(32 Total References)
by Mary Frances Barthel, ...
by Mary Frances Barthel, MD
explains how her
hospitalist group has asked for revision of bylaws to prevent such practices.
Mary Frances Barthel, MD, is director of the Cogent Healthcare hospitalist program at Blessing Hospital in Quincy, Ill.
has been a hospitalist since 2002.
WHEN MEDICARE LAUNCHED its two-midnight ...
WHEN MEDICARE LAUNCHED its two-midnight rule last fall, Mary Frances Barthel, MD, thought she had it all figured out.
As director of the Cogent Healthcare hospitalist program at Blessing Hospital in Quincy, Ill., Dr. Barthel spent a great deal of time hammering the point home that under the new rule, doctors' expectations of how much time patients would need in the hospital would determine whether they would be admitted or placed in observation.
No longer, as Dr. Barthel
understood it, would she
colleagues have to parse out admission criteria in commercial
"We did a big blitz around the Oct. 1 kickoff," says Dr. Barthel
"We had a medical staff meeting, mailings and one-on-one education with physicians who admit a lot of patients.
We came up with a really good synopsis of the final rule and advice on what to do."
But six months later, Dr. Barthel
has had to circle back to those same doctors with a different approach.
"The more we heard from the advisory company, the less confident we were saying that time was the most important factor," says Dr. Barthel
"Lately, we've gone back to using InterQual
to answer whether the patient's presenting problems meet medical necessity for inpatient admission, and then we also ask the physician to predict how long he
expects the patient to be in the hospital."
group now bills many more ICU patients as observation than they did before Oct. 1.
As for the rest of the one-midnight inpatient stays, "I get the impression that the advisory company believes such stays should basically never happen," says Dr. Barthel
Or should they-like Dr. Barthel
colleagues- still rely on admission criteria that may (may!) provide some protection once recovery audit contractors (RACs) start tackling claims?
"It used to be that outpatient physicians who admit their own patients could just fax an order to the admitting office, but we no longer allow that," says Mary Frances Barthel, MD, director of the Cogent Healthcare hospitalist program at the hospital.
Instead, a representative from the physician's clinic has to call one of the hospital's utilization nurses to discuss the patient's status and expected length of stay.
For outpatient physicians covered in the hospital by hospitalists, that's now a two-step process: The outpatient physician has to call the hospitalist, who then calls a utilization nurse.
"That order used to be a fax before," says Dr. Barthel
"Now, it has to be a phone call."
Then there's this innovation: Dr. Barthel, who's also the hospital's utilization management physician advisor, has designed two versions of the letter sent to the attending physician when an admission is downgraded to observation status before discharge.
"One version says, 'Your patient did not meet medical necessity requirements so was changed to observation,' " she
Today's Hospitalist :: For hospital medicine, burnout is a continuing threat
"I don't know anybody personally who can just do shifts month after month after month and never feel burnout," says another veteran hospitalist Mary Frances Barthel, MD, who is medical director with the Cogent Healthcare hospitalist program at Blessing Hospital in Quincy, Ill.
In the wake of new duty-hour rules protecting residents' time during training, Dr. Barthel
expected to see newly-trained doctors burning out fast once they started to practice.
But that hasn't been the case.
"The new people have tons of energy and no issues at all seeing a high volume of patients," says Dr. Barthel
"But I can't say the same for people I know who have been doing this for several years."
Here's a look at the lessons that both Drs.
Kendall and Barthel
have learned on how to mitigate burnout.
For Dr. Barthel
, the seven-on/seven-off block of 12-hour shifts she
colleagues currently work is the biggest burnout factor they face.
sees it as a major reason why veteran hospitalists face a greater risk of burning out than doctors just out of residency.
"The 12-hour shifts get to be really draining," she
As the parent of school-age children, she's
leading the charge in her
program to renegotiate her
group's contract to go to an hourly wage.
That will allow some group members each day to choose to work an eight-hour shift while another hospitalist holds down a traditional 12-hour one. (A nurse practitioner will provide coverage for the other four hours each day when a hospitalist won't be on.)
"Instead of 15 shifts per month, those of us working eight-hour shifts would have to do 22," Dr. Barthel
agrees that being able to draw on reserve physicians helps protect group members already on board.
She points to the advantage of working for a national management group, with Cogent sending what it calls a "traveling physician" to her group at Blessing, starting next month.
"We're losing one physician, partly because he
wants to teach but also because he's
tired of working seven-on/seven-off," Dr. Barthel
"The traveling physician could be here six months until we fill that slot."
A line in the sand
says that the one downside to working as a traveling physician or a locum is that "little bit of skepticism when physicians first arrive.
There's some hesitancy to really accept them.
Overall, however, Dr. Barthel
says that she
colleagues are very well received within the medical staff.
That's important, Dr. Kendall notes, because he
sees not being treated well on the job as a major factor in hospitalist burnout.
That's why, as another condition for heading up the program, he
negotiated having the freedom to choose whom the group admits for.
says that her
passion is quality improvement, and she
looks forward to negotiating more time to pursue it.
Right now, her
job is about one-quarter administrative vs.
75% clinical, but she'd like a 50-50 split.
"I enjoy patient care," she
says, "but there's rarely a day when I can come in, see patients, get my administrative issues taken care of, and be able to go home and be in a good mood with my family."
The problem, Dr. Barthel
adds, "is these hectic, busy days when you're on for 12 hours and you're running the whole time.
-Mary Frances Barthel, ...
-Mary Frances Barthel, MD
Today's Hospitalist :: What's the sweet spot for unit-based staffing?
Mary Frances Barthel, MD, is now medical director of the Cogent HMG group at Blessing Hospital in Quincy, Ill. With only two providers working during the day, she doesn't think the group yet has the critical mass to consider localization.
former job was as hospitalist medical director at Gundersen Lutheran Health System
in La Crosse, Wis., a group Dr. Barthel
continues to work with as a consultant.
The program implemented some unit localization in 2010 and saw a quick jump in the number of patients placed geographically for each hospitalist team from 30% to 50%.
says the group wanted to build on that "early win," but the hospitalists' push for more comprehensive localization ran into another major priority of the hospital: improving ED throughput.
When hospitalists would advocate for sending patients to geographic units, other hospital personnel would want to send patients through to the first available bed instead.
"The staff in the admission center had to decide who to listen to that day to figure out where to place patients," Dr. Barthel recalls.
"I'd be on the phone saying, 'Put them on my unit,' but a hospital supervisor would be saying, 'No, put them over there.'"
When the first-available-bed option slowed down localization, Dr. Barthel
says the group opted for "workarounds.
One was that the group-which has 12 MDs and eight PAs-assigned a PA to a specific unit.
While hospitalists would still be roaming the hospital to see at least half their patients, the PAs could stay put and participate in multidisciplinary rounds on a particular unit, even if the hospitalist wasn't available.
Nursing staff also would accommodate physicians who had to attend multidisciplinary rounds on more than one unit.
"It wasn't the ideal, but it was the reality," says Dr. Barthel
"They'd work with me to be available when I was able to get over there."
The workarounds were successful, she
But the downside of that success was that hospitalists lost some of their focus on localization.
"The doctors didn't see as much value assigned to the actual geography," she
explains, "so I don't think it's a big priority for them right now."