Published in the October 2013 issue of Today’s Hospitalist
AS HEALTH CARE REFORM IS GRADUALLY ROLLED OUT across the country, hospitalists are facing new scrutiny. One major change is the advent of care managers “and the role they are playing in clinical practice and documentation.
The hospitalists at one Midwestern hospital system, which has signed on as an accountable care organization, can take comfort in the fact that the majordomo for care management at their facilities is one of their own. Wael Khouli, MD, a hospitalist for the HealthEast Care System in St. Paul, Minn., recently picked up an MBA from Yale School of Management. Although doctors with business degrees are increasingly common, most remain full-time clinicians. Dr. Khouli, however, is charting a different course. He’s been promoted to system director for care management, tasked with maximizing clinical performance for HealthEast’s three acute-care hospitals.
Contributing editor David Frenz, MD, recently caught up with Dr. Khouli to discuss life on the other side.
For several years you were a hospitalist grinding out shifts. What personal and professional factors motivated your recent career transition?
I started identifying inefficiencies in care delivery at the hospital. After working as a hospitalist for a few years, I thought that I could have an impact beyond treating patients. Hospitalists understand how hospitals operate better than any other specialist, and going into health care management allowed me to use that knowledge. I was also looking for a new challenge after four years of primary care and six years of hospital medicine.
Why did you pursue an MBA instead of an MHA or MMM?
It took me about two years to make up my mind regarding the best type of master’s degree. Initially, I thought about doing an MHA because the education would be more focused on health care. But I decided to seek a core business education because there is great value to learning from industries outside of health care.
How do you spend your day?
My time is split between handling individual cases referred by care managers and working on long-term plans to improve efficiency and resource utilization. In terms of the former, I work to make sure that we are in compliance with Medicare regulations for medical necessity for the services that we provide.
I also help care managers move patients as quickly and safety as possible from admission to discharge by serving as the liaison with the medical staff. For a patient making slow progress, we figure out how to transition him or her sooner to a long-term care facility, for instance. Or we work getting endoscopy or MRIs done more quickly or in an outpatient setting so discharges aren’t being put on hold.
Because I’m a physician, it’s easier for me than for care managers to translate business strategies into clinical practice when talking to other doctors. A significant portion of my time is spent on physician education, and I meet monthly with the hospitalists. I also meet regularly with physicians in other departments, but less frequently.
With regards to long-term planning, I collaborate with leaders from different departments internally, as well as skilled nursing facilities, long-term acute care hospitals, home care agencies and outpatient practices to ensure smooth transitions in care across the continuum. We have, for instance, had hospitalist teams meet with post-acute care providers to help create more direct channels of communication. Previously, they’ve pretty much been in two different worlds.
How does your work add value to the organization? And what sorts of metrics are you playing with?
My work creates value by helping reduce length of stay and readmissions and improving care transitions. All these measures are quantifiable and are tracked on a continuous basis. The end result is better utilization of limited resources and reduced waste. Right now, our readmission rate is below 7%.
Fewer denials for service through physician education to improve documentation also create value. Health systems lose significant revenue by not getting reimbursed for services they provide unless they have a solid process to reduce denials and appeal them appropriately.
What mistakes do hospitalists make that wind up in your lap?
The most common mistake is choosing the wrong admission status. Patients are frequently assigned to observation status when they qualify for inpatient and vice versa. These mistakes can result in denials by Medicare and other insurers. I’ve actually been surprised at how much hospitalists want to know the different criteria for observation vs. inpatient admission. Several hospitalists are now interested in helping us with our concurrent reviews, looking at charts to make sure patients had the right status.
Another common mistake is ordering diagnostic tests or consultations that prolong hospitalization and could be done in an outpatient setting instead.
Doing a colonoscopy in the hospital for a patient with chronic anemia would be one example. Another is scheduling an in-hospital oncology consult instead of having one arranged the next day as an outpatient.
How can hospitalists work smarter to add value to their organizations?
Hospitalists traditionally have added value by reducing length of stay. While this is still important, the stakes are higher so our focus now has to include the entire health care continuum. In some cases, we provide the care directly; other times, we ensure smooth transitions to other venues for care.
Hospitalists can also make a huge impact at a time when health care is going through a historic transition. We are gradually moving from a fee-for-service model to one that focuses on total cost of care. Hospitalists can no longer look at their work in isolation, but need to understand and integrate all other aspects of care. Ironically, the role of the hospitalist now extends beyond the walls of the hospital.
Finally, hospitalists can add value through better communication with post-acute care providers, especially for complicated patients.
Do you still see patients?
Now and then. It’s very important to stay connected with the front line. Understanding the challenges that hospitalists and other physicians face is crucial to my current role. It’s pretty difficult to understand without being in the trenches, at least every once in a while.
Ten years from now, what do you think you will be doing?
Before going to business school, my answer would have been somewhere in hospital administration “and that may be where I end up. But there are so many other options out there, I can’t really predict. My passion is optimizing the efficiency of health care delivery while improving the quality of care. There are ways to do that outside hospitals, including in the for-profit sector. Starting a private venture at some point in the future is a potential option.
David Frenz, MD, is a hospitalist for HealthEast Care System and is board certified in both family and addiction medicine. You can learn more about him and his work at www.davidfrenz.com.