In the News

Hospital Medicine 2008; new rules from CMS.

Hospitalist salaries spiked over last two years, SHM reports

Hospitalist salaries rose significantly over the past two years even while productivity remained flat, according to the Society of Hospital Medicine's (SHM) 2007-2008 survey reported at the group's annual meeting in San Diego last month.

The survey did not examine causes of the trends, but researchers who presented the findings suggested that continuing hospitalist shortages or increased appreciation of the profession's value may explain the rising salaries. Overall, they found that hospitalist compensation was closely linked to hours worked and number of patient encounters. That is bad news for nocturnalists, new hospitalists and women (who make up a disproportionate percentage of younger hospitalists), all of whom were found to have lower than average production and compensation.

Specifically, the survey found that the average hospitalist made $193,300 in 2007 to 2008 (a 13% increase over 2005 to 2006) while producing 2,447 encounters (a 4% decrease from the previous survey). Hospitalists whose income was based entirely on production (6% of the total) had higher production and compensation that those who received a flat salary (25%) or mixed compensation plans (69%).

The survey also looked at leaders of hospitalist groups and found them lacking in both administrative time and knowledge. More than a third of surveyed leaders did not know the annual expenses or professional fee revenues of their groups. Of those who did know, 85% were operating at a deficit. The leaders appear to be spending their time on clinical work instead of business management, the survey found. Group leaders reported the same quantities of encounters and hours worked as non-leaders, with slightly increased compensation (6% higher).

SHM's sixth annual survey collected data from 440 hospital medicine groups, which researchers estimated represent about 15% of U.S. hospitalists. Because the results were not audited or verified, the findings should be used as a frame of reference only, the SHM researchers said. Their final report is expected to be available in print later this month.

Program improves satisfaction, readmission rates in the elderly

A systematic discharge process helped improve care satisfaction and hospital readmission rates in elderly hospitalized patients, researchers reported at Hospital Medicine 2008 last month.

Researchers developed the Safe STEPs initiative (Safe and Successful Transition of Elderly Patients), an intervention to improve the transition of elderly patients from the hospital to home, and tested it at three facilities: Johns Hopkins Bayview Medical Center in Baltimore, Geisinger Medical Center in Danville, Pa., and NorthEast Medical Center in Concord, N.C. Included patients were at least 65 years of age (mean age, 77 years) and were being discharged home rather than to a nursing home or rehab facility. Four hundred twenty-two patients were included in the study, 237 in the control group and 185 in the intervention group.

The Safe STEPs intervention had five components:

1. A history and physical process tailored to geriatric patients; 2. Use of a “fast facts fax,” a focused communication to the patient's primary care provider; 3. An interdisciplinary worksheet that included input from all of the groups and departments involved with the patient's care; 4. A detailed evaluation of the patient's medications with a hospital pharmacist; and 5. A predischarge appointment involving the patient, his or her caregivers, and providers to review hospital and postdischarge care.

After the intervention was implemented, patient satisfaction with the transition from hospital to home increased, while rates of three-day and 30-day ED revisits and hospital readmissions decreased. Three days after discharge, 88% of patients in the intervention group reported that their health was better than it had been before their hospitalization, compared with 79% of those in the control group (P= 0.003). At 30 days, these percentages were 87% versus approximately 70%, respectively (P= 0.001). The odds ratio for three-day ED revisits and readmissions in the study group versus the control group was 0.25 (95% CI, 0.10 to 0.62), while the odds ratios for ED revisits and readmission, respectively, at 30 days were 0.58 (CI, 0.34 to 0.99) and 0.55 (CI, 0.32 to 0.55).

Although the study had limitations, including its pre-post design, the authors concluded that the intervention improved care transition in this group of patients. Johns Hopkins instructor and lead author Param Dedhia, ACP Member, noted that implications and next steps include identifying patients at greatest risk for poor transition and tailoring the Safe STEPs toolkit to other hospitals and hospitalist groups.

Care fragmentation increases hospital length of stay

Care by more physicians during a hospital stay could make that stay longer, according to a study presented at Hospital Medicine 2008 last month.

Researchers from IPC The Hospitalist Company set out to examine the impact of physician discontinuity on care, specifically length of stay, in hospitalized patients. The study involved 10,233 patients (1,724 with pneumonia and 8,509 with congestive heart failure) at 223 mostly nonteaching hospitals in 16 states. Fragmentation of care was defined as the percentage of care given by hospitalists other than the hospitalist who had seen a patient for most of his or her stay.

The authors found that for every 10% increase in fragmentation of care, length of stay increased by 0.45 day for pneumonia and 0.38 day for congestive heart failure. Fragmentation was not associated with a statistically significant increase in postdischarge complications. The authors acknowledged that their study had limitations, including the inability to demonstrate a causal relationship between length of stay and care fragmentation, but concluded that the former increases along with the latter. Lead author Kenneth Epstein, ACP Member, noted that future studies should focus on better defining fragmentation of care and determining the potential impact of different staffing models on this variable, as well as the effects of care fragmentation at other points of care.

CMS proposes nine new conditions for ‘do not pay’ list

CMS is proposing to add nine conditions to its ‘do not pay’ list, the agency announced in April:

  • surgical site infections following certain elective procedures,
  • Legionnaires' disease,
  • extreme blood sugar derangement,
  • iatrogenic pneumothorax,
  • delirium,
  • ventilator-associated pneumonia,
  • deep venous thrombosis/pulmonary embolism,
  • Staphylococcus aureus septicemia, and
  • Clostridium difficile-associated disease

The proposed rule would apply to services provided to patients who are discharged from the hospital during fiscal year (FY) 2009, which begins on Oct. 1, 2008, CMS said in a press release. Beginning on that date, Medicare will no longer reimburse hospitals for eight previously released conditions or any of the nine new conditions added to the final rule if these conditions are acquired in the hospital.

Last year, CMS announced that as of Oct. 1, 2008, it would no longer reimburse for eight conditions: objects inadvertently left in a patient after surgery, air embolisms, blood incompatibility, catheter-associated urinary tract infections, pressure ulcers, vascular catheter-associated infection, surgical site infection or mediastinitis after coronary artery bypass graft surgery, and certain types of falls and trauma if these events or conditions occurred during a hospital visit.

CMS is also expanding the hospital quality measure reporting program by adding 43 new quality measures. Hospitals will be required to report data on the existing 30 measures plus the new measures to receive the full annual payment update for FY 2010.

CMS will accept comments on the proposed rule through June 13 and will issue a final rule on or before Aug. 1.