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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.

Nocturnist: A new concept?

One of my colleagues, Richard Rohr, MD, MMM, FACP, FHM, posts frequently about hospitalist issues. I thought I would poke a little too.

In a recent issue of the Tennessean, the concept of “nocturnists” was discussed. The article states what we all know: Hospitals are not safe places. Truth be told, we all knew this prior to the Institute for Medicine’s 1999 report, but it was one of healthcare’s dirty little secrets that we kept from the public. However this article cited several studies showing that hospitals are even less safe on nights and weekends. (Would that be another of our secrets?)

So is a nocturnist a new concept or is this a better dressed house doctor of yesterday? Should the goal of a hospital be to have physicians at night, or should the nocturnist really be a member of an integrated hospitalist system? I’ll agree that if there isn’t a physician in house at night (exclusive of the ED) that having one is a great first step. However having a nocturnist should not be the end game. Consistent coverage by a team of well-trained, experience hospitalists should be the goal. Thoughts?


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 sleep doctor question

An article in the July 1, 2011 Los Angeles Times, titled “Limiting resident physicians’ work hours to save lives” again raises the question of whether resident fatigue affects patient care. I assume there is no coincidence that the article appeared the day that the newly minted physicians began training. The article, co-authored by Lucian Leape, MD, chair of the Lucian Leape Institute and adjunct professor of health policy at Harvard School of Public Health and Helen Haskell, founder of Mothers Against Medical Error, cites studies that go back at least 40 years demonstrating that fatigued residents make more mistakes than well-rested residents.

New rules limit first year residents to shifts no longer than 16 hours, and more senior residents to 28-hour shifts. When I was in training, my surgical brethren and I thought that if you were only on call every other night, you missed half of the interesting cases. I wonder whether today’s residents are as “tough” as we were back in the day. Should slave labor be reintroduced? Or are folks like Dr. Leape right?  Back in the day, we assumed our patients were safe and received quality care—were we right?  I don’t think so. So is 16 hours right?  Should it be 12?  Should it be less?  Should residency programs add a year to training programs so that residents can get the necessary experience, and still get some sleep?  What do you think?

Provide hospitalists with adequate billing and coding training

One of the best things that hospitalist program managers can do to ensure adequate training is to work with the billing department to find an individual who is qualified to educate hospitalists about billing.

“More and more practices have a certified coder on staff whose job it is to work with the doctors, train them, and conduct audits of the documentation to give them feedback on what they are doing right and wrong,” says Leslie Flores, MHA, partner at Nelson Flores Hospital Medicine Consultants in La Quinta, CA.

Not all hopsitalist programs have a certified coder available. In that case, the program may need to rely on a noncertified individual in the billing department or a hospitalist who is charged with training newcomers. However, having a hospitalist conduct the training may be dangerous, says Flores. “If that physician has developed bad habits, he may pass them on to new people.”

Another option for hospitalist programs is to hire an external consultant. “It is more expensive, but I think it is worth it,” says Jonathan Lovins, MD, SFHM, hospitalist and assistant clinical professor of medicine at Duke University School of Medicine in Durham, NC. Facilities may be able to find coding auditors and trainers through the Society of Hospital Medicine or the American Association of Certified Coders.

The rule of thumb, says Lovins, is for every hospitalist to receive at least two hours of training on billing and coding when they first start and refresher courses every year. The training should include notes from previous encounters with patients. “If you do it without notes, it is very abstract, and people don’t take away much from it. Bring in real hopsitalist notes.”

Check out the June 2011 issue of Medical Staff Briefing for more information about training hospitalists in billing and coding (subscription required).

ACGME-compliant staffing model reduces costs for hospital

When the ACGME released its new Common Program Requirements, many balked at the estimated cost of implementing and remaining compliant with the new rules. However, the University of California, San Francisco’s (UCSF) Benioff Children’s Hospital found that the right staffing model can reduce hospitalization costs by 11% and shorten lengths of stay by 18%, reports Hospitalist News Digital Network.

“In September 2008, UCSF expanded and reorganized its pediatric inpatient hospitalist service, moving from a traditional call model to a shift-based staffing model. In the process, the hospital eliminated cross-coverage of different teams in favor of dedicated night teams that were subsets of their day teams,” the article states.

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.


The ACO proposed rules: A party starter or a party killer?

We all anxiously, and many hopefully, waited and watched as the CMS proposed rules for the accountable care organizations (ACO) were being prepared. Now that the rules have been released and many have had a chance to read them, what I’m hearing from hospitalists and administrators alike is a collective state of disappointment.

Some common observations that surround the ACO new rules: too much regulation, not enough potential or risk sharing and too much investment involved. The general feeling among those I’ve been talking to is that there will be muted participation in the ACO program because of all the barriers to entry.

For example, there are 65 quality measures that all must be met to qualify for any shared savings. How many practices can accurately collect and report data on even just a few Physician Quality Reporting Initiative (PQRI) metric? Another challenge is that 50% of providers in an ACO must meet the meaningful use definition for electronic health records. This represents a very large investment by physician practices regardless of size, many of which are not prepared to take on this burden. In addition, the rules call for a 25% holdback on funds earned in the shared savings program. This withhold is to protect against underperformance in future years when a repayment might be required of the ACO. However, as currently written, the withhold is never released! A successful ACO could accumulate several years of shared savings that they will never receive.

These are just a few of the elements of the proposed ACO rules that are taking the wind out of the sails of some in hospital medicine. It seems that the rules have not energized or empowered the potential participant organizations to embark on the effort to create ACOs. Instead, they seem to create barriers and skepticism. I am certain that large health systems that have already made most of the required investment in EHR, etc., will proceed with their plans, but I wonder how many smaller systems will view the return as being worth the risk and take the plunge.

What to do you think? What have you heard? Have the proposed rules put a damper on the ACO party? I am eager to hear from others on this topic.

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.