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Grassroots policymaking demands that hospitalists team up
LAS VEGAS – Alla Zilbering, MD, sat at attention for hours during HM17, jotting notes like a scribe about the myriad of federal rules that are pretty rapidly pushing hospitalists and health care as a whole away from fee-for-service payments to a world where doctors are paid for quality.
So, why did she do it? Why all that time on policy, instead of practice?
Because Dr. Zilbering felt compelled to get more involved. As a lead hospitalist at Cigna-HealthSpring, a Medicare Advantage program in Philadelphia, she’s already part of initiatives to improve transitions of care and reduce readmissions.
However, she said she wants to do more. “I’m feeling like, unless you actually address the policy, you can’t get that far in terms of what you can physically do with a patient.”
HM17 was the meeting for her, then. SHM, this year, unveiled its first Health Policy Mini Track, dedicated to updating attendees on the implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the Bundled Payments for Care Improvement initiative, and a host of other federal programs. Hospitalists were updated on a litany of advocacy efforts, including observation status, interoperability of electronic health records systems, and the recent launch of the first hospitalist billing code.
Two of the meeting’s three keynote speakers were Washington veterans who confirmed that, while nightly news reports may suggest that health care reforms contained in the Affordable Care Act are constantly in flux, the trajectory toward paying for higher quality care at lower costs shows no signs of abating.
Plenary speaker Patrick Conway, MD, MSc, MHM, deputy administrator for innovation and quality at the Centers for Medicare & Medicaid Services and director of its Center for Medicare and Medicaid Innovation, noted that the proposed American Health Care Act doesn’t have a “single word dealing with the Innovation Center,” which is the government agency tasked with supporting the development and testing of new payment and service delivery models.
He added that the policy’s gravitation away from fee-for-service toward alternative payment models will ideally lead to better patient outcomes, more coordinated care, and financial savings. So, he urged hospitalists to continue to help design those new payment and care-delivery systems.
M.A. Williams, MD, FHM, the medical director of perioperative services at Porter Adventist Hospital in Denver, said that the way to help design those systems is to get involved. Policy may seem like an issue for C-suite denizens and wonks, but individual practitioners can make more impact than they think.
“Learn enough to be dangerous and go to your CMO [or] whoever you can get a meeting with because MACRA is going to effect all physicians in the organization, even if the system is not doing anything active about it,” Dr. Williams said. “If you show interest and show that you have a little bit of knowledge, you’d be surprised with what kind of traction you might be able to get.”
And that traction isn’t just within the walls of a given institution, Dr. Greeno said. He wants more hospitalists involved in the society’s overall advocacy efforts. That includes lobbying Congress both in person and with phone calls, letters, and emails and pressuring people at home via conduits like SHM’s Grassroots Network, which has nearly 1,200 members from 490 states.
Don’t think those things work? Dr. Greeno said, one need look no further than the new C6 Medicare billing code for hospitalists that went live in April. That didn’t come to pass without a concentrated effort.
“That was a ton of work by our staff and several years of lobbying,” he said. “We had to be able to explain to them why our data should be treated differently as a specialty and compared only to other hospitalists as opposed to other internists or family practitioners.”
The code will help differentiate hospitalists at a time when MACRA will force changes in how hospitalists are paid. But, it will also define the specialty in a way that has never before been accomplished.
“It is an identity within Medicare,” said Josh Boswell, SHM’s director of government affairs.
While the ACA and the potential repeal of its insurance reforms have taken center stage in the media, Dr. Greeno urged hospitalists to focus more on the implementation and rule-making via MACRA.
The bill, which eliminated the Sustainable Growth Rate formula, states that, starting in 2019, Medicare payments will be provided through one of two pathways. The first is the Merit-based Incentive Payment System that combines the Physician Quality Reporting System, the Physician Value-Based Modifier, and Meaningful Use into a single performance-based payment system.
The second option is Alternative Payment Models, which is meant to incentivize the adoption of payment models that move physicians away from fee-for-service models more quickly. To qualify in this pathway, the criteria require elements of “upside and downside financial risk,” as well as meeting threshold requirements for either patients or payments. Those physicians that meet the criteria qualify for a 5% incentive payment.
The first payments in 2019 are based on performance data for 2017. As most hospitalists won’t quality for APMs in the first year, they will default to the MIPS pathway, Dr. Greeno said.
“This bill will have a greater impact on ... providers than any piece of legislation in our lifetime,” he noted. “Now, the ACA had a bigger impact on consumers, but, in terms of us as providers, MACRA is a sea change.”
The topic is so important, SHM has created a website at www.macraforhm.org that is meant to serve as a tutorial to the law’s basics. The guide is intended to educate hospitalists and to motivate them to get involved in the policy work that affects them all, Dr. Greeno said
“If you don’t know how the system works, you can’t influence it,” he added. “My view of the world is, if you’re not at the table, you’re on the menu.”
LAS VEGAS – Alla Zilbering, MD, sat at attention for hours during HM17, jotting notes like a scribe about the myriad of federal rules that are pretty rapidly pushing hospitalists and health care as a whole away from fee-for-service payments to a world where doctors are paid for quality.
So, why did she do it? Why all that time on policy, instead of practice?
Because Dr. Zilbering felt compelled to get more involved. As a lead hospitalist at Cigna-HealthSpring, a Medicare Advantage program in Philadelphia, she’s already part of initiatives to improve transitions of care and reduce readmissions.
However, she said she wants to do more. “I’m feeling like, unless you actually address the policy, you can’t get that far in terms of what you can physically do with a patient.”
HM17 was the meeting for her, then. SHM, this year, unveiled its first Health Policy Mini Track, dedicated to updating attendees on the implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the Bundled Payments for Care Improvement initiative, and a host of other federal programs. Hospitalists were updated on a litany of advocacy efforts, including observation status, interoperability of electronic health records systems, and the recent launch of the first hospitalist billing code.
Two of the meeting’s three keynote speakers were Washington veterans who confirmed that, while nightly news reports may suggest that health care reforms contained in the Affordable Care Act are constantly in flux, the trajectory toward paying for higher quality care at lower costs shows no signs of abating.
Plenary speaker Patrick Conway, MD, MSc, MHM, deputy administrator for innovation and quality at the Centers for Medicare & Medicaid Services and director of its Center for Medicare and Medicaid Innovation, noted that the proposed American Health Care Act doesn’t have a “single word dealing with the Innovation Center,” which is the government agency tasked with supporting the development and testing of new payment and service delivery models.
He added that the policy’s gravitation away from fee-for-service toward alternative payment models will ideally lead to better patient outcomes, more coordinated care, and financial savings. So, he urged hospitalists to continue to help design those new payment and care-delivery systems.
M.A. Williams, MD, FHM, the medical director of perioperative services at Porter Adventist Hospital in Denver, said that the way to help design those systems is to get involved. Policy may seem like an issue for C-suite denizens and wonks, but individual practitioners can make more impact than they think.
“Learn enough to be dangerous and go to your CMO [or] whoever you can get a meeting with because MACRA is going to effect all physicians in the organization, even if the system is not doing anything active about it,” Dr. Williams said. “If you show interest and show that you have a little bit of knowledge, you’d be surprised with what kind of traction you might be able to get.”
And that traction isn’t just within the walls of a given institution, Dr. Greeno said. He wants more hospitalists involved in the society’s overall advocacy efforts. That includes lobbying Congress both in person and with phone calls, letters, and emails and pressuring people at home via conduits like SHM’s Grassroots Network, which has nearly 1,200 members from 490 states.
Don’t think those things work? Dr. Greeno said, one need look no further than the new C6 Medicare billing code for hospitalists that went live in April. That didn’t come to pass without a concentrated effort.
“That was a ton of work by our staff and several years of lobbying,” he said. “We had to be able to explain to them why our data should be treated differently as a specialty and compared only to other hospitalists as opposed to other internists or family practitioners.”
The code will help differentiate hospitalists at a time when MACRA will force changes in how hospitalists are paid. But, it will also define the specialty in a way that has never before been accomplished.
“It is an identity within Medicare,” said Josh Boswell, SHM’s director of government affairs.
While the ACA and the potential repeal of its insurance reforms have taken center stage in the media, Dr. Greeno urged hospitalists to focus more on the implementation and rule-making via MACRA.
The bill, which eliminated the Sustainable Growth Rate formula, states that, starting in 2019, Medicare payments will be provided through one of two pathways. The first is the Merit-based Incentive Payment System that combines the Physician Quality Reporting System, the Physician Value-Based Modifier, and Meaningful Use into a single performance-based payment system.
The second option is Alternative Payment Models, which is meant to incentivize the adoption of payment models that move physicians away from fee-for-service models more quickly. To qualify in this pathway, the criteria require elements of “upside and downside financial risk,” as well as meeting threshold requirements for either patients or payments. Those physicians that meet the criteria qualify for a 5% incentive payment.
The first payments in 2019 are based on performance data for 2017. As most hospitalists won’t quality for APMs in the first year, they will default to the MIPS pathway, Dr. Greeno said.
“This bill will have a greater impact on ... providers than any piece of legislation in our lifetime,” he noted. “Now, the ACA had a bigger impact on consumers, but, in terms of us as providers, MACRA is a sea change.”
The topic is so important, SHM has created a website at www.macraforhm.org that is meant to serve as a tutorial to the law’s basics. The guide is intended to educate hospitalists and to motivate them to get involved in the policy work that affects them all, Dr. Greeno said
“If you don’t know how the system works, you can’t influence it,” he added. “My view of the world is, if you’re not at the table, you’re on the menu.”
LAS VEGAS – Alla Zilbering, MD, sat at attention for hours during HM17, jotting notes like a scribe about the myriad of federal rules that are pretty rapidly pushing hospitalists and health care as a whole away from fee-for-service payments to a world where doctors are paid for quality.
So, why did she do it? Why all that time on policy, instead of practice?
Because Dr. Zilbering felt compelled to get more involved. As a lead hospitalist at Cigna-HealthSpring, a Medicare Advantage program in Philadelphia, she’s already part of initiatives to improve transitions of care and reduce readmissions.
However, she said she wants to do more. “I’m feeling like, unless you actually address the policy, you can’t get that far in terms of what you can physically do with a patient.”
HM17 was the meeting for her, then. SHM, this year, unveiled its first Health Policy Mini Track, dedicated to updating attendees on the implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the Bundled Payments for Care Improvement initiative, and a host of other federal programs. Hospitalists were updated on a litany of advocacy efforts, including observation status, interoperability of electronic health records systems, and the recent launch of the first hospitalist billing code.
Two of the meeting’s three keynote speakers were Washington veterans who confirmed that, while nightly news reports may suggest that health care reforms contained in the Affordable Care Act are constantly in flux, the trajectory toward paying for higher quality care at lower costs shows no signs of abating.
Plenary speaker Patrick Conway, MD, MSc, MHM, deputy administrator for innovation and quality at the Centers for Medicare & Medicaid Services and director of its Center for Medicare and Medicaid Innovation, noted that the proposed American Health Care Act doesn’t have a “single word dealing with the Innovation Center,” which is the government agency tasked with supporting the development and testing of new payment and service delivery models.
He added that the policy’s gravitation away from fee-for-service toward alternative payment models will ideally lead to better patient outcomes, more coordinated care, and financial savings. So, he urged hospitalists to continue to help design those new payment and care-delivery systems.
M.A. Williams, MD, FHM, the medical director of perioperative services at Porter Adventist Hospital in Denver, said that the way to help design those systems is to get involved. Policy may seem like an issue for C-suite denizens and wonks, but individual practitioners can make more impact than they think.
“Learn enough to be dangerous and go to your CMO [or] whoever you can get a meeting with because MACRA is going to effect all physicians in the organization, even if the system is not doing anything active about it,” Dr. Williams said. “If you show interest and show that you have a little bit of knowledge, you’d be surprised with what kind of traction you might be able to get.”
And that traction isn’t just within the walls of a given institution, Dr. Greeno said. He wants more hospitalists involved in the society’s overall advocacy efforts. That includes lobbying Congress both in person and with phone calls, letters, and emails and pressuring people at home via conduits like SHM’s Grassroots Network, which has nearly 1,200 members from 490 states.
Don’t think those things work? Dr. Greeno said, one need look no further than the new C6 Medicare billing code for hospitalists that went live in April. That didn’t come to pass without a concentrated effort.
“That was a ton of work by our staff and several years of lobbying,” he said. “We had to be able to explain to them why our data should be treated differently as a specialty and compared only to other hospitalists as opposed to other internists or family practitioners.”
The code will help differentiate hospitalists at a time when MACRA will force changes in how hospitalists are paid. But, it will also define the specialty in a way that has never before been accomplished.
“It is an identity within Medicare,” said Josh Boswell, SHM’s director of government affairs.
While the ACA and the potential repeal of its insurance reforms have taken center stage in the media, Dr. Greeno urged hospitalists to focus more on the implementation and rule-making via MACRA.
The bill, which eliminated the Sustainable Growth Rate formula, states that, starting in 2019, Medicare payments will be provided through one of two pathways. The first is the Merit-based Incentive Payment System that combines the Physician Quality Reporting System, the Physician Value-Based Modifier, and Meaningful Use into a single performance-based payment system.
The second option is Alternative Payment Models, which is meant to incentivize the adoption of payment models that move physicians away from fee-for-service models more quickly. To qualify in this pathway, the criteria require elements of “upside and downside financial risk,” as well as meeting threshold requirements for either patients or payments. Those physicians that meet the criteria qualify for a 5% incentive payment.
The first payments in 2019 are based on performance data for 2017. As most hospitalists won’t quality for APMs in the first year, they will default to the MIPS pathway, Dr. Greeno said.
“This bill will have a greater impact on ... providers than any piece of legislation in our lifetime,” he noted. “Now, the ACA had a bigger impact on consumers, but, in terms of us as providers, MACRA is a sea change.”
The topic is so important, SHM has created a website at www.macraforhm.org that is meant to serve as a tutorial to the law’s basics. The guide is intended to educate hospitalists and to motivate them to get involved in the policy work that affects them all, Dr. Greeno said
“If you don’t know how the system works, you can’t influence it,” he added. “My view of the world is, if you’re not at the table, you’re on the menu.”
Making sense of MACRA: MIPS and Advanced APMs
Several months into 2017, physicians around the country are preparing for the first benchmark year of MACRA, the Medicare Access and CHIP Reauthorization Act. Passed in 2015, MACRA is the bipartisan health care law responsible for eliminating the Sustainable Growth Rate and it promises to continue to fundamentally alter the way providers are paid. This year determines reimbursement in 2019.
Under the law, physicians must report performance under one of two pathways: MIPS, the Merit-based Incentive Payment System, or participation in a qualified Advanced Alternative Payment Model, or Advanced APM. The first, MIPS, replaces the Physician Quality Reporting System, Meaningful Use and the Physician Value-Based Payment Modifier and is the track most providers can expect to follow, at least initially, because most will not meet the requirements for Advanced APMs.1,2
This is especially true for hospitalists, most of whom are not yet participating in qualifying alternative payment models.2
The MIPS track is budget neutral, which means for every physician or physician group that receives a boost in reimbursement, another will receive a cut. Others will receive a neutral adjustment. All physicians see an annual 0.5% increase in payment between 2016 and 2019 and MIPS clinicians receive a 0.25% annual boost starting in 2026. Providers participating in Advanced APMs will also receive an annual 5% payment bonus between 2019 and 2024, and a 0.75% annual increase in payments beginning in 2026.1
Both pathways are complex and will affect different clinicians in unique ways, particularly hospitalists.
Some health policy experts, like Robert Berenson, MD, FACP, Institute Fellow of the Health Policy Center at the Urban Institute, say MACRA could actually drive more hospitalists into employment to avoid the costs associated with complying with the law.
Regardless, there is much about MACRA that hospitalists should familiarize themselves with this year. The CMS has announced 2018 will also be a transition year and, as such, additional rules are forthcoming.
Here is what to know for now:
MIPS
All providers who receive Medicare Physician Fee Schedule payments and do not participate in an Advanced APM will fall into MIPS, and reporting applies to all patients, not just Medicare beneficiaries.3 There are, however, exemptions: providers in their first year of Medicare, those billing Medicare Part B less than $30,000 annually, and those who see 100 or fewer Medicare patients.4
Under MIPS, physicians are scored on a scale of 1 to 100 based on performance across four weighted categories: Quality (60%), Advancing Care Information (25%), Improvement Activities (15%), and Cost (not included for 2017). Hospitalists who provide 75% or more of their services in hospital inpatient or outpatient settings, or in the emergency department, are exempt from Advancing Care Information, which replaced meaningful use. As a result, the Quality category will make up 85% of the overall score in 2017.
The CMS also announced added flexibility for 2017 with regard to reporting under MIPS, intended to give providers who need it extra time to prepare.5 Physicians and physician groups can report for a full year, starting January 1, 2017, or report for just 90 days, to be eligible for a positive payment adjustment. To avoid a negative adjustment, they can simply submit more than one quality measure, improvement activity, or advancing care information measure (for those not exempt). Or, providers can choose to report nothing and incur a negative 4% payment.
The approach to MIPS in 2017 will vary widely among SHM members, said Joshua Boswell, SHM’s director of government relations.
“Some are looking to do just the bare minimum, not because of their lack of readiness, but for at least this year, to avoid the time, resources, and cost associated with reporting.” he said. “Other groups are considering jumping in with both feet and fully reporting, their thinking being that they can’t lose, and if there is money on the table for high performers, they might as well go for it.”
For 2017, providers who score 70 or more points are eligible for a performance bonus, drawn from a $500 million pool set aside by CMS. The minimum point threshold defined by CMS is three, which a clinician can earn by submitting just one of the six required quality measures.4
“We’re working to ensure the program is structured so that providers can confidently report on just the measures applicable to them, even if it’s fewer than six,” he said. To ensure physicians are not penalized or disadvantaged for being unable to report the required number of measures, Dr. Greeno said CMS is working to develop a validation test, though it has not yet released details.
The measures most applicable to hospitalists include two related to heart failure (ACE inhibitor/angiotensin receptor blocker for left ventricular systolic dysfunction [LVSD] and beta-blocker for LVSD), one stroke measure (DC on antithrombotic therapy), advance care planning, prevention of catheter-related bloodstream infection (central venous catheter insertion protocol), documentation of current medications and appropriate treatment of methicillin-resistant Staphylococcus aureus bacteremia.
However, Dr. Afsarmanesh expects hospitalists will shine in the improvement activities category. “It’s part of our DNA,” she said. “Improvement activities... have become part of the core responsibilities for many of us within hospitalist groups, hospitals, and health systems.”
In 2017, CMS requires providers to report four improvement activities, which include: implementation of antibiotic stewardship programs, connecting patients to community chronic-disease management programs, and integrating pharmacists into a patient care team. Dr. Afsarmanesh suggests hospitalists visit SHM’s Quality and Innovation guide for ideas, implementation toolkits, and more.
In the cost category, “for the most part, hospitalists aren’t acquainted with cost and there is not a lot of cost transparency around what we do... In general, medical care needs to be discussed between physicians and patients so they can weigh the cost-benefit,” she said, which includes not just dollars and cents, but the impact associated with procedures, like radiation exposure from a CT scan.
However, Dr. Afsarmanesh acknowledges this is challenging, given the overall lack of cost transparency in the American health care system. “It is disjointed and we don’t have any other system where the professionals who do the work are so far-removed from the actual cost,” she said. “The good thing is, I think we are heading toward an era of more cost-conscious practice.”
In addition, hospitalists are poised to help with overall cost-reduction in the hospital. “I could imagine something relevant around readmissions and total cost,” said Dr. Patel. “But risk-adjustment is key.”
This category will increase to 30% of a provider’s or group’s overall score by payment year 2021, CMS says. It will be determined using claims data to calculate per capita costs for all attributed beneficiaries and a Medicare Spending per Beneficiary measure. The CMS also says it is finalizing 10 episode-based measures determined to be reliable and that will be made available to providers in feedback reports starting in 2018.4
Clinicians may report MIPS data as individual providers (a single National Provider Identifier tied to a single Tax Identification Number) by sending data for each category through electronic health records, registries, or qualified clinical data registries. Quality data may be reported through Medicare claims.
Hospitalists who report through a group will receive a single payment adjustment based on the group’s performance, using group-level data for each category. Groups can submit using the same mechanisms as individual providers, or through a CMS web interface (though groups must register by June 30, 2017).5
The SHM has also asked CMS to consider allowing employed hospitalists to align with and report with their facilities, though Dr. Greeno says this should be voluntary since not every hospitalist may be interested in reporting through their hospital. Dr. Greeno says CMS is “very interested and receptive” to how it could be done.
“We are trying to create the incentive for everybody to provide care at lower costs,” Dr. Greeno said. “There are two goals: Create alignment, and decrease the reporting burden on hospitalist groups.”
Additionally, CMS recognizes the potential burden MIPS imposes on small practices and is working to allow individuals and groups of 10 or fewer clinicians to combine to create virtual groups. This option is not available in 2017.4
The CMS has also authorized $100 million, dispersed over 5 years, for certain organizations to provide technical assistance to MIPS providers with fewer than 15 clinicians, in rural areas and those in health professional shortage areas.4
According to Modern Healthcare, projections by CMS, released last May, show that 87% of solo practitioners and 70% of physician groups with two to nine providers will see their reimbursement rates fall in 2019. Meanwhile, 55% of groups with 25 to 99 providers and 81% of those with 100 or more clinicians will see an increase in reimbursement.7
“I think it’s going to be pretty tough unless you’re big enough to commit the resources you need to do it right,” Dr. Greeno said. “If I was just a really small group with very little overhead, no infrastructure to support, I’d consider taking the penalty and just living with it because I don’t have many costs and just pay my own salary. But it’s still a hard road.”
Dr. Afsarmanesh says SHM continues to look across the board and advocate for all its members.
In 2019, physicians reporting under MIPS will see up to a 4% increase and as low as a 4% decrease in reimbursement. This rises to plus-or-minus 5% in 2020, 7% in 2021 and 9% thereafter.2
Dr. Patel and many others say it appears to be the intention of CMS to move providers toward alternative payment models. A January 2015 news release from the U.S. Department of Health and Human Services announced a goal of tying 50% of Medicare payments to Accountable Care Organizations (ACO) by the end of 2018 (it’s worth noting this was pre-MACRA, and not all ACOs qualify as Advanced APMs).8
“The awkwardness and clunkiness of MIPS needs to be addressed in order to make it successful because many people will be in MIPS,” Dr. Patel said. “I think it’s the intention to move people into Advanced APMs, but how long it takes to get to that point – 3-5 years, it could be 10 – physicians have to thrive in MIPS in order to live.”
One of the most important things, she and Dr. Berenson said, is adequately capturing the quality and scope of the care physicians provide.
“I know hospitalists complain how little their care is reflected in HCAHPS (the Hospital Consumer Assessment of Healthcare Providers and Systems) and the quality measures they have now, and readmission rates don’t reflect what doctors do inside the hospital. My colleagues are telling me they want something better,” Dr. Patel said.
Advanced APMs
Physicians who participate in Advanced APMs are exempt from MIPS. Advanced APMs must use Certified Electronic Health Record Technology (CEHRT) and take on a minimum amount of risk. For 2017 and 2018, providers must risk losing the lesser of 3% of their total Medicare expenditures or 8% of their revenue.9 They are paid based on the parameters of their particular model.
Additionally, for the 2019 payment year, 25% of a provider’s or group’s Medicare payments or 20% of their patients must be through the Advanced APM. This increases to 50% of payments and 35% of patients for 2021 and 2022, and in 2023, to 75% of payments and 50% of patients.
In 2017, APMs that meet the criteria for Advanced include: Comprehensive End-Stage Renal Disease Care, Comprehensive Primary Care Plus, Next Generation ACO Model, Shared Savings Program Tracks 2 and 3, Comprehensive Joint Replacement Payment Model Track 1, the Vermont Medicare ACO Initiative, and the Oncology Care Model. (APMs that do not qualify must report under MIPS.)5
The CMS also says that services provided at critical access hospitals, rural health clinics, and federally qualified health centers may qualify using patient counts, and medical home models and the Medicaid Medical Home Model may also be considered Advanced APMs using financial criteria.4
At this time, SHM is unable to quantify the number of hospitalists participating in Advanced APMs, and some, Dr. Greeno said, may not know whether they are part of an Advanced APM.
Currently, BPCI (Bundled Payments for Care Improvement) is the only alternative payment model in which hospitalists can directly take risk, Dr. Greeno says, but it does not yet qualify as an Advanced APM. However, that could change.
Prior to the passage of MACRA, Brandeis University worked with CMS to create the Episode Grouper for Medicare (EGM), software that converts claims data into episodes of care based on a patient’s condition or conditions or procedures. The American College of Surgeons (ACS) has since proposed an alternative payment model, called ACS-Brandeis, that would use the diagnostic grouper to take into account all of the work done by every provider on any episode admitted to the hospital and use algorithms to decide who affected a particular patient’s care.
“Anyone who takes care of the patient can take risk or gain share if the episode initiator allows them,” said Dr. Greeno.
For example, if a patient is admitted for surgery, but has an internist on their case because they have diabetes and heart failure, and they also have an anesthesiologist and an infectious disease specialist, everybody has an impact on their care and makes decisions about the resources used on the case. The risk associated with the case is effectively divided.
The ACS submitted the proposal to PTAC (the Physician-Focused Payment Model Technical Advisory Committee) in 2016 and SHM submitted a letter of support.
“In this model, everybody’s taking risk and everybody has the opportunity to gain share if the patient is managed well,” said Dr. Greeno. “It’s a very complicated, very complex model... Theoretically, everybody on that case should be optimally engaged – that’s the beauty of it – but we don’t know if it will work.”
The SHM got involved at the request of ACS, because it would not apply solely to surgical patients. Dr. Greeno says ACS asked SHM to look at common surgical diagnoses and review every medical scenario that could come to pass, from heart failure and pneumonia to infection.
“There’s bundles within bundles, medical bundles within surgical bundles,” he said. “It’s fascinating and it’s daunting but it is truly a big data approach to episodes of care. We’re thrilled to be invited and ACS was very enthusiastic about our involvement.”
Dr. Patel, who sits on PTAC, is heartened by the amount of physician-led innovation taking place. “Proposals are coming directly from doctors; they are telling us what they want,” she said.
For Dr. Greeno, this captures the intent of MACRA: “There is going to be a continual increase in the sophistication of models, and hopefully toward ones that are better and better and create the right incentives for everyone involved in the health care system.”
References
1. S. Findlay. Medicare’s new physician payment system. http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=156. Published April 21, 2016. Accessed March 6, 2017.
2. The Society of Hospital Medicine. Medicare physician payments are changing. http://www.macraforhm.org/. Accessed March 6, 2017.
3. A. Maciejowski. MACRA: What’s really in the final rule. http://blog.ncqa.org/macra-whats-really-in-the-final-rule/. Blog post published November 15, 2016. Accessed March 6, 2017.
4. Department of Health and Human Services, Centers for Medicare and Medicaid Services. Quality Payment Program executive summary. https://qpp.cms.gov/docs/QPP_Executive_Summary_of_Final_Rule.pdf. Published Oct. 14, 2016. Accessed March 6, 2017.
5. Department of Health and Human Services, Centers for Medicare and Medicaid Services. Quality Payment Program: Modernizing Medicare to provide better care and smarter spending for a healthier America. https://qpp.cms.gov/. Accessed March 6, 2017.
6. D. Barkholz. Potential MACRA byproduct: physician consolidation. http://www.modernhealthcare.com/article/20160630/NEWS/160639995. Published June 30, 2016. Accessed March 6, 2017.
7. United States Department of Health and Human Services. Better, smarter, healthier: In historic announcement, HHS sets clear goals and timeline for shifting Medicare reimbursement from volume to value. http://wayback.archive-it.org/3926/20170127185400/https://www.hhs.gov/about/news/2015/01/26/better-smarter-healthier-in-historic-announcement-hhs-sets-clear-goals-and-timeline-for-shifting-medicare-reimbursements-from-volume-to-value.html. Published January 26, 2015. Accessed March 6, 2017.
8. B. Wynne. MACRA Final Rule: CMS strikes a balance; will docs hang on? http://healthaffairs.org/blog/2016/10/17/macra-final-rule-cms-strikes-a-balance-will-docs-hang-on/. Published October 17, 2016. Accessed March 6, 2017.
9. United States Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. Documents for Public Comment: Physician-Focused Payment Model Technical Advisory Committee. Proposal for a Physician-Focused Payment Model: CAS-Brandeis Advanced Alternative Payment Model, American College of Surgeons. https://aspe.hhs.gov/system/files/pdf/253406/TheACSBrandeisAdvancedAPM-ACS.pdf. Published December 13, 2016. Accessed March 6, 2017.
Several months into 2017, physicians around the country are preparing for the first benchmark year of MACRA, the Medicare Access and CHIP Reauthorization Act. Passed in 2015, MACRA is the bipartisan health care law responsible for eliminating the Sustainable Growth Rate and it promises to continue to fundamentally alter the way providers are paid. This year determines reimbursement in 2019.
Under the law, physicians must report performance under one of two pathways: MIPS, the Merit-based Incentive Payment System, or participation in a qualified Advanced Alternative Payment Model, or Advanced APM. The first, MIPS, replaces the Physician Quality Reporting System, Meaningful Use and the Physician Value-Based Payment Modifier and is the track most providers can expect to follow, at least initially, because most will not meet the requirements for Advanced APMs.1,2
This is especially true for hospitalists, most of whom are not yet participating in qualifying alternative payment models.2
The MIPS track is budget neutral, which means for every physician or physician group that receives a boost in reimbursement, another will receive a cut. Others will receive a neutral adjustment. All physicians see an annual 0.5% increase in payment between 2016 and 2019 and MIPS clinicians receive a 0.25% annual boost starting in 2026. Providers participating in Advanced APMs will also receive an annual 5% payment bonus between 2019 and 2024, and a 0.75% annual increase in payments beginning in 2026.1
Both pathways are complex and will affect different clinicians in unique ways, particularly hospitalists.
Some health policy experts, like Robert Berenson, MD, FACP, Institute Fellow of the Health Policy Center at the Urban Institute, say MACRA could actually drive more hospitalists into employment to avoid the costs associated with complying with the law.
Regardless, there is much about MACRA that hospitalists should familiarize themselves with this year. The CMS has announced 2018 will also be a transition year and, as such, additional rules are forthcoming.
Here is what to know for now:
MIPS
All providers who receive Medicare Physician Fee Schedule payments and do not participate in an Advanced APM will fall into MIPS, and reporting applies to all patients, not just Medicare beneficiaries.3 There are, however, exemptions: providers in their first year of Medicare, those billing Medicare Part B less than $30,000 annually, and those who see 100 or fewer Medicare patients.4
Under MIPS, physicians are scored on a scale of 1 to 100 based on performance across four weighted categories: Quality (60%), Advancing Care Information (25%), Improvement Activities (15%), and Cost (not included for 2017). Hospitalists who provide 75% or more of their services in hospital inpatient or outpatient settings, or in the emergency department, are exempt from Advancing Care Information, which replaced meaningful use. As a result, the Quality category will make up 85% of the overall score in 2017.
The CMS also announced added flexibility for 2017 with regard to reporting under MIPS, intended to give providers who need it extra time to prepare.5 Physicians and physician groups can report for a full year, starting January 1, 2017, or report for just 90 days, to be eligible for a positive payment adjustment. To avoid a negative adjustment, they can simply submit more than one quality measure, improvement activity, or advancing care information measure (for those not exempt). Or, providers can choose to report nothing and incur a negative 4% payment.
The approach to MIPS in 2017 will vary widely among SHM members, said Joshua Boswell, SHM’s director of government relations.
“Some are looking to do just the bare minimum, not because of their lack of readiness, but for at least this year, to avoid the time, resources, and cost associated with reporting.” he said. “Other groups are considering jumping in with both feet and fully reporting, their thinking being that they can’t lose, and if there is money on the table for high performers, they might as well go for it.”
For 2017, providers who score 70 or more points are eligible for a performance bonus, drawn from a $500 million pool set aside by CMS. The minimum point threshold defined by CMS is three, which a clinician can earn by submitting just one of the six required quality measures.4
“We’re working to ensure the program is structured so that providers can confidently report on just the measures applicable to them, even if it’s fewer than six,” he said. To ensure physicians are not penalized or disadvantaged for being unable to report the required number of measures, Dr. Greeno said CMS is working to develop a validation test, though it has not yet released details.
The measures most applicable to hospitalists include two related to heart failure (ACE inhibitor/angiotensin receptor blocker for left ventricular systolic dysfunction [LVSD] and beta-blocker for LVSD), one stroke measure (DC on antithrombotic therapy), advance care planning, prevention of catheter-related bloodstream infection (central venous catheter insertion protocol), documentation of current medications and appropriate treatment of methicillin-resistant Staphylococcus aureus bacteremia.
However, Dr. Afsarmanesh expects hospitalists will shine in the improvement activities category. “It’s part of our DNA,” she said. “Improvement activities... have become part of the core responsibilities for many of us within hospitalist groups, hospitals, and health systems.”
In 2017, CMS requires providers to report four improvement activities, which include: implementation of antibiotic stewardship programs, connecting patients to community chronic-disease management programs, and integrating pharmacists into a patient care team. Dr. Afsarmanesh suggests hospitalists visit SHM’s Quality and Innovation guide for ideas, implementation toolkits, and more.
In the cost category, “for the most part, hospitalists aren’t acquainted with cost and there is not a lot of cost transparency around what we do... In general, medical care needs to be discussed between physicians and patients so they can weigh the cost-benefit,” she said, which includes not just dollars and cents, but the impact associated with procedures, like radiation exposure from a CT scan.
However, Dr. Afsarmanesh acknowledges this is challenging, given the overall lack of cost transparency in the American health care system. “It is disjointed and we don’t have any other system where the professionals who do the work are so far-removed from the actual cost,” she said. “The good thing is, I think we are heading toward an era of more cost-conscious practice.”
In addition, hospitalists are poised to help with overall cost-reduction in the hospital. “I could imagine something relevant around readmissions and total cost,” said Dr. Patel. “But risk-adjustment is key.”
This category will increase to 30% of a provider’s or group’s overall score by payment year 2021, CMS says. It will be determined using claims data to calculate per capita costs for all attributed beneficiaries and a Medicare Spending per Beneficiary measure. The CMS also says it is finalizing 10 episode-based measures determined to be reliable and that will be made available to providers in feedback reports starting in 2018.4
Clinicians may report MIPS data as individual providers (a single National Provider Identifier tied to a single Tax Identification Number) by sending data for each category through electronic health records, registries, or qualified clinical data registries. Quality data may be reported through Medicare claims.
Hospitalists who report through a group will receive a single payment adjustment based on the group’s performance, using group-level data for each category. Groups can submit using the same mechanisms as individual providers, or through a CMS web interface (though groups must register by June 30, 2017).5
The SHM has also asked CMS to consider allowing employed hospitalists to align with and report with their facilities, though Dr. Greeno says this should be voluntary since not every hospitalist may be interested in reporting through their hospital. Dr. Greeno says CMS is “very interested and receptive” to how it could be done.
“We are trying to create the incentive for everybody to provide care at lower costs,” Dr. Greeno said. “There are two goals: Create alignment, and decrease the reporting burden on hospitalist groups.”
Additionally, CMS recognizes the potential burden MIPS imposes on small practices and is working to allow individuals and groups of 10 or fewer clinicians to combine to create virtual groups. This option is not available in 2017.4
The CMS has also authorized $100 million, dispersed over 5 years, for certain organizations to provide technical assistance to MIPS providers with fewer than 15 clinicians, in rural areas and those in health professional shortage areas.4
According to Modern Healthcare, projections by CMS, released last May, show that 87% of solo practitioners and 70% of physician groups with two to nine providers will see their reimbursement rates fall in 2019. Meanwhile, 55% of groups with 25 to 99 providers and 81% of those with 100 or more clinicians will see an increase in reimbursement.7
“I think it’s going to be pretty tough unless you’re big enough to commit the resources you need to do it right,” Dr. Greeno said. “If I was just a really small group with very little overhead, no infrastructure to support, I’d consider taking the penalty and just living with it because I don’t have many costs and just pay my own salary. But it’s still a hard road.”
Dr. Afsarmanesh says SHM continues to look across the board and advocate for all its members.
In 2019, physicians reporting under MIPS will see up to a 4% increase and as low as a 4% decrease in reimbursement. This rises to plus-or-minus 5% in 2020, 7% in 2021 and 9% thereafter.2
Dr. Patel and many others say it appears to be the intention of CMS to move providers toward alternative payment models. A January 2015 news release from the U.S. Department of Health and Human Services announced a goal of tying 50% of Medicare payments to Accountable Care Organizations (ACO) by the end of 2018 (it’s worth noting this was pre-MACRA, and not all ACOs qualify as Advanced APMs).8
“The awkwardness and clunkiness of MIPS needs to be addressed in order to make it successful because many people will be in MIPS,” Dr. Patel said. “I think it’s the intention to move people into Advanced APMs, but how long it takes to get to that point – 3-5 years, it could be 10 – physicians have to thrive in MIPS in order to live.”
One of the most important things, she and Dr. Berenson said, is adequately capturing the quality and scope of the care physicians provide.
“I know hospitalists complain how little their care is reflected in HCAHPS (the Hospital Consumer Assessment of Healthcare Providers and Systems) and the quality measures they have now, and readmission rates don’t reflect what doctors do inside the hospital. My colleagues are telling me they want something better,” Dr. Patel said.
Advanced APMs
Physicians who participate in Advanced APMs are exempt from MIPS. Advanced APMs must use Certified Electronic Health Record Technology (CEHRT) and take on a minimum amount of risk. For 2017 and 2018, providers must risk losing the lesser of 3% of their total Medicare expenditures or 8% of their revenue.9 They are paid based on the parameters of their particular model.
Additionally, for the 2019 payment year, 25% of a provider’s or group’s Medicare payments or 20% of their patients must be through the Advanced APM. This increases to 50% of payments and 35% of patients for 2021 and 2022, and in 2023, to 75% of payments and 50% of patients.
In 2017, APMs that meet the criteria for Advanced include: Comprehensive End-Stage Renal Disease Care, Comprehensive Primary Care Plus, Next Generation ACO Model, Shared Savings Program Tracks 2 and 3, Comprehensive Joint Replacement Payment Model Track 1, the Vermont Medicare ACO Initiative, and the Oncology Care Model. (APMs that do not qualify must report under MIPS.)5
The CMS also says that services provided at critical access hospitals, rural health clinics, and federally qualified health centers may qualify using patient counts, and medical home models and the Medicaid Medical Home Model may also be considered Advanced APMs using financial criteria.4
At this time, SHM is unable to quantify the number of hospitalists participating in Advanced APMs, and some, Dr. Greeno said, may not know whether they are part of an Advanced APM.
Currently, BPCI (Bundled Payments for Care Improvement) is the only alternative payment model in which hospitalists can directly take risk, Dr. Greeno says, but it does not yet qualify as an Advanced APM. However, that could change.
Prior to the passage of MACRA, Brandeis University worked with CMS to create the Episode Grouper for Medicare (EGM), software that converts claims data into episodes of care based on a patient’s condition or conditions or procedures. The American College of Surgeons (ACS) has since proposed an alternative payment model, called ACS-Brandeis, that would use the diagnostic grouper to take into account all of the work done by every provider on any episode admitted to the hospital and use algorithms to decide who affected a particular patient’s care.
“Anyone who takes care of the patient can take risk or gain share if the episode initiator allows them,” said Dr. Greeno.
For example, if a patient is admitted for surgery, but has an internist on their case because they have diabetes and heart failure, and they also have an anesthesiologist and an infectious disease specialist, everybody has an impact on their care and makes decisions about the resources used on the case. The risk associated with the case is effectively divided.
The ACS submitted the proposal to PTAC (the Physician-Focused Payment Model Technical Advisory Committee) in 2016 and SHM submitted a letter of support.
“In this model, everybody’s taking risk and everybody has the opportunity to gain share if the patient is managed well,” said Dr. Greeno. “It’s a very complicated, very complex model... Theoretically, everybody on that case should be optimally engaged – that’s the beauty of it – but we don’t know if it will work.”
The SHM got involved at the request of ACS, because it would not apply solely to surgical patients. Dr. Greeno says ACS asked SHM to look at common surgical diagnoses and review every medical scenario that could come to pass, from heart failure and pneumonia to infection.
“There’s bundles within bundles, medical bundles within surgical bundles,” he said. “It’s fascinating and it’s daunting but it is truly a big data approach to episodes of care. We’re thrilled to be invited and ACS was very enthusiastic about our involvement.”
Dr. Patel, who sits on PTAC, is heartened by the amount of physician-led innovation taking place. “Proposals are coming directly from doctors; they are telling us what they want,” she said.
For Dr. Greeno, this captures the intent of MACRA: “There is going to be a continual increase in the sophistication of models, and hopefully toward ones that are better and better and create the right incentives for everyone involved in the health care system.”
References
1. S. Findlay. Medicare’s new physician payment system. http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=156. Published April 21, 2016. Accessed March 6, 2017.
2. The Society of Hospital Medicine. Medicare physician payments are changing. http://www.macraforhm.org/. Accessed March 6, 2017.
3. A. Maciejowski. MACRA: What’s really in the final rule. http://blog.ncqa.org/macra-whats-really-in-the-final-rule/. Blog post published November 15, 2016. Accessed March 6, 2017.
4. Department of Health and Human Services, Centers for Medicare and Medicaid Services. Quality Payment Program executive summary. https://qpp.cms.gov/docs/QPP_Executive_Summary_of_Final_Rule.pdf. Published Oct. 14, 2016. Accessed March 6, 2017.
5. Department of Health and Human Services, Centers for Medicare and Medicaid Services. Quality Payment Program: Modernizing Medicare to provide better care and smarter spending for a healthier America. https://qpp.cms.gov/. Accessed March 6, 2017.
6. D. Barkholz. Potential MACRA byproduct: physician consolidation. http://www.modernhealthcare.com/article/20160630/NEWS/160639995. Published June 30, 2016. Accessed March 6, 2017.
7. United States Department of Health and Human Services. Better, smarter, healthier: In historic announcement, HHS sets clear goals and timeline for shifting Medicare reimbursement from volume to value. http://wayback.archive-it.org/3926/20170127185400/https://www.hhs.gov/about/news/2015/01/26/better-smarter-healthier-in-historic-announcement-hhs-sets-clear-goals-and-timeline-for-shifting-medicare-reimbursements-from-volume-to-value.html. Published January 26, 2015. Accessed March 6, 2017.
8. B. Wynne. MACRA Final Rule: CMS strikes a balance; will docs hang on? http://healthaffairs.org/blog/2016/10/17/macra-final-rule-cms-strikes-a-balance-will-docs-hang-on/. Published October 17, 2016. Accessed March 6, 2017.
9. United States Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. Documents for Public Comment: Physician-Focused Payment Model Technical Advisory Committee. Proposal for a Physician-Focused Payment Model: CAS-Brandeis Advanced Alternative Payment Model, American College of Surgeons. https://aspe.hhs.gov/system/files/pdf/253406/TheACSBrandeisAdvancedAPM-ACS.pdf. Published December 13, 2016. Accessed March 6, 2017.
Several months into 2017, physicians around the country are preparing for the first benchmark year of MACRA, the Medicare Access and CHIP Reauthorization Act. Passed in 2015, MACRA is the bipartisan health care law responsible for eliminating the Sustainable Growth Rate and it promises to continue to fundamentally alter the way providers are paid. This year determines reimbursement in 2019.
Under the law, physicians must report performance under one of two pathways: MIPS, the Merit-based Incentive Payment System, or participation in a qualified Advanced Alternative Payment Model, or Advanced APM. The first, MIPS, replaces the Physician Quality Reporting System, Meaningful Use and the Physician Value-Based Payment Modifier and is the track most providers can expect to follow, at least initially, because most will not meet the requirements for Advanced APMs.1,2
This is especially true for hospitalists, most of whom are not yet participating in qualifying alternative payment models.2
The MIPS track is budget neutral, which means for every physician or physician group that receives a boost in reimbursement, another will receive a cut. Others will receive a neutral adjustment. All physicians see an annual 0.5% increase in payment between 2016 and 2019 and MIPS clinicians receive a 0.25% annual boost starting in 2026. Providers participating in Advanced APMs will also receive an annual 5% payment bonus between 2019 and 2024, and a 0.75% annual increase in payments beginning in 2026.1
Both pathways are complex and will affect different clinicians in unique ways, particularly hospitalists.
Some health policy experts, like Robert Berenson, MD, FACP, Institute Fellow of the Health Policy Center at the Urban Institute, say MACRA could actually drive more hospitalists into employment to avoid the costs associated with complying with the law.
Regardless, there is much about MACRA that hospitalists should familiarize themselves with this year. The CMS has announced 2018 will also be a transition year and, as such, additional rules are forthcoming.
Here is what to know for now:
MIPS
All providers who receive Medicare Physician Fee Schedule payments and do not participate in an Advanced APM will fall into MIPS, and reporting applies to all patients, not just Medicare beneficiaries.3 There are, however, exemptions: providers in their first year of Medicare, those billing Medicare Part B less than $30,000 annually, and those who see 100 or fewer Medicare patients.4
Under MIPS, physicians are scored on a scale of 1 to 100 based on performance across four weighted categories: Quality (60%), Advancing Care Information (25%), Improvement Activities (15%), and Cost (not included for 2017). Hospitalists who provide 75% or more of their services in hospital inpatient or outpatient settings, or in the emergency department, are exempt from Advancing Care Information, which replaced meaningful use. As a result, the Quality category will make up 85% of the overall score in 2017.
The CMS also announced added flexibility for 2017 with regard to reporting under MIPS, intended to give providers who need it extra time to prepare.5 Physicians and physician groups can report for a full year, starting January 1, 2017, or report for just 90 days, to be eligible for a positive payment adjustment. To avoid a negative adjustment, they can simply submit more than one quality measure, improvement activity, or advancing care information measure (for those not exempt). Or, providers can choose to report nothing and incur a negative 4% payment.
The approach to MIPS in 2017 will vary widely among SHM members, said Joshua Boswell, SHM’s director of government relations.
“Some are looking to do just the bare minimum, not because of their lack of readiness, but for at least this year, to avoid the time, resources, and cost associated with reporting.” he said. “Other groups are considering jumping in with both feet and fully reporting, their thinking being that they can’t lose, and if there is money on the table for high performers, they might as well go for it.”
For 2017, providers who score 70 or more points are eligible for a performance bonus, drawn from a $500 million pool set aside by CMS. The minimum point threshold defined by CMS is three, which a clinician can earn by submitting just one of the six required quality measures.4
“We’re working to ensure the program is structured so that providers can confidently report on just the measures applicable to them, even if it’s fewer than six,” he said. To ensure physicians are not penalized or disadvantaged for being unable to report the required number of measures, Dr. Greeno said CMS is working to develop a validation test, though it has not yet released details.
The measures most applicable to hospitalists include two related to heart failure (ACE inhibitor/angiotensin receptor blocker for left ventricular systolic dysfunction [LVSD] and beta-blocker for LVSD), one stroke measure (DC on antithrombotic therapy), advance care planning, prevention of catheter-related bloodstream infection (central venous catheter insertion protocol), documentation of current medications and appropriate treatment of methicillin-resistant Staphylococcus aureus bacteremia.
However, Dr. Afsarmanesh expects hospitalists will shine in the improvement activities category. “It’s part of our DNA,” she said. “Improvement activities... have become part of the core responsibilities for many of us within hospitalist groups, hospitals, and health systems.”
In 2017, CMS requires providers to report four improvement activities, which include: implementation of antibiotic stewardship programs, connecting patients to community chronic-disease management programs, and integrating pharmacists into a patient care team. Dr. Afsarmanesh suggests hospitalists visit SHM’s Quality and Innovation guide for ideas, implementation toolkits, and more.
In the cost category, “for the most part, hospitalists aren’t acquainted with cost and there is not a lot of cost transparency around what we do... In general, medical care needs to be discussed between physicians and patients so they can weigh the cost-benefit,” she said, which includes not just dollars and cents, but the impact associated with procedures, like radiation exposure from a CT scan.
However, Dr. Afsarmanesh acknowledges this is challenging, given the overall lack of cost transparency in the American health care system. “It is disjointed and we don’t have any other system where the professionals who do the work are so far-removed from the actual cost,” she said. “The good thing is, I think we are heading toward an era of more cost-conscious practice.”
In addition, hospitalists are poised to help with overall cost-reduction in the hospital. “I could imagine something relevant around readmissions and total cost,” said Dr. Patel. “But risk-adjustment is key.”
This category will increase to 30% of a provider’s or group’s overall score by payment year 2021, CMS says. It will be determined using claims data to calculate per capita costs for all attributed beneficiaries and a Medicare Spending per Beneficiary measure. The CMS also says it is finalizing 10 episode-based measures determined to be reliable and that will be made available to providers in feedback reports starting in 2018.4
Clinicians may report MIPS data as individual providers (a single National Provider Identifier tied to a single Tax Identification Number) by sending data for each category through electronic health records, registries, or qualified clinical data registries. Quality data may be reported through Medicare claims.
Hospitalists who report through a group will receive a single payment adjustment based on the group’s performance, using group-level data for each category. Groups can submit using the same mechanisms as individual providers, or through a CMS web interface (though groups must register by June 30, 2017).5
The SHM has also asked CMS to consider allowing employed hospitalists to align with and report with their facilities, though Dr. Greeno says this should be voluntary since not every hospitalist may be interested in reporting through their hospital. Dr. Greeno says CMS is “very interested and receptive” to how it could be done.
“We are trying to create the incentive for everybody to provide care at lower costs,” Dr. Greeno said. “There are two goals: Create alignment, and decrease the reporting burden on hospitalist groups.”
Additionally, CMS recognizes the potential burden MIPS imposes on small practices and is working to allow individuals and groups of 10 or fewer clinicians to combine to create virtual groups. This option is not available in 2017.4
The CMS has also authorized $100 million, dispersed over 5 years, for certain organizations to provide technical assistance to MIPS providers with fewer than 15 clinicians, in rural areas and those in health professional shortage areas.4
According to Modern Healthcare, projections by CMS, released last May, show that 87% of solo practitioners and 70% of physician groups with two to nine providers will see their reimbursement rates fall in 2019. Meanwhile, 55% of groups with 25 to 99 providers and 81% of those with 100 or more clinicians will see an increase in reimbursement.7
“I think it’s going to be pretty tough unless you’re big enough to commit the resources you need to do it right,” Dr. Greeno said. “If I was just a really small group with very little overhead, no infrastructure to support, I’d consider taking the penalty and just living with it because I don’t have many costs and just pay my own salary. But it’s still a hard road.”
Dr. Afsarmanesh says SHM continues to look across the board and advocate for all its members.
In 2019, physicians reporting under MIPS will see up to a 4% increase and as low as a 4% decrease in reimbursement. This rises to plus-or-minus 5% in 2020, 7% in 2021 and 9% thereafter.2
Dr. Patel and many others say it appears to be the intention of CMS to move providers toward alternative payment models. A January 2015 news release from the U.S. Department of Health and Human Services announced a goal of tying 50% of Medicare payments to Accountable Care Organizations (ACO) by the end of 2018 (it’s worth noting this was pre-MACRA, and not all ACOs qualify as Advanced APMs).8
“The awkwardness and clunkiness of MIPS needs to be addressed in order to make it successful because many people will be in MIPS,” Dr. Patel said. “I think it’s the intention to move people into Advanced APMs, but how long it takes to get to that point – 3-5 years, it could be 10 – physicians have to thrive in MIPS in order to live.”
One of the most important things, she and Dr. Berenson said, is adequately capturing the quality and scope of the care physicians provide.
“I know hospitalists complain how little their care is reflected in HCAHPS (the Hospital Consumer Assessment of Healthcare Providers and Systems) and the quality measures they have now, and readmission rates don’t reflect what doctors do inside the hospital. My colleagues are telling me they want something better,” Dr. Patel said.
Advanced APMs
Physicians who participate in Advanced APMs are exempt from MIPS. Advanced APMs must use Certified Electronic Health Record Technology (CEHRT) and take on a minimum amount of risk. For 2017 and 2018, providers must risk losing the lesser of 3% of their total Medicare expenditures or 8% of their revenue.9 They are paid based on the parameters of their particular model.
Additionally, for the 2019 payment year, 25% of a provider’s or group’s Medicare payments or 20% of their patients must be through the Advanced APM. This increases to 50% of payments and 35% of patients for 2021 and 2022, and in 2023, to 75% of payments and 50% of patients.
In 2017, APMs that meet the criteria for Advanced include: Comprehensive End-Stage Renal Disease Care, Comprehensive Primary Care Plus, Next Generation ACO Model, Shared Savings Program Tracks 2 and 3, Comprehensive Joint Replacement Payment Model Track 1, the Vermont Medicare ACO Initiative, and the Oncology Care Model. (APMs that do not qualify must report under MIPS.)5
The CMS also says that services provided at critical access hospitals, rural health clinics, and federally qualified health centers may qualify using patient counts, and medical home models and the Medicaid Medical Home Model may also be considered Advanced APMs using financial criteria.4
At this time, SHM is unable to quantify the number of hospitalists participating in Advanced APMs, and some, Dr. Greeno said, may not know whether they are part of an Advanced APM.
Currently, BPCI (Bundled Payments for Care Improvement) is the only alternative payment model in which hospitalists can directly take risk, Dr. Greeno says, but it does not yet qualify as an Advanced APM. However, that could change.
Prior to the passage of MACRA, Brandeis University worked with CMS to create the Episode Grouper for Medicare (EGM), software that converts claims data into episodes of care based on a patient’s condition or conditions or procedures. The American College of Surgeons (ACS) has since proposed an alternative payment model, called ACS-Brandeis, that would use the diagnostic grouper to take into account all of the work done by every provider on any episode admitted to the hospital and use algorithms to decide who affected a particular patient’s care.
“Anyone who takes care of the patient can take risk or gain share if the episode initiator allows them,” said Dr. Greeno.
For example, if a patient is admitted for surgery, but has an internist on their case because they have diabetes and heart failure, and they also have an anesthesiologist and an infectious disease specialist, everybody has an impact on their care and makes decisions about the resources used on the case. The risk associated with the case is effectively divided.
The ACS submitted the proposal to PTAC (the Physician-Focused Payment Model Technical Advisory Committee) in 2016 and SHM submitted a letter of support.
“In this model, everybody’s taking risk and everybody has the opportunity to gain share if the patient is managed well,” said Dr. Greeno. “It’s a very complicated, very complex model... Theoretically, everybody on that case should be optimally engaged – that’s the beauty of it – but we don’t know if it will work.”
The SHM got involved at the request of ACS, because it would not apply solely to surgical patients. Dr. Greeno says ACS asked SHM to look at common surgical diagnoses and review every medical scenario that could come to pass, from heart failure and pneumonia to infection.
“There’s bundles within bundles, medical bundles within surgical bundles,” he said. “It’s fascinating and it’s daunting but it is truly a big data approach to episodes of care. We’re thrilled to be invited and ACS was very enthusiastic about our involvement.”
Dr. Patel, who sits on PTAC, is heartened by the amount of physician-led innovation taking place. “Proposals are coming directly from doctors; they are telling us what they want,” she said.
For Dr. Greeno, this captures the intent of MACRA: “There is going to be a continual increase in the sophistication of models, and hopefully toward ones that are better and better and create the right incentives for everyone involved in the health care system.”
References
1. S. Findlay. Medicare’s new physician payment system. http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=156. Published April 21, 2016. Accessed March 6, 2017.
2. The Society of Hospital Medicine. Medicare physician payments are changing. http://www.macraforhm.org/. Accessed March 6, 2017.
3. A. Maciejowski. MACRA: What’s really in the final rule. http://blog.ncqa.org/macra-whats-really-in-the-final-rule/. Blog post published November 15, 2016. Accessed March 6, 2017.
4. Department of Health and Human Services, Centers for Medicare and Medicaid Services. Quality Payment Program executive summary. https://qpp.cms.gov/docs/QPP_Executive_Summary_of_Final_Rule.pdf. Published Oct. 14, 2016. Accessed March 6, 2017.
5. Department of Health and Human Services, Centers for Medicare and Medicaid Services. Quality Payment Program: Modernizing Medicare to provide better care and smarter spending for a healthier America. https://qpp.cms.gov/. Accessed March 6, 2017.
6. D. Barkholz. Potential MACRA byproduct: physician consolidation. http://www.modernhealthcare.com/article/20160630/NEWS/160639995. Published June 30, 2016. Accessed March 6, 2017.
7. United States Department of Health and Human Services. Better, smarter, healthier: In historic announcement, HHS sets clear goals and timeline for shifting Medicare reimbursement from volume to value. http://wayback.archive-it.org/3926/20170127185400/https://www.hhs.gov/about/news/2015/01/26/better-smarter-healthier-in-historic-announcement-hhs-sets-clear-goals-and-timeline-for-shifting-medicare-reimbursements-from-volume-to-value.html. Published January 26, 2015. Accessed March 6, 2017.
8. B. Wynne. MACRA Final Rule: CMS strikes a balance; will docs hang on? http://healthaffairs.org/blog/2016/10/17/macra-final-rule-cms-strikes-a-balance-will-docs-hang-on/. Published October 17, 2016. Accessed March 6, 2017.
9. United States Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. Documents for Public Comment: Physician-Focused Payment Model Technical Advisory Committee. Proposal for a Physician-Focused Payment Model: CAS-Brandeis Advanced Alternative Payment Model, American College of Surgeons. https://aspe.hhs.gov/system/files/pdf/253406/TheACSBrandeisAdvancedAPM-ACS.pdf. Published December 13, 2016. Accessed March 6, 2017.
Practice management skills more relevant than ever
LAS VEGAS – Babatunde Akinsete, MD, took a new job about 18 months ago as a lead hospitalist within Adventist Health System of Florida. The role has the expected leadership responsibilities, but those folks he’s now partly supervising are the same ones who used to be his peers.
The same people he spent time “in the trenches” with, complaining about the problems they saw – issues that are now partly his job to help fix.
“It’s tough,” Dr. Akinsete said at the annual meeting of the Society of Hospital Medicine. “How do you motivate people?”
Welcome to managing a practice, circa 2017. The day-to-day doings of an HM group – recruiting, retention, compensation, scheduling and more – are the backbone of the specialty. And SHM’s annual meeting makes the topics a principal point, from a dedicated precourse to dozens of presentations to networking opportunities introducing experienced leaders to nascent ones.
The subject is more relevant than ever these days as the maturing specialty now has three generations of hospitalists practicing side by side, including those who founded the society and laid the groundwork for the specialty some 20 years ago and those who will now infuse it with new blood for the next 20 years, said Jerome Siy, MD, SFHM, an HM17 faculty member and chair of SHM’s Practice Management Committee.
“We’re heading into a cycle of a lot of change,” he said. “Being able to manage change is going to be pretty key.”
The first step in building or bettering a “healthy practice” is building a “culture of ownership,” Dr. Siy said.
“You must have the right culture first if you’re going to tackle any of these issues, whether it’s things like schedules to finances to negotiations,” he added. “Second is this openness and innovation to think outside the box and to allow yourself to hear things that might not work for you. Be open to it because whether you hear something that doesn’t work or not, it may inspire you to figure out … what is the key element you were missing before.”
That’s what Liza Rodriguez Jimenez, MD, is taking away from the meeting. She is moving into a codirector position for her medical group at St. Luke’s in Boise, Idaho. A crash course in alternative-payment models, full-time equivalents (FTEs), relative value units (RVUs) and scheduling was an eye-opener for her.
But to Dr. Siy’s point, it wasn’t the specific examples of how other people do what they do that intrigued Dr. Rodriguez Jimenez. It was more so that people just did it differently.
“It’s just helpful to know that there are other choices,” Dr. Rodriguez Jimenez said. “In other words, why do we do 7 on, 7 off? I don’t know. We just do. If you don’t know that you don’t know, then how do you know to change it? You get exposed to so much stuff here now that you can theoretically go back and say, ‘why do we do 7 on, 7 off? … And then let the group say we want 5 on, 10 off, 4 on, 3 off. Whatever people decide.”
Nasim Afsar, MD, SFHM, chief quality officer of the department of medicine at UCLA Health in Los Angeles, said that idea of just framing the question differently is a big deal, and a leadership skill in and of itself. For example, say a hospital medicine group’s leaders are trying to discuss whether the practice should continue its comanagement focus.
“If you frame a decision as, ‘We are going to lose this comanagement,’ there’s just something, like a gut feeling, you don’t want to lose stuff,” she said. “As opposed to, if you say, ‘Gosh, think about the gains. That we will have all this free time that we now have where we can develop other aspects of our hospital medicine group.’ So when you frame the same exact thing in terms of loss, it becomes so much more difficult for us to actually let go of that.”
Leadership is more than just framing, of course. Dr. Afsar and former SHM president Eric Howell, MD, MHM, said that leadership traits include using standardized processes to make decisions, as well as getting group members involved in those decisions when necessary and using feedback and motivation properly.
But, at day’s end, practice management is managing the needs of your practice.
For Abdul-Hady Kheder, MD, of Hamilton Hospitalists LLC in Central New Jersey, the meeting opened his eyes to techniques he could use to deal with lower reimbursement figures and less patients.
“What can help my situation will be increasing the volume of the practice,” he said. “Right now, we admit 30%-40% of the patients admitted into the hospital. National average is 60%-90% of total hospital admissions. I think that most probably will balance my financial dilemma.”
For Rodney Hollis, practice administrator for Eskenazi Health of Indianapolis, the meeting was a way to glean tips on improving his practice. One nugget he’s excited about: pairing an experienced hospitalist with a new hire for a year. As a nonclinical administrator, Hollis said he views his role as helping clinicians work on the things they are best at, while he handle the rest.
“The more clinical time that the clinical directors can spend, that’s more advantageous to the group,” Hollis said. “Allowing the nonclinical activities to be done by an administrator helps. We want more responsibility and if there’s something that our clinical is doing that I can do, why not have me do it?”
For Dr. Rodriguez Jimenez, open-ended questions like that one are among the most “insightful” takeaways from the meeting.
“There is no right or wrong way, so maybe we’ve been doing it this way ‘just because,’ ” she said. “Now we need to look at it and say, ‘Can we do it a different way? Can we adapt it? Can we change it?’”
She’s starting to sound like a practice manager already.
LAS VEGAS – Babatunde Akinsete, MD, took a new job about 18 months ago as a lead hospitalist within Adventist Health System of Florida. The role has the expected leadership responsibilities, but those folks he’s now partly supervising are the same ones who used to be his peers.
The same people he spent time “in the trenches” with, complaining about the problems they saw – issues that are now partly his job to help fix.
“It’s tough,” Dr. Akinsete said at the annual meeting of the Society of Hospital Medicine. “How do you motivate people?”
Welcome to managing a practice, circa 2017. The day-to-day doings of an HM group – recruiting, retention, compensation, scheduling and more – are the backbone of the specialty. And SHM’s annual meeting makes the topics a principal point, from a dedicated precourse to dozens of presentations to networking opportunities introducing experienced leaders to nascent ones.
The subject is more relevant than ever these days as the maturing specialty now has three generations of hospitalists practicing side by side, including those who founded the society and laid the groundwork for the specialty some 20 years ago and those who will now infuse it with new blood for the next 20 years, said Jerome Siy, MD, SFHM, an HM17 faculty member and chair of SHM’s Practice Management Committee.
“We’re heading into a cycle of a lot of change,” he said. “Being able to manage change is going to be pretty key.”
The first step in building or bettering a “healthy practice” is building a “culture of ownership,” Dr. Siy said.
“You must have the right culture first if you’re going to tackle any of these issues, whether it’s things like schedules to finances to negotiations,” he added. “Second is this openness and innovation to think outside the box and to allow yourself to hear things that might not work for you. Be open to it because whether you hear something that doesn’t work or not, it may inspire you to figure out … what is the key element you were missing before.”
That’s what Liza Rodriguez Jimenez, MD, is taking away from the meeting. She is moving into a codirector position for her medical group at St. Luke’s in Boise, Idaho. A crash course in alternative-payment models, full-time equivalents (FTEs), relative value units (RVUs) and scheduling was an eye-opener for her.
But to Dr. Siy’s point, it wasn’t the specific examples of how other people do what they do that intrigued Dr. Rodriguez Jimenez. It was more so that people just did it differently.
“It’s just helpful to know that there are other choices,” Dr. Rodriguez Jimenez said. “In other words, why do we do 7 on, 7 off? I don’t know. We just do. If you don’t know that you don’t know, then how do you know to change it? You get exposed to so much stuff here now that you can theoretically go back and say, ‘why do we do 7 on, 7 off? … And then let the group say we want 5 on, 10 off, 4 on, 3 off. Whatever people decide.”
Nasim Afsar, MD, SFHM, chief quality officer of the department of medicine at UCLA Health in Los Angeles, said that idea of just framing the question differently is a big deal, and a leadership skill in and of itself. For example, say a hospital medicine group’s leaders are trying to discuss whether the practice should continue its comanagement focus.
“If you frame a decision as, ‘We are going to lose this comanagement,’ there’s just something, like a gut feeling, you don’t want to lose stuff,” she said. “As opposed to, if you say, ‘Gosh, think about the gains. That we will have all this free time that we now have where we can develop other aspects of our hospital medicine group.’ So when you frame the same exact thing in terms of loss, it becomes so much more difficult for us to actually let go of that.”
Leadership is more than just framing, of course. Dr. Afsar and former SHM president Eric Howell, MD, MHM, said that leadership traits include using standardized processes to make decisions, as well as getting group members involved in those decisions when necessary and using feedback and motivation properly.
But, at day’s end, practice management is managing the needs of your practice.
For Abdul-Hady Kheder, MD, of Hamilton Hospitalists LLC in Central New Jersey, the meeting opened his eyes to techniques he could use to deal with lower reimbursement figures and less patients.
“What can help my situation will be increasing the volume of the practice,” he said. “Right now, we admit 30%-40% of the patients admitted into the hospital. National average is 60%-90% of total hospital admissions. I think that most probably will balance my financial dilemma.”
For Rodney Hollis, practice administrator for Eskenazi Health of Indianapolis, the meeting was a way to glean tips on improving his practice. One nugget he’s excited about: pairing an experienced hospitalist with a new hire for a year. As a nonclinical administrator, Hollis said he views his role as helping clinicians work on the things they are best at, while he handle the rest.
“The more clinical time that the clinical directors can spend, that’s more advantageous to the group,” Hollis said. “Allowing the nonclinical activities to be done by an administrator helps. We want more responsibility and if there’s something that our clinical is doing that I can do, why not have me do it?”
For Dr. Rodriguez Jimenez, open-ended questions like that one are among the most “insightful” takeaways from the meeting.
“There is no right or wrong way, so maybe we’ve been doing it this way ‘just because,’ ” she said. “Now we need to look at it and say, ‘Can we do it a different way? Can we adapt it? Can we change it?’”
She’s starting to sound like a practice manager already.
LAS VEGAS – Babatunde Akinsete, MD, took a new job about 18 months ago as a lead hospitalist within Adventist Health System of Florida. The role has the expected leadership responsibilities, but those folks he’s now partly supervising are the same ones who used to be his peers.
The same people he spent time “in the trenches” with, complaining about the problems they saw – issues that are now partly his job to help fix.
“It’s tough,” Dr. Akinsete said at the annual meeting of the Society of Hospital Medicine. “How do you motivate people?”
Welcome to managing a practice, circa 2017. The day-to-day doings of an HM group – recruiting, retention, compensation, scheduling and more – are the backbone of the specialty. And SHM’s annual meeting makes the topics a principal point, from a dedicated precourse to dozens of presentations to networking opportunities introducing experienced leaders to nascent ones.
The subject is more relevant than ever these days as the maturing specialty now has three generations of hospitalists practicing side by side, including those who founded the society and laid the groundwork for the specialty some 20 years ago and those who will now infuse it with new blood for the next 20 years, said Jerome Siy, MD, SFHM, an HM17 faculty member and chair of SHM’s Practice Management Committee.
“We’re heading into a cycle of a lot of change,” he said. “Being able to manage change is going to be pretty key.”
The first step in building or bettering a “healthy practice” is building a “culture of ownership,” Dr. Siy said.
“You must have the right culture first if you’re going to tackle any of these issues, whether it’s things like schedules to finances to negotiations,” he added. “Second is this openness and innovation to think outside the box and to allow yourself to hear things that might not work for you. Be open to it because whether you hear something that doesn’t work or not, it may inspire you to figure out … what is the key element you were missing before.”
That’s what Liza Rodriguez Jimenez, MD, is taking away from the meeting. She is moving into a codirector position for her medical group at St. Luke’s in Boise, Idaho. A crash course in alternative-payment models, full-time equivalents (FTEs), relative value units (RVUs) and scheduling was an eye-opener for her.
But to Dr. Siy’s point, it wasn’t the specific examples of how other people do what they do that intrigued Dr. Rodriguez Jimenez. It was more so that people just did it differently.
“It’s just helpful to know that there are other choices,” Dr. Rodriguez Jimenez said. “In other words, why do we do 7 on, 7 off? I don’t know. We just do. If you don’t know that you don’t know, then how do you know to change it? You get exposed to so much stuff here now that you can theoretically go back and say, ‘why do we do 7 on, 7 off? … And then let the group say we want 5 on, 10 off, 4 on, 3 off. Whatever people decide.”
Nasim Afsar, MD, SFHM, chief quality officer of the department of medicine at UCLA Health in Los Angeles, said that idea of just framing the question differently is a big deal, and a leadership skill in and of itself. For example, say a hospital medicine group’s leaders are trying to discuss whether the practice should continue its comanagement focus.
“If you frame a decision as, ‘We are going to lose this comanagement,’ there’s just something, like a gut feeling, you don’t want to lose stuff,” she said. “As opposed to, if you say, ‘Gosh, think about the gains. That we will have all this free time that we now have where we can develop other aspects of our hospital medicine group.’ So when you frame the same exact thing in terms of loss, it becomes so much more difficult for us to actually let go of that.”
Leadership is more than just framing, of course. Dr. Afsar and former SHM president Eric Howell, MD, MHM, said that leadership traits include using standardized processes to make decisions, as well as getting group members involved in those decisions when necessary and using feedback and motivation properly.
But, at day’s end, practice management is managing the needs of your practice.
For Abdul-Hady Kheder, MD, of Hamilton Hospitalists LLC in Central New Jersey, the meeting opened his eyes to techniques he could use to deal with lower reimbursement figures and less patients.
“What can help my situation will be increasing the volume of the practice,” he said. “Right now, we admit 30%-40% of the patients admitted into the hospital. National average is 60%-90% of total hospital admissions. I think that most probably will balance my financial dilemma.”
For Rodney Hollis, practice administrator for Eskenazi Health of Indianapolis, the meeting was a way to glean tips on improving his practice. One nugget he’s excited about: pairing an experienced hospitalist with a new hire for a year. As a nonclinical administrator, Hollis said he views his role as helping clinicians work on the things they are best at, while he handle the rest.
“The more clinical time that the clinical directors can spend, that’s more advantageous to the group,” Hollis said. “Allowing the nonclinical activities to be done by an administrator helps. We want more responsibility and if there’s something that our clinical is doing that I can do, why not have me do it?”
For Dr. Rodriguez Jimenez, open-ended questions like that one are among the most “insightful” takeaways from the meeting.
“There is no right or wrong way, so maybe we’ve been doing it this way ‘just because,’ ” she said. “Now we need to look at it and say, ‘Can we do it a different way? Can we adapt it? Can we change it?’”
She’s starting to sound like a practice manager already.
HM17 session summary: The art of story in delivering memorable lectures
Presenter
Ethan Cumbler, MD, FACP, FHM
Session summary
This session was designed to give learners a different paradigm in thinking about the structure and organization of presentations, for a more dynamic and engaging lecture.
Memorable teaching points are tied to a narrative with emotional impact. One study of surgery residents immediately after finishing grand rounds found that learners only remember approximately 10% of the material embedded in a lecture. Therefore, the focus of the lecture should not necessarily be to include a comprehensive amount of information, but to make the major points as “sticky” as possible.
This will help anchor your presentation and will hopefully assist in creating an organizational framework. Most people are familiar with lectures that have a “standard” format: “I’m going to talk about disease/problem X. This is the scope of the problem, epidemiology, pathology, etiology, diagnosis, treatment, complications, and prognosis.” While this is an organizational structure, it doesn’t draw the audience in. Instead, what was suggested was to think about a real patient case to keep the audience engaged. Since everything may not be known in real time, you can add drama and suspense as the audience and the speaker work through the case together.
One should have a “hook” as an analogy to engage with the audience while reinforcing the central “take-home” message. One can think of it as a kind of leitmotif. Another example would be the “call-back” in stand-up comedy where a concept or joke is introduced early in the routine, is not addressed for a period of time, and then reintroduced and becomes more funny the second time around.
Many people are used to seeing PowerPoint presentations with 5-7 lines per slide, 5-7 words per line, with greater than 24 point font. Dr. Cumbler recommends thinking of one’s slide from a design perspective. For example, in TED talks, one will often see large images that act as a reference but there is often very little text on the slide. In order to provide more content while not burdening slides with more text, one should reconsider handouts. Instead of sheets of paper with 6 slides which are repeats of the PowerPoint, use the handout to provide information that one cannot show during the presentation.
It is incredibly difficult to stay engaged in a lecture delivered at the same pace and in a monotone. Timing is important in music, comedy, and presentations. One should vary the volume and tempo during the talk and allow for pauses when appropriate. An example to illustrate the point was dubstep music; it is set at a tempo of 140 beats per minute, but the song is not 140 beats per minute the entire time. It will sometimes slow down, and there is always a point where the “beat drops.”
Again, a good talk is not only the information itself, but a presenter’s presence, so one should think of body language and positioning. One should use hand gestures to emphasize points in the lecture and draw the learners in. Dr. Cumbler recommended making eye contact with individuals periodically instead of a distant, vacant stare into the great expanse. One should feel free to move across the stage or walk through the audience, so ask for a wireless microphone to liberate oneself from the podium.
Key takeaways for HM
- Consider the stand-up comedy concept of the “call-back.” Start with a concept, and then return to this concept in different forms through the presentation. One can return to another variation of this for a surprise at the end. One can make a key point memorable by using a theme with multiple variations.
- Think about structure in order to draw listeners into a talk and keep them invested (organizational framework centered around a patient); create a “hook”; think about slides visually, not from a content perspective (that’s what handouts are for); keep the tempo, timing, and volume dynamic; use body language and presence to engage the room.
- If one would like to learn more, consider reading the book Presentation Zen; watch TED talks; practice multiple times to hone various aspects of the talk; give the talk multiple times for iterative improvement; always ask for feedback and try to change at least one thing from one talk to another to continuously improve.
Dr. Kim is a hospitalist who works at Emory University Hospital in Atlanta, and is an editorial board member of The Hospitalist.
Presenter
Ethan Cumbler, MD, FACP, FHM
Session summary
This session was designed to give learners a different paradigm in thinking about the structure and organization of presentations, for a more dynamic and engaging lecture.
Memorable teaching points are tied to a narrative with emotional impact. One study of surgery residents immediately after finishing grand rounds found that learners only remember approximately 10% of the material embedded in a lecture. Therefore, the focus of the lecture should not necessarily be to include a comprehensive amount of information, but to make the major points as “sticky” as possible.
This will help anchor your presentation and will hopefully assist in creating an organizational framework. Most people are familiar with lectures that have a “standard” format: “I’m going to talk about disease/problem X. This is the scope of the problem, epidemiology, pathology, etiology, diagnosis, treatment, complications, and prognosis.” While this is an organizational structure, it doesn’t draw the audience in. Instead, what was suggested was to think about a real patient case to keep the audience engaged. Since everything may not be known in real time, you can add drama and suspense as the audience and the speaker work through the case together.
One should have a “hook” as an analogy to engage with the audience while reinforcing the central “take-home” message. One can think of it as a kind of leitmotif. Another example would be the “call-back” in stand-up comedy where a concept or joke is introduced early in the routine, is not addressed for a period of time, and then reintroduced and becomes more funny the second time around.
Many people are used to seeing PowerPoint presentations with 5-7 lines per slide, 5-7 words per line, with greater than 24 point font. Dr. Cumbler recommends thinking of one’s slide from a design perspective. For example, in TED talks, one will often see large images that act as a reference but there is often very little text on the slide. In order to provide more content while not burdening slides with more text, one should reconsider handouts. Instead of sheets of paper with 6 slides which are repeats of the PowerPoint, use the handout to provide information that one cannot show during the presentation.
It is incredibly difficult to stay engaged in a lecture delivered at the same pace and in a monotone. Timing is important in music, comedy, and presentations. One should vary the volume and tempo during the talk and allow for pauses when appropriate. An example to illustrate the point was dubstep music; it is set at a tempo of 140 beats per minute, but the song is not 140 beats per minute the entire time. It will sometimes slow down, and there is always a point where the “beat drops.”
Again, a good talk is not only the information itself, but a presenter’s presence, so one should think of body language and positioning. One should use hand gestures to emphasize points in the lecture and draw the learners in. Dr. Cumbler recommended making eye contact with individuals periodically instead of a distant, vacant stare into the great expanse. One should feel free to move across the stage or walk through the audience, so ask for a wireless microphone to liberate oneself from the podium.
Key takeaways for HM
- Consider the stand-up comedy concept of the “call-back.” Start with a concept, and then return to this concept in different forms through the presentation. One can return to another variation of this for a surprise at the end. One can make a key point memorable by using a theme with multiple variations.
- Think about structure in order to draw listeners into a talk and keep them invested (organizational framework centered around a patient); create a “hook”; think about slides visually, not from a content perspective (that’s what handouts are for); keep the tempo, timing, and volume dynamic; use body language and presence to engage the room.
- If one would like to learn more, consider reading the book Presentation Zen; watch TED talks; practice multiple times to hone various aspects of the talk; give the talk multiple times for iterative improvement; always ask for feedback and try to change at least one thing from one talk to another to continuously improve.
Dr. Kim is a hospitalist who works at Emory University Hospital in Atlanta, and is an editorial board member of The Hospitalist.
Presenter
Ethan Cumbler, MD, FACP, FHM
Session summary
This session was designed to give learners a different paradigm in thinking about the structure and organization of presentations, for a more dynamic and engaging lecture.
Memorable teaching points are tied to a narrative with emotional impact. One study of surgery residents immediately after finishing grand rounds found that learners only remember approximately 10% of the material embedded in a lecture. Therefore, the focus of the lecture should not necessarily be to include a comprehensive amount of information, but to make the major points as “sticky” as possible.
This will help anchor your presentation and will hopefully assist in creating an organizational framework. Most people are familiar with lectures that have a “standard” format: “I’m going to talk about disease/problem X. This is the scope of the problem, epidemiology, pathology, etiology, diagnosis, treatment, complications, and prognosis.” While this is an organizational structure, it doesn’t draw the audience in. Instead, what was suggested was to think about a real patient case to keep the audience engaged. Since everything may not be known in real time, you can add drama and suspense as the audience and the speaker work through the case together.
One should have a “hook” as an analogy to engage with the audience while reinforcing the central “take-home” message. One can think of it as a kind of leitmotif. Another example would be the “call-back” in stand-up comedy where a concept or joke is introduced early in the routine, is not addressed for a period of time, and then reintroduced and becomes more funny the second time around.
Many people are used to seeing PowerPoint presentations with 5-7 lines per slide, 5-7 words per line, with greater than 24 point font. Dr. Cumbler recommends thinking of one’s slide from a design perspective. For example, in TED talks, one will often see large images that act as a reference but there is often very little text on the slide. In order to provide more content while not burdening slides with more text, one should reconsider handouts. Instead of sheets of paper with 6 slides which are repeats of the PowerPoint, use the handout to provide information that one cannot show during the presentation.
It is incredibly difficult to stay engaged in a lecture delivered at the same pace and in a monotone. Timing is important in music, comedy, and presentations. One should vary the volume and tempo during the talk and allow for pauses when appropriate. An example to illustrate the point was dubstep music; it is set at a tempo of 140 beats per minute, but the song is not 140 beats per minute the entire time. It will sometimes slow down, and there is always a point where the “beat drops.”
Again, a good talk is not only the information itself, but a presenter’s presence, so one should think of body language and positioning. One should use hand gestures to emphasize points in the lecture and draw the learners in. Dr. Cumbler recommended making eye contact with individuals periodically instead of a distant, vacant stare into the great expanse. One should feel free to move across the stage or walk through the audience, so ask for a wireless microphone to liberate oneself from the podium.
Key takeaways for HM
- Consider the stand-up comedy concept of the “call-back.” Start with a concept, and then return to this concept in different forms through the presentation. One can return to another variation of this for a surprise at the end. One can make a key point memorable by using a theme with multiple variations.
- Think about structure in order to draw listeners into a talk and keep them invested (organizational framework centered around a patient); create a “hook”; think about slides visually, not from a content perspective (that’s what handouts are for); keep the tempo, timing, and volume dynamic; use body language and presence to engage the room.
- If one would like to learn more, consider reading the book Presentation Zen; watch TED talks; practice multiple times to hone various aspects of the talk; give the talk multiple times for iterative improvement; always ask for feedback and try to change at least one thing from one talk to another to continuously improve.
Dr. Kim is a hospitalist who works at Emory University Hospital in Atlanta, and is an editorial board member of The Hospitalist.
HM17 plenaries: Hospital medicine leading health care shift to value, quality
LAS VEGAS – The path to improved health care in the U.S. may never be straight – and it certainly won’t be easy – but the three plenary speakers at HM17 think its destination is pretty clear: a system that increasingly rewards quality care delivered at lower costs.
And the three experts agreed that there may be “no finer group” than hospitalists to continue leading the charge.
Hospitalists “have been at the center of change, not only in building a new field and showing us that medicine doesn’t have to be the way it always was,” said Karen DeSalvo, MD, MPH, MSc, former acting assistant secretary for health in the U.S. Department of Health and Human Services. “You have been at the forefront of seeing that we’re getting better value out of our health care system.”
Dr. DeSalvo believes HM’s scope of practice must evolve to include a focus on social determinants – such as economic stability, neighborhood and physical environment, education, and access to healthy options for food – because they have “direct relationships with mortality and morbidity and cost.”
In other words, Dr. DeSalvo wondered aloud, what good is treating a grandmother’s heart failure over and over if she’s always going to return to the hospital because her home, her neighborhood, or her finances mean she is unable to prevent recurring issues?
“If you listen to the hoof-beats that are coming, there is definitely a financial imprimatur to do this,” Dr. DeSalvo said. “There is going to be an expectation from public and private payers... that we are going to be taking into account and addressing social factors. Just look at the data from the people of this country – they are shouting loudly to you that they need help.”
“I can tell you our system still does not have a highly reliable, whole health system for those children and their families,” he said. “Every weekend, I have a family that I can’t discharge because they don’t have the social and home-based supports for them to go home. So they literally sit in the hospital until Monday. That makes no sense for our overall health system.”
Dr. Conway assured attendees that health system transformation is a bipartisan ideal and that for all the tumult in Washington, the progress of testing new payment- and service-delivery models will move forward.
The work “on value, the work on accountability, the work on bundled payments... will continue and will continue to be important to you and the patients you serve,” he said.
Robert Wachter, MD, MHM, concluded the meeting – as is tradition – by telling hospitalists the field remains positioned to take the lead for hospital transformation. And technology, despite its myriad frustrations, is still the tool that will get the field there.
“Digital is really important here, because it becomes an enabler for those stakeholders who care about what we do to measure what we do, and our ability to change what we do in a far more robust way than we could ever do before, if we get our acts together,” Dr. Wachter said. “We’re well past the time where you can nibble around the edges here, you can get this done with little mini projects. You really have to remake your whole delivery system, the way you do your work in order to succeed in this environment.”
Dr. Wachter agreed that social determinants must be addressed. He said HM might do better to partner with folks handling those issues, rather than tackling them head on. Instead, HM needs to be “focusing on the right things” amid mounting pressures from digitization, consolidation of everything from health systems to insurance companies to HM companies, and the gravitation toward population health.
“We have successfully positioned ourselves as the people who are leaders in this work,” Dr. Wachter said, “and it is increasingly important that we continue to do that as we go forward.”
LAS VEGAS – The path to improved health care in the U.S. may never be straight – and it certainly won’t be easy – but the three plenary speakers at HM17 think its destination is pretty clear: a system that increasingly rewards quality care delivered at lower costs.
And the three experts agreed that there may be “no finer group” than hospitalists to continue leading the charge.
Hospitalists “have been at the center of change, not only in building a new field and showing us that medicine doesn’t have to be the way it always was,” said Karen DeSalvo, MD, MPH, MSc, former acting assistant secretary for health in the U.S. Department of Health and Human Services. “You have been at the forefront of seeing that we’re getting better value out of our health care system.”
Dr. DeSalvo believes HM’s scope of practice must evolve to include a focus on social determinants – such as economic stability, neighborhood and physical environment, education, and access to healthy options for food – because they have “direct relationships with mortality and morbidity and cost.”
In other words, Dr. DeSalvo wondered aloud, what good is treating a grandmother’s heart failure over and over if she’s always going to return to the hospital because her home, her neighborhood, or her finances mean she is unable to prevent recurring issues?
“If you listen to the hoof-beats that are coming, there is definitely a financial imprimatur to do this,” Dr. DeSalvo said. “There is going to be an expectation from public and private payers... that we are going to be taking into account and addressing social factors. Just look at the data from the people of this country – they are shouting loudly to you that they need help.”
“I can tell you our system still does not have a highly reliable, whole health system for those children and their families,” he said. “Every weekend, I have a family that I can’t discharge because they don’t have the social and home-based supports for them to go home. So they literally sit in the hospital until Monday. That makes no sense for our overall health system.”
Dr. Conway assured attendees that health system transformation is a bipartisan ideal and that for all the tumult in Washington, the progress of testing new payment- and service-delivery models will move forward.
The work “on value, the work on accountability, the work on bundled payments... will continue and will continue to be important to you and the patients you serve,” he said.
Robert Wachter, MD, MHM, concluded the meeting – as is tradition – by telling hospitalists the field remains positioned to take the lead for hospital transformation. And technology, despite its myriad frustrations, is still the tool that will get the field there.
“Digital is really important here, because it becomes an enabler for those stakeholders who care about what we do to measure what we do, and our ability to change what we do in a far more robust way than we could ever do before, if we get our acts together,” Dr. Wachter said. “We’re well past the time where you can nibble around the edges here, you can get this done with little mini projects. You really have to remake your whole delivery system, the way you do your work in order to succeed in this environment.”
Dr. Wachter agreed that social determinants must be addressed. He said HM might do better to partner with folks handling those issues, rather than tackling them head on. Instead, HM needs to be “focusing on the right things” amid mounting pressures from digitization, consolidation of everything from health systems to insurance companies to HM companies, and the gravitation toward population health.
“We have successfully positioned ourselves as the people who are leaders in this work,” Dr. Wachter said, “and it is increasingly important that we continue to do that as we go forward.”
LAS VEGAS – The path to improved health care in the U.S. may never be straight – and it certainly won’t be easy – but the three plenary speakers at HM17 think its destination is pretty clear: a system that increasingly rewards quality care delivered at lower costs.
And the three experts agreed that there may be “no finer group” than hospitalists to continue leading the charge.
Hospitalists “have been at the center of change, not only in building a new field and showing us that medicine doesn’t have to be the way it always was,” said Karen DeSalvo, MD, MPH, MSc, former acting assistant secretary for health in the U.S. Department of Health and Human Services. “You have been at the forefront of seeing that we’re getting better value out of our health care system.”
Dr. DeSalvo believes HM’s scope of practice must evolve to include a focus on social determinants – such as economic stability, neighborhood and physical environment, education, and access to healthy options for food – because they have “direct relationships with mortality and morbidity and cost.”
In other words, Dr. DeSalvo wondered aloud, what good is treating a grandmother’s heart failure over and over if she’s always going to return to the hospital because her home, her neighborhood, or her finances mean she is unable to prevent recurring issues?
“If you listen to the hoof-beats that are coming, there is definitely a financial imprimatur to do this,” Dr. DeSalvo said. “There is going to be an expectation from public and private payers... that we are going to be taking into account and addressing social factors. Just look at the data from the people of this country – they are shouting loudly to you that they need help.”
“I can tell you our system still does not have a highly reliable, whole health system for those children and their families,” he said. “Every weekend, I have a family that I can’t discharge because they don’t have the social and home-based supports for them to go home. So they literally sit in the hospital until Monday. That makes no sense for our overall health system.”
Dr. Conway assured attendees that health system transformation is a bipartisan ideal and that for all the tumult in Washington, the progress of testing new payment- and service-delivery models will move forward.
The work “on value, the work on accountability, the work on bundled payments... will continue and will continue to be important to you and the patients you serve,” he said.
Robert Wachter, MD, MHM, concluded the meeting – as is tradition – by telling hospitalists the field remains positioned to take the lead for hospital transformation. And technology, despite its myriad frustrations, is still the tool that will get the field there.
“Digital is really important here, because it becomes an enabler for those stakeholders who care about what we do to measure what we do, and our ability to change what we do in a far more robust way than we could ever do before, if we get our acts together,” Dr. Wachter said. “We’re well past the time where you can nibble around the edges here, you can get this done with little mini projects. You really have to remake your whole delivery system, the way you do your work in order to succeed in this environment.”
Dr. Wachter agreed that social determinants must be addressed. He said HM might do better to partner with folks handling those issues, rather than tackling them head on. Instead, HM needs to be “focusing on the right things” amid mounting pressures from digitization, consolidation of everything from health systems to insurance companies to HM companies, and the gravitation toward population health.
“We have successfully positioned ourselves as the people who are leaders in this work,” Dr. Wachter said, “and it is increasingly important that we continue to do that as we go forward.”
HM17 session summary: Building a practice that people want to be part of
Presenters
Roberta Himebaugh MBA, SHM; John Nelson, MD, FACP, MHM; Jerome Siy, MD, SFHM
Session summary
Creating a “culture of ownership” by recruiting the right people, promoting physician leadership, and improving structural elements such as compensation model and schedule were topics discussed in this practice management precourse at HM17.
The presenters said leaders must reduce hierarchy and promote shared decision making among the group, while instilling a “thank you culture” that recognizes motivations such as autonomy, mastery, and purpose.
Leaders must also consider current changes in health care payment models, such as MIPS (Merit-based Incentive Payment System), bundled payments, and Hospital Value-based Purchasing. Hospitalist groups must be prepared for these changes by learning about them and looking for potential cost reduction opportunities (e.g., reducing the number of patients going to skilled nursing facilities after joint replacement by sending patients home whenever possible).
Promoting a culture of engagement might include the development of interpersonal support strategies (e.g., meditation and mindfulness), innovative staffing (is 7 on/7 off right for everyone?), and comprehensive support for career and leadership development.
Finally, hospitalists should give special attention to the value formula by focusing on improving patient outcomes and experience, but also reducing direct and indirect costs. This is crucial for the sustainability of any hospitalist group.
Key takeaways for HM
• Create a culture of ownership to promote engagement and job satisfaction.
• Make adjustments to schedule and workflow to improve efficiency.
• Prepare for evolving pay-for-performance programs.
• Demonstrate the value of the group by setting expectations with key stakeholders, developing a practice score, and providing effective feedback to providers.
Dr. Villagra is a chief hospitalist in Batesville, Ark., and an editorial board member of The Hospitalist.
Presenters
Roberta Himebaugh MBA, SHM; John Nelson, MD, FACP, MHM; Jerome Siy, MD, SFHM
Session summary
Creating a “culture of ownership” by recruiting the right people, promoting physician leadership, and improving structural elements such as compensation model and schedule were topics discussed in this practice management precourse at HM17.
The presenters said leaders must reduce hierarchy and promote shared decision making among the group, while instilling a “thank you culture” that recognizes motivations such as autonomy, mastery, and purpose.
Leaders must also consider current changes in health care payment models, such as MIPS (Merit-based Incentive Payment System), bundled payments, and Hospital Value-based Purchasing. Hospitalist groups must be prepared for these changes by learning about them and looking for potential cost reduction opportunities (e.g., reducing the number of patients going to skilled nursing facilities after joint replacement by sending patients home whenever possible).
Promoting a culture of engagement might include the development of interpersonal support strategies (e.g., meditation and mindfulness), innovative staffing (is 7 on/7 off right for everyone?), and comprehensive support for career and leadership development.
Finally, hospitalists should give special attention to the value formula by focusing on improving patient outcomes and experience, but also reducing direct and indirect costs. This is crucial for the sustainability of any hospitalist group.
Key takeaways for HM
• Create a culture of ownership to promote engagement and job satisfaction.
• Make adjustments to schedule and workflow to improve efficiency.
• Prepare for evolving pay-for-performance programs.
• Demonstrate the value of the group by setting expectations with key stakeholders, developing a practice score, and providing effective feedback to providers.
Dr. Villagra is a chief hospitalist in Batesville, Ark., and an editorial board member of The Hospitalist.
Presenters
Roberta Himebaugh MBA, SHM; John Nelson, MD, FACP, MHM; Jerome Siy, MD, SFHM
Session summary
Creating a “culture of ownership” by recruiting the right people, promoting physician leadership, and improving structural elements such as compensation model and schedule were topics discussed in this practice management precourse at HM17.
The presenters said leaders must reduce hierarchy and promote shared decision making among the group, while instilling a “thank you culture” that recognizes motivations such as autonomy, mastery, and purpose.
Leaders must also consider current changes in health care payment models, such as MIPS (Merit-based Incentive Payment System), bundled payments, and Hospital Value-based Purchasing. Hospitalist groups must be prepared for these changes by learning about them and looking for potential cost reduction opportunities (e.g., reducing the number of patients going to skilled nursing facilities after joint replacement by sending patients home whenever possible).
Promoting a culture of engagement might include the development of interpersonal support strategies (e.g., meditation and mindfulness), innovative staffing (is 7 on/7 off right for everyone?), and comprehensive support for career and leadership development.
Finally, hospitalists should give special attention to the value formula by focusing on improving patient outcomes and experience, but also reducing direct and indirect costs. This is crucial for the sustainability of any hospitalist group.
Key takeaways for HM
• Create a culture of ownership to promote engagement and job satisfaction.
• Make adjustments to schedule and workflow to improve efficiency.
• Prepare for evolving pay-for-performance programs.
• Demonstrate the value of the group by setting expectations with key stakeholders, developing a practice score, and providing effective feedback to providers.
Dr. Villagra is a chief hospitalist in Batesville, Ark., and an editorial board member of The Hospitalist.
Sneak Peek: The Hospital Leader Blog
We go to the altar together.
Last month, I wrote about onboarding and the important responsibility that everyone associated with a hospitalist program has to ensure that each new provider quickly comes to believe he or she made a terrific choice to join the group.
Upon reflection, it seems important to address the other side of this equation. I’m talking about the responsibilities that each candidate has when deciding whether to apply for a job, to interview, and to accept or reject a group’s offer.
The relationship between a hospitalist and the group he or she is part of is a lot like a marriage. Both parties go to the altar together, and the relationship is most likely to be successful when both enter it with their eyes open, having done their due diligence, and with an intention to align their interests and support each other. Here are some things every hospitalist should be thinking about as they assess potential job opportunities:
1. Be clear about your own needs, goals, and priorities. Before you embark on the job-hunting process, take time to do some careful introspection. My partner John Nelson is fond of saying that one of the key reasons many doctors choose to become hospitalists is that they prefer to “date” their practice rather than “marry” it. Which do you want? Are you willing to accept both the benefits and the costs of your preference? What are your short- and long-term career goals? In what part of the country do you want to live, and are you looking for an urban, suburban, or small-town environment? Is it important to be in a teaching setting? Are there specific pieces of work, such as ICU care or procedures, that you want to either pursue or avoid? What personal considerations, such as the needs of your spouse or kids, might limit your options? What structural aspects of the job are most important to you? Schedule? Daily workload? Compensation? I encourage you to think through these and other similar questions so that you are clear in your own mind about your personal job selection criteria. This will enable you to honestly articulate these things to others and to assess potential job opportunities in light of them.
Read the full text of this blog post at hospitalleader.org.
Leslie Flores is a founding partner at Nelson Flores Hospital Medicine Consultants, a consulting practice that has specialized in helping clients enhance the effectiveness and value of hospital medicine programs.
Also on The Hospital Leader …
Don’t Compare HM Group Part B Costs Hospital to Hospital by Brad Flansbaum, DO, MPH, MHM
Overcoming a Continued Physician Shortage by Danielle Scheurer, MD, MSCR, SFHM
Is Patient-Centered Care Bad for Resident Education? by Vineet Arora, MD, MPP, MHM
We go to the altar together.
Last month, I wrote about onboarding and the important responsibility that everyone associated with a hospitalist program has to ensure that each new provider quickly comes to believe he or she made a terrific choice to join the group.
Upon reflection, it seems important to address the other side of this equation. I’m talking about the responsibilities that each candidate has when deciding whether to apply for a job, to interview, and to accept or reject a group’s offer.
The relationship between a hospitalist and the group he or she is part of is a lot like a marriage. Both parties go to the altar together, and the relationship is most likely to be successful when both enter it with their eyes open, having done their due diligence, and with an intention to align their interests and support each other. Here are some things every hospitalist should be thinking about as they assess potential job opportunities:
1. Be clear about your own needs, goals, and priorities. Before you embark on the job-hunting process, take time to do some careful introspection. My partner John Nelson is fond of saying that one of the key reasons many doctors choose to become hospitalists is that they prefer to “date” their practice rather than “marry” it. Which do you want? Are you willing to accept both the benefits and the costs of your preference? What are your short- and long-term career goals? In what part of the country do you want to live, and are you looking for an urban, suburban, or small-town environment? Is it important to be in a teaching setting? Are there specific pieces of work, such as ICU care or procedures, that you want to either pursue or avoid? What personal considerations, such as the needs of your spouse or kids, might limit your options? What structural aspects of the job are most important to you? Schedule? Daily workload? Compensation? I encourage you to think through these and other similar questions so that you are clear in your own mind about your personal job selection criteria. This will enable you to honestly articulate these things to others and to assess potential job opportunities in light of them.
Read the full text of this blog post at hospitalleader.org.
Leslie Flores is a founding partner at Nelson Flores Hospital Medicine Consultants, a consulting practice that has specialized in helping clients enhance the effectiveness and value of hospital medicine programs.
Also on The Hospital Leader …
Don’t Compare HM Group Part B Costs Hospital to Hospital by Brad Flansbaum, DO, MPH, MHM
Overcoming a Continued Physician Shortage by Danielle Scheurer, MD, MSCR, SFHM
Is Patient-Centered Care Bad for Resident Education? by Vineet Arora, MD, MPP, MHM
We go to the altar together.
Last month, I wrote about onboarding and the important responsibility that everyone associated with a hospitalist program has to ensure that each new provider quickly comes to believe he or she made a terrific choice to join the group.
Upon reflection, it seems important to address the other side of this equation. I’m talking about the responsibilities that each candidate has when deciding whether to apply for a job, to interview, and to accept or reject a group’s offer.
The relationship between a hospitalist and the group he or she is part of is a lot like a marriage. Both parties go to the altar together, and the relationship is most likely to be successful when both enter it with their eyes open, having done their due diligence, and with an intention to align their interests and support each other. Here are some things every hospitalist should be thinking about as they assess potential job opportunities:
1. Be clear about your own needs, goals, and priorities. Before you embark on the job-hunting process, take time to do some careful introspection. My partner John Nelson is fond of saying that one of the key reasons many doctors choose to become hospitalists is that they prefer to “date” their practice rather than “marry” it. Which do you want? Are you willing to accept both the benefits and the costs of your preference? What are your short- and long-term career goals? In what part of the country do you want to live, and are you looking for an urban, suburban, or small-town environment? Is it important to be in a teaching setting? Are there specific pieces of work, such as ICU care or procedures, that you want to either pursue or avoid? What personal considerations, such as the needs of your spouse or kids, might limit your options? What structural aspects of the job are most important to you? Schedule? Daily workload? Compensation? I encourage you to think through these and other similar questions so that you are clear in your own mind about your personal job selection criteria. This will enable you to honestly articulate these things to others and to assess potential job opportunities in light of them.
Read the full text of this blog post at hospitalleader.org.
Leslie Flores is a founding partner at Nelson Flores Hospital Medicine Consultants, a consulting practice that has specialized in helping clients enhance the effectiveness and value of hospital medicine programs.
Also on The Hospital Leader …
Don’t Compare HM Group Part B Costs Hospital to Hospital by Brad Flansbaum, DO, MPH, MHM
Overcoming a Continued Physician Shortage by Danielle Scheurer, MD, MSCR, SFHM
Is Patient-Centered Care Bad for Resident Education? by Vineet Arora, MD, MPP, MHM
On 15 years: Celebrating a nocturnist’s career longevity
“Nocturnist years are like dog years. So really we’re celebrating you for 105 years of service!”
Shawn Lee, MD, a day shift hospitalist at Overlake Medical Center in Bellevue, Wash. (where I work), said this about our colleague, Arash Nadershahi, MD, on the occasion of his 15th anniversary as a nocturnist with our group. Every hospitalist group should be so lucky to have someone like Arash among them, whether working nights or days.
When Arash joined our group the job simply entailed turning on the pager at 9 p.m. and coming in to the hospital only when the need arose. Some nights meant only answering some “cross-cover” calls from home, while other nights started with one or more patients needing admission right at the start of the shift.
As the months went by, patient volume climbed rapidly and Arash, as well as the nocturnists who joined us subsequently, began arriving at the hospital no later than the 9:00 p.m. shift start and staying in-house until 7 a.m. We never had a meeting or contentious conversation to make it official that the night shift changed to in-house all night instead of call-from-home. It just evolved that way to meet the need.
We all value Arash’s steady demeanor, excellent clinical skills, and good relationships with ED staff and nurses as well as patients. And for many years he and our other two nocturnists have covered all night shifts, including filling in when one of them is unexpectedly out for the birth of a child, illness, or other reason. The day doctors have never been called upon to work night shifts to cover an unexpected nocturnist absence.
Configuring the nocturnist position
A full-time nocturnist in our group works ten 10-hour night shifts and two 6-hour evening shifts (5-11 p.m.) per month. I like to think this has contributed to longevity for our nocturnists. One left last year after working nights for 10 years, and another just started his 9th year in the group.
The three nocturnists can work any schedule they like as long as one of them is on duty each night. For more than 10 years they’ve worked 7 consecutive night shifts followed by 14 off (that is sometimes interrupted by an evening shift). To my way of thinking, though, they’re essentially devoting 9 days to the practice for every seven consecutive shifts. The days before they start their rotation and after they complete it are spent preparing/recovering by adjusting their sleep, so aren’t really days of R&R.
For this work their compensation is very similar to that of full-time day shift doctors. The idea is that their compensation premium for working nights comes in the form of less work rather than more money; they work fewer and shorter shifts than their daytime counterparts. And we discourage moonlighting during all those days off. We want to provide the conditions for a healthy lifestyle to offset night work.
The longest-tenured nocturnist?
At 15 years of full-time work as a nocturnist, Arash may be one of the longest-tenured doctors in this role nationally. (I would love to hear about others who’ve been at it longer.) I like to think that our “pay ’em the same and work ’em less” approach may be a meaningful contributor to his longevity in the role, but I’m convinced his personal attributes are also a big factor.
His interests and creativity find their way into our workplace. For a while the day shift doctors would arrive to find our office full of motorcycle parts in various stages of assembly. Many of his doodles and drawings and witty writings are taped to the walls and cabinets. A few years ago he started writing haikus and before long everyone in the group joined in. This even led to one of our docs hosting a really fun party at which every guest wrote haikus and all had to guess the author of each one.
Other groups can’t count on finding someone as valuable as Arash, but they’ll have the best chance of it if they think carefully about how the nocturnist role is configured.
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.
“Nocturnist years are like dog years. So really we’re celebrating you for 105 years of service!”
Shawn Lee, MD, a day shift hospitalist at Overlake Medical Center in Bellevue, Wash. (where I work), said this about our colleague, Arash Nadershahi, MD, on the occasion of his 15th anniversary as a nocturnist with our group. Every hospitalist group should be so lucky to have someone like Arash among them, whether working nights or days.
When Arash joined our group the job simply entailed turning on the pager at 9 p.m. and coming in to the hospital only when the need arose. Some nights meant only answering some “cross-cover” calls from home, while other nights started with one or more patients needing admission right at the start of the shift.
As the months went by, patient volume climbed rapidly and Arash, as well as the nocturnists who joined us subsequently, began arriving at the hospital no later than the 9:00 p.m. shift start and staying in-house until 7 a.m. We never had a meeting or contentious conversation to make it official that the night shift changed to in-house all night instead of call-from-home. It just evolved that way to meet the need.
We all value Arash’s steady demeanor, excellent clinical skills, and good relationships with ED staff and nurses as well as patients. And for many years he and our other two nocturnists have covered all night shifts, including filling in when one of them is unexpectedly out for the birth of a child, illness, or other reason. The day doctors have never been called upon to work night shifts to cover an unexpected nocturnist absence.
Configuring the nocturnist position
A full-time nocturnist in our group works ten 10-hour night shifts and two 6-hour evening shifts (5-11 p.m.) per month. I like to think this has contributed to longevity for our nocturnists. One left last year after working nights for 10 years, and another just started his 9th year in the group.
The three nocturnists can work any schedule they like as long as one of them is on duty each night. For more than 10 years they’ve worked 7 consecutive night shifts followed by 14 off (that is sometimes interrupted by an evening shift). To my way of thinking, though, they’re essentially devoting 9 days to the practice for every seven consecutive shifts. The days before they start their rotation and after they complete it are spent preparing/recovering by adjusting their sleep, so aren’t really days of R&R.
For this work their compensation is very similar to that of full-time day shift doctors. The idea is that their compensation premium for working nights comes in the form of less work rather than more money; they work fewer and shorter shifts than their daytime counterparts. And we discourage moonlighting during all those days off. We want to provide the conditions for a healthy lifestyle to offset night work.
The longest-tenured nocturnist?
At 15 years of full-time work as a nocturnist, Arash may be one of the longest-tenured doctors in this role nationally. (I would love to hear about others who’ve been at it longer.) I like to think that our “pay ’em the same and work ’em less” approach may be a meaningful contributor to his longevity in the role, but I’m convinced his personal attributes are also a big factor.
His interests and creativity find their way into our workplace. For a while the day shift doctors would arrive to find our office full of motorcycle parts in various stages of assembly. Many of his doodles and drawings and witty writings are taped to the walls and cabinets. A few years ago he started writing haikus and before long everyone in the group joined in. This even led to one of our docs hosting a really fun party at which every guest wrote haikus and all had to guess the author of each one.
Other groups can’t count on finding someone as valuable as Arash, but they’ll have the best chance of it if they think carefully about how the nocturnist role is configured.
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.
“Nocturnist years are like dog years. So really we’re celebrating you for 105 years of service!”
Shawn Lee, MD, a day shift hospitalist at Overlake Medical Center in Bellevue, Wash. (where I work), said this about our colleague, Arash Nadershahi, MD, on the occasion of his 15th anniversary as a nocturnist with our group. Every hospitalist group should be so lucky to have someone like Arash among them, whether working nights or days.
When Arash joined our group the job simply entailed turning on the pager at 9 p.m. and coming in to the hospital only when the need arose. Some nights meant only answering some “cross-cover” calls from home, while other nights started with one or more patients needing admission right at the start of the shift.
As the months went by, patient volume climbed rapidly and Arash, as well as the nocturnists who joined us subsequently, began arriving at the hospital no later than the 9:00 p.m. shift start and staying in-house until 7 a.m. We never had a meeting or contentious conversation to make it official that the night shift changed to in-house all night instead of call-from-home. It just evolved that way to meet the need.
We all value Arash’s steady demeanor, excellent clinical skills, and good relationships with ED staff and nurses as well as patients. And for many years he and our other two nocturnists have covered all night shifts, including filling in when one of them is unexpectedly out for the birth of a child, illness, or other reason. The day doctors have never been called upon to work night shifts to cover an unexpected nocturnist absence.
Configuring the nocturnist position
A full-time nocturnist in our group works ten 10-hour night shifts and two 6-hour evening shifts (5-11 p.m.) per month. I like to think this has contributed to longevity for our nocturnists. One left last year after working nights for 10 years, and another just started his 9th year in the group.
The three nocturnists can work any schedule they like as long as one of them is on duty each night. For more than 10 years they’ve worked 7 consecutive night shifts followed by 14 off (that is sometimes interrupted by an evening shift). To my way of thinking, though, they’re essentially devoting 9 days to the practice for every seven consecutive shifts. The days before they start their rotation and after they complete it are spent preparing/recovering by adjusting their sleep, so aren’t really days of R&R.
For this work their compensation is very similar to that of full-time day shift doctors. The idea is that their compensation premium for working nights comes in the form of less work rather than more money; they work fewer and shorter shifts than their daytime counterparts. And we discourage moonlighting during all those days off. We want to provide the conditions for a healthy lifestyle to offset night work.
The longest-tenured nocturnist?
At 15 years of full-time work as a nocturnist, Arash may be one of the longest-tenured doctors in this role nationally. (I would love to hear about others who’ve been at it longer.) I like to think that our “pay ’em the same and work ’em less” approach may be a meaningful contributor to his longevity in the role, but I’m convinced his personal attributes are also a big factor.
His interests and creativity find their way into our workplace. For a while the day shift doctors would arrive to find our office full of motorcycle parts in various stages of assembly. Many of his doodles and drawings and witty writings are taped to the walls and cabinets. A few years ago he started writing haikus and before long everyone in the group joined in. This even led to one of our docs hosting a really fun party at which every guest wrote haikus and all had to guess the author of each one.
Other groups can’t count on finding someone as valuable as Arash, but they’ll have the best chance of it if they think carefully about how the nocturnist role is configured.
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.
RIV spotlights HM-focused research in real-time
LAS VEGAS – Masih Shinwa, MD, stood beside a half-circle of judges at SHM’s annual Research, Innovations, and Clinical Vignettes poster competition and argued why his entry, already a finalist, should win.
To think, his work, “Please ‘THINK’ Before You Order: A Multidisciplinary Approach to Decreasing Overutilization of Daily Labs,” was borne simply of a group of medical students who incredulously said that they were amazed patients would be woken up in the night for tests.
Dr. Shinwa’s project shows just how an idea can blossom into a recognized poster.
Some 18 months ago, the students he works with at Mount Sinai Hospital in New York just couldn’t understand why so many tests had to be done overnight while a patient slept. So, Dr. Shinwa and his colleagues looked at ways to reduce unnecessary lab tests and chemistry testing.
Now, Dr. Shinwa was humbled to think his work and that of his colleagues could be a pathway to eliminating tests that don’t need to happen across the country, a focal point of SHM and the American Board of Internal Medicine Foundation’s Choosing Wisely Campaign.
“This is a way to make it national,” he said. “You may have affected the lives of the patients in your hospital, but, unless you attend these types of national meetings, it’s hard to get that perspective across (the country).”
That level of personal and professional collaboration is the purpose of the RIV, said Margaret Fang, MD, MPH, FHM, program chair for the HM17 competition.
“One of the amazing things is, everyone has their own poster. They’re doing their work,” she added. “But then they start up conversations with the people next to them. ... Seeing the organic networking and discussion that arise from that is really exciting. RIV serves as a way of connecting people who might not have know the other person was doing that kind of work.”
Dr. Fang said that the intergenerational aspect of the RIV, where early-career hospitalists mingle with the field’s founders and leaders, creates an environment where research is encouraged.
“Just seeing the intense interest that more senior hospitalists have in mentoring and guiding the next generation is delightful,” she added.
Dr. Shinwa said that the specialty’s focus on both clinical research and systems-level change is important, as the work positions the field to be leaders not just in patient care but for hospitals as a whole.
“We are physicians,” he said. “Our role is taking care of patients. Knowing that there are people who are not just focusing on taking care of specific patients but are actually there to improve the entire system and the process – that’s really gratifying.”
That’s the word that Merideth Prevost, MD, of New Mexico VA Health Care System, Albuquerque also used to describe presenting her poster, “Improving Accuracy in Measuring Fluid Balance on a General Medicine Ward.”
“If we can improve our little microcosm, then spread it to other folks, then patients all over the country can be helped by what we do,” she said. “And that’s a really cool thought.”
The RIV also has the unique advantage of letting people have immediate and direct access to lead researchers at the exact moment of reading their research. HM17 attendees had conversations that usually went beyond just the results, which can be downloaded at www.shmabstracts.com.
Dr. Prevost believes that the chats can helpfully highlight the behind-the-scenes pitfalls and mistakes of research that can sometimes be just as valuable as the published results.
“The things that don’t make it to the posters are all the challenges that people experienced on the way to get to this particular work,” she added. “Like ‘Oh, well, I’ve tried this before, and it didn’t work at all.’ Or, ‘Oh yeah we tried this and it didn’t work at all, but we tried this other thing that worked really great.’ Or, ‘This was the key to our success.’ You can brainstorm with every poster that you’re interested in, which is really exciting.”
LAS VEGAS – Masih Shinwa, MD, stood beside a half-circle of judges at SHM’s annual Research, Innovations, and Clinical Vignettes poster competition and argued why his entry, already a finalist, should win.
To think, his work, “Please ‘THINK’ Before You Order: A Multidisciplinary Approach to Decreasing Overutilization of Daily Labs,” was borne simply of a group of medical students who incredulously said that they were amazed patients would be woken up in the night for tests.
Dr. Shinwa’s project shows just how an idea can blossom into a recognized poster.
Some 18 months ago, the students he works with at Mount Sinai Hospital in New York just couldn’t understand why so many tests had to be done overnight while a patient slept. So, Dr. Shinwa and his colleagues looked at ways to reduce unnecessary lab tests and chemistry testing.
Now, Dr. Shinwa was humbled to think his work and that of his colleagues could be a pathway to eliminating tests that don’t need to happen across the country, a focal point of SHM and the American Board of Internal Medicine Foundation’s Choosing Wisely Campaign.
“This is a way to make it national,” he said. “You may have affected the lives of the patients in your hospital, but, unless you attend these types of national meetings, it’s hard to get that perspective across (the country).”
That level of personal and professional collaboration is the purpose of the RIV, said Margaret Fang, MD, MPH, FHM, program chair for the HM17 competition.
“One of the amazing things is, everyone has their own poster. They’re doing their work,” she added. “But then they start up conversations with the people next to them. ... Seeing the organic networking and discussion that arise from that is really exciting. RIV serves as a way of connecting people who might not have know the other person was doing that kind of work.”
Dr. Fang said that the intergenerational aspect of the RIV, where early-career hospitalists mingle with the field’s founders and leaders, creates an environment where research is encouraged.
“Just seeing the intense interest that more senior hospitalists have in mentoring and guiding the next generation is delightful,” she added.
Dr. Shinwa said that the specialty’s focus on both clinical research and systems-level change is important, as the work positions the field to be leaders not just in patient care but for hospitals as a whole.
“We are physicians,” he said. “Our role is taking care of patients. Knowing that there are people who are not just focusing on taking care of specific patients but are actually there to improve the entire system and the process – that’s really gratifying.”
That’s the word that Merideth Prevost, MD, of New Mexico VA Health Care System, Albuquerque also used to describe presenting her poster, “Improving Accuracy in Measuring Fluid Balance on a General Medicine Ward.”
“If we can improve our little microcosm, then spread it to other folks, then patients all over the country can be helped by what we do,” she said. “And that’s a really cool thought.”
The RIV also has the unique advantage of letting people have immediate and direct access to lead researchers at the exact moment of reading their research. HM17 attendees had conversations that usually went beyond just the results, which can be downloaded at www.shmabstracts.com.
Dr. Prevost believes that the chats can helpfully highlight the behind-the-scenes pitfalls and mistakes of research that can sometimes be just as valuable as the published results.
“The things that don’t make it to the posters are all the challenges that people experienced on the way to get to this particular work,” she added. “Like ‘Oh, well, I’ve tried this before, and it didn’t work at all.’ Or, ‘Oh yeah we tried this and it didn’t work at all, but we tried this other thing that worked really great.’ Or, ‘This was the key to our success.’ You can brainstorm with every poster that you’re interested in, which is really exciting.”
LAS VEGAS – Masih Shinwa, MD, stood beside a half-circle of judges at SHM’s annual Research, Innovations, and Clinical Vignettes poster competition and argued why his entry, already a finalist, should win.
To think, his work, “Please ‘THINK’ Before You Order: A Multidisciplinary Approach to Decreasing Overutilization of Daily Labs,” was borne simply of a group of medical students who incredulously said that they were amazed patients would be woken up in the night for tests.
Dr. Shinwa’s project shows just how an idea can blossom into a recognized poster.
Some 18 months ago, the students he works with at Mount Sinai Hospital in New York just couldn’t understand why so many tests had to be done overnight while a patient slept. So, Dr. Shinwa and his colleagues looked at ways to reduce unnecessary lab tests and chemistry testing.
Now, Dr. Shinwa was humbled to think his work and that of his colleagues could be a pathway to eliminating tests that don’t need to happen across the country, a focal point of SHM and the American Board of Internal Medicine Foundation’s Choosing Wisely Campaign.
“This is a way to make it national,” he said. “You may have affected the lives of the patients in your hospital, but, unless you attend these types of national meetings, it’s hard to get that perspective across (the country).”
That level of personal and professional collaboration is the purpose of the RIV, said Margaret Fang, MD, MPH, FHM, program chair for the HM17 competition.
“One of the amazing things is, everyone has their own poster. They’re doing their work,” she added. “But then they start up conversations with the people next to them. ... Seeing the organic networking and discussion that arise from that is really exciting. RIV serves as a way of connecting people who might not have know the other person was doing that kind of work.”
Dr. Fang said that the intergenerational aspect of the RIV, where early-career hospitalists mingle with the field’s founders and leaders, creates an environment where research is encouraged.
“Just seeing the intense interest that more senior hospitalists have in mentoring and guiding the next generation is delightful,” she added.
Dr. Shinwa said that the specialty’s focus on both clinical research and systems-level change is important, as the work positions the field to be leaders not just in patient care but for hospitals as a whole.
“We are physicians,” he said. “Our role is taking care of patients. Knowing that there are people who are not just focusing on taking care of specific patients but are actually there to improve the entire system and the process – that’s really gratifying.”
That’s the word that Merideth Prevost, MD, of New Mexico VA Health Care System, Albuquerque also used to describe presenting her poster, “Improving Accuracy in Measuring Fluid Balance on a General Medicine Ward.”
“If we can improve our little microcosm, then spread it to other folks, then patients all over the country can be helped by what we do,” she said. “And that’s a really cool thought.”
The RIV also has the unique advantage of letting people have immediate and direct access to lead researchers at the exact moment of reading their research. HM17 attendees had conversations that usually went beyond just the results, which can be downloaded at www.shmabstracts.com.
Dr. Prevost believes that the chats can helpfully highlight the behind-the-scenes pitfalls and mistakes of research that can sometimes be just as valuable as the published results.
“The things that don’t make it to the posters are all the challenges that people experienced on the way to get to this particular work,” she added. “Like ‘Oh, well, I’ve tried this before, and it didn’t work at all.’ Or, ‘Oh yeah we tried this and it didn’t work at all, but we tried this other thing that worked really great.’ Or, ‘This was the key to our success.’ You can brainstorm with every poster that you’re interested in, which is really exciting.”
Hospitalists share strategies to secure, excel at jobs
LAS VEGAS – In the view of academic hospitalist Alfred Burger, MD, SFHM, portability was long a dirty word in HM circles. But not anymore.
“My good friends in law and business do this all the time,” said Dr. Burger, associate program director of the internal medicine residency program at Mount Sinai Beth Israel in New York. “You’re not going to make partner in city X, but they’ve got an opening to be partner in city Y if you go there and perform for a year. People up and leave coasts, people up and leave states, people have up and left the country. ... Doctors are starting to view it the same way.”
The lessons of career development were a focal point of HM17, particularly for younger physicians who could take advantage of the Early-Career Hospitalists mini-track. But Dr. Burger said that those strategies of upward mobility can apply whether someone is chasing their first job or their fifth.
First, identify one’s strengths and play to those. Then identify the skills you don’t have or don’t excel at, and address those deficiencies.
“How can you acquire the skills to put yourself in the best position to move up, if you wish to develop your career as a leader?” Dr. Burger said. “If you wish to be the best clinician, you still need to stay on top of the game. Things like coming to SHM, staying on top of the content. That’s important.”
Another skill set is self-advocacy.
“Be your own champion,” said Brian Markoff, MD, SFHM, chief of hospital medicine at Mount Sinai St. Luke’s in New York. “Many of us are very good at this and many of us are terrible at this. You may fall somewhere in between, but you do have to be your own champion.”
Dr. Burger said that he understands that there is a fine line between too much self-promotion and too little. But he urged hospitalists at all career points to take responsibility for marketing themselves.
“Nobody is going to invest in your career unless you yourself invest in it,” he added. “You have to put it as a priority, and not in a selfish way, but in a way [that,] if you wish to move forward and move up, you’ve got to put the time in. It’s not a natural assumption anymore that, if you are the best and brightest of a group of doctors, you will just be chosen to lead.”
In a similar vein, networking is a major boon to career development that can be a double-edged scalpel.
“Having a great ‘social game’ is important, but if all you bring to the table is a social game, you’ll find yourself out of a job just as quickly as you found that job,” Dr. Burger said. “Meaning, you might be able to get it based on that, but you’re not going to be able to sustain it. At the same time, being highly accomplished and having no social graces is also a killer. So, you need to be sort of strong in both areas.”
Many of the meeting’s opportunities for tips on professional development are personal, but HM group leaders have to consider developing the careers of their employees. One of the main planks of that is physician engagement, said Flora Kisuule, MD, MPH, SFHM, of Johns Hopkins University, Baltimore.
“I don’t believe your institution or your organization can go anywhere if your employees are not engaged or if the people you work with are not engaged,” she said, adding that disengaged employees “are actively working against you. You don’t want that. You can’t go in any direction when there are people rowing in the opposite direction. At best, you stay in one place. At worst, you can end up losing ground.”
Hospitalist Christie Masters, MD, MBA, MHA, who practices at UCLA, disclosed during a session that she also runs a wellness coaching firm. She added that a focus on personal wellness and well-being is its own form of career development. It works in tandem with engagement, morale, and professional growth.
“If you’re only focusing on wellness and you don’t have hospitalists or a group that’s engaged or with high morale, they’re going to burnout or they’re going to leave,” Dr. Masters said. “And nobody wants that for their group. So, if we surround ourselves with people who feel well and feel whole, that’s going to have intangible benefits ... that affect the bottom line.”
LAS VEGAS – In the view of academic hospitalist Alfred Burger, MD, SFHM, portability was long a dirty word in HM circles. But not anymore.
“My good friends in law and business do this all the time,” said Dr. Burger, associate program director of the internal medicine residency program at Mount Sinai Beth Israel in New York. “You’re not going to make partner in city X, but they’ve got an opening to be partner in city Y if you go there and perform for a year. People up and leave coasts, people up and leave states, people have up and left the country. ... Doctors are starting to view it the same way.”
The lessons of career development were a focal point of HM17, particularly for younger physicians who could take advantage of the Early-Career Hospitalists mini-track. But Dr. Burger said that those strategies of upward mobility can apply whether someone is chasing their first job or their fifth.
First, identify one’s strengths and play to those. Then identify the skills you don’t have or don’t excel at, and address those deficiencies.
“How can you acquire the skills to put yourself in the best position to move up, if you wish to develop your career as a leader?” Dr. Burger said. “If you wish to be the best clinician, you still need to stay on top of the game. Things like coming to SHM, staying on top of the content. That’s important.”
Another skill set is self-advocacy.
“Be your own champion,” said Brian Markoff, MD, SFHM, chief of hospital medicine at Mount Sinai St. Luke’s in New York. “Many of us are very good at this and many of us are terrible at this. You may fall somewhere in between, but you do have to be your own champion.”
Dr. Burger said that he understands that there is a fine line between too much self-promotion and too little. But he urged hospitalists at all career points to take responsibility for marketing themselves.
“Nobody is going to invest in your career unless you yourself invest in it,” he added. “You have to put it as a priority, and not in a selfish way, but in a way [that,] if you wish to move forward and move up, you’ve got to put the time in. It’s not a natural assumption anymore that, if you are the best and brightest of a group of doctors, you will just be chosen to lead.”
In a similar vein, networking is a major boon to career development that can be a double-edged scalpel.
“Having a great ‘social game’ is important, but if all you bring to the table is a social game, you’ll find yourself out of a job just as quickly as you found that job,” Dr. Burger said. “Meaning, you might be able to get it based on that, but you’re not going to be able to sustain it. At the same time, being highly accomplished and having no social graces is also a killer. So, you need to be sort of strong in both areas.”
Many of the meeting’s opportunities for tips on professional development are personal, but HM group leaders have to consider developing the careers of their employees. One of the main planks of that is physician engagement, said Flora Kisuule, MD, MPH, SFHM, of Johns Hopkins University, Baltimore.
“I don’t believe your institution or your organization can go anywhere if your employees are not engaged or if the people you work with are not engaged,” she said, adding that disengaged employees “are actively working against you. You don’t want that. You can’t go in any direction when there are people rowing in the opposite direction. At best, you stay in one place. At worst, you can end up losing ground.”
Hospitalist Christie Masters, MD, MBA, MHA, who practices at UCLA, disclosed during a session that she also runs a wellness coaching firm. She added that a focus on personal wellness and well-being is its own form of career development. It works in tandem with engagement, morale, and professional growth.
“If you’re only focusing on wellness and you don’t have hospitalists or a group that’s engaged or with high morale, they’re going to burnout or they’re going to leave,” Dr. Masters said. “And nobody wants that for their group. So, if we surround ourselves with people who feel well and feel whole, that’s going to have intangible benefits ... that affect the bottom line.”
LAS VEGAS – In the view of academic hospitalist Alfred Burger, MD, SFHM, portability was long a dirty word in HM circles. But not anymore.
“My good friends in law and business do this all the time,” said Dr. Burger, associate program director of the internal medicine residency program at Mount Sinai Beth Israel in New York. “You’re not going to make partner in city X, but they’ve got an opening to be partner in city Y if you go there and perform for a year. People up and leave coasts, people up and leave states, people have up and left the country. ... Doctors are starting to view it the same way.”
The lessons of career development were a focal point of HM17, particularly for younger physicians who could take advantage of the Early-Career Hospitalists mini-track. But Dr. Burger said that those strategies of upward mobility can apply whether someone is chasing their first job or their fifth.
First, identify one’s strengths and play to those. Then identify the skills you don’t have or don’t excel at, and address those deficiencies.
“How can you acquire the skills to put yourself in the best position to move up, if you wish to develop your career as a leader?” Dr. Burger said. “If you wish to be the best clinician, you still need to stay on top of the game. Things like coming to SHM, staying on top of the content. That’s important.”
Another skill set is self-advocacy.
“Be your own champion,” said Brian Markoff, MD, SFHM, chief of hospital medicine at Mount Sinai St. Luke’s in New York. “Many of us are very good at this and many of us are terrible at this. You may fall somewhere in between, but you do have to be your own champion.”
Dr. Burger said that he understands that there is a fine line between too much self-promotion and too little. But he urged hospitalists at all career points to take responsibility for marketing themselves.
“Nobody is going to invest in your career unless you yourself invest in it,” he added. “You have to put it as a priority, and not in a selfish way, but in a way [that,] if you wish to move forward and move up, you’ve got to put the time in. It’s not a natural assumption anymore that, if you are the best and brightest of a group of doctors, you will just be chosen to lead.”
In a similar vein, networking is a major boon to career development that can be a double-edged scalpel.
“Having a great ‘social game’ is important, but if all you bring to the table is a social game, you’ll find yourself out of a job just as quickly as you found that job,” Dr. Burger said. “Meaning, you might be able to get it based on that, but you’re not going to be able to sustain it. At the same time, being highly accomplished and having no social graces is also a killer. So, you need to be sort of strong in both areas.”
Many of the meeting’s opportunities for tips on professional development are personal, but HM group leaders have to consider developing the careers of their employees. One of the main planks of that is physician engagement, said Flora Kisuule, MD, MPH, SFHM, of Johns Hopkins University, Baltimore.
“I don’t believe your institution or your organization can go anywhere if your employees are not engaged or if the people you work with are not engaged,” she said, adding that disengaged employees “are actively working against you. You don’t want that. You can’t go in any direction when there are people rowing in the opposite direction. At best, you stay in one place. At worst, you can end up losing ground.”
Hospitalist Christie Masters, MD, MBA, MHA, who practices at UCLA, disclosed during a session that she also runs a wellness coaching firm. She added that a focus on personal wellness and well-being is its own form of career development. It works in tandem with engagement, morale, and professional growth.
“If you’re only focusing on wellness and you don’t have hospitalists or a group that’s engaged or with high morale, they’re going to burnout or they’re going to leave,” Dr. Masters said. “And nobody wants that for their group. So, if we surround ourselves with people who feel well and feel whole, that’s going to have intangible benefits ... that affect the bottom line.”