Published in the April 2006 issue of Today’s Hospitalist
If it’s true that imitation is the most sincere form of flattery, hospitalists have reason to be pleased. Even as hospitalists expand their role in U.S. hospitals, other specialties are embracing their model of practice to improve both the care of their patients and the lifestyles of their practitioners.
Hospitalist programs operating outside the sphere of internal medicine are still far from common, but two specialties “ob/gyn and gastroenterology ” are taking significant strides in making the hospitalist model their own. Experts say they expect the use of hospitalists in both specialties to grow sharply as more and more physicians get a glimpse of the model’s benefits.
These programs are working through some challenges that will be alltoo- familiar to medical hospitalists, such as workload intensity and financial concerns. But it seems that one of the biggest concerns faced by internal medicine hospitalists “acceptance by physicians, and to a lesser degree patients “is largely a nonstarter among gastroenterologists and ob/gyns.
Some of the physicians interviewed for this article said that may be because medical hospitalists have already paved the way for physicians and patients to accept their programs. It may also be a testament to just how effective the hospitalist model can be, even in specialties outside of internal medicine.
Talk to an ob/gyn physician, and you’ll hear that one of the major issues driving the acceptance of hospitalist programs is the urgency of patients in labor. The most obvious scenario is the woman who comes into the hospital in labor and can’t wait for her ob/gyn to arrive.
The urgency of ob/gyn practice also manifests itself in another way. When patients who have no privatepractice ob/gyn arrive in labor, another physician who is on call must abandon his or her practice and rush to the hospital.
Both of these all-too-common scenarios have driven a number of hospitals around the country to implement an ob/gyn hospitalist program that has given its physicians two primary charges: Care for indigent and unassigned patients, and give private-practice ob/gyns some back-up for those patients who just can’t wait.
Richard Frieder, MD, is one of five ob/gyn hospitalists who fills both those roles at Washington Hospital in Fremont, Calif. Every fourth day, he works a 24-hour shift treating indigent and unassigned patients and serving as a safety net of sorts for his office-based colleagues.
Because the hospital has created an ob/gyn hospitalist program, community-based physicians no longer have to drop what they’re doing to come to the hospital and care for these patients. “We serve as a pinch hitter while that patient’s personal physician is on the way,” Dr. Frieder says.
That back-up role is particularly popular with outpatient ob/ gyns, Dr. Frieder explains. Before Washington Hospital created an ob/gyn hospitalist program, community-based ob/gyns would have to leave their practice and rush to the hospital anytime an unassigned ob/gyn patient was admitted.
“It’s not like these patients have pneumonia and you can start them on their meds and see them the next day,” says Dr. Frieder, who also works as a private-practice ob/gyn in another community. “You have to see them initially and make an evaluation, then the nurse calls you at least every hour until she’s ready to deliver. Then at some point, you’re going to get called back in for another hour or two to deliver the baby. It’s very disruptive to an outpatient ob/gyn’s schedule.”
But improving the practice lives of outpatient ob/gyns is only one of the missions of these programs. Because women often need care quickly, ob/gyn hospitalist programs offer an obvious way to improve care, particularly at non-teaching hospitals that don’t have housestaff.
That was the case at Parkridge East Chattanooga Hospital in Chattanooga, Tenn., which started an ob/gyn hospitalist program a few years ago to cover nights and weekends. Because the hospital has no housestaff presence, administrators felt they needed to bring in ob/gyn hospitalists to cover nights and 24-hour shifts on weekends, when most community- based ob/gyns had left the hospital.
Like the hospitalists at Washington Hospital, Parkridge’s ob/gyn hospitalists don’t take over the care of patients who have a community-based ob/gyn, but they function as a safety net while their outpatient colleagues are on the way. Private-practice physicians still take call for uninsured and indigent patients on nights and weekends.
“If you have a level-2 NICU and you tout yourself as a facility that handles difficult pregnancies, you need to provide that coverage, because just about anything can walk in your door,” says Judy Rhyne, RN, the hospital’s chief nursing officer.
The group-practice model
That type of thinking persuaded Life Stages Samaritan Centers for Women in Dayton, Ohio, to start a hospitalist program about nine years ago. Physicians in the eight-member ob/gyn group work a 24-hour shift in the hospital every sixth or seventh day. They care for their own patients as well as unassigned and indigent patients.
“Here you’ve got the most important event in the beginning of life,” explains Bruce Bernie, MD, the group’s CEO and a practicing ob/gyn. “How can you not have someone there who’s immediately available to take care of any major issues?”
Dr. Bernie argues that his group’s hospitalist model ratchets up the quality of care a notch or two because he and his colleagues cover their patients’ entire continuum of care, not just labor and delivery. “We’re coordinating prenatal care and we’re giving 24-hour coverage for the hospital,” he explains. “The delivery part is only one piece.”
He says that all of the group’s clinicians, including physicians, midwives and NPs, meet regularly to review all patients who are close to giving birth. “When a patient comes into the hospital,” he says, “we know who they are and what their issues are. You’re aware and you’re prepared.”
The 24-hour shifts can be difficult, Dr. Bernie says, but they make life much easier during the other days.
“When you’re in the office,” he explains, “you don’t have to worry about leaving your patients to deliver babies. All you have to think about is doing your job for that day. You don’t have to worry about anything else.”
The business case
The business model behind the hospitalist program at Dr. Bernie’s practice is relatively simple, at least when it comes to patients with health care coverage. Physicians working as hospitalists simply bill the patient’s insurer or health plan for services rendered, which adequately pays for their time.
When the group treats patients with no insurance, that business plan changes somewhat. Dr. Bernie says the group has an arrangement in which the hospital helps share the costs of treating those patients.
While the system has worked well, some experts claim that slightly different ob/gyn hospitalist models can not only help indigent patients, but boost hospitals’ bottom lines.
Delphi Healthcare Partners in Raleigh, N.C., operates five ob/gyn hospitalist programs, including the one at Washington Hospital in Fremont, Calif. David Joyce, Delphi’s president and CEO, says that by taking unassigned and indigent patients off the shoulders of community-based ob/gyns, hospitals can increase the number of commercially paid deliveries at their facility.
Mr. Joyce describes one hospital that implemented an ob/gyn hospitalist program “and took over the care of 1,000-plus unassigned and indigent patients that used to tie up community-based ob/gyns. In the year that followed, he explains, the hospitalist program allowed the outpatient ob/gyns to deliver an additional 200 babies in the hospital to patients with commercial insurance.
Because the hospital at that time was collecting about $5,000 for each of those privately insured deliveries, the hospitalist program helped the hospital bring in more than $1 million in additional revenues from labor and delivery. That amount paid for the ob/gyn hospitalist program and then some, Mr. Joyce recalls.
“These programs do not cost money,” he says, adding that they instead bring in millions of dollars above and beyond the cost of the service.
Mr. Joyce notes that Delphi has also helped create hospitalist programs in two other specialties: general surgery and orthopedics, because those physicians often don’t want to provide ED coverage for unassigned patients.
GI hospitalists: a group model
Gastroenterologists may not always face as much pressure to get to the hospital as ob/gyns, but a number are nevertheless discovering the benefits of GI hospitalists. Gastroenterologists who have started these programs say that GI hospitalists not only help improve quality of care for hospitalized patients, but make the outpatient practice setting more efficient.
At Gastroenterology Consultants, a division of Gastrointestinal and Liver Specialists of Tidewater in Virginia Beach, Va., the group’s six physicians created a hospitalist program a few years ago to address exactly those types of issues. Every sixth week, for an entire week, a gastroenterologist works as a hospitalist covering the two hospitals where the group has admitting privileges.
The GI hospitalist covers daytime hours during the week and then provides 24-hour coverage Friday night through Monday morning. The group’s other members take call at night Monday through Thursday.
When working as a hospitalist, the group’s physicians have no office responsibilities during the week. They cover not only the group’s patients, but unassigned and indigent patients in the hospital.
“Physicians like the model very much,” says Irving M. Pike, MD, the group’s managing partner. “They find themselves a lot more efficient than when they had responsibilities in both places every day.”
While he acknowledges that working an entire week in the hospital is not always easy, he says that it dramatically frees up his time when he’s working as an office-based physician. “During the other five weeks,” Dr. Pike says, “it gives you more time to be home. It’s a reasonable balance.”
Dedicated GI hospitalists
Gastrointestinal Associates in Knoxville, Tenn., uses a different variation of the GI hospitalist model, but with similar results. Instead of rotating its hospital work, the 13-physician group hired a gastroenterologist in 1998 to work only as a GI hospitalist.
Bergein F. Overholt, MD, the group’s managing partner, says that bringing a full-time GI hospitalist on board has led to a huge improvement in both practice efficiency and lifestyle. “It’s been so much better than we envisioned,” he says. And the hospitalist, Dr. Overholt adds, enjoys a job with no night or weekend call.
He gives much of the credit for the program’s success to the GI hospitalist who started the program and who continues there today. He says that the job requires a strong, independent personality, and that gastroenterologists who prefer a scheduled day with few surprises might find working as a GI hospitalist stressful.
Dr. Overholt also notes that although there are many positives, there is a downside for gastroenterologists working as GI hospitalists in that they they’ll never be one of the specialty’s biggest earners. The group guarantees a salary that is approximately equal to the average salary of one of the outpatient gastroenterologists. Dr. Overholt says a dedicated GI hospitalist could be an average or above earner, but not likely to be one of the group’s top earners.
The business case
While his group guarantees the salary of its GI hospitalist in case revenues fall short, Dr. Overholt says the practice has never had to contribute any money to pay for that physician’s salary. Even if the group had to pay part of the GI hospitalist’s salary, he adds, the additional procedures the outpatient physicians can perform because they’re not seeing hospitalized patients would more than make up for it by allowing them to see more patients in the office.
At Gastroenterology Consultants in Virginia Beach, the GI hospitalist program has had a positive impact on the practice, but in a different way. Dr. Pike says that before the group created a hospitalist program, its physicians were spending about 25 percent of their time at the hospital, but earning only about 7 percent of their revenue from inpatient work.
By eliminating the need for gastroenterologists to go to the hospital during the day, the group instantly reduced the percent of time its physicians spend in the hospital. At the same time, the group’s physicians began spending an additional one to two hours in the office each day. “In essence,” he says, “we increased availability in the office by one physician FTE without hiring another doctor.”
Dr. Pike says that because the group’s physicians equally split revenues, there is no financial downside for individual physicians, and the program has helped boost overall revenues “and everyone’s income.
When hospitalists intersect
While medical hospitalists and ob/gyn hospitalists might work in the hospital for years without ever crossing paths, the same can’t be said of GI hospitalists. Dr. Pike says that in his experience, medical hospitalists and GI hospitalists can help each other and make each other’s lives easier.
Before the hospitals where he works implemented medical hospitalist programs, Dr Pike says, he used to frequently return to the hospital at night to manage patients or consult. Now, however, the internists working as hospitalists typically take care of GI patients and then consult with him in the morning.
“Unless it’s a true emergency that needs immediate attention from a gastroenterologist,” he says, “we don’t get a phone call.”
Dr. Pike says the relationship works both ways, and that he suspects medical hospitalists are more quick to call for a GI consult because they know there’s a GI hospitalist in the building. He says that’s generally a good thing for patient care.
“We’re all there,” he explains, “and we’re communicating directly. The hospitalists know who’s covering, they know who to contact, they see you on a daily basis. They know they can find you in the endo suite if you’re not on the floor.”
One or the other
Will gastroenterologists ever walk away from hospital work altogether, as has happened with many internists and family physicians? When asked if gastroenterologists would miss working in the hospital, both Drs. Pike and Overholt laughed.
It’s not that gastroenterologists don’t like the work, explains Dr. Overholt, but that hospital work is so inef- ficient. Getting a call from the hospital can wreak havoc on your schedule, particularly if you’re already tightly booked with procedures.
“Hospital work takes travel time,” Dr. Overholt explains, and “you spend a lot of time waiting to get things done. It’s not as attractive as the outpatient environment.”
Dr. Pike says that he would personally miss hospital work. “There’s a certain mental energy and excitement from solving very different medical problems that you don’t get on a day-in, day-out basis in the office,” he explains.
Dr. Pike notes, however, that not all his colleagues share that view. “I think there are many gastroenterologists who would be very content to work in the office and not spend any time in the hospital.”
Edward Doyle is Editor of Today’s Hospitalist.