Mary Ellen Schneider

Medicare officials are expanding the list of quality measures that hospitals will be judged on as part of a new pay-for-performance program created under the Affordable Care Act.

In a final rule released Nov. 1, detailing Medicare payment rates for hospital outpatient departments, officials at the Centers for Medicare and Medicaid Services announced that they are adding a new clinical process of care measure related to urinary catheters to the Hospital Inpatient Value-Based Purchasing (VBP) Program. The new measure, which will go into effect in October 2013 for fiscal year 2014, will assess whether a urinary catheter inserted during surgery is removed on the first or second postsurgical day. Hospitals will begin reporting data to the CMS on the new measure in 2012.

The new measure will be added to 12 clinical process measures and 1 patient experience measure that were adopted for the first year of the program. The CMS also finalized plans to include three outcome measures related to 30-day mortality for acute myocardial infarction, heart failure, and pneumonia in the program for fiscal year 2014.

At the same time, the CMS is delaying plans to include other measures. The agency had planned to include eight measures on hospital-acquired conditions, two composite measures from the Agency for Healthcare Research and Quality, and a Medicare Spending per Beneficiary measure in the Hospital VBP program in fiscal year 2014. But after receiving public comments noting that performance data had not been publicly available long enough for hospitals to prepare to incorporate the measures, Medicare officials relented.

According to the final rule, the CMS will post hospital performance data on the measures to Medicare’s Hospital Compare website for at least 1 year before requiring hospitals to report data on them.

Under the Hospital VBP program, the CMS will begin making incentive payments to hospitals based on quality on Oct. 1, 2012. The payments are funded by reducing Medicare payments to hospitals by 1% during fiscal year 2013 and 1.25% in fiscal year 2014.

Hospital payments under the program will be based on performance on clinical process-of-care measures, patient satisfaction, and clinical outcomes. In fiscal year 2014, process-of-care measures will be weighted at 45% of the score, patient satisfaction at 30%, and outcomes at 25%. During the first year of the program, process-of-care measures will weighted at 70% and patient satisfaction measures at 30%.

Medicare officials are also moving ahead with plans to require ambulatory surgical centers (ASCs) to report on quality measures next year.

In the final rule, the CMS adopted four clinical outcome measures and one surgical infection control measure that ASCs must report on beginning in October 2012. The final list includes measures related to patient burns; patient falls; wrong site, wrong side, wrong patient, wrong procedure, wrong implant surgery; rate of ASC admissions requiring a hospital transfer/admission upon discharge, and prophylactic intravenous antibiotic timing. The data reported will be used to determine payments for 2014, according to the final rule.

In 2013, ASCs will also have to report on their use of the safe surgery checklist and report data on their facility volume on selected procedures. That information will be used in setting payments for 2015. Additionally, hospitals will be required to report on influenza vaccination coverage among health care workers starting in 2014, which will affect their 2016 payments.

The more than 1,500-page final rule also outlines the 2012 payments to hospitals and ASCs for outpatient services. The CMS estimates that in 2012, it will spend about $41.1 billion to pay the more than 4,000 general acute care hospitals, inpatient rehabilitation facilities, inpatient psychiatric facilities, long-term acute care hospitals, children’s hospitals, and cancer hospitals under Medicare’s Outpatient Prospective Payment System. And the agency will pay another $3.5 billion to about 5,000 ASCs next year.

The final rule increased payments to hospital outpatient departments by 1.9% in 2012. Under the rule, payments to cancer hospitals will go up by 11.3% due to adjustments required under the Affordable Care Act. ACSs will also see their payments increase by 1.6% in 2012.

Medicare officials are expanding the list of quality measures that hospitals will be judged on as part of a new pay-for-performance program created under the Affordable Care Act.

In a final rule released Nov. 1, detailing Medicare payment rates for hospital outpatient departments, officials at the Centers for Medicare and Medicaid Services announced that they are adding a new clinical process of care measure related to urinary catheters to the Hospital Inpatient Value-Based Purchasing (VBP) Program. The new measure, which will go into effect in October 2013 for fiscal year 2014, will assess whether a urinary catheter inserted during surgery is removed on the first or second postsurgical day. Hospitals will begin reporting data to the CMS on the new measure in 2012.

The new measure will be added to 12 clinical process measures and 1 patient experience measure that were adopted for the first year of the program. The CMS also finalized plans to include three outcome measures related to 30-day mortality for acute myocardial infarction, heart failure, and pneumonia in the program for fiscal year 2014.

At the same time, the CMS is delaying plans to include other measures. The agency had planned to include eight measures on hospital-acquired conditions, two composite measures from the Agency for Healthcare Research and Quality, and a Medicare Spending per Beneficiary measure in the Hospital VBP program in fiscal year 2014. But after receiving public comments noting that performance data had not been publicly available long enough for hospitals to prepare to incorporate the measures, Medicare officials relented.

According to the final rule, the CMS will post hospital performance data on the measures to Medicare’s Hospital Compare website for at least 1 year before requiring hospitals to report data on them.

Under the Hospital VBP program, the CMS will begin making incentive payments to hospitals based on quality on Oct. 1, 2012. The payments are funded by reducing Medicare payments to hospitals by 1% during fiscal year 2013 and 1.25% in fiscal year 2014.

Hospital payments under the program will be based on performance on clinical process-of-care measures, patient satisfaction, and clinical outcomes. In fiscal year 2014, process-of-care measures will be weighted at 45% of the score, patient satisfaction at 30%, and outcomes at 25%. During the first year of the program, process-of-care measures will weighted at 70% and patient satisfaction measures at 30%.

Medicare officials are also moving ahead with plans to require ambulatory surgical centers (ASCs) to report on quality measures next year.

In the final rule, the CMS adopted four clinical outcome measures and one surgical infection control measure that ASCs must report on beginning in October 2012. The final list includes measures related to patient burns; patient falls; wrong site, wrong side, wrong patient, wrong procedure, wrong implant surgery; rate of ASC admissions requiring a hospital transfer/admission upon discharge, and prophylactic intravenous antibiotic timing. The data reported will be used to determine payments for 2014, according to the final rule.

In 2013, ASCs will also have to report on their use of the safe surgery checklist and report data on their facility volume on selected procedures. That information will be used in setting payments for 2015. Additionally, hospitals will be required to report on influenza vaccination coverage among health care workers starting in 2014, which will affect their 2016 payments.

The more than 1,500-page final rule also outlines the 2012 payments to hospitals and ASCs for outpatient services. The CMS estimates that in 2012, it will spend about $41.1 billion to pay the more than 4,000 general acute care hospitals, inpatient rehabilitation facilities, inpatient psychiatric facilities, long-term acute care hospitals, children’s hospitals, and cancer hospitals under Medicare’s Outpatient Prospective Payment System. And the agency will pay another $3.5 billion to about 5,000 ASCs next year.

The final rule increased payments to hospital outpatient departments by 1.9% in 2012. Under the rule, payments to cancer hospitals will go up by 11.3% due to adjustments required under the Affordable Care Act. ACSs will also see their payments increase by 1.6% in 2012.

Medicare officials are expanding the list of quality measures that hospitals will be judged on as part of a new pay-for-performance program created under the Affordable Care Act.

In a final rule released Nov. 1, detailing Medicare payment rates for hospital outpatient departments, officials at the Centers for Medicare and Medicaid Services announced that they are adding a new clinical process of care measure related to urinary catheters to the Hospital Inpatient Value-Based Purchasing (VBP) Program. The new measure, which will go into effect in October 2013 for fiscal year 2014, will assess whether a urinary catheter inserted during surgery is removed on the first or second postsurgical day. Hospitals will begin reporting data to the CMS on the new measure in 2012.

The new measure will be added to 12 clinical process measures and 1 patient experience measure that were adopted for the first year of the program. The CMS also finalized plans to include three outcome measures related to 30-day mortality for acute myocardial infarction, heart failure, and pneumonia in the program for fiscal year 2014.

At the same time, the CMS is delaying plans to include other measures. The agency had planned to include eight measures on hospital-acquired conditions, two composite measures from the Agency for Healthcare Research and Quality, and a Medicare Spending per Beneficiary measure in the Hospital VBP program in fiscal year 2014. But after receiving public comments noting that performance data had not been publicly available long enough for hospitals to prepare to incorporate the measures, Medicare officials relented.

According to the final rule, the CMS will post hospital performance data on the measures to Medicare’s Hospital Compare website for at least 1 year before requiring hospitals to report data on them.

Under the Hospital VBP program, the CMS will begin making incentive payments to hospitals based on quality on Oct. 1, 2012. The payments are funded by reducing Medicare payments to hospitals by 1% during fiscal year 2013 and 1.25% in fiscal year 2014.

Hospital payments under the program will be based on performance on clinical process-of-care measures, patient satisfaction, and clinical outcomes. In fiscal year 2014, process-of-care measures will be weighted at 45% of the score, patient satisfaction at 30%, and outcomes at 25%. During the first year of the program, process-of-care measures will weighted at 70% and patient satisfaction measures at 30%.

Medicare officials are also moving ahead with plans to require ambulatory surgical centers (ASCs) to report on quality measures next year.

In the final rule, the CMS adopted four clinical outcome measures and one surgical infection control measure that ASCs must report on beginning in October 2012. The final list includes measures related to patient burns; patient falls; wrong site, wrong side, wrong patient, wrong procedure, wrong implant surgery; rate of ASC admissions requiring a hospital transfer/admission upon discharge, and prophylactic intravenous antibiotic timing. The data reported will be used to determine payments for 2014, according to the final rule.

In 2013, ASCs will also have to report on their use of the safe surgery checklist and report data on their facility volume on selected procedures. That information will be used in setting payments for 2015. Additionally, hospitals will be required to report on influenza vaccination coverage among health care workers starting in 2014, which will affect their 2016 payments.

The more than 1,500-page final rule also outlines the 2012 payments to hospitals and ASCs for outpatient services. The CMS estimates that in 2012, it will spend about $41.1 billion to pay the more than 4,000 general acute care hospitals, inpatient rehabilitation facilities, inpatient psychiatric facilities, long-term acute care hospitals, children’s hospitals, and cancer hospitals under Medicare’s Outpatient Prospective Payment System. And the agency will pay another $3.5 billion to about 5,000 ASCs next year.

The final rule increased payments to hospital outpatient departments by 1.9% in 2012. Under the rule, payments to cancer hospitals will go up by 11.3% due to adjustments required under the Affordable Care Act. ACSs will also see their payments increase by 1.6% in 2012.

Legislation introduced in the U.S. House of Representatives would require that women be informed of their breast density when they receive their mammogram results, and that those with denser breasts be advised that they could benefit from additional screening.

The Breast Density and Mammography Reporting Act of 2011 (H.R. 3102), introduced in October by Rep. Rosa DeLauro (D-Conn.) and Rep. Steve Israel (D-N.Y.), is modeled after laws enacted in Connecticut in 2009 and in Texas earlier this year. Similar legislation was recently passed by the California legislature, but was vetoed by the governor.

Bills on breast density are also slated to be introduced in at least six other states next year, according to the consumer advocacy group Are You Dense.

The movement to pass these bills has grown largely from the outrage of women who have received years of normal mammogram results only to find out that they have an advanced-stage breast cancer that went undetected because of their dense breast tissue.

That was the experience of Are You Dense founder Nancy M. Cappello, Ph.D., who successfully lobbied lawmakers to enact the Connecticut legislation.

Although information on breast density is available on the mammography report sent to referring physicians, it’s not mentioned in the "lay letter" received by women, Dr. Cappello said. That leaves most women in the dark about the fact that dense breasts can make mammograms more difficult to read, and that women with extremely dense breasts are at a higher risk for breast cancer, she said.

"It’s a hoax in some respects, a cruel hoax," she said.

Are You Dense and its supporters around the country have been working state by state to enact laws that require that women be notified of their breast density and their options for additional screening. They are also working at the federal level to change either the law or the regulations surrounding mammography.

Dr. Cappello said that trying to legislate the change wasn’t her first choice, but without a national cancer organization or physician group stepping up to educate women, she doesn’t have a better option for standardizing the communication on breast density.

On Nov. 4, Dr. Cappello will take her case to the Food and Drug Administration’s National Mammography Quality Assurance Advisory Committee. She plans to ask the committee, which provided nonbinding advice to the FDA, to recommend changing the federally mandated lay letter to include information on breast density.

So far, Dr. Cappello’s efforts have failed to gain support from major physician groups and patient advocacy organizations. Susan G. Komen for the Cure and the American Cancer Society both stayed on the sidelines during the recent legislative debate in California. The California chapter of the American College of Obstetricians and Gynecologists and the California Medical Association opposed the bill.

"It was a very difficult bill for us to oppose," said Dr. Philip Diamond, a San Diego ob.gyn. and chair of ACOG District IX in California.

The problem was that the bill went beyond notifying women about their density and on to suggest that they speak with their physician about supplemental screening. The bill’s language on supplemental screening goes beyond the existing evidence, Dr. Diamond said, and raised a host of concerns about what the cost of screening would mean for state-funded health programs.

"In the absence of a guideline nationally by either the cancer society or the radiology society or anyone, it’s impossible to be able to figure out who needs supplement screening and who doesn’t," he said.

A big concern in California, Dr. Diamond said, is that such legislation would lead to the automatic ordering of supplemental ultrasounds and MRIs, regardless of the individual risk factors of the women involved.

That’s exactly what has happened after the Connecticut law was enacted, according to New Haven ob.gyn. Howard Shaw, vice chair for the Connecticut section of ACOG.

Although the law has probably raised some awareness of the breast density issues for women, it has also sparked a reflexive ordering of supplemental testing for any women with dense breasts, he said, adding that the ordering is largely driven by liability concerns.

"There is a feeling by many that we’re just going to order it because if we don’t order it and something happens, we’re going to have a problem," said Dr. Steven Fleischman, associate chief of ob.gyn. at Yale–New Haven Hospital and the legislative chair of ACOG District I.

Another problem with the Connecticut law is that there’s a lack of data on how it’s working, he said. Because there was no tracking component built into the law, there are many lingering questions about the number of supplemental tests, the additional costs, and whether more cancers are being detected earlier, he said.

"It’s not just about cost; it’s about ‘Are we getting more cases, and are we getting them earlier,’ " Dr. Fleischman said.

Legislation introduced in the U.S. House of Representatives would require that women be informed of their breast density when they receive their mammogram results, and that those with denser breasts be advised that they could benefit from additional screening.

The Breast Density and Mammography Reporting Act of 2011 (H.R. 3102), introduced in October by Rep. Rosa DeLauro (D-Conn.) and Rep. Steve Israel (D-N.Y.), is modeled after laws enacted in Connecticut in 2009 and in Texas earlier this year. Similar legislation was recently passed by the California legislature, but was vetoed by the governor.

Bills on breast density are also slated to be introduced in at least six other states next year, according to the consumer advocacy group Are You Dense.

The movement to pass these bills has grown largely from the outrage of women who have received years of normal mammogram results only to find out that they have an advanced-stage breast cancer that went undetected because of their dense breast tissue.

That was the experience of Are You Dense founder Nancy M. Cappello, Ph.D., who successfully lobbied lawmakers to enact the Connecticut legislation.

Although information on breast density is available on the mammography report sent to referring physicians, it’s not mentioned in the "lay letter" received by women, Dr. Cappello said. That leaves most women in the dark about the fact that dense breasts can make mammograms more difficult to read, and that women with extremely dense breasts are at a higher risk for breast cancer, she said.

"It’s a hoax in some respects, a cruel hoax," she said.

Are You Dense and its supporters around the country have been working state by state to enact laws that require that women be notified of their breast density and their options for additional screening. They are also working at the federal level to change either the law or the regulations surrounding mammography.

Dr. Cappello said that trying to legislate the change wasn’t her first choice, but without a national cancer organization or physician group stepping up to educate women, she doesn’t have a better option for standardizing the communication on breast density.

On Nov. 4, Dr. Cappello will take her case to the Food and Drug Administration’s National Mammography Quality Assurance Advisory Committee. She plans to ask the committee, which provided nonbinding advice to the FDA, to recommend changing the federally mandated lay letter to include information on breast density.

So far, Dr. Cappello’s efforts have failed to gain support from major physician groups and patient advocacy organizations. Susan G. Komen for the Cure and the American Cancer Society both stayed on the sidelines during the recent legislative debate in California. The California chapter of the American College of Obstetricians and Gynecologists and the California Medical Association opposed the bill.

"It was a very difficult bill for us to oppose," said Dr. Philip Diamond, a San Diego ob.gyn. and chair of ACOG District IX in California.

The problem was that the bill went beyond notifying women about their density and on to suggest that they speak with their physician about supplemental screening. The bill’s language on supplemental screening goes beyond the existing evidence, Dr. Diamond said, and raised a host of concerns about what the cost of screening would mean for state-funded health programs.

"In the absence of a guideline nationally by either the cancer society or the radiology society or anyone, it’s impossible to be able to figure out who needs supplement screening and who doesn’t," he said.

A big concern in California, Dr. Diamond said, is that such legislation would lead to the automatic ordering of supplemental ultrasounds and MRIs, regardless of the individual risk factors of the women involved.

That’s exactly what has happened after the Connecticut law was enacted, according to New Haven ob.gyn. Howard Shaw, vice chair for the Connecticut section of ACOG.

Although the law has probably raised some awareness of the breast density issues for women, it has also sparked a reflexive ordering of supplemental testing for any women with dense breasts, he said, adding that the ordering is largely driven by liability concerns.

"There is a feeling by many that we’re just going to order it because if we don’t order it and something happens, we’re going to have a problem," said Dr. Steven Fleischman, associate chief of ob.gyn. at Yale–New Haven Hospital and the legislative chair of ACOG District I.

Another problem with the Connecticut law is that there’s a lack of data on how it’s working, he said. Because there was no tracking component built into the law, there are many lingering questions about the number of supplemental tests, the additional costs, and whether more cancers are being detected earlier, he said.

"It’s not just about cost; it’s about ‘Are we getting more cases, and are we getting them earlier,’ " Dr. Fleischman said.

Legislation introduced in the U.S. House of Representatives would require that women be informed of their breast density when they receive their mammogram results, and that those with denser breasts be advised that they could benefit from additional screening.

The Breast Density and Mammography Reporting Act of 2011 (H.R. 3102), introduced in October by Rep. Rosa DeLauro (D-Conn.) and Rep. Steve Israel (D-N.Y.), is modeled after laws enacted in Connecticut in 2009 and in Texas earlier this year. Similar legislation was recently passed by the California legislature, but was vetoed by the governor.

Bills on breast density are also slated to be introduced in at least six other states next year, according to the consumer advocacy group Are You Dense.

The movement to pass these bills has grown largely from the outrage of women who have received years of normal mammogram results only to find out that they have an advanced-stage breast cancer that went undetected because of their dense breast tissue.

That was the experience of Are You Dense founder Nancy M. Cappello, Ph.D., who successfully lobbied lawmakers to enact the Connecticut legislation.

Although information on breast density is available on the mammography report sent to referring physicians, it’s not mentioned in the "lay letter" received by women, Dr. Cappello said. That leaves most women in the dark about the fact that dense breasts can make mammograms more difficult to read, and that women with extremely dense breasts are at a higher risk for breast cancer, she said.

"It’s a hoax in some respects, a cruel hoax," she said.

Are You Dense and its supporters around the country have been working state by state to enact laws that require that women be notified of their breast density and their options for additional screening. They are also working at the federal level to change either the law or the regulations surrounding mammography.

Dr. Cappello said that trying to legislate the change wasn’t her first choice, but without a national cancer organization or physician group stepping up to educate women, she doesn’t have a better option for standardizing the communication on breast density.

On Nov. 4, Dr. Cappello will take her case to the Food and Drug Administration’s National Mammography Quality Assurance Advisory Committee. She plans to ask the committee, which provided nonbinding advice to the FDA, to recommend changing the federally mandated lay letter to include information on breast density.

So far, Dr. Cappello’s efforts have failed to gain support from major physician groups and patient advocacy organizations. Susan G. Komen for the Cure and the American Cancer Society both stayed on the sidelines during the recent legislative debate in California. The California chapter of the American College of Obstetricians and Gynecologists and the California Medical Association opposed the bill.

"It was a very difficult bill for us to oppose," said Dr. Philip Diamond, a San Diego ob.gyn. and chair of ACOG District IX in California.

The problem was that the bill went beyond notifying women about their density and on to suggest that they speak with their physician about supplemental screening. The bill’s language on supplemental screening goes beyond the existing evidence, Dr. Diamond said, and raised a host of concerns about what the cost of screening would mean for state-funded health programs.

"In the absence of a guideline nationally by either the cancer society or the radiology society or anyone, it’s impossible to be able to figure out who needs supplement screening and who doesn’t," he said.

A big concern in California, Dr. Diamond said, is that such legislation would lead to the automatic ordering of supplemental ultrasounds and MRIs, regardless of the individual risk factors of the women involved.

That’s exactly what has happened after the Connecticut law was enacted, according to New Haven ob.gyn. Howard Shaw, vice chair for the Connecticut section of ACOG.

Although the law has probably raised some awareness of the breast density issues for women, it has also sparked a reflexive ordering of supplemental testing for any women with dense breasts, he said, adding that the ordering is largely driven by liability concerns.

"There is a feeling by many that we’re just going to order it because if we don’t order it and something happens, we’re going to have a problem," said Dr. Steven Fleischman, associate chief of ob.gyn. at Yale–New Haven Hospital and the legislative chair of ACOG District I.

Another problem with the Connecticut law is that there’s a lack of data on how it’s working, he said. Because there was no tracking component built into the law, there are many lingering questions about the number of supplemental tests, the additional costs, and whether more cancers are being detected earlier, he said.

"It’s not just about cost; it’s about ‘Are we getting more cases, and are we getting them earlier,’ " Dr. Fleischman said.

Dr. Kendall M. Rogers, the division chief of hospital medicine at the University of New Mexico Health Sciences Center, helped dramatically improve glycemic control for patients at the Albuquerque hospital. In just 2 years, the glycemic control quality improvement project that Dr. Rogers launched helped to lower the hospital’s rate of hyperglycemia from 55% to 36%. And in the 2009 RALS (Remote Automated Laboratory System) report, the hospital was rated in the top 10 out of 575 hospitals for glycemic control. Since then, Dr. Rogers has been sharing what he learned as the Society of Hospital Medicine’s lead mentor in the Glycemic Control Mentored Implementation program.

In an interview with Hospitalist News, Dr. Rogers offered advice on how to succeed in a quality improvement initiative and how aspiring hospitalists can prepare for future leadership roles.

Hospitalist News: You launched a successful hospital-wide glycemic control initiative. What lessons did you learn about how to get a new program like this off the ground?

DR. ROGERS: Any quality improvement project is a continuous process. My initial thoughts were that our glycemic control project was something that was going to be accomplished in a finite amount of time. But I think anyone who gets involved with a large-scale quality improvement (QI) project like this very soon realizes that they it is an ongoing process.

I’ve also learned that quality isn’t just about coming up with good ideas, leadership skills are also necessary to be successful. It’s about managing people, managing attitudes, and having an understanding of change management. And the importance of data cannot be understated. Data are the foundation of any successful quality improvement project. Data are used to motivate, and without data, you have no idea where you’re starting from and if you’re having an impact.

HN: How do you sustain interest in the effort over time?

DR. ROGERS: I think it’s important to set achievable goals within a realistic time frame. To keep interest in a project you just continue to raise those targets. When we first started the glycemic control project, we set our goals with sample-level data. Then we raised the bar by using the same goals, but with day-weighted means. Then we went to stay-weighted means. Each of these changes raised the bar and maintained the sense of urgency necessary to keep team members and hospital staff motivated.

While you want to celebrate your successes, you do not want people to think that the problem is solved.

HN: Multidisciplinary teams are considered essential to QI efforts. How can the hospitalist ensure that all members of the team are equally valued and doing what they need to do?

DR. ROGERS: My recommendation for any QI project is to always have a physician and a nonphysician co-lead the project. Having co-leads really gives you a foot in each camp that you need to influence right off the bat. I also think it’s important that anyone who’s going to be affected by the changes that you’re making has a place at the table. It’s never us deciding first what changes we’re going to make and then trying to convince others; everyone needs to be involved in developing the solutions so you have buy-in from the beginning.

HN: You teach a 1-month elective for internal medicine residents on health policy and leadership. Why is this important?

DR. ROGERS: I think all physicians have leadership roles whether they realize it or not. They are leading teams. They are trying to motivate patients. They are leaders even if they’re not in physician management. This training can’t be started too early.

I think all physicians need to have an understanding of change management, teamwork, communication skills, and negotiation. With my elective, I teach 3 weeks of a fixed curriculum starting with health policy, health law, and quality. Quality is something that no physician can ignore. Then I spend a week on informatics, which is another tool that I think all physicians need to have a role in understanding and designing for it to reach its full potential.

I think it is never too early to start teaching these skills, from premed curriculums to medical school. But residency is really the first place where young physicians get to apply those skills, so it’s paramount to teach them there.

Take us to your leader. Nominate a hospitalist whose work inspires you. E-mail suggestions to m.schneider@elsevier.com and read previous columns at ehospitalistnews.com.

Dr. Kendall M. Rogers, the division chief of hospital medicine at the University of New Mexico Health Sciences Center, helped dramatically improve glycemic control for patients at the Albuquerque hospital. In just 2 years, the glycemic control quality improvement project that Dr. Rogers launched helped to lower the hospital’s rate of hyperglycemia from 55% to 36%. And in the 2009 RALS (Remote Automated Laboratory System) report, the hospital was rated in the top 10 out of 575 hospitals for glycemic control. Since then, Dr. Rogers has been sharing what he learned as the Society of Hospital Medicine’s lead mentor in the Glycemic Control Mentored Implementation program.

In an interview with Hospitalist News, Dr. Rogers offered advice on how to succeed in a quality improvement initiative and how aspiring hospitalists can prepare for future leadership roles.

Hospitalist News: You launched a successful hospital-wide glycemic control initiative. What lessons did you learn about how to get a new program like this off the ground?

DR. ROGERS: Any quality improvement project is a continuous process. My initial thoughts were that our glycemic control project was something that was going to be accomplished in a finite amount of time. But I think anyone who gets involved with a large-scale quality improvement (QI) project like this very soon realizes that they it is an ongoing process.

I’ve also learned that quality isn’t just about coming up with good ideas, leadership skills are also necessary to be successful. It’s about managing people, managing attitudes, and having an understanding of change management. And the importance of data cannot be understated. Data are the foundation of any successful quality improvement project. Data are used to motivate, and without data, you have no idea where you’re starting from and if you’re having an impact.

HN: How do you sustain interest in the effort over time?

DR. ROGERS: I think it’s important to set achievable goals within a realistic time frame. To keep interest in a project you just continue to raise those targets. When we first started the glycemic control project, we set our goals with sample-level data. Then we raised the bar by using the same goals, but with day-weighted means. Then we went to stay-weighted means. Each of these changes raised the bar and maintained the sense of urgency necessary to keep team members and hospital staff motivated.

While you want to celebrate your successes, you do not want people to think that the problem is solved.

HN: Multidisciplinary teams are considered essential to QI efforts. How can the hospitalist ensure that all members of the team are equally valued and doing what they need to do?

DR. ROGERS: My recommendation for any QI project is to always have a physician and a nonphysician co-lead the project. Having co-leads really gives you a foot in each camp that you need to influence right off the bat. I also think it’s important that anyone who’s going to be affected by the changes that you’re making has a place at the table. It’s never us deciding first what changes we’re going to make and then trying to convince others; everyone needs to be involved in developing the solutions so you have buy-in from the beginning.

HN: You teach a 1-month elective for internal medicine residents on health policy and leadership. Why is this important?

DR. ROGERS: I think all physicians have leadership roles whether they realize it or not. They are leading teams. They are trying to motivate patients. They are leaders even if they’re not in physician management. This training can’t be started too early.

I think all physicians need to have an understanding of change management, teamwork, communication skills, and negotiation. With my elective, I teach 3 weeks of a fixed curriculum starting with health policy, health law, and quality. Quality is something that no physician can ignore. Then I spend a week on informatics, which is another tool that I think all physicians need to have a role in understanding and designing for it to reach its full potential.

I think it is never too early to start teaching these skills, from premed curriculums to medical school. But residency is really the first place where young physicians get to apply those skills, so it’s paramount to teach them there.

Take us to your leader. Nominate a hospitalist whose work inspires you. E-mail suggestions to m.schneider@elsevier.com and read previous columns at ehospitalistnews.com.

Dr. Kendall M. Rogers, the division chief of hospital medicine at the University of New Mexico Health Sciences Center, helped dramatically improve glycemic control for patients at the Albuquerque hospital. In just 2 years, the glycemic control quality improvement project that Dr. Rogers launched helped to lower the hospital’s rate of hyperglycemia from 55% to 36%. And in the 2009 RALS (Remote Automated Laboratory System) report, the hospital was rated in the top 10 out of 575 hospitals for glycemic control. Since then, Dr. Rogers has been sharing what he learned as the Society of Hospital Medicine’s lead mentor in the Glycemic Control Mentored Implementation program.

In an interview with Hospitalist News, Dr. Rogers offered advice on how to succeed in a quality improvement initiative and how aspiring hospitalists can prepare for future leadership roles.

Hospitalist News: You launched a successful hospital-wide glycemic control initiative. What lessons did you learn about how to get a new program like this off the ground?

DR. ROGERS: Any quality improvement project is a continuous process. My initial thoughts were that our glycemic control project was something that was going to be accomplished in a finite amount of time. But I think anyone who gets involved with a large-scale quality improvement (QI) project like this very soon realizes that they it is an ongoing process.

I’ve also learned that quality isn’t just about coming up with good ideas, leadership skills are also necessary to be successful. It’s about managing people, managing attitudes, and having an understanding of change management. And the importance of data cannot be understated. Data are the foundation of any successful quality improvement project. Data are used to motivate, and without data, you have no idea where you’re starting from and if you’re having an impact.

HN: How do you sustain interest in the effort over time?

DR. ROGERS: I think it’s important to set achievable goals within a realistic time frame. To keep interest in a project you just continue to raise those targets. When we first started the glycemic control project, we set our goals with sample-level data. Then we raised the bar by using the same goals, but with day-weighted means. Then we went to stay-weighted means. Each of these changes raised the bar and maintained the sense of urgency necessary to keep team members and hospital staff motivated.

While you want to celebrate your successes, you do not want people to think that the problem is solved.

HN: Multidisciplinary teams are considered essential to QI efforts. How can the hospitalist ensure that all members of the team are equally valued and doing what they need to do?

DR. ROGERS: My recommendation for any QI project is to always have a physician and a nonphysician co-lead the project. Having co-leads really gives you a foot in each camp that you need to influence right off the bat. I also think it’s important that anyone who’s going to be affected by the changes that you’re making has a place at the table. It’s never us deciding first what changes we’re going to make and then trying to convince others; everyone needs to be involved in developing the solutions so you have buy-in from the beginning.

HN: You teach a 1-month elective for internal medicine residents on health policy and leadership. Why is this important?

DR. ROGERS: I think all physicians have leadership roles whether they realize it or not. They are leading teams. They are trying to motivate patients. They are leaders even if they’re not in physician management. This training can’t be started too early.

I think all physicians need to have an understanding of change management, teamwork, communication skills, and negotiation. With my elective, I teach 3 weeks of a fixed curriculum starting with health policy, health law, and quality. Quality is something that no physician can ignore. Then I spend a week on informatics, which is another tool that I think all physicians need to have a role in understanding and designing for it to reach its full potential.

I think it is never too early to start teaching these skills, from premed curriculums to medical school. But residency is really the first place where young physicians get to apply those skills, so it’s paramount to teach them there.

Take us to your leader. Nominate a hospitalist whose work inspires you. E-mail suggestions to m.schneider@elsevier.com and read previous columns at ehospitalistnews.com.

Nearly 50 million people in the United States lacked health insurance in 2010, up almost a million from the year before, according to statistics released by the Census Bureau.

While the number of people without insurance rose to 49.9 million in 2010 from 49.0 million the year before, there was no statistically significant change in the uninsurance rate, which was 16.3% in 2010.

A similar trend was seen among children: 9.8% of children (7.3 million) were uninsured in 2010, a rate not significantly different from the rate of 9.7% in 2009.

Other age groups did experience significant changes. Among those aged 65 years and older, the uninsurance rate in 2010 increased to 2.0%, up from 1.7% in 2009. During a press briefing, Census Bureau officials said they could not offer an explanation for the increase in this age group, which traditionally has very low uninsurance rates because of Medicare coverage. The uninsurance rate also rose among people aged 35-64 years.

However, more young adults aged 18-24 years became insured in 2010. The uninsurance rate for that group dropped to 27.2% in 2010 from 29.3% the year before. A provision of the Affordable Care Act that allows parents to keep children on their health insurance policy up to age 26 could be a factor in the increase in coverage in this age group, Brett O'Hara, Ph.D., chief of the Health and Disability Statistics Branch at the Census Bureau, said during a press briefing.

The report also showed that once again, private insurance coverage in the United States is declining while public coverage is increasing. Employment-based insurance dropped to 55.3% in 2010 from 56.1% in 2009. The number of people who received their health insurance through their employer fell from 170.8 million to 169.3 million.

At the same time, the number of people covered by government-sponsored health insurance increased by nearly 2 million, bringing the total number to 95 million in 2010.

Nearly 50 million people in the United States lacked health insurance in 2010, up almost a million from the year before, according to statistics released by the Census Bureau.

While the number of people without insurance rose to 49.9 million in 2010 from 49.0 million the year before, there was no statistically significant change in the uninsurance rate, which was 16.3% in 2010.

A similar trend was seen among children: 9.8% of children (7.3 million) were uninsured in 2010, a rate not significantly different from the rate of 9.7% in 2009.

Other age groups did experience significant changes. Among those aged 65 years and older, the uninsurance rate in 2010 increased to 2.0%, up from 1.7% in 2009. During a press briefing, Census Bureau officials said they could not offer an explanation for the increase in this age group, which traditionally has very low uninsurance rates because of Medicare coverage. The uninsurance rate also rose among people aged 35-64 years.

However, more young adults aged 18-24 years became insured in 2010. The uninsurance rate for that group dropped to 27.2% in 2010 from 29.3% the year before. A provision of the Affordable Care Act that allows parents to keep children on their health insurance policy up to age 26 could be a factor in the increase in coverage in this age group, Brett O'Hara, Ph.D., chief of the Health and Disability Statistics Branch at the Census Bureau, said during a press briefing.

The report also showed that once again, private insurance coverage in the United States is declining while public coverage is increasing. Employment-based insurance dropped to 55.3% in 2010 from 56.1% in 2009. The number of people who received their health insurance through their employer fell from 170.8 million to 169.3 million.

At the same time, the number of people covered by government-sponsored health insurance increased by nearly 2 million, bringing the total number to 95 million in 2010.

Nearly 50 million people in the United States lacked health insurance in 2010, up almost a million from the year before, according to statistics released by the Census Bureau.

While the number of people without insurance rose to 49.9 million in 2010 from 49.0 million the year before, there was no statistically significant change in the uninsurance rate, which was 16.3% in 2010.

A similar trend was seen among children: 9.8% of children (7.3 million) were uninsured in 2010, a rate not significantly different from the rate of 9.7% in 2009.

Other age groups did experience significant changes. Among those aged 65 years and older, the uninsurance rate in 2010 increased to 2.0%, up from 1.7% in 2009. During a press briefing, Census Bureau officials said they could not offer an explanation for the increase in this age group, which traditionally has very low uninsurance rates because of Medicare coverage. The uninsurance rate also rose among people aged 35-64 years.

However, more young adults aged 18-24 years became insured in 2010. The uninsurance rate for that group dropped to 27.2% in 2010 from 29.3% the year before. A provision of the Affordable Care Act that allows parents to keep children on their health insurance policy up to age 26 could be a factor in the increase in coverage in this age group, Brett O'Hara, Ph.D., chief of the Health and Disability Statistics Branch at the Census Bureau, said during a press briefing.

The report also showed that once again, private insurance coverage in the United States is declining while public coverage is increasing. Employment-based insurance dropped to 55.3% in 2010 from 56.1% in 2009. The number of people who received their health insurance through their employer fell from 170.8 million to 169.3 million.

At the same time, the number of people covered by government-sponsored health insurance increased by nearly 2 million, bringing the total number to 95 million in 2010.

College Offers Advertising Advice

It is ethical for physicians to advertise their services, but they must be careful not to mislead the public or imply a lack of competence by their competition, according to an updated policy statement from the American College of Obstetricians and Gynecologists. It advises physicians to use caution when putting together advertisements because the public can easily be mislead. For example, potential patients might assume that any obstetrician advertising under the heading “infertility” has special training or certification in that area. Physicians should also be able to substantiate their claims if they use words like “top” or “pioneer.” If a physician is voted a “top doctor” by magazine readers, that fact can be advertised. But if that designation was paid for, that must be disclosed in the ad as well, according to the ACOG policy. Also, doctors should shy away from advertising specific outcomes since treatment success often depends on patient factors. The policy, developed by the ACOG Committee of Ethics, was scheduled to be published in the November issue of Obstetrics and Gynecology.

Public Citizen Attacks Liability Caps

The medical liability reform law enacted in Texas in 2003 has failed to bring down medical costs or attract physicians to the state, according to an analysis by Public Citizen. The consumer-watchdog group said the law, which includes a $250,000 cap on noneconomic damages, benefited malpractice insurance companies and physicians, who saw premiums and payouts decrease, but not the public. The report notes that Medicare spending per beneficiary in Texas has risen 13% faster than the national average and that diagnostic-testing expenses rose 25% more than the national average. Meanwhile, the increase in physicians per capita has slowed to less than half its rate in the years before the law was enacted. But Texas Medical Association President Dr. C. Bruce Malone said in an interview that the state has not boosted its physician population much because it's difficult to attract doctors to a poor state with a large population of uninsured people. Dr. Malone also said that liability reform has improved patients' access to care, especially in obstetrics. There are now many rural areas that have ob.gyns. for the first time, and more obstetricians are willing to take on high-risk pregnancies, he said.

Defending Planned Parenthood

House Democrats are standing up for Planned Parenthood, saying that the organization is being unfairly targeted for political reasons. In September, the Republican-controlled House Energy and Commerce subcommittee on oversight and investigations launched an inquiry into how the Planned Parenthood Federation and its affiliates handle federal funds. In a letter to the subcommittee's chairman, Rep. Cliff Stearns (R.-Fla.), top Democrats on the full committee criticized the investigation as an “unfair and unjustified assault.” Rep. Henry Waxman (D.-Calif.) and Rep. Diana DeGette (D.-Colo.) wrote that the investigation was unnecessary because the Health and Human Services Inspector General and state Medicaid programs routinely audit Planned Parenthood and report their findings to the public.

Millions Get Free Mammograms

More than 4 million women have received free mammograms this year as a benefit from the Affordable Care Act. The 2010 health-reform law allows Medicare beneficiaries to receive preventive services, including mammograms and cervical cancer screening, without paying a deductible or other cost. The benefit also includes a free annual wellness visit. The Department of Health and Human Services estimated that more than 20 million Medicare beneficiaries have received some type of preventive service this year, from cholesterol screening to bone-mass measurement.

Baby-Friendly Hospitals Sought

Officials at the Centers for Disease Control and Prevention are spending $6 million over 3 years to help hospitals do a better job of supporting breastfeeding by new mothers. The goal is to get more U.S. hospitals to become “baby-friendly” facilities along the lines of a World Health Organization–UNICEF program that recognizes hospitals that follow science-based practices that increase breastfeeding rates. Currently, only about 5% of babies in the United States are born in “baby-friendly” hospitals, according to the CDC. The agency awarded its $6 million to the National Initiative for Children's Healthcare Quality, which will work with hospitals to bring in experts in breastfeeding and quality improvement to develop system-level changes.

Panel: Patients' Needs Overlooked

Even though most doctors realize that improving patient engagement can reduce costs and improve care, physicians still frequently overlook patients' needs and concerns, according to a report from the Institute of Medicine. For example, studies show that quality improves when providers listen carefully to patients and their families, according to the report based on an April workshop. However, other research has shown that physicians typically interrupt within 15 seconds of a patient beginning to raise concerns.

College Offers Advertising Advice

It is ethical for physicians to advertise their services, but they must be careful not to mislead the public or imply a lack of competence by their competition, according to an updated policy statement from the American College of Obstetricians and Gynecologists. It advises physicians to use caution when putting together advertisements because the public can easily be mislead. For example, potential patients might assume that any obstetrician advertising under the heading “infertility” has special training or certification in that area. Physicians should also be able to substantiate their claims if they use words like “top” or “pioneer.” If a physician is voted a “top doctor” by magazine readers, that fact can be advertised. But if that designation was paid for, that must be disclosed in the ad as well, according to the ACOG policy. Also, doctors should shy away from advertising specific outcomes since treatment success often depends on patient factors. The policy, developed by the ACOG Committee of Ethics, was scheduled to be published in the November issue of Obstetrics and Gynecology.

Public Citizen Attacks Liability Caps

The medical liability reform law enacted in Texas in 2003 has failed to bring down medical costs or attract physicians to the state, according to an analysis by Public Citizen. The consumer-watchdog group said the law, which includes a $250,000 cap on noneconomic damages, benefited malpractice insurance companies and physicians, who saw premiums and payouts decrease, but not the public. The report notes that Medicare spending per beneficiary in Texas has risen 13% faster than the national average and that diagnostic-testing expenses rose 25% more than the national average. Meanwhile, the increase in physicians per capita has slowed to less than half its rate in the years before the law was enacted. But Texas Medical Association President Dr. C. Bruce Malone said in an interview that the state has not boosted its physician population much because it's difficult to attract doctors to a poor state with a large population of uninsured people. Dr. Malone also said that liability reform has improved patients' access to care, especially in obstetrics. There are now many rural areas that have ob.gyns. for the first time, and more obstetricians are willing to take on high-risk pregnancies, he said.

Defending Planned Parenthood

House Democrats are standing up for Planned Parenthood, saying that the organization is being unfairly targeted for political reasons. In September, the Republican-controlled House Energy and Commerce subcommittee on oversight and investigations launched an inquiry into how the Planned Parenthood Federation and its affiliates handle federal funds. In a letter to the subcommittee's chairman, Rep. Cliff Stearns (R.-Fla.), top Democrats on the full committee criticized the investigation as an “unfair and unjustified assault.” Rep. Henry Waxman (D.-Calif.) and Rep. Diana DeGette (D.-Colo.) wrote that the investigation was unnecessary because the Health and Human Services Inspector General and state Medicaid programs routinely audit Planned Parenthood and report their findings to the public.

Millions Get Free Mammograms

More than 4 million women have received free mammograms this year as a benefit from the Affordable Care Act. The 2010 health-reform law allows Medicare beneficiaries to receive preventive services, including mammograms and cervical cancer screening, without paying a deductible or other cost. The benefit also includes a free annual wellness visit. The Department of Health and Human Services estimated that more than 20 million Medicare beneficiaries have received some type of preventive service this year, from cholesterol screening to bone-mass measurement.

Baby-Friendly Hospitals Sought

Officials at the Centers for Disease Control and Prevention are spending $6 million over 3 years to help hospitals do a better job of supporting breastfeeding by new mothers. The goal is to get more U.S. hospitals to become “baby-friendly” facilities along the lines of a World Health Organization–UNICEF program that recognizes hospitals that follow science-based practices that increase breastfeeding rates. Currently, only about 5% of babies in the United States are born in “baby-friendly” hospitals, according to the CDC. The agency awarded its $6 million to the National Initiative for Children's Healthcare Quality, which will work with hospitals to bring in experts in breastfeeding and quality improvement to develop system-level changes.

Panel: Patients' Needs Overlooked

Even though most doctors realize that improving patient engagement can reduce costs and improve care, physicians still frequently overlook patients' needs and concerns, according to a report from the Institute of Medicine. For example, studies show that quality improves when providers listen carefully to patients and their families, according to the report based on an April workshop. However, other research has shown that physicians typically interrupt within 15 seconds of a patient beginning to raise concerns.

College Offers Advertising Advice

It is ethical for physicians to advertise their services, but they must be careful not to mislead the public or imply a lack of competence by their competition, according to an updated policy statement from the American College of Obstetricians and Gynecologists. It advises physicians to use caution when putting together advertisements because the public can easily be mislead. For example, potential patients might assume that any obstetrician advertising under the heading “infertility” has special training or certification in that area. Physicians should also be able to substantiate their claims if they use words like “top” or “pioneer.” If a physician is voted a “top doctor” by magazine readers, that fact can be advertised. But if that designation was paid for, that must be disclosed in the ad as well, according to the ACOG policy. Also, doctors should shy away from advertising specific outcomes since treatment success often depends on patient factors. The policy, developed by the ACOG Committee of Ethics, was scheduled to be published in the November issue of Obstetrics and Gynecology.

Public Citizen Attacks Liability Caps

The medical liability reform law enacted in Texas in 2003 has failed to bring down medical costs or attract physicians to the state, according to an analysis by Public Citizen. The consumer-watchdog group said the law, which includes a $250,000 cap on noneconomic damages, benefited malpractice insurance companies and physicians, who saw premiums and payouts decrease, but not the public. The report notes that Medicare spending per beneficiary in Texas has risen 13% faster than the national average and that diagnostic-testing expenses rose 25% more than the national average. Meanwhile, the increase in physicians per capita has slowed to less than half its rate in the years before the law was enacted. But Texas Medical Association President Dr. C. Bruce Malone said in an interview that the state has not boosted its physician population much because it's difficult to attract doctors to a poor state with a large population of uninsured people. Dr. Malone also said that liability reform has improved patients' access to care, especially in obstetrics. There are now many rural areas that have ob.gyns. for the first time, and more obstetricians are willing to take on high-risk pregnancies, he said.

Defending Planned Parenthood

House Democrats are standing up for Planned Parenthood, saying that the organization is being unfairly targeted for political reasons. In September, the Republican-controlled House Energy and Commerce subcommittee on oversight and investigations launched an inquiry into how the Planned Parenthood Federation and its affiliates handle federal funds. In a letter to the subcommittee's chairman, Rep. Cliff Stearns (R.-Fla.), top Democrats on the full committee criticized the investigation as an “unfair and unjustified assault.” Rep. Henry Waxman (D.-Calif.) and Rep. Diana DeGette (D.-Colo.) wrote that the investigation was unnecessary because the Health and Human Services Inspector General and state Medicaid programs routinely audit Planned Parenthood and report their findings to the public.

Millions Get Free Mammograms

More than 4 million women have received free mammograms this year as a benefit from the Affordable Care Act. The 2010 health-reform law allows Medicare beneficiaries to receive preventive services, including mammograms and cervical cancer screening, without paying a deductible or other cost. The benefit also includes a free annual wellness visit. The Department of Health and Human Services estimated that more than 20 million Medicare beneficiaries have received some type of preventive service this year, from cholesterol screening to bone-mass measurement.

Baby-Friendly Hospitals Sought

Officials at the Centers for Disease Control and Prevention are spending $6 million over 3 years to help hospitals do a better job of supporting breastfeeding by new mothers. The goal is to get more U.S. hospitals to become “baby-friendly” facilities along the lines of a World Health Organization–UNICEF program that recognizes hospitals that follow science-based practices that increase breastfeeding rates. Currently, only about 5% of babies in the United States are born in “baby-friendly” hospitals, according to the CDC. The agency awarded its $6 million to the National Initiative for Children's Healthcare Quality, which will work with hospitals to bring in experts in breastfeeding and quality improvement to develop system-level changes.

Panel: Patients' Needs Overlooked

Even though most doctors realize that improving patient engagement can reduce costs and improve care, physicians still frequently overlook patients' needs and concerns, according to a report from the Institute of Medicine. For example, studies show that quality improves when providers listen carefully to patients and their families, according to the report based on an April workshop. However, other research has shown that physicians typically interrupt within 15 seconds of a patient beginning to raise concerns.

If you’re considering adding nonphysician providers to your hospital medicine group, it’s important to know your state laws. Different states have different rules for what nurse practitioners and physician assistants are allowed to do. But here’s an overview of the traditional scope of practice of nurse practitioners and physician assistants and how they are trained.

Nurse Practitioners

Nurse practitioners are advanced practice nurses with additional education beyond their registered nurse training. Typically, NPs earn a bachelor’s degree in nursing as well as a 2- or 4-year graduate degree. Increasingly, NP programs are offering doctoral-level degrees with the title of doctor of nursing practice (DNP).

NPs are trained to provide nursing and medical services that include taking histories, conducting physical exams, writing orders, conducting and interpreting diagnostic tests, prescribing medications, and providing counseling. NPs can practice independently or in collaboration with physicians depending on the applicable state laws and regulations.

Sources: The American Academy of Nurse Practitioners and the American College of Nurse Practitioners.

Learn more:

What is a Nurse Practitioner?

Nurse Practitioner Scope of Practice

Physician Assistants

Most physician assistants have completed a bachelor’s degree and have some health care experience before beginning a 24- to 32-month PA training program. PAs must also pass a national certification exam administered by the National Commission on Certification of Physician Assistants. And they need to complete 100 hours of continuing medical education every 2 years and a recertification exam every 6 years in order to maintain their certification.

PA education includes courses in basic sciences, pharmacology, behavioral sciences, clinical medicine, as well as clinical rotations. To practice, PAs must be authorized by the state and work under the supervision of a licensed physician. PAs are trained to take histories and conduct physical exams, order and interpret tests, assist in surgery, prescribe medications, and provide counseling on preventive care.

Source: American Academy of Physician Assistants.

Learn more:

Quick Facts About Physician Assistants

If you’re considering adding nonphysician providers to your hospital medicine group, it’s important to know your state laws. Different states have different rules for what nurse practitioners and physician assistants are allowed to do. But here’s an overview of the traditional scope of practice of nurse practitioners and physician assistants and how they are trained.

Nurse Practitioners

Nurse practitioners are advanced practice nurses with additional education beyond their registered nurse training. Typically, NPs earn a bachelor’s degree in nursing as well as a 2- or 4-year graduate degree. Increasingly, NP programs are offering doctoral-level degrees with the title of doctor of nursing practice (DNP).

NPs are trained to provide nursing and medical services that include taking histories, conducting physical exams, writing orders, conducting and interpreting diagnostic tests, prescribing medications, and providing counseling. NPs can practice independently or in collaboration with physicians depending on the applicable state laws and regulations.

Sources: The American Academy of Nurse Practitioners and the American College of Nurse Practitioners.

Learn more:

What is a Nurse Practitioner?

Nurse Practitioner Scope of Practice

Physician Assistants

Most physician assistants have completed a bachelor’s degree and have some health care experience before beginning a 24- to 32-month PA training program. PAs must also pass a national certification exam administered by the National Commission on Certification of Physician Assistants. And they need to complete 100 hours of continuing medical education every 2 years and a recertification exam every 6 years in order to maintain their certification.

PA education includes courses in basic sciences, pharmacology, behavioral sciences, clinical medicine, as well as clinical rotations. To practice, PAs must be authorized by the state and work under the supervision of a licensed physician. PAs are trained to take histories and conduct physical exams, order and interpret tests, assist in surgery, prescribe medications, and provide counseling on preventive care.

Source: American Academy of Physician Assistants.

Learn more:

Quick Facts About Physician Assistants

If you’re considering adding nonphysician providers to your hospital medicine group, it’s important to know your state laws. Different states have different rules for what nurse practitioners and physician assistants are allowed to do. But here’s an overview of the traditional scope of practice of nurse practitioners and physician assistants and how they are trained.

Nurse Practitioners

Nurse practitioners are advanced practice nurses with additional education beyond their registered nurse training. Typically, NPs earn a bachelor’s degree in nursing as well as a 2- or 4-year graduate degree. Increasingly, NP programs are offering doctoral-level degrees with the title of doctor of nursing practice (DNP).

NPs are trained to provide nursing and medical services that include taking histories, conducting physical exams, writing orders, conducting and interpreting diagnostic tests, prescribing medications, and providing counseling. NPs can practice independently or in collaboration with physicians depending on the applicable state laws and regulations.

Sources: The American Academy of Nurse Practitioners and the American College of Nurse Practitioners.

Learn more:

What is a Nurse Practitioner?

Nurse Practitioner Scope of Practice

Physician Assistants

Most physician assistants have completed a bachelor’s degree and have some health care experience before beginning a 24- to 32-month PA training program. PAs must also pass a national certification exam administered by the National Commission on Certification of Physician Assistants. And they need to complete 100 hours of continuing medical education every 2 years and a recertification exam every 6 years in order to maintain their certification.

PA education includes courses in basic sciences, pharmacology, behavioral sciences, clinical medicine, as well as clinical rotations. To practice, PAs must be authorized by the state and work under the supervision of a licensed physician. PAs are trained to take histories and conduct physical exams, order and interpret tests, assist in surgery, prescribe medications, and provide counseling on preventive care.

Source: American Academy of Physician Assistants.

Learn more:

Quick Facts About Physician Assistants

Some hospitals, feeling hamstrung by an unwieldy web of federal and state scope-of-practice rules, layer on their own in-house policies to govern just what their nonphysician providers can do. But those days could soon be over as a recent proposal by the Department of Health and Human Services aims to make it easier for hospitals expand their use of physician assistants and nurse practitioners.

On Oct. 24, the agency declared that it wants to "further modernize hospitals’ medical staffing policies" and give them "the clarity they need to explore new and expanded approaches to care giving."

The proposed regulation<http://www.gpo.gov/fdsys/pkg/FR-2011-10-24/pdf/2011-27175.pdf> seeks to make clear that hospitals can grant privileges to NPPs to work within the scope of practice allowed under state law, regardless of whether they have been appointed to the hospital’s medical staff. The proposed rule is also designed to help hospitals to address workforce shortages, particularly in medically underserved communities.

"Having an M.D. or D.O. after your name doesn’t magically make you a good business person or a good leader."

Existing rules are a hurdle that "may be unduly limiting access to care and/or delaying treatment for patients and causing undue burden to practitioners (for example, the need to seek out physicians to co-sign orders)," the agency noted.

The regulations are part of a broader initiative created by President Obama to cut red tape and roll back overly burdensome or outdated federal rules.

"More and more people are realizing the value of NPPs," said Dr. David Friar, the CEO of Hospitalists of Northern Michigan, who has integrated NPPs into three of the company’s five hospital medicine programs. He sees the growing use of NPPs in hospital medicine groups as just one part of the natural evolution of the field of hospital medicine.

Though many hospitals are already doing this, red-tape notwithstanding, supporters of NPPs praised the symbolic impact of the government’s proposal.

Tricia Marriott, PA-C, said the take home message from the HHS proposal is that hospitals should apply their state laws, but that creating more restrictive in-house policies for how NPPs operate is unnecessary.

Ms. Marriott said Some hospitals have very restrictive policies about what physician assistants (PAs) can do, allowing them to act only as scribes at the bedside. That means PAs can’t do rounds or independently assess patients, which could limit patient access to care, she said.

One reason that NPPs are being embraced in some hospitals but not others is that physicians and hospital officials just don’t understand what PAs and nurse practitioners can do, Ms. Marriott said.

<[stk -2]>"If people haven’t trained with PAs in their hospital, they don’t know the possibilities," she said. <[etk]>

Ryan Genzink, PA-C, a physician assistant in Grand Rapids, Mich., and the medical liaison between the American Academy of Physician Assistants and the Society of Hospital Medicine, agrees, saying, "The biggest issue is familiarity."

Right now there are many physicians who simply don’t know how NPPs can be integrated into a hospital medicine group. And others may think it wouldn’t work in their system, he said.Mr. Genzink said h He’s optimistic that more people will come around to the idea as they see case studies, success stories, and research on the different NPP models.

For those programs that are willing to give it a try, Mr. Genzink advised getting buy-in from the physicians involved ahead of time. And he stressed the importance of having a physician champion. "When you have a physician who is a champion of the cause and who understands that their success is dependent on the PA’s success, that’s when you have programs that really work well," he said.

"More and more people are realizing the value of NPPs."

<[stk -2]>At the hospital medicine program at Northwestern University, Chicago, which has had NPPs for about 5 years, the challenge was finding a way to integrate a handful of PAs and NPs into a group with 50-60 hospitalists, all of whom had slightly different practice styles. The answer was to find a niche for each of the NPPs, such assigning a PA to work only on the oncology service. That has allowed the NPPs to get to know the practice styles of a smaller group of physicians and for trust to build among the group, said Dr. Nita Kulkarni, assistant professor of medicine and medical director of the PA training program at Northwestern. <[etk]>

The reaction from physicians to working with NPPs has been mixed, Dr. Kulkarni said. For instance, for some attending physicians who are fresh out of their residency training, working with a PA or NP can be a little unsettling because they are still figuring out their own role.

"They sometimes find it difficult to know how to delegate work," she said. "Oftentimes they don’t really know what PAs learn, what PA school is like, how many years is it, and what their learning model is. It takes some education and just experience with working with the NPPs."

Dr. Friar, who was an instructor at a recent "boot camp" for NPPs sponsored by Society of Hospital Medicine, said the NPPs they have worked with have been an asset not just from the clinical side. Their group also has NPPs who sit on hospital boards. They are oftentimes a better fit for this work than the physicians because they possess excellent leadership skills.

"Having an M.D. or D.O. after your name doesn’t magically make you a good business person or a good leader," Dr. Friar said. "That’s something that a lot of providers in a lot of hospitals forget."

Some hospitals, feeling hamstrung by an unwieldy web of federal and state scope-of-practice rules, layer on their own in-house policies to govern just what their nonphysician providers can do. But those days could soon be over as a recent proposal by the Department of Health and Human Services aims to make it easier for hospitals expand their use of physician assistants and nurse practitioners.

On Oct. 24, the agency declared that it wants to "further modernize hospitals’ medical staffing policies" and give them "the clarity they need to explore new and expanded approaches to care giving."

The proposed regulation<http://www.gpo.gov/fdsys/pkg/FR-2011-10-24/pdf/2011-27175.pdf> seeks to make clear that hospitals can grant privileges to NPPs to work within the scope of practice allowed under state law, regardless of whether they have been appointed to the hospital’s medical staff. The proposed rule is also designed to help hospitals to address workforce shortages, particularly in medically underserved communities.

"Having an M.D. or D.O. after your name doesn’t magically make you a good business person or a good leader."

Existing rules are a hurdle that "may be unduly limiting access to care and/or delaying treatment for patients and causing undue burden to practitioners (for example, the need to seek out physicians to co-sign orders)," the agency noted.

The regulations are part of a broader initiative created by President Obama to cut red tape and roll back overly burdensome or outdated federal rules.

"More and more people are realizing the value of NPPs," said Dr. David Friar, the CEO of Hospitalists of Northern Michigan, who has integrated NPPs into three of the company’s five hospital medicine programs. He sees the growing use of NPPs in hospital medicine groups as just one part of the natural evolution of the field of hospital medicine.

Though many hospitals are already doing this, red-tape notwithstanding, supporters of NPPs praised the symbolic impact of the government’s proposal.

Tricia Marriott, PA-C, said the take home message from the HHS proposal is that hospitals should apply their state laws, but that creating more restrictive in-house policies for how NPPs operate is unnecessary.

Ms. Marriott said Some hospitals have very restrictive policies about what physician assistants (PAs) can do, allowing them to act only as scribes at the bedside. That means PAs can’t do rounds or independently assess patients, which could limit patient access to care, she said.

One reason that NPPs are being embraced in some hospitals but not others is that physicians and hospital officials just don’t understand what PAs and nurse practitioners can do, Ms. Marriott said.

<[stk -2]>"If people haven’t trained with PAs in their hospital, they don’t know the possibilities," she said. <[etk]>

Ryan Genzink, PA-C, a physician assistant in Grand Rapids, Mich., and the medical liaison between the American Academy of Physician Assistants and the Society of Hospital Medicine, agrees, saying, "The biggest issue is familiarity."

Right now there are many physicians who simply don’t know how NPPs can be integrated into a hospital medicine group. And others may think it wouldn’t work in their system, he said.Mr. Genzink said h He’s optimistic that more people will come around to the idea as they see case studies, success stories, and research on the different NPP models.

For those programs that are willing to give it a try, Mr. Genzink advised getting buy-in from the physicians involved ahead of time. And he stressed the importance of having a physician champion. "When you have a physician who is a champion of the cause and who understands that their success is dependent on the PA’s success, that’s when you have programs that really work well," he said.

"More and more people are realizing the value of NPPs."

<[stk -2]>At the hospital medicine program at Northwestern University, Chicago, which has had NPPs for about 5 years, the challenge was finding a way to integrate a handful of PAs and NPs into a group with 50-60 hospitalists, all of whom had slightly different practice styles. The answer was to find a niche for each of the NPPs, such assigning a PA to work only on the oncology service. That has allowed the NPPs to get to know the practice styles of a smaller group of physicians and for trust to build among the group, said Dr. Nita Kulkarni, assistant professor of medicine and medical director of the PA training program at Northwestern. <[etk]>

The reaction from physicians to working with NPPs has been mixed, Dr. Kulkarni said. For instance, for some attending physicians who are fresh out of their residency training, working with a PA or NP can be a little unsettling because they are still figuring out their own role.

"They sometimes find it difficult to know how to delegate work," she said. "Oftentimes they don’t really know what PAs learn, what PA school is like, how many years is it, and what their learning model is. It takes some education and just experience with working with the NPPs."

Dr. Friar, who was an instructor at a recent "boot camp" for NPPs sponsored by Society of Hospital Medicine, said the NPPs they have worked with have been an asset not just from the clinical side. Their group also has NPPs who sit on hospital boards. They are oftentimes a better fit for this work than the physicians because they possess excellent leadership skills.

"Having an M.D. or D.O. after your name doesn’t magically make you a good business person or a good leader," Dr. Friar said. "That’s something that a lot of providers in a lot of hospitals forget."

Some hospitals, feeling hamstrung by an unwieldy web of federal and state scope-of-practice rules, layer on their own in-house policies to govern just what their nonphysician providers can do. But those days could soon be over as a recent proposal by the Department of Health and Human Services aims to make it easier for hospitals expand their use of physician assistants and nurse practitioners.

On Oct. 24, the agency declared that it wants to "further modernize hospitals’ medical staffing policies" and give them "the clarity they need to explore new and expanded approaches to care giving."

The proposed regulation<http://www.gpo.gov/fdsys/pkg/FR-2011-10-24/pdf/2011-27175.pdf> seeks to make clear that hospitals can grant privileges to NPPs to work within the scope of practice allowed under state law, regardless of whether they have been appointed to the hospital’s medical staff. The proposed rule is also designed to help hospitals to address workforce shortages, particularly in medically underserved communities.

"Having an M.D. or D.O. after your name doesn’t magically make you a good business person or a good leader."

Existing rules are a hurdle that "may be unduly limiting access to care and/or delaying treatment for patients and causing undue burden to practitioners (for example, the need to seek out physicians to co-sign orders)," the agency noted.

The regulations are part of a broader initiative created by President Obama to cut red tape and roll back overly burdensome or outdated federal rules.

"More and more people are realizing the value of NPPs," said Dr. David Friar, the CEO of Hospitalists of Northern Michigan, who has integrated NPPs into three of the company’s five hospital medicine programs. He sees the growing use of NPPs in hospital medicine groups as just one part of the natural evolution of the field of hospital medicine.

Though many hospitals are already doing this, red-tape notwithstanding, supporters of NPPs praised the symbolic impact of the government’s proposal.

Tricia Marriott, PA-C, said the take home message from the HHS proposal is that hospitals should apply their state laws, but that creating more restrictive in-house policies for how NPPs operate is unnecessary.

Ms. Marriott said Some hospitals have very restrictive policies about what physician assistants (PAs) can do, allowing them to act only as scribes at the bedside. That means PAs can’t do rounds or independently assess patients, which could limit patient access to care, she said.

One reason that NPPs are being embraced in some hospitals but not others is that physicians and hospital officials just don’t understand what PAs and nurse practitioners can do, Ms. Marriott said.

<[stk -2]>"If people haven’t trained with PAs in their hospital, they don’t know the possibilities," she said. <[etk]>

Ryan Genzink, PA-C, a physician assistant in Grand Rapids, Mich., and the medical liaison between the American Academy of Physician Assistants and the Society of Hospital Medicine, agrees, saying, "The biggest issue is familiarity."

Right now there are many physicians who simply don’t know how NPPs can be integrated into a hospital medicine group. And others may think it wouldn’t work in their system, he said.Mr. Genzink said h He’s optimistic that more people will come around to the idea as they see case studies, success stories, and research on the different NPP models.

For those programs that are willing to give it a try, Mr. Genzink advised getting buy-in from the physicians involved ahead of time. And he stressed the importance of having a physician champion. "When you have a physician who is a champion of the cause and who understands that their success is dependent on the PA’s success, that’s when you have programs that really work well," he said.

"More and more people are realizing the value of NPPs."

<[stk -2]>At the hospital medicine program at Northwestern University, Chicago, which has had NPPs for about 5 years, the challenge was finding a way to integrate a handful of PAs and NPs into a group with 50-60 hospitalists, all of whom had slightly different practice styles. The answer was to find a niche for each of the NPPs, such assigning a PA to work only on the oncology service. That has allowed the NPPs to get to know the practice styles of a smaller group of physicians and for trust to build among the group, said Dr. Nita Kulkarni, assistant professor of medicine and medical director of the PA training program at Northwestern. <[etk]>

The reaction from physicians to working with NPPs has been mixed, Dr. Kulkarni said. For instance, for some attending physicians who are fresh out of their residency training, working with a PA or NP can be a little unsettling because they are still figuring out their own role.

"They sometimes find it difficult to know how to delegate work," she said. "Oftentimes they don’t really know what PAs learn, what PA school is like, how many years is it, and what their learning model is. It takes some education and just experience with working with the NPPs."

Dr. Friar, who was an instructor at a recent "boot camp" for NPPs sponsored by Society of Hospital Medicine, said the NPPs they have worked with have been an asset not just from the clinical side. Their group also has NPPs who sit on hospital boards. They are oftentimes a better fit for this work than the physicians because they possess excellent leadership skills.

"Having an M.D. or D.O. after your name doesn’t magically make you a good business person or a good leader," Dr. Friar said. "That’s something that a lot of providers in a lot of hospitals forget."

As policy makers and payers contemplate the role of primary care under health care reform, some physicians in the Midwest have decided to tackle those questions on their own.

About 34 primary care physicians from Sanford Health, an integrated health care system that spans five Midwestern states, gathered in Bemidji, Minn., for 2 days in October to compare notes on their experiences and come up with a concrete plan for improving the quality and efficiency of the care they provide. The brainstorming session resulted in both a long-term vision and plans for the next 100 days.

Courtesy Michael Smith, Sanford Health Photography

Among the items on their immediate to-do list are plans to test group wellness visits, establish service agreements between primary care physicians and subspecialists, and share best practices and innovative ideas by sending physicians to visit other practices around the Sanford system. Sanford officials also plan to educate physicians across their system about the design and basis of quality measures. "Our doctors get a lot of quality data and one of the things that came out of the retreat was that they didn’t always quite know how to react to it or what to do with it," said Dr. Bruce Pitts, president of Sanford Health Clinic North in Fargo, N.D.

The retreat, which included internists, pediatricians, family physicians, ob.gyns., and psychiatrists, was a way for the executives at Sanford to get on-the-ground input on their next 5-year strategic plan for primary care, Dr. Pitts said. It was the first primary care retreat to include physicians from across the system, which has facilities in Minnesota, North Dakota, South Dakota, Nebraska, and Iowa.

But what quickly emerged was a clear picture that primary care physicians across the system are facing similar challenges. Regardless of specialty or practice area, the physicians who participated in the 2-day session agreed that the main problem was how to find the time to do everything they should be doing for their patients. If a primary care doctor provides all the care that is recommended, it would take him or her 18-20 hours each day, Dr. Pitts said. "Therefore, it takes a team and it takes a system," he said.

Dr. Howard Hoody, a family physician in Bemidji, Minn., who attended the retreat, said that primary care physicians feel "pulled in so many different directions at any moment during the day." And for some there is the added sense that the specialty is not appreciated, he said. However, clearly there are many other physicians facing the same challenges, and the retreat generated a lot of ideas on how to move forward, he said.

The electronic health record was one of those common challenges. Sanford has an electronic health record system that is in various stages of implementation. But while it has the potential to improve efficiency, Dr. Pitts said that’s true only if it’s successfully integrated into the practice’s workflow. Dr. Pitts said that for many physicians who were trained in the old way of practicing, it’s a little like spending most of your career as a golfer and then having to learn to play basketball.

"It’s a huge adjustment and it’s not technical; it’s an adaptive adjustment," Dr. Pitts said. "They have to change the way they think and behave, and that’s hard."

The physicians who gathered in Bemidji devoted a lot of time discussing the patient-centered medical home. For instance, the physicians were very interested in the best way to integrate behavioral health services into their practices to provide the full spectrum of care. "When you have a psychologist or a psychiatrist sitting in the office next door, access is easier and people are more willing to go," Dr. Pitts said. It also can be a tool in helping patients with chronic diseases to cope with the anxiety and depression that can accompany those conditions, he said.

The development of the medical home will figure prominently in the system’s long-term plan for primary care, Dr. Pitts said. As part of the 3- to 5-year plan they will also try to tackle some of the thorny issues related to how to recruit and retain primary care physicians in the current health care environment, he said.

As primary care physicians around the country look to take on these same issues, Dr. Pitts advised them to keep their eyes open for opportunities to collaborate, but to choose their partners carefully. "If you’re going to care for a population of patients and get the results that you need to get, it’s going to take relationships and the development of a system," he said.

Dr. Hoody agreed that collaboration is the key for moving forward with ideas like the medical home. If a physician doesn’t have behavioral health in their practice, they should go out and partner with someone to make it available, he said.

Sanford Health officials are planning to hold another retreat with the same group of primary care physicians at the end of January. At that meeting, they will report on their progress in the first 100 days and work on a plan for the next 100 days, Dr. Pitts said.

As policy makers and payers contemplate the role of primary care under health care reform, some physicians in the Midwest have decided to tackle those questions on their own.

About 34 primary care physicians from Sanford Health, an integrated health care system that spans five Midwestern states, gathered in Bemidji, Minn., for 2 days in October to compare notes on their experiences and come up with a concrete plan for improving the quality and efficiency of the care they provide. The brainstorming session resulted in both a long-term vision and plans for the next 100 days.

Courtesy Michael Smith, Sanford Health Photography

Among the items on their immediate to-do list are plans to test group wellness visits, establish service agreements between primary care physicians and subspecialists, and share best practices and innovative ideas by sending physicians to visit other practices around the Sanford system. Sanford officials also plan to educate physicians across their system about the design and basis of quality measures. "Our doctors get a lot of quality data and one of the things that came out of the retreat was that they didn’t always quite know how to react to it or what to do with it," said Dr. Bruce Pitts, president of Sanford Health Clinic North in Fargo, N.D.

The retreat, which included internists, pediatricians, family physicians, ob.gyns., and psychiatrists, was a way for the executives at Sanford to get on-the-ground input on their next 5-year strategic plan for primary care, Dr. Pitts said. It was the first primary care retreat to include physicians from across the system, which has facilities in Minnesota, North Dakota, South Dakota, Nebraska, and Iowa.

But what quickly emerged was a clear picture that primary care physicians across the system are facing similar challenges. Regardless of specialty or practice area, the physicians who participated in the 2-day session agreed that the main problem was how to find the time to do everything they should be doing for their patients. If a primary care doctor provides all the care that is recommended, it would take him or her 18-20 hours each day, Dr. Pitts said. "Therefore, it takes a team and it takes a system," he said.

Dr. Howard Hoody, a family physician in Bemidji, Minn., who attended the retreat, said that primary care physicians feel "pulled in so many different directions at any moment during the day." And for some there is the added sense that the specialty is not appreciated, he said. However, clearly there are many other physicians facing the same challenges, and the retreat generated a lot of ideas on how to move forward, he said.

The electronic health record was one of those common challenges. Sanford has an electronic health record system that is in various stages of implementation. But while it has the potential to improve efficiency, Dr. Pitts said that’s true only if it’s successfully integrated into the practice’s workflow. Dr. Pitts said that for many physicians who were trained in the old way of practicing, it’s a little like spending most of your career as a golfer and then having to learn to play basketball.

"It’s a huge adjustment and it’s not technical; it’s an adaptive adjustment," Dr. Pitts said. "They have to change the way they think and behave, and that’s hard."

The physicians who gathered in Bemidji devoted a lot of time discussing the patient-centered medical home. For instance, the physicians were very interested in the best way to integrate behavioral health services into their practices to provide the full spectrum of care. "When you have a psychologist or a psychiatrist sitting in the office next door, access is easier and people are more willing to go," Dr. Pitts said. It also can be a tool in helping patients with chronic diseases to cope with the anxiety and depression that can accompany those conditions, he said.

The development of the medical home will figure prominently in the system’s long-term plan for primary care, Dr. Pitts said. As part of the 3- to 5-year plan they will also try to tackle some of the thorny issues related to how to recruit and retain primary care physicians in the current health care environment, he said.

As primary care physicians around the country look to take on these same issues, Dr. Pitts advised them to keep their eyes open for opportunities to collaborate, but to choose their partners carefully. "If you’re going to care for a population of patients and get the results that you need to get, it’s going to take relationships and the development of a system," he said.

Dr. Hoody agreed that collaboration is the key for moving forward with ideas like the medical home. If a physician doesn’t have behavioral health in their practice, they should go out and partner with someone to make it available, he said.

Sanford Health officials are planning to hold another retreat with the same group of primary care physicians at the end of January. At that meeting, they will report on their progress in the first 100 days and work on a plan for the next 100 days, Dr. Pitts said.

As policy makers and payers contemplate the role of primary care under health care reform, some physicians in the Midwest have decided to tackle those questions on their own.

About 34 primary care physicians from Sanford Health, an integrated health care system that spans five Midwestern states, gathered in Bemidji, Minn., for 2 days in October to compare notes on their experiences and come up with a concrete plan for improving the quality and efficiency of the care they provide. The brainstorming session resulted in both a long-term vision and plans for the next 100 days.

Courtesy Michael Smith, Sanford Health Photography

Among the items on their immediate to-do list are plans to test group wellness visits, establish service agreements between primary care physicians and subspecialists, and share best practices and innovative ideas by sending physicians to visit other practices around the Sanford system. Sanford officials also plan to educate physicians across their system about the design and basis of quality measures. "Our doctors get a lot of quality data and one of the things that came out of the retreat was that they didn’t always quite know how to react to it or what to do with it," said Dr. Bruce Pitts, president of Sanford Health Clinic North in Fargo, N.D.

The retreat, which included internists, pediatricians, family physicians, ob.gyns., and psychiatrists, was a way for the executives at Sanford to get on-the-ground input on their next 5-year strategic plan for primary care, Dr. Pitts said. It was the first primary care retreat to include physicians from across the system, which has facilities in Minnesota, North Dakota, South Dakota, Nebraska, and Iowa.

But what quickly emerged was a clear picture that primary care physicians across the system are facing similar challenges. Regardless of specialty or practice area, the physicians who participated in the 2-day session agreed that the main problem was how to find the time to do everything they should be doing for their patients. If a primary care doctor provides all the care that is recommended, it would take him or her 18-20 hours each day, Dr. Pitts said. "Therefore, it takes a team and it takes a system," he said.

Dr. Howard Hoody, a family physician in Bemidji, Minn., who attended the retreat, said that primary care physicians feel "pulled in so many different directions at any moment during the day." And for some there is the added sense that the specialty is not appreciated, he said. However, clearly there are many other physicians facing the same challenges, and the retreat generated a lot of ideas on how to move forward, he said.

The electronic health record was one of those common challenges. Sanford has an electronic health record system that is in various stages of implementation. But while it has the potential to improve efficiency, Dr. Pitts said that’s true only if it’s successfully integrated into the practice’s workflow. Dr. Pitts said that for many physicians who were trained in the old way of practicing, it’s a little like spending most of your career as a golfer and then having to learn to play basketball.

"It’s a huge adjustment and it’s not technical; it’s an adaptive adjustment," Dr. Pitts said. "They have to change the way they think and behave, and that’s hard."

The physicians who gathered in Bemidji devoted a lot of time discussing the patient-centered medical home. For instance, the physicians were very interested in the best way to integrate behavioral health services into their practices to provide the full spectrum of care. "When you have a psychologist or a psychiatrist sitting in the office next door, access is easier and people are more willing to go," Dr. Pitts said. It also can be a tool in helping patients with chronic diseases to cope with the anxiety and depression that can accompany those conditions, he said.

The development of the medical home will figure prominently in the system’s long-term plan for primary care, Dr. Pitts said. As part of the 3- to 5-year plan they will also try to tackle some of the thorny issues related to how to recruit and retain primary care physicians in the current health care environment, he said.

As primary care physicians around the country look to take on these same issues, Dr. Pitts advised them to keep their eyes open for opportunities to collaborate, but to choose their partners carefully. "If you’re going to care for a population of patients and get the results that you need to get, it’s going to take relationships and the development of a system," he said.

Dr. Hoody agreed that collaboration is the key for moving forward with ideas like the medical home. If a physician doesn’t have behavioral health in their practice, they should go out and partner with someone to make it available, he said.

Sanford Health officials are planning to hold another retreat with the same group of primary care physicians at the end of January. At that meeting, they will report on their progress in the first 100 days and work on a plan for the next 100 days, Dr. Pitts said.

Emergency physicians now have a pathway for earning board certification in critical care medicine under an arrangement approved by the American Board of Medical Specialties.

At the end of September, the ABMS board of directors approved a plan to allow emergency physicians to be board certified in critical care medicine through a pathway cosponsored by the American Board of Emergency Medicine (ABEM) and the American Board of Internal Medicine (ABIM). The arrangement allows emergency physicians with additional training in critical care medicine to take advantage of the existing certification available through the ABIM.

Residents in emergency medicine who are interested in critical care medicine board certification would need to meet additional requirements that include 6 months of general internal medicine training. Three months of that training would need to be in an internal medicine–critical care medicine unit.

"I think in the past it’s been quite risky to do a fellowship not knowing if you’ll ever be board certified."

Emergency medicine residents who accomplish this additional training could be accepted into a 2-year internal medicine–critical care medicine fellowship program. Completion of that program will allow them to sit for the ABIM’s critical care medicine certification exam, according to the ABIM.

Emergency medicine residents will be eligible to enter critical care medicine fellowships in July 2012, said Dr. William F. Iobst, vice president of academic affairs at the ABIM. The certification pathway is available for critical care medicine only, not pulmonary critical care medicine, he said.

Emergency physicians who have already trained in an accredited 2-year critical care medicine program, under the umbrella of general surgery, anesthesia, or internal medicine, are eligible to sit for the ABIM critical care certification exam under a "grandfather" provision. These "grandfathered" physicians need to provide documentation that they spend a significant amount of their clinical time in critical care units. The "grandfather" option is expected to be available for 5 years, Dr. Iobst said.

"It’s an opportunity to recognize that there are a certain number of people who have been doing this who have not been eligible to seek certification," Dr. Iobst said. "The real goal here is to ensure that people are meeting a standard and can demonstrate that they are meeting a standard of practice."

Efforts to allow emergency physicians access to some type of U.S. board certification in critical care medicine have been underway for years. Prior to this agreement, the only option open to emergency physicians who completed a critical care medicine fellowship was certification through the European Society of Intensive Care Medicine.

As early as 2006, leaders in internal medicine and emergency medicine began meeting to come up with another option for these physicians. In March 2009, a task force of physicians from the ABIM and the ABEM held a day-long meeting and unanimously agreed that the two boards should cosponsor a critical care medicine subspecialty certification pathway for emergency physicians.

Dr. Debra G. Perina of the department of emergency medicine at the University of Virginia in Charlottesville and a past president of the ABEM, said the creation of the pathway took time in part because the specialties and programs involved needed to mature. But today, it’s clear that emergency medicine training has evolved so that its competencies are consistent with entering internal medicine graduates, and it has a number of points in common with critical care training, she said.

The availability of the critical care certification is an exciting development, said Dr. Richard N. Nelson, president of the ABEM, and could encourage more emergency medicine residents to consider fellowship training in critical care medicine. "I think in the past it’s been quite risky to do a fellowship not knowing if you’ll ever be board certified," he said. "If you aren’t, then that would limit your employment opportunities."

Even with that risk, the ABEM estimates that about 150 emergency physicians have already completed critical care medicine fellowships. For those physicians, the availability of U.S. board certification could be a big benefit. "That opens the doors for these physicians to seek employment at different hospitals," Dr. Nelson said.

Allowing a greater number of physicians to be board certified in critical medicine will also benefit patients, said Dr. Nelson, who is also a professor and vice chair of the department of emergency medicine at Ohio State University, Columbus. And the addition of emergency physicians to the critical care workforce is a good fit, he said, especially as some emergency departments begin developing their own critical care units.

In some emergency departments, the units are a holding area for patients when traditional critical care units in the hospital are full. In other cases, these new ED-based units are used for patients who need critical care but are likely to be discharged in a short amount of time. Having a physician who is board certified in critical care medicine and emergency medicine would be "ideal" for that situation, Dr. Nelson said.

Emergency physicians now have a pathway for earning board certification in critical care medicine under an arrangement approved by the American Board of Medical Specialties.

At the end of September, the ABMS board of directors approved a plan to allow emergency physicians to be board certified in critical care medicine through a pathway cosponsored by the American Board of Emergency Medicine (ABEM) and the American Board of Internal Medicine (ABIM). The arrangement allows emergency physicians with additional training in critical care medicine to take advantage of the existing certification available through the ABIM.

Residents in emergency medicine who are interested in critical care medicine board certification would need to meet additional requirements that include 6 months of general internal medicine training. Three months of that training would need to be in an internal medicine–critical care medicine unit.

"I think in the past it’s been quite risky to do a fellowship not knowing if you’ll ever be board certified."

Emergency medicine residents who accomplish this additional training could be accepted into a 2-year internal medicine–critical care medicine fellowship program. Completion of that program will allow them to sit for the ABIM’s critical care medicine certification exam, according to the ABIM.

Emergency medicine residents will be eligible to enter critical care medicine fellowships in July 2012, said Dr. William F. Iobst, vice president of academic affairs at the ABIM. The certification pathway is available for critical care medicine only, not pulmonary critical care medicine, he said.

Emergency physicians who have already trained in an accredited 2-year critical care medicine program, under the umbrella of general surgery, anesthesia, or internal medicine, are eligible to sit for the ABIM critical care certification exam under a "grandfather" provision. These "grandfathered" physicians need to provide documentation that they spend a significant amount of their clinical time in critical care units. The "grandfather" option is expected to be available for 5 years, Dr. Iobst said.

"It’s an opportunity to recognize that there are a certain number of people who have been doing this who have not been eligible to seek certification," Dr. Iobst said. "The real goal here is to ensure that people are meeting a standard and can demonstrate that they are meeting a standard of practice."

Efforts to allow emergency physicians access to some type of U.S. board certification in critical care medicine have been underway for years. Prior to this agreement, the only option open to emergency physicians who completed a critical care medicine fellowship was certification through the European Society of Intensive Care Medicine.

As early as 2006, leaders in internal medicine and emergency medicine began meeting to come up with another option for these physicians. In March 2009, a task force of physicians from the ABIM and the ABEM held a day-long meeting and unanimously agreed that the two boards should cosponsor a critical care medicine subspecialty certification pathway for emergency physicians.

Dr. Debra G. Perina of the department of emergency medicine at the University of Virginia in Charlottesville and a past president of the ABEM, said the creation of the pathway took time in part because the specialties and programs involved needed to mature. But today, it’s clear that emergency medicine training has evolved so that its competencies are consistent with entering internal medicine graduates, and it has a number of points in common with critical care training, she said.

The availability of the critical care certification is an exciting development, said Dr. Richard N. Nelson, president of the ABEM, and could encourage more emergency medicine residents to consider fellowship training in critical care medicine. "I think in the past it’s been quite risky to do a fellowship not knowing if you’ll ever be board certified," he said. "If you aren’t, then that would limit your employment opportunities."

Even with that risk, the ABEM estimates that about 150 emergency physicians have already completed critical care medicine fellowships. For those physicians, the availability of U.S. board certification could be a big benefit. "That opens the doors for these physicians to seek employment at different hospitals," Dr. Nelson said.

Allowing a greater number of physicians to be board certified in critical medicine will also benefit patients, said Dr. Nelson, who is also a professor and vice chair of the department of emergency medicine at Ohio State University, Columbus. And the addition of emergency physicians to the critical care workforce is a good fit, he said, especially as some emergency departments begin developing their own critical care units.

In some emergency departments, the units are a holding area for patients when traditional critical care units in the hospital are full. In other cases, these new ED-based units are used for patients who need critical care but are likely to be discharged in a short amount of time. Having a physician who is board certified in critical care medicine and emergency medicine would be "ideal" for that situation, Dr. Nelson said.

Emergency physicians now have a pathway for earning board certification in critical care medicine under an arrangement approved by the American Board of Medical Specialties.

At the end of September, the ABMS board of directors approved a plan to allow emergency physicians to be board certified in critical care medicine through a pathway cosponsored by the American Board of Emergency Medicine (ABEM) and the American Board of Internal Medicine (ABIM). The arrangement allows emergency physicians with additional training in critical care medicine to take advantage of the existing certification available through the ABIM.

Residents in emergency medicine who are interested in critical care medicine board certification would need to meet additional requirements that include 6 months of general internal medicine training. Three months of that training would need to be in an internal medicine–critical care medicine unit.

"I think in the past it’s been quite risky to do a fellowship not knowing if you’ll ever be board certified."

Emergency medicine residents who accomplish this additional training could be accepted into a 2-year internal medicine–critical care medicine fellowship program. Completion of that program will allow them to sit for the ABIM’s critical care medicine certification exam, according to the ABIM.

Emergency medicine residents will be eligible to enter critical care medicine fellowships in July 2012, said Dr. William F. Iobst, vice president of academic affairs at the ABIM. The certification pathway is available for critical care medicine only, not pulmonary critical care medicine, he said.

Emergency physicians who have already trained in an accredited 2-year critical care medicine program, under the umbrella of general surgery, anesthesia, or internal medicine, are eligible to sit for the ABIM critical care certification exam under a "grandfather" provision. These "grandfathered" physicians need to provide documentation that they spend a significant amount of their clinical time in critical care units. The "grandfather" option is expected to be available for 5 years, Dr. Iobst said.

"It’s an opportunity to recognize that there are a certain number of people who have been doing this who have not been eligible to seek certification," Dr. Iobst said. "The real goal here is to ensure that people are meeting a standard and can demonstrate that they are meeting a standard of practice."

Efforts to allow emergency physicians access to some type of U.S. board certification in critical care medicine have been underway for years. Prior to this agreement, the only option open to emergency physicians who completed a critical care medicine fellowship was certification through the European Society of Intensive Care Medicine.

As early as 2006, leaders in internal medicine and emergency medicine began meeting to come up with another option for these physicians. In March 2009, a task force of physicians from the ABIM and the ABEM held a day-long meeting and unanimously agreed that the two boards should cosponsor a critical care medicine subspecialty certification pathway for emergency physicians.

Dr. Debra G. Perina of the department of emergency medicine at the University of Virginia in Charlottesville and a past president of the ABEM, said the creation of the pathway took time in part because the specialties and programs involved needed to mature. But today, it’s clear that emergency medicine training has evolved so that its competencies are consistent with entering internal medicine graduates, and it has a number of points in common with critical care training, she said.

The availability of the critical care certification is an exciting development, said Dr. Richard N. Nelson, president of the ABEM, and could encourage more emergency medicine residents to consider fellowship training in critical care medicine. "I think in the past it’s been quite risky to do a fellowship not knowing if you’ll ever be board certified," he said. "If you aren’t, then that would limit your employment opportunities."

Even with that risk, the ABEM estimates that about 150 emergency physicians have already completed critical care medicine fellowships. For those physicians, the availability of U.S. board certification could be a big benefit. "That opens the doors for these physicians to seek employment at different hospitals," Dr. Nelson said.

Allowing a greater number of physicians to be board certified in critical medicine will also benefit patients, said Dr. Nelson, who is also a professor and vice chair of the department of emergency medicine at Ohio State University, Columbus. And the addition of emergency physicians to the critical care workforce is a good fit, he said, especially as some emergency departments begin developing their own critical care units.

In some emergency departments, the units are a holding area for patients when traditional critical care units in the hospital are full. In other cases, these new ED-based units are used for patients who need critical care but are likely to be discharged in a short amount of time. Having a physician who is board certified in critical care medicine and emergency medicine would be "ideal" for that situation, Dr. Nelson said.

Pressure is mounting for the Supreme Court to consider the constitutionality of the Affordable Care Act, with six petitions for review now before the high court.

Most recently, Liberty University filed a petition for writ of certiorari asking the Supreme Court justices to consider overturning a ruling by the 4th Circuit Court of Appeals that dismissed Liberty’s ACA challenge. The college had argued that the health law’s tax penalties for Americans who did not obtain insurance were unconstitutional. However, the appeals court dismissed the case, saying that Liberty could not challenge the law until the law’s tax penalties went into effect in 2014.

If the Supreme Court chooses to take up the ACA, as legal scholars predict it will, the justices will have their pick of cases. In addition to Liberty University’s petition, the Obama administration recently requested a review from the high court. The Justice Department asked the high court to reconsider a decision by the 11th Circuit Court of Appeals that struck down the health law’s so-called individual mandate. That court ruled that the mandate to buy insurance was a violation of the Constitution’s Commerce Clause.

The Supreme Court also has received petitions requesting review of the constitutional questions surrounding the ACA from a coalition of 26 states, the Thomas More Law Center of Ann Arbor, Mich., the National Federation of Independent Business, and the state of Virginia.

The current Supreme Court session began Oct. 3. If the justices take up one of the ACA cases, a decision is likely to be handed down during the height of the 2012 presidential campaign.

Pressure is mounting for the Supreme Court to consider the constitutionality of the Affordable Care Act, with six petitions for review now before the high court.

Most recently, Liberty University filed a petition for writ of certiorari asking the Supreme Court justices to consider overturning a ruling by the 4th Circuit Court of Appeals that dismissed Liberty’s ACA challenge. The college had argued that the health law’s tax penalties for Americans who did not obtain insurance were unconstitutional. However, the appeals court dismissed the case, saying that Liberty could not challenge the law until the law’s tax penalties went into effect in 2014.

If the Supreme Court chooses to take up the ACA, as legal scholars predict it will, the justices will have their pick of cases. In addition to Liberty University’s petition, the Obama administration recently requested a review from the high court. The Justice Department asked the high court to reconsider a decision by the 11th Circuit Court of Appeals that struck down the health law’s so-called individual mandate. That court ruled that the mandate to buy insurance was a violation of the Constitution’s Commerce Clause.

The Supreme Court also has received petitions requesting review of the constitutional questions surrounding the ACA from a coalition of 26 states, the Thomas More Law Center of Ann Arbor, Mich., the National Federation of Independent Business, and the state of Virginia.

The current Supreme Court session began Oct. 3. If the justices take up one of the ACA cases, a decision is likely to be handed down during the height of the 2012 presidential campaign.

Pressure is mounting for the Supreme Court to consider the constitutionality of the Affordable Care Act, with six petitions for review now before the high court.

Most recently, Liberty University filed a petition for writ of certiorari asking the Supreme Court justices to consider overturning a ruling by the 4th Circuit Court of Appeals that dismissed Liberty’s ACA challenge. The college had argued that the health law’s tax penalties for Americans who did not obtain insurance were unconstitutional. However, the appeals court dismissed the case, saying that Liberty could not challenge the law until the law’s tax penalties went into effect in 2014.

If the Supreme Court chooses to take up the ACA, as legal scholars predict it will, the justices will have their pick of cases. In addition to Liberty University’s petition, the Obama administration recently requested a review from the high court. The Justice Department asked the high court to reconsider a decision by the 11th Circuit Court of Appeals that struck down the health law’s so-called individual mandate. That court ruled that the mandate to buy insurance was a violation of the Constitution’s Commerce Clause.

The Supreme Court also has received petitions requesting review of the constitutional questions surrounding the ACA from a coalition of 26 states, the Thomas More Law Center of Ann Arbor, Mich., the National Federation of Independent Business, and the state of Virginia.

The current Supreme Court session began Oct. 3. If the justices take up one of the ACA cases, a decision is likely to be handed down during the height of the 2012 presidential campaign.