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How "rules of engagement" can help bridge the divide between surgery and medicine

June 2007

Published in the June 2007 issue of Today’s Hospitalist.

As the eight-physician hospitalist group at Kadlec Medical Center in Richland, Wash., launches its first surgical co-management service this summer, there are plenty of logistical issues to work out, like how to structure billing.

But according to Matthew Szvetecz, MD, the director of Kadlec’s hospitalist program, one of the trickiest aspects of the new endeavor has been figuring out how to navigate what he describes as "bipolar" cultural differences between medicine and surgery.

"From medical school, we learn about the different social constructs of different medical fields," Dr. Szvetecz explains. Surgeons, he points out, tend to be action-oriented and come in an either/or mode: either they operate or they don’t. As for medicine, "that is very thought-process oriented," he says. "What is the differential diagnosis, and how do we go through the process to find out what’s going on?"

As more hospitalist programs embark on surgical co-management ventures, learning to bridge that divide is becoming increasingly important. While co-management can lead to higher quality and more cost-effective care, it can also be a source of friction, especially when the ground rules aren’t established upfront.

"You need to set up the ‘rules of engagement’ for the relationship to work," says Steven Nahm, vice president of The Camden Group, a consulting practice in El Segundo, Calif.

Mr. Nahm says those rules need to cover three key areas: admitting procedures, clinical responsibilities and physician communications. For a co-management program to succeed, he adds, programs should not only set those rules early on, but tweak them often.

Whose patient is it?
The majority of hospitalist programs are now forging ahead with co-management services. According to the latest industry survey, as many as 85% of hospitalist programs report offering or providing surgical co-management.

For many groups, co-management means learning how to iron out problems. Not only do hospitalists and surgeons bring a different mindset to patient care, but the two groups are often separated by age-related and even ethnic differences.

That was a lesson learned by Tarek Shawkat, MD, lead hospitalist at Cape Canaveral Hospital in Cocoa Beach, Fla., when he helped launch a co-management program last year.

"It didn’t help that our hospitalists were from out of town, and the surgeons had been here much longer," Dr. Shawkat says. "There were also cultural and background differences between the groups."

The real source of tension, however, was the fact that the two groups didn’t work out in advance which doctors would be responsible for which patients.

"The surgeons simply didn’t understand the hospitalists’ function," he explains. "They thought we’d handle all surgical admissions, even if the patient didn’t have any complicating medical issues." That became especially problematic when a patient needed to be seen by a surgeon right away.

After a few sometimes heated discussions, the two groups agreed that the surgeons would immediately take over all acute surgical cases. Dr. Shawkat is now in the process of working with both the surgeons and the ED staff to develop objective criteria to triage patients.

Relying on algorithms
Such criteria can go a long way toward creating a smoother relationship. About two years ago, Joseph Li, MD, director of the hospitalist program at Beth Israel Deaconess Medical Center in Boston, sat down with the chief of orthopedics to develop a process for handling ED patients with hip fractures.

"We were operating in separate spheres," he notes. "Orthopedics would admit a patient with a broken hip, for example, and several days later, we’d get consulted about the patient’s anemia or hyperglycemia. We began to realize that several patients would have been better served if we’d been consulted earlier."

The solution was to develop an algorithm that the emergency department follows when presented with a hip fracture patient. "Elderly patients with multiple medical problems would be better served by having a hospitalist as the primary care provider, with orthopedic surgeons acting as consultants," Dr. Li points out. "Younger patients could go directly to the orthopedic service." Now, when a patient comes in, Dr. Li says, "the emergency department can follow the algorithm and immediately know which service to transfer the patient to and who to call."

The two groups also set clear expectations for how they would continue working together through the end of the patient’s stay. If the patient is on the hospitalist service and the surgeon is consulting, for example, the hospitalist writes all the orders; if, however, the hospitalist is consulting, the surgeon writes them.

The groups also agreed that the attending of record, not the consultant, would be responsible for the discharge summary.

Open communication
The hospitalists and surgeons also had to establish lines of communication, to avoid misunderstandings that could waste time or compromise care. "If the scheduled surgery time has changed, it’s important to let the hospitalists know so we’re not still working on the old plan," says Dr. Li. Each group makes sure to contact the other via pager with any changes in a patient’s care plan.

To keep each other in the loop about patients, groups use different methods for passing daily information back and forth. At Good Samaritan Regional Medical Center in Corvallis, Ore., for instance, lead hospitalist Cliff Hall, MD, says the group works closely with the surgical physician assistants.

For the orthopedic co-management service at the University of Michigan Medical Center in Ann Arbor, the go-between is an orthopedic resident, according to clinical assistant professor and hospitalist David Wesorick, MD.

"Hospitalists do cursory or ‘card-flip’ rounds with orthopedic residents at least once a day, via phone or in person," Dr. Wesorick says. While the hospitalist-resident team may not necessarily see each patient together, it will discuss relevant details, such as who can be discharged and which patient had an overnight complication, as well as major changes to the care plan. "The resident then relays information to the orthopedic attending as needed."

Avoiding pitfalls
Another key component of a good working relationship: making sure that the surgeons themselves are available. At Baptist Hospital in Pensacola, Fla., for example, hospitalists co-manage neurosurgery patients who have nonoperative intracranial hemorrhages.

"Many hospitalists wouldn’t want to take on neurosurgery patients because they tend to be unstable and can get very sick very fast," says medical director Mark Strauss, MD. "But we feel comfortable admitting those patients because we know the neurosurgeons will stay in close contact in case something goes wrong."

Hospitalists, who become the admitting physician after these patients have been evaluated in the ED, know that a neurosurgeon is available 24/7. Dr. Strauss says that arrangement "was agreed to before we started assuming the primary care of this group of patients."

What areas of tension crop up? For one, Dr. Strauss says, "we sometimes feel that a surgeon gets unnecessary consultation from other subspecialists for things we manage." Surgeons will, for example, consult nephrologists for patients with electrolyte abnormalities or mild renal insufficiency, or pulmonologists for patients with mild COPD exacerbations. However, once the hospitalists "set ego aside," he adds, "we have come to realize that a lot of times, this is done to get outpatient follow-up with the specialist."

Miscommunications around discharges can also lead to hard feelings." We do have a few surgeons who feel we don’t treat them fairly," Dr. Strauss points out. Those surgeons tend to be the same ones, he adds, who want the hospitalists to follow their patients through discharge. "Otherwise," he says, "when patients are medically stable, we often sign off."

Developing clinical protocols
Clinical protocols are another area that needs close attention. According to Dr. Strauss, orthopedic surgeons take a variety of approaches to DVT prophylaxis. But because the hospitalists and orthopedists have already mapped out their respective admitting and consulting roles, they know whose protocols will take precedence.

"If the patient is admitted to the surgeons, then they call the shots, and we may just recommend a different approach," says Dr Strauss. "If the patient is admitted to us, we order what we want, but we get the clearance to begin from the surgeon."

Ron Greeno, MD, chief medical officer of Cogent Healthcare, a national hospitalist management company based in Irvine, Calif., suggests another approach: sitting down with surgeons at the outset to develop protocols for pain management and DVT prophylaxis.

"Surgical patients lend themselves to protocols," Dr. Greeno notes. The key is developing the protocols early and getting the surgeons involved at the outset. "Too many people wait until problems occur," he says.

He also suggests looking at non-clinical process issues, such as when and where the patient is going to be pre-operatively evaluated and who will be responsible for communicating with the patient’s family.

And Dr. Greeno recommends putting your processes in writing. "You don’t necessarily have to have a written contract, but you’ve got to have your basic approach written down. Otherwise," he says, "you’re putting yourself in the position where you’re being reactive and not doing justice to your patients."

Staying on track
By taking on co-management, hospitalists say that both they and the surgeons they work with gain a much better understanding of what each other brings to patient care.

"Before we did this, the orthopedists hadn’t seen the benefits of consulting the hospitalists early on, and the hospitalists didn’t necessarily want surgical patients on their service," says Beth Israel’s Dr. Li. But as the system began to work, "it really brought the orthopedic and hospitalist staff closer together" “and helped each of them appreciate the other’s expertise.

To keep such a relationship running smoothly, however, Mr. Nahm suggests that hospitalists and surgeons meet periodically to discuss how the rules of engagement are working out. At Oregon’s Good Samaritan, Dr. Hall invites all new surgeons to meet with the hospitalist group to discuss their mutual expectations. Dr. Li’s group regularly attends the surgeons’ staff meetings, while surgeons occasionally stop by the hospitalists’ meetings as well.

Experts also suggest piloting a co-management project with a subset of patients. "Groups tend to be more successful when they ease into co-management specialty by specialty: first orthopedics, then cardiac surgery," says Mr. Nahm. "They can learn and improve at each stage." By staggering the implementation of different co-management services, hospitalists can also evaluate whether they have the right staffing before taking on another service.

Such assessment is essential because, as with other hospitalist services, the demands of surgical co-management tend to quickly outpace projected volume. Mr. Nahm has heard of hospitalists terminating a co-management agreement with an individual surgeon because that physician was too slow to respond to phone calls and consult requests.

But "the only reason I know that an entire service was suspended," says Mr. Nahm, "was due to the inability of the hospitalists to handle the volume."

Yasmine Iqbal is a freelance writer based in Wallingford, Pa., specializing in health care.

How to bill for co-management services

When it comes to launching a surgical co-management service, some hospitalists are leery of the logistics, thinking they’re going to have to start battling with surgeons and payers for part of a global surgical fee.

But that’s not the case, according to Krishan Nagda, MD, founder and chief executive officer of Central Florida Inpatient Medicine, a 32-hospitalist group that is based in Central Florida and serves five hospitals. As a five-plus year veteran of surgical co-management, Dr. Nagda says that his group typically manages between 30 and 35 joint replacement cases every week.

In addition, the group provides co-management for neurosurgery, urology and cardiothoracic surgery, as well as general surgery.

When billing for those services, Dr. Nagda explains, he does not try to unbundle the global surgical fee. Taking that unbundling route “which involves both surgeons and hospitalists submitting bills that would include modifiers, along with CPT codes “may be the way to go, he says, for multispecialty groups to which both the surgeons and the hospitalists belong.

But because Central Florida Inpatient is an independent company, going after a slice of a global fee isn’t an option. "The surgeons do not want to split that, and we’re not dipping into that piece at all," says Dr. Nagda. "We’re two different organizations, billing for two different levels and types of service."

He says that for pre-op evaluations, for instance, the surgeon writes a consult order for the hospitalist to complete medical pre-op clearance. The hospitalist then bills the consult using an outpatient consultation code (99241-99245).

As for post-operative care, if the surgeon writes an order for medical evaluation of a specific diagnosis, such as COPD or diabetes, the hospitalist bills those consults using inpatient consult codes (99251-99254). If, on the other hand, hospitalists are providing general medical management for a patient without a specific diagnosis, they bill those services with the subsequent visit codes (99231-99233).

So if billing for surgical co-management is so straightforward, what’s the problem? Dr. Nagda says it’s getting payers to recognize the fact that hospitalists are billing “and deserve to be paid for “additional service, such as a pre-op evaluation, rather than receiving a case rate for complete care of, say, a patient admitted for pneumonia.

Typically, he points out, hospitalist case rates with payers are all-inclusive and need to be renegotiated to carve out pre-op evaluations.

In fact, Dr. Nagda points out, when his group first started doing co-management, it faced a slew of payment denials. "We had to show the value of what we were doing in terms of outcomes."

His group made the case that the patients receiving pre-op evaluations had more co-morbidities and were usually sicker. Because of the hospitalist service, those patients ended up having fewer post-op complications, with less nursing home and skilled nursing care. The group utilized data provided by the hospitals to make its case to payers.

The ultimate solution, Dr. Nagda adds, was renegotiating some payer contracts to include pre-op evaluations and to not have those evaluations included in the hospitalist case rate.

"We actually had to go back and modify the contract," Dr. Nagda says, a route he urges hospitalist groups to take if they’re facing a lot of denials or if payers insist on lumping payments for co-management services into a global surgical fee or hospitalist case rate. "Over a period of two years, we ended up renegotiating some contracts that now pay us extra for that pre-op side."