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The Boutique Lure

From: The Hospitalist, October 2007

by Dr. Hospitalist

Dr. Hospitalist

The Boutique Lure

Question: I recently received a brochure in the mail about a hospital that caters only to cardiac patients. While I think this job sounds intriguing, I’m concerned that this may be a boutique hospital. What do you think of the movement toward boutique hospitals? Do you think they are ethical?
Curious in Boston

Dr. Hospitalist responds: Boutique or specialty hospitals have been hotly debated among healthcare policymakers over the past few years. Compared with the number of general hospitals, the numbers of specialty hospitals—typically those that focus on cardiac, orthopedic, surgical, and women’s procedures—are small.

A Government Accounting Office (GAO) report in 2003 identified 100 such hospitals in the country. More than two-thirds of the hospitals are in seven states (Arizona, California, Kansas, Oklahoma, Louisiana, South Dakota, and Texas).

The GAO found that compared with general hospitals, specialty hospitals are “much less likely to have emergency departments, treated smaller percentages of Medicaid patients and derived a smaller share of their revenues from inpatient services.” Although small, this is a growing segment of the healthcare industry.

Specialty hospitals are controversial because many are for-profit and often owned by some of the physicians who work at the hospital. Specialty hospital supporters believe competition between specialty and general hospitals for services can lower costs and improve care.

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A 2005 Medicare Payment Advisory Commission study found that physician-owned specialty hospitals decreased lengths of stay but didn’t lower costs for Medicare patients.

In general, specialty hospitals treated less-severe cases and tended to have lower numbers of Medicaid patients than community hospitals.

Specialty care hospital critics are concerned that specialty hospitals take care of the most profitable patients (those who are less ill) and leave the general hospital with the sicker patients who incur higher costs.

They fear growing numbers of specialty hospitals will make it financially difficult for general hospitals to meet all of a community’s needs, including charity care and emergency services.

Critics are also concerned that physician ownership of specialty hospitals could affect physicians’ clinical behavior by driving inappropriate referrals.

You may remember that the federal Stark law (named after Rep. Peter Stark, D-Calif.) generally prohibits physicians from referring Medicare patients for healthcare services to facilities where they have financial interests.

This law was enacted after several studies demonstrated that physicians with ownership interest in clinical laboratories, diagnostic imaging centers, and physical therapy providers made more referrals to these centers and ordered more services at higher costs.

The Stark law lets physicians who have an ownership interest in an entire hospital and are authorized to perform services there to refer patients to that hospital.

As you consider this opportunity, further investigate the risks, benefits, and potential effect of the specialty hospital on your community and our healthcare system.

Some physicians and patients believe medical education outside this country is inferior. In some cases, they are correct—in others, they could not be more wrong. Medical education outside this country varies in standards and curricula.

Holiday Dilemma

Question: I just took over scheduling for our hospitalist group. I’ve been practicing nearly two years and am wondering how to staff holidays. I’m finding it difficult handling the multiple requests for Thanksgiving, Christmas, and New Year’s Eve. Do you know of any innovative scheduling techniques?
Schedule Grinch in Philadelphia

Dr. Hospitalist responds: Congratulations on your new responsibility! I write this with my tongue firmly planted in my cheek. As you now realize, completing the schedule is not easy.

Unfortunately, most hospitalists don’t recognize the enormous challenge one faces in filling the schedule until they are given the task.

Unless you were a chief medical resident, you probably didn’t learn or practice scheduling in the course of your medical training. Inevitably, everyone wants and expects to get their choice of days off. Of course, that is rarely possible.

How do you make everyone happy? It is important to recognize that making everyone happy every time is not possible. But it is possible and important to be fair to everyone all the time. There are some steps you can take to ensure the scheduling process is fair.

The first step is to set appropriate expectations. It is critical for the group leader and the staff member making the schedule to help each group member understand the enormous challenges that come with scheduling.

Providers who understand the difficulties of scheduling will be more understanding and accommodating in their requests.

The second step is to establish and clearly state the rules of engagement. For example, be explicit in explaining the rules for submitting requests and the deadline for requests. Avoid misconceptions by stating when the final schedule will be revealed.

The last step is to clearly state how to handle requests for schedule changes. Many hospitalist groups keep track of who works which holidays so the distribution of work on holidays is fair from year to year.

I have one last suggestion. Consider rotating the job of scheduling so everyone understands firsthand the challenges of the job. To entice people to assume this responsibility, the job should come with remuneration—either salary support and/or preference in choosing their own holiday schedule.

Of course, recognize that not everyone will want the job or be good at it. An effective group leader helps individuals identify opportunities and helps them succeed.

Foreign Medical Grads

Question: What’s your opinion on the effect of foreign medical graduates in the U.S.?
IMG in Cincinnati

Dr. Hospitalist responds: The U.S. healthcare system would be quite different without foreign (aka international) medical graduates (IMGs), who play important clinical, educational, administrative, and research roles.

Some physicians and patients believe medical education outside this country is inferior. In some cases, they are correct—in others, they could not be more wrong. Medical education outside this country varies in standards and curricula.

Many people are not aware that IMGs who wish to enter an Accreditation Council for Graduate Medical Education residency of fellowship program in the United States must have Educational Commission for Foreign Medical Graduates (ECFMG) certification. ECFMG certification requires the applicant to pass a series of examinations, including United States Medical Licensing Examination (USMLE) Steps 1 and 2.

ECFMG certification is also required before an applicant can take Step 3 of the USMLE and is required before a physician can obtain an unrestricted license to practice medicine in the United States.

I suspect some IMGs face discrimination in this country because some may speak with an accent. But truth be told, the United States healthcare system could not exist without the contributions made by IMGs. TH


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