Published in the October 2013 issue of Today’s Hospitalist
YOU MIGHT THINK that hospitals just starting a hospitalist program today would have an easier time than their colleagues who pioneered the concept 10 or 15 years ago. The specialty has a great track record, after all, and programs just starting out can learn from the mistakes of older, established groups.
But talk to hospitalists leading these new programs, and you’ll hear a different story. Madhu Anvekar, MD, for example, the founder of a hospitalist service launched a few years ago at Huntington Hospital in Pasadena, Calif., remembers the night he was approached on the wards by a community physician. What started out as a friendly conversation about the new program took a puzzling turn.
“The physician said, ‘Just be careful what you’re doing. You have a really nice family,’ ” Dr. Anvekar recalls. “I wasn’t sure exactly what that meant, but I realized at that moment how much a small faction of doctors still resists the hospital medicine movement.”
Dr. Anvekar quickly adds that the resistance was short-lived and that his group, because it provided high-quality care, has enjoyed continued growth and success. But his experience points to one of the challenges hospitalists face in facilities just embracing hospital medicine for the first time.
Those problems aren’t limited to reluctant primary care physicians. From physician recruiting to staffing models, these first-time groups are working through issues that harken back to the old days of hospital medicine. At the same time, these new groups have to face the same challenges that established groups are struggling with, which are being ushered in by health care reform.
Money on the line
Hospitals just now jumping on the hospitalist bandwagon have held out, either because the status quo worked or because it was easier to not rock the boat and upset primary care physicians averse to change. According to Martin Buser, MPH, between 15% and 20% of hospitals nationwide don’t have hospitalist programs.
“Implementing a program for a hospital that doesn’t have one today is a lot harder than 10 years ago, when most community doctors wanted hospitalists to relieve them of inpatient coverage,” says Mr. Buser, founding partner of Hospitalist Management Resources LLC, a national hospitalist consulting firm based in Del Mar, Calif., and Colorado Springs, Colo. In communities where primary care physicians still insist on providing inpatient care, those doctors are loathe to lose what Mr. Buser says can be as much as $80,000 in annual revenue from picking up unassigned ED patients, billing their own patients’ hospital care and taking ED-call stipends.
“When you have to pry doctors out of taking call,” Mr. Buser says, “administrators throw their hands up and don’t know what to do. They want better results but are afraid to upset the referral network.” But health care reform is now forcing hospitals’ hands, and the growth of programs in those holdouts has accelerated.
“There is no longer the cushion that allowed hospitals to ‘look the other way,’ and specialists now realize that the survival of the hospital trumps the need to keep PCPs happy,” Mr. Buser notes. When his company runs an analysis of primary care physicians taking call and compares their inpatient contribution margin per case to that of a focused hospitalist practice, “we see that PCPs are costing hospitals a lot of money.” In an era when hospital margins are slim and could become slimmer, that cost has finally become too high.
At Huntington Hospital, Dr. Anvekar responded to the outpatient physician’s comment by talking more with local physicians who had handled unassigned patients. While the environment remained “somewhat tense” for a time, most outpatient physicians eventually came around, he says.
Many of them recouped their potential losses with increased office revenue, he notes. But “what had a huge impact” in selling outpatient doctors on hospital medicine was “the improvement in their quality of life.”
Still, the experience convinced Dr. Anvekar that starting a program is not for the faint of heart. “It’s important to know that things won’t all go right, that there will be some conflict to work through and some turmoil,” he says. “That’s just the nature of starting a program.”
Doing the math
At Boone Hospital in Columbia, Mo., some community-based physicians had concerns when the 397-bed facility started a hospitalist program several years ago. Those physicians were worried about the impact hospitalists might have on their existing relationships with patients.
Medical staff leaders and the chief medical officer met one-on-one with those doctors to address their concerns. Leaders also followed up with department meetings explaining how hospitalists are equal members of the medical staff to be treated as peers and what the expectations were for both hospitalists and staff physicians.
As the medical staff discovered the advantages of not having to come to the hospital, resistance waned and even specialists got on board.
“It’s evolved to where almost everyone on the medical staff realizes the benefits of the program and utilizes these physicians, particularly at night,” says Jerry Kennett, MD, vice president and chief medical officer.
But revenue can remain a sticking point. When Avera St. Mary’s Hospital in Pierre, S.D., launched a hospitalist program two years ago, thinly-stretched office-based doctors welcomed it, in part because having hospitalists would help primary care practices with their own recruiting. But many outpatient physicians remained leery of how the program would hurt their bottom line.
Dale Vizcarra, MD, who is codirector of the program and had been a family physician in the area for two decades, offered a practical solution. “We did the math,” she says.
According to her numbers, primary care physicians would need to see only between two and three additional patients per day to maintain the revenue they’d lose once the new hospitalist program got off the ground. That helped foster acceptance of the new program.
Mr. Buser notes that his firm has run analyses in communities where primary care physicians would need to see six more patients a day to make up for lost inpatient revenue. But in his experience, outpatient doctors not only replace their lost inpatient revenue, but add another $20,000 a year.
Mr. Buser also points out that with health care reform, primary care doctors will be in high demand and should see added revenue from the development of medical homes.
Making the case
In other cases, hospitals launching a hospitalist program appeal not to outpatient physicians’ financial interests, but to their concerns about patient care. At Pomona Valley Hospital Medical Center in Pomona, Calif., for example, Debra Blankenship, RN, director of utilization management and hospitalist services, began collecting data a full two years before launching a hospitalist program. The goal was to gain support for the concept, as well as evaluate the potential for improving quality, LOS, cost per case, readmission rates and patient satisfaction scores.
To make her case for having hospitalists even stronger, Ms. Blankenship brought in an outside consultant, who projected cost-benefit data and met with leadership and medical staff.
“Without this deliberate process, physicians may have viewed this initiative as one the administration was pushing on the medical staff,” she says. “The way it was managed made a difference in their understanding of why it was important to the hospital and the community.” The program went live a few months ago.
Ms. Blankenship also notes that she made sure to have a solid understanding of what hospitalists’ expected outcomes were and to develop a comprehensive request for proposals. And including clinicians on the hospitalist selection committee ensured that the physicians selected would be well received by the medical staff at large.
Not all the problems facing new programs come from community-based physicians. Some hospital administrators new to hospital medicine may have preconceived notions of how to run a program that can backfire.
Ellie Novin-Baheran, MD, director of the EmCare hospitalist program at the 60-bed Lompoc Valley Medical Center in Lompoc, Calif., recalls her group’s growing pains when it was launched three years ago: One of the two full-time hospitalists she hired quit after working only nine shifts. The physician found the program’s 24hour shifts too arduous.
Administrators liked the idea of 24-hour shifts with hospitalists taking beeper call from home, in part because it meant hiring fewer physicians. According to Dr. Novin-Baheran, the administrators didn’t at first understand the toll that 24-hour shifts took or how they would hurt her staffing efforts.
A welcome scheduling change finally came this June. Dr. Novin-Baheran now works 12-hour split shifts “with the occasional 24-hour stint “with another hospitalist and two nocturnists.
Another challenge for new programs can be meeting compensation targets. Sanjay Vadgama, MD, director of hospitalist programs, launched a new hospitalist service at the 350-bed Valley Presbyterian Hospital in Van Nuys, Calif., last month.
Dr. Vadgama was able not only to offer a base salary a bit higher than community averages, but provide additional income based on achieving and maintaining several quality-related targets.
Still, he points out, “It’s harder now to start a hospital medicine program because there are high expectations and so many changes happening in health care.”
Other new programs, particularly those in rural facilities, have to contend with decades-old bylaws, dictating that all staff physicians must live within minutes of the hospital. That can be an insurmountable barrier for recruiting hospitalists used to being mobile.
To avoid problems, Dr. Novin-Baheran advises new programs to discuss backup staffing plans upfront with the hospital and get contingency plans in writing, including whether primary care physicians will still take call at night. Sources also say that new groups should spell out in their contract what increase in daily census will trigger starting a separate shift and/or hiring more staff.
Taking advantage of opportunities
The good news is that while new groups face the same challenges as their colleagues 10 years ago, they have a body of data now to draw on to make a case to their hospitals. “We know a lot more and have gone from using crude to very sophisticated dashboards for feedback,” Mr. Buser says. “Fifteen years ago, we didn’t even look at patient satisfaction scores.”
New programs can also take advantage of their late start by building in proven quality initiatives and physician satisfiers from the very beginning. When Avera St. Mary’s Hospital launched its hospitalist program, for instance, it rolled out multidisciplinary rounds at the same time. It was a bold move, considering that the hospital had never used multidisciplinary rounds before, but Dr. Vizcarra decided to make the most of the opportunity.
When Premier Health in Dayton, Ohio, launched its hospitalist program at Upper Valley Medical Center just months ago, it used the occasion to put standardization and quality initiatives in place across all four hospital sites within its system. Jeffrey W. Petry, MD, Premier’s system hospitalist director, used the new start-up, for instance, to implement a template for discharge summaries and establish performance standards and quality incentives. The program also began measuring quality metrics including patient and primary care satisfaction, readmissions, and core measures.
Dr. Petry also made sure the new program started strong by adopting an attractive schedule from the very beginning. A previous hospitalist program at Upper Valley, run by a local pulmonology group, had derailed over their employed hospitalists’ schedule: taking night call and working every third weekend. In the new program, doctors work seven-on/seven-off, with nurse practitioners as nocturnists.
At the same time, the push to standardize care processes can be a shock to medical staff who have never worked with hospitalists before. Dr. Novin-Baheran at Lompoc Valley, for instance, notes that even the surgeons at her hospital had never before used standardized order sets, something the hospitalists helped implement hospital-wide. She is also championing the use of a new EHR.
New programs also have to help patients understand how hospital medicine works. That can be a challenge in small towns or rural areas where physicians have cared for generations of patients and their families.
In Pierre, Avera St. Mary’s bought TV ads to discuss the benefits of its hospitalist program. And when Pomona Valley’s hospitalist program went live this summer, the hospital held a formal meet-and-greet for the community to get to know the new physicians.
And as most hospitalist groups have learned over the years, the flip side of reducing primary-care concerns is managing growing expectations.
“When the service is full, we get pushback from private physicians,” says Dr. Kennett from Boone Hospital. “They ask, ‘Why do I have to take the admission?’ ”
Dr. Vadgama at Valley Presbyterian notes that some benchmarks for length of stay and patient satisfaction scores will be hard to meet. That’s because some primary care physicians will continue to admit their own patients to the hospital, which will skew overall performance data.
He is also being realistic about finances and does not expect the group to make a profit for some time.
“There are a lot of expectations on me and the group of doctors I’ve hired,” Dr. Vadgama says. “We need at least six months to start to show a difference.”
Of course, it helps when numbers prove success. At Pomona Valley Hospital, the new program shaved two days off the hospital’s average length of stay within its first month of operation.
And two years after beginning the hospitalist program at Avera St. Mary, Dr. Vizcarra says reductions in LOS and improvements in patient satisfaction scores remain encouraging. Other upsides for the hospital include more telemedicine opportunities.
But perhaps most impressively, notes Dr. Vizcarra, having a hospitalist program has helped the hospital recruit new subspecialists and performed what she calls “a near miracle” at the rural clinic: no physician turnover.
Paula S. Katz is a freelance health care writer based in Vernon Hills, Ill.