an advance care plan, though, proved complicated: The man was not married, had no children, and had no family members who lived in the state.
Although Dr. Fahy was aware of the Medicare advance care planning codes, she did not bill the session as such.
“Even in the course of having that conversation, I’m more apt to bill on time than I am specifically to meet the Medicare requirements for the documentation for [the benefit],” she said.
“There are two pieces required to take advantage of the advance care planning benefit code: having the conversation and documenting it,” Dr. Fahy noted. “What I write at the end of a resident note or an advanced practice provider note is going to be more focused on the counseling I had with the patient about their condition, the evaluation, and what the treatment plan is going to be. For surgeons to utilize the advance care planning codes, they have to have knowledge of the code, which many do not; they must know the requirements for documenting the conversation; and they have to have the time needed to have the conversation while also addressing all of the surgery-specific issues that need to be covered during the visit. There are a number of hurdles to overcome.”
Danielle B. Scheurer, MD, a hospitalist and chief quality officer at the Medical University of South Carolina, Charleston, said that she, too, has not used advance care planning codes. The reimbursement tool is a positive step forward, she said, but so far, it’s not an easy insert into a hospitalist’s practice.
“It’s not top of mind as far as a billing practice,” she said. “It’s not built into the typical work flow. Obviously, it’s not every patient, it’s not everyday, so you have to remember to put it into your work flow. That’s probably the biggest barrier for most hospitalists: either not knowing about it at all or not yet figuring out how to weave it into what they already do.”
Overcoming hurdles through experience
Using the advance care planning benefit has been easier said than done in his practice, according to Carl R. Olden, MD, a family physician in Yakima, Wash. The logistics of scheduling and patient reluctance are contributing to low usage of the new codes, said Dr. Olden, a member of the American Academy of Family Physicians board of directors.
Between Sept. 1, 2016, and Aug. 31, 2017, the family medicine, primary care, internal medicine, and pulmonary medicine members of Dr. Olden’s network who provide end-of-life counseling submitted billing for a total of 106,160 Medicare visits. Of those visits, the 99497 code was submitted only 32 times, according to data provided by Dr. Olden.
At Dr. Olden’s 16-physician practice, there are no registered nurses to help set up and start Medicare wellness visits, which the advance care planning session benefit is designed to fit within, he said.
“Most of those Medicare wellness visits are driven by having a registered nurse do most of the work,” he said. “[For us] to schedule a wellness visit, it’s mostly physician work and to do a 30-minute wellness visit, most of us can see three patients in that 30-minute slot, so it ends up not being very cost effective.”
“Most of my Medicare patients are folks that have four to five chronic medical conditions, and for them to make a 30-minute visit to the office and not talk about any of those conditions but to talk about home safety and advance directives and fall prevention, it’s hard for them to understand that,” he said.
Dr. Newman stresses that while the billing approach takes time to learn, the codes can be weaved into regular practice with some preparation and planning. At her practice, she primarily uses the codes for patients with challenging changes in their health status, sometimes setting up meetings in advance and, other times, conducting a spur-of-the-moment conversation.
“It’s a wonderful benefit,” she said. “I’m not surprised it’s taking awhile to take hold. The reason is you have to prepare for these visits. It takes preparation, including a chart review.”
A common misconception is that the visit must be scheduled separately and cannot be added to another visit, she said. Doctors can bill the advance care planning codes on the same day as an evaluation and management service. For instance, if a patient is accompanied by a family member and seen for routine follow-up, the physician can discuss the medical conditions first and later have a discussion about advance care planning. When billing, the physician can then use an evaluation and management code for the part of the visit related to the patient’s medical conditions and also bill for the advance care planning discussion using the new Medicare codes, Dr. Newman said.
“You’re allowed to use a modifier to attach to it to get paid for both on the same day,” she said. She suggested checking local Medicare policy for the use of the appropriate modifier, usually 26. “One thing that’s important to understand is there’s a lot of short discussions about advanced care planning that doesn’t fit the code. So if a patient wants to have a 5-minute conversation – that happens a lot – these will not be billable or counted under this new benefit. Fifteen minutes is the least amount of time that qualifies for 99497.”
Dr. Sweet said that she expects greater use of the codes as more doctors become aware of how they can be used.
“Once people use it a time or two, they will use it a lot more,” Dr. Sweet said. “It takes time to change, and it takes time to make time to do the things we need to do. But especially, as we move into high-value care, something like this hopefully, [doctors] will embrace.”
[email protected]
On Twitter @legal_med
When Donna Sweet, MD, sees patients for routine exams, death and dying are often the furthest thing from their minds. Regardless of age or health status, however, Dr. Sweet regularly asks patients about end-of-life care and whether they’ve considered their options.
In the past, physicians had to be creative in how they coded for such conversations, but Medicare’s newish advance care planning benefit is changing that.
Staring in 2016, the Centers for Medicare & Medicaid Services began reimbursing physicians for advance care planning discussions with the approval of two new codes: 99497 and 99498. The codes pay about $86 for the first 30-minutes of a face-to-face conversation with a patient, family member, and/or surrogate and about $75 for additional sessions. Services can be furnished in both inpatient and ambulatory settings, and payment is not limited to particular physician specialties.
Dr. Sweet said that she uses these codes a couple times a week when patients visit for reasons such as routine hypertension or diabetes exams or annual Medicare wellness visits. To broach the subject, Dr. Sweet said it helps to have literature about advance care planning in the room that patients can review.
“It’s just a matter of bringing it up,” she said. “Considering some of the other codes, the advance care planning code is really pretty simple.”
However, doctors like Dr. Sweet appear to be in the minority when it comes to providing this service. Of the nearly 57 million beneficiaries enrolled in Medicare at the end of 2016, only about 1% received advance care planning sessions, according to analysis of Medicare data posted by Kaiser Health News. Nationwide, health providers submitted about $93 million in charges, of which $43 million was paid by Medicare.
Challenges deter conversations
During a recent visit with a 72-year-old cancer patient, Bridget Fahy, MD, a surgical oncologist at the University of New Mexico, Albuquerque, spent time discussing advance directives and the importance of naming a surrogate decision maker. Dr. Fahy had treated the patient for two different cancers over the course of 4 years, and he was now diagnosed with a third, she recalled during an interview. Figuring out an advance care plan, though, proved complicated: The man was not married, had no children, and had no family members who lived in the state.
Although Dr. Fahy was aware of the Medicare advance care planning codes, she did not bill the session as such.
“Even in the course of having that conversation, I’m more apt to bill on time than I am specifically to meet the Medicare requirements for the documentation for [the benefit],” she said.
“There are two pieces required to take advantage of the advance care planning benefit code: having the conversation and documenting it,” Dr. Fahy noted. “What I write at the end of a resident note or an advanced practice provider note is going to be more focused on the counseling I had with the patient about their condition, the evaluation, and what the treatment plan is going to be. For surgeons to utilize the advance care planning codes, they have to have knowledge of the code, which many do not; they must know the requirements for documenting the conversation; and they have to have the time needed to have the conversation while also addressing all of the surgery-specific issues that need to be covered during the visit. There are a number of hurdles to overcome.”
Danielle B. Scheurer, MD, a hospitalist and chief quality officer at the Medical University of South Carolina, Charleston, said that she, too, has not used advance care planning codes. The reimbursement tool is a positive step forward, she said, but so far, it’s not an easy insert into a hospitalist’s practice.
“It’s not top of mind as far as a billing practice,” she said. “It’s not built into the typical work flow. Obviously, it’s not every patient, it’s not everyday, so you have to remember to put it into your work flow. That’s probably the biggest barrier for most hospitalists: either not knowing about it at all or not yet figuring out how to weave it into what they already do.”
Overcoming hurdles through experience
Using the advance care planning benefit has been easier said than done in his practice, according to Carl R. Olden, MD, a family physician in Yakima, Wash. The logistics of scheduling and patient reluctance are contributing to low usage of the new codes, said Dr. Olden, a member of the American Academy of Family Physicians board of directors.
Between Sept. 1, 2016, and Aug. 31, 2017, the family medicine, primary care, internal medicine, and pulmonary medicine members of Dr. Olden’s network who provide end-of-life counseling submitted billing for a total of 106,160 Medicare visits. Of those visits, the 99497 code was submitted only 32 times, according to data provided by Dr. Olden.
At Dr. Olden’s 16-physician practice, there are no registered nurses to help set up and start Medicare wellness visits, which the advance care planning session benefit is designed to fit within, he said.
“Most of those Medicare wellness visits are driven by having a registered nurse do most of the work,” he said. “[For us] to schedule a wellness visit, it’s mostly physician work and to do a 30-minute wellness visit, most of us can see three patients in that 30-minute slot, so it ends up not being very cost effective.”
“Most of my Medicare patients are folks that have four to five chronic medical conditions, and for them to make a 30-minute visit to the office and not talk about any of those conditions but to talk about home safety and advance directives and fall prevention, it’s hard for them to understand that,” he said.
Dr. Newman stresses that while the billing approach takes time to learn, the codes can be weaved into regular practice with some preparation and planning. At her practice, she primarily uses the codes for patients with challenging changes in their health status, sometimes setting up meetings in advance and, other times, conducting a spur-of-the-moment conversation.
“It’s a wonderful benefit,” she said. “I’m not surprised it’s taking awhile to take hold. The reason is you have to prepare for these visits. It takes preparation, including a chart review.”
A common misconception is that the visit must be scheduled separately and cannot be added to another visit, she said. Doctors can bill the advance care planning codes on the same day as an evaluation and management service. For instance, if a patient is accompanied by a family member and seen for routine follow-up, the physician can discuss the medical conditions first and later have a discussion about advance care planning. When billing, the physician can then use an evaluation and management code for the part of the visit related to the patient’s medical conditions and also bill for the advance care planning discussion using the new Medicare codes, Dr. Newman said.
“You’re allowed to use a modifier to attach to it to get paid for both on the same day,” she said. She suggested checking local Medicare policy for the use of the appropriate modifier, usually 26. “One thing that’s important to understand is there’s a lot of short discussions about advanced care planning that doesn’t fit the code. So if a patient wants to have a 5-minute conversation – that happens a lot – these will not be billable or counted under this new benefit. Fifteen minutes is the least amount of time that qualifies for 99497.”
Dr. Sweet said that she expects greater use of the codes as more doctors become aware of how they can be used.
“Once people use it a time or two, they will use it a lot more,” Dr. Sweet said. “It takes time to change, and it takes time to make time to do the things we need to do. But especially, as we move into high-value care, something like this hopefully, [doctors] will embrace.”
[email protected]
On Twitter @legal_med
When Donna Sweet, MD, sees patients for routine exams, death and dying are often the furthest thing from their minds. Regardless of age or health status, however, Dr. Sweet regularly asks patients about end-of-life care and whether they’ve considered their options.
In the past, physicians had to be creative in how they coded for such conversations, but Medicare’s newish advance care planning benefit is changing that.
Staring in 2016, the Centers for Medicare & Medicaid Services began reimbursing physicians for advance care planning discussions with the approval of two new codes: 99497 and 99498. The codes pay about $86 for the first 30-minutes of a face-to-face conversation with a patient, family member, and/or surrogate and about $75 for additional sessions. Services can be furnished in both inpatient and ambulatory settings, and payment is not limited to particular physician specialties.
Dr. Sweet said that she uses these codes a couple times a week when patients visit for reasons such as routine hypertension or diabetes exams or annual Medicare wellness visits. To broach the subject, Dr. Sweet said it helps to have literature about advance care planning in the room that patients can review.
“It’s just a matter of bringing it up,” she said. “Considering some of the other codes, the advance care planning code is really pretty simple.”
However, doctors like Dr. Sweet appear to be in the minority when it comes to providing this service. Of the nearly 57 million beneficiaries enrolled in Medicare at the end of 2016, only about 1% received advance care planning sessions, according to analysis of Medicare data posted by Kaiser Health News. Nationwide, health providers submitted about $93 million in charges, of which $43 million was paid by Medicare.
Challenges deter conversations
During a recent visit with a 72-year-old cancer patient, Bridget Fahy, MD, a surgical oncologist at the University of New Mexico, Albuquerque, spent time discussing advance directives and the importance of naming a surrogate decision maker. Dr. Fahy had treated the patient for two different cancers over the course of 4 years, and he was now diagnosed with a third, she recalled during an interview. Figuring out an advance care plan, though, proved complicated: The man was not married, had no children, and had no family members who lived in the state.
Although Dr. Fahy was aware of the Medicare advance care planning codes, she did not bill the session as such.
“Even in the course of having that conversation, I’m more apt to bill on time than I am specifically to meet the Medicare requirements for the documentation for [the benefit],” she said.
“There are two pieces required to take advantage of the advance care planning benefit code: having the conversation and documenting it,” Dr. Fahy noted. “What I write at the end of a resident note or an advanced practice provider note is going to be more focused on the counseling I had with the patient about their condition, the evaluation, and what the treatment plan is going to be. For surgeons to utilize the advance care planning codes, they have to have knowledge of the code, which many do not; they must know the requirements for documenting the conversation; and they have to have the time needed to have the conversation while also addressing all of the surgery-specific issues that need to be covered during the visit. There are a number of hurdles to overcome.”
Danielle B. Scheurer, MD, a hospitalist and chief quality officer at the Medical University of South Carolina, Charleston, said that she, too, has not used advance care planning codes. The reimbursement tool is a positive step forward, she said, but so far, it’s not an easy insert into a hospitalist’s practice.
“It’s not top of mind as far as a billing practice,” she said. “It’s not built into the typical work flow. Obviously, it’s not every patient, it’s not everyday, so you have to remember to put it into your work flow. That’s probably the biggest barrier for most hospitalists: either not knowing about it at all or not yet figuring out how to weave it into what they already do.”
Overcoming hurdles through experience
Using the advance care planning benefit has been easier said than done in his practice, according to Carl R. Olden, MD, a family physician in Yakima, Wash. The logistics of scheduling and patient reluctance are contributing to low usage of the new codes, said Dr. Olden, a member of the American Academy of Family Physicians board of directors.
Between Sept. 1, 2016, and Aug. 31, 2017, the family medicine, primary care, internal medicine, and pulmonary medicine members of Dr. Olden’s network who provide end-of-life counseling submitted billing for a total of 106,160 Medicare visits. Of those visits, the 99497 code was submitted only 32 times, according to data provided by Dr. Olden.
At Dr. Olden’s 16-physician practice, there are no registered nurses to help set up and start Medicare wellness visits, which the advance care planning session benefit is designed to fit within, he said.
“Most of those Medicare wellness visits are driven by having a registered nurse do most of the work,” he said. “[For us] to schedule a wellness visit, it’s mostly physician work and to do a 30-minute wellness visit, most of us can see three patients in that 30-minute slot, so it ends up not being very cost effective.”
“Most of my Medicare patients are folks that have four to five chronic medical conditions, and for them to make a 30-minute visit to the office and not talk about any of those conditions but to talk about home safety and advance directives and fall prevention, it’s hard for them to understand that,” he said.
Dr. Newman stresses that while the billing approach takes time to learn, the codes can be weaved into regular practice with some preparation and planning. At her practice, she primarily uses the codes for patients with challenging changes in their health status, sometimes setting up meetings in advance and, other times, conducting a spur-of-the-moment conversation.
“It’s a wonderful benefit,” she said. “I’m not surprised it’s taking awhile to take hold. The reason is you have to prepare for these visits. It takes preparation, including a chart review.”
A common misconception is that the visit must be scheduled separately and cannot be added to another visit, she said. Doctors can bill the advance care planning codes on the same day as an evaluation and management service. For instance, if a patient is accompanied by a family member and seen for routine follow-up, the physician can discuss the medical conditions first and later have a discussion about advance care planning. When billing, the physician can then use an evaluation and management code for the part of the visit related to the patient’s medical conditions and also bill for the advance care planning discussion using the new Medicare codes, Dr. Newman said.
“You’re allowed to use a modifier to attach to it to get paid for both on the same day,” she said. She suggested checking local Medicare policy for the use of the appropriate modifier, usually 26. “One thing that’s important to understand is there’s a lot of short discussions about advanced care planning that doesn’t fit the code. So if a patient wants to have a 5-minute conversation – that happens a lot – these will not be billable or counted under this new benefit. Fifteen minutes is the least amount of time that qualifies for 99497.”
Dr. Sweet said that she expects greater use of the codes as more doctors become aware of how they can be used.
“Once people use it a time or two, they will use it a lot more,” Dr. Sweet said. “It takes time to change, and it takes time to make time to do the things we need to do. But especially, as we move into high-value care, something like this hopefully, [doctors] will embrace.”
[email protected]
On Twitter @legal_med
SHM suggests tweaks to CMS QPP proposal
The Society of Hospital Medicine approves of the direction the Centers for Medicare & Medicaid Services is heading when it comes to measuring pay-for-performance for hospitalists in its Quality Payment Program (QPP) but is suggesting some tweaks to make it a better system.
The proposed CMS 2018 update to the QPP, the value-based payment scheme developed by the Medicare Access and CHIP Reauthorization Act (MACRA), included an option that would allow all physicians who primarily practice in a hospital setting to report as a unified group under the hospital umbrella – as an alternative to reporting as an individual in the Merit-Based Incentive Payment System (MIPS) track.
He said there is lot to like in that option, although there are things that need to be changed as well.
One key area SHM would like to see changed is how time spent in a hospital is measured. In the CMS proposal, codes related to site of service capture only those in the emergency room and those admitted for in-patient services. Doctors who are seeing patients on an observation basis before they are admitted are not captured and could not be included in the facility payment.
“Observation services are virtually indistinguishable from inpatient care and frequently occur on the same wards of the hospital,” SHM said in Aug. 21, 2017, comments to CMS on the proposed QPP update, noting that observational care is built around the two-midnight rule.
“We disagree with this interpretation,” the SHM letter continues. “While it is true observation is generally time limited for a given patient, practice structures and provider scheduling have a profound [impact] on the proportion of observation care an individual clinician provides.” The letter noted that hospitalists who are on observation service could have a high proportion of observation (outpatient) billing, which could in turn exclude them from qualifying for a facility-based reporting option “despite the fact they are truly hospital-based inpatient providers.”
Dr. Greeno noted that some hospitals have hospitalists that exclusively provide observational care.
The proposal designates physicians who meet a 75% threshold of providing care in an emergency room or in-patient setting as eligible to opt into facility-based reporting.
SHM suggests that if observation services cannot be included in the 75% threshold, those services should be included and “couple the calculation with a cross-check to ensure most other billing is also hospital-based. As a further check, CMS could look at specialty codes – is the provider also enrolled in Medicare as a hospitalist?” SHM also recommends lowering the threshold “to 70% or, ideally, 60%. Due to the wide variation in hospitalist practice, we are uncomfortable with the use of thresholds in general, but lowering this threshold would at least provide a kind of safety net for hospitalists who are caring for high numbers of patients on observation.”
Another key area that needs to be addressed is the quality metrics that are used for scoring, which Dr. Greeno acknowledged is “surprisingly hard to do.”
For the 2018 reporting year, CMS is proposing that the required number of measures for the MIPS program be six, that same is it currently is for 2017. While SHM agrees with this level, “we remind CMS that even six measures may be a challenge for some providers, including hospitalists, to meet. Concerted efforts should be made to ensure that those providers who have fewer than six measures available for reporting are not disadvantaged in any way.”
Two of the six hospitalist-specific quality metrics relate to heart attacks, Dr. Seymann noted.
“Most hospitalists do take care of these patients, but they can only be reported via registry or via an electronic health record, and I don’t know that all hospitalist groups have access to reporting those ways,” Dr. Seymann said. “Most folks are reporting when they submit their billing claims. That takes two measures away from them. That may significantly decrease your score, even if you are trying your best.”
While Dr. Seymann applauded CMS for the slow rollout of the MIPS program in general, “we haven’t seen great progress as far as the growth of available relevant measures for hospitalists, and I am not confident that 2 years down the line we are going to have 12 measures to choose from.”
He did suggest that hospitalists would like a greater variety of measures and want to be measured on the quality of care they provide.
“We truly believe that the majority of hospitalist groups are really heavily invested in improving the quality of care that is provided at their hospitals – that is a big part of the culture of hospital medicine in general,” Dr. Seymann said. “We want to make our ability to succeed and participate in this program as effective as we can. We want to try to minimize barriers to hospitalists hitting this one out of the park.”
SHM also noted that certain measures rarely meet the volume threshold, which could ultimately put hospitalists at a disadvantage when it comes to receiving bonus payments.
“This is not an acceptable outcome, and we strongly urge CMS to develop a solution for providers with low-volume measures, such as removing low-volume measures from the Quality category score,” SHM wrote.
Ultimately, Dr. Greeno believes the facility reporting opt-in will survive when the rule is finalized.
“We fully expect there to be a facility-based option for hospital-based doctors, including hospitalists,” he said. “So rather than reporting on physician metrics, especially metrics through MIPS, they can get rewarded or penalized based on the hospital value-based purchasing metrics for their hospital.”
The Society of Hospital Medicine approves of the direction the Centers for Medicare & Medicaid Services is heading when it comes to measuring pay-for-performance for hospitalists in its Quality Payment Program (QPP) but is suggesting some tweaks to make it a better system.
The proposed CMS 2018 update to the QPP, the value-based payment scheme developed by the Medicare Access and CHIP Reauthorization Act (MACRA), included an option that would allow all physicians who primarily practice in a hospital setting to report as a unified group under the hospital umbrella – as an alternative to reporting as an individual in the Merit-Based Incentive Payment System (MIPS) track.
He said there is lot to like in that option, although there are things that need to be changed as well.
One key area SHM would like to see changed is how time spent in a hospital is measured. In the CMS proposal, codes related to site of service capture only those in the emergency room and those admitted for in-patient services. Doctors who are seeing patients on an observation basis before they are admitted are not captured and could not be included in the facility payment.
“Observation services are virtually indistinguishable from inpatient care and frequently occur on the same wards of the hospital,” SHM said in Aug. 21, 2017, comments to CMS on the proposed QPP update, noting that observational care is built around the two-midnight rule.
“We disagree with this interpretation,” the SHM letter continues. “While it is true observation is generally time limited for a given patient, practice structures and provider scheduling have a profound [impact] on the proportion of observation care an individual clinician provides.” The letter noted that hospitalists who are on observation service could have a high proportion of observation (outpatient) billing, which could in turn exclude them from qualifying for a facility-based reporting option “despite the fact they are truly hospital-based inpatient providers.”
Dr. Greeno noted that some hospitals have hospitalists that exclusively provide observational care.
The proposal designates physicians who meet a 75% threshold of providing care in an emergency room or in-patient setting as eligible to opt into facility-based reporting.
SHM suggests that if observation services cannot be included in the 75% threshold, those services should be included and “couple the calculation with a cross-check to ensure most other billing is also hospital-based. As a further check, CMS could look at specialty codes – is the provider also enrolled in Medicare as a hospitalist?” SHM also recommends lowering the threshold “to 70% or, ideally, 60%. Due to the wide variation in hospitalist practice, we are uncomfortable with the use of thresholds in general, but lowering this threshold would at least provide a kind of safety net for hospitalists who are caring for high numbers of patients on observation.”
Another key area that needs to be addressed is the quality metrics that are used for scoring, which Dr. Greeno acknowledged is “surprisingly hard to do.”
For the 2018 reporting year, CMS is proposing that the required number of measures for the MIPS program be six, that same is it currently is for 2017. While SHM agrees with this level, “we remind CMS that even six measures may be a challenge for some providers, including hospitalists, to meet. Concerted efforts should be made to ensure that those providers who have fewer than six measures available for reporting are not disadvantaged in any way.”
Two of the six hospitalist-specific quality metrics relate to heart attacks, Dr. Seymann noted.
“Most hospitalists do take care of these patients, but they can only be reported via registry or via an electronic health record, and I don’t know that all hospitalist groups have access to reporting those ways,” Dr. Seymann said. “Most folks are reporting when they submit their billing claims. That takes two measures away from them. That may significantly decrease your score, even if you are trying your best.”
While Dr. Seymann applauded CMS for the slow rollout of the MIPS program in general, “we haven’t seen great progress as far as the growth of available relevant measures for hospitalists, and I am not confident that 2 years down the line we are going to have 12 measures to choose from.”
He did suggest that hospitalists would like a greater variety of measures and want to be measured on the quality of care they provide.
“We truly believe that the majority of hospitalist groups are really heavily invested in improving the quality of care that is provided at their hospitals – that is a big part of the culture of hospital medicine in general,” Dr. Seymann said. “We want to make our ability to succeed and participate in this program as effective as we can. We want to try to minimize barriers to hospitalists hitting this one out of the park.”
SHM also noted that certain measures rarely meet the volume threshold, which could ultimately put hospitalists at a disadvantage when it comes to receiving bonus payments.
“This is not an acceptable outcome, and we strongly urge CMS to develop a solution for providers with low-volume measures, such as removing low-volume measures from the Quality category score,” SHM wrote.
Ultimately, Dr. Greeno believes the facility reporting opt-in will survive when the rule is finalized.
“We fully expect there to be a facility-based option for hospital-based doctors, including hospitalists,” he said. “So rather than reporting on physician metrics, especially metrics through MIPS, they can get rewarded or penalized based on the hospital value-based purchasing metrics for their hospital.”
The Society of Hospital Medicine approves of the direction the Centers for Medicare & Medicaid Services is heading when it comes to measuring pay-for-performance for hospitalists in its Quality Payment Program (QPP) but is suggesting some tweaks to make it a better system.
The proposed CMS 2018 update to the QPP, the value-based payment scheme developed by the Medicare Access and CHIP Reauthorization Act (MACRA), included an option that would allow all physicians who primarily practice in a hospital setting to report as a unified group under the hospital umbrella – as an alternative to reporting as an individual in the Merit-Based Incentive Payment System (MIPS) track.
He said there is lot to like in that option, although there are things that need to be changed as well.
One key area SHM would like to see changed is how time spent in a hospital is measured. In the CMS proposal, codes related to site of service capture only those in the emergency room and those admitted for in-patient services. Doctors who are seeing patients on an observation basis before they are admitted are not captured and could not be included in the facility payment.
“Observation services are virtually indistinguishable from inpatient care and frequently occur on the same wards of the hospital,” SHM said in Aug. 21, 2017, comments to CMS on the proposed QPP update, noting that observational care is built around the two-midnight rule.
“We disagree with this interpretation,” the SHM letter continues. “While it is true observation is generally time limited for a given patient, practice structures and provider scheduling have a profound [impact] on the proportion of observation care an individual clinician provides.” The letter noted that hospitalists who are on observation service could have a high proportion of observation (outpatient) billing, which could in turn exclude them from qualifying for a facility-based reporting option “despite the fact they are truly hospital-based inpatient providers.”
Dr. Greeno noted that some hospitals have hospitalists that exclusively provide observational care.
The proposal designates physicians who meet a 75% threshold of providing care in an emergency room or in-patient setting as eligible to opt into facility-based reporting.
SHM suggests that if observation services cannot be included in the 75% threshold, those services should be included and “couple the calculation with a cross-check to ensure most other billing is also hospital-based. As a further check, CMS could look at specialty codes – is the provider also enrolled in Medicare as a hospitalist?” SHM also recommends lowering the threshold “to 70% or, ideally, 60%. Due to the wide variation in hospitalist practice, we are uncomfortable with the use of thresholds in general, but lowering this threshold would at least provide a kind of safety net for hospitalists who are caring for high numbers of patients on observation.”
Another key area that needs to be addressed is the quality metrics that are used for scoring, which Dr. Greeno acknowledged is “surprisingly hard to do.”
For the 2018 reporting year, CMS is proposing that the required number of measures for the MIPS program be six, that same is it currently is for 2017. While SHM agrees with this level, “we remind CMS that even six measures may be a challenge for some providers, including hospitalists, to meet. Concerted efforts should be made to ensure that those providers who have fewer than six measures available for reporting are not disadvantaged in any way.”
Two of the six hospitalist-specific quality metrics relate to heart attacks, Dr. Seymann noted.
“Most hospitalists do take care of these patients, but they can only be reported via registry or via an electronic health record, and I don’t know that all hospitalist groups have access to reporting those ways,” Dr. Seymann said. “Most folks are reporting when they submit their billing claims. That takes two measures away from them. That may significantly decrease your score, even if you are trying your best.”
While Dr. Seymann applauded CMS for the slow rollout of the MIPS program in general, “we haven’t seen great progress as far as the growth of available relevant measures for hospitalists, and I am not confident that 2 years down the line we are going to have 12 measures to choose from.”
He did suggest that hospitalists would like a greater variety of measures and want to be measured on the quality of care they provide.
“We truly believe that the majority of hospitalist groups are really heavily invested in improving the quality of care that is provided at their hospitals – that is a big part of the culture of hospital medicine in general,” Dr. Seymann said. “We want to make our ability to succeed and participate in this program as effective as we can. We want to try to minimize barriers to hospitalists hitting this one out of the park.”
SHM also noted that certain measures rarely meet the volume threshold, which could ultimately put hospitalists at a disadvantage when it comes to receiving bonus payments.
“This is not an acceptable outcome, and we strongly urge CMS to develop a solution for providers with low-volume measures, such as removing low-volume measures from the Quality category score,” SHM wrote.
Ultimately, Dr. Greeno believes the facility reporting opt-in will survive when the rule is finalized.
“We fully expect there to be a facility-based option for hospital-based doctors, including hospitalists,” he said. “So rather than reporting on physician metrics, especially metrics through MIPS, they can get rewarded or penalized based on the hospital value-based purchasing metrics for their hospital.”
‘Observationists’: Ready for prime time in an internal medicine residency program
The Institute of Medicine, in its report “Hospital-Based Emergency Care – At the Breaking Point,” has identified Observation Units (OUs) as a “particularly promising” technique to improve patient flow.1 Many hospitals across the country either already have them or are in the process of establishing such units.
Multiple studies have shown that a highly efficient OU can save billions in health care costs.2 Historically, such units have existed within and are staffed by emergency departments. Since the implementation of the two-midnight rule in Oct. 2013, the complexities of observation care changed dramatically from run of the mill 30- to 40-year-old chest pain patients to 80- to 90-year-olds with multiple comorbidities being placed in observation.3 In many cases, this shifted the care out of the emergency department and into the arena of hospital medicine.
At our institution OUs are staffed by internal medicine residents supervised by faculty 24/7 year round. This, we believe, is a unique model. We implemented our model after a mini SWOT (strengths, weaknesses, opportunities, and threats ) analysis in August 2014. The biggest strength was that we were educating the next generation of “Observationists” as we improved the quality of care delivered to our patients. Our biggest opportunity was no existing curriculum for teaching internal medicine residents the art of observation medicine. So we designed our own. Just like Peter Drucker said, “The best way to predict the future is to create it.”
The curriculum is extremely innovative and exposes our residents to both the business and administrative aspect of OUs. Upon surveying our own residents anonymously within 6 months of instituting this rotation, over 90% felt this to be a valuable rotation towards their training. Since we went live, some of our residents who have graduated are now leading OUs at other hospitals.
To measure our program outcomes, we developed a dashboard with multiple metrics for our team. With such data, this rotation became an incubator for our residents for quality improvement projects. They have developed, implemented, and published multiple abstracts, presented posters and even won the first place for innovation at the Midwest Regional Society of General Internal Medicine conference.5-8
We have learned many lessons, and every challenge has been addressed as an opportunity. The first lesson was that we needed strong physician leadership to act as the gatekeeper to the unit. Second, as the rotation matured, we always kept our focus on high-quality patient care; we created a quality dashboard which includes length of stay, falls, and patient satisfaction as examples. Last but not least, we stayed mindful of stakeholder buy in, which for us was primarily our residents. We created the curriculum that provides the next generation of internists the broad experience of medicine, with the appropriate amount of autonomy and supervision. This, we believe, is a win-win proposition for all stakeholders – hospitals, physicians, residents, and most importantly the patients we serve. Additionally, data at our institution shows that our resident-run units are educationally, clinically, and financially beneficial to the residency programs and the hospitals.
Teaching and exposure to observation medicine is not currently a mainstay in many internal medicine residency programs. Our program provides a framework to establish an observation medicine rotation, which exposes residents to quality metrics and expands their scope of medical education.
Dr. Nand is medical director, care management & observation unit, and associate program director, internal medicine residency program, at the University of Illinois College of Medicine/Advocate Christ Medical Center.
References
1. “Hospital-Based Emergency Care: At the Breaking Point” (Washington: National Academies Press, 2006) 2. Baugh, CJ et al. “Making greater use of dedicated hospital observation units for many short-stay patients could save $3.1 billion a year” Health Aff (Millwood). 2012 Oct;31(10):2314-23
3. Fact Sheet: Two-Midnight Rule. 2015. Available at www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-07-01-2.html. Accessed March 29, 2016.
4. Society of Hospital Medicine. The observation unit white paper. http://www.hospitalmedicine.org, April 3, 2013.
5. Yousuf T. et al. “Intermediate chest pain protocol in an observation unit” Won first place award for innovation at the Midwest Regional SGIM conference, August 2015.
6. Sarfraz S et al. “Hand hygiene intervention increases compliance in observation unit” Poster: May 2016, Macy Midwest GME Conference, Michigan.
7. “Impact of syncope protocol in an observation unit of an academic tertiary care center” Poster for Oct 2016 AAIM skills development conference, National Harbor, Md.
8. Metgud S et al. “Integrating residents in providing high-value care via improved results of the ACGME annual resident survey” Poster: May 2016, Macy Midwest GME Conference, Michigan.
The Institute of Medicine, in its report “Hospital-Based Emergency Care – At the Breaking Point,” has identified Observation Units (OUs) as a “particularly promising” technique to improve patient flow.1 Many hospitals across the country either already have them or are in the process of establishing such units.
Multiple studies have shown that a highly efficient OU can save billions in health care costs.2 Historically, such units have existed within and are staffed by emergency departments. Since the implementation of the two-midnight rule in Oct. 2013, the complexities of observation care changed dramatically from run of the mill 30- to 40-year-old chest pain patients to 80- to 90-year-olds with multiple comorbidities being placed in observation.3 In many cases, this shifted the care out of the emergency department and into the arena of hospital medicine.
At our institution OUs are staffed by internal medicine residents supervised by faculty 24/7 year round. This, we believe, is a unique model. We implemented our model after a mini SWOT (strengths, weaknesses, opportunities, and threats ) analysis in August 2014. The biggest strength was that we were educating the next generation of “Observationists” as we improved the quality of care delivered to our patients. Our biggest opportunity was no existing curriculum for teaching internal medicine residents the art of observation medicine. So we designed our own. Just like Peter Drucker said, “The best way to predict the future is to create it.”
The curriculum is extremely innovative and exposes our residents to both the business and administrative aspect of OUs. Upon surveying our own residents anonymously within 6 months of instituting this rotation, over 90% felt this to be a valuable rotation towards their training. Since we went live, some of our residents who have graduated are now leading OUs at other hospitals.
To measure our program outcomes, we developed a dashboard with multiple metrics for our team. With such data, this rotation became an incubator for our residents for quality improvement projects. They have developed, implemented, and published multiple abstracts, presented posters and even won the first place for innovation at the Midwest Regional Society of General Internal Medicine conference.5-8
We have learned many lessons, and every challenge has been addressed as an opportunity. The first lesson was that we needed strong physician leadership to act as the gatekeeper to the unit. Second, as the rotation matured, we always kept our focus on high-quality patient care; we created a quality dashboard which includes length of stay, falls, and patient satisfaction as examples. Last but not least, we stayed mindful of stakeholder buy in, which for us was primarily our residents. We created the curriculum that provides the next generation of internists the broad experience of medicine, with the appropriate amount of autonomy and supervision. This, we believe, is a win-win proposition for all stakeholders – hospitals, physicians, residents, and most importantly the patients we serve. Additionally, data at our institution shows that our resident-run units are educationally, clinically, and financially beneficial to the residency programs and the hospitals.
Teaching and exposure to observation medicine is not currently a mainstay in many internal medicine residency programs. Our program provides a framework to establish an observation medicine rotation, which exposes residents to quality metrics and expands their scope of medical education.
Dr. Nand is medical director, care management & observation unit, and associate program director, internal medicine residency program, at the University of Illinois College of Medicine/Advocate Christ Medical Center.
References
1. “Hospital-Based Emergency Care: At the Breaking Point” (Washington: National Academies Press, 2006) 2. Baugh, CJ et al. “Making greater use of dedicated hospital observation units for many short-stay patients could save $3.1 billion a year” Health Aff (Millwood). 2012 Oct;31(10):2314-23
3. Fact Sheet: Two-Midnight Rule. 2015. Available at www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-07-01-2.html. Accessed March 29, 2016.
4. Society of Hospital Medicine. The observation unit white paper. http://www.hospitalmedicine.org, April 3, 2013.
5. Yousuf T. et al. “Intermediate chest pain protocol in an observation unit” Won first place award for innovation at the Midwest Regional SGIM conference, August 2015.
6. Sarfraz S et al. “Hand hygiene intervention increases compliance in observation unit” Poster: May 2016, Macy Midwest GME Conference, Michigan.
7. “Impact of syncope protocol in an observation unit of an academic tertiary care center” Poster for Oct 2016 AAIM skills development conference, National Harbor, Md.
8. Metgud S et al. “Integrating residents in providing high-value care via improved results of the ACGME annual resident survey” Poster: May 2016, Macy Midwest GME Conference, Michigan.
The Institute of Medicine, in its report “Hospital-Based Emergency Care – At the Breaking Point,” has identified Observation Units (OUs) as a “particularly promising” technique to improve patient flow.1 Many hospitals across the country either already have them or are in the process of establishing such units.
Multiple studies have shown that a highly efficient OU can save billions in health care costs.2 Historically, such units have existed within and are staffed by emergency departments. Since the implementation of the two-midnight rule in Oct. 2013, the complexities of observation care changed dramatically from run of the mill 30- to 40-year-old chest pain patients to 80- to 90-year-olds with multiple comorbidities being placed in observation.3 In many cases, this shifted the care out of the emergency department and into the arena of hospital medicine.
At our institution OUs are staffed by internal medicine residents supervised by faculty 24/7 year round. This, we believe, is a unique model. We implemented our model after a mini SWOT (strengths, weaknesses, opportunities, and threats ) analysis in August 2014. The biggest strength was that we were educating the next generation of “Observationists” as we improved the quality of care delivered to our patients. Our biggest opportunity was no existing curriculum for teaching internal medicine residents the art of observation medicine. So we designed our own. Just like Peter Drucker said, “The best way to predict the future is to create it.”
The curriculum is extremely innovative and exposes our residents to both the business and administrative aspect of OUs. Upon surveying our own residents anonymously within 6 months of instituting this rotation, over 90% felt this to be a valuable rotation towards their training. Since we went live, some of our residents who have graduated are now leading OUs at other hospitals.
To measure our program outcomes, we developed a dashboard with multiple metrics for our team. With such data, this rotation became an incubator for our residents for quality improvement projects. They have developed, implemented, and published multiple abstracts, presented posters and even won the first place for innovation at the Midwest Regional Society of General Internal Medicine conference.5-8
We have learned many lessons, and every challenge has been addressed as an opportunity. The first lesson was that we needed strong physician leadership to act as the gatekeeper to the unit. Second, as the rotation matured, we always kept our focus on high-quality patient care; we created a quality dashboard which includes length of stay, falls, and patient satisfaction as examples. Last but not least, we stayed mindful of stakeholder buy in, which for us was primarily our residents. We created the curriculum that provides the next generation of internists the broad experience of medicine, with the appropriate amount of autonomy and supervision. This, we believe, is a win-win proposition for all stakeholders – hospitals, physicians, residents, and most importantly the patients we serve. Additionally, data at our institution shows that our resident-run units are educationally, clinically, and financially beneficial to the residency programs and the hospitals.
Teaching and exposure to observation medicine is not currently a mainstay in many internal medicine residency programs. Our program provides a framework to establish an observation medicine rotation, which exposes residents to quality metrics and expands their scope of medical education.
Dr. Nand is medical director, care management & observation unit, and associate program director, internal medicine residency program, at the University of Illinois College of Medicine/Advocate Christ Medical Center.
References
1. “Hospital-Based Emergency Care: At the Breaking Point” (Washington: National Academies Press, 2006) 2. Baugh, CJ et al. “Making greater use of dedicated hospital observation units for many short-stay patients could save $3.1 billion a year” Health Aff (Millwood). 2012 Oct;31(10):2314-23
3. Fact Sheet: Two-Midnight Rule. 2015. Available at www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-07-01-2.html. Accessed March 29, 2016.
4. Society of Hospital Medicine. The observation unit white paper. http://www.hospitalmedicine.org, April 3, 2013.
5. Yousuf T. et al. “Intermediate chest pain protocol in an observation unit” Won first place award for innovation at the Midwest Regional SGIM conference, August 2015.
6. Sarfraz S et al. “Hand hygiene intervention increases compliance in observation unit” Poster: May 2016, Macy Midwest GME Conference, Michigan.
7. “Impact of syncope protocol in an observation unit of an academic tertiary care center” Poster for Oct 2016 AAIM skills development conference, National Harbor, Md.
8. Metgud S et al. “Integrating residents in providing high-value care via improved results of the ACGME annual resident survey” Poster: May 2016, Macy Midwest GME Conference, Michigan.