Switching to a hospitalist model is simple
Try these guidelines from the experts
Hospitals across the nation are finding out that they can become more efficient and cost-effective if they adopt a hospitalist model in treating patients admitted to the hospital.
"Managed care likes this model because most people who study this kind of thing believe hospitalists enable you to maintain and perhaps improve on the quality of care while lowering costs at the same time," says John Nelson, MD, a hospitalist with a group practice devoted solely to hospital work in Gainesville, FL.
Nelson says his hospitalist practice is about a half a day shorter on lengths of stay for the top 10 DRGs than the traditional model used at Shands at AGH Hospital in Gainesville.
Making the change to a hospitalist model requires some patience and planning, experts say.
But a physician hospital organization (PHO), hospital, or independent physician’s group can make the change easier by following these guidelines:
1. Assess whether the hospital or PHO can support hospitalists.
A PHO needs to look at the operational efficiency of the group to see if it would be smarter to start a hospitalist service, suggests Sandra McGraw, MBA, JD, principle with The Health Care Group in Plymouth Meeting, PA.
For example, she says, a physician’s group might have 12 out of 30 doctors visiting the hospital each day. "You’re going to take doctors away from seeing patients and driving to the hospital twice a day to do rounds. Is that an efficient way of using doctors?"
In that case, the physician’s group could have one physician do hospital rounds all week while the others see patients at their outpatient clinic, McGraw says. "They could take turns with one physician doing it week one and another physician doing it week two." Or a PHO could hire hospitalists, but this requires a "critical mass," McGraw says.
"In many PHOs there’s a large internal medicine group that’s able to support a hospitalist," she says. Depending on whether the group has a high percentage of elderly patients that might require more hospitalization, the organization could support a hospitalist with anywhere from eight to 14 physicians.
2. Decide whether hospitalists will be hospital employees or in private practice.
Shands at AGH Hospital in Gainesville, FL, started a hospitalist’s service in the early 1990s with two main goals: It was to serve community physicians who did not want to admit patients to the hospital, and it was to admit patients from the hospital’s sister facilities, which are small rural hospitals, says Tim Rearick, director of business development for the 400-bed hospital. Shands at AGH is part of Shands HealthCare, a nonprofit health system affiliated with the University of Florida.
Initially, Rearick says, the hospital hired the physicians. But after a few years, the hospital decided to let this become a private practice.
"We felt after we had some experience with this that the physicians would be more motivated and willing to seek out the referrals and get up in the middle of the night and do all those things you have to do to support a service like this if they were self-employed," he explains.
3. Aim for buy-in among physicians.
Mercy Hospital in Springfield, MA, held extensive meetings with the medical staff prior to establishing a hospitalist model in July 1993, says Winthrop F. Whitcomb, MD, one of seven hospitalists at Mercy.
"It turned out the medical staff was getting tired of taking unassigned patients from the emergency room patients who had no doctor," Whitcomb says.
Still there were a few local physicians who felt threatened by the concept. "You have a pie, and then you have another party that’s wanting a piece," he explains.
Slowly, these doctors were won over after the hospitalists group began working. The physicians saw that the hospitalists would do their admissions at night and relieve them of the responsibility of caring for unassigned patients, Whitcomb says.
"As they became more comfortable with this new group of doctors they felt less threatened, and now the reception is excellent."
4. Decide the hospitalists’ schedule.
Some areas, including Nelson’s group in Gainesville, FL, might have private practice hospitalists who simply take referrals from any area physicians.
Others, such as Scripps Clinic Medical Group in La Jolla, CA, have no full-time hospitalists. Physicians volunteer to perform hospitalist duties on a rotational model, says Dan Dworsky, MD, vice president and medical director of the resource management department at Scripps.
The hospitalist’s schedule starts on Thursday and typically runs through the weekend, so they’ll typically follow the same patients over the weekend, Dworsky says.
The hospitalists admit on average two to three patients a day, and they will round on 13 to 15 patients.
Park Nicollet Medical Group of Minneapolis has four full-time hospitalists, and others work as hospitalists on a rotating basis, says Tom Schmidt, MD, internist and administrator.
"The physicians we’ve got spending all of their time in the hospital have chosen that as a more rewarding career for them. They don’t like seeing the mundane problems and like to see patients who are critically ill," Schmidt explains.
"The folks who rotate through that service like the excitement and challenge of different patients but also like the continuity and day-to-day work of a clinical practice."
5. Set up billing and establish fees.
Typically, the hospitalists bill patients’ insurers in the same way a primary care physician would bill them. It works like a referral to a specialist, in which the primary care physician is charged nothing for sending the patient to the hospitalist.
PHOs vary in how they pay hospitalists who are part of the group.
Scripps Clinic pays the hospitalists a stipend of money during their week of rotation that keeps their salaries the same as when they’re working in the outpatient clinic, Dworsky says.
"Some doctors like to do hospital work, and it’s more interesting for them," Dworsky explains. "But we don’t want them to lose any money we want to make sure their income stays the same."
Rearick says Shands at AGH pays the hospitalists a stipend for additional services.
"You can construct these things a million different ways, but in our case we call this a medical director’s fee," Rearick says.
"The stipend covers them being available and taking all patients regardless of their ability to pay, and it covers their educating the medical staff on resource utilization and being advocates for resource control."
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