Hospitalists can cut LOS, help get MCO contracts
A new breed of physician leader for hospitals
Managed care organizations’ emphasis on keeping inpatient hospital stays as short and as cost-effective as possible has led to a new breed of physician specialists being increasingly employed by hospitals and health systems: the hospitalist.
Although the concept is fairly new, organizations adopting this approach report shorter lengths of stay with no decrease in patient satisfaction.
Growing numbers of hospitals across the country are switching to the hospitalist model in treating hospitalized patients, and some are finding this has helped with managed care contracts.
The model still is so new that no comprehensive studies have been conducted. But anecdotal evidence and initial outcomes suggest that hospitals that use hospitalists instead of the traditional intensivists have lower lengths of stay with no decrease in patient satisfaction.
Scripps Clinic Medical Group in La Jolla, CA, for example, conducted a study comparing the use of hospitalists with the traditional model and found that patient satisfaction was no different.
Hospitalists specialize in inpatient medicine and see no patients outside of the hospital setting. This differs from the traditional model of physicians treating their own patients in the outpatient clinic and then seeing them in the hospital when they’re seriously ill.
Experts say the hospitalist model will make a PHO more efficient and cuts its costs in several ways because of the following benefits:
• Hospitalists develop more skills in treating the very sick.
The hospitalists become more skilled in treating hospitalized patients. They may see 12 to 15 patients in the hospital each day, while the community physician may treat only a few hospitalized patients each week. This can reduce referrals to specialists because the hospitalist is more likely to feel confident about unilaterally making treatment decisions.
• Organizations can become more productive.
When organizations assign all inpatient visits to hospitalists, the community physicians become more productive because they’re no longer driving to and from the hospital and making rounds.
• It can stop duplication.
The hospitalist model can eliminate duplication of services because one physician will see the same patient all week and know exactly what was prescribed and ordered the day before. Under the traditional model, two or three different community physicians might make rounds each week at a hospital, so duplication is possible.
• Hospitalists can lower lengths of stay.
Hospitalists can help lower the patient’s length of stay because they are always available to work with patients and hospital staff in discharging patients. For example, a hospital might schedule a patient to be discharged at 3 p.m., but if the patient’s physician is busy at the outpatient clinic until 7 p.m. that day, then the discharge will be delayed by four hours. The hospitalist easily could be there at 3 p.m.
A Massachusetts hospital that has had hospitalists for more than four years has found that using a hospitalist model has helped in arranging managed care contracts, including one with Kaiser Permanente of Oakland, CA. (See story on how hospitals can make hospitalist model attractive to managed care organizations, p. 138.)
"The managed care organizations like to see that you’re committed to efficiency, so with our utilization data we’re showing we’re able to be efficient and are improving with efficiency over time," says Winthrop F. Whitcomb, MD, one of seven hospitalists at Mercy Hospital of Springfield, MA. Mercy Hospital has 200 beds and serves a medium-sized city and outlying areas.
Mercy Hospital’s raw data, not adjusted for severity, showed a significant reduction in length of stay for patients treated by hospitalists during an 11-month period in 1996. The patients were hospitalized for five different diseases, including pneumonia, congestive heart failure, stroke, complicated urinary tract infection, and chronic obstructive pulmonary disease.
The same study showed lower costs for each of these except for the urinary tract infections, which had nearly identical costs.
Park Nicollet Medical Group of Minneapolis, MN, started using hospitalists about five years ago and now has four physicians who work solely in the hospital. Other physicians in the 400 physician multispecialty group rotate turns as hospitalists.
The medical group studied the number of consultations with specialty services under the new hospitalist model and the traditional model and discovered that the number of consultations dropped by 20%, says Tom Schmidt, MD, internist and administrator of the Park Nicollet group.
"In the old system, it was not uncommon for a primary care doctor to ask for consultation with a specialist every day," Schmidt says. "Now that you have one doctor handling the patients, there’s not as much consultation because the [hospitalists] have more experience."
Also, Schmidt says, "In the old model, if a primary doctor was called away during the day, he’d have to call someone else because he couldn’t get away from his practice."
Whitcomb and John Nelson, MD, a hospitalist from Gainesville, FL, have founded the National Association of Inpatient Physicians to serve as an information forum for hospitalists.
Nelson says the association’s mailing list has grown to 1,000 hospitalists since it was formed in January 1997. "We estimate there are between 1,500 and 2,000 hospitalists practicing now, and the number is growing explosively," Nelson adds.
Nelson’s five physician hospitalist group in Gainesville was founded 10 years ago, long before managed care pressures made the model more attractive to PHOs. "We became very successful when people in Gainesville didn’t know what the word meant, and I know other markets where the same thing happened," Nelson says.
"Twenty years ago a primary care doctor might have had 10 people in the hospital; maybe two or three were very sick and the other seven were just getting tests," he explains. "Now that same doctor will have only two or three very sick people in the hospital at the same time."
It’s difficult for physicians to become skilled at treating these hospitalized patients when he or she sees so few cases, Nelson adds.
"It only makes sense for some people to try to become experts at either the kinds of things the doctor needs to be good at in the hospital or the kinds of things the doctor needs to be good at in the outpatient center," he says.
Nelson says preliminary findings show that hospitalized patients treated by his group have a lower length of stay of about one-half a day for the top 10 DRGs than the patients treated by traditional physicians. This reduces costs by $400-$700 per patient, he adds.
Scripps Clinic Medical Group, a 273-physician group in La Jolla, CA, started using hospitalists in 1992, although the group lacked full physician support.
"We pitched it to our different clinics, and half said yes,’ and the largest clinic said no,’" recalls Dan Dworsky, MD, vice president and medical director of the resource management department at Scripps in La Jolla.
So Scripps started using hospitalists and compared the outcomes of the patients seen by the hospitalists with those of the patients seen in the usual way.
The results showed a 16% to 18% decrease in lengths of stay for the patients seen by the hospitalists and a similar reduction in charges per day, Dworsky states.
Two other indicators, patient satisfaction and readmission rates, were the same for both models. "So we didn’t have a bump in readmission rates; patients were happy with our care, and we cut costs," Dworsky says.
Eventually the entire physicians’ group switched to the hospitalist model. (See story on how to switch to the hospitalist model, p. 138.)
The hospitalist model can reduce lengths of stay because a physician is always on hand to see how a patient is doing, experts say.
Hospitalists can make several visits
Traditionally, a patient’s community physician would visit the patient once during morning rounds before starting an outpatient practice and once in the evening after the practice. The hospitalist could see that same patient several times in the day.
"You have people routinely looking at these hospitalized people, saying Can I discharge you? When can I discharge you?’ says Sandra McGraw, MBA, JD, principle with The Health Care Group of Plymouth Meeting, PA. The group is a medical practice consulting firm that consults on operational efficiencies, physician organizations, staffing, and legal arrangements.
McGraw says the hospitalist model can help PHOs’ bottom line because 90% of the PHOs benefit financially from cost saving measures.
Creating hospitalist positions also could benefit an integrated delivery system by enhancing the continuity of care and improving communication between the hospital staff and physicians, says Randy Killian, MBA, MS, executive vice president of American Association of Integrated Healthcare Delivery Systems in Glen Allen, VA. The nonprofit health care association advises health care groups on how to be successful with managed care and an integrated delivery system.
"Assuming that your hospitalist is working five or six days a week making rounds, you have the same continuity of care, with the same provider making visits and interacting with the patient all week," Killian says.
He gives this example of how this continuity can lower costs by eliminating duplication of services and referrals to specialists: "A lot of times if a physician walks into a patient’s room and talks with Mrs. Bailey, Mrs. Bailey might say I have chest pains,’ and then the physician will order a referral to a cardiologist," Killian says. "He might not know that the previous day the doctor making rounds issued an EKG and everything was normal."
Killian says the hospitalist likely saw Mrs. Bailey the previous day, so he would know that her heart is all right.
Hospitalists also will get to know the hospital staff and become part of the team in an integrated delivery system, Killian adds.
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