Home Feature The brave new world of ACOs “and beyond

The brave new world of ACOs “and beyond

October 2013

Published in the October 2013 issue of Today’s Hospitalist

Hospitalists need to claim their rightful share of political power on the hospital medicine staff.

THAT WAS ONE OF THE MESSAGES delivered by Larry Spratling, MD, chief medical officer of Banner Baywood Medical Center in Mesa, Ariz., as he addressed hospitalists at this year’s Society of Hospital Medicine annual meeting. As Dr. Spratling explained, hospital executives already view hospitalists as their go-to physicians for better quality and patient flow. So it doesn’t make sense that the specialty continues to cede leadership roles to medical staff who don’t live and breathe in the hospital.

“Medical staffs are still dominated by office-based physicians and specialists,” Dr. Spratling pointed out. “Even though they spend most of their time outside the hospital, they still hold sway in terms of hospital decision-making.” Hospitalists, on the other hand, care for most of the patients and are the largest group of physicians on the medical staff, “but have little political power or say in how things are done.”

Why? Because, he added, many hospitalists have not been politically active in their hospitals or savvy enough to realize they need to represent themselves. And too many hospitalists limit their involvement to individual patient care.

“From the hospital’s perspective,” Dr. Spratling said, “we’re looking for more than a patient-care shift worker. We want physician partners to engage with us “on quality improvement, peer review and operational performance “in adapting to the new health care environment.”

But to successfully engage with hospitals in the brave new world of value-based purchasing and ACOs, Dr. Spratling noted that hospitalists will need more than a successful power play. They will also have to re-engineer many of their clinical roles “and perhaps even reconsider where they work. “Maybe we won’t need as many hospitalists in the hospital as we do right now,” said Dr. Spratling. “I don’t know if the name ‘hospitalist’ will continue to be appropriate, because there won’t be room for you all to practice in the hospital in the future.”

The hospital of the future
What will the hospital of the fairly near future look like? According to Dr. Spratling, who was one of the session’s two presenters, “fewer patients will probably be admitted to the hospital. Hospitals will have a lower overall census, but the patients will have higher acuity.”

Only physicians who are team players need apply, he added. Not only will midlevels and other extenders have a big role to play, but care will be much more tightly coordinated across settings. Hospitalized patients will be assigned care coordinators to follow patients in and out of different facilities.

And “cost management and waste control will permeate everything that we do,” he said. Hospitals are not going to be paid more money, but less. “If we’re going to make it economically,” said Dr. Spratling, “we have to become conscious of cost.”

Saving costs will be a good thing, he added, because “much of what we do” “surgeries, diagnostic testing “”is unnecessary.” Banner’s own data, he explained, suggest that hospitalists order way more tests than they need to. But they make up for those unnecessary costs by delivering a shorter length of stay than nonhospitalists.

However, excessive ordering “which he chalked up in part to physician defensiveness and “liability phobia” ” won’t be tolerated in the new health care environment.

“We want you to start working with us in understanding cost management,” Dr. Spratling said. “Start thinking about the cost implications of what you order before you actually feel the financial impact personally.”

The upside of all that cost consciousness? “We’re ready to include you in the ACO work and let you share in the shared savings,” said Dr. Spratling. “But this is risk-based reimbursement, so you have to save it to share it.”

New skills and “focused factories”
As part of health care’s new cost containment, hospitalists will have to take the lead in smoothing out clinical variations, working to define consensus around best practices and making sure colleagues comply.

“We’re going to have to narrow that bell-shaped curve and move it to the left,” Dr. Spratling said.

He also believes hospitalists will need to play a much bigger role in end-of-life care. “It’s a lot to expect hospitalists to take on those conversations with patients they’ve just met,” he noted. “But we’re going to have to ask you to help us guide patients to make more appropriate decisions.”

Dr. Spratling also predicted that the number of surgeries will decline, particularly elective ones, once surgery becomes a cost center instead of “the economic engine of the hospital.” Physicians will have to start paying much more attention to optimizing patients for elective procedures, he explained.

And systems like Banner “are already thinking about how we can create focused factories for specialty procedures, such as joint replacement, rather than offering it everywhere,” he noted. “We’re going to drive all our network patients to those facilities that are most efficient, so we’ll be looking at surgeons’ performance as well.”

Among hospitalists, a real premium will be placed on those physicians who, said Dr. Spratling, “will be able to manage the 5% of patients who create 50% of the charges.” While there’s a lot of talk of primary care medical homes taking ownership of such patients, he personally doesn’t think primary care doctors are up to the task.

“These are seriously ill patients for the most part, and primary care physicians “as we say in the South, ‘bless their hearts’ “don’t take care of acutely ill patients any more.” But someone will have to, he pointed out. “Who better than hospitalists?”

Moving into post-acute care?
If fewer patients will be admitted and primary care physicians can’t manage acutely ill patients, where are sick patients going to go? Co-presenter Kerry Weiner, MD, chief medical officer of IPC The Hospitalist Company, a national physician practice company, said that skilled nursing facilities (SNFs) are already “a big growth area” and will get only bigger.

“Hospital care will feature much shorter stays,” Dr. Weiner said. “The patients who are currently on your med-surg floors will be in a SNF.”

Already in California, many patients who have traditionally been treated in long-term acute care or inpatient rehab facilities have been moved to SNFs, Dr. Weiner said, because of cost savings and the penetration of managed care. Medicare managed care plans in that state already directly admit patients to SNFs from emergency departments and treat patients with much higher acuity in that setting.

IPC has moved aggressively over the past several years into building post-acute care practices around its traditional acute care groups. But Dr. Weiner admitted that the idea that many hospitalists might have to move into post-acute care poses a real problem.

“Embedding a hospitalist culture in a post-acute facility doesn’t happen overnight,” he said. “But hospitalists who succeed in bringing their hospital experience with them into a SNF, while adapting to the demands of a post-acute setting, will bring enormous value “and get a whole lot of job satisfaction to boot.”

Big post-acute challenges
Dr. Weiner was blunt about some of the challenges found in post-acute care, which may explain part of hospitalists’ resistance to working in that setting.

As hospitalists already know, “Current access to well-trained providers in these facilities is really inadequate,” he said.

Both nursing staff and clinical infrastructure need upgrades. “You don’t have the same access to labs, equipment or electronic medical records at many of these facilities,” Dr. Weiner said. “So hospitalists need to adjust the way they work.”

Post-acute care also has nuances that hospitalists would need to learn: how to bill in a different DRG-like system, for instance. SNF administrators have the ability to direct patients to certain primary care physicians, even if the acute-care hospitalist refers patients to someone else. And there are special documentation issues related to medical necessity.

“Most patients need to be seen often, a lot more often than the minimal standard of one visit per month,” said Dr. Weiner. “But the CMS is carefully auditing SNF documentation to ensure that patients aren’t being

New clinical skills
Still, hospitalists are well-suited to reinventing post-acute care, Dr. Weiner continued, because they have so much practice upgrading care in facilities and working with multidisciplinary teams. But hospitalists moving into post-acute care need some new clinical competencies.

For example, end-of-life care in SNFs is much more extensive than in acute care. “You start the discussion in the hospital,” Dr. Weiner said, “but that discussion really gets going when the patient is in the SNF three weeks and the family is going through a lot of adjustments.” Doctors in post-acute care need skills in palliative care and end-of-life planning.

“You also need skills in managing depression, dementia and agitation, and how to use psychiatric medicine in a geriatric population,” he pointed out. Physicians also need to “become experts in pain control to a much higher level than in the hospital because pain in these patients is a major problem. And you need to become the family counselor, getting to know the family members and their financial and social issues because those will affect the treatment plan.”

What hospitalists are being called on to do, Dr. Weiner noted, is to transform the traditional care model that’s still very much alive in most facilities.

“That traditional model is the geriatric specialist model where you come in, do a comprehensive evaluation, come up with a huge treatment plan and visit infrequently,” he explained. “That model has not worked.”

Instead, post-acute care should be fashioned “more like the hospitalist model,” he added. “You have a flexible treatment plan, then keep making incremental adjustments as you reevaluate the patient, and that requires frequent visits.” To make that model financially viable, Dr. Weiner said, “you need to have a much greater census in each facility.”

On the plus side, he added, “Compensation is very competitive for hospitalists, and in many regards it offers a more flexible lifestyle.” And because hospitalists are at the vanguard of a new specialty that has a huge impact on the health care system, Dr. Weiner noted, “Patients, as well as their families, are hungry for your expertise.”

Phyllis Maguire is Executive Editor of Today’s Hospitalist.

Getting doctors in line

DURING A PRESENTATION on the future of hospital medicine at this year’s Society of Hospital Medicine meeting, audience members noted that there are significant roadblocks to moving into the new health care environment of standardized practices and cost containment. One audience member described a dilemma she and her hospitalist colleagues are now dealing with.

The hospital COO has called out the hospitalist group for ordering too many tests for cardiology patients. But when the hospitalists approach the cardiologists to develop a standardized testing protocol, they get only pushback. The cardiologists all practice independently and want to be able individually to order different tests.

“It’s still a fee-for-service environment, and they bring business to the hospital,” the audience member noted. “And the hospital doesn’t want to get them in alignment.”

Larry Spratling, MD, chief medical officer of Banner Baywood Medical Center in Mesa, Ariz., one of the two speakers at the presentation, explained how practice differences are smoothed out at Banner, where best practices are identified by clinical consensus groups. There are 17 of these groups, each staffed by clinicians from different departments.

“Each group gets together, looks at the evidence and comes to a consensus on what’s the best practice,” he said. The approval process for that consensus statement goes all the way through the care management council.

“If you deviate from what we think is the best care pathway, we’re going to talk to you about your participation in our ACO because participation requires compliance with expected practices,” Dr. Spratling said.

“We expect you to comply, but if you absolutely refuse and can’t get on board, then we’re going to have to exclude you.”

Co-presenter Kerry Weiner, MD, chief medical officer of IPC The Hospitalist Company, noted that many hospitalists facing the same dilemma probably won’t get much overt help from the C-suite.

“They want you to do that work, and that’s where hospitalist leadership comes in,” he said. “The CEO wants you to meet with the cardiologists over dinner and say, ‘Can we agree on this protocol because we’re going to all be accountable?’ Even if you move toward consensus a little bit, that establishes you as a leader. That’s the kind of thing hospitalists are going to be expected to do.”