Providing overnight coverage for surgeons is putting a new spin on a contentious issue by Paula S. Katz
Published in the December 2007 issue of Today's Hospitalist
The patient comes into the emergency room with a broken leg at 11 p.m. and arrives on the floor two hours later. Until the orthopedic surgeon shows up the next morning, a hospitalist will monitor fluids, manage pain and take care of the patient’s general needs.
Because surgical co-management is such a growth industry for hospitalists, most physicians would gladly agree to care for the above patient until the surgeon arrives. That’s a big change from just a few years ago, when many hospitalists would have derisively referred to such an arrangement as
“We don’t want to become an island of care in the community that is off limits to the primary care docs.”
–Lee D. Litvinas, MD Martha Jefferson Hospital
little more than a “tuck-in” service.
What’s changed? Hospitalists and experts alike say that the boom in surgical co-management has some hospitalists reconsidering their stance toward the tuck-in, particularly when the request comes from a surgeon.
At Martha Jefferson Hospital in Charlottesville, Va., for example, the eight-physician hospitalist program already sees a lot of orthopedic patients. But it also recognizes that it may soon need to expand its menu of night-service admissions to include patients in neurosurgery and surgery. “Our job description is growing,” explains Lee D. Litvinas, MD, medical director of the hospitalist program. “We’re becoming subspecialty extenders.”
That’s not to say that a similar request for night services from primary care physicians doesn’t irk hospitalists, because it often does. But as hospitalist groups mature, some say they are taking a new view of those requests. Just as surgical tuck-ins may prove to be a path to more business, some hospitalists say there can be a silver lining to requests for tuck-in services from their primary care colleagues.
Waiting for “the real doctor”?
The idea that hospitalists provide overnight care to a newly admitted patient until another physician shows up has long been a point of contention. That’s particularly true when the request comes from primary care physicians who simply don’t want to come to the hospital in the middle of the night.
Hospitalists typically complain that a tuck-in service creates an unnecessary handoff that can increase the odds of mistakes being made. Another key concern is that watching a primary care physician’s patients until she arrives at the hospital reduces hospitalists to little more than an intern or resident. Midcareer hospitalists especially may balk at providing a service that seems less than comprehensive.
“ ‘Tuck-in’ implies not doing a full evaluation on the patient, just providing some sort of basic service to make sure the patient has an IV and holding orders,” says Winthrop F. Whitcomb, MD, director of performance improvement at the 200-bedMercyMedical Center in Springfield, Mass.
“It leaves the impression that the next morning, ‘the real doctor’ will come,” says Martin B. Buser, MPH, founding partner of Hospitalist Management Resources LLC, a consulting and management company that specializes in hospital medicine.
Growing a business
But there’s another school of thought on tuck-ins: providing night service is a key way to maintain goodwill and referrals. Even as the group grows to include more night-time specialty admissions, for example, Dr. Litvinas says his program
continues to provide nighttime admissions to primary care physicians.
He explains that the hospital finds the service critical to keep primary care physicians connected to the hospital so they don’t fall off the map when they drop their clinical privileges. “We don’t want to become an island of care in the community that is off limits to the primary care docs,” Dr. Litvinas says. “We value their perspective and input to help make the patient’s hospital experience the best it can be.”
And many hospitalist groups starting out use tuck-in services as a strategy to market themselves and build business.
That approach worked for David G. Zipes, MD, director of the pediatric hospitalist service at Peyton Manning Children’s Hospital in Indianapolis. His service used to admit patients at night, then turn their care over to a primary care doctor the next day.
As time passed, he says, those physicians got used to the hospitalists, saw the benefits of their care and turned over their patients. “It was a way to let the PCPs in our community see our service and generate business,” he explains. In fact, Dr. Zipes adds, he doesn’t use the term “tuck-in” because he finds it derogatory. Instead, he prefers to call this type of care “cooperative evening services.”
A role in program evolution
Many groups still find themselves on some point of a tuck-in service continuum that ranges between perpetuating such a service, as Dr. Livinias’ group continues to do, and Dr. Zipes’ experience, where a night service for primary care physicians becomes a thing of the past.
Dr. Whitcomb, for instance, says his group started out providing such a service to three different primary care groups, but is now doing it for only one. In fact, the hospitalists’ coverage hours have increased from 11 p.m. to 7 a.m. to 6 p.m. to 7 a.m., but the group now has dedicated nocturnists helping to shoulder that load.
When he arrived in Randolph, Vt., hospitalist Martin C. Johns, MD, found that tuck-in services continued to be in demand by primary care physicians, particularly those who have been in practice for many years and find it hard to pass on patients. That is due, Dr. Johns said, to the longstanding relationships established over time between practitioners and patients in rural Vermont.
At Gifford Medical Center where he practices, Dr. Johns says that he eventually convinced those physicians to allow their patients to be cared for by the hospitalist service.
He did so by working with office-based physicians on all major inpatient decision-making. Even now, “If there are end-of-life issues, the primary care doctor will be called and meet me here to meet with the family,” he says. “That creates a synergy between the hospitalist and the outpatient doctor.”
And at St. Francis Hospital in Greenville, S.C., by comparison, the 10-physician hospitalist group still finds itself extending a night service to select community physicians.
But the group definitely encourages most local doctors to turn their patients over completely to the hospitalists, says Scott J. Perlman, MD, medical director at the hospital and regional medical director with TeamHealth, a provider of hospital-based clinical outsourcing services.
That “just-say-no” stance is ultimately a better business decision for the hospitalist group, says Dr. Perlman, because it hastens the usually inevitable transfer of patients. “That’s also much better for quality,” Dr. Perlman points out. “The hospital ends up achieving better outcomes for patients.”
Like Dr. Perlman, some hospitalist groups worry that such a service could in fact limit growth.
Then there are pitfalls that could apply to specialist admissions as well. Dr. Whitcomb, for instance, says his group lost a long-standing nocturnist because the nights were too hectic.
“It became too rigorous, with too much floor cross-coverage and too many admissions,” he says. “It takes a very skilled hospitalist to be effective at night. Tasks get stacked up ten deep at times.”
Hospitalist programs may find that providing night services can be a tough sell when recruiting. And the likelihood of more errors is real, Dr. Whitcomb says.
As an example, he mentions a hospitalist who left a message for a primary care physician about a patient admitted as part of a night service. What that hospitalist didn’t know was that another physician was covering for the PCP the next morning and never got that message. “Any system that introduces new handoffs,” says Dr. Whitcomb, “opens that system up to new errors.”
Surgical tuck-ins: a new frontier
But because the surgical tuck-in is so different from similar services for primary care physicians, it presents both challenges and opportunities.
On the plus side, many hospitalists seem to agree that caring for a patient about to undergo surgery doesn’t bring up feelings of being treated like housestaff. After all, when they hand the patient off, the next physician is doing something they can’t do: surgery. That’s a big difference from handing the patient off to another internist who may or may not have the same level of inpatient skills as you.
Another plus is the leverage such a service gives hospitalists with hospital administrators. By embracing surgical tuck-ins, hospitalists can relieve pressure on their facility’s ED.
And by making life easier for surgeons, hospitalists help keep surgeons—and their lucrative procedures—in the hospital.
“Even now,” says Dr. Zipes of Indianapolis, “the orthopedic surgeons, GIs and cardiologists go to the administrators and say, ‘Life would be terrible without hospitalists.’ ”
That said, there are challenges. For one, hospitalists must make sure that subspecialists respond promptly in case something goes wrong.
“No one expects hospitalists to do orthopedics or neurosurgery, so you have to have guaranteed back-up from the subspecialists,” says Mr. Buser. He noted that there have been lawsuits where a specialist hasn’t shown up until late the next day and the “hospitalist is in over his head.”
Some believe that the whole notion of a tuck-in service as an interim solution to promote hospitalist programs will end as hospitalists become more accepted. “Only a small minority of hospitalist programs five years from now will be doing an open-ended arrangement for night coverage,” Dr. Whitcomb predicts.
Eventually, such a service may exist solely to serve subspecialists. TeamHealth’s Dr. Perlman sees that use growing already as economics force private practice physicians out of the hospital altogether.
“Tuck-ins are transitional, but we’re still figuring out the future,” he says. “It could be the hospitalist taking care of all patients in the hospital along with critical care doctors, pulmonologists and surgeons, while most everyone else comes in, does consults and leaves. The question is how do we get to that point.”
Paula S. Katz is a freelance writer in Vernon Hills, Ill., who specializes in health care.
Readers sound off on tuck-in services
We recently asked readers on the Today’s Hospitalist Web site
about providing night services. Here’s what they had to say:
“Either there should be a contractual relationship and fee for the service, or avoid the whole situation. This coverage increases your liability.” Ashland, Ky.
“Our group has an ‘all or nothing’ mentality. Could I see myself engaging in this practice? Only if I was well reimbursed with, say, $250 plus billings (and with the PCP group paying the CPT bill amount if the patient was uninsured). I would also try to keep those funds separate from the overall accounting that determines the magnitude of the hospital subsidy.” Rocky Mountain
“Do not get involved in patchwork coverage unless the hospital or your group decides to staff for this coverage as if it were 24/7. One of the biggest contributers to hospitalist burnout is the overly busy nights, weekends and holidays that others do not want to cover.” Greenwood, Ind.
“Even though this practice may be good from a business point, I view it as risky. If the PCP does not do a good job with the patient the next day, you are at risk.” Waterloo, Iowa
“Just say no!” Prescott, Ariz.
You’ve agreed to do night service. Will you get paid?
Along with issues of turf and patient continuity, night services raise questions about the bottom line.
Hospitalists who choose or must do “tuck-ins” should pay attention to billing, advises Martin B. Buser, MPH, founding partner of Hospitalist Management Resources, LLC, a San Diego-based consulting company for hospital medicine practices.
That’s because you can bill for a patient only once every 24 hours, he warns. “It becomes a race to see who will bill first,” he says.
Plus, not all hospitalists who provide “tuck-in” services get paid for doing so. Even if it’s not a choice, night services would work better if there were bonuses tied to the work, says Scott J. Perlman, MD, medical director at St. Francis Hospital in Greenville, S.C., and regional medical director with TeamHealth.
His group “reluctantly” agreed to provide the service to select primary care physicians. “Had the hospital tied a bonus or incentive to use, we would have had a smoother transition,” he says.
His advice to hospitalists going to a new group with a “tuck-in” service: Tie it to a bonus, or say no deal. At Mercy Medical Center in Springfield, Mass., for instance, hospitalists get 15% more per hour for the night shift.
In addition, experts advise hospitalists to clarify the hospital’s financial goals. What is the anticipated revenue? Is insurance going to pay both bills? And even if it seems like the service will be a financial loss, hospitalists looking to make the system work or to advocate for a bonus should factor in the gains of keeping other physicians—such as orthopods—happy and continuing to admit.
How to make the most of night services
Even as surgical co-management services lead to a greater acceptance of tuck-in services, hospitalists face very real issues as tuck-in providers, especially given their own workforce shortages.
That’s why hospitalists should be discriminating about whether or not they want to offer such a service. Here are tips to help you decide if you want to proceed:
How much is too much? Martin B. Buser, MPH, with Hospitalist Management Resources LLC, recommends that hospitalists asked to take on night admissions examine hospital records. “Anticipate the volume likely to come,” he says, “from PCPs and the payer mix.”
Make it a combo. Combine a tuck-in service with providing 24/7 in-house care for the rest of the patients, even joining a rapid response team, for example. This makes the service more satisfying and easier to justify financially.
Define expectations. Clearly lay out your expectations ahead of time to your group, the hospital administration and to physicians whose patients you’re going to admit. For example, when an orthopedic patient needs specialist care in the middle of the night, make sure the orthopod comes in.
Keep everyone involved. Even if you have a nocturnist program, make sure everyone is included. Some programs use what they call “paper rounding,” which forwards information from the tuck-in service to the physicians that come on board in the morning.
Coordinate with PCPs and specialists. Sit down with all the physicians to find out how they feel using hospitalists will affect them. Dispel rumors and myths and set out exact communication rules: who calls who, when the call is made and what time the doctor takes over care.
Get that financial incentive. If the administration wants a night service program, get the hospital to tie an incentive to it so the hospitalists don’t feel like housestaff.
Think of the future. Consider the long-term impact on the hospitalists and how it will affect recruitment.