Published in the March 2011 issue of Today's Hospitalist
Ask Darren Swenson, MD, if he'd ever go back to the days when all the specialists he worked with divided their time between an office and the hospital, and the answer is a definite "no."
The director of medical affairs for the Nevada region of IPC The Hospitalist Company Inc., a national hospitalist management company, Dr. Swenson practices at Sunrise Hospital in Las Vegas. He and his fellow hospitalists now work beside a host of other "ists" who have adopted the hospitalist model as their own, including hematology-oncology specialists, neurologists, OBs, pulmonologists, and
"The old country-club way of practicing just doesn't work anymore."
–David Yu, MD, MBA Presbyterian Medical Group
general surgeons. Sunrise now has at least a dozen specialists who work in-house exclusively, half of whom were hired within the past year.
When Dr. Swenson ticks off the big pluses of having that onsite access, the list contains many of the same benefits that led hospitals to embrace hospital medicine in the first place. Patients' length of stay has gone down, and hospitalists don't have to waste time figuring out which specialists are on ED call.
The "ists" are there if patients' clinical situations change and to sit down with the hospitalists to review the care plans for all the patients they've admitted, which Dr. Swenson says was "a huge time-saver for the hospitalists." The presence of onsite specialists means more comprehensive decision-making, which results in "a more consistent care plan and discharge."
And having specialists—particularly surgeons—in the house allows hospitalists to do what they do better. "As you spend more time together, you fine-tune your physical exam skills and determine much more accurately who needs a surgical evaluation vs. medical management," Dr. Swenson explains. "When you look at pay for performance and compensating for efficiency, hospital-based specialists let us deliver more timely care."
In facilities that have in-house specialists, hospitalists say they love the model. But hospitals are getting pushback from the same specialists who've been taking ED call reluctantly. Much like concerns from primary care physicians in the early days of hospital medicine, community specialists worry that specialists who work only in the hospital will lower quality—and that long-established referral patterns will be disrupted. Related article: How to end the handoff free-for-all Tipping point in ED-call payments
Some areas of the country have jumped on the "other ist" bandwagon faster than others. (See "Regional variations on the 'other-ist' theme," below.) But analysts expect the growing trend— particularly hiring or contracting with surgicalists—to become a flood.
Some specialists may be reacting to reimbursement changes that suddenly make working for a hospital more attractive. Len Scarpinato, DO, MS, a practicing hospitalist and chief medical officer of Cogent Healthcare's North Central region, says that he now sees more cardiologists, for instance, becoming hospital employees.
"For outpatient procedures like nuclear medicine scans, Medicare has decided to pay only 10% of what it pays for the same procedure to be done in the hospital," Dr. Scarpinato says. "All of a sudden, you see cardiologists joining hospital groups in droves."
But a much broader push for in-house specialists is coming from hospital CEOs and CFOs. Cash-strapped hospitals don't want to pay specialists ever- growing stipends to take ED call for unassigned and emergency patients. Plus, the looming arrival of bundled payments will only increase the pressure for more tightly coordinated care.
And in what may be a subtle power shift within medical staffs, hospitals now realize that spotty specialist coverage slows their hospitalists down. "The limiting factor for throughput for hospitalists at this stage is not the hospitalists themselves, but the specialists and ancillary services," says David Yu, MD, MBA. Dr. Yu is medical director for adult hospitalist services with Presbyterian Medical Group, which serves two Albuquerque hospitals. The hospitals brought in a cadre of surgicalists two years ago.
"The old country-club way of practicing just doesn't work anymore," he adds. "What good is it if you have a hospitalist program to increase throughput when your specialists are operating on a different schedule and agenda? It's like putting a racecar on the road and driving it only during rush hour."
It's not uncommon now for Presbyterian's hospitalists to request two evaluations in one day if the stability of a postop patient is in question. In other cases, the hospitalists catch the surgeon in the hallway to talk briefly about a patient's status— a vast improvement, Dr. Yu says, over the phone tag they used to play. Per program design, the surgeons generally respond to a consult call within 30 minutes, but always in less than an hour.
Based on the program's experience with surgicalists, Dr. Yu notes, hospitalists would gladly work with other inside specialists. Presbyterian is already considering bringing in cardiology hospitalists and possibly neurohospitalists as well. "Think about it," says Dr. Yu. "If you're waiting for an echo to discharge a syncope patient, a lot of time is just wasted waiting for ancillary services or consults to come in."
Smoothing the waters
According to general surgeon Kevin Hudenko, MD, who helped launch Presbyterian's in-house surgery program in 2008, the program still relies on private-practice community surgeons under age 55 to take call two days a month.
"No one here appreciates being on call," Dr. Hudenko says, "and even today, if we were to completely take over call, the community surgeons would welcome it."
Among Presbyterian's "surgicalists" are eight surgeons employed by the hospital who still have thriving outpatient practices; only two surgeons, who operate only on weekends, are strict surgicalists with no outside practice. The eight employed surgeons "each suspend his private practice for one week to become the in-house 'surgeon of the week,' " Dr. Hudenko explains. In the planning stages, he did offer to let the nonemployed, community surgeons participate in the program.
"But we never had the opportunity to work out the details as they all declined immediately, happy to get out of call more than twice a month," he says. Because surgery volumes were so high before the program was launched, the hospital experienced no pushback from the community surgeons.
A rocky transition
That peaceful transition didn't happen at NorthBay Medical Center in Fairfield, Calif., a 130-bed facility with a smaller, nearby sister hospital. Together, the facilities not only have a thriving hospitalist program, but specialty hospitalists in general surgery, obstetrics, orthopedics and pediatrics, as well as intensivists.
"Basically, we had a growing number of patients for the local specialists to handle, and our doctors wanted higher stipends," says Deborah Sugiyama, president of NorthBay Healthcare Group. "I thought, 'That's a train that's going to go out of control.' "
While the economic case was clear to Ms. Sugiyama, the physicians didn't see things the same. "I had brisk disagreements with many doctors on the medical staff," she recalls. Community doctors claimed, for instance, that in-house specialists would simply be low-quality "docs for hire," and that referrals to their practices would be diverted to these new physicians.
Ms. Sugiyama eventually broke that standoff by seeking a middle ground, giving protesting special- ists the option of joining the new in-house arrangement part-time while keeping their private practice— provided they met stringent criteria for coverage and availability. Some physicians took her up on the offer to work as a specialty hospitalist, although she has also hired new specialists to specifically work onsite.
The quality solution
In-house specialists are proving to be a solution not only for economic problems, but for quality concerns as well. Sutter Health in Sacramento, Calif., is a case in point. Three years ago, the health system moved to hire surgicalists for its busy downtown hospital, in part to put an end to squabbling among competing surgery groups in the community.
"Frankly, we just weren't getting good service," explains Jatinder Chana, MD, a hospitalist at both Sutter General Hospital and Sutter Memorial Hospital. "A lot of times, the surgeons were just trying to dump unassigned patients on each other, and we were getting left in the lurch."
Hospitalists also had to waste time sorting out who was truly on call and when that physician might actually arrive. "Some surgeons just wanted to buy time, so they would just order a CT scan or antibiotics," Dr. Chana says. "We had some bad outcomes as a result."
Now that three general surgeons and one trauma surgeon work as surgicalists, those problems no longer occur. "If I call the surgeons and say, 'Hey, I need you to lay your hands on this patient's tummy,' they're there," Dr. Chana says. "Our frustration level has gone way down."
Surgeons on duty promise a callback within five minutes of receiving a page, and a consult within 30 minutes. While Dr. Chana has no data, he believes the improved communication between the hospitalists and in-house specialists has reduced the rate of surgical complications.
The current model isn't perfect, Dr. Chana admits. "But at least now we are working together, so we can discuss cases and improve processes," he says. "Before, there was no such dialogue."
Making the case
The local surgeons serving the Sutter hospitals grumbled loudly when the health system brought in outsiders, despite the coverage problems. Surgicalist M. Shay O'Mara, MD, medical director of the program at the two Sutter Sacramento hospitals, recalls those painful politics well.
"For the local surgeons, you would have thought it was the worst thing that ever happened to them," he says. "They said, 'You're going to take our cases and take our patients—and you'll just be itinerant surgeons.' Now, three years later, they couldn't live without us."
The hard feelings faded when community surgeons saw their case load go up, not down, since the surgicalist program was implemented. In part, that's due to local surgeons being able to schedule more elective surgeries and not having to slot in emergency procedures.
And in terms of convincing local physicians about the caliber of in-house specialists, Dr. O'Mara says that he and his colleagues have taken pains to distinguish themselves from itinerant surgeons who are often brought in only temporarily to deal with coverage crises.
"We've created a system of management guidelines, protocols and focused peer review, which allow us to assess our own quality," Dr. O'Mara says. "We've also worked to become more facile at choosing surgeons to work onsite, which became one of the challenges we did not expect." Not every surgeon is cut out to be a surgicalist, he notes; the job is more about personality and style than ability or knowledge. Good surgicalists, he says, are able to collaborate with other surgeons and even follow another surgeon's plan of care.
Surgeons in private practice, he explains, rely much more on themselves, "so they may lose that facility to collaborate."
One problem that confronts "ist" programs, at least from the specialists' perspective, is the same sort of mission creep that hospitalists have known all too well, particularly if the newcomers' roles aren't clearly defined. "We had some specialists who thought that we would take over all the abscesses," Dr. O'Mara recalls. "We learned that you have to get everybody on the medical staff on board first."
But the biggest downside of applying the hospitalist model to specialty physicians is ensuring post-discharge follow-up, particularly for surgery patients. Dr. O'Mara says his group has worked hard to create what he calls "a coherent system of referrals. We still have problems referring the uninsured or minimally insured, but that's a problem of the times, not of our specific system." To ensure good follow-up, Dr. O'Mara and his group also operate two half-day clinics per week.
In some cases, site-based specialists are charged with finding a "doc on the outside" to handle postop care. That can be tough if community specialists aren't keen to take on patients they didn't treat.
At Presbyterian in Albuquerque, Dr. Hudenko points out that the "surgeon of the week" follows up on patients operated on by the weekend surgicalists.
"Each Monday during checkout, a different surgicalist is assigned to pick up the care of those patients," he explains. "They follow them in the clinic and take care of them until discharge. That's the deal we worked out to keep their weekends free of ED call."
Bonnie Darves is a freelance health care writer based in Seattle.
Regional variations on the "other-ist" theme
TO DATE, THE "OTHER-IST" MODEL appears to be gaining momentum in some parts of the country but barely registering in others. In the Midwest, reports Len Scarpinato, DO, MS, chief medical officer of Cogent Healthcare's North Central region who's also a practicing hospitalist at Aurora St. Luke's Medical Center in Milwaukee, "hospitals don't pay ED stipends for specialists." The one exception is the occasional hospital that may pay an orthopedic group to cover the ED.
"What will drive the nail into this is when surgeons buck on taking call in the ER," says Dr. Scarpinato. But that hasn't happened yet in the Midwest.
On the East Coast, "other ists" are catching on slowly. Part of that may be labeling, suggests Sanjay Bhatia, MD, vice president of the hospitalist division for Physician's Practice Enhancement LLC, a hospitalist management company, and director of hospitalist medicine at Lower Bucks Hospital in Bristol, Pa.
"I don't think it's really been embraced here yet, in part because hospitals want to cater to the local specialists," says Dr. Bhatia, who also founded the consulting firm Prime Clinical Solutions Corp. "They don't want them to take their business elsewhere, so hospital executives are afraid of using the label." Instead, some hospitals on the East Coast are carving out arrangements with groups to place their physicians in inpatient-only schedules for designated periods of time. A contracted neurologist might be on call for the stroke alert, for instance, or a gastroenterologist for cases that develop in medical inpatients.
"We're seeing a lot of this kind of hybrid model," says Dr. Bhatia, "with neurologists, psychiatrists, gastroenterologists and the surgical specialties working like hospitalists did initially."
Dr. Bhatia knows, however, that the "ist" movement is gaining ground, he says, because he and other hospitalists are being increasingly asked to help hospitals figure out how to set up schedules and compensation models.
But in Sacramento, Calif., Craig Tsuboi, MD, hospitalist director at Sutter Roseville Medical Center, says that specialists are feeling the need—particularly in the face of the formation of accountable care organizations— to align themselves with a major hospital system.
"It's getting incredibly difficult for independent specialists to survive," Dr. Tsuboi says. "Their referral base is going down because big medical groups are hiring their own specialists." That leaves independent specialists, he notes, "second in line."
Paving the way for in-house specialists
THINKING OF LOBBYING YOUR HOSPITAL to bring some specialists in-house? Martin Buser, MPH, a founding partner of Hospitalist Management Resources LLC in Del Mar, Calif., a hospitalist consulting firm, is convinced that the "ist" movement is the wave of the future, as long as it's done right.
In the post-health care reform world of bundled payments, Mr. Buser says, hospitals can't afford specialist stipends or gaps in coverage or quality. Nor can they afford to alienate their hospitalists who derive big benefits from having specialists in-house.
"Hospitalists don't have to 'dial a doc' anymore because they see them everyday," says Mr. Buser. "They're working with three dedicated specialists now, instead of 10 who don't want to be there."
But hospitals can go about hiring or contracting with in-house specialists the wrong way. "This is not something to do in a hurry," he cautions. "You really have to move slowly, and honor existing referral patterns as much as possible."
Hospitals in a hurry to hire may poison the well for bringing specialists in-house for years—especially when medical staff has little or no input in hiring specialty hospitalists. "If the hospital hires physicians of inferior quality in a rush to improve," Mr. Buser explains, "the overall reputation of the institution can suffer."
All too often, he adds, hospitalists bear the brunt of that mistake. "If the hospitalist is forced to work with someone who isn't up to par," says Mr. Buser, "it's a real negative."
To help mitigate political fallout, M. Shay O'Mara, MD, medical director of the surgicalist program at two Sutter Health hospitals in Sacramento, Calif., urges hospitals to tell everyone about plans for an "ist" program up-front. "You're creating a system," he says, "not just hiring doctors to operate."
David Likosky, MD, a neurohospitalist and stroke program director who was on the early end of the "other-ist" curve 10 years ago at Evergreen Hospital Medical Center in Kirkland, Wash., concurs. While there's a good chance local neurologists will be "overjoyed" at the idea of having inpatient neurohospitalist coverage, hospitals shouldn't take anything for granted.
"If local neurology clinics aren't very busy, the dynamics can be very different" and political damage can occur, says Dr. Likosky. "And hospitals benefit from neurologist and other specialist referrals for laboratory evaluations, rehabilitation therapies and imaging. If the hospital alienates community neurologists, the hospital may lose revenue when those physicians refer elsewhere for outpatient services."
Patients may also lose, he adds, if testy relations between outpatient and in-house specialists lead to poor communication—and less comprehensive transitional care. That's why Evergreen took the same cautious approach when it brought in onsite intensivists, obstetricians and pediatric hospitalists, Dr. Likosky says, "and that really reduced the pushback."