Published in the April 2017 Today’s Hospitalist
FOUR YEARS AGO, I made an unusual career move: I became the designated hospitalist for a Medicare Advantage plan managed by our hospital’s independent physician association (IPA). That change has reaped many benefits for not only the patients and the IPA, but the designated hospitalists as well.
The physicians in my community hospital once realized significant shared savings on our IPA’s capitated contracts. But that bonus disappeared years ago, as the plans attracted sicker, older subscribers.
As subscribers aged, the elderly were shifted to a single plan. Out of the roughly 60 IPA groups servicing this plan in Massachusetts, ours has the highest percentage of patients over age 90. To serve patients better and recoup some shared savings, the IPA now manages that contract.
An indispensable team
In 2007, I began working as a hospitalist after 30 years of outpatient practice. The hospital’s nurse managers noticed that I pushed the limit of what could be accomplished with outpatient and home care.
An IPA with skin in the game needs to prioritize having hospitalists spend extra time with patients and families.
As a result, the IPA—along with the hospital and my employer, a large university-based physician group—asked me to stop alternating admissions with my hospitalist colleagues and to focus instead on the Medicare Advantage patients. I recruited another hospitalist from our group to work with me seven-on/seven-off, with a daily census of between 10 and 15 patients.
The IPA also assembled its own designated SNF nurse practitioners, SNF case managers, visiting nurses and inpatient case managers to better manage complicated patients. The IPA also implemented three disease management programs targeting the three most common readmissions: heart failure, COPD, and frail patients or those with multi-system disorders. A medical director—an internist who makes all expensive utilization decisions—manages the overall program.
Being a designated accountable care hospitalist would be pointless without this team: They help me make the hospital stay more efficient and the discharge more secure. The team meets weekly to discuss the hospitalized and rehab patients, as well as those at home who appear to be failing. Primary care physicians receive a stipend to attend a separate monthly meeting that focuses on their role in improving outcomes and reducing readmissions.
Redefining hospitalists’ role
We have redefined the designated hospitalist’s position to prioritize extra time with patients and their families—not a role every hospitalist enjoys or performs well.
Tasks include calling outpatient providers on the day of discharge and the SNF NP on the day of transfer; interfacing with visiting nurses; sleuthing out why readmissions occur by talking to pharmacists to see if patients filled prescriptions; calling a tenuous, homebound patient the day after discharge; and spending time in the hospital educating patients and caregivers about what could cause decompensation and readmission.
An IPA with skin in the game needs to make such tasks a major part of hospitalists’ job description, not an afterthought for days with a light census. Integrating such behaviors will never be a priority if doctors are induced by productivity bonuses to instead see more patients.
My shift partner and I receive a salary supplement from the IPA to make up for our lower productivity and reduced bonus opportunities. Another option to boost hospitalist compensation for a group without shared savings would be to lower the productivity threshold—an inexpensive investment that an IPA or ACO would recoup with only a few prevented readmissions.
After one year, our accountable care team had the second best overall readmission rate among all the IPAs in the state managing this contract. The other hospitalists in our group have also reduced readmissions, not only because the IPA takes many older and sicker patients, but because the hospital implemented daily care coordination rounds for discharge planning.
These 30-minute meetings are attended by at least one charge nurse, physical therapist, pharmacist, social worker, nurse case manager, hospice/visiting nurse liaison, utilization case manager and nursing supervisor from each ward. Each hospitalist and resident gets two five-minute slots to present a brief summary of each of his or her patient’s discharge plan. This 10-minute investment saves hospitalists from having to chase down an urgent PT evaluation or home nebulizer—and means we all now focus more on the discharge process to reduce length of stay.
In addition, I finalize our discharge plans in a quick daily call to the IPA’s outside case manager to discuss, for example, whether to authorize rehab for a particular patient. That IPA input results in cost savings compared to standard Medicare patients, who may often be transferred to rehab settings without any likely benefit.
One of the joys of this arrangement is also the most embarrassing: My partner and I get to know well the readmitted patients.
All hospitalists eventually meet the frequent recidivists and their caretakers, but our plan’s sickest patients always come back to us. Their families appreciate the expedited admissions and discharge. And our familiarity allows us to start an earlier dialogue about advanced illness management, palliation or hospice, or even triage a pelvic fracture straight from the ED to a SNF.
Such a position carries potential conflicts of interest. Because Medicare pays a lump-sum DRG for admissions, the hospital wants the shortest possible stay. The Medicare Advantage plan, on the other hand, wants at all costs to avoid a readmission and another full payment.
That means making sure patients are fully stable before discharge or keeping them extra days in the hospital to avoid a costly SNF stay.
On any given day, I talk with case managers from the IPA and the hospital, who have divergent discharge priorities. I solve this inherent conflict by doing what is best for the patient and family, while keeping overall cost-effectiveness in mind.
I also participate in the unassigned-patient rotation from the ED, so I appreciate the difference in managing IPA patients and standard Medicare patients. Managing Medicare patients without financial accountability risks losing the team commitment to both quality and the bottom line.
Indeed, one reason why hospitalists burn out is that we often see ourselves as shift workers with no control over or input into outcomes. Being part of an accountable team makes me feel like a business owner responsible for quality of care.
Jay Glaser, MD, is a hospitalist at UMass HealthAlliance Hospital in Leominster, Mass., and a faculty member of the University of Massachusetts Medical School. His book, “Body Renewal: The Lost Art of Self Repair,” discusses the behavioral and non-pharmacological treatment of common chronic disorders.