CBO projects reduced healthcare spending growth

Last week, the bipartisan Congressional Budget Office (CBO) announced they had lowered their estimates on projected federal expenditures to reflect an overall reduction in healthcare spending. The CBO now projects that federal healthcare spending through 2023 will total $7.9 trillion. Although the figure is lower than the $8.1 trillion it predicted in February, the smaller figure remains significantly higher than the projected GDP.

Doctors Waiting on Medicaid Pay Raise

Although a threat remains to reduce Medicare reimbursement rates, many primary care physicians are still waiting on a Medicaid payment increase guaranteed to them under the Affordable Care Act (ACA). The hold-up seems to be coming from states that have been resistant or unable to increase the dollars allotted to their respective Medicaid programs. Under the ACA, the payment increase is to come from matching funds from the federal and state governments. However, while primary care physicians stand to benefit, the payment bump would not apply to emergency physicians.

Emergency Medical Care Cost Estimates Suspected of Being Too Low

An article in the Annals of Emergency Medicine “finds that national expenditures on emergency care are likely significantly higher than previously thought.” While the Agency for Healthcare Research and Quality (AHRQ) has long stood by its claim that only 2 percent of healthcare spending goes towards emergency medical care, the report’s authors believe the actual figure could be as high as 10 percent. This realization would certainly undermine many of the efforts being adopted to reduce overall spending. Although, as Myles Riner, MD, writes, “How much is the nation spending on ER Care? Wrong Question”.

The IRS and the ACA

Lastly, as details emerge about the recent controversy with the IRS, questions emerge as to how this may affect the implementation of the ACA. Because the IRS will play a key role in certain aspects of the ACA, this relationship is coming under scrutiny. In fact, a report says that the person who oversaw the tax-exempt organizations at the IRS during that time now has a key role with the IRS healthcare section.   

By Jim Strafford

If you have practiced healthcare pretty much anywhere in the United States during the last five years, you have probably been involved in at least one Electronic Health Record (EHR) conversion or implementation. In some cases, you may have converted from a user friendly template to a less user friendly EMR. In other cases, your hospital may have converted from one EHR brand to another. Regardless of the specifics of your transition, it is likely that some degree of frustration happened at the point when you adjusted to the first EHR. And it is also likely that after months of frustration you contacted one of those Scribe companies.

EHRs are still in their relative infancy and continuously improving. Penalties for not automating will be implemented in 2015, so they are here to stay. Learning from implementation issues is critical to improving implementation and effective use of EMRs. 

I have been involved in a number of client EHR conversions during the last decade. And although EMR systems are improving, the start up phase is often problematic. Much has been written about EHR implementation and training, but not much about the implementation aftermath; as well as how to prevent the implementation issues from recurring the next time your hospital converts (as they most likely will).  Below are some of the key issues that may arise during an EMR implementation, along with a few lessons and questions from my experience over the years working in the Acute Care Continuum.  (A note: I am using the terms EHR and EMR (Electronic Medical Record) interchangeably, although a distinction is that an EHR tends to be a hospital wide implementation that is inflicted on the ED, while an EMR tends to be a self-inflicted practice-specific implementation). 

1. Provider Training
   
   
- It is a given that time and planning were allotted for provider and stakeholder training. In addition, an EMR “super user” or champion was probably appointed from your colleagues. But post start-up, charting speed and accuracy have  suffered. What went wrong?

-Was enough time really allotted for provider training? 
Learning to use an EMR and becoming fast and proficient at complete documentation are separate issues. Training must be organized, well documented and geared toward the challenges of your specialty. 

-Was the training appropriate? 
You did receive adequate training in use of the EMR. But was the training geared toward achieving complete documentation? Often EMR trainers are more versed in computer coding than Current Procedural Terminology (CPT) Coding. ER coding personnel at your facility should have input and be involved in the implementation and training.

-Was the training complete?  
Were there meaningful EMR competency benchmarks? Consider developing a course for EMR use that leads to a completion certificate. Providers can learn from coding entities that typically require at least 95% accuracy as well as reasonable speed in coding your services. To prevent the type productivity and quality drop off that is often experienced post implementation, consider establishing benchmarks for key chart completion elements such as HPI, ROS, FH, SH etc... as well as procedures. Training is not complete until the provider has achieved 95% compliance.


2. EHR Implementation Deadlines
   
   
-A second issue is the problems often encountered in meeting EMR implementation deadlines. For example, a client of mine in the Midwest once experienced multiple deadline delays with their EMR conversion. In addition to causing stress and affecting productivity, the missed deadlines had the effect of delaying other projects affecting the ED. What can be done?

-Set realistic, flexible deadlines. 
Deadlines are important as a measure of project management. But time must be allotted for the training, testing and connectivity issues that come with EMR implementation. If the necessary time is not allotted at the front-end of the project, often a great deal of hospital IT personnel time is burned trying to make the EMR work.

-Have a back up plan. 
Things that are controllable, and some that can’t be controlled, do go wrong. I once saw a client with a well-planned EHR conversion in the direct path of Hurricane Sandy in the middle of their EMR implementation. In fact, their project manager was stranded in a shelter on Long Island! We all want to believe new technology will work in a timely fashion, but a Plan B is often necessary. If you are converting from a paper template to an EMR, a phased in approach might be considered with the necessary supply to cover implementation emergencies kept on hand. If possible, the same phased approach should be considered for an EMR to EMR conversion.

-Get the necessary support. 
Support is typically provided with EMRs. However, the support required for a clean, timely EMR implementation is sometimes lacking. Your hospital should be contracting for the support needed, but that doesn’t always happen. Additionally, the support personnel might not understand all of the documentation issues specific to your practice. A commitment and proper time allotment from all of the stakeholders whether clinical, IT, EHR or from the EMR entity is necessary for a timely conversion.


3. Connectivity
   
   
-A major selling point of many EHRs is the ability to interface with multiple provider sites, such as the lab, other practices etc... And the good systems generally do connect. But the assumption can’t be made that connectivity will be seamless. For example, EDs often outsource their coding. This means that the EMR must interface with an outside vendor or the vendor must have access to the EMR.

-A client of mine once put major effort into all interfaces, including the billing company. The entire chart was visible to coding personnel. But there was only one problem: the provider signature was not visible to the outside coders. A workaround was then completed to solve the problem, but only after a major back log of unsigned charts developed.

-All interfaces and connections of any sort must be identified and tested multiple times prior to go live.

By Imamu Tomlinson, MD, MBA

In an era of healthcare when there is a call for emergency physicians and hospitalists to increase collaboration, and many working hard to facilitate this, I have seen this pairing blend together effectively just by putting together highly motivated and empowered physicians.

In 1996, my physician group signed an emergency department (ED) contract in Selma, CA. Since that time, we have been invited to staff three EDs, three inpatient departments, an urgent care center (UCC) and a skilled nursing facility (SNF)—all within the forty mile area that includes Selma. How did this come about?

When the administration at Selma saw good patient care metrics in their ED, they asked us to manage their hospitalist service, too, on the premise that what is good for outpatients is good for inpatients. And, sure enough, within six months, not only did throughput time decrease in the ED, but hospital length of stay decreased also. The Case Mix Index (CMI) for the hospital increased, but still our cost per patient has decreased. Our style of coordinating care in the ED was successful in coordinating care throughout the hospital.

What is it that has enabled us to improve performance in a range of different enterprises with different missions and different metrics? ED physicians, hospitalists and SNFists have diverse skill sets and perform varied functions, but at the end of the day, they are all similar in that they want to be empowered as physicians and be leaders in the community. I have seen physicians gravitate towards a physician-led group with a democratic structure. In this case all the physicians own their practices. When we work for ourselves, we have a very demanding boss! Self-employment gives people that extra bit of motivation to work well and efficiently, and to become leaders in the community. This not only attracts physicians to work with us, but it attracts hospital administrators who want us to work with them. 

So how does a physician group handle it when the hospital asks for more and more inter-departmental integration and collaboration? I know this: when physicians feel as if they own their own practice, they are empowered and motivated to come up with solutions that work.  I have seen with my own eyes what happens when the collective power of physicians is brought together.

Managing from the viewpoint of the Acute Care Continuum (and beyond) can allow the coordination of care in a way that has not been possible since family doctors managed their own patients twenty years ago. Now we are creating a culture of integration that coordinates all episodes of care from the ED, through the hospital, and right through to the SNF.  While there can be challenges in coming together in this way, I have seen no negatives as a result of doing this, and, to the contrary, much in the way of positive results.  Think of it as a jazz band. We in the ED played the piano so well that we were asked to play the clarinet, too, and then the trumpet, and each player, playing independently, contributes to a wonderful sound.

Imamu Tomlinson, MD, MBA joined CEP in 2004 and is Regional Director for the Sequoia region. He received his bachelor of science in Biology from St. Lawrence University in New York and his medical degree from the University of Cincinnati. He completed his residency at Miami Valley Hospital in Ohio and is Board Certified in Emergency Medicine. In 2012, Dr. Tomlinson completed his MBA in Healthcare Administration from California Coast University. Dr. Tomlinson served as the Medical Director at Adventist Medical Center Selma from 2006 to 2013, and served as the Medical Director at Adventist Medical Center Hanford from 2006 to 2011. He is currently serving as Chief of Staff Elect for Adventist Medical Center Hanford and Adventist Medical Center Selma. Dr. Tomlinson was the Mid Valley Emergency Nursing Association Emergency Physician of the Year in 2006 and received a CEP America distinguished service award in 2008. In 2009, both Hanford and Selma received CEP America site of the year distinctions. Dr. Tomlinson has been an active member of the Hospital Medical Executive Committee. He led an effort to create the Department of Emergency and Diagnostic Medicine and currently serves as the chair of that department. As a result of his leadership, both medical centers have increased their volume by more than 90% and only 0.5% of patients leave prior to seeing a medical provider.

This was first published in The Fickle Finger.

By Lori Winston, MD

According to the Association of American Medical Colleges (AAMC), the United States will face a shortage of 90,000 physicians by 2020 and 130,000 by 2025. And making it more difficult to climb out of this hole, the federal government is reducing Graduate Medical Education (GME) funding, both in the general budget and in sequestration cuts. As a result, the AAMC is pushing for Congress to lift the cap on Medicare-funded residency training programs which was adopted as part of the Balanced Budget Act of 1997. Last month, two bills were introduced to address the shortage. The House’s Training Tomorrow’s Doctors Today Act and the Senate’s Resident Physician Shortage Reduction Act of 2013 would phase in 15,000 residency positions over five years.

Kaweah Delta Medical Center, the hospital where I practice, has invested in starting its own GME department with the addition of residency programs in emergency medicine (EM), family practice, psychiatry, general surgery and transitional year training. This is a win-win on many levels for everyone involved. It will benefit the doctors accepted to the program, the hospital, my physician group, and the entire community.

As the person entrusted with developing this new EM residency program, I have been delighted with the flood of excellent candidates applying to our program. One reason for the spate of applicants is that competition for residency placements is growing throughout the country. The National Resident Matching Program reports that the number of applicants for residencies already exceeds the available positions (pdf).

Another potential reason for our popularity is that we are located in a rural area of California, which as Barbara Katz points out can be a much less popular destination for physicians. However, only a few residencies in EM exist in California, and of those, many are four year programs. By contrast, we are a three year program, and many EM residents prefer three year programs. They often joke that the difference between a three year program and a four year program is about $200,000. If they want an additional year of training they often favor short fellowship programs, through which they can gain additional credentialing. Because of these advantages, we are able to recruit the best and the brightest young doctors to our program.

Those residents who are fortunate enough to match with Kaweah Delta’s new EM residency program will receive excellent training. Our institution has enough high acuity and ED volume for twice the number of residents we are currently accredited for, which means that trainees will have no shortage of exposure to multiple types of patient pathology. In addition, because this hospital is new to the world of GME, our residents will not be fighting over procedures in the trauma bay with other residents. In this program we will be sure that residents get an opportunity to learn without being exploited as inexpensive labor. We will closely monitor duty hours and eliminate marathon shifts in accordance with ACGME regulations. On one full morning each week we will emphasize this ideal of “education over service” by keeping Thursday morning as “protected educational time” for EM residents in training.

Besides creating a great training opportunity for new physicians, the residency program will also furnish advantages to the hospital. Residents will provide in-house coverage and also increase the number of physicians available to treat patients. Furthermore, supervising and teaching the trainees will be stimulating for our attending physicians. Being a hospital with residency training programs will increase our prestige and will help in physician recruitment. We expect that our efforts to educate and graduate outstanding residents will put this hospital ahead of the competition when the time comes to hire these residents.

This residency program has benefits for my physician group, too. This is our first experience in starting an allopathic residency program, and it will give us experience that will be helpful in setting up others. This program will open up recruiting for my physician group, as many of the already vetted and graduating residents will have the opportunity to join our group. The new EM residency program at Kaweah Delta is both a needed residency program to help meet the physician shortage, and an opportunity for both the future of my physician group and for this local community.

Lori Winston, MD received her medical degree from Loyola University Stritch School of Medicine and is board certified in Emergency Medicine. Dr. Winston is the Program Director of the Kaweah Delta Health Care District’s Emergency Medicine Residency Program.

Our bi-weekly news updates are designed to keep you up to date with current developments relating to the Acute Care Continuum. Feel free to share your perspective on these stories or link to articles that you have found relevant to today’s healthcare environment.

Boston Hospitals Praised for their Response to Marathon Bombings

After two explosive devices went off at the finish line of the Boston Marathon, first responders mobilized and patients were quick triaged and dispatched to emergency departments (EDs) around the city. The quick response resulted in only three confirmed deaths, which is “attributable to more than just providence and the extraordinary skill and courage of the volunteer and professional responders…the response was enabled by the medial community’s prior efforts to build and sustain emergency-preparedness programs and, perhaps most important, to practice its response in exercises and drills”. This recent perspective in the New England Journal of Medicine examines how Boston was able to respond in such a quick and coordinated fashion thanks to a decade of emergency planning across the city’s hospitals, EDs, and public health organizations.

Using Advertising to Steer Patients Away from the ED

An advertisement created by Britain’s National Health Service and part of their “choosing wisely” campaign has been garnering attention stateside because of its message of steering patients with less severe illnesses away from the ED to an alternate location. Similar to the US, trips to the ED in Great Britain can be expensive and increase the wait times for higher-acuity patients. However, the practice of educating patients with lower acuity symptoms to visit an urgent care center(UCC) or other setting is a relatively new practice in the United States.  In fact, many US hospitals choose to advertise their shorter wait times instead of steering patients elsewhere out of fear of losing that additional revenue.

Freestanding Emergency Departments Questioned

As the demand for emergency medical care has grown, so has the number of freestanding EDs across the country. Operating similarly as UCCs, these freestanding EDs are often located in rural areas where there is not a nearby hospital and appeal to patients for their (on average) shorter wait times and convenient location. However, as the article describes, private insurers have grown uneasy because freestanding EDs have become revenue-generating centers for the physicians and hospitals that run them.

By Dan Culhane, MD, FACEP

The cost of losing someone from your company is quite significant.  The actual financial loss, including factors such as lost productivity and costs of integrating employee new person into your organization, can be greater than their salary.  For someone as highly specialized as a physician, according to industry experts this can add up to more than twice their salary.   

Cejka Search and AMGA recently published their 2012 Physician Retention Survey, which studies data and trends in physician retention.  Their report on the current physician turnover rate makes it obvious that reducing this number would create huge operational and financial benefits to healthcare companies.

The study also discusses the challenges in accomplishing this.  They point out that as the economy has recovered, the workforce has become more mobile.  As Lor Schutte, president of Cejka Search says, “Turnover in medical groups continues to climb along with the economy.”  Human resource expert Barbara Katz explains that rising housing prices and sales opportunities are key drivers for physicians to change cities and move to their desired locations.

What are the strategies that a medical group can implement to reduce turnover?  First, we must accept that a certain degree of turnover is inevitable and measure it.  Although many physicians work well into their golden years, a handful can be expected to retire every year.  My physician group has recently implemented a software program to document and measure the mobility of our staff.   This allows us to predict future turnover and growth so that we can plan for change and, hopefully, create positive outcomes

Just as in all parts of medicine, it is most valuable to focus on factors that are potentially controllable. The Cejka survey points out that, “Culture is the top controllable factor driving turnover.”  Empowering each individual physician helps create a culture that favors retention.  On the level of the company as a whole, the structure of power is also crucial. Democratic physician groups can be an environment to create a culture of empowerment. Further, companies that focus on employee engagement are most successful at retaining staff.   At each site, the local medical director has a large responsibility and opportunity to make a defining contribution to the culture and the satisfaction of each physician at that location.  A critical part of the medical director’s job is to be a steward for each physician’s career on their team.  In order to build stability and loyalty, the medical director needs to pay attention to the career path of each staff member.

While physician retention is clearly an important concern, jobs data from the Bureau of Labor Statistics show that over a five year period, the turnover rate of physicians is actually low compared to other professions in the United States.  Physician turnover was 6.8% over a 12 month period in 2011, while it averaged 36.7% for all industries and workers. This is a testament to how committed physicians are to the communities they serve, as well as to their practice groups.

The take-home message for a healthcare leader is that organizations must understand their workforce retention and turnover rates in order to be able to influence them. Once the metrics are clear, leaders can design programs to motivate their doctors to stay with the group.  Holding on to providers will give healthcare groups a financial advantage.

Dan Culhane, MD, FACEP, is Board Certified in Emergency Medicine and a Fellow of the American College of Emergency Physicians. He serves as Vice President for CEP America, overseeing provider recruitment and retention. Prior to serving as Regional Director, Dr. Culhane was the Medical Director at both Arroyo Grande Community Hospital and French Hospital Medical Center. He received a Bachelor of Science in Biochemistry and Molecular Biology from the University of California, Santa Barbara and earned his medical degree at the University of California, Los Angeles. He completed his residency in Emergency Medicine at the San Joaquin/Valley Medical Center of Fresno Campus of UCSF. Dr. Culhane practices at French Hospital and Arroyo Grande Community Hospital. He has served on multiple committees, including Chief of Staff at these facilities. He currently serves on the Peer Review and Medical Executive Committees.

By Gary Li, MD, FACEP

In most of the prior blogs you have heard a lot about the inexorable forces of change in our healthcare system which are leading to consolidation of health care entities, integration of service lines, accountable care organizations, and so on. Fundamentally, these forces are the oft-state three mandates of improving quality, improving access, and decreasing costs. Keith Bontrager of mountain bike building fame used to say “strong, light, cheap—pick two out of three.” Well, perhaps carbon fiber has changed that paradigm for bikes. Going forward, in medicine, we are also expected to go three for three. Here I would like get into the weeds a bit and ponder resource utilization in clinical practice and the relationship with the Acute Care Continuum.

Analogous to fast food “supersize” meals, more medical care does not always mean better care. Gradually, many healthcare providers and members of the public are beginning to understand this. The “Choosing Wisely” initiative of the American Board of Internal Medicine Foundation is indicative of this recognition and concern. In this program, each medical specialty identifies five diagnostic or therapeutic interventions that may be of questionable value. Programs like this are encouraging medical providers to let go of tests and procedures that are not helpful, may be harmful, and are expensive.

Excess or inappropriate utilization of resources directly affects cost and quality and has a secondary effect upon access -- lower costs presumably free up more money within the overall healthcare system to improve access. For providers, with more shared risk coming down the pipeline (e.g. “bundled payments” or ACOs), there will be direct financial incentives to improve value. Currently, most focus remains on a volume or fee-for-service model, due to the balance of incentives and penalties. But entities or individual providers who do not recognize and prepare for the fundamental paradigm shift will not be successful in the near future.

The cost component of improving resource utilization is intuitively clear; no one wants to pay for tests or treatments that do not add value. But the harm done by inappropriate utilization is more complex. Complications of over-testing, over-diagnosing, false positives, and over-treating are real concerns. Recent studies have shown associations between increased ED utilization, increased ED LOS, and poorer outcomes (Pitt, et. al. Annals of EM 2012, Sun, et. al. Annals of EM 2012, BMJ 2011). Though there is no proven cause-effect in these studies, we would all agree that we should never do what is unnecessary or harmful.

I would also advocate caution in how we utilize new technology or incorporate well-intentioned new recommendations into clinical practice. Sometimes these can create a vicious cycle of further increasing utilization and potential harm. Take sepsis, for example. Yes, we can and should do better. However, as we include more low-acuity patients as “septic,” we will invariably have better outcomes simply because they are less ill. We then may come to the false conclusion that the more aggressive screening and management are beneficial, leading to an even more aggressive process. In this example, individual patients who may not need treatment are also exposed to the potential harm of unnecessary treatment. Such situations remind me of the Will Rogers’ quote “when the Oakies left Oklahoma and moved to California, it raised the IQ of both states.” No one really got smarter.

So, what to do? Decreasing utilization in a system and society accustomed to “more is better” will be hard work. Ultimately, we will need to communicate and collaborate better across the entire Acute Care Continuum in order to decrease unnecessary utilization. Although integration of the players into single entities may be helpful, lack of such integration should not slow our efforts. 

Our default should be to do less unless there is reasonable evidence that doing more is valuable. We must keep abreast of the latest evidence. For example, the Society of Hospital Medicine has already come out with its initial list of questionable tests and treatments and the American College of Emergency Physicians is currently developing one.

Locally, we need to work on narrowing the bell-shaped curve of practice variation to a range that is supported by the evidence. This will require valid data, discussion, feedback, and education. In our own clinical practices we should always consider the risks, benefits, and harms of each and every test and treatment ordered and have realistic discussions with our patients. For example, my physician group has such an initiative for decreasing CT utilization.

Reducing overutilization will not be a simple task and raises other questions. For example, how can we practice with such restraint and still protect ourselves from malpractice suits? And how do we deal with patients and families who continue to demand more? Also, we are stuck with many regulatory mandates that may be of dubious value. Nonetheless, if we as clinicians do not take the initiative, we will risk harming patients, being hurt financially, and others (like regulators and legislators) will prescribe and proscribe patient care in ways that are in no one’s best interest.

What can we do to balance all these varying pressures on resource utilization? I welcome your thoughts.

Gary Li, MD, FACEP joined CEP America in 1993. Dr. Li is a member of the Santa Clara County Medical Association, California Medical Association, American Medical Association, and Alpha Omega Alpha Honor Medical Society. He is former president of the South Bay Emergency Medical Directors Association. He received a Bachelor of Science degree in Biological Sciences from the University of California, Davis. After continuing on to Medical School at UC Davis, Dr. Li completed his Emergency Medicine residency at the Los Angeles County Harbor-UCLA Medical Center in Torrance, California. Dr. Li is an American College of Emergency Physicians Fellow and an American Board of Emergency Medicine Diplomate.

By Amina Martel, MD

The term “hospitalist” was first mentioned in 1996 in an article in the New England Journal of Medicine. Although the field has come far since then, there are still no residencies offered for hospital medicine. Without a formal residency to train hospitalist candidates, administrators must decide whether to recruit recent graduates or experienced hospitalists to fill their needs for this rapidly growing specialty.  

Since there are no hospitalist residencies, most of our candidates apply to us after doing a traditional Internal Medicine (IM) residency. We are fortunate to have a plethora of qualified physicians applying for our positions and the majority of them tend to be recent graduates. Being in the San Francisco South Bay region helps us draw candidates, as does our affiliation with a major teaching center. In addition, having our own IM residency gives us a pool of applicants who are already familiar with our hospital. We tend to get more CVs than we have capacity for, which, as physician recruiting expert Barbara Katz points out, is not the norm right now across the country.

So what is my approach on how to train a recent graduate? First of all, I realize that it takes about a year for the new graduates to be comfortable in their new roles as hospitalists. In the first few months, we help them lose the "over the shoulder syndrome"—the habit of looking for the attending to sign off. It is important that they learn to take responsibility for both patient care and the operations of the hospital, and for this to happen they must feel empowered to think and act quickly.

When they start, we have a hands-on orientation. On the first day, we have them shadow one of the more experienced hospitalists to learn our technology system, and then, when they have mastered the basic computer applications, we have them see a patient. They gradually add more patients until, by the third day, they are seeing a full load of patients on their own. 

They are never alone during the training period and beyond. They work side by side with two or three experienced hospitalists so they can ask questions, get to know the consultants and case managers, and become familiar with all parts of the Acute Care Continuum. We teach them how to navigate the system, and this takes time since each system is unique unto itself. Of course, it does take extra work to train someone without experience. But I find this investment to be well worth it for their career satisfaction and our retention rate. 

As the medical director, I work as many shifts as our full time hospitalists, so I am on the floor to help train our new physicians. To evaluate their progress, I often take over their patients so I can see their H&P, progress notes and discharge summaries, and I ask for feedback about the trainees from the other hospitalists in my group. I use this information and my own observations to give lots of feedback to the new graduates. I watch them round, and if they seem to be overly stressed, I help them analyze what they are doing in order to find a better/easier way of doing things. I try to push the new graduates to think for themselves, but also to know their limits and ask for help when they need it. After six months, they should be getting more comfortable in their role, and if they are not, I sit down with them to figure out why. I believe that this proactive approach early on and then and on-going intervention creates better job satisfaction. 

Some doctors are meant to be hospitalists and some are not. Over the years, we have found that with careful screening we can find the right people for our program. We look for physicians with excellent qualifications who fit well into our group, who share our work ethic, are willing to be flexible and cover for each other, and who are eager to learn something new. As hospitalists, we often spend more time with our colleagues than we do at home, and building a cohesive team at work can be as determinant to our happiness as a happy marriage. Ninety percent of the physicians currently working in our group were hired as new graduates, and we have minimal turnover. That tells me that we are doing something right.

Amina Martel, MD is the Hospitalist Medical Director of a site in San Jose, California. She holds a BA in Biology from Boston University and an MD from St. George’s University School of Medicine. She completed her Internal Medicine residency at Cook County Hospital.

By Ted Kloth, MD, FACEP

The time is coming when consolidation and transparency will reign supreme, and the effects are already being felt throughout the healthcare arena.

Looking at the healthcare landscape and how the major players are reacting to the effects of reform, it is obvious to me that the need to consolidate is becoming a reality for many physician groups and service providers. Health systems are merging with larger health systems and clinical outsourcing groups are entering into joint ventures with their long-time clients to provide care at a lower cost. The rationale behind this shift is the belief that integrated systems reduce costs and increase profits for all parties involved. And with fewer reimbursement dollars at play, it seems most are looking for ways to increase profit margins by doing more for less.

The rush to consolidate services is also driven by another factor of healthcare reform: data transparency. Up until now, an under-performing group or hospital might have been able to fly under the radar. This is no longer the case. Hospital administrators, their board members, competition, and the community at large will all have access to performance metrics online and everyone will be held accountable.  As a result, many physician groups are scrambling to integrate their services and produce measurable results.

As a practicing physician and an officer with a physician group, I have seen firsthand the effects of administrators’ having dollars on the brain and access to quality data at their fingertips. Whereas it was once sufficient to showcase successful cases at one or two hospitals, hospital administrators now come with performance metrics for numerous facilities, asking why this one or that one isn’t performing as well as the others. Although my organization has a long-standing commitment to quality and integration, more than ever it is necessary to translate that commitment into performance. Transparency is a game changer.

Fortunately, my group has the economies of scale and resources to translate our commitment into results. We have focused on developing initiatives to improve performance across the Acute Care Continuum while simultaneously aligning our organizational goals with those of our hospital clients. We listen to them to identify what’s most important and adjust our strategic plan accordingly. By focusing on better integration in this era of transparency, we’re able to justify our costs and deliver on our promises.  A key component that is the basis of a successfully integrated system is the level of trust that emerges between the people and departments that are working together.

It is important for all physician groups and service providers to understand that administrators are not looking down a blind rabbit hole anymore. Without an organization-wide dedication to improving performance and integrating across departments, it will grow increasingly difficult to justify one’s value. We all must understand that what worked yesterday may not be sufficient today; and if we don’t evolve, we will face extinction.  On the other hand, working collaboratively and with high levels of trust, while also utilizing advances in data analysis, will create a competitive advantage.

Ted Kloth, MD, FACEP, is the Chief Business Officer of CEP America. Dr. Kloth is responsible for the company’s business development efforts. In this role, Dr. Kloth has put CEP America’s practice model in front of a national audience of hospital administrators, and successfully demonstrated its value across hospital sizes, settings, and systems. A tireless advocate for democratic practice with a realist’s worldview, Dr. Kloth’s expertise in emergency physician group integration ensures a smooth transition for new emergency physicians into the CEP America culture and organizational structure.

For the past 24 years, Dr. Kloth has also worked as a staff physician at the John Muir Medical Center emergency department in Walnut Creek, CA. Dr. Kloth joined CEP America in 1976 and served as Chairman of the Board from 2003 to 2006. He obtained his MD degree from Tulane University and is an American Board of Emergency Medicine Diplomat, a member of the Alpha Omega Alpha Honorary Medical society, a member of the AMA and AOA, and an American College of Emergency Physicians Fellow.