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Making plans for health care reform
Five case studies
by Deborah Gesensway



Published in the April 2012 issue of Today's Hospitalist

FACED WITH BUNDLED PAYMENTS, shared savings, accountable care and all the other payment (and penalty) mechanisms that are about to debut with health care reform, hospitalists around the country are starting to see signs of change.

Some health systems have gone on buying sprees, bulking up their physician and hospital networks. Others are redoubling efforts to make the most of electronic health records to reap rewards from interconnectivity and data management.

For physicians, these strategies may mean having to merge different practices into one coherent unit or working with new colleagues to reduce
"One key to making an IPA work is aligning ourselves electronically."

–Lancer Gates, DO
Gates Hospitalists

readmissions, one of the primary targets for cutting unnecessary health care spending.

Whatever strategies health systems pursue to prepare for health care reform, many hospitalists are already making adjustments in how they work. Here are five snapshots of how hospitalists are being affected by local efforts to thrive in a new health care era.

Peoria, Ill.: Paying to improve patient experience
For the hospitalists at OSF Healthcare System in Peoria, Ill., getting ready for health reform has in part meant revisiting how they get paid.

Since the hospitalist group began in 2006, the hospitalists at OSF St. Francis Medical Center haven't been paid based on RVUs. Instead, they have received a set salary with 10% at risk for meeting quality goals. Past indicators for those goals, which are chosen annually, have included DVT prophylaxis, discharge before 10 a.m. and admission orders within an hour. (The quality bonus has been available to the entire group at two levels: 5% for hitting an agreed-upon threshold, and 10% for outstanding performance.)

Brian S. Curtis, MD, a founding member of the hospitalist group who's now regional director for specialty care for OSF Medical Group's Central Region, says the quality incentive isn't earned by individual physicians. It's instead earned by the whole group and then divided up equally among the doctors.

"It wasn't that I got it and you didn't," Dr. Curtis says. The group's culture from the beginning was "all or none—either all four of us got the same amount or none of us did. We had to function as a group. I couldn't just do well, but I also needed to help my partner, and he or she needed to help me. It kept us focused on the patient."

With health reform on the way—and OSF Healthcare System is one of CMS's 32 pioneer ACOs—it turns out that that decision was prescient, in part because it laid the groundwork for the next iteration of the group's pay structure.

Last year, the group, which now includes 15 hospitalists, realized it had to raise its pay levels to be competitive. It decided to put another 10% at risk, but this time, the carveout based on meeting satisfaction goals.

Starting this year, on top of the continuing 10% quality incentive, another 10% of the hospitalists' salary will be based on how well they do on a survey that will be sent out to everyone from patients and referring primary care physicians to nurses, respiratory therapists, dieticians, housekeeping staff and anyone else "who wants to fill it out and send it back," Dr. Curtis says.

"We realize that we need a team-based concept of care," Dr. Curtis explains. "If the nurse likes me and is happy with what I am doing, she is going to convey that to the patient, in body language alone." The satisfaction survey will be done annually and, like the quality incentive, will be paid in the same all-or-nothing fashion to the group. (Responses for individuals will be tracked, he notes, to identify any outliers.)

"Patient experience" is a major part of health reform's value-based purchasing program, with hospital performance on its patient-experience measure making up 30% of the composite score that will be used to adjust each hospital's payment update. Although the hospitalist group came up with the salary modification on its own, Dr. Curtis says, it meshes with the work the health system has been doing at the corporate level putting together an ACO.

The next step, he says, is to figure out how hospitalists can help do a better job coordinating care. "We currently have a nursing home with nursing home physicians," he says. "Can the hospitalists help with that?

Dallas/Ft. Worth: Integrating providers
Texas Health Resources, part of another pioneer ACO, has spent the last three years building an employed physician group. That move has helped the multispecialty group focus on reducing 30-day readmission rates, which are a key metric under health care reform.

The thinking behind the group's acquisitions was simple: Building a powerhouse network of employed providers can improve care while saving the system money. The group, which now has nearly 800 physicians and midlevels, includes 90 employed hospitalists who serve in 11 of the system's 13 wholly owned hospitals. It also now includes a group of nurse practitioners who originally provided home care as extenders for primary care physicians.

According to Donald E. Benson, MD, medical director for the physician group's hospitalist division, he and his colleagues started thinking about how integrating hospitalists and those NPs could reduce hospital readmissions.

"There are many reasons for a readmission besides problems with the handoff," Dr. Benson says. "You can do that handoff beautifully, but we know that problems with medication reconciliation and follow-up appointments are two factors that contribute to unnecessary readmissions."

Linking the hospitalists to the home care NPs seemed like a good solution. Hospitalists now identify patients who they suspect may be at greater risk of being readmitted "because their medications were significantly changed or because they think the patient may have problems getting to the doctor."

It's the hospitalists' job to talk to patients about the need for a home visit and "try to get buy-in before they leave," Dr. Benson says. Then, as part of the discharge process, hospitalists electronically order a "transitions house call."

The NP group takes it from there and schedules a home visit. During that visit, the NPs have electronic access to all the hospital notes and records, and they communicate with both the primary care physician and the hospitalists as needed.

Where the NPs have been particularly helpful is being "very aggressive with medication reconciliation to make sure the patient is on the right medicines" and that prescriptions have been filled, Dr. Benson notes. And because NPs in the state can prescribe, "they can adjust prescriptions if they think it's needed."

The payoff? "With our first 400 or so patients where we have made a post-discharge visit," he says, "we are seeing less than half the expected readmissions."

Given the health system's integrated electronic medical record, Dr. Benson also can now track which hospitalists have been slow to refer patients. As such, the hospitalist-NP collaboration has become an informal performance metric. Each hospital's hospitalist group holds a monthly business meeting, he explains. "Now, we present how many referrals to the post-discharge program doctors had in the previous month," he says. "We can then ask those hospitalists without any post-discharge NP visits if they really don't have any patients who could have benefited from this."

Because the post-discharge home visits are so time-consuming, the seven providers can see only between six and eight post-discharge patients a day.

"But it's a start," Dr. Benson says, "and we look at it as creating an important part of the infrastructure for the ACO."

Wichita, Kan.: Merging different groups
Another example of getting bigger to prepare for health care reform can be found in Kansas's Via Christi Health System. Just over a year ago, Via Christi, which is itself the product of a merger of two Catholic health care systems, purchased Wichita Clinic, one of the state's largest multispecialty physician groups.

While the purchase was designed in part to help the health system prepare for health care reform, it has meant big changes for hospitalists in the group. Before the acquisition, Wichita Clinic had four or five hospitalists taking care of the inpatients of that clinic's primary care physicians. The health system merged that group with an employed group of about 14 hospitalists that works at Via Christi's St. Francis Hospital.

The hospitalist group merger is a work-in-progress, says Stephen Nesbit, DO, MBA, chief medical officer for Via Christi Hospitals, who now oversees the combined hospitalist group. While the combined practice has decided to retain the chief hospitalists of both groups as co-directors, the goal is "to create a new program" that reflects some of the culture of each group.

That might be difficult, he acknowledges, because until now, the two groups have operated under very different philosophies. While the private group operated more like "rounders," Dr. Nesbit says, the hospital-employed physicians were more used to taking a larger role within hospital operations.

"We want all our hospitalists to be aligned with our goals of the hospital," Dr. Nesbit says. That means working together to improve ED throughput, exercise hospital-wide leadership and provide rigorous documentation of core measures.

Developing a single, cohesive hospitalist program out of the two now-employed groups should also provide lessons in what Dr. Nesbit calls the process of "how do we create a Switzerland, so to speak." A third, independent hospitalist group also sees a sizeable portion of St. Francis's medical inpatients, and the hospital will work to help that group reduce length of stay and cost per case.

"It's all part of the idea of building an integrated health system," Dr. Nesbit says.

Kansas City, Mo.: Staying independent
While bigger is generally thought to be better in preparing for health care reform, some groups are looking for ways to bulk up while remaining independent.

Gates Hospitalists, a private hospitalist group in suburban Kansas City, Mo., is a good example. The four-physician group has joined a newly formed independent practice association (IPA) of office-based internists, family physicians and pediatricians.

Nearly half of the primary care physicians in the Kansas City area have made the decision to join hospital systems, says group founder Lancer Gates, DO. But "the remaining half want to continue practicing privately and are putting a lot of work into building and maintaining medical homes" for their patients.

These independent PCPs, Dr. Gates explains, approached his group, looking for a hospitalist partner. Now his practice, which sees patients at North Kansas City Hospital, is the only hospitalist co-owner in the
100-member association. "One key to making an IPA work," he notes, "is aligning ourselves electronically," improving the electronic interface between the hospital and the primary care groups. For Dr. Gates, that became a personal endeavor. For the last several months, he has championed a project that grew out of IPA discussions on what kinds of information primary care physicians need to improve transitions to and from the hospital.

As a result, North Kansas City Hospital has now added several tabs to its EMR to allow office-based physicians to more easily—and in real time—access information about their hospitalized patients. Instead of having to wait for a call or fax from the hospitalists with admission information, outpatient doctors can now pull up a list of all admitted patients for whom they are the primary care physician of record—and follow the daily progress notes from hospitalists and consultants.

Another EMR improvement his group helped design, Dr. Gates says, allows primary care physicians to pull up a list of all their patients who have been discharged in the last two weeks. "They can find out which patients should have followed up with them in their office," he says.

Another innovation is what he calls the "Duck, Duck, Goose" tab. "Many patients come to the emergency department more than once before they are admitted," explains Dr. Gates, saying that most of these patients are admitted on their third visit to the ED. "We made a tab for patients who had been to the ER in the last two weeks, so family physicians can follow up."

The new EMR tabs can be used not only by IPA members but by any referring physician group that has at least one doctor with affiliate or active hospital privileges. According to Dr. Gates, the hope is that the enhanced flow of electronic information will help reduce unnecessary readmissions. "It should also," he says, "be a step toward the quality integration being espoused by Medicare and private payers."

Grand Forks, N.D.: Clinical, not financial integration
While some health systems are getting bigger, others are experimenting with new models of clinical integration.

Since last fall, the physicians at the Altru Health System's hospital in Grand Forks, N.D., have had a new source of help to improve care and, potentially, reduce patients' length of stay: They can consult specialists at the world-famous Mayo Clinic and get a guaranteed 48-hour turnaround.
Altru's relationship with the Rochester, Minn.-based giant gives the North Dakota hospital a local marketing edge. The hospital also hopes that it will promote better quality care, because Mayo will be sharing clinical protocols and templates as well as information it has developed on how to improve patient satisfaction. Neither Mayo nor Altru has any financial stake in the other.

"We don't want patients to fall through the cracks and have untreated disease for long periods of time so that their condition escalates and ends up costing more than it should," explains Dave Molmen, Altru's CEO. "It's about making sure that you don't have needless readmissions, duplicate services and a bill that's run up on things that could be treated at a low level and inexpensively." If the new approach to integration can achieve those goals for Altru, he adds, "then whatever form health reform presents itself in, we will be able to do that well."

Last September, the North Dakota health system became the first member of the Mayo Clinic Care Network. Previously, the system would transfer patients to Mayo, but now there's much more collaboration between the two systems' physicians.

While hospitalists are not at the center of that partnership, explains Casey Ryan, MD, Altru's president, they are certainly aware of it and can take advantage of it. When Altru's hospitalists ask for a subspecialist consult, that subspecialist can then ask for a Mayo consult.

The subspecialist gives all the patient information to a non-physician Altru staffer who electronically sends the records to a Mayo counterpart. That doctor in turn responds electronically within 48 hours. The original electronic system is being expanded to include video conferencing between the two specialists, Dr. Ryan says. Between 15 and 30 cases each month are now being sent through the system.

"We can prevent people from having to go to Mayo who don't need to go there and can stay here for treatment," Dr. Ryan points out. "Also, we can get the right people down there quicker to intervene earlier in the disease course and markedly reduce the cost of caring for those patients."

As part of the collaboration, he says, Mayo will share strategies to improve patient satisfaction as well as clinical protocols and templates.

"We can take their templates and modify them for us," Dr. Ryan says. "Mayo has already done them, so why reinvent those wheels?"

Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto.

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