The evolving medical staff: keeping up with the practice of hospital medicine.
Take a look at how the hospitalist movement has impacted the medical staff, including making some staff categories obsolete.
It has been almost a decade since the term "hospitalist" was coined. According to the Society of Hospital Medicine, 80 percent of hospitals with over 200 beds use hospitalists and there are more than 30,000 hospitalists practicing in more than 3,300 hospitals.
As hospitals continue to trend toward the use of hospitalists, we are seeing more and more specialty care provided within the hospital including cardiology, psychiatry, infectious disease, and surgery. This is a trend that is expected to continue to increase as many see benefits from these programs.
The use of hospitalists has caused the role of the primary care physician (PCP) in the hospital to change significantly. Where most PCPs once provided hospital inpatient care, many are finding that hospitalists provide some major benefits to their practice.
The time previously spent driving to and from the hospital, seeing the patient, discussing care with nursing staff and consultants, and the resulting medical records documentation is now spent more efficiently seeing patients in the office. By assigning all patient admissions to the hospitalist, the PCP can also avoid those 2:00 a.m. hospital calls, thus making for a better quality of personal time.
Patients reap the benefit of having the ongoing care of the hospitalist. When a problem arises, the hospitalist is typically in the building and is only a phone call away.
The hospital also benefits. A study published in the Mayo Clinic Proceedings showed that, in general, inpatient care by hospitalist physicians leads to decreased LOS and reduced cost of hospitalization.1 Staff have more ready access to physicians which enhances communication.
Seems like a win-win situation for all involved. But, like many great ideas, there are a few unforeseen challenges that have arisen from the hospitalist movement.
Obsolete medical staff categories
Hospitals are struggling to make the new breed of medical staff fit into the old mold and are finding that there just doesn't seem to be a staff category into which they fit.
The changes in the medical staff environment require hospitals to reevaluate the role of the non-admitting PGP and make some changes in the traditional medical staff structure. Medical staff bylaws typically include a number of categories into which a practitioner is assigned.
This usually includes an "active" staff category whose members are eligible to vote, hold office and are responsible for the medical staff oversight function--as well as a variety of other categories (associate, courtesy, consulting, referring, honorary, etc.). Unfortunately, these categories were developed based on the past medical staff model and, in many cases, are obsolete.
The new medical staff requires a new set of relevant staff categories. Particularly, the "active" category needs a major overhaul.
One option is to include everyone who uses the hospital to admit, treat, consult, conduct inpatient or outpatient surgical or diagnostic procedures, interpret diagnostic procedures or tests or refer patients for inpatient care by a hospitalist in the "active" staff category.
These practitioners would be required to participate in medical staff oversight functions as well as emergency room call for unassigned patients. Telemedicine practitioners would be an exception.
Those practitioners who don't meet the criteria for active staff would be assigned to another category, such as a "courtesy" staff category.
Privileges tied to appointment
Many bylaws include a requirement for practitioners to be a member of the medical staff in order to be granted clinical privileges. Additionally, they may include admitting privileges as a "qualification" or "prerogative" for a staff category.
In today's environment, privileges and medical staff appointments should be thought of as two separate and distinct elements that are not necessarily dependent on each other.
In order to fix this problem, hospitals need to revise bylaws to separate privileges from medical staff appointment and categories. Rather than including the admitting privileges as a "prerogative" for a staff category, reword the prerogative to include the ability to "request clinical privileges, including the privilege to admit patients."
Include admitting and consulting privileges on clinical privilege forms so that the practitioner has to specifically request these privileges. In this way, privileges are customized to the practitioner, and the facility is not trying to make the practitioner "fit" into the current medical staff structure.
Lack of medical staff participation
There has been a major shift in the medical staff leadership environment in the hospital. In the past, PCPs who spent a lot of time at the hospital were major players in medical staff leadership.
They served on committees, participated in peer review and quality improvement initiatives, and helped with patient and staff education. They hung around the nurse's station and the medical staff lounge and were well known to staff. Today, if they refer to a hospitalist, they may never show up at the hospital unless it is to attend a mandatory medical staff meeting.
Some hospitals have developed a special staff category to accommodate these practitioners--one that, in many cases, does not require participation in medical staff oversight functions or emergency room call for unassigned patients. This results in a smaller pool of physicians being responsible for these functions.
One solution is to require all practitioners on the medical staff who use the hospital to participate in medical staff oversight functions. The only practitioners who would be excluded are those whose only relationship with the hospital is referring patients for outpatient testing and diagnostic procedures.
Assign penalties, such as higher dues, for those who do not participate. Provide incentives, such as the ability to block out preferred time on the OR schedule, for those who participate in oversight functions.
Many hospital medical staffs have a "consulting" category that allows for practitioners to provide consultations only. These practitioners are typically exempt from participation on medical staff committees and are not required to take ER call.
In many cases, they are very active in the hospital, so they reap the benefits of an active practice without having to participate in medical staff oversight functions. The consulting category also includes many physicians who initially requested to be on staff in order to obtain referrals that never materialized. In many cases, these physicians never sec a patient, but remain on staff being reappointed over and over again.
Most bylaws do not allow for "honorary" or "emeritus" staff members to participate in medical staff committees. These physicians have a wealth of experience and, in many cases, make great additions to committees. They also have more time than practicing physicians.
Revising bylaws to allow for these physicians to participate in committees gives the medical staff additional resources for oversight functions and allows the retired physician a mechanism for staying involved in patient care.
Relevant data not available
Accreditation standards of all hospital accreditors and the Interpretative Guidelines of the Centers for Medicare & Medicaid Services' Hospital Regulations require review of data in making determinations of competency of practitioners with privileges.
Previously, this issue was addressed by requiring physicians not actively admitting patients to provide data from another facility where they were currently practicing and by obtaining peer recommendations from colleagues who could attest to the practitioner's competency to perform the requested privileges.
When PCPs quit admitting patients, they stop performing many of the procedures that are included on their hospital privilege forms. For example, a PCP may have hospital privileges for ventilator management or administration of conscious sedation. If these are not performed in the inpatient setting, there would be no way to determine current competency.
An additional area for the hospital to consider is that medical malpractice carriers assign rates to a practitioner based on whether or not minor and major risk procedures are performed.
For example, assisting in surgery and providing vascular access for dialysis are two privileges typically requested by PCPs that may place the practitioner into a minor risk class.
A practitioner no longer providing hospital care may choose to change the classification of coverage to decrease the premium. They don't always think to revise hospital privileges to reflect this change in coverage leading to hospital privileges that are not covered by medical malpractice insurance.
Hospital medical staffs need to closely examine credentialing and privileging processes to determine whether or not they provide a mechanism for obtaining adequate data on which to base a reasoned decision to recommend granting and/or continuation privileges.
If adequate information is not available through routine credentialing and recredentialing processes, the burden should be placed on the practitioner requesting privileges to obtain data from other practice facilities.
Procedure lists from other facilities and practitioner offices may document numbers of procedures performed, but this will not be an indication of the quality of that work. Recommendations from peers, department chairs, service chiefs, and medical directors who have a good knowledge of the practitioner's competency and ability should be requested.
Typically, bylaws contain a provision that privileges are based on current competence and documented experience. If PCPs are using a hospitalist and have not provided any inpatient care during the most recent recredentialing period, the medical staff may wish to consider granting medical staff appointment, but not clinical privileges. Alternatively, privileges could be granted with the stipulation of a required proctorship and/or a period of focused review.
No hospital privileges
In the past, all managed care organizations (MCOs) required panel practitioners to have admitting privileges at a hospital included in the plan. Although there are still some MCOs that require admitting privileges, many allow for an arrangement with another practitioner to provide care should the patient require hospital admission.
State Medicaid rules may also require admitting privileges. For example, Alabama Medicaid Rules for Ambulatory Surgical Center Services (2) require ambulatory surgical centers to have a written transfer agreement with a hospital for patients requiring emergency medical care beyond the capabilities of the center and that physicians performing surgery in the center have admitting privileges at that hospital.
When a practitioner with an arrangement with a hospitalist needs admitting privileges to meet the requirement for participation in a managed care plan or Medicaid requirement, this poses a difficult problem. One solution is to grant privileges to "admit patient and refer to hospitalist." Should such an option be pursued, medical staff policies should clearly delineate patient care responsibility including responsibilities for writing admission orders.
In order to meet ongoing and focused professional practice evaluation requirements, the medical staff can monitor the appropriateness of the admission and referral orders. This can be accomplished through the utilization review process and with the help of the hospitalist who takes over care of the patient. The hospital should contact the managed care organizations it contracts with to determine if such an arrangement would be acceptable prior to initiation.
ER call coverage
A hospital that operates an emergency department is required by the Emergency Medical Treatment and Labor Act to provide an on-call panel of physicians based on the available specialties of its medical staff. Traditionally, physicians in the hospital's active staff membership category have admitting privileges and are required to take call for unassigned emergency patient.
According to a March 2010 study by the American Hospital Association, 75 percent of hospitals require physicians with admitting privileges to take emergency room call. (3) This shows that many hospitals are developing staff categories with admitting privileges that do not require participation in ER call. Some physicians feel that taking ER call is part of their obligation to the community. Some want to participate in ER call to help build up their practice. Others feel that ER call is a burden and that a good percentage of patients referred through ER call are indigent. They are also concerned that they have to keep appointment slots open on their office schedules to accommodate patients who are referred to the office for follow-up, thus inconveniencing established patients with longer wait times for appointments.
Not all ER patients are "charity cases." According to U.S. Department of Health and Human Services 2010 study of 2007 data regarding ER visits, private insurance accounted for 39 percent of ER visits, 25.2 percent had Medicaid or State Children's Health Insurance, and 17.2 percent had Medicare.
Uninsured patients (defined as self-pay, no charge, or charity) represented only 15.3 percent of visits. The study also showed that 61.7 percent of patients seen were referred from the emergency department to an outside physician or clinic. (4)
Hospitals struggle to meet patient needs without overwhelming their medical staff. One option is to require all medical staff members to take ER call, regardless of their staff category. This will spread the responsibility among all who want to provide care for their patients at the hospital.
Of course, this may also lead to some physicians choosing to resign from the hospital. Another option is to compensate physicians for time spent in ER coverage with stipends or by providing per diem payments.
Low or no-volume practitioners
Considerable time and expense are put into credentialing, recredentialing, and ongoing monitoring of practitioners by both hospital employees and medical staff leaders. If the practitioner's relationship with the hospital does not benefit the hospital or its patients, there is no return on investment and the practitioner becomes a drain to resources.
Medical staffs may wish to consider a sliding scale for medical staff dues dependent on the practitioner's participation in staff oversight functions and the level of patient care provided. Increased application and reapplication fees can also be applied to low or no-volume practitioners. These funds can be used to provide stipends for medical staff leaders and those participating in peer review functions.
The medical staff may choose to take a harder stance for practitioners who do not use the hospital for any type of patient care, treatment, or services. In this case, the medical staff may decide to not renew the practitioner's membership and privileges.
Prior to removing an inactive practitioner from the staff, the hospital may wish to contact the physician and ask why he or she wants to be a member. Some physicians hold medical staff membership at a number of facilities. In many cases, physician office personnel complete reapplications for medical staff appointment and the physician only signs the application.
This means that the physician does not spend much time considering whether or not he or she wishes to remain on that medical staff. When reconsidering the issue, the physician may choose to voluntarily resign membership.
(1.) A Systematic Review of Outcomes and Quality Measures in Adult Patients Cared for by Hospitalists vs. Nonhospitalists-Michael C. Peterson, MD - Mayo Clinic Proceedings 84(3) 1248-54, Mar. 2009.
(2.) Chapter 38. Ambulatory Surgical Center Services Rule No. 560-X-38-.05. Ambulatory Surgical Center Transfer Procedures'
(3.) AHA Rapid Response Survey, Telling the Hospital Story Survey, March 2010
(4.) The National Hospital Ambulatory Medical Care Survey (NHAMCS)
By Kathy Matzka, CPMSM, CPCS
Kathy Matzka, CPMSM. CPCS, is a consultant and speaker basked in Lebanon, III.
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|Title Annotation:||Medical Staff|
|Date:||Sep 1, 2011|
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