Savings and satisfaction — what’s not to like about hospitalist programs?
One caveat: Primary care physicians must buy into the patient handoff
Keeping your hospital’s physicians happy in a world of increasing administrative responsibility and decreasing reimbursement is difficult. But what if you could offer them a way to spend more time in their offices seeing patients while still ensuring that your inpatient population gets the best possible care? And what if you could also improve the way you look to managed care organizations by decreasing your length of stays (LOS) and improving outcomes?
This isn’t some fantasy. By starting up a hospitalist program, you could achieve all of those at your facility. But first, you must see that the primary care physicians and specialists admitting patients to your facility see the value — to their practices and the hospital — of handing off responsibility for their hospitalized patients to the staff doctor known as a hospitalist.
Hospitalists act as intermediaries, taking on the management of inpatients, whether they are admitted through your emergency department, come in for an illness, or a surgical procedure. They coordinate care and report back to primary care physicians or specialists.
Proponents of the hospitalist model focus many of their arguments on the basis of economics. "On average, most places that have developed hospitalist programs have seen decreases in patient care costs and LOS of about 20%," says Robert M. Wachter, MD, in the department of medicine at the University of California in San Francisco.
Other major advantages of the hospitalist model, as published in a 1998 report by the Council on Medical Service of the American Medical Association (AMA), The Emerging Use of Hospitalists, include:
• Improved quality of care and clinical outcomes in the inpatient setting due to the increased expertise and experience of hospitalists, particularly with respect to severely ill patients.
• Improved efficiency and patient satisfaction in the inpatient setting, because the hospitalist is available throughout the entire day to see hospitalized patients and assess potential admissions from the emergency room.
• Improved quality, efficiency, and patient satisfaction in the outpatient setting, because the practice of the office-based physician is not interrupted by inpatient rounds and midday emergencies with hospitalized patients, and time is not wasted traveling to and from the hospital.
• Enhanced "accountability" and "investment" in the hospital quality improvement process, due to the hospitalist being located in the hospital for a considerable portion of each day.
Controversy causes backlash
There are a number of potential disadvantages to the hospitalist model — one of which, in the eyes of many, counterbalances all the purported benefits.
"When the primary physician doesn’t follow the patient into the hospital, the continuity of care is negatively affected," according to Lanny Copeland, MD, president of the American Academy of Family Physicians.
This is a valid concern, says Winthrop F. Whitcomb, MD, co-president of the National Association of Inpatient Physicians (NAIP). "The handoff’ of the patient from primary physician to hospitalist upon admission is definitely the weak link in the chain," he notes. "When care is transferred from one physician to another, there is typically a voltage drop’ in information that goes along with the patient."
Copeland also has other concerns. "Cost savings [resulting from hospitalist use] have been talked about — but I have seen no figures to substantiate it as cost-effective," he says. "Indeed, I sometimes wonder if a hospitalist who does not know a patient — despite having discussed the patient with the primary physician — may be more inclined to order more in the way of studies and tests."
While the final jury may still be out on whether the hospitalist model saves health care payer dollars, "Managed care companies are looking at preliminary data showing hospitalists cut costs by roughly 10% to 25%," says Whitcomb. As a result, many MCOs, primarily in Texas, Missouri, and Florida, "are requiring their primary care physicians to hand off hospital care — effectively mandating the use of hospitalists."
This approach has caused a backlash on the part of primary care physicians and organized medicine, according to Whitcomb. This is unfortunate, he says.
"It is critical that primary physicians be vested in the success of the hospitalist model — because it is a good model for outpatient, as well as inpatient care," says Whitcomb. "When primary physicians hand off to hospitalists, it changes the way they practice office medicine," he notes. "We’ve seen data showing that access, wait times, and patient satisfaction in outpatient settings improves with the use of hospitalists, because of the increased availability of primary physicians who aren’t making trips to the hospital any more."
Making the model work
The key to making the hospitalist model work in today’s health care system is to make the "handoff at the hospital" voluntary, which is the official NAIP position, according to Whitcomb. "The primary physician has to endorse the hospitalist to the patient, introduce the patient to what is going on, and assure the patient that there will be continued communication between the primary physician and the hospitalist," he explains. Cooperation between the two caregivers is essential to avoiding the "voltage drop" phenomenon, says Whitcomb. At the same time, "this cooperation will not occur under the `mandatory’ hospitalist model."
Physicians Inpatient Care (PIC), an Austin, TX-based independent, physician-owned hospitalist group, has brought successful in-patient management programs to several hospitals in its market. The 13-physician group recently started a program at Texas Medical Center in San Marcos.
In the eight months of operation, medical director Rubin Harris, MD, says internists and other primary care physicians have come to appreciate the freedom that having a hospitalist program in their community brings.
There is also less of a wait in the emergency department, as hospitalists have sped up admissions to the hospital or otherwise taken over determining what care a patient needs to have. "You don’t have to beg someone to come and take care of patients who have no regular doctor," he says. "We are there to do that, to make their job easier."
The group is still compiling LOS and costs per admission data, but if the San Marcos facility is like the others at which PIC works, there will be successes in those areas, too. Outcomes will also likely improve, says Harris. "We are in the hospital all day long and can nip potential problems in the bud as they happen."
Overcoming community fears
To build a successful hospitalist program does take some effort, says Dorothy Merriwether, president of D. Merriwether & Associates, a Houston consulting firm that has worked with PIC in the past.
There are attitudinal barriers to overcome, she says. For instance, the local primary care community may worry that the program will expand into outpatient management, and the hospitalists will take their patients away. But that wasn’t an issue with PIC, which was formed to run hospitalist programs alone, freeing up primary care physicians to spend more time in their office seeing more patients.
"From the perspective of the hospital administrator, this is a great selling point to physicians," says Harris. "They will have better quality of life, they will be able to spend more time in their practice. You end up with a happy medical staff that want to be in the hospital."
There are also some wider community concerns that you will have to address, Merriwether says. The community may be concerned that hospitalist programs will be made mandatory.
Merriwether worked with one hospital that tried it that way initially. It was a dismal failure, and the hospital had to backtrack and make the program voluntary. Meanwhile, there were many bridges to rebuild with area physicians. In this instance, PIC was adamant that its program be voluntary. This appeals to physicians, as well as patients. "The most successful programs are always a matter of physician and family choice."
Once you overcome those fears, though, you can educate the community about the benefits they and their loved ones will receive from these kinds of programs. Patients and their families have more access to a physician to answer questions. "They have the peace of mind of knowing that the physician is in the building," she says.
In San Marcos, there weren’t as many fears about the program as there may be in other markets — in part because PIC had launched a successful program in Austin. Local primary care physicians who wanted to "get out of the hospital business" approached PIC to start a program in San Marcos so that their patients wouldn’t have to be referred to Austin, says Merriwether.
Now, in addition to the primary care community, referrals are coming from subspecialists, such as orthopedic surgeons. They may take care of a hip fracture patient initially, but they are very interested in having hospitalists manage the care of those patients who may have multiple health problems, Harris says.
It’s not an indigent care program
Even though it was an easier sell in San Marcos, PIC still faced another common problem: making sure the program was structured so that it didn’t become an indigent care program. Often, Merriwether explains, hospitals will look to hospitalist programs as a way to deal with unassigned patients — those who come through the emergency room with no primary care physician.
"You have to make it clear what will happen with unassigned patients," says Harris. PIC has an agreement with community internists that those patients without a physician will be doled out on a rotating basis. "If a patient comes in, I find out who is on call on a given day for unassigned patients," Harris explains. "I call and make arrangements for their follow-up care, discuss the case, and fill out a discharge form with all the pertinent data. That makes sure no one falls through the cracks, and they don’t end up back in the hospital. That would defeat the purpose." (For a sample discharge form, see p. 112.)
"It’s a real mistake to implement a program without this kind of support," says Merriwether. "Otherwise, it becomes an indigent care program, and the hospitalist sees no one but indigent and unassigned patients. A true hospitalist takes care of all patients, both referred and unassigned."
If you do make that kind of mistake, adds Harris, you’ll end up with burned out hospitalists who never become part of the medical community. The net result: A group of physicians who don’t deliver the kind of results you expect or of which they are capable.
Assess value of program by your goals
Let’s say you have a physician community that is willing to step back from hospital work and share the unassigned patient population. That alone won’t bring you success. Merriwether says you have some degree of managed care penetration, and your incentives must be aligned with the physicians. In other words, if your hospital will lose money by cutting LOS on patients, you probably aren’t interested in a hospitalist program. But if you stand to benefit from cutting LOS, then starting a program designed to do just that might be for you.
To ensure a program is viable, Merriwether says you also need to have an average of five new daily admissions and 12 patients per day to support one hospitalist. Each hospitalist can safely care for 18 to 20 patients per day. (For more on what it takes to build a successful hospitalist program, see related story, below.)
Merriwether has seen hospitalist programs bring benefits as wide-ranging as better coordination of care, increased patient/physician and physician/physician communication, and decreased waiting times in the offices of physicians who are no longer burdened with hospital care.
Better outcomes, better patient and physician satisfaction. What else could a hospital want? How about lower costs, asks Merriwether. Hospitalists’ offices are the hospital, she says. "They are more attuned to the hospital view of delivery of care. They understand how to improve efficiency and processes because they understand the way a hospital works."
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