Published in the February 2010 issue of Today’s Hospitalist
On a typical morning, Sandip Patel, MD, a hospitalist employed by a health plan in Southern California, rounds on patients at the hospital, then meets with case managers and a medical director to review care plans and decide which patients will stay or go.
In the afternoon, Dr. Patel may see recently discharged patients “those coded “red” or “yellow,” based on medical complexity “at an integrated-care center, which is also owned and run by the health plan. Then he might head to a nursing home to check on patients discharged a week ago.
Dr. Patel considers himself an “extensivist” for CareMore, a Medicare Advantage plan in Southern California that started out as a medical group and IPA. The health plan’s care model is based on keeping hospitalists front and center throughout a range of patient settings, and providing physicians with resources “including disease management and home-care programs “that enhance continuity of care and reduce readmissions.
While many hospitalist programs are already implementing post-discharge innovations such as phone calls to discharged patients within 72 hours, health plans are motivated to provide even more post-discharge interventions to stop patients from bouncing back. Health plans are also extending hospitalists’ range of care into post-acute and even sub-acute settings.
“It’s fundamentally a different model, and that’s what intrigued me,” says Dr. Patel, who joined Care- More a year ago after three years of working in a more traditional hospitalist program.
Because the health plan has hospitalists targeting “the highest risk Medicare patients,” Dr. Patel says, “the profit motive coincides with the best interests of patients. We want to keep them as healthy as possible and out of the hospital, and we function like their second option for primary care.”
A tight focus on readmissions
Hospitalists working for health plans may seem like a throwback to the specialty’s early days, when a number of health plans in Southern California employed hospitalists to round on their patients in the hospital. While the idea of employing hospitalists may not be particularly new, health plans are turning to the specialty to reduce unnecessary readmissions.
Medicare and the Joint Commission have each made cutting readmissions a top priority, particularly because studies show that one in five Medicare patients is readmitted within 30 days and that 50% of those patients don’t see an outpatient physician before their readmission. Medicare has launched pilot projects in several states targeting readmissions, and it may move to financially penalize hospitals for high readmission rates.
“Readmission is our main focus as our extensivists follow patients during hospitalization and post discharge,” says hospitalist Balu Gadhe, MD, CareMore’s senior medical officer. “Lowering readmission rates is within the purview of the hospitalists.”
The plan’s goal, he adds, is for the extensivists “who are board-certified internists “to manage “that 15% to 20% of the frail population that utilizes 60% to 80% of the resources, giving them extra care and attention.”
Advocating for patients
Dr. Gadhe, who has been with CareMore since its inception in 1993, notes that the health plan has continuously tweaked its care model, adding a growing number of personnel and programs to target patients in the weeks after discharge.
CareMore, for instance, provides “talking” pill boxes that remind patients to take their medications. The plan enrolls patients in its own disease-management programs, including one for heart failure that relies on telemonitoring and the use of wireless weight scales. Those initiatives, says Dr. Gadhe, have reduced readmissions for heart failure by 56%.
As part of its post-acute care, a CareMore house call physician-nurse team makes home visits to “frequent-flyer” plan members to identify looming medical problems. Other health plan personnel, including social workers, case managers and mental health professionals, may even work with government agencies, if need be, to get patients more assistance.
“What’s the point of spending up to $300,000 for a complicated inpatient CHF episode if we discharge the patient to a home where there’s no support, no food in the fridge and no money for medications?” Dr. Gadhe asks.
The approach appears to be working. CareMore, which employs 22 hospitalists and is expanding into Northern California and the Southwest, now has readmission rates in the 13% to 14% range, though there are spikes, Dr. Patel notes, at certain times of the year. Those rates are well below national averages.
Dr. Patel admits that one big difference in being employed by a health plan, rather than a private hospitalist group or hospital, is that physicians have to make a case for why patients should remain in the hospital. “We must have stated goals and objectives and come up with efficient discharge-planning procedures,” he says.
To make sure those plans are met, Dr. Patel says, hospitalists occasionally must lean on consultants who are not employees of the health plan to expedite testing or procedures. That “isn’t always easy,” says Dr. Patel. “They have different agendas than we do, so it can get a little political.”
Creating outpatient alternatives
For Bijo Chacko, MD, hospitalist medical director of Preferred Health Partners in Brooklyn, N.Y., the advantages of working with a health plan include resources for better continuity of care.
None of the 15 hospitalists in his multispecialty group is employed by a health plan, but the group is responsible for the care of nearly 95,000 members of a single insurer, in addition to other patients. That alliance, Dr. Chacko says, carries some weight as far as what resources are available and how care is coordinated.
The alliance, for instance, provides clinical care coordinators who set up patients’ post-discharge appointments and fast-track those appointments with a subspecialist.
The medical group has also set up three urgent care centers to help health plan members with pre-and post-admission issues, Dr. Chacko points out. The centers make it possible to treat a patient with a mild COPD exacerbation without being admitted to a hospital.
Medical group members also hold regular meetings with health plan administrators to focus on how to improve outpatient resources, such as transportation to follow-up appointments, the timely arrival of durable medical equipment for “frequent flyers” or enrollment in disease management programs.
At the same time, the medical group’s doctors are required to call hospitalists before sending a plan member to the emergency room so they can discuss possible alternatives to inpatient care.
For patients with dehydration, cellulitis, mild asthma or gastroenteritis, for instance, treatment in one of the urgent care centers, rather than the hospital, “avoids unnecessary admissions or ED visits and can deliver more timely, efficient care,” says Dr. Chacko.
“Wait times in the ED can be long, and this is a service to patients who can’t see their primary care physicians during regular office hours,” he points out. “Ultimately, the cost savings come down to providing access to care and physician resources in the outpatient setting.”
Issues of autonomy
Christine Reynoso, MD, MMM, medical director of hospital medicine for Southwest Medical Associates Inc. (SMA) in Las Vegas, initially had concerns about autonomy when SMA in 2008 became a subsidiary of UnitedHealthcare Nevada, which operates an HMO and point-of-service plan. But she says that any worries that health plan personnel might interfere with care decisions have proved unwarranted.
“The attending makes the decisions, not a health plan medical director,” says Dr. Reynoso, who has been a hospitalist since 1998.
In addition to resources like case and disease management, SMA hospitalists have a direct link to a comprehensive sub-acute care center where they can send “and follow “patients who aren’t ready to go home. Dr. Reynoso cites a typical example: an 85-yearold hip-fracture patient who is postop and healing, but has a host of other issues.
“She might have acquired pneumonia in the hospital and have heart failure, but she happens to be living alone,” Dr. Reynoso says. “She is the kind of patient who needs more time in the sub-acute facility afterwards, not just for PT but also for our hospitalist to explore medical issues that need stabilizing.”
Resources for transitions
On the front end of a possible admission, SMA’s hospitalists can work with UnitedHealthcare staff to set up needed outpatient testing or consults. After discharge, case managers can not only make sure that patients have transportation to follow-up appointments but ensure that they can afford copays for their drugs and office visits.
“That may help us prioritize which office visits and drugs patients actually get at discharge,” says Laurine Tibaldi, MD, SMA’s chief hospitalist. “It’s not as simple as ‘order everything’ these days.”
SMA’s hospitalists have also begun developing protocols and care plans for diagnoses, conditions and disease exacerbations that might be better managed outside the hospital. Those include chest pain, transient ischemic attacks and abdominal pain.
“We’re looking at things that historically have resulted in one-day lengths of stay,” Dr. Reynoso explains. “If you look at these things critically, you don’t just say, ‘It’s great that the LOS was low.’ You realize that maybe some of those patients could have been managed as outpatients, and we’ve created something to get that done.”
Expanded skill sets
HealthCare Partners, a large California multispecialty group, also assumes global risk for inpatient costs, professional fees and pharmacy expenditures for several national health plans that operate in California, and it has shared-risk arrangements with others.
The group’s 75 hospitalists care for the more than 600,000 patients in California for whom HCP “picks up the bills,” says Manoj Mathew, MD, a lead hospitalist for the company.
They do so by focusing efforts and resources on the post-discharge period. Many of the hospitalists rotate into skilled nursing facilities and will work in the company’s growing network of post-discharge clinics for high-risk patients. Hospitalists can easily develop the skill sets needed to care for chronically ill patients in a post-acute setting, he says.
“The key difference between acute and post-acute care,” Dr. Mathew explains, “is knowing and addressing all the social issues and regulatory measures associated with this population. We really believe that hospitalist continuity into the post-acute setting allows a bit higher level of care.” Hospitalists may even be involved in the group’s home care program, visiting high-risk patients.
Like other hospitalist groups, HealthCare Partners staffs a program that calls all discharged patients or caregivers within 72 hours. In addition, it’s piloting a medication-reconciliation program in which the PharmDs who also run the group’s anticoagulation clinics call discharged patients to review medications and make sure patients have the medications at home.
Dr. Mathew bristles at the notion that hospitalists could be induced by health plan dictates to hold back care. “I’m sure at times we all feel pressured to meet some sort of corporate expectation,” he says, “but in the end it’s our decision how the patient’s cared for.” That’s becoming easier, he adds, with standardized protocols and treatment plans.
Besides, he adds, it’s no secret that readmissions have been very expensive for health plans. Increasingly, readmissions “not only affect profit margins, but also health plans’ national and industry rankings.” says Dr. Mathew. “It’s almost like there are a bunch of Zagat ratings out there. Pretty soon, everyone will receive stars and rankings on readmissions.”
The push for better continuity of care is driving the development of several innovations at health plans that work closely with hospitalists. One is the hospitalist-managed post-discharge center concept, which many health plan-sponsored programs are moving toward.
Bravo Health, which operates Medicare Advantage plans in several states, has affiliated with outpatient practices to operate advanced care centers. Those centers, which are exclusively for plan members, will be fully staffed by hospitalists. The first center opened in Philadelphia last month, with others planned elsewhere on the East Coast.
The goal is to provide immediate care when plan members have a non-emergent condition and their primary care physician isn’t available, explains Andrew Aronson, MD, Bravo Health’s vice president of physician practice operations of the Philadelphia center.
But the centers are also designed to manage “complex conditions that require time and resources that primary care physicians can’t easily offer,” Dr. Aronson points out. Those include administering IV fluids or IV diuretics, and doing INRs or immediate lab testing. The centers will target patients with mild disease exacerbations, like a COPD patient who may just need a short course of oxygen to get back on track.
“We decided that we want the hospitalists’ skill set for these centers,” says Dr. Aronson. “We need people who are comfortable managing inpatients and understand the use of hospital resources.”
Bonnie Darves is a freelance health care writer based in Seattle.
Readmissions: putting physician dollars on the line
HOSPITALISTS EMPLOYED by or affiliated with health plans say that aligning with insurers’ objectives is not markedly different from being employed by hospitals or health systems.
But many physicians working with health plans already have one incentive that hospitalists nationwide may soon become familiar with: potential bonus dollars tied to readmission rates. As Medicare considers financially penalizing hospitals for high readmission rates, health plans that employ hospitalists are already factoring that metric into physician compensation.
Hospitalist Balu Gadhe, MD, for instance, is the senior medical officer for CareMore, a Medicare Advantage plan in California and the Southwest that employs 22 hospitalists. According to Dr. Gadhe, hospitalists with the plan have a base salary that tops $200,000 a year, plus the potential for a bonus.
While those bonuses are tied to factors like accurate documentation, timely discharge summaries and patient satisfaction measures, incentives “are based on readmissions, first and foremost,” Dr. Gadhe says. The plan’s goal is to have a 30-day readmission rate of only 15%. (The national average, according to studies, is closer to 20%.)
Hospitalists whose patients meet or beat that rate can get a bonus of up to 50% of their salary, says Dr. Gadhe. If, however, their patients’ readmission rate is “higher than that,” he points out, “they do not get their admission bonus.”