RSSAuthor Archive for Richard Rohr, MD, MMM, FACP, FHM

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Richard Rohr MD, MMM, FACP, started one of the first hospitalist programs in Connecticut in 1996 and is a charter member of the Society of Hospital Medicine. He is a graduate of Columbia University, New York Medical College, and received the Master of Medical Management degree from Tulane University. Dr. Rohr is certified in internal medicine and pulmonary disease. He began his career practicing pulmonary and internal medicine for two staff-model HMOs in MA and CT, and then directed a long-term care facility specializing in medically complex patients before joining Milford Hospital to establish the hospitalist program. Dr. Rohr spent a year as vice president for medical affairs at a small hospital in upstate New York before assuming his current position directing hospitalist programs for the Guthrie Healthcare System in Sayre, PA.

Connect the dots

I have been spending most of my time reviewing admission documentation for hospitals across the country, and it is surprising to me that rather few physicians will commit to a diagnosis for incoming patients.  I see “dyspnea” instead of “CHF” or “pneumonia,” “diarrhea” instead of “gastroenteritis” and “dysuria” instead of “urinary infection.”

Emergency physicians seem to be especially reticent to make a diagnosis, but hospitalists are not far behind. It creates a problem for the hospital because medical necessity for inpatient services is based on the presence of a condition that may incur significant morbidity or mortality, and the prescription of a treatment regimen appropriate for the condition. Determining necessity is more certain when a specific diagnosis is made. No one dies from shortness of breath, but one can certainly die from CHF or pneumonia, and there are well-established courses of treatment for those diseases.

I suspect that we started down this slippery slope because the definitive diagnosis of myocardial infarction can be difficult, even when the electrocardiogram and enzymes are abnormal.  This led to the term “R/O MI” as an admitting diagnosis. Ruling out a medical condition is really an observation service. Reticence to commit to a diagnosis can cost the hospital money. If you believe that the chest pain is related to heart disease, why not describe it as “acute coronary syndrome?” If the patient has fever, cough, and hypoxemia, it is appropriate to connect the dots and call it pneumonia, even if the x-ray is unclear. It is understood that admitting diagnoses may differ from the discharge diagnosis as more information becomes available. There is nothing to lose and much to gain from making your best estimate of the patent’s disease on admission.


One of the newest plans being proposed for Medicare payment involves combining the payments for hospital and physician services into a single amount to be divided between the parties as they see fit. The goal for Medicare is to pay less in total than is currently going to doctors and hospitals separately, by encouraging the two parties to work together on economies. 

It reminds me of a practice in Colonial times, also called bundling, in which two persons would be placed in a bed with a board between them in order to conserve heat during the night. Either form of bundling requires the parties to respect each other’s space while drawing together as closely as possible to achieve maximum efficiency. 

Hospital-employed physicians are effectively bundled already, while independent groups are likely to face this issue in the near future. It is closely connected to the subsidy issue, as the parties must determine how much money each needs to live on. Bundling increases the stakes by bringing multiple specialties into the negotiation. Hospitalists in medical specialties will need to advocate their case effectively against that of procedural specialists who have long been the darlings of hospital administrators because they bring money into the institution. Hospitalists need to generate visible cost savings to avoid being smothered by their bedmates.

The day of reckoning

Hospital medicine in America has reached its 15-year anniversary and finds itself with serious questions as to whether its remarkable growth can be sustained. 

The threat comes primarily from new initiatives to stop further growth in Medicare expenditures by constraining hospital revenues. This is forcing hospital managers to change their attitude toward hospitalists from, “we’ll pay whatever it costs to get them,” to, “what are we getting for all this money we are paying?” Leaders in hospital medicine are scrambling to find good answers to that question.

 A recent study in the Annals of Internal Medicine showed that hospitalists produce savings in hospital expenditures averaging $282 per case, but they increase overall costs in the post-hospital period. Medicare intends to hold hospitals responsible for those costs, which will add to administrators’ concerns. Hospital Care Quality Information from the Consumer Perspective scores are another matter of concern, and hospitalists tend to have lower scores than other physicians in the hospital. 

Hospitalists make significant contributions to quality of care and safety, but much of this occurs at academic programs where physicians have protected time to work on these activities. The average hospitalist can barely get through a list of patients each day without worrying about costs or quality or patient relations. 

What does this mean for the specialty?  It is not likely that primary care physicians will come back into the hospital in any large number, but there will be curbs on program expansion and a rollback in hospitalist compensation is likely for those who cannot demonstrate extra value in their services.

This is akin to putting toothpaste back into the tube. There is no nice way to reduce someone’s salary. Bonuses will shrink and disappear. Hospitals will be attracted to IPC, which has built its business without subsidies. Other national hospitalist firms will develop their own no-subsidy plans. This will squeeze local and regional companies hard. Hospitals running their own programs will look to vendors who can slash costs. In my last post, I estimated that hospitalists need to deliver savings of $260 per case to cover the present subsidies, so there is not much of a safety margin for salaries. New savings will be required as hospitals have less revenue to spend on doctors and more doctors to spend it on. Hospitalists need to throw themselves into spirited dialogue with hospital managers in order to hold on to whatever they can, and prepare to live on less.

Where the money is

Subsidies are a hot topic in hospital medicine right now. The latest SHM-MGMA survey indicates that the average hospitalist receives about $136,000 in support from hospital funds other than fee collections. The Affordable Care Act (aka Obamacare) requires an annual 1.4%, reduction in Medicare payments to hospitals, and a CMS actuary recently told a congressional committee that 40% of hospitals will be insolvent by 2050. The day of reckoning for hospitalists will come much sooner than that because nearly every physician who treats hospital patients is standing in line for a handout from the institution. The surgeons and cardiologists will be paid because they bring in patients for well-reimbursed procedures. What’s the business case for supporting hospitalists? The early growth in hospital medicine came after administrators found that hospitalists help reduce average length of stay by about one day. The average subsidy has doubled since then, so we need to come up with something else. SHM leaders tout quality improvement (QI) and patient safety as the new business case for hospital medicine, but the numbers don’t add up. If you value a hospitalist’s time at $130 per hour, then the physician would have to devote more than 1000 hours a year to this activity, on top of clinical time, to justify the subsidy.  Even if it were possible to do this, the hospital could hire two nurses with formal training in QI and get 4000 hours a year of work for the same price.

The best hope for justifying hospitalist salaries is in reducing the cost of care. The average hospitalist treats about 500 patients a year, so a mean reduction of $260 in cost per case is needed. Antibiotics are an obvious target for cost control, but what about the indiscriminate use of PPIs that are not needed for the routine medical admission? There is no justification for broad spectrum antibiotic therapy once culture results are known. Oxygen is another item used profligately. Most hospitals assign the responsibility for tapering oxygen to the respiratory therapists, but it is not done consistently. Unnecessary testing is another opportunity for savings, though the accounting here is tricky. Much of the cost is in the labor of technologists. Unless the test volume reduces enough to eliminate a position, the savings will be limited to the cost of the materials used. This is not easy stuff, but hospitalists can sit down with the finance staff in the hospital to find opportunities for savings. This kind of cost accounting has not been done very much in hospitals, so don’t expect an enthusiastic reception from management, but with few other opportunities for savings, this is an opportunity for leadership.

The New Normal

Most press coverage of the Affordable Care Act (or Obamacare, as it is known to some) has emphasized the expansion of insurance coverage , leaving the impression that overall healthcare costs will increase under this law. An article by Gail Wilensky in the New England Journal of Medicine points out that the act requires costs to decrease. Although almost everyone will have access to care, payments to medical providers will be reduced by the extent necessary to achieve savings. Unlike the Sustainable Growth Rate initiative, Medicare costs will not be allowed to grow at all, and the cuts will be borne by all providers, not just doctors.  This confirms my earlier impression that value-based purchasing is basically a shell game. 

Uncle Sam is now dealing three-card monte. There will be no winners in this game, but some will lose less than others. Hospitals may lose up to 10% of Medicare revenue by the time the Affordable Care Act is fully implemented.  In Philadelphia, where I now live, only one of the 16 hospitals had an operating profit margin greater than 10% last year. None of the 27 hospitals in Connecticut achieved a 10% margin in 2009.  Hospitals are not entirely dependent on Medicare, but private insurers are not likely to make up the losses from Medicare. In fact, many insurance providers are developing their own pay-for-performance systems. 

Where is this going? One could envision that multiple rounds of payment cuts could force most of the hospitals in America out of business. This will not occur, as public demand will cause modifications once access to care is significantly reduced, but at least some hospitals will close. 

Everyone reading this must understand that healthcare in America will be less lucrative than in the past.  Some physicians and hospitals may benefit at others’ expense.  Hospitalists need to prepare for very difficult negotiations with hospitals and expect to come away with less money for a given level of effort.  It is time to abandon the notion that one is entitled to a certain level of income by virtue of holding a medical license or a particular set of skills.  Your work is worth what the market will pay for it.  I am old enough to remember when a visit with a doctor cost only two dollars, and patients paid out of their own pockets.  We are not returning to those days, but the era of unlimited taxation to support the medical-industrial complex is over.  Get ready for the new normal.

Hospitalist-nurse partnerships

I have written in previous posts about the importance of developing partnerships between hospitalists and nurses. The quality of those relationships may determine the difference between a hospital that succeeds and one that fails. The key to a successful partnership is rapid flow of information between the parties and the ability to trust each other. Consider the needs of each side: hospitalists need nurses who can make accurate patient assessments and provide timely alerts to changes in condition, while nurses need physicians who provide clear instructions and provide rapid and respectful responses to contacts from the nurses.

Let’s start with the basics. Nurses need to know at all times which doctor is responsible for each of their patients. It is not acceptable for nurses to have to guess, try several doctors, or call an office to figure out which hospitalist is caring for a patient. When patient responsibility is transferred from one physician to another, the primary nurse needs to have that information promptly, and every hospitalist program needs a system to relay that information. If a nurse is confused and calls the incorrect physician, hospitalists should not dismiss the call with a brusque “Call Dr. X.” If the problem is simple and does not require detailed knowledge of the patient, handle it yourself and then refer the nurse to the appropriate physician for additional assistance.

The next level involves changing the work dynamics between hospitalists and nurses. Nurses document reams of information about patients throughout the course of a day, most of which physicians ignore. Unlock that information by holding a daily meeting in which physicians and nurses share their knowledge about patients. Formal rounding is great if you can do it, but a quick huddle with the nurse to go over the nurse’s observations about the patient and the doctor’s plan for diagnosis and treatment can be tremendously valuable in speeding treatment plans and in reducing phone calls during the remainder of the day.

The final level involves breaking down the wall between the professional status of doctors and nurses. If the patient asks for a cup of water, do you need to ring for a nurse? Would it kill you to fill a cup from the sink and bring it to the bedside? If you do a bedside procedure, how about taking the used items and placing them in the proper receptacles? A little bit of humility goes a long way in helping nurses feel that they are valued colleagues, rather than servants.

Alligators in the hospital: Part II

My last two posts have dealt with the analogy between hospitalist program managers and civil engineers who find that they cannot drain the swamp as contracted because they are occupied with fighting off alligators. I want to discuss now the most prevalent type of alligators in hospitals—the nurses. Doctor-nurse relationships run deep and may well be the prime determinant between hospitals that fail and those that succeed. The nurse was historically a handmaiden to the physician and maintained extreme deference. Advances in nursing education have prepared nurses for a professional role that is still subordinate to the physician, but the relationship between the two varies from cooperative to antagonistic.

What makes a nurse into an alligator? Nurses are expected to carry out a daily care plan for a group of patients that may number from one (in the ICU) to 30 or more (typically on a night shift). They are expected to respond promptly to call buttons, answer calls from doctors and families, send patients off to scheduled tests and procedures, administer complex medication regimens correctly, and document their activities thoroughly. There is a lot to do in the course of a day and not quite enough time to do it. Years ago, all of a nurse’s patients might be in a single room and she (no male nurses back then) could see them all and shift attention quickly to those that needed it. Today’s nurse may have each patient in a different room and the rooms may be at opposite ends of the floor.


Taming the alligators

My last post introduced the idea that hospitalist medical directors are in the position of an engineer hired to drain a swamp but distracted from doing so by the numerous alligators inhabiting the swamp. I would like to explore further the concept of keeping the alligators at bay so that one can concentrate on draining the swamp, that is, improving the quality of hospital care.

My only direct experience with real alligators occurred while I was bicycling along a path on Kiawah Island, SC.  An alligator was lying about 20 feet off the path. It paid no attention to me as I cycled pass. Under different circumstances, that alligator would have raced toward me and potentially been able to attack. Why not that time? I presume that the alligator had satisfied its food needs and I did not fit into its agenda. The point is that alligators are not naturally malevolent. They become dangerous when they are hungry.


Draining the swamp

I have been chided for the downbeat tone of some of my recent posts. You need to understand the financial challenges ahead, but having said that, it is time to refocus on what is good and positive about hospital medicine. The difficulty in doing so reminds me of a saying among civil engineers: When you are up to your buttocks in alligators, it is hard to remember that you were hired to drain the swamp. The swamp contains all the things that prevent hospital care from being perfect—readmissions, medical errors, quality deficiencies, delays, excess costs, inadequate communication, poor patient satisfaction, to name some.

Hospital medicine has made definite strides in solving some of these problems, yet most hospitals have each of these problems to some extent. Hospital medicine programs have been sold to administrators as a solution to these problems, but most smaller and nonacademic programs have trouble delivering the goods. The reason is that medical directors are given few resources to drain the swamp and spend most of their time wrestling with alligators. The alligators are most of the hospital stakeholders, nurses, emergency doctors, specialists, primary doctors, patients, families, insurers, and, regrettably, hospitalists.

What makes an alligator? A stakeholder becomes an alligator when the hospital medicine program fails to deliver some portion of the desired benefit, and the stakeholder becomes angry and demanding.

I have been a physician for more than 30 years, and I have never seen so many angry people in hospitals as there are today. I got into hospital medicine because it offered an opportunity to make hospital care work, but after 15 years in the field, the goals seem more elusive than when I started. Whoops, there goes the downbeat tone again.

The problem is in getting enough resources to perform effective quality improvement work. Pronovost and Marsteller, writing in the February 2 issue of JAMA, note the peripheral role of physicians in quality improvement (QI) work. They call for physician managers with dedicated time and salary support for quality work. Most hospital medicine program directors have little or no salary support for activities other than direct patient care. A few larger hospital systems are creating true executive positions for hospital medicine, but this is still a rarity. Some academic hospitalists are able to do QI work as part of their scholarly activity. We clearly need to find ways to make things better within the time available to us. I’ll explore that in subsequent posts.

The ‘S’ word

As value-based purchasing approaches, hospitalists are going to feel the heat from hospital administrators. I believe that this is largely a shell game played by the Centers for Medicare & Medicaid Services to give hospitals the idea that they can win at this game, when all but a few will lose. The reality is that Medicare needs to reduce payments to hospitals to avoid impossible deficits. There will be pressure in all areas to reduce costs, and I can’t help but believe that hospitalist subsidies will be a prime target.


When it’s over, it’s over

January is the month of looking forward and back and a good time to review the topic of employment transitions. Clinicians enjoy almost total job security, but management is a different story. Hospitalist programs are called upon to deliver ever-higher levels of clinical quality and patient satisfaction, but program directors have few tools to deliver on these mandates and must get good work from inexperienced physicians placed under high stress. Judging by the number of directorship opportunities being advertised for established programs, a lot of directors have trouble delivering on the mandates. It will probably get worse as the government squeezes hospital revenues harder and harder; I’ll have more about that next month. The rest of this piece will discuss what to do when a job ends.


Where do we go from here?

The Republicans are back in control of Congress. With a majority in the House, they have the ability to filibuster in the Senate. Speaker-to-be John Boehner has made no secret of his desire to kill Obamacare. He can’t get it repealed just yet, but he can prevent the appropriations needed to make it work. Half of the state legislatures are now under Republican control, so there will be little progress on the state insurance exchanges that are part of the plan. What can we expect to happen?