Mary Ellen Schneider

New federal regulations mandated by the Affordable Care Act will give patients new rights to appeal claims denials made by their health plans.

The rules, announced in July, will allow consumers in new health plans to appeal decisions both through their insurer's internal process and to an outside, independent entity. While most health plans already provide for an internal appeals process, not all offer an external review of plan decisions, according to the U.S. Department of Health and Human Services.

HHS officials estimate that in 2011 there will be about 31 million people in new employer plans and another 10 million people in new individual market plans who will be able to take advantage of these new appeals opportunities. By 2013, that number is expected to grow to 88 million people. The rules do not apply to grandfathered health plans.

Under the new rules, health plans that began on or after Sept. 23, 2010 must have an internal appeals process that allows consumers to appeal whenever the plan denies a claim for a covered service or rescinds coverage. The internal appeals process must also offer consumers detailed information about the grounds for their denial and information on how to file an appeal.

The new rules aim to make internal appeals more objective by ensuring that the person considering the appeal does not have a conflict of interest. For example, the health plan is not allowed to offer financial incentives to employees based on the number of claims that are denied. Health plans will also have to provide an expedited appeals process, which would allow urgent cases to be reviewed within 24 hours.

The new federal appeals regulations also standardize rules for external appeals. Currently, 44 states require health plans to have some type of external appeal but those processes vary greatly, according to HHS. Under the federal rules, health plans must provide clear information about external appeals and expedited access to the process. The decisions made through external appeals are binding under the new federal rules.

New federal regulations mandated by the Affordable Care Act will give patients new rights to appeal claims denials made by their health plans.

The rules, announced in July, will allow consumers in new health plans to appeal decisions both through their insurer's internal process and to an outside, independent entity. While most health plans already provide for an internal appeals process, not all offer an external review of plan decisions, according to the U.S. Department of Health and Human Services.

HHS officials estimate that in 2011 there will be about 31 million people in new employer plans and another 10 million people in new individual market plans who will be able to take advantage of these new appeals opportunities. By 2013, that number is expected to grow to 88 million people. The rules do not apply to grandfathered health plans.

Under the new rules, health plans that began on or after Sept. 23, 2010 must have an internal appeals process that allows consumers to appeal whenever the plan denies a claim for a covered service or rescinds coverage. The internal appeals process must also offer consumers detailed information about the grounds for their denial and information on how to file an appeal.

The new rules aim to make internal appeals more objective by ensuring that the person considering the appeal does not have a conflict of interest. For example, the health plan is not allowed to offer financial incentives to employees based on the number of claims that are denied. Health plans will also have to provide an expedited appeals process, which would allow urgent cases to be reviewed within 24 hours.

The new federal appeals regulations also standardize rules for external appeals. Currently, 44 states require health plans to have some type of external appeal but those processes vary greatly, according to HHS. Under the federal rules, health plans must provide clear information about external appeals and expedited access to the process. The decisions made through external appeals are binding under the new federal rules.

New federal regulations mandated by the Affordable Care Act will give patients new rights to appeal claims denials made by their health plans.

The rules, announced in July, will allow consumers in new health plans to appeal decisions both through their insurer's internal process and to an outside, independent entity. While most health plans already provide for an internal appeals process, not all offer an external review of plan decisions, according to the U.S. Department of Health and Human Services.

HHS officials estimate that in 2011 there will be about 31 million people in new employer plans and another 10 million people in new individual market plans who will be able to take advantage of these new appeals opportunities. By 2013, that number is expected to grow to 88 million people. The rules do not apply to grandfathered health plans.

Under the new rules, health plans that began on or after Sept. 23, 2010 must have an internal appeals process that allows consumers to appeal whenever the plan denies a claim for a covered service or rescinds coverage. The internal appeals process must also offer consumers detailed information about the grounds for their denial and information on how to file an appeal.

The new rules aim to make internal appeals more objective by ensuring that the person considering the appeal does not have a conflict of interest. For example, the health plan is not allowed to offer financial incentives to employees based on the number of claims that are denied. Health plans will also have to provide an expedited appeals process, which would allow urgent cases to be reviewed within 24 hours.

The new federal appeals regulations also standardize rules for external appeals. Currently, 44 states require health plans to have some type of external appeal but those processes vary greatly, according to HHS. Under the federal rules, health plans must provide clear information about external appeals and expedited access to the process. The decisions made through external appeals are binding under the new federal rules.

Accountable care organizations are garnering a lot of attention as a way to reform how health care is paid for in the United States, but just about the only thing that experts can agree on right now is that the ACO concept is still in its infancy.

“This is sort of an evolving area of health policy, and it's not exactly clear that, when people are talking about ACOs, [everyone] has the same thing in mind,” said Dr. Francis J. Crosson, senior fellow in the Kaiser Permanente Institute for Health Policy in Oakland, Calif., and a member of a task force on ACOs that was recently convened by the National Committee for Quality Assurance (NCQA).

In general, ACOs would allow primary care physicians, specialists, and hospitals to form a partnership to provide care to a group of patients. The idea is that all the providers would work together to improve quality and manage costs, and that they would share in any savings that were produced as a result. A few models already exist for both pediatric and adult populations.

While many hospitals are still just contemplating their potential role in an ACO, Nationwide Children's Hospital in Columbus, Ohio, is billing itself as the country's largest pediatric ACO. It offers one model for how to pursue this concept in the care of children.

Starting about 5 years ago, Nationwide officials partnered with the state of Ohio to assume financial risk in treating children who were covered by the Medicaid managed care program in central and southeast Ohio. To help run the program, they formed a nonprofit physician-hospital organization called Partners for Kids that includes not only Nationwide-employed physicians but also other physicians working in the community.

Under the arrangement, Partners for Kids receives a capitated fee to care for about 285,000 pediatric Medicaid recipients. The organization contracts with three Medicaid managed care plans that retain a percentage of the Medicaid premium to provide claims processing, member relations, and other medical management functions. The hospital and physicians assume the business risk for clinical and financial outcomes.

The idea was to move away from the conventional fee-for-service model while improving access for children who might otherwise have difficulty finding a physician, said Dr. Steve Allen, chief executive officer for Nationwide. For example, Partners for Kids pays primary care physicians in rural areas an increased fee to keep their panels open for these Medicaid patients.

“We saw this as an opportunity to change the paradigm so that we could improve access,” Dr. Allen said.

Officials at Nationwide Children's Hospital have conducted an analysis of the current ACO landscape and found that about a dozen institutions around the country are planning to develop or have launched some type of a pediatric ACO, with sizes ranging from 30,000 patients to Nationwide's high of 285,000. Most of the more developed models are among integrated delivery systems, Dr. Allen said.

One integrated system looking to become an ACO is University Hospitals in northeast Ohio.

Participating in an ACO will mean shifting the system's focus from an acute, episodic care model to a prevention and wellness model, according to Dr. Eric Bieber, chief medical officer at University Hospitals Case Medical Center and Rainbow Babies and Children's Hospital.

“Health care in its present design is highly episodic. It doesn't relate one piece to the other,” he said. Switching to an ACO model “is a transformational change in how care is going to be delivered.”

There has been a lot of buzz around ACOs since the passage of the Affordable Care Act. The massive health reform law includes three sections with implications for forming ACOs. The section that has received the most attention is the Medicare shared-savings program, which will allow groups of providers to work together to treat patients and to share in any savings they achieve. That program is set to launch in January 2012. CMS is expected to put out its criteria for the shared-savings program sometime this fall.

ACOs may also end up being part of testing performed by the Center for Medicare and Medicaid Innovation, a new office created under the law. The innovation center has broad authority to test new payment ideas and will launch in January 2011.

Finally, the Affordable Care Act includes a pediatric ACO demonstration project that allows states to recognize pediatric medical providers as ACOs and to award incentive payments through Medicaid. That project is also expected to launch in January 2012.

Since the passage of the Affordable Care Act, there's been a “flurry of activity” going on around the country, similar to what happened in the early 1990s around the growth of HMOs and capitation, said Dr. Crosson of the Kaiser Permanente Institute. “All over the country, hospital boards are going off with their medical staffs and asking the question, 'Do we want to become an ACO?'”

In the near term, there is likely to be a range of ACO models, Dr. Crosson predicted. Some will be tightly constructed around integrated delivery systems in which physicians and hospitals are part of the same economic entity. Other will be looser models that bring together a group of physicians and hospitals that are financially separate from one another, he said.

The real question, Dr. Crosson noted, is not whether various models can be designed, but which ones will work best. And for that, he said, only time will tell.

Naseem S. Miller contributed to this report.

Accountable care organizations are garnering a lot of attention as a way to reform how health care is paid for in the United States, but just about the only thing that experts can agree on right now is that the ACO concept is still in its infancy.

“This is sort of an evolving area of health policy, and it's not exactly clear that, when people are talking about ACOs, [everyone] has the same thing in mind,” said Dr. Francis J. Crosson, senior fellow in the Kaiser Permanente Institute for Health Policy in Oakland, Calif., and a member of a task force on ACOs that was recently convened by the National Committee for Quality Assurance (NCQA).

In general, ACOs would allow primary care physicians, specialists, and hospitals to form a partnership to provide care to a group of patients. The idea is that all the providers would work together to improve quality and manage costs, and that they would share in any savings that were produced as a result. A few models already exist for both pediatric and adult populations.

While many hospitals are still just contemplating their potential role in an ACO, Nationwide Children's Hospital in Columbus, Ohio, is billing itself as the country's largest pediatric ACO. It offers one model for how to pursue this concept in the care of children.

Starting about 5 years ago, Nationwide officials partnered with the state of Ohio to assume financial risk in treating children who were covered by the Medicaid managed care program in central and southeast Ohio. To help run the program, they formed a nonprofit physician-hospital organization called Partners for Kids that includes not only Nationwide-employed physicians but also other physicians working in the community.

Under the arrangement, Partners for Kids receives a capitated fee to care for about 285,000 pediatric Medicaid recipients. The organization contracts with three Medicaid managed care plans that retain a percentage of the Medicaid premium to provide claims processing, member relations, and other medical management functions. The hospital and physicians assume the business risk for clinical and financial outcomes.

The idea was to move away from the conventional fee-for-service model while improving access for children who might otherwise have difficulty finding a physician, said Dr. Steve Allen, chief executive officer for Nationwide. For example, Partners for Kids pays primary care physicians in rural areas an increased fee to keep their panels open for these Medicaid patients.

“We saw this as an opportunity to change the paradigm so that we could improve access,” Dr. Allen said.

Officials at Nationwide Children's Hospital have conducted an analysis of the current ACO landscape and found that about a dozen institutions around the country are planning to develop or have launched some type of a pediatric ACO, with sizes ranging from 30,000 patients to Nationwide's high of 285,000. Most of the more developed models are among integrated delivery systems, Dr. Allen said.

One integrated system looking to become an ACO is University Hospitals in northeast Ohio.

Participating in an ACO will mean shifting the system's focus from an acute, episodic care model to a prevention and wellness model, according to Dr. Eric Bieber, chief medical officer at University Hospitals Case Medical Center and Rainbow Babies and Children's Hospital.

“Health care in its present design is highly episodic. It doesn't relate one piece to the other,” he said. Switching to an ACO model “is a transformational change in how care is going to be delivered.”

There has been a lot of buzz around ACOs since the passage of the Affordable Care Act. The massive health reform law includes three sections with implications for forming ACOs. The section that has received the most attention is the Medicare shared-savings program, which will allow groups of providers to work together to treat patients and to share in any savings they achieve. That program is set to launch in January 2012. CMS is expected to put out its criteria for the shared-savings program sometime this fall.

ACOs may also end up being part of testing performed by the Center for Medicare and Medicaid Innovation, a new office created under the law. The innovation center has broad authority to test new payment ideas and will launch in January 2011.

Finally, the Affordable Care Act includes a pediatric ACO demonstration project that allows states to recognize pediatric medical providers as ACOs and to award incentive payments through Medicaid. That project is also expected to launch in January 2012.

Since the passage of the Affordable Care Act, there's been a “flurry of activity” going on around the country, similar to what happened in the early 1990s around the growth of HMOs and capitation, said Dr. Crosson of the Kaiser Permanente Institute. “All over the country, hospital boards are going off with their medical staffs and asking the question, 'Do we want to become an ACO?'”

In the near term, there is likely to be a range of ACO models, Dr. Crosson predicted. Some will be tightly constructed around integrated delivery systems in which physicians and hospitals are part of the same economic entity. Other will be looser models that bring together a group of physicians and hospitals that are financially separate from one another, he said.

The real question, Dr. Crosson noted, is not whether various models can be designed, but which ones will work best. And for that, he said, only time will tell.

Naseem S. Miller contributed to this report.

Accountable care organizations are garnering a lot of attention as a way to reform how health care is paid for in the United States, but just about the only thing that experts can agree on right now is that the ACO concept is still in its infancy.

“This is sort of an evolving area of health policy, and it's not exactly clear that, when people are talking about ACOs, [everyone] has the same thing in mind,” said Dr. Francis J. Crosson, senior fellow in the Kaiser Permanente Institute for Health Policy in Oakland, Calif., and a member of a task force on ACOs that was recently convened by the National Committee for Quality Assurance (NCQA).

In general, ACOs would allow primary care physicians, specialists, and hospitals to form a partnership to provide care to a group of patients. The idea is that all the providers would work together to improve quality and manage costs, and that they would share in any savings that were produced as a result. A few models already exist for both pediatric and adult populations.

While many hospitals are still just contemplating their potential role in an ACO, Nationwide Children's Hospital in Columbus, Ohio, is billing itself as the country's largest pediatric ACO. It offers one model for how to pursue this concept in the care of children.

Starting about 5 years ago, Nationwide officials partnered with the state of Ohio to assume financial risk in treating children who were covered by the Medicaid managed care program in central and southeast Ohio. To help run the program, they formed a nonprofit physician-hospital organization called Partners for Kids that includes not only Nationwide-employed physicians but also other physicians working in the community.

Under the arrangement, Partners for Kids receives a capitated fee to care for about 285,000 pediatric Medicaid recipients. The organization contracts with three Medicaid managed care plans that retain a percentage of the Medicaid premium to provide claims processing, member relations, and other medical management functions. The hospital and physicians assume the business risk for clinical and financial outcomes.

The idea was to move away from the conventional fee-for-service model while improving access for children who might otherwise have difficulty finding a physician, said Dr. Steve Allen, chief executive officer for Nationwide. For example, Partners for Kids pays primary care physicians in rural areas an increased fee to keep their panels open for these Medicaid patients.

“We saw this as an opportunity to change the paradigm so that we could improve access,” Dr. Allen said.

Officials at Nationwide Children's Hospital have conducted an analysis of the current ACO landscape and found that about a dozen institutions around the country are planning to develop or have launched some type of a pediatric ACO, with sizes ranging from 30,000 patients to Nationwide's high of 285,000. Most of the more developed models are among integrated delivery systems, Dr. Allen said.

One integrated system looking to become an ACO is University Hospitals in northeast Ohio.

Participating in an ACO will mean shifting the system's focus from an acute, episodic care model to a prevention and wellness model, according to Dr. Eric Bieber, chief medical officer at University Hospitals Case Medical Center and Rainbow Babies and Children's Hospital.

“Health care in its present design is highly episodic. It doesn't relate one piece to the other,” he said. Switching to an ACO model “is a transformational change in how care is going to be delivered.”

There has been a lot of buzz around ACOs since the passage of the Affordable Care Act. The massive health reform law includes three sections with implications for forming ACOs. The section that has received the most attention is the Medicare shared-savings program, which will allow groups of providers to work together to treat patients and to share in any savings they achieve. That program is set to launch in January 2012. CMS is expected to put out its criteria for the shared-savings program sometime this fall.

ACOs may also end up being part of testing performed by the Center for Medicare and Medicaid Innovation, a new office created under the law. The innovation center has broad authority to test new payment ideas and will launch in January 2011.

Finally, the Affordable Care Act includes a pediatric ACO demonstration project that allows states to recognize pediatric medical providers as ACOs and to award incentive payments through Medicaid. That project is also expected to launch in January 2012.

Since the passage of the Affordable Care Act, there's been a “flurry of activity” going on around the country, similar to what happened in the early 1990s around the growth of HMOs and capitation, said Dr. Crosson of the Kaiser Permanente Institute. “All over the country, hospital boards are going off with their medical staffs and asking the question, 'Do we want to become an ACO?'”

In the near term, there is likely to be a range of ACO models, Dr. Crosson predicted. Some will be tightly constructed around integrated delivery systems in which physicians and hospitals are part of the same economic entity. Other will be looser models that bring together a group of physicians and hospitals that are financially separate from one another, he said.

The real question, Dr. Crosson noted, is not whether various models can be designed, but which ones will work best. And for that, he said, only time will tell.

Naseem S. Miller contributed to this report.

The Federal Trade Commission has again postponed enforcement of the “Red Flags” rule, giving physicians until the end of 2010 before they must implement identity-theft prevention programs in their practices.

Enforcement of the rule had been scheduled to begin on June 1. In a statement issued over the summer, the FTC said it was delaying enforcement to give Congress time to consider pending legislation that would exclude some small physician practices and small businesses from the rule. Last year, the House passed a bill (H.R. 3763) that would have exempted physician practices with 20 or fewer employees from the Red Flags rule, but that legislation has failed to gain traction in the Senate.

FTC officials urged lawmakers to act quickly to clarify what groups should be covered by the regulation. “As an agency, we're charged with enforcing the law, and endless extensions delay enforcement,” FTC chairman Jon Leibowitz said in a statement.

The Red Flags rule was written to implement provisions of the Fair and Accurate Credit Transactions Act, which calls on creditors and financial institutions to address the risk of identity theft. The rule requires creditors to develop formal identity-theft prevention programs that would allow an organization to identify, detect, and respond to any suspicious practices, or “red flags,” that could indicate identity theft.

The rule became effective on Jan. 1, 2008, with an original enforcement deadline of Nov. 1, 2008.

However, the FTC has delayed enforcement of the rule several times, first to give organizations more time to get familiar with the requirements and later at the request of members of Congress.

The American Medical Association has joined the American Osteopathic Association and the Medical Society of the District Columbia in a federal lawsuit that seeks to prevent the FTC from applying the Red Flags rule to physicians. The groups contend that not only are physicians not creditors, but that the rules would be burdensome and that they duplicate requirements already in place under the Health Insurance Portability and Accountability Act.

“Physicians are already ethically and legally responsible for ensuring the confidentiality and security of patients' medical information,” Dr. Peter E. Lavine, president of the Medical Society of the District of Columbia, said in a statement. “It is unnecessary to add to the existing web of federal security regulations physicians must follow.'

The Federal Trade Commission has again postponed enforcement of the “Red Flags” rule, giving physicians until the end of 2010 before they must implement identity-theft prevention programs in their practices.

Enforcement of the rule had been scheduled to begin on June 1. In a statement issued over the summer, the FTC said it was delaying enforcement to give Congress time to consider pending legislation that would exclude some small physician practices and small businesses from the rule. Last year, the House passed a bill (H.R. 3763) that would have exempted physician practices with 20 or fewer employees from the Red Flags rule, but that legislation has failed to gain traction in the Senate.

FTC officials urged lawmakers to act quickly to clarify what groups should be covered by the regulation. “As an agency, we're charged with enforcing the law, and endless extensions delay enforcement,” FTC chairman Jon Leibowitz said in a statement.

The Red Flags rule was written to implement provisions of the Fair and Accurate Credit Transactions Act, which calls on creditors and financial institutions to address the risk of identity theft. The rule requires creditors to develop formal identity-theft prevention programs that would allow an organization to identify, detect, and respond to any suspicious practices, or “red flags,” that could indicate identity theft.

The rule became effective on Jan. 1, 2008, with an original enforcement deadline of Nov. 1, 2008.

However, the FTC has delayed enforcement of the rule several times, first to give organizations more time to get familiar with the requirements and later at the request of members of Congress.

The American Medical Association has joined the American Osteopathic Association and the Medical Society of the District Columbia in a federal lawsuit that seeks to prevent the FTC from applying the Red Flags rule to physicians. The groups contend that not only are physicians not creditors, but that the rules would be burdensome and that they duplicate requirements already in place under the Health Insurance Portability and Accountability Act.

“Physicians are already ethically and legally responsible for ensuring the confidentiality and security of patients' medical information,” Dr. Peter E. Lavine, president of the Medical Society of the District of Columbia, said in a statement. “It is unnecessary to add to the existing web of federal security regulations physicians must follow.'

The Federal Trade Commission has again postponed enforcement of the “Red Flags” rule, giving physicians until the end of 2010 before they must implement identity-theft prevention programs in their practices.

Enforcement of the rule had been scheduled to begin on June 1. In a statement issued over the summer, the FTC said it was delaying enforcement to give Congress time to consider pending legislation that would exclude some small physician practices and small businesses from the rule. Last year, the House passed a bill (H.R. 3763) that would have exempted physician practices with 20 or fewer employees from the Red Flags rule, but that legislation has failed to gain traction in the Senate.

FTC officials urged lawmakers to act quickly to clarify what groups should be covered by the regulation. “As an agency, we're charged with enforcing the law, and endless extensions delay enforcement,” FTC chairman Jon Leibowitz said in a statement.

The Red Flags rule was written to implement provisions of the Fair and Accurate Credit Transactions Act, which calls on creditors and financial institutions to address the risk of identity theft. The rule requires creditors to develop formal identity-theft prevention programs that would allow an organization to identify, detect, and respond to any suspicious practices, or “red flags,” that could indicate identity theft.

The rule became effective on Jan. 1, 2008, with an original enforcement deadline of Nov. 1, 2008.

However, the FTC has delayed enforcement of the rule several times, first to give organizations more time to get familiar with the requirements and later at the request of members of Congress.

The American Medical Association has joined the American Osteopathic Association and the Medical Society of the District Columbia in a federal lawsuit that seeks to prevent the FTC from applying the Red Flags rule to physicians. The groups contend that not only are physicians not creditors, but that the rules would be burdensome and that they duplicate requirements already in place under the Health Insurance Portability and Accountability Act.

“Physicians are already ethically and legally responsible for ensuring the confidentiality and security of patients' medical information,” Dr. Peter E. Lavine, president of the Medical Society of the District of Columbia, said in a statement. “It is unnecessary to add to the existing web of federal security regulations physicians must follow.'

Provisions of the new Affordable Care Act, coupled with other payment changes, will save Medicare nearly $8 billion over 2 years and extend the solvency of the Medicare Trust Funds by 12 years, according to a report from the Centers for Medicare and Medicaid Services.

The immediate savings come from cuts to Medicare Advantage payments, competitive bidding for durable medical equipment, changes to how Medicare pays for advanced imaging services, productivity improvements in the hospital, and efforts to reduce waste, fraud, and abuse. These changes are expected to save $7.8 billion for the Medicare program by the end of next year.

The report analyzes cost-cutting provisions that the CMS has already implemented or will be implementing soon.

“For too long, we've paid too much for health care, gotten too little in return, and watched the situation get worse each and every year,” Health and Human Services Secretary Kathleen Sebelius said at a press conference to release the report. “The Affordable Care Act is already putting our health care system on a new course, bringing down costs while improving the quality of care and giving all Americans more value for their dollars.”

Ms. Sebelius noted that the new law will protect Medicare beneficiaries by maintaining current benefits and adding new ones such as free preventive care and the eventual closing of the Medicare Part D prescription drug doughnut hole.

Over the long-term, CMS officials estimate that Medicare savings will exceed $418 billion by 2019. Some of those savings will come from reducing hospital readmissions and hospital-acquired infections, bundling payments for end-stage renal disease care, promoting Accountable Care Organizations, and improving quality reporting by physicians. The CMS also expects the establishment of the Independent Payment Advisory Board (IPAB), which will recommend payment changes aimed at slowing growth in Medicare spending, to contribute to those savings by cutting Medicare costs by about $23 billion by 2019. The IPAB may pose problems for physicians down the road, Robert Doherty, senior vice president for governmental affairs and public policy at the American College of Physicians, said in an interview. Many physician groups have been critical of the IPAB, saying that Congress has placed too much authority in the hands of an unelected body. Under the Affordable Care Act, the IPAB's recommendations will take effect unless Congress passes legislation that meets the same budgetary targets.

However, the payment changes being touted by Medicare could be good news for office-based physicians, Mr. Doherty said. For example, under new models such as bundled payments and accountable care organizations, office-based physicians who help to reduce preventable hospital readmissions could see a share of the savings from that improved care.

“Right now under Medicare, Part B is Part B and Part A is Part A, and never the twain shall meet,” Mr. Doherty said. “No matter what physicians do to reduce Part A expenses by managing care more effectively, there's no mechanism under the existing Medicare payment system for physicians to benefit from that.”

The current payment system misaligns the financial incentives, paying for volume rather than quality of care, Dr. Lori Heim, president of the American Academy of Family Physicians, said in an interview. Concepts such as accountable care organizations, which are still in their infancy, could benefit physicians by paying them to coordinate care and reimbursing them for work that keeps costs down for the health care system as a whole, she said.

“We know that to really coordinate the care, to work with the patient's family, to create the community environment and really help to manage these patients, a lot of that is not in the face-to-face visit that we're currently being paid for,” Dr. Heim said.

Provisions of the new Affordable Care Act, coupled with other payment changes, will save Medicare nearly $8 billion over 2 years and extend the solvency of the Medicare Trust Funds by 12 years, according to a report from the Centers for Medicare and Medicaid Services.

The immediate savings come from cuts to Medicare Advantage payments, competitive bidding for durable medical equipment, changes to how Medicare pays for advanced imaging services, productivity improvements in the hospital, and efforts to reduce waste, fraud, and abuse. These changes are expected to save $7.8 billion for the Medicare program by the end of next year.

The report analyzes cost-cutting provisions that the CMS has already implemented or will be implementing soon.

“For too long, we've paid too much for health care, gotten too little in return, and watched the situation get worse each and every year,” Health and Human Services Secretary Kathleen Sebelius said at a press conference to release the report. “The Affordable Care Act is already putting our health care system on a new course, bringing down costs while improving the quality of care and giving all Americans more value for their dollars.”

Ms. Sebelius noted that the new law will protect Medicare beneficiaries by maintaining current benefits and adding new ones such as free preventive care and the eventual closing of the Medicare Part D prescription drug doughnut hole.

Over the long-term, CMS officials estimate that Medicare savings will exceed $418 billion by 2019. Some of those savings will come from reducing hospital readmissions and hospital-acquired infections, bundling payments for end-stage renal disease care, promoting Accountable Care Organizations, and improving quality reporting by physicians. The CMS also expects the establishment of the Independent Payment Advisory Board (IPAB), which will recommend payment changes aimed at slowing growth in Medicare spending, to contribute to those savings by cutting Medicare costs by about $23 billion by 2019. The IPAB may pose problems for physicians down the road, Robert Doherty, senior vice president for governmental affairs and public policy at the American College of Physicians, said in an interview. Many physician groups have been critical of the IPAB, saying that Congress has placed too much authority in the hands of an unelected body. Under the Affordable Care Act, the IPAB's recommendations will take effect unless Congress passes legislation that meets the same budgetary targets.

However, the payment changes being touted by Medicare could be good news for office-based physicians, Mr. Doherty said. For example, under new models such as bundled payments and accountable care organizations, office-based physicians who help to reduce preventable hospital readmissions could see a share of the savings from that improved care.

“Right now under Medicare, Part B is Part B and Part A is Part A, and never the twain shall meet,” Mr. Doherty said. “No matter what physicians do to reduce Part A expenses by managing care more effectively, there's no mechanism under the existing Medicare payment system for physicians to benefit from that.”

The current payment system misaligns the financial incentives, paying for volume rather than quality of care, Dr. Lori Heim, president of the American Academy of Family Physicians, said in an interview. Concepts such as accountable care organizations, which are still in their infancy, could benefit physicians by paying them to coordinate care and reimbursing them for work that keeps costs down for the health care system as a whole, she said.

“We know that to really coordinate the care, to work with the patient's family, to create the community environment and really help to manage these patients, a lot of that is not in the face-to-face visit that we're currently being paid for,” Dr. Heim said.

Provisions of the new Affordable Care Act, coupled with other payment changes, will save Medicare nearly $8 billion over 2 years and extend the solvency of the Medicare Trust Funds by 12 years, according to a report from the Centers for Medicare and Medicaid Services.

The immediate savings come from cuts to Medicare Advantage payments, competitive bidding for durable medical equipment, changes to how Medicare pays for advanced imaging services, productivity improvements in the hospital, and efforts to reduce waste, fraud, and abuse. These changes are expected to save $7.8 billion for the Medicare program by the end of next year.

The report analyzes cost-cutting provisions that the CMS has already implemented or will be implementing soon.

“For too long, we've paid too much for health care, gotten too little in return, and watched the situation get worse each and every year,” Health and Human Services Secretary Kathleen Sebelius said at a press conference to release the report. “The Affordable Care Act is already putting our health care system on a new course, bringing down costs while improving the quality of care and giving all Americans more value for their dollars.”

Ms. Sebelius noted that the new law will protect Medicare beneficiaries by maintaining current benefits and adding new ones such as free preventive care and the eventual closing of the Medicare Part D prescription drug doughnut hole.

Over the long-term, CMS officials estimate that Medicare savings will exceed $418 billion by 2019. Some of those savings will come from reducing hospital readmissions and hospital-acquired infections, bundling payments for end-stage renal disease care, promoting Accountable Care Organizations, and improving quality reporting by physicians. The CMS also expects the establishment of the Independent Payment Advisory Board (IPAB), which will recommend payment changes aimed at slowing growth in Medicare spending, to contribute to those savings by cutting Medicare costs by about $23 billion by 2019. The IPAB may pose problems for physicians down the road, Robert Doherty, senior vice president for governmental affairs and public policy at the American College of Physicians, said in an interview. Many physician groups have been critical of the IPAB, saying that Congress has placed too much authority in the hands of an unelected body. Under the Affordable Care Act, the IPAB's recommendations will take effect unless Congress passes legislation that meets the same budgetary targets.

However, the payment changes being touted by Medicare could be good news for office-based physicians, Mr. Doherty said. For example, under new models such as bundled payments and accountable care organizations, office-based physicians who help to reduce preventable hospital readmissions could see a share of the savings from that improved care.

“Right now under Medicare, Part B is Part B and Part A is Part A, and never the twain shall meet,” Mr. Doherty said. “No matter what physicians do to reduce Part A expenses by managing care more effectively, there's no mechanism under the existing Medicare payment system for physicians to benefit from that.”

The current payment system misaligns the financial incentives, paying for volume rather than quality of care, Dr. Lori Heim, president of the American Academy of Family Physicians, said in an interview. Concepts such as accountable care organizations, which are still in their infancy, could benefit physicians by paying them to coordinate care and reimbursing them for work that keeps costs down for the health care system as a whole, she said.

“We know that to really coordinate the care, to work with the patient's family, to create the community environment and really help to manage these patients, a lot of that is not in the face-to-face visit that we're currently being paid for,” Dr. Heim said.

New health plans will soon be required to offer a range of recommended preventive health services to patients free of charge under the Affordable Care Act.

The requirements will affect new private health plans in the individual and group markets starting with plan years that began on or after Sept. 23. The Health and Human Services department estimates that in 2011, the rules will affect about 30 million people in group health plans and an additional 10 million in individual market plans.

The rules do not apply to grandfathered plans.

Under the final rule, health plans may not collect copayments, coinsurance, or deductibles for numerous recommended preventive services. However, they might collect fees for the associated office visit if the preventive service wasn't the primary purpose of the visit.

Patients might also incur cost sharing if they go out of network for the recommended screenings.

The covered services include those given an evidence rating of “A” or “B” from the U.S. Preventive Services Task Force.

Those services include screening for depression for adults and adolescents; HIV, colon cancer, diabetes, blood pressure and cholesterol testing; obesity counseling for adults and children; and counseling to prevent sexually transmitted infections and for tobacco cessation.

The rule also calls for coverage of additional preventive services for women, which will be developed by an independent group of experts. The task force now recommends screening for hepatitis B virus infection in pregnant women at their first prenatal visit.

Health plans will have some extra time to begin covering newly recommended services. For recommendations that have been in effect for less than a year, plans will have 1 year to comply after the effective date.

A list of the recommended preventive services is available online at www.healthcare.gov/center/regulations/prevention/recommendations.html

New health plans will soon be required to offer a range of recommended preventive health services to patients free of charge under the Affordable Care Act.

The requirements will affect new private health plans in the individual and group markets starting with plan years that began on or after Sept. 23. The Health and Human Services department estimates that in 2011, the rules will affect about 30 million people in group health plans and an additional 10 million in individual market plans.

The rules do not apply to grandfathered plans.

Under the final rule, health plans may not collect copayments, coinsurance, or deductibles for numerous recommended preventive services. However, they might collect fees for the associated office visit if the preventive service wasn't the primary purpose of the visit.

Patients might also incur cost sharing if they go out of network for the recommended screenings.

The covered services include those given an evidence rating of “A” or “B” from the U.S. Preventive Services Task Force.

Those services include screening for depression for adults and adolescents; HIV, colon cancer, diabetes, blood pressure and cholesterol testing; obesity counseling for adults and children; and counseling to prevent sexually transmitted infections and for tobacco cessation.

The rule also calls for coverage of additional preventive services for women, which will be developed by an independent group of experts. The task force now recommends screening for hepatitis B virus infection in pregnant women at their first prenatal visit.

Health plans will have some extra time to begin covering newly recommended services. For recommendations that have been in effect for less than a year, plans will have 1 year to comply after the effective date.

A list of the recommended preventive services is available online at www.healthcare.gov/center/regulations/prevention/recommendations.html

New health plans will soon be required to offer a range of recommended preventive health services to patients free of charge under the Affordable Care Act.

The requirements will affect new private health plans in the individual and group markets starting with plan years that began on or after Sept. 23. The Health and Human Services department estimates that in 2011, the rules will affect about 30 million people in group health plans and an additional 10 million in individual market plans.

The rules do not apply to grandfathered plans.

Under the final rule, health plans may not collect copayments, coinsurance, or deductibles for numerous recommended preventive services. However, they might collect fees for the associated office visit if the preventive service wasn't the primary purpose of the visit.

Patients might also incur cost sharing if they go out of network for the recommended screenings.

The covered services include those given an evidence rating of “A” or “B” from the U.S. Preventive Services Task Force.

Those services include screening for depression for adults and adolescents; HIV, colon cancer, diabetes, blood pressure and cholesterol testing; obesity counseling for adults and children; and counseling to prevent sexually transmitted infections and for tobacco cessation.

The rule also calls for coverage of additional preventive services for women, which will be developed by an independent group of experts. The task force now recommends screening for hepatitis B virus infection in pregnant women at their first prenatal visit.

Health plans will have some extra time to begin covering newly recommended services. For recommendations that have been in effect for less than a year, plans will have 1 year to comply after the effective date.

A list of the recommended preventive services is available online at www.healthcare.gov/center/regulations/prevention/recommendations.html

Dr. Sanjay Saint and his colleagues at the Veterans Affairs Medical Center in Ann Arbor, Mich., are turning the inpatient service there into a laboratory, trying to create the ideal hospital experience for patients.

The project, called the “Gold Service,” began over the summer and is a small part of Dr. Saint’s decade-long quest to curb hospital-acquired complications and infections.

Dr. Saint, a professor of internal medicine at the University of Michigan, said he strives to bring the same type of prevention focus that general internists bring to the outpatient setting to the most vulnerable patients in the hospital. “I wanted to apply that framework to those patients who are so sick that if they actually get a complication under our watch, that could tip them over and it could mean that either they die or they never go home,” he said.

For the last 9 years, Dr. Saint has served as director of the Patient Safety Enhancement Program at the Ann Arbor VA Medical Center and the University of Michigan Health System. In this latest project, he is working to create an inpatient service that is highly efficient and effective, achieves a high level of safety, and keeps patients satisfied, while also fulfilling the research and education missions of the VA and the University of Michigan.

The overall goal, Dr. Saint said, is to provide the type of care that physicians would want for their own family members.

In practice, that means translating research into practice more quickly, providing appropriate oversight of residents and medical students, and improving communications across disciplines. On his service, they provide reading lists to learners, encourage better communication between nurses and physicians, and conduct multidisciplinary rounds.

Dr. Saint also urges the hospitalists and attending physicians to practice what they preach. For example, physicians can talk about the importance of preventing nosocomial infections, but if they don’t wash their hands before and after touching the patient, it doesn’t matter what they say. “Learners see that,” he said.

Although there are no data to report from the project so far, Dr. Saint said they plan to measure their progress on several metrics and compare them to those of other services. Specifically, they hope to examine mortality, readmission rates, nosocomial infection rates, hand hygiene adherence rates, length of stay, patient and nurse satisfaction, and teaching evaluations.

The project is just getting off the ground, but Dr. Saint said they have already encountered challenges. One issue is overcoming the “outdated” mindset that physicians, nurses, and social workers should operate in separate silos, he said, rather than functioning as a true health care team. Ultimately, he hopes physicians and nurses will spend less time worrying about what’s in their job descriptions and more time figuring out how to make the patient “the central focus,” Dr. Saint said.

Another challenge is balancing some of the trade-offs between quality and resource utilization. For example, keeping patients in the hospital slightly longer could increase their satisfaction and potentially decrease readmission rates, but increasing the length of stay has other drawbacks. “We have to look at all these things not in a vacuum, but at how they interrelate,” he said.

If he and his team are successful in improving patient care through the Gold Service, Dr. Saint hopes to see the lessons picked up by all kinds of hospitals, not just in the United States, but in countries all around the world. Since the research is being done at a VA facility, which is part of a large, centralized system, other countries with centralized health care systems like Canada, England, Italy, and France may be able to make similar changes, he said.

Dr. Sanjay Saint and his colleagues at the Veterans Affairs Medical Center in Ann Arbor, Mich., are turning the inpatient service there into a laboratory, trying to create the ideal hospital experience for patients.

The project, called the “Gold Service,” began over the summer and is a small part of Dr. Saint’s decade-long quest to curb hospital-acquired complications and infections.

Dr. Saint, a professor of internal medicine at the University of Michigan, said he strives to bring the same type of prevention focus that general internists bring to the outpatient setting to the most vulnerable patients in the hospital. “I wanted to apply that framework to those patients who are so sick that if they actually get a complication under our watch, that could tip them over and it could mean that either they die or they never go home,” he said.

For the last 9 years, Dr. Saint has served as director of the Patient Safety Enhancement Program at the Ann Arbor VA Medical Center and the University of Michigan Health System. In this latest project, he is working to create an inpatient service that is highly efficient and effective, achieves a high level of safety, and keeps patients satisfied, while also fulfilling the research and education missions of the VA and the University of Michigan.

The overall goal, Dr. Saint said, is to provide the type of care that physicians would want for their own family members.

In practice, that means translating research into practice more quickly, providing appropriate oversight of residents and medical students, and improving communications across disciplines. On his service, they provide reading lists to learners, encourage better communication between nurses and physicians, and conduct multidisciplinary rounds.

Dr. Saint also urges the hospitalists and attending physicians to practice what they preach. For example, physicians can talk about the importance of preventing nosocomial infections, but if they don’t wash their hands before and after touching the patient, it doesn’t matter what they say. “Learners see that,” he said.

Although there are no data to report from the project so far, Dr. Saint said they plan to measure their progress on several metrics and compare them to those of other services. Specifically, they hope to examine mortality, readmission rates, nosocomial infection rates, hand hygiene adherence rates, length of stay, patient and nurse satisfaction, and teaching evaluations.

The project is just getting off the ground, but Dr. Saint said they have already encountered challenges. One issue is overcoming the “outdated” mindset that physicians, nurses, and social workers should operate in separate silos, he said, rather than functioning as a true health care team. Ultimately, he hopes physicians and nurses will spend less time worrying about what’s in their job descriptions and more time figuring out how to make the patient “the central focus,” Dr. Saint said.

Another challenge is balancing some of the trade-offs between quality and resource utilization. For example, keeping patients in the hospital slightly longer could increase their satisfaction and potentially decrease readmission rates, but increasing the length of stay has other drawbacks. “We have to look at all these things not in a vacuum, but at how they interrelate,” he said.

If he and his team are successful in improving patient care through the Gold Service, Dr. Saint hopes to see the lessons picked up by all kinds of hospitals, not just in the United States, but in countries all around the world. Since the research is being done at a VA facility, which is part of a large, centralized system, other countries with centralized health care systems like Canada, England, Italy, and France may be able to make similar changes, he said.

Dr. Sanjay Saint and his colleagues at the Veterans Affairs Medical Center in Ann Arbor, Mich., are turning the inpatient service there into a laboratory, trying to create the ideal hospital experience for patients.

The project, called the “Gold Service,” began over the summer and is a small part of Dr. Saint’s decade-long quest to curb hospital-acquired complications and infections.

Dr. Saint, a professor of internal medicine at the University of Michigan, said he strives to bring the same type of prevention focus that general internists bring to the outpatient setting to the most vulnerable patients in the hospital. “I wanted to apply that framework to those patients who are so sick that if they actually get a complication under our watch, that could tip them over and it could mean that either they die or they never go home,” he said.

For the last 9 years, Dr. Saint has served as director of the Patient Safety Enhancement Program at the Ann Arbor VA Medical Center and the University of Michigan Health System. In this latest project, he is working to create an inpatient service that is highly efficient and effective, achieves a high level of safety, and keeps patients satisfied, while also fulfilling the research and education missions of the VA and the University of Michigan.

The overall goal, Dr. Saint said, is to provide the type of care that physicians would want for their own family members.

In practice, that means translating research into practice more quickly, providing appropriate oversight of residents and medical students, and improving communications across disciplines. On his service, they provide reading lists to learners, encourage better communication between nurses and physicians, and conduct multidisciplinary rounds.

Dr. Saint also urges the hospitalists and attending physicians to practice what they preach. For example, physicians can talk about the importance of preventing nosocomial infections, but if they don’t wash their hands before and after touching the patient, it doesn’t matter what they say. “Learners see that,” he said.

Although there are no data to report from the project so far, Dr. Saint said they plan to measure their progress on several metrics and compare them to those of other services. Specifically, they hope to examine mortality, readmission rates, nosocomial infection rates, hand hygiene adherence rates, length of stay, patient and nurse satisfaction, and teaching evaluations.

The project is just getting off the ground, but Dr. Saint said they have already encountered challenges. One issue is overcoming the “outdated” mindset that physicians, nurses, and social workers should operate in separate silos, he said, rather than functioning as a true health care team. Ultimately, he hopes physicians and nurses will spend less time worrying about what’s in their job descriptions and more time figuring out how to make the patient “the central focus,” Dr. Saint said.

Another challenge is balancing some of the trade-offs between quality and resource utilization. For example, keeping patients in the hospital slightly longer could increase their satisfaction and potentially decrease readmission rates, but increasing the length of stay has other drawbacks. “We have to look at all these things not in a vacuum, but at how they interrelate,” he said.

If he and his team are successful in improving patient care through the Gold Service, Dr. Saint hopes to see the lessons picked up by all kinds of hospitals, not just in the United States, but in countries all around the world. Since the research is being done at a VA facility, which is part of a large, centralized system, other countries with centralized health care systems like Canada, England, Italy, and France may be able to make similar changes, he said.

For Dr. Karen Wilson, research holds the key to improving the care of hospitalized children.

As an assistant professor of pediatric hospital medicine at the University of Rochester (N.Y.), Dr. Wilson has spent the last few years studying how secondhand smoke affects children, especially the high-risk children who end up hospitalized for respiratory illnesses.

Despite widespread recognition that secondhand smoke is bad for children, scientists don’t really understand the underlying pathophysiology, she said. “We haven’t really looked at what it does to kids on the cellular level, but I think that if we knew what it did to kids on [that] level there would be a lot more pressure for there to be absolutely no smoking around children ever.”

For her part, Dr. Wilson is currently collecting data on cytokine levels in healthy children. This data can later be compared with data from hospitalized children to provide evidence about the impact of secondhand smoke.

She recently completed a study looking at the effectiveness of screening children for secondhand smoke exposure in the inpatient setting. She and her colleagues compared what was documented in the chart regarding exposure, information from parent interviews, and measurements of cotinine levels in the children. They found that physicians aren’t doing a very good job of identifying children who have been exposed to secondhand smoke, she said.

For her next project, Dr. Wilson is hoping to take her research to the cellular level – looking at the cellular effects of secondhand smoke and how those changes relate to the severity of illness in hospitalized children. Once researchers have achieved a better understanding of the actual effects of secondhand smoke exposure, the information could be used to develop therapeutic interventions.

Dr. Wilson said she can envision a scenario someday when physicians could use a biochemical profile to determine whether children are at increased risk for complications from a respiratory illness.

On the policy and prevention side, Dr. Wilson said she hopes that being able to document biologic changes in children who have been exposed to secondhand smoke will give physicians more leverage with parents and policy makers in advocating avoidance of smoking around children.

Dr. Wilson is a member of a small group of pediatric hospitalists who are doing research on the effects of secondhand smoke exposure. Part of the problem is that pediatric hospital medicine is a new subspecialty and there are few fellowships, particularly ones that focus on research skills. But the field is starting to expand, she said.

“There are so many important questions that need to be answered, and there are a number of people doing great work,” she said. “There’s just not enough to do all the work that needs to be done at this point.”

Training a cadre of research-focused physicians in pediatric hospital medicine is essential to improving the quality of care for children, Dr. Wilson said. Without evidence from rigorous studies, pediatric hospitalists are left to rely too heavily on case studies or “eminence-based” medicine.

“I strongly believe that in order to provide the best care for children, we need to have a strong base of research that informs those decisions,” she said.

Dr. Wilson’s work is funded by the AAP Julius B. Richmond Center of Excellence, the Flight Attendant Medical Research Institute, and the National Institutes of Health.

For Dr. Karen Wilson, research holds the key to improving the care of hospitalized children.

As an assistant professor of pediatric hospital medicine at the University of Rochester (N.Y.), Dr. Wilson has spent the last few years studying how secondhand smoke affects children, especially the high-risk children who end up hospitalized for respiratory illnesses.

Despite widespread recognition that secondhand smoke is bad for children, scientists don’t really understand the underlying pathophysiology, she said. “We haven’t really looked at what it does to kids on the cellular level, but I think that if we knew what it did to kids on [that] level there would be a lot more pressure for there to be absolutely no smoking around children ever.”

For her part, Dr. Wilson is currently collecting data on cytokine levels in healthy children. This data can later be compared with data from hospitalized children to provide evidence about the impact of secondhand smoke.

She recently completed a study looking at the effectiveness of screening children for secondhand smoke exposure in the inpatient setting. She and her colleagues compared what was documented in the chart regarding exposure, information from parent interviews, and measurements of cotinine levels in the children. They found that physicians aren’t doing a very good job of identifying children who have been exposed to secondhand smoke, she said.

For her next project, Dr. Wilson is hoping to take her research to the cellular level – looking at the cellular effects of secondhand smoke and how those changes relate to the severity of illness in hospitalized children. Once researchers have achieved a better understanding of the actual effects of secondhand smoke exposure, the information could be used to develop therapeutic interventions.

Dr. Wilson said she can envision a scenario someday when physicians could use a biochemical profile to determine whether children are at increased risk for complications from a respiratory illness.

On the policy and prevention side, Dr. Wilson said she hopes that being able to document biologic changes in children who have been exposed to secondhand smoke will give physicians more leverage with parents and policy makers in advocating avoidance of smoking around children.

Dr. Wilson is a member of a small group of pediatric hospitalists who are doing research on the effects of secondhand smoke exposure. Part of the problem is that pediatric hospital medicine is a new subspecialty and there are few fellowships, particularly ones that focus on research skills. But the field is starting to expand, she said.

“There are so many important questions that need to be answered, and there are a number of people doing great work,” she said. “There’s just not enough to do all the work that needs to be done at this point.”

Training a cadre of research-focused physicians in pediatric hospital medicine is essential to improving the quality of care for children, Dr. Wilson said. Without evidence from rigorous studies, pediatric hospitalists are left to rely too heavily on case studies or “eminence-based” medicine.

“I strongly believe that in order to provide the best care for children, we need to have a strong base of research that informs those decisions,” she said.

Dr. Wilson’s work is funded by the AAP Julius B. Richmond Center of Excellence, the Flight Attendant Medical Research Institute, and the National Institutes of Health.

For Dr. Karen Wilson, research holds the key to improving the care of hospitalized children.

As an assistant professor of pediatric hospital medicine at the University of Rochester (N.Y.), Dr. Wilson has spent the last few years studying how secondhand smoke affects children, especially the high-risk children who end up hospitalized for respiratory illnesses.

Despite widespread recognition that secondhand smoke is bad for children, scientists don’t really understand the underlying pathophysiology, she said. “We haven’t really looked at what it does to kids on the cellular level, but I think that if we knew what it did to kids on [that] level there would be a lot more pressure for there to be absolutely no smoking around children ever.”

For her part, Dr. Wilson is currently collecting data on cytokine levels in healthy children. This data can later be compared with data from hospitalized children to provide evidence about the impact of secondhand smoke.

She recently completed a study looking at the effectiveness of screening children for secondhand smoke exposure in the inpatient setting. She and her colleagues compared what was documented in the chart regarding exposure, information from parent interviews, and measurements of cotinine levels in the children. They found that physicians aren’t doing a very good job of identifying children who have been exposed to secondhand smoke, she said.

For her next project, Dr. Wilson is hoping to take her research to the cellular level – looking at the cellular effects of secondhand smoke and how those changes relate to the severity of illness in hospitalized children. Once researchers have achieved a better understanding of the actual effects of secondhand smoke exposure, the information could be used to develop therapeutic interventions.

Dr. Wilson said she can envision a scenario someday when physicians could use a biochemical profile to determine whether children are at increased risk for complications from a respiratory illness.

On the policy and prevention side, Dr. Wilson said she hopes that being able to document biologic changes in children who have been exposed to secondhand smoke will give physicians more leverage with parents and policy makers in advocating avoidance of smoking around children.

Dr. Wilson is a member of a small group of pediatric hospitalists who are doing research on the effects of secondhand smoke exposure. Part of the problem is that pediatric hospital medicine is a new subspecialty and there are few fellowships, particularly ones that focus on research skills. But the field is starting to expand, she said.

“There are so many important questions that need to be answered, and there are a number of people doing great work,” she said. “There’s just not enough to do all the work that needs to be done at this point.”

Training a cadre of research-focused physicians in pediatric hospital medicine is essential to improving the quality of care for children, Dr. Wilson said. Without evidence from rigorous studies, pediatric hospitalists are left to rely too heavily on case studies or “eminence-based” medicine.

“I strongly believe that in order to provide the best care for children, we need to have a strong base of research that informs those decisions,” she said.

Dr. Wilson’s work is funded by the AAP Julius B. Richmond Center of Excellence, the Flight Attendant Medical Research Institute, and the National Institutes of Health.

As the first editor-in-chief of the Journal of Hospital Medicine, Dr. Mark V. Williams has been helping to shape the first draft of the history of this new field.

In that role, he has watched hospital medicine grow and mature. The peer-reviewed journal, which was launched in January 2006, was once home to articles aimed at proving the value of adding hospitalists to an institution’s roster. But now most articles focus on how to optimize care within the hospitalist model and how to more efficiently manage the hospital itself.

“We have actually rejected articles in the recent past that were descriptions of the implementation of a hospitalist program,” Dr. Williams said. “That’s already been done.”

Dr. Williams, who currently serves as chief of the division of hospital medicine at the Northwestern University Feinberg School of Medicine and Northwestern Memorial Hospital in Chicago, is a former president of the Society of Hospital Medicine and in 1998 established the first hospitalist program at a public hospital at Grady Memorial Hospital in Atlanta.

Despite his credentials, Dr. Williams said he was a little anxious about accepting the job as editor-in-chief of the Journal of Hospital Medicine back in 2005. Having never served as an editor of a journal, he didn’t know what to expect. But his training in evidence-based medicine and the team of editors assembled by the Society of Hospital Medicine have made the job a lot of fun, he said.

The job has not been without challenges, he said, but not always the ones he was expecting. Going into the position with a newly launched journal in a new field, Dr. Williams said he was expecting to have trouble finding high-quality research articles to fill all the pages. It turned out that his biggest challenge has been sorting through the large volume of submissions and having to reject interesting articles. Dr. Williams and the rest of the staff have tried to address this by publishing more articles online, and in the future they hope to expand both the number of issues of the journal and the number of pages in each issue.

The volume of submissions shows that hospital medicine is maturing as a field, he said.

“There has never been a journal focused on care delivery in the hospital, and yet this is where one-third of federal health care funding is expended,” he said. “I think it was a natural.”

The volume of high-quality research being conducted by hospitalists is only likely to grow, Dr. Williams said, as academic institutions begin establishing divisions of hospital medicine and devoting research dollars to this area. For example, the Northwestern University Feinberg School of Medicine, where he works, has just hired four hospitalists who will devote the majority of their time to research on hospital medicine. Additionally, many other physicians at the institution are involved in smaller research projects.

“It’s this investment in hospital medicine research that’s going to grow the entire field long term, demonstrating the importance of hospitalists in improving care delivery and quality improvement at hospitals,” Dr. Williams said.

As for the journal, Dr. Williams sees his next big task as helping to prepare to hand over the reins to the next editor. He also wants to stabilize the size and frequency of the journal, and hopes to see it become a monthly publication sometime in the next 2 years. But he’s pleased with the journal’s progress so far. For instance, the journal was listed in Medline, the National Library of Medicine’s bibliographic medical database, in its first year. And a recent measurement of the journal’s “impact factor,” or how often it is cited by other journals, also showed that it is gaining credibility within the larger research community.

“I’ve been surprised that we’ve achieved everything that we set out to do so fast,” Dr. Williams said.

As the first editor-in-chief of the Journal of Hospital Medicine, Dr. Mark V. Williams has been helping to shape the first draft of the history of this new field.

In that role, he has watched hospital medicine grow and mature. The peer-reviewed journal, which was launched in January 2006, was once home to articles aimed at proving the value of adding hospitalists to an institution’s roster. But now most articles focus on how to optimize care within the hospitalist model and how to more efficiently manage the hospital itself.

“We have actually rejected articles in the recent past that were descriptions of the implementation of a hospitalist program,” Dr. Williams said. “That’s already been done.”

Dr. Williams, who currently serves as chief of the division of hospital medicine at the Northwestern University Feinberg School of Medicine and Northwestern Memorial Hospital in Chicago, is a former president of the Society of Hospital Medicine and in 1998 established the first hospitalist program at a public hospital at Grady Memorial Hospital in Atlanta.

Despite his credentials, Dr. Williams said he was a little anxious about accepting the job as editor-in-chief of the Journal of Hospital Medicine back in 2005. Having never served as an editor of a journal, he didn’t know what to expect. But his training in evidence-based medicine and the team of editors assembled by the Society of Hospital Medicine have made the job a lot of fun, he said.

The job has not been without challenges, he said, but not always the ones he was expecting. Going into the position with a newly launched journal in a new field, Dr. Williams said he was expecting to have trouble finding high-quality research articles to fill all the pages. It turned out that his biggest challenge has been sorting through the large volume of submissions and having to reject interesting articles. Dr. Williams and the rest of the staff have tried to address this by publishing more articles online, and in the future they hope to expand both the number of issues of the journal and the number of pages in each issue.

The volume of submissions shows that hospital medicine is maturing as a field, he said.

“There has never been a journal focused on care delivery in the hospital, and yet this is where one-third of federal health care funding is expended,” he said. “I think it was a natural.”

The volume of high-quality research being conducted by hospitalists is only likely to grow, Dr. Williams said, as academic institutions begin establishing divisions of hospital medicine and devoting research dollars to this area. For example, the Northwestern University Feinberg School of Medicine, where he works, has just hired four hospitalists who will devote the majority of their time to research on hospital medicine. Additionally, many other physicians at the institution are involved in smaller research projects.

“It’s this investment in hospital medicine research that’s going to grow the entire field long term, demonstrating the importance of hospitalists in improving care delivery and quality improvement at hospitals,” Dr. Williams said.

As for the journal, Dr. Williams sees his next big task as helping to prepare to hand over the reins to the next editor. He also wants to stabilize the size and frequency of the journal, and hopes to see it become a monthly publication sometime in the next 2 years. But he’s pleased with the journal’s progress so far. For instance, the journal was listed in Medline, the National Library of Medicine’s bibliographic medical database, in its first year. And a recent measurement of the journal’s “impact factor,” or how often it is cited by other journals, also showed that it is gaining credibility within the larger research community.

“I’ve been surprised that we’ve achieved everything that we set out to do so fast,” Dr. Williams said.

As the first editor-in-chief of the Journal of Hospital Medicine, Dr. Mark V. Williams has been helping to shape the first draft of the history of this new field.

In that role, he has watched hospital medicine grow and mature. The peer-reviewed journal, which was launched in January 2006, was once home to articles aimed at proving the value of adding hospitalists to an institution’s roster. But now most articles focus on how to optimize care within the hospitalist model and how to more efficiently manage the hospital itself.

“We have actually rejected articles in the recent past that were descriptions of the implementation of a hospitalist program,” Dr. Williams said. “That’s already been done.”

Dr. Williams, who currently serves as chief of the division of hospital medicine at the Northwestern University Feinberg School of Medicine and Northwestern Memorial Hospital in Chicago, is a former president of the Society of Hospital Medicine and in 1998 established the first hospitalist program at a public hospital at Grady Memorial Hospital in Atlanta.

Despite his credentials, Dr. Williams said he was a little anxious about accepting the job as editor-in-chief of the Journal of Hospital Medicine back in 2005. Having never served as an editor of a journal, he didn’t know what to expect. But his training in evidence-based medicine and the team of editors assembled by the Society of Hospital Medicine have made the job a lot of fun, he said.

The job has not been without challenges, he said, but not always the ones he was expecting. Going into the position with a newly launched journal in a new field, Dr. Williams said he was expecting to have trouble finding high-quality research articles to fill all the pages. It turned out that his biggest challenge has been sorting through the large volume of submissions and having to reject interesting articles. Dr. Williams and the rest of the staff have tried to address this by publishing more articles online, and in the future they hope to expand both the number of issues of the journal and the number of pages in each issue.

The volume of submissions shows that hospital medicine is maturing as a field, he said.

“There has never been a journal focused on care delivery in the hospital, and yet this is where one-third of federal health care funding is expended,” he said. “I think it was a natural.”

The volume of high-quality research being conducted by hospitalists is only likely to grow, Dr. Williams said, as academic institutions begin establishing divisions of hospital medicine and devoting research dollars to this area. For example, the Northwestern University Feinberg School of Medicine, where he works, has just hired four hospitalists who will devote the majority of their time to research on hospital medicine. Additionally, many other physicians at the institution are involved in smaller research projects.

“It’s this investment in hospital medicine research that’s going to grow the entire field long term, demonstrating the importance of hospitalists in improving care delivery and quality improvement at hospitals,” Dr. Williams said.

As for the journal, Dr. Williams sees his next big task as helping to prepare to hand over the reins to the next editor. He also wants to stabilize the size and frequency of the journal, and hopes to see it become a monthly publication sometime in the next 2 years. But he’s pleased with the journal’s progress so far. For instance, the journal was listed in Medline, the National Library of Medicine’s bibliographic medical database, in its first year. And a recent measurement of the journal’s “impact factor,” or how often it is cited by other journals, also showed that it is gaining credibility within the larger research community.

“I’ve been surprised that we’ve achieved everything that we set out to do so fast,” Dr. Williams said.

After spending nearly 3 years in Washington working on current health policy issues, Dr. Patrick Conway, a pediatric hospitalist, is eager to get back to caring for patients.

In 2007, he began a 1-year appointment to the White House Fellowship Program, a nonpartisan program that pairs young people from a cross-section of professions with senior leaders in the federal government. After a year working with then Health and Human Services Secretary Michael Leavitt and Dr. Carolyn Clancy, director of the Agency for Healthcare Research and Quality, Dr. Conway was offered a position as chief medical officer in the secretary’s policy division at HHS. In that role he worked on quality measurement and links to payment, health information technology, comparative effectiveness research, and the hot topic of the day – health care reform.

Today he is back in the trenches, working as director of the hospital medicine division at Cincinnati Children’s Hospital. Dr. Conway said the experience in Washington gave him a better sense of the big picture, and he wants to apply that broader view to how he does things in Cincinnati. With that in mind, he and his colleagues in hospital medicine are considering starting an intermediate care unit and are investigating a potential regional expansion to more community hospitals. Dr. Conway said he wants to develop a long-term vision for how to improve outcomes for children, while performing his essential day-to-day responsibilities.

“Even though taking care of 25% of the kids who come to our $1 billion health care system is a huge chore, I’m also looking at what we need to do in the future,” he said.

A large part of that effort will involve measurement. As part of the strategic planning process, the hospital medicine group is identifying key conditions, such as asthma, where physicians think they can make substantial improvements. Dr. Conway said they will track performance in those key areas.

He also wants to measure performance at the individual physician level. Right now, hospitalists at Cincinnati Children’s Hospital typically don’t know their individual performance metrics, but Dr. Conway said that needs to change. He wants all the Cincinnati Children’s hospitalists to get a report card that lets them know how they are performing on measures such as readmissions, billing, and adherence to clinical practice guidelines.

“I’m a big believer in physician feedback,” he said.

Dr. Conway will be bringing his insider’s view of health care reform to his work in Cincinnati, but he said all hospitalists should be thinking about how the recently enacted Affordable Care Act will affect them. His personal opinion is that some of the key elements will offer opportunities for hospitalists to shine.

For example, the Affordable Care Act puts an increased focus on reducing hospital readmissions, which is an area where many hospitalist programs are already doing a lot of work, Dr. Conway said. “I think we have a huge potential role to play in decreasing readmissions and improving transitions of care,” he said.

Another area where health care reform will touch the lives of hospitalists is in value-based purchasing for hospitals. Under this initiative, Medicare will pay hospitals more if they provide higher-quality care, and less if they don’t. That means that if a hospitalist group does a consistent job of improving care, it will have a significant impact on the hospital’s bottom line, which in turn is likely give hospitalist groups greater leverage in negotiating their contracts, he said.

“By definition, some hospitals will win and some hospitals will lose,” Dr. Conway said. “However, potentially almost all, or most, hospitalist programs will win through our focus on delivering higher-quality care to patients.”

Patrick Conway

After spending nearly 3 years in Washington working on current health policy issues, Dr. Patrick Conway, a pediatric hospitalist, is eager to get back to caring for patients.

In 2007, he began a 1-year appointment to the White House Fellowship Program, a nonpartisan program that pairs young people from a cross-section of professions with senior leaders in the federal government. After a year working with then Health and Human Services Secretary Michael Leavitt and Dr. Carolyn Clancy, director of the Agency for Healthcare Research and Quality, Dr. Conway was offered a position as chief medical officer in the secretary’s policy division at HHS. In that role he worked on quality measurement and links to payment, health information technology, comparative effectiveness research, and the hot topic of the day – health care reform.

Today he is back in the trenches, working as director of the hospital medicine division at Cincinnati Children’s Hospital. Dr. Conway said the experience in Washington gave him a better sense of the big picture, and he wants to apply that broader view to how he does things in Cincinnati. With that in mind, he and his colleagues in hospital medicine are considering starting an intermediate care unit and are investigating a potential regional expansion to more community hospitals. Dr. Conway said he wants to develop a long-term vision for how to improve outcomes for children, while performing his essential day-to-day responsibilities.

“Even though taking care of 25% of the kids who come to our $1 billion health care system is a huge chore, I’m also looking at what we need to do in the future,” he said.

A large part of that effort will involve measurement. As part of the strategic planning process, the hospital medicine group is identifying key conditions, such as asthma, where physicians think they can make substantial improvements. Dr. Conway said they will track performance in those key areas.

He also wants to measure performance at the individual physician level. Right now, hospitalists at Cincinnati Children’s Hospital typically don’t know their individual performance metrics, but Dr. Conway said that needs to change. He wants all the Cincinnati Children’s hospitalists to get a report card that lets them know how they are performing on measures such as readmissions, billing, and adherence to clinical practice guidelines.

“I’m a big believer in physician feedback,” he said.

Dr. Conway will be bringing his insider’s view of health care reform to his work in Cincinnati, but he said all hospitalists should be thinking about how the recently enacted Affordable Care Act will affect them. His personal opinion is that some of the key elements will offer opportunities for hospitalists to shine.

For example, the Affordable Care Act puts an increased focus on reducing hospital readmissions, which is an area where many hospitalist programs are already doing a lot of work, Dr. Conway said. “I think we have a huge potential role to play in decreasing readmissions and improving transitions of care,” he said.

Another area where health care reform will touch the lives of hospitalists is in value-based purchasing for hospitals. Under this initiative, Medicare will pay hospitals more if they provide higher-quality care, and less if they don’t. That means that if a hospitalist group does a consistent job of improving care, it will have a significant impact on the hospital’s bottom line, which in turn is likely give hospitalist groups greater leverage in negotiating their contracts, he said.

“By definition, some hospitals will win and some hospitals will lose,” Dr. Conway said. “However, potentially almost all, or most, hospitalist programs will win through our focus on delivering higher-quality care to patients.”

Patrick Conway

After spending nearly 3 years in Washington working on current health policy issues, Dr. Patrick Conway, a pediatric hospitalist, is eager to get back to caring for patients.

In 2007, he began a 1-year appointment to the White House Fellowship Program, a nonpartisan program that pairs young people from a cross-section of professions with senior leaders in the federal government. After a year working with then Health and Human Services Secretary Michael Leavitt and Dr. Carolyn Clancy, director of the Agency for Healthcare Research and Quality, Dr. Conway was offered a position as chief medical officer in the secretary’s policy division at HHS. In that role he worked on quality measurement and links to payment, health information technology, comparative effectiveness research, and the hot topic of the day – health care reform.

Today he is back in the trenches, working as director of the hospital medicine division at Cincinnati Children’s Hospital. Dr. Conway said the experience in Washington gave him a better sense of the big picture, and he wants to apply that broader view to how he does things in Cincinnati. With that in mind, he and his colleagues in hospital medicine are considering starting an intermediate care unit and are investigating a potential regional expansion to more community hospitals. Dr. Conway said he wants to develop a long-term vision for how to improve outcomes for children, while performing his essential day-to-day responsibilities.

“Even though taking care of 25% of the kids who come to our $1 billion health care system is a huge chore, I’m also looking at what we need to do in the future,” he said.

A large part of that effort will involve measurement. As part of the strategic planning process, the hospital medicine group is identifying key conditions, such as asthma, where physicians think they can make substantial improvements. Dr. Conway said they will track performance in those key areas.

He also wants to measure performance at the individual physician level. Right now, hospitalists at Cincinnati Children’s Hospital typically don’t know their individual performance metrics, but Dr. Conway said that needs to change. He wants all the Cincinnati Children’s hospitalists to get a report card that lets them know how they are performing on measures such as readmissions, billing, and adherence to clinical practice guidelines.

“I’m a big believer in physician feedback,” he said.

Dr. Conway will be bringing his insider’s view of health care reform to his work in Cincinnati, but he said all hospitalists should be thinking about how the recently enacted Affordable Care Act will affect them. His personal opinion is that some of the key elements will offer opportunities for hospitalists to shine.

For example, the Affordable Care Act puts an increased focus on reducing hospital readmissions, which is an area where many hospitalist programs are already doing a lot of work, Dr. Conway said. “I think we have a huge potential role to play in decreasing readmissions and improving transitions of care,” he said.

Another area where health care reform will touch the lives of hospitalists is in value-based purchasing for hospitals. Under this initiative, Medicare will pay hospitals more if they provide higher-quality care, and less if they don’t. That means that if a hospitalist group does a consistent job of improving care, it will have a significant impact on the hospital’s bottom line, which in turn is likely give hospitalist groups greater leverage in negotiating their contracts, he said.

“By definition, some hospitals will win and some hospitals will lose,” Dr. Conway said. “However, potentially almost all, or most, hospitalist programs will win through our focus on delivering higher-quality care to patients.”

Patrick Conway

Dr. William Ford knows that working “collaboratively” can be kind of an overused buzzword in medicine, but he also knows that it works.

At least that’s the case at Temple University Hospital in Philadelphia where taking a collaborative approach has made the hospitalist-run observation unit a success.

The hospitalist group at Temple launched the observation unit in early 2007 with 18 beds and about 130 admissions per month. Today, they average 340-380 admissions per month and are planning to expand to 36 beds in the fall.

“It is the cornerstone of our institution,” said Dr. Ford, chief of the section of hospital medicine at Temple and medical director for Cogent Healthcare.

The unit, known at Temple as the clinical decision unit, is a bit different from a conventional observation unit. Rather than handling mostly chest pain patients for 24-hour observation, patients in the clinical decision unit stay 2-48 hours, and the admission criteria include chest pain, heart failure, pneumonia, asthma, simple cellulitis, syncope, and seizures.

The results are encouraging. The length of stay in the clinical decision unit is 0.8-1.2 days shorter for those patients than for similar patients who receive cared in other parts of the hospital. “That’s obviously a huge cost savings for the hospital,” Dr. Ford said.

The key to their success has been the processes used in the unit, he said, which include reliance on multidisciplinary team rounding, regular audits of performance, and weekly meetings among the hospitalists, nurses, and hospital administrators. The unit also tries to keep the lines of communication open with the emergency department and provides the physicians working there with strict criteria for admitting patients to the clinical decision unit.

Dr. Ford and his team also routinely use protocols that they developed, including order sets for asthma, chronic obstructive pulmonary disorder, chest pain, and heart failure.

Although the clinical decision unit has been a success, Dr. Ford cautioned other hospitalists that there are some pitfalls. Hospitals need to be vigilant about making sure they have correct documentation to show that they are compliant with Medicare and Medicaid rules in the unit. Otherwise, they could be penalized in an audit. Hospitalist programs should also consider rotating the physicians who work in the unit. The work can be intense, he said, so physicians rotate back out to their regular duty after a few months. The hospitalists who work in Temple’s clinical decision unit typically round on 18-22 patients during a 12-hour shift, and discharge about half of those.

As Dr. Ford and his team have shown success in managing the clinical decision unit and shortening the length of stay, hospital officials have called on them to take on more responsibility for quality throughout the hospital. The hospitalist group is now responsible for deep vein thrombosis rates, glycemic control, and urinary tract infections for all patients, not just those under their direct care.

It’s a challenge, Dr. Ford said, but the group is approaching it the same way they did the observation unit: collaboratively. For example, they are working with the hospital’s diabetic care committee to influence the education of the nursing staff and the residents on glycemic control. They are also working with the pharmacists to set up standard drug protocols.

“It’s that type of indirect influence” that is critical to hospitalists’ success. Dr. Ford said. “As a specialty, that’s where we’re headed.”

Dr. William Ford knows that working “collaboratively” can be kind of an overused buzzword in medicine, but he also knows that it works.

At least that’s the case at Temple University Hospital in Philadelphia where taking a collaborative approach has made the hospitalist-run observation unit a success.

The hospitalist group at Temple launched the observation unit in early 2007 with 18 beds and about 130 admissions per month. Today, they average 340-380 admissions per month and are planning to expand to 36 beds in the fall.

“It is the cornerstone of our institution,” said Dr. Ford, chief of the section of hospital medicine at Temple and medical director for Cogent Healthcare.

The unit, known at Temple as the clinical decision unit, is a bit different from a conventional observation unit. Rather than handling mostly chest pain patients for 24-hour observation, patients in the clinical decision unit stay 2-48 hours, and the admission criteria include chest pain, heart failure, pneumonia, asthma, simple cellulitis, syncope, and seizures.

The results are encouraging. The length of stay in the clinical decision unit is 0.8-1.2 days shorter for those patients than for similar patients who receive cared in other parts of the hospital. “That’s obviously a huge cost savings for the hospital,” Dr. Ford said.

The key to their success has been the processes used in the unit, he said, which include reliance on multidisciplinary team rounding, regular audits of performance, and weekly meetings among the hospitalists, nurses, and hospital administrators. The unit also tries to keep the lines of communication open with the emergency department and provides the physicians working there with strict criteria for admitting patients to the clinical decision unit.

Dr. Ford and his team also routinely use protocols that they developed, including order sets for asthma, chronic obstructive pulmonary disorder, chest pain, and heart failure.

Although the clinical decision unit has been a success, Dr. Ford cautioned other hospitalists that there are some pitfalls. Hospitals need to be vigilant about making sure they have correct documentation to show that they are compliant with Medicare and Medicaid rules in the unit. Otherwise, they could be penalized in an audit. Hospitalist programs should also consider rotating the physicians who work in the unit. The work can be intense, he said, so physicians rotate back out to their regular duty after a few months. The hospitalists who work in Temple’s clinical decision unit typically round on 18-22 patients during a 12-hour shift, and discharge about half of those.

As Dr. Ford and his team have shown success in managing the clinical decision unit and shortening the length of stay, hospital officials have called on them to take on more responsibility for quality throughout the hospital. The hospitalist group is now responsible for deep vein thrombosis rates, glycemic control, and urinary tract infections for all patients, not just those under their direct care.

It’s a challenge, Dr. Ford said, but the group is approaching it the same way they did the observation unit: collaboratively. For example, they are working with the hospital’s diabetic care committee to influence the education of the nursing staff and the residents on glycemic control. They are also working with the pharmacists to set up standard drug protocols.

“It’s that type of indirect influence” that is critical to hospitalists’ success. Dr. Ford said. “As a specialty, that’s where we’re headed.”

Dr. William Ford knows that working “collaboratively” can be kind of an overused buzzword in medicine, but he also knows that it works.

At least that’s the case at Temple University Hospital in Philadelphia where taking a collaborative approach has made the hospitalist-run observation unit a success.

The hospitalist group at Temple launched the observation unit in early 2007 with 18 beds and about 130 admissions per month. Today, they average 340-380 admissions per month and are planning to expand to 36 beds in the fall.

“It is the cornerstone of our institution,” said Dr. Ford, chief of the section of hospital medicine at Temple and medical director for Cogent Healthcare.

The unit, known at Temple as the clinical decision unit, is a bit different from a conventional observation unit. Rather than handling mostly chest pain patients for 24-hour observation, patients in the clinical decision unit stay 2-48 hours, and the admission criteria include chest pain, heart failure, pneumonia, asthma, simple cellulitis, syncope, and seizures.

The results are encouraging. The length of stay in the clinical decision unit is 0.8-1.2 days shorter for those patients than for similar patients who receive cared in other parts of the hospital. “That’s obviously a huge cost savings for the hospital,” Dr. Ford said.

The key to their success has been the processes used in the unit, he said, which include reliance on multidisciplinary team rounding, regular audits of performance, and weekly meetings among the hospitalists, nurses, and hospital administrators. The unit also tries to keep the lines of communication open with the emergency department and provides the physicians working there with strict criteria for admitting patients to the clinical decision unit.

Dr. Ford and his team also routinely use protocols that they developed, including order sets for asthma, chronic obstructive pulmonary disorder, chest pain, and heart failure.

Although the clinical decision unit has been a success, Dr. Ford cautioned other hospitalists that there are some pitfalls. Hospitals need to be vigilant about making sure they have correct documentation to show that they are compliant with Medicare and Medicaid rules in the unit. Otherwise, they could be penalized in an audit. Hospitalist programs should also consider rotating the physicians who work in the unit. The work can be intense, he said, so physicians rotate back out to their regular duty after a few months. The hospitalists who work in Temple’s clinical decision unit typically round on 18-22 patients during a 12-hour shift, and discharge about half of those.

As Dr. Ford and his team have shown success in managing the clinical decision unit and shortening the length of stay, hospital officials have called on them to take on more responsibility for quality throughout the hospital. The hospitalist group is now responsible for deep vein thrombosis rates, glycemic control, and urinary tract infections for all patients, not just those under their direct care.

It’s a challenge, Dr. Ford said, but the group is approaching it the same way they did the observation unit: collaboratively. For example, they are working with the hospital’s diabetic care committee to influence the education of the nursing staff and the residents on glycemic control. They are also working with the pharmacists to set up standard drug protocols.

“It’s that type of indirect influence” that is critical to hospitalists’ success. Dr. Ford said. “As a specialty, that’s where we’re headed.”