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Health plan hospitalists: “Extensivists”?

By Kirk Mathews, MBA

In a recent article from Today’s Hospitalist, a concept emerges about a number of physicians called “extensivists” who are employed by health plans and work to increase post-discharge intervention. The primary goal of their post-discharge work is to reduce readmission rates.

Ensuring follow-up care upon discharge can be a challenge, especially with some unassigned, noncompliant patients. Most hospitalist programs encourage follow-up calls to primary care physicians (PCP) and patients within 72 hours of discharge, but health-plan hospitalists are doing more. According to this article, some health-plan hospitalists are going to see their discharged patients at integrated care centers and nursing homes after daily rounds in the hospital. And in some instances, they are rewarded with a significant bonus if readmission rate targets are met.


Economic downturn not over yet

St. Vincent’s Hospital Manhattan recently laid off 300 employees, including 32 residents, managers at all levels, dietary workers, transporters, and housekeeping staff, according to The New York Times. Although hospitalists are in high demand across the country, stories like this make you ponder your job security and just how far you would go to keep your hospital afloat. As a hospitalist or hospitalist program director, would you take a 25% pay decrease, as many St. Vincent employees have been asked to do?

In an April 2009 PBS report, Paul Levy, CEO of Beth Israel Deaconess Medical Center, described how, when his hospital was facing layoffs, he asked everyone to share the pain. To his surprise, hospital and medical staffs embraced the idea. “I said to the staff, ‘I’d really like to avoid layoffs to the extent possible because it’s a hard time for people to get jobs, and many people’s spouses have already lost their jobs, and we don’t want to put folks through that…In addition, I said to them, ‘I’d like to do what we can to protect the low-wage earners in the hospital, the housekeepers, the transporters, the food service workers, who face a particularly hard time just because of their income level,’ and the response from people was overwhelmingly positive,” Levy said.

Juggling motherhood and medicine

I recently completed an article on work-life balance for the upcoming issue of Hospitalist Leadership Advisor, a supplement to Medical Staff Briefing. When it comes to work-life balance, one of the first questions that comes to my mind is how do physicians juggle parenthood with one of the most demanding jobs on the market? Those of us whose jobs don’t involve the pressure of saving lives have a hard enough time! Our friends at pointed out a great blog for physician moms: Check it out!

Where’s the beef? Recruiting hospitalists requires helping them move

The Hospitalist reported in its February issue that if you are going to recruit a hospitalist from afar, you should count on forking over some cash to help them move. The article states that though many other sectors are unable to offer housing or moving assistance due to the down economy, hospital medicine is upping the ante as demand for hospitalists grows. 

However, you may need to get a little more creative than that, said Kirk Mathews, MBA, CEO of St. Louis–based Inpatient Management, Inc., a hospitalist consulting and recruiting firm, and author of Practical Guide to Hospitalist Recruitment and Retention. In the March issue of Hospitalist Leadership Advisor, a supplement to Medical Staff Briefing, Mathews suggested that offering six months of housing assistance may not be enough to recruit some hospitalists with unique needs. 

“I was once asked to relocate a herd of championship cattle. This particular physician’s passion away from medicine was beef cattle, and moving them was part of the deal. If someone has a unique need and you can find a way to meet that need with a reasonable amount of dollars, that is when you have a successful recruitment,” said Mathews. 

A situation that you’re more likely to run into is a physician whose spouse can’t relocate right away. For them, instead of offering housing assistance, you may wish to offer to pay for that physician’s transportation home during his or her time off. 

How does your program accommodate unique recruiting needs? What was the most unusual request you’ve received?

Is your job like an episode of House?

Last night while watching House, M.D., I had to explain to someone, “You know what I do all day? I write for people like Cuddy.” It’s always easiest to explain your job in terms of medical dramas. Although I’m not an inpatient director, or even a physician, I find that using television characters is a good basis of explaining who I write for.

I don’t want to be the spoiler, but in this particular episode, Lisa Cuddy, the director of inpatient medicine and hospital administrator could exemplify a day in the life of similar executives who both practice and lead.

Tied to her Blackberry throughout the day, Cuddy negotiates a new insurance contract, meets with the board, uncovers and fires a rogue, drug-stealing pharmacy technician, sees a patient in the clinic, ends a fight in the OR, talks to a suing patient, and all while managing to be a good parent of a sick infant.

Though dramatized, the show had me wondering if your job resembles that of the fictional Princeton-Plainsboro Teaching Hospital.

What’s the incentive?

By Richard Rohr, MD, MMM, FACP, FHM

What inspires us to work harder or more effectively? Most hospitalist programs offer physicians some sort of bonus or incentive compensation, but the evidence to support this practice is limited. Medical practices have traditionally offered employed nonpartner physicians a portion of collected revenues beyond a certain threshold. This is intended to spur new physicians to actively generate patient referrals and build their practices quickly. This seems to work in office practices, but how well does it apply to hospitalists? In some communities, hospitalists must obtain referrals from outpatient physicians to build up their volume. Incentives based on billings would seem to be appropriate in that case, but what about programs that draw all of their patients from the ED? Productivity for individual physicians in such cases is dependent on the luck of the draw. It still may be reasonable to compensate doctors for unequal workloads, but it won’t do much to build up the group.

When hospitalists become intensivists

Hospitalist and intensivists will continue to collaborate when caring for critically ill patients, according to a new article, “Hospitalists and intensivists: Partners in caring for the critically ill – The time has come,” published in the January issue of the Journal of Hospital Medicine.

According to the article, the limited availability yet growing need for intensivists will create a shortfall of 22% by the year 2020. This means that many hospitalists are starting to step in to co-manage patients with intensivists. Given this trend, the pressing question is “Do hospitalists have the appropriate training to care for critically ill patients?”  The article recommends that governing bodies implement a process to certify physicians to provide critical care services, so I’m curious what you think needs to be included in a training program for hospitalists taking on a critical care role.

To  help gague this trend, please take the poll below.

Mayo Clinic develops first hospital medicine PA program

The Mayo Clinic Department of Medicine has developed the first hospitalist-specific physician assistant (PA) fellowship for certification, according to the paper, “A hospitalist postgraduate training program for physician assistants,” published in the January issue of Journal of Hospital Medicine.

According to the paper, finding PAs with dedicated hospitalist experience can be difficult since many are skilled in specialties other than hospital medicine. As a result, hospitals often recruit newly graduated PAs who may have limited experience in the hospital setting.

The Mayo program is a 12-month postgraduate fellowship and is based on the Society of Hospital Medicine’s Core Competencies. “This postgraduate physician assistant training program represents a model that can be utilized at almost any institution, academic or community-based,” states the study.

Medicare coding changes give hospitalists more to remember

I recently spoke on the phone with Leslie Flores, MHA, partner at Nelson Flores Hospital Medicine Consultants in La Quinta, CA for an article in the upcoming issue of Hospitalist Leadership Advisor, a supplement to Medical Staff Briefing. We discussed CMS’s recent decision to stop reimbursing physicians for consulting codes and requiring that physicians bill an initial or subsequent care code for activities that were previously considered consultations. Admitting physicians will have to add the modifier -AI to the codes they submit to distinguish them from other physicians caring for the same patient. Flores brings up a good point:

“To distinguish the admitting physician from the consulting physicians, the admitting physician has to add a modifier. One of the things that worries me is that the billing office is going to get initial hospital care codes from several physicians, and if the admitting doctor forgets to append the code, the billing office is going to have to go around asking all the physicians who admitted the patient. It is not so hard to do if all the docs are in the same group, but if they are not, it could get tricky.”

Share how your hospitalist program is managing the recent coding changes in the comment box below.

Readmission rates top of mind for regulators, hospitalists can help

To hear that physicians can avoid rehospitalizations by implementing an ironclad discharge process isn’t surprising. To hear that reducing rehospitalizations could save $26 billion over 10 years may just knock your socks off.

Rehospitalizations  have been brushed off for quite some time under the presumption that they were often due to factors outside of a hospital’s control. However, the hefty price tag has grabbed regulators’ attention and prompted them to scrawl “Reduce hospitalizations” on the top of their to-do lists, according to a Jan. 22 Hospitals & Health Networks article.  

Several hospital readmission prevention programs have popped up recently, including SHM’s BOOST (Better Outcomes for Older Patients through Safe Transitions) and CMS’s Care Transition Project. Although these projects are young, preliminary data is optimistic. 

But don’t wait for these projects to be finalized and the results to be turned into regulation before jumping on the lower-readmission-rate bandwagon. Individual hospitalists can take the steps highlighted in “Communication in the hospitalist-PCP relationship” in the March 2009 issue of Hospitalist Leadership Advisor, a supplement to Medical Staff Briefing, to improve the quality of their own discharges and contribute to lower readmission rates. 

These steps include:

  • Hospitalist program clinical directors visiting referring physicians regularly to build rapport and answer questions
  • Picking up the phone to speak directly to PCPs regarding a patient’s discharge plan
  • Providing local PCPs with a monthly or quarterly newsletter to update them on hospital happenings, announce changes to the program’s operations and policies, introduce new providers, and share performance and quality data
  • Experiment with various communication technologies to find the most streamlined approach to communicating with PCPs and possibly patients
  • Making sure patients understand their get-well gameplan prior to discharge

Q&A with Richard Rohr: How Medicare coding changes affect hospitalists

CMS’s recent decision to stop reimbursing physicians for consult codes has hospitalists everywhere wondering how their practices will be affected. I spoke with Richard E. Rohr, MD, MMM, FACP, FHM, director of hospitalist programs at Guthrie Healthcare System in Sayre, PA, to find out what the buzz is about and get some background on the recent changes. 

LJ: Why are hospitalists concerned about the new coding changes? 

RR: Up until now, there have been a set of codes for services that are provided by physicians who see their own patients, and then there is a set of codes for consultations. Traditionally, those codes have carried a somewhat higher payment than the codes one would use for seeing your own patient, even for the same level of complexity of examination and record keeping. 

LJ: Why were consulting codes historically reimbursed at a higher rate? 

RR: Back in the 1960s when Medicare was created, consultations were a big deal and they weren’t done very often, [more]

Hospitalist programs and critical access hospitals collaborate: How it works

By Kirk Mathews, MBA

Many of the hospitalists that serve in our client hospitals regularly accept transfers from smaller facilities, including critical access hospitals (CAHs). This is a service to both institutions, as well as the patients, and has been part of our practice for a long time. However, we are now seeing referrals from some of our larger client hospitals back to the CAH where hospitalists also care for patients.

Hospitalist programs have been springing up in CAHs for some time now. CAHs face some of the same challenges as large hospitals but often have significantly less resources with which to confront them. So how can they make them sustainable?  Well, administrators at CAHs can be very resourceful and creative.

One of our hospitals receives quite a number of transfer patients from a CAH located about 50 minutes away. Our service is a sizable program at a busy full-service hospital. When this particular CAH wanted to start a hospitalist program, they spoke with our client hospital, as well as with our hospitalists. The resulting program provided a win for all involved.

Our service uses a seven-on/seven-off schedule. Each week, there are enough physicians off who are interested in moonlighting that they can cover the CAH for most of the daytime hours. They get help from the CAH emergency room docs when they cannot be there, including at night. Keep in mind that this hospital had an average daily census less than eight patients. The local over-burdened PCPs welcomed the program.

As you might suspect, patients scheduled for hip or knee replacement surgeries would go to the larger hospital for the surgery. However, the acute rehab facility at the larger hospital is very busy. Once the patient (from out of the area) is stable, they transfer back to the CAH for their rehab and are followed by the hospitalists. Since the physicians on both ends are on the same team, transfers are seamless. These rehab patients greatly help offset the cost of the hospitalist program.

This is just one example of a creative way to make the hospitalist model work at a CAH. There are many others. Please comment and tell us of your experience in this area.