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Paid For Being Special


It’s official. I am a “recognized” hospitalist. I’m certified. I’m special.

Although I’ve always felt that HM was special, that it’s a field with its own defined body of knowledge, area of expertise, and dedicated providers, it is now official. It is special; I am special. I got the letter in the mail the other day to prove it.

The correspondence arrived in an important-looking white envelope, with a return address stamped with the “American Board of Internal Medicine” insignia. The letter itself congratulated me on becoming a member of the first class of internists to complete their Maintenance of Certification (MOC) with Recognition of Focused Practice in Hospital Medicine (FPHM). As you’ve no doubt heard, the ABIM developed this MOC process to recognize hospitalists who’ve been in practice for at least three years after their initial certification in internal medicine (IM).

This is the first ABIM certification program that recognizes physician expertise in a field that is not tied directly to either residency or specialty fellowship training. In other words, unlike the cardiology certification exam, which requires a physician to have completed a fellowship training program, the FPHM allows for clinical experience to substitute for fellowship training. While the FPHM does not confer true “specialty status” (like the cardiology certification exam does), it does, as the moniker implies, recognize that we have focused our practice.

This is a massive step forward for HM, as it lends significant credibility to the work we do and helps the public better understand what a hospitalist is and does.

Implicit within that is the understanding that this focus brings with it a level of expertise that distinguishes hospitalists from nonhospitalists. This is a massive step forward for HM, as it lends significant credibility to the work we do and helps the public better understand what a hospitalist is and does. Most important, it helps set apart that cadre of true hospitalists who are dedicating their careers to fundamentally improving the care and outcomes of hospitalized patients.

It is this last point that came to mind as I reviewed this month’s cover story on value-based purchasing (see “Value-Based Purchasing Raises the Stakes,” p. 1).

Sticky Yet Crucial Point

One of the sticking points that I’ve heard from some hospitalists is that the FPHM requires a three-year cycle of self-evaluation. For those new to this process, let’s clear up some of the nomenclature. When IM residents graduate, they are eligible to sit for the ABIM certification exam. Upon passage, they are board-certified internists and can choose to enter into the maintenance of certification process. This is a 10-year process whereby diplomates (ABIM-speak for those certified as a specialist, with a diploma in medicine; not to be confused with a diplomat—a person who conducts negotiations and maintains political rest through the tactful handling of delicate situations, something perhaps more appropriate to the bulk of patient situations we encounter) must complete self-evaluation of medical knowledge modules, self-evaluation of practice performance, and ultimately a secure exam. This is where the FPHM differs.

The 10-year cycle for MOC is maintained for FPHM, such that diplomates only recertify every 10 years. However, the self-evaluation must occur every three years to maintain one’s certification. In other words, fail to keep up with the self-evaluation process, and your FPHM is revoked. This is different than the MOC for IM, and it is why some hospitalists are choosing not to enroll in the FPHM. This is a mistake.

Unnecessary Burden?

For many hospitalists, this extra evaluation, especially the practice improvement, is seen as an undue burden. Why is it that hospitalists should have to do more frequent self-evaluation than other specialists? My answer is that this is an important part of what defines our hospitalist specialty—that is, our ability to go beyond the individual patient encounter to fundamentally improve outcomes for the patients under our care. This is not done through “good doctoring.” Hospitalists are not necessarily better doctors than nonhospitalists. Rather, we have embodied a commitment to process and quality improvement within the hospital. This is what our patients need from us. This is what makes us hospitalists. This is what makes us special.

And this brings me back to value-based purchasing.

The Next Phase: Purchasing Value

For those of you, like me, who struggle to comprehend what buying value actually means, take a few minutes to peruse Bryn Nelson’s cover story this month. Not only will it help you understand the healthcare reform bill, it will help you understand the future of our field. I’ve personally witnessed HM traverse three distinct phases.

In the late 1990s and early 2000s, HM growth was driven by the need to improve efficiency. In most ways, this was code for reducing costs. Hospital executives recognized that hospitalists could reduce the overall costs of a patient admission, thus turning the balance of the prospective payment into profit. In other words, the amount of money a hospital receives for a patient stay is most often fixed and determined up front (prospectively), such that more efficiently moving patients through the system equates to more profit (or less loss).

This growth phase was quickly supplanted by the volume phase—a phase that was driven by the relative departure of primary-care physicians and subspecialists from the hospital. Although some of these doctors still admit their own patients, most of them now take advantage of hospitalist programs to focus their own practice to the outpatient or procedural arenas. Effectively, many of the other doctors have left the house, and hospitalists have had to back-fill this patient volume. To a certain degree, we are all still filling this need.

Connect the Dots

However, it is clear that the next HM driver is going to be quality. And it is programs like VBP that will drive it. Essentially, VBP means that hospitals will be competing with each other to be the best. By best, I mean “most able” to achieve pre-determined quality, safety, and patient-satisfaction indicators. By competing, I mean the reimbursement pie is fixed and those who achieve will get more, and those who fall short will get less.

When you consider that as much as 2% of a hospital’s Medicare reimbursement will soon be at risk, we are talking about millions of dollars per hospital per year. To hospitals with a 1% to 2% profit margin, this is the difference between being in or out of business. It also is interestingly close to the amount of support most hospitals give their HM groups; the exact groups that touch the majority of the patients that will determine their VBP outcomes. Connect the dots, and you can see that your hospitalist group—indeed, your paycheck—is very much at risk.

Which brings me back to the FPHM. In a serendipitous turn of events, the FPHM not only recognizes hospitalists as “special,” but, more important, it also gives us the opportunity to simultaneously enhance both our patients’ outcomes and our compensation. If we get this right, the every-three-year improvement projects required to maintain your certification are exactly the type of work you’ll need to be doing to achieve the outcomes your hospital needs to maintain its Medicare payments. In turn, this will ensure your group maintains its hospital support, and you, your paycheck.

It’s the kind of work that will ensure the best possible outcomes for our patients. And in the end, that, more than an ABIM certificate, is what truly makes us special. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

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