Home On the Wards “Hey, are you the no-doc doc tonight?”

“Hey, are you the no-doc doc tonight?”

May 2010

Published in the May 2010 issue of Today’s Hospitalist

It’s an old problem that recently has gotten worse: Patients arrive at the ED in need of admission, but they don’t have a doctor to manage their care. Until a few years ago, taking “no-doc call” was a standard way for new physicians to build a practice, and even established doctors were expected to provide that service in return for admitting privileges.

But unassigned call was one of the first things that primary care physicians handed over to hospitalists. It’s a key service line for hospitalists employed by a hospital. And hospitals that don’t have in-house programs are contracting that service to outside hospitalist groups, sometimes offering a subsidy to compensate them for the care of “non-resource” patients.

As hospitals face the twin dilemma of budgetary pressures and growing numbers of uninsured patients, however, some administrators are scrutinizing how they care for the unassigned population. While some are renegotiating how they pay for unassigned care, others may offer contracts to several different groups to care for this complex “and potentially costly “group of patients.

While it remains to be seen how newly enacted health care reform will change your mix of unassigned patients, one thing is clear: These are often the most interesting “and grateful ” patients you will treat. They may have been misdiagnosed elsewhere or putting off treatment for fear of a bad diagnosis, or maybe they’re just sick and miserable.

Finding that you are both competent and sympathetic will make their day, and helping them find a way into the health care system can make a long-term difference in their lives. But is caring for unassigned patients a good fit for your group?

Figuring out the logistics
If your group is receiving its first offer to cover unassigned patients, spend time reviewing the situation and the effect the contract will have on your practice.

First, does this entail 24/7 coverage, or only as many shifts as your group can comfortably handle? One Houston group found that taking just a portion of unassigned shifts at first, then increasing coverage as the group hired new hospitalists, allowed it to adjust to the load.

Others have had to share coverage with competitors or even give away shifts to other groups when doctors left the program or the load got too heavy. One Texas group that lost several hospitalists over a short period had to invoke the cancellation clause in its contract, which caused bad feelings that took months to repair.

Second, is there a “protected” group within the hospital, such as a teaching service or a multispecialty group, that admits there exclusively? Will that group find your presence threatening, and will the administration back that group in case of a conflict?

Third, how much input does the administration expect to have in how you run this service? Many hospitals already track individual physicians’ length of stay, cost per admission and patient satisfaction ratings. Will your compensation or the continuation of your contract be tied to yardsticks like these for these patients?

And finally, is the administration realistic about the problems patients have when they lack primary care and insurance? These people frequently delay medical care until they have a whole list of issues, and they may have other problems like substance abuse and personality disorders that make them more difficult to work with.

Because many unassigned patients have no insurance to cover an outpatient test or procedure, hospitalists are often left addressing a wide range of health issues, which lengthens hospital stay. Substance abusers drift from one hospital to another, finding that a few days off their medications for diabetes or heart failure make it easy to convince an ED doctor to admit them. If administrators haven’t heard about these problems from case managers and social workers, they either weren’t asking or weren’t listening.

Chip Robertson MD, chief medical officer of Intercede Health, a multistate hospitalist group with practices in Houston, explains that you need to evaluate how much the administration “gets it.” That includes not only the group’s need for financial aid but support in political battles that arise, so make sure administrators understand both.

Start with the ED
A good way to get a read on these issues is to visit with the ED doctors. The ED group can give you an idea of how the administration regards physician extenders, how patient complaints are handled and how much control physicians have over their work.

Unless your hospital is a referral center that accepts specialty transfers, most no-doc admissions will come through the ED. Many of the problems these patients have such as hip fractures or diverticular abscesses sound like a job for another specialty. Will the hospital’s orthopedists and general surgeons insist on taking care of their own patients, or do they want all adults to be admitted by an internist “to manage other problems” (which means answering calls for sleeping pills)? Or are they flexible about which of you is the primary and which the consultant?

Ask the ED doctors how hard they have to work to get some patients admitted. Do surgery and medicine docs argue over who has to take that pancreatitis? If a patient is vomiting blood, do gastroenterologists come promptly, regardless of insurance status?

Also ask ED doctors about your competition. One hospitalist group was invited by an inner-city hospital to handle no-doc medicine admissions, but the internists already on staff saw that as a threat to their practice. Fortunately, no one had made a commitment yet, and the administration worked out a subsidy arrangement with the established doctors. While it was disappointing for the outside hospitalist group, trying to build a practice in a hostile environment would have been more painful.

Consult the consultants
You’re great at stabilizing a GI bleeder and working up a lung neoplasm, but you can’t manage everything on your own. Somebody is going to have to band those varices, bronchoscope the lesion and write dialysis orders. How helpful will consultants be if you start admitting uninsured and/or noncompliant patients?

In fairness, a consult for these patients is often not a one-time event. While you may not see the patient again after discharge, chronic medical problems require longterm outpatient care, and Dr. Consultant may be monitoring drug doses and lab work for a long time to come.

Ask subspecialist and surgical friends what they think. Dr. Nephron may not come out and say he doesn’t want a lot of non-resource patients, but he may strongly suggest spreading the work among doctors in his specialty. Dr. Gastro may be more blunt “and expect to share some of the hospital’s subsidy if he sees uninsured people.

If your practice group is popular and respected, specialists can probably tolerate a fair number of “freebie” consults. But if you’re new to the hospital, being known as “the guys who admit all the uninsured patients” can adversely affect the rest of your practice.

Can you count on administration?
Case managers and social workers, those unsung heroes of discharge planning, already work for the hospital and know the business well. Find their office and ask them what they see as obstacles to discharging unassigned patients.

Try to get a feel for how active the hospital administration is in providing help. Is it willing to pay for a skilled nursing facility for someone who no longer meets the criteria for an acute care bed? Will the administration help with Medicaid and disability applications? Does the hospital have its own skilled nursing facility or rehab floor?

How much financial support you need will depend on the number of unassigned patients. It could be a daily rate, from $200 in a quiet suburban facility to more in a busy big-city hospital. Many groups find that a per-case payment works best.

If you keep the rate low “say, between Medicare and Medicaid reimbursement rates “you won’t risk losing the contract by being perceived as greedy. On the other hand, a hospital administration unwilling to pay its share of the bill may be telling you that your interests are not a high priority.

Unassigned patients themselves can be more difficult than others you admit. A small number lack a primary care physician not because they lost coverage, but due to noncompliance, substance abuse or personality disorders. When a patient is critical or uncooperative, does the hospital assume that “the customer is always right,” or does it look at both sides of the story? Length of stay and other quality measures will come up as numbers by your name. Ask if outliers, like the paraplegic with osteomyelitis and no home support (total: eight months in acute care), are averaged in with more typical cases. If they are, a single patient who has run out of Medicare days can ruin your score.

Similar precautions apply to measures like mortality, which common sense suggests is higher in patients unable or unwilling to cooperate with medical care. A group that admits a high percentage of no-doc patients may do well just keeping even with the average for internists on staff. Does the administration realize this and adjust expectations accordingly?

Editing the contract
What I’ve written so far should give you a checklist of things you want “and don’t want “in a contract, and possibly reasons to prefer a more open arrangement, such as sharing the duty with other staff doctors.

Phrases like “physicians will work to improve length of stay and maintain quality scores” set a reasonable goal, but watch for wording “such as an expected percentage improvement in scores “that could be the basis for canceling the agreement or reducing payment. And try to avoid contracts that last more than a year. A look at the evening news or morning paper will make it clear that changes in health care payments are coming.

If you can’t get accurate numbers on last year’s admissions, or if there’s been a large-scale loss of jobs in your area, you may want a way to adjust your financial compensation during the period covered by the contract. If you’re concerned about the availability of consultants (some specialties will be short-staffed everywhere but at major academic centers), make sure that you won’t be penalized for transferring a patient to another hospital for care.

Have an attorney review the contract and suggest changes such as an escape clause (60 days’ notice is fairly common for either party to end the agreement) or ways to renegotiate financial support. Mentioning in a non-threatening way that your legal staff will review the contract lets people know that you are careful and thorough, and that’s not a bad image to cultivate.

On the plus side
Taking no-doc patients can be a great way to expand your practice, build a good reputation and feel that you’re making a difference. Unless you’re way off in your estimate of the financial support you need, your cash flow should do well. And once consultants see the quality of your work, they will start sending patients your way, either asking you to handle both routine and emergent admissions so they can concentrate on what they do best or, in the case of surgeons, consulting you for perioperative management.

“If you can’t be good, be careful.” Remember: These are the patients who need you the most. Be both good and careful, and those no-doc patients will be a valued part of your practice.

Stella Fitzgibbons, MD, trained in public and private hospitals during her medicine residency at Baylor College of Medicine. As a hospitalist, she has admitted many no-doc patients to hospitals in the Houston area.