Public reporting will highlight variation among hospitals, programs, and, possibly, physicians. Parents and payers will vote with their feet. Overall, this will create less variation in care as best practices are identified and adopted. Shortcomings will be revealed in programs that fail to practice state-of-the-art pediatrics or that are inadequately staffed from either the physician or nursing perspective. This likely will result in a consolidation of pediatric care. Smaller units closer to larger pediatric centers probably will close or become affiliates of the referral center. Geographic proximity will be a secondary concern to outcomes for parents and office-based pediatricians.
The methodological and political considerations of pay for performance are beyond most of us. Nonetheless, we in pediatric HM can begin to prepare for these changes by identifying the benchmarks that highlight our successes and failures as hospitalists, groups, hospitals, and the field as a whole. Potential clinical, quality, economic, and logistic metrics include severity-adjusted lengths of stay (LOS) for asthma and bronchiolitis, readmission rates, time to antibiotics for ruling out sepsis less than 30 days, patient and referring physician satisfaction, and coordination of transitions of care.
Expand children’s health insurance: SCHIP and universal insurance for children enjoys significant support.
The AAP’s efforts in this area deserve praise and demand continued support. As noted previously, large public expenditures on SCHIP likely will be linked to public reporting of outcomes. It is crucial to the economic viability of pediatrics that SCHIP reimbursement is equivalent to Medicare reimbursement on a code-for-code basis. It is indefensible to suggest that we as a nation value the care of children less than the care of the elderly.
Ultimately, SCHIP and state Medicaid programs would do well to move beyond a per diem-based system of reimbursement for pediatric inpatient care to a system based either on diagnosis-related groups (DRGs) or disease episodes. This would benefit HM programs by rewarding hospitals that can shorten LOS while providing the same high-quality outcomes. Current per diem reimbursement paradigms at best fail to maximally encourage efficiency and at worst create perverse incentives to prolong LOS.
Relentlessly pursue career satisfaction: Many programs are asking pediatric hospitalists to work at a clinical pace not sustainable over a 20- to 30-year career. Particularly efficient programs can produce burnout in one to three years of excessive workloads and call obligations.
SHM’s “A White Paper on Hospitalist Career Satisfaction” identifies four pillars: reward/recognition, workload/schedule, autonomy/control, and community/environment. (Each pillar has been featured in the “Career Development” section, starting with the June issue.) In pediatrics we can turn to neonatology, pediatric critical care, and (pediatric) emergency medicine for help in establishing realistic guidelines for clinical hours in house.
The harder question to answer is: What is a reasonable number of patients for a hospitalist to cover at a time? This depends on patient acuity, patient and family expectations, teaching responsibilities, hospitalist responsibilities outside the ward, and physician style. It is unlikely that prospective randomized controlled trials will be conducted to answer this question. The answer is likely to come from individual programs, hospitalists, and—regrettably—patients suffering the consequences of pushing the limits too far. We will learn from our mistakes. Failed models will not be repeated. To the extent that quality rather than economics becomes the overriding driver for HM programs, I favor 15 encounters per hospitalist per day over 20.
Hospitalists also must diversify beyond pure clinical practice for long-term career satisfaction. Focusing on a specific clinical interest, subspecialty, or practice environment can provide some variety.
Teaching and research is another source of career satisfaction. Each hospitalist within a group should be involved in at least one QI project and/or committee—if only to appreciate the importance and complexity of a systems approach to improving overall outcomes. Job descriptions must include protected time for these nonclinical activities. Career growth and satisfaction will be stifled without these additional outlets.