Emerging MD specialty can help you cut costs, optimize LOS
Hospitalists focus on inpatient care, acute care needs
If the hospitalist movement hasn’t reached your facility by now, you’ll probably see its inception soon. Increasingly, hospital administrators and payers are pushing for the integration of inpatient-only practitioners into the medical staff because they see them as a way to achieve high-quality, cost-effective care. Who is this new breed of physician, and how could hospitalists affect quality of care and the bottom line at your institution?
Statistics regarding hospitalist outcomes don’t exist yet because the concept is so new. Raw data on length of stay and cost per case for five DRGs have been gathered and documented by Winthrop Whitcomb, MD, however, who established a seven-doctor hospitalist group in Springfield, MA. He says the evidence, though preliminary, gives an indication of how effectively fledgling hospitalist programs can improve a hospital’s bottom line.
"The program has demonstrably improved quality of care at Mercy Hospital," Whitcomb says. (See bar graphs showing raw data on length of stay and cost per case, p. 62. The figures compare Whitcomb’s hospitalist group with the rest of Mercy Hospital’s medical staff. The data have not been adjusted for severity of illness.)
Quality has to be better
Hospitalists are specialists in inpatient medicine. Distinct from hospital intensivists, the hospitalist works within the hospital exclusively. The more traditional intensivist manages acute care inpatients, but may have a private practice as well, depending upon how busy the in-hospital program is. (See related story on where hospitalists come from, p. 64.)
Hospitalist programs improve quality of care because, put simply, the more you do something, the better you get at it. Hospitalists treat high volumes of exclusively inpatient-type medical problems, so they possess sound clinical skills in the management of acute care illness. An internist with an office practice may follow 100 patients a year in the hospital; a hospitalist may see that many in a week.
A hospitalized, acutely ill patient benefits from being seen by a doctor who sees problems of that type all the time and knows the ins and outs of moving a patient through the hospital efficiently.
John C. McDonald, RN, vice president of clinical services for Physicians’ Community Health, a large independent practice association in Brentwood, TN, says they are not quite ready for a hospitalist program, but are definitely headed in that direction.
"Once we institute the program," McDonald says, "quality and utilization of care will be improved because there’ll be less variation in the patient flow process. Instead of lots of doctors being a part of the process and each having their own way of doing things, there’ll be just one or two who are familiar with protocols and know the problem areas. That level of care works."
John R. Nelson, MD, an internist and hospitalist in Gainesville, FL, started his hospitalist group practice, Inpatient Medical Services, in 1988. He says, "If a patient has sepsis, for example, he’s better off seeing a hospitalist who’s treated many patients with that condition over the past year as opposed to being seen by a primary care doctor in a traditional practice who may have treated only one that year."
Whittle away at utilization
The system benefits patients and facility alike, because the doctor in control decides what resources are consumed. Hospitalists tend to deviate less from standards than their colleagues in office practice, so they become highly skilled in utilization management. They generally manage laboratories aggressively, ordering fewer, more precise tests than colleagues in more traditional practices.
"Hospitalists give good medical care in a cost-effective manner," says Nelson. "The fees charged by Inpatient Medical Services tend to be slightly lower than those of internists in traditional practice in this part of the country our overhead is lower but that has little to do with the cost-effectiveness of the hospitalist. You have to whittle down utilization of hospital resources, not doctors’ fees, to save real money."
Hospitalists become more efficient at recognizing and treating inpatient medical problems. They may feel comfortable ordering only one CT scan rather than two, for example, during an episode.
"Even though 20%, for example, is a significant physician fee discount," says Nelson, "the bill for a five-day hospital stay is going to be in the thousands. A 20% fee discount may save $80, but eliminating one CT scan saves $600. In addition, length of stay is decreased with the patient going home half a day earlier. All this adds up to cost savings because the hospital can charge the full DRG without consuming as many resources as expected." At the end of the day, the health care network saves that money by negotiating with the hospital for lower rates.
The Park Nicollet Medical Group in Minneapolis is a large multispecialty practice that utilizes a hybrid hospitalist model two full-time hospitalists complemented by rotating general internists and family physicians.
"We looked at cost and found that we were able to reduce our number of consultations to specialty services by about 20%," says Thomas Schmidt, MD, internist and administrator of the Park Nicollet group. "Patients are better served because a hospitalist is in the hospital 24 hours a day. Care is not turned over to one specialist or another who may be in the hospital half that time.
"Here’s another thing we saw happening," continues Schmidt. "Before the hospitalist service came into effect, we had a large number of specialists who were rendering primary care to their patients by virtue of their disease processes. We’d have pulmonologists, for example, who were the primary caregivers for people with chronic obstructive pulmonary disease. When the hospitalist program got going, specialists began referring their patients to hospitalists for primary care, reserving their time for consultations."
As a result, Park Nicollet’s initial estimations of the staffing needed to run their hospitalist program were too low. "We thought we could manage our population of patients with two hospital services," says Schmidt. "We’ve grown now to five, and will need a sixth by this summer."
Tim Rearick, administrator and director of business development of Shands at AGH Hospital in Gainesville, FL, says, "We created our hospitalist program three or four years ago because, at the time, physicians from three rural hospitals were having difficulty getting their patients taken care of. We needed internists who could admit medical transfers, take care of those patients in the hospital, then discharge them back to the referring physicians. The hospital hired three physicians to fulfill that need." Shands overestimated the demand on the new hires, however, so at first the program was not cost-effective.
"That soon changed, however," continues Rearick. "We came to realize that our hospitalists were treating patients more efficiently than were physicians with outside practices. The in-hospital practitioners were here all the time; office practices didn’t interfere with their availability. And they were very good at what they did. On a gross basis gross average charge per DRG they were working more cost-effectively than physicians in traditional practices.
"So much so, in fact, that we asked them to teach efficiencies to our other physicians. When we implemented clinical pathways last year, the hospitalists were our advocates with the rest of the medical staff. We didn’t have a director of quality management at that point. Today we do, and we plan on asking our quality personnel to work alongside our hospitalist group to evaluate quality issues."
Quality managers agree that assuring the patient that the hospitalist represents his or her primary physician is vital to a successful hospitalist program.
"Park Nicollet’s hospitalist program has been running for two or three years," says Schmidt. "After starting the program, we were eager to see if patients noticed a difference. We had baseline patient satisfaction data on a system where internists hospitalized their own patients and did inpatient care themselves. So we surveyed hospitalist-treated patients to see how their level of satisfaction compared. We found no change. That can be interpreted as a lack of improvement, but on a more positive note, it’s also an indication that our hospitalist system is as satisfactory as the traditional system."
Some patients feel their care becomes fragmented when they are passed from the doctor they saw in the office to a hospitalist. They miss the continuity of care. (See related article on continuity of care, p. 63.) Communication among the office-based physicians, the hospitalists, and patients is of primary importance. "The difficult part for us," continues Schmidt, "has been to convince patients that their primary doc is involved with their care even though they’re not physically managing their care. We’ve addressed that problem by making sure the hospitalists keep the patients’ primary docs continually apprised of their progress. In addition, we encourage the original physicians to do social rounds."
Is the hospitalist program good for Park Nicollet? "On balance, the outcome is good," says Schmidt, "but the outpatient primary care physician has a huge responsibility. It takes due diligence on the part of a patient’s original primary care doctor to maintain contact with the hospitalist and with his patient."
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