Inpatient Practice Medical Economics

What Machiavelli Would Say About Hospital Length Of Stay

Machiavelli famously said to the prince: “It is better to be both loved and feared but if you can only be one, be feared”. I’ve been wondering what Machiavelli would say about time of hospital discharge versus length of stay?

Hospital length of stay is measured by the length of stay index. This adjusts the length of stay (in days) for the patient’s diagnosis. Because sicker patients are expected to be in the hospital for more days than less sick patients, the length of stay index makes more sense than just the plain length of stay. A patient who was in the hospital for the expected number of days for that patient’s diagnosis would have a length of stay index of 1.00. A patient who was in the hospital more days than would be expected would have an index of greater than 1.00. And if that patient was in the hospital for fewer days than expected, the index would be less than 1.00.  We benchmark our hospital’s length of stay to Vizient, which is composed of most of the academic medical centers nationwide. Our medical center’s goal is a length of stay index of 0.95; we have been proud that our hospital’s length of stay index last year was only 0.88.

But here is the problem with length of stay. If you are going to get a patient out of the hospital a day earlier than expected, that usually means you have to cram a lot of testing, consults, treatments, and case management into that last hospital day. That means that the patient is going to get out of the hospital later because you are waiting for that test result, or that last antibiotic infusion, or the discharge arrangements to a nursing facility.

In addition to the length of stay, the other metric that we watch carefully is the time of day that patients are discharged. Ideally, you like to get  your patients out of the hospital early in the day so you can have a bed available when the next patient needs to be admitted. Think about hotels – they usually want you to check-out by 11:00 AM so they can get the room cleaned and ready for the next guest arriving in the afternoon. The reality is that hospitals only have so many environmental services employees and so there is a limit to the number of rooms that can be cleaned at any one time. Therefore, what you like to see is an even distribution of patients being discharged over the course of the day so that rooms can be cleaned as soon as a patient leaves without having to leave the room dirty for hours waiting for environmental services.

Often, getting the patient out early in the day is in direct conflict with shortening the hospital length of stay. It is kind of like a game of Whack-A-Mole; if you get the patient out of the hospital a day early, that patient is more likely to leave later in the afternoon (or in the evening) rather than early in the morning. Therefore, shortening the length of stay will usually push back the time of discharge.

So, what is a hospital to do?

You have to be realistic. the goal is NOT to get all of the patients out by noon (like a hotel) but rather to get some of the patients out before noon so you can get those rooms cleaned and then get a few more patients out by 2 PM so you can then get those rooms cleaned, etc. Hospitals are not like hotels – in a hotel, most of the guests arrive between 4 PM and 8 PM but in a hospital, patients show up in the emergency room and are getting admitted 24 hours a day.

I think if Machiavelli was alive today, he would say: “It is better to have both a short length of stay and an early average hospital discharge time but if you can only have one, have the short length of stay”.

February 22, 2017

Outpatient Practice

Why The Number Of Patient Phone Calls Are Increasing

Does it sometimes feel like you are getting more and more patient phone calls? Well, maybe you just are. Twenty years ago, there were some days that I would get no phone calls from my outpatients. Now, if I get less than 10, it is a really good day. So why are patients calling their doctors more now than they did in the past? I believe that it is a confluence of several different factors:

  1. Office visit co-pays. As medical costs have become more expensive in the past decade, insurance companies have looked for ways to keep their costs down. One way that they have done it is by increasing the co-pays that a patient has for each office visit. These are typically $20-50 per visit. In order to avoid having to pay out of pocket to see a physician for acute bronchitis, patients are increasingly calling, in hopes of getting a free diagnosis and treatment over the phone.
  2. Office schedule templates. As more and more physicians have become employed by hospitals or large group practices, there has been more emphasis on improving office efficiency and from this has come the concept of schedule template optimization. The advantage of this is that a physician’s schedule of outpatient visits is highly organized so that there is minimal “down time” when an exam room is empty and the office staff are unoccupied. The consequence of this is that it can be very difficult to squeeze in a patient for a short notice sick-call. Although many primary care physicians will have some sick call slots on their schedule templates, on some days there are more sick calls than there are open slots. Many specialists do not have sick call slots on their schedule templates.
  3. The culture of immediate information access. Remember back when people didn’t carry cell phones with them 24 hours a day? Or when you had more letters in your mailbox than you had email messages on your computer? Americans today expect immediate access to information and to communication. A patient who would have waited 3 days until they could see their physician about a headache now wants their headache addressed in 3 hours.
  4. Complexity of care. Today’s patients are on more medications and those medications have more side effects. This adds up to more things that can go wrong and more side effects of treatments. This adds up to more worried patients calling their doctor.
  5. Formulary changes. Every January is formulary month for physicians who take care of outpatients. Health insurance companies annually re-negotiate their deals with pharmaceutical companies to get the lowest price on medications. And so Spiriva may be the preferred anti-cholinergic inhaler one year and Incruse the preferred inhaler the next year. In January, patients will get a letter from their insurance company that Spiriva is no longer covered by insurance and they have to call their doctor’s office to get a new prescription for a medication that is covered. The problem is that the letters usually don’t say which equivalent drug is now covered. So the physician either has to call the insurance company or find the new formulary listing for that insurance company on-line to determine that Incruse is now the covered inhaler. I think the hope of the insurance company is that physicians will get tired of the hassle and just discontinue the inhaler prescription.

So, what can you do to reduce the number of phone calls?

  1. Use email. OK, so you can’t exactly use regular email without violating HIPPA laws. But most electronic medical record programs will have encrypted secure messaging with patients. Typically, patients sign into their “patient portal” and then can send messages to their physician’s office. I can type in an answer to a patient’s question in about 30 seconds. If I am returning a call to that same patient for that same questions, it will take me about 3 minutes since there is always a wait time for the patient’s spouse who answers the phone to get the patient on the phone and then the patient inevitably will have “just one more question while I have you on the phone, doc”.
  2. Empower your nurses. In our practice, these messages are routed to a pool of office staff that screen messages. Those that are for appointment scheduling are routed to a scheduler. Those that are for refills are routed to a nurse to tee up the refill order and then route it to the doctor. And, those that are about medical questions are routed to the physician. However, a lot of medical questions can be answered by nurses. For example, a patient with COPD calls and wants to know if he can wear his nasal oxygen cannula in the shower – your nurse can answer that one, you don’t have to.
  3. Optimize medication refills. For maintenance drugs, it should always be 12 refills for 30-day prescriptions and 4 refills for 90-day prescriptions. Pharmacies will honor refills up to 1 year from the original prescription. So, if you give an initial prescription plus 11 refills (a total of 12 30-day prescriptions), that would be 12 x 30 = 360 (five days short of a full year). For patients who return to the office for an annual visit, they are usually coming in at 365 days (or, more often, a week or two after 365 days). Therefore, with 11 refills, they run out of medicine a week or two before their annual visit and have to call to get a refill. By doing 12 refills, they can still get their last refill inside of the 1-year refill limit but the last refill will last them until 390 days from their previous visit, plenty of time to get in for their routine check up and refill encounter without having to also have the the extra phone call to the office for a refill.
  4. Refill medications proactively. Here is where the office staff can really help. Lets say you prescribe hydrocholorothiazide for a patient’s hypertension in December and you give the patient a 90-day supple with 4 refills (390 days worth). But their next annual visit ends up being 11 months later in November because they’ll be wintering in Florida for the next 4 months. They will still have another refill until either the patient or their pharmacist calls your office to request a refill. But, if your office staff check the electronic medical record to determine the number of refills remaining when the patient is in the office in November, they can tee up another year’s worth of refills and eliminate a phone call in January when your patient runs out of medications on the beach in Fort Myers.
  5. Make use of patient information handouts. With most electronic medical records, there is something called an “after visit summary” that is printed out for the patient. It will include information about their visit such as the diagnosis and any changes to the patient’s medications. No matter what you tell them, patients will only remember 3 things. If you tell them 3 things, they will remember 3 things. If you tell them 5 things, they will remember 3 things. So, if you want them to remember all 5 things, add clinical information sheets to the after visit summary. If you just diagnosed a patient with chronic systolic heart failure, include printed information about what the disease is, the need for logging daily weights, sodium restriction, etc. If you are prescribing methotrexate for a patient with rheumatoid arthritis, include information about taking all of the pills at one time once a week, taking folic acid every day, and common side effects of methotrexate to be on the look-out for. These can eliminate the patient getting home, turning to their spouse and asking: “What did he say?” and then eliminating the inevitable phone call asking for a clarification of the doctor’s instructions.
  6. Make test results available. If I order a toothbrush from today, it will show up at my front door tomorrow. If a patient gets a blood test today, they expect to know the results tomorrow. We live in an age of immediate information. If a patient is signed up for a “patient portal” on your electronic medical record, then make sure that test results are released every day – either do it yourself or have the tests auto-released to the patient. We have auto-release of common blood test results such as CBC, chemistry panels, etc. Some of our physicians objected to this for fear that their patients “can’t handle the truth” of their test results and will call the office for every abnormal monocyte count on their CBC. That is not my experience – my patients love it and it reduces the phone calls from patients wanting to know what their annual cholesterol level was. In nearly a year, I’ve only gotten 1 call about an abnormal monocyte count. Also, set expectations. If you order a weird blood test that has to be sent to a specialty laboratory in northern Saskatchewan by dogsled, make sure that the patient knows that the results won’t be back for 3-4 weeks.

Currently in American medicine, we don’t get paid for phone calls – we just get paid for face-to-face office visits. In the future, if we have some form of capitated health care system where we get paid by the size of our patient panels rather than the number of office visits, then phone calls may all of a sudden be an efficient and desirable way of taking care of your patients. Until then, avoidable phone calls can clog up your day with uncompensated time. There are times when our patients truly need to speak with their doctor by phone and at those times, a phone call can equate to better care of the patient. Our challenge is to eliminate the phone calls about issues that could have been handled preemptively with better planning and office structure.

February 19, 2017

Hospital Finances

Take The Money Or Take The Quality Metric?

Yesterday, I was faced with a philosophical dilemma: is it better for the hospital to get paid more for a hospital admission or to have a better score on publicly reported quality outcomes?

Heroin overdose is an epidemic in Ohio (see the post: Found Down With A Needle In The Arm). At issue was a patient transferred to our hospital two days ago from a smaller hospital in Southern Ohio after an out-of-hospital cardiopulmonary arrest following a heroin overdose. He was found apneic and pulseless. The EMS personnel did CPR and managed to get his heart started but by then, he had sustained severe anoxic brain injury. He was intubated and on a mechanical ventilator. He had shock liver and acute kidney failure. On admission to our hospital, he was suspected of being brain dead but the hospitalist needed to wait until the following day for a physician credentialed in brain death determination to assess the patient.

So, the issue was, do we admit him to the ICU as a regular hospital admission or do we put him in observation status? In a previous post, Moon Over Medicare Or Mooned By Medicare?, I laid out the differences in regular admission status versus observation status. The bottom line is that the hospital gets paid a lot more if a patient is in regular admission status than if they are in observation status; a patient in observation status is considered to be an outpatient rather than an inpatient and is anticipated to be in the hospital for < 2 midnights. For a patient being admitted to the ICU after a cardiac arrest who is in acute respiratory failure, acute liver failure, and acute renal failure, normally, this would be a slam-dunk regular hospital admission. The DRG associated with this admission would pay the hospital pretty well. But, you can also make the argument that since the patient was suspected of being brain dead, he could also be in observation status since life support would be discontinued the following day if he is truly determined to be brain dead.

On the other hand, if he is in regular admission status, he counts against our hospital’s publicly reported inpatient mortality rate but if he is an outpatient in observation status, his death would not count against our inpatient mortality rate.

Last year, our hospital finished with an inpatient mortality index of 0.54. This was the second to the lowest mortality rate of all academic hospitals in the United States and we are incredibly proud of it. This year, however, we have seen our mortality index creep up and for the month of December, it was greater than 1.0. In drilling down into our hospital deaths this year, the only thing different is that we have been taking more hospital transfers this year, that is, patients admitted to another hospital and then transferred to our hospital for a higher level of care. In fact, hospital transfers account for 3% of all of our hospital admissions but account for 24% of all of our hospital deaths.

We like hospital transfers because these patients have diagnoses that put them into higher-paying DRG classifications and they tend to have a lot of co-morbidities that amplify the DRG and get the hospital paid even more. But these transfers come with a cost of a higher likelihood of dying in the hospital.

Yesterday, I had to make the decision: should we put the patient in regular admission status and get paid more but take a hit on our mortality rate? Or should we put him in observation status and get paid considerably less but not have his death count against our inpatient mortality rate? I spoke with a number of people in our hospital. Some recommended taking the money and the mortality hit. Others recommended avoiding the mortality and take the financial hit.

So last night I made my decision before we pronounced him brain dead.

What would you have done?

February 16, 2017

Life In The Hospital

Run, Hide, Fight

The text message on my phone read: “Buckeye Alert: Active Shooter on campus. Run Hide Fight. Watts Hall. 19th and College”. It was a deranged student who went on a stabbing spree on the Ohio State University campus, injuring 13 people before being shot to death by OSU police last November. My son lives in a dormitory about 500 feet away from the event. He was working out in the gym and when all of the students and staff got the text message, they went into a back room and barricaded the door to prevent entrance.

Partly as a response to that event and partly in response to our JCAHO site visit last summer, the hospital began plans for active shooter drills. There has been a rash of shootings in hospitals: January 2015 Brigham and Women’s Hospital in Boston, March 2016, East Jefferson General Hospital in New Orleans, July 2016 Benjamin Franklin Hospital in Berlin. Each of these three resulted in the shooting death of a physician.

The key to surviving any threat is preparation and situational awareness. On a subway station in a foreign country? Preparation is moving your wallet from your back pocket to your front pocket and situational awareness is looking at the people in front and behind you. Driving on the highway where there have been wrong-way driver fatalities? Preparation is planning whether to pull off into the left or right berm and situational awareness is looking ahead to the next exit ramp for headlights coming toward you.

Our hospital’s active shooter training is all about preparation and situational awareness. The University has prepared short videos on the OSU website, all staff have to do a CBL module (Computer Based Learning module), we have “table top” discussions with a target participation by 60% of all employees and 100% of employees in vulnerable areas (e.g., the emergency department), and this spring, we will be holding a hospital-wide active shooter drill.

Last week, I attended one of the table top discussions. We watched a series of short videos produced by the Ohio State University Police Department about “Run, Hide, Fight” and then discussion was lead by one of our hospital security officers. It was pretty enlightening and I’m better prepared because of it. Here’s what Run, Hide, Fight is all about:

Run. This is your best option. Have an escape route in mind – ever since the Colorado theater shooting, the first thing I do when going to a movie is to check where the exits are and then find a seat that gives me clear access to it. Leave your belongings behind – a purse, backpack, or computer can only slow you down. Spread out – 5 people running in a group is an easier and more inviting target for someone with a gun than 5 people running in different directions. Don’t freeze up – it is a natural reaction to stop to try to sort out what is going on; resist that temptation and sort things out while you are running. Keep your hands visible – when police arrive, you need to be sure that you are not mistaken for the shooter. Get out of the way – when police arrive, lie down with your hands out and palms up or move to the side so they have a clear view of the assailant behind you.

Hide. If you can’t run, this is your second best option. Get into a room and close the door. Turn off the lights. Turn your cell phone to vibrate. Don’t talk. Don’t huddle together with other people. Barricade the door – in a hospital room, move a patient bed to the door and lock the wheels on the bed.

Fight. Your choice of last resort. If you have to fight, there are no rules. Kick, bite, scratch and do anything to subdue the assailant. Throw things. Improvise weapons – a fire extinguisher, a chair, an IV pole.

In the hospital, we do fire drills, code blue drills, tornado drills, and now, we are doing active shooter drills. Run, Hide, Fight can save your life.

February 11, 2017

Medical Economics

The Starling Curve Of Physician Productivity

As physicians, we learn about the Starling curve in the first year of medical school. It expresses the relationship between left ventricular end-diastolic volume and cardiac output. The same can be applied to the relationship between physician RVU productivity and departmental/institutional health. The physiologic relationship dictates that as end-diastolic volume increases, cardiac output also increases, but only up to a point. At some level of high end-diastolic volume, the heart gets over distended and over stressed – resulting in a progressive fall in cardiac output. It is the so-called “going over the top of the Starling curve”. This is the mechanism of heart failure – you over-fill the left ventricle and the heart “bags-out” with a reduction in cardiac output.

Last week, our medical center had its annual review of the departments. Each department gets 1 hour to update the Dean of the College of Medicine, the CEO & CFO of the medical center, and various medical center leaders about their department. Big departments, such as internal medicine and surgery, get longer than an hour. During each session, the department chairman provides an update on physician productivity, faculty attrition, faculty gender percentages, annual procedures, inpatient & outpatient visit numbers, etc. It culminates with the department’s assessment of strengths, weakness, opportunities, and threats. Medical center leaders use this information for strategic planning for the next fiscal year budget and resource allocation planning. As the medical director of one of our hospitals, I attended the sessions which went all day for 3 consecutive days.

As the department chairs successively presented every department’s data, I was struck by another curve that has the exact same appearance of the Starling curve.

As background, our institution has a goal that physicians will produce at the 75th percentile of benchmark productivity. We use data from Vizient (formerly, the University Healthsystem Consortium, or UHC). The Vizient database collects information from nearly all academic medical centers on things like physician salaries and productivity (measured by work relative value units – aka, wRVUs). A physician who produces at the 50th percentile of wRVU productivity would be average among peer academic physicians in that particular specialty. A physician who generates annual wRVUs at the 25th percentile produces annual wRVUs at the level of the bottom 25% of other academic physicians in that specialty and a physician at the 75th percentile would be producing more annual RVUs than 75% of all academic physicians in that specialty. At the Ohio State University, we are held to a 75th percentile goal.

On the surface, that sounds awful, like we are flogging our doctors to produce more than doctors at other academic medical centers. But under the surface, this turns out to not be true. You see, the Vizient wRVU benchmark is based on what a 100% full-time clinician would produce. Few, if any, of our doctors are 100% clinical FTEs (Full Time Equivalents). Most of the medical faculty have some portion of their time reserved for academic pursuits – generally 10-20% of their time. This time is meant to be used for teaching medical students & residents, writing papers, preparing lectures, writing research grants, etc. The problem is that there is no money coming in from anywhere to cover that 10-20% uncompensated academic time. So, we have to fund that academic time out of our clinal income from taking care of patients.

Lets take an example of a physician who works 50 hours per week. This physician is 80% clinical time (40 hours a week) and 20% unfunded academic time (10 hours per week). If this physician produces wRVUs at the 75th percentile during the 40 hours per week that they are doing clinical care, it turns out that this is usually pretty close to a physician producing at the 50th percentile during a 50 hour clinical care week week. In other words, the productivity all pretty much balances out given that our physicians rarely are 100% clinical FTEs.

So, getting back to the annual departmental reviews, for most of the departments, about half of the physicians were producing at the 75th percentile. This seems appropriate – younger physicians need a ramp-up period before they get optimally efficient and productive, consultants and surgeons need a few years to build up a referral base, and inevitably even some seasoned physicians are going to be more productive than others. Ideally, you want the department to be producing at the 75th percentile, in order to allow for these variances in individual physician productivity.

But one of the departments had a striking graph. In 2015, 96% of the physicians in that department were exceeding the 75th percentile of wRVU productivity compared to other academic physicians in that specialty. In 2016, about a third of the physicians in that department resigned – mostly to go into private practice. I got to thinking that wRVU productivity is a lot like end-diastolic volume. And department/institution health is a lot like cardiac output. Increasing physician productivity is healthy for the department up to a point. But each department has a peak to its productivity curve, and if productivity gets too high, then the department is stressed, moral declines, and physicians leave.

It turns out that when it comes to physician productivity, more is not always better. If it reaches a point where academic physicians have to see more patients than physicians in private practice (but still get paid less than physicians in private practice), at some point, those physicians leave in order to work less and make more.

I don’t know exactly where the peak of the physician productivity Starling curve is. I suspect that it likely will vary from specialty to specialty depending on a number of variables. But my best estimate is that when a department’s average annual productivity exceeds the 85th to 90th percentile of wRVU productivity, bad things happen: physician burn-out, physician salary envy, lack of time to teach, etc.

Some physicians are going to always be extreme producers and aren’t happy unless they are in the 95th percentile of productivity. For those physicians, you get them a really nice office, publicly acknowledge them, and make sure that they get plenty of administrative/nursing support. Those are the physicians that give others in your institution the extra time that they need to teach and do research. But for most physicians, if you see their productivity getting that high, it is a sign that you need more physicians if you are going to retain them in the future.

February 8, 2017

Inpatient Practice Medical Economics

Is A Nurse Practitioner Cost-Effective?

One of the most common requests that I get this time of year is for a doctor or a service to ask for hospital support for a nurse practitioner or physician assistant. In each instance, you have to do an analysis to determine if adding an NP or PA for inpatient management is financially worth it. In Ohio, although PAs and NPs have different training, they have similar scopes of practice and are often used interchangeably. So in this post, when I refer to nurse practitioners, it can also mean physician assistants.

In most situations, you want to ensure that by using an NP, that you are at least breaking even with the cost of the NP by the revenue generated by the NP. In Ohio, NPs can write prescriptions and bill independently. In the hospital, there are two ways that NPs can provide care with regular daily visits. (1) They can do a “shared visit” so that they do part of the encounter and documentation and the physician does part of the encounter and also does part of the documentation – in this case, the reimbursement is 100% of the physician’s reimbursement. (2) They can do an independent visit in which case the physician does not need to see the patient or document anything – these are reimbursed at 85% of the physician’s reimbursement.

NPs can either be hired by the hospital or hired by the physician. The key difference is that if they are hired by the hospital, then they are a hospital employee and as such, none of their documentation can be used for the physician’s note in order to bill a daily hospital visit. Therefore, if a physician wants an NP to help with daily rounds and note writing, then the physician has to hire the NP. Otherwise, it is a Stark violation. This primarily applies to medical admission patients – since surgeons get paid by a global fee for a given surgery, they are not required to have the same degree of individual documentation for billing daily encounters and so documentation by a hospital-employed NP doesn’t affect the physician’s reimbursement for the surgery. For hospital-employed NPs, there are creative ways that the physician can lease a portion of the NP’s time from the hospital but the NP would still need to generate enough income to pay for the portion of time that the physician leases.

In our hospital, there is a bylaw that requires that a patient has to be seen by a physician daily. Therefore, having an NP on an admitting service limits them to doing shared visits – they cannot see patients independently without a physician also seeing that patient. However, on a consult service, the NP can see a patient without the physician also seeing the patients, since the admitting physician is also seeing/documenting a daily visit on that patient. Therefore, an NP on a consult service can either do shared visits or independent visits.

Lets take the situation when the NP is on a consult service and is seeing patients independently. The average NP salary is $100,000; add in 25% benefits and that comes to $125,000. NPs tend to usually work closer to a 40-hour work week so let’s say they see inpatients Monday through Friday and the physician covering the weekend sees all of the patients the NP was following during the weekdays. We will further assume that the NP works 46 weeks a year (4 weeks vacation and 2 weeks of holidays over the course of the year).

Therefore, the salary/benefits cost of the NP is $2,717 per worked week or $544 per worked day. In order to break even on the cost of that NP, the NP would need to generate $544 of revenue per day after expenses. In a private practice, there are relatively fewer overhead expenses but in an academic practice, there are a bunch of expenses, for example: Dean’s tax, departmental expenses, divisional expenses, malpractice, billing/administrative expenses, etc. All told these typically run about 21%. So, taking into account overhead, the NP would need to bring in $688 per worked day to fully break even.

In most practices, the physician will see the initial consult on a patient and the NP will see the return visits to that patient – a consult is usually a request for the learned opinion of an experienced specialist who has spent additional years of training to become an expert in an area of medicine and so the physician usually does the initial visit and lays out an impression and plan for that admission. So, we’ll assume that the NP is seeing only return visits and bills, on average, level 2 returns (CPT 99232) – Medicare pays $71 for this level of visits; adjusting this for the 85% reimbursement received by NPs for independent visits, this equates to $60 per encounter (a little less for Medicaid and a little more for commercial insurance). Therefore, based on Medicare reimbursement, the NP would need to see 11.5 inpatient return visits per day in order to pay for his/her salary. That would work out to about 40 minutes per return visit encounter which is very achievable (assuming that the consult service is large enough to support this volume of return visits).

Physicians have higher salaries than NPs and thus the cost per hour of a physician’s time is greater than the cost per hour of an NP’s time. Therefore, NPs can be cost effective when doing very time-intensive activities such as palliative medicine, smoking cessation counseling, diabetic education, etc. Also, you have to take into account what the physician will be doing if they don’t see the return consult visits. If the gastroenterologist will be able to do more colonoscopies or the cardiologist will be able to read more stress tests, then you can afford to lose money on an NP’s salary and still come out ahead because you are able to do a lot more of a more highly reimbursed activity than you otherwise would.

So, putting all of this together, what can we conclude:

  1. NPs need to see an average of 11.5 return visits per workday in order to break even financially.
  2. It can be cost-effective for an NP to see fewer than 11.5 return visits per day on procedure-oriented services such as surgery, cardiology, or gastroenterology since the NP frees up the physician to do more procedures that pay more per hour than return hospital visits.
  3. The practice’s payor mix affects the number of visits necessary to pay the NP’s salary – a practice with little Medicaid and a lot of commercial insurance may only need the NP to see 9-10 visits per day whereas a practice with a lot of Medicaid may need the NP to see 13-14 visits per day.
  4. It is financially more advantageous to have NPs do time-intensive activities (such as counseling, arranging follow-up testing, etc.) instead of having physicians do these.
  5. It is financially more advantageous to have NPs see uninsured/charity care patients since the cost of the NP’s time is less than the cost of the physician’s time.

If the NP is doing a shared visit (either with the admitting service physician or a consult physician), then the number of return visits needed to cover the NP’s salary is less – 9.7 per day. However, since the physician still needs to see each of these patients and do a component of the progress note documentation for each of these patients, that physician’s time now needs to be considered since all of the revenue from those 9.7 encounters will be going to cover the NP’s salary.

February 5, 2017

Medical Economics Medical Education

The Hidden Time Cost Of Being A Doctor

It takes a lot of time to become a doctor. And once you become a doctor it takes a lot of time to keep being a doctor. The amount of regulatory requirements per year are staggering. These add up to time costs and every doctor has to pay these time costs, regardless of the number of patients that you see. As you will see in this post, these costs add up quickly and result in those doctors who do a lot of teaching, research, or administration spending a disproportionate amount of their time meeting these requirements.

Protected time (for research, administration, or teaching) is highly sought and highly prized in academic medicine. It has to be – the only way to get promoted and get a salary increase is to do something other than clinical care of patients. There is the obvious cost of these activities: they don’t pay very well so if a physician is going to make anywhere close to a full-time clinician’s salary, then someone else has to contribute money. But there are hidden costs – those that no one ever talks about but that can eat away at your physicians’ productivity and suck the life out of an academic department.

They’re the fixed time costs that we all pay in order to do our regular jobs. Whether you are a 100% clinical FTE (i.e., a physician who only takes care of patients) or a 25% clinical FTE (i.e., someone who only spends 1 out of 4 working hours taking care of patients), you have to do these regular activities in order to maintain licensure and medical staff privileges. And they can add up… a lot. Let’s take a look at some of the more common of these:

  1. Continuing medical education. In Ohio, we have to do 50 hours per year of CME to maintain our medical license.
  2. ACLS (Advanced Cardiac Life Support). Required for many specialties; for others, ATLS (Advanced Trauma Life Support), or PALS (Pediatric Advanced Life Support) may be required. Preparation and classwork is about 10 hours every 2 years.
  3. CITI (Collaborative Institutional Training initiative). This is required for any physician who is involved in human subject research. Because this includes enrollment in trials and not just being a funded researcher, many/most academic physicians have to keep their CITI certificate up to date just to be able to assist clinical researchers by referring patients into clinical trials. It takes about 12 hours to do the program and it has to be renewed every 3 years.
  4. Department faculty meetings. At our University, these are mandatory and held quarterly – 4 hours per year.
  5. Division faculty meetings. In our division, these are mandatory and held monthly – 12 hours per year.
  6. Electronic medical record training. Initially, this takes about 10-20 hours. However, once you are facile with it, you just need to get trained on the periodic software updates – about 1 hour per year.
  7. Compliance training. At our hospital, we have a mandatory 2 hours per year for billing/coding compliance training to ensure that we are documenting our services and billing correctly.
  8. Hospital training. At Ohio State, these fall under “CBL” (Computer Based Learning) modules. These cover everything from what to do in a fire, to how to read a hazardous materials label, to the hospital’s sexual harassment policy. They vary from year to year but typically, it is about 10 hours per year.
  9. Hospital committees. I attend an enormous number of committee meetings but I get paid to attend them as a medical director. However, no one fully escapes committees and most physicians find themselves on a couple. I’ll estimate 15 hours a year.
  10. “Justify your existence forms”. These are part of the annual review that every academic physician has to fill out to document their annual clinical/research/publication/teaching/administrative productivity and describe how they have spent all of their time over the past year. Included in this category is the “promotion and tenure dossier” that all academic physicians have to complete periodically as they move toward promotion to associate professor to full professor. In our institution, if a physician is in the so-called clinical track, even full professors have to fill these out every 2-5 years in order to have their university contracts renewed. If you include the required face-to-face meeting with the division director or department chairman, the process requires about 6 hours per year.
  11. Emails. I get 50-100 a day – most physicians don’t get quite this many. Many of these are mass emails to all physicians. Some are worthy of reading (like weekly hospital news briefs) but a lot are garbage (like people who hit the “respond to all” button on every congratulatory email sent by a chairman to recognize a notable achievement by one of the faculty members). You have to at least open all of them and skim the first few sentences to see if you need to read the rest or if you can just click the delete button on your email program. Probably about 50 hours per year on average.
  12. Licensure forms. Medical license, DEA license, etc. Plan on 1 hour a year on average to fill these out.
  13. Surveys. We get surveyed constantly – from the College, from the hospital, from the department, from outside agencies. Most physicians don’t answer most of them because there are just too many. But some are inescapable – figure 2 hours per year.
  14. Board certification maintenance of certification. This includes required “MOC modules” that some boards require physicians to do every year and also includes the renewal board examination test (every 8-10 years depending on the specific board) as well as studying in order to pass the board exam. Although some of these activities can double for continuing medical education requirements, some can’t so figure an overall average is about 5 hours per year that can’t be included in CME.
  15. Employee health. This includes the time it takes to get your annual flu shot and the time it takes to do the annual infection control learning module, among other employee health & epidemiology requirements. Overall, 2 hours per year.

So, add all of this up and you get approximately 169 hours per year that every physician has to spend doing required activities just to be able to see a single patient or to see a thousand patients. Given that most physicians work about 56 hours per week, this equates to 3 weeks of time over the course of a year. Let’s assume a physician works 48 weeks a year (off 3 weeks for vacation and 1 week for the sum of all holidays for a year). A 100% clinical FTE would need to spend 3 weeks doing all of their required activities resulting in 45 weeks of patient care per year. A 25% clinical FTE (for example, someone who spends 75% of their time doing research or administration) would have 36 weeks per year doing research/administration leaving 12 weeks per year left over to do clinical activities. However, because that physician would need to spend 3 weeks of time on all of the above activities, they would only really be seeing patients for 9 weeks per year.

The reality is that most of us end up doing most of these activities during the evening or on weekends. But they still represent a huge fixed time cost to any academic physician. As a result, you can potentially get more clinical work from one 100% clinical FTE than you do from four 25% clinical FTEs.

February 1, 2017

Electronic Medical Records

Using 50 Words To Express A 6-Word Thought

My college freshman English professor told me: “You are not writing for yourself, you are writing for your reader. Always put the reader first.” It is a great message… and one that electronic medical records (EMRs) have made us totally forget. That professor would once a week have us critique an article by a particular reporter for the Cincinnati Enquirer – our job was to completely tear it apart from the perspective of the reader. If he could get a hold of a single progress note from our hospital’s electronic medical record, he would have a enough material for an entire semester.

In a previous post, I mentioned that there are fundamentally 3 reasons to have a progress note:

  1. To communicate with other healthcare providers
  2. To provide documentation for medial-legal purposes
  3. To provide documentation for billing purposes

Electronic medical records make it really easy for us to document for billing but as a communication tool to other healthcare providers, they often fall woefully short. Our hospital uses the electronic medical record program, Epic. It is an incredibly powerful program that allows us to import all kinds of information into a progress note: lab test results, vital signs, past medical history, vaccination records, etc. As a physician, you can go wild with documentation – you can generate a 10-page note full of data just for an office visit note for a patient who comes in to get ear wax removed.

I’m on both the sending and the receiving end of electronic medical record progress notes. From other hospitals, I’ll get printed copies of notes mailed to me – pages and pages of data for a single office visit with a doctor who is co-managing the patient with me. From our own hospital, I’ll get notes from a colleague in a different specialty routed to my electronic medical record “Inbasket” and I’ll need to scroll through mounds of regurgitated data just to find the physician’s impression and plan.

But here’s the thing. If I’m treating the a person’s COPD, I don’t really need to know nor care about what their chloride level was in 2011 or the results of their last 6 normal EKGs. If I need that information, I can go to the lab or EKG section of the electronic medical record and I don’t need that information clogging up a progress note sent to me by another specialist seeing the patient for an unrelated problem.

The electronic medical record is a great documentation tool but we make it a poor communication tool.

Fear has taught us that more is better. If we include everything in the patient’s chart in our progress note, then surely we’ll get all of the right elements to withstand a Medicare billing audit. And shouldn’t we include every lab test the patient has had in the past 3 years just in case the person reading the note wants to see them? As a referring physician, I don’t really care about reading a consultant’s 11-point review of systems and re-statement of the patient’s family history since I already know this information and it is just a click away on the EMR if I need it. When it comes to really communicating in an EMR, less is usually more.

Don’t make the reader have to work to read your note.

There is a reason that we speak in sentences and that books are written using sentences. It is the most efficient way that we process the communications that are given to us. Tables and lists can help support the sentences but it takes a lot of time and brain energy to analyze tables and lists and in an EMR, most of them are just unnecessary fluff for the reader. When I get a communication from another doctor, what I really want to know is what their impression of the patient’s disease is and what they plan on doing about it. Sometimes that impression and plan is at the beginning of a long note of otherwise tabular documentation garbage, sometimes it is at the end, and sometimes it is in the middle – causing us to scroll up and down the notes trying to find out the information that we really want to know. The reader shouldn’t look at reading the progress note as a chore. The absolute best communications I get are from one of our surgeons who sends me a 1-paragraph letter saying what he thinks the patient’s problem is and what he is going to do about it. He communicates more in 2 sentences than most routed EMR notes communicate in 6 pages.

An inpatient progress note is often a communication to the outpatient physician.

My return outpatient visits are scheduled every 15 minutes. That means that when I see a patient in the office after a hospitalization, I have 15 minutes to review the record, talk to the patient, do an examination, order tests and medications, and complete my office note. I don’t have 7 or 8 minutes to spare to hunt through the recent inpatient chart to figure out what was going on with the patient and what I need to specifically follow up on. So I go to the last pulmonary consult note in the inpatient chart to see what pulmonary problem the patient was in with and what I need to be focusing on. If the patient needs a follow-up chest x-ray, or pulmonary function tests, or a decision about when to stop a pulmonary medication, I’m expecting that note to have that information. In this sense, the inpatient progress notes are not just a communication to the other physicians and practitioners seeing the patient in the hospital, they are also a communication with the outpatient physicians to insure a smooth transition from inpatient to outpatient care. Often, I’m both the pulmonary consultant in the hospital and the outpatient pulmonologist for a given patient and in this situation, my inpatient notes are notes to me and the nurse practitioner that I work with.

Don’t use a $25 word in a 25¢ sentence.

William F. Buckley was the conservative host of the TV show Firing Line and was famous for using 5 syllable words that he would pull from deep in the bowels of the English dictionary. He sounded extremely learned and intelligent but the average person couldn’t understand half of what he said. He used his extensive vocabulary like a weapon in political debates. That is great for entertainment but terrible for trying to communicate critical medical information to a wide audience of healthcare providers who will be reading your note. So don’t describe a person as macrosmatic, valetudinarian, or pauciloquent in an EMR note just because it showed up this morning on your “word of the day” app – no one else knows what it means any more than you did yesterday.

January 27, 2017

Electronic Medical Records

The PATH Audit That Almost Was

There are fundamentally 3 reasons to have a progress note:

  1. To communicate with other healthcare providers
  2. To provide documentation for medial-legal purposes
  3. To provide documentation for billing purposes

In the 1980’s, communication with other healthcare providers reigned king. We marked up medical student H&Ps with red ink if they didn’t have perfect grammar and we carefully dictated referral letters and then edited them before sending them out. Nobody cared about billing documentation back then – it just wasn’t important. All of that changed on June 21, 1996, when the Office of the Inspector General announced the PATH audits – “Physicians At Teaching Hospitals”. Although designed to be a way to protect Medicare against billing fraud, the PATH audits turned into the medical billing equivalent of the Spanish Inquisition. Federal Inspectors would do probing chart reviews of physicians at academic medical centers and if they found charts that didn’t have the right documentation elements, they would swoop in and do a massive audit of all of the physicians, often resulting in fines of 10’s of millions of dollars.

It was easy for these investigators – Medicare had established billing rules and required that the each progress note contain sufficient elements to justify different levels of billing. So, for example, a given level of billing for a new patient visit had to have at least 3 symptoms, a past medical/social/family history, 9 different systems documented in a review of systems and at least 11 different body parts examined. If the inspectors (who were not physicians) did not find all of those elements, the physician had to pay back the money from that particular bill and was also susceptible to an additional fine for each progress note that didn’t pass muster.

Although there were examples of clear fraud, for example, a surgeon who billed surgical procedures in Minnesota but had credit card receipt documentation that he was in London, England at the time, most of the cases labeled as “fraud” were really just good doctors trying to take care of patients but not documenting every part of their physical exam or forgetting to list all of the patient’s previous surgeries in their H&Ps. There was also a dark side of the PATH audits because they could also be vindictively.

You see, if a person called the Inspector General’s whistleblower hotline and it resulted in an audit of a physician (or better yet, a large academic medical center group practice), then the whistleblower got to keep up to half of all of the fines that the government collected. You could become a multimillionaire simply by calling in the dogs of the Inspector General.

In the late 1990’s, I was the subject of such a vindictive investigation. We had recently cut the salary of some of the physicians in our group because of low productivity and I was in charge of the clinical/financial management of the group. That year, 3 of our physicians left and one particular physician left the University, harboring a lot of anger and resentment, mainly directed to me since I was perceived as the one who cut his salary. So, he called the Inspector General’s whistleblower hotline alleging that I had fraudulently billed millions of dollars to Medicare. Because of the enormous dollar amount alleged, the OIG descended on our hospital’s medical records department and pulled every single progress note, procedure note, and H&P I had written or co-signed over a 3-month period.

It took them months to comb through thousands of my notes and with each note, they had a scorecard that they would check whether or not I had enough review of systems documented and enough body part examinations documented. It must have cost the OIG a small fortune to send investigators to review all of these notes. We hired an attorney to represent me through this process because of the fear that if I didn’t have the right documentation, it could open the door to a dreaded PATH audit that could essentially wipe-out the physician faculty ranks at Ohio State University. After the completion of the audit, here is what they found:

  1. I had over-billed by one level about 5 times (I had to pay back the difference – total was less than $100)
  2. I had under-billed by one or two levels about 25 times (total was about $2,000 but they don’t give you any money back in this situation)
  3. I had a few notes that I had written when billing ventilator management charges (used by pulmonologists rather than the more documentation-intensive return visit charges). Unfortunately, in addition to my notes, my medical students also had notes in the chart that referred to the ventilator settings and ventilator weaning. Because Medicare classifies ventilator management as a procedure and because any procedure done by a medical student, even with full supervision by the attending physicians, cannot be billed to Medicare, they asked for all of the money back for these notes – total about $200. Although I had done all of the actual ventilator analysis and written all of the orders, since the students also documented the ventilator settings, they said that the “procedure” of ventilator management involved medical students so I couldn’t bill it.
  4. I had come into the hospital one night to see a patient with acute respiratory failure in the ICU – I intubated her, put a central line in her, and did a bronchoscopy. In addition to the procedures, I also billed a critical care charge – for this charge, you have to document that you spent at least 31 minutes providing critical care services independent of any procedures. I had my documentation right there – 11:40 PM to 12:25 AM and I had each procedure note timed with a different time either before or after the critical care times. However, the auditors stated that since the time crossed midnight, 20 minutes of the time had to be accounted to one calendar day and 25 minutes to the next calendar day and since neither of the days’ time was >31 minutes, I couldn’t bill any critical care charges and in fact, was not allowed to bill anything. I had to give back $175.

Before this, I had been a documentation freak so my notes were actually very well-documented and so the amount I had to pay back to Medicare was truly trivial. The OIG spent many times that much in salary, hotels, food, and airfare for the inspectors that they sent to Columbus. My ex-partner got nothing as a “whistle-blower” and our University did not get a resultant PATH audit.

Our electronic medical records now make it simple to ensure that each note has the required number of body parts examined and the correct minimum number of systems documented to be reviewed in the review of systems. The PATH audits have gone away because there just isn’t any money in it for the OIG anymore. However, the legacy of the PATH audits is the topic of my next post – the cluttering of physician progress notes with excess documentation by doctors who do electronic medical record documentation overkill to avoid even a chance of not having enough documentation to support a Medicare bill in the event of an audit.

January 23, 2016

Operating Room

Robots In The Hospital – Its Not Like Robots In The Factory

There are a lot of signs that the “great recession” that began in 2008 is over. The unemployment rate is the lowest that it has been in 12 years. Manufacturing output is back to pre-recession 2008 levels and close to a record high. However, manufacturing jobs are not; in fact, America has lost 5 million manufacturing jobs since 2000. The reason isn’t that they’ve been stolen from low wage countries, the reason is robotics.

Over the past 25 years, advances in production robotics has resulted in many of the factory jobs once done by assembly line human workers now being done by robots. They are faster, they are more accurate, they don’t have expensive fringe benefits, they don’t go on strike, and they don’t call in sick. In other words, automation of U.S. factories has reduced production costs and eliminated an enormous number of manufacturing jobs. And those jobs are not coming back. In our factories, robots replace people.

The robots are gaining a foothold in our operating rooms, too. But in the OR, they are not replacing people. The most commonly used surgical robot is the da Vinci system. It runs about $2.5 million per robotic unit. Until last month, our hospital was the only hospital in town without a da Vinci robot but we recently purchased one in order to grow our hernia repair program and our gynecologic surgery program. You see, we compete with our neighboring hospitals to attract surgeons and younger surgeons want access to the robots that they used when they were training as residents and fellows. If you don’t have a robot, the top young surgical recruits are going to go across town to your competitor hospital. Moreover, many patients have a perception that surgeries done with a robot are better than those done solely by hand. Having a surgical robot is no longer a competitive advantage for a hospital, it is a competitive necessity.

You need just as many people in the operating room when you are doing a robotic surgery as you do without a robot. You see, unlike in the factory, where manufacturing robots replace people, in the operating rooms, surgical robots augment people. The surgical robot is not used for “automated surgery” but instead is controlled by the surgeon who sits in a console and controls the arms of the robot. Instead of the surgeons hand holding a scalpel, the robot’s arm holds the scalpel and the surgeon’s hand controls the robot’s arm. With cameras on the end of the robotic arms, this allows the surgeon to get into tight places and use smaller incisions than he/she could with  a regular open procedure. This translates to less post-operative pain and more rapid recovery. It doesn’t necessarily make the surgery faster or less expensive – it just makes the surgery better.

Automation, robotics, and computerization has had huge impact on U.S. manufacturing jobs. But that is just the beginning. The prototypic self-driving cars of today will give way to the self-driving trucks of tomorrow and in 15 years, we as a country will be lamenting the loss of transportation and trucking jobs just as today we lament the loss of manufacturing jobs.

But at least for the foreseeable future, the intrusion of robots into the operating room is not going to translate to a loss of OR jobs. So, if you are a teenager and your career goal was a  union job at the General Motors plant, you need a new goal. And if you think you can go to truck driving school and have a job to last a lifetime, think again. But for the next 15 years, a robot is not going to take your operating room job away.

January 20, 2017