Published in the November 2015 issue of Today’s Hospitalist
TAKE A LOOK AT SURVEY DATA, and it’s clear that most hospitalists are still not participating in accountable care organizations (ACOs). The 2015 Today’s Hospitalist Compensation & Career Survey, for example, found that more than three-quarters of hospitalists (76.4%) report having no ACO affiliation.
But flip those data around, and you realize that one in four hospitalists are doing some ACO work. That is a startling percentage given that the country’s first ACO was launched in January 2012, less than four years ago.
While the number of Medicare Pioneer ACOs ” which accept full risk “has shrunk to 19, the number of ACOs participating in Medicare’s Shared Savings Program has grown to more than 400, covering more than 7 million Medicare beneficiaries. In addition, commercial insurers have launched a host of their own ACO programs.
“One of the simple things I tell people: Don’t order tests just because you’re interested.”
And what do ACOs expect from the hospitalists with whom they partner? The answer depends on your hospital’s local market, as well as its number “and type “of ACO contract, says Martin Buser, MPH, founding partner of Hospitalist Management Resources LLC, a national hospitalist consulting firm based in Del Mar, Calif., and Colorado Springs, Colo.
“When hospitals enter ACOs, their first response is, ‘We want the hospitalists to help us figure this out and work with us to prevent readmissions and reduce low-value care,’ ” Mr. Buser says. A different response, however, comes from hospitals and ACOs that have moved on to accepting full risk for patients and are worried about dollars on the line as well as the quality of care.
“When hospitals are actually at risk for capitation and start monitoring patient days per thousand, hospitalists are key players,” he says. For both types of ACOs ” ones that accept risk and those that don’t “hospitalists participating in them realize they have to make “a big leap in terms of care coordination,” Mr. Buser adds. “Up to now, when patients left the hospital, doctors didn’t need to pay attention to what happened to them.”
But to participate successfully in ACOs, he warns, “that has got to stop.”
WHEN IT COMES to ACOs, Good Samaritan Medical Practice Association, an independent practice association (IPA) in southern California, is just dipping its toe in the water. The IPA, which has four hospitalists working at Good Samaritan Hospital in Los Angeles, has contracted with only one commercial ACO to cover 500 patients.
But the IPA, which has 130 primary care physicians and 300 specialists, is a seasoned veteran of full-risk capitation. According to Nupur Kumar, DO, the IPA’s medical director, the association has four large full-risk contracts with Good Samaritan Hospital, two with Medicare Advantage plans and two with Medi-Cal plans, the state’s Medicaid program. While these contracts aren’t technically ACOs, they have taught the IPA to manage risk.
“We’re striving for tight control, whether it’s an ACO or a risk contract,” says Dr. Kumar. One key way the IPA expects to exert that control, she adds, is through the evolving role of its hospitalists.
Beginning next year, the IPA’s hospitalists will start to follow high-risk patients out of the hospital into a post-discharge clinic, seeing them within 48 hours of discharge. “One doctor will rotate a couple of hours a day into that clinic,” Dr. Kumar explains.
The plan is to grow that post-discharge clinic into a high-risk clinic for patients with multiple comorbidities that put them at high risk of readmission. Hospitalists would see those patients in those clinics at least weekly, Dr. Kumar says. Down the road, the high-risk clinics would further evolve to be disease-specific.
Drawing hospitalists out of the hospital into such clinic settings has been a model used successfully in California by Kaiser Permanente and CareMore, a Medicare Advantage plan that started out as a medical group and IPA.
“Large groups in southern California are aware of both the Kaiser and CareMore models,” Dr. Kumar says. “We know that it’s the future of health care.”
She adds that the model also represents the future of hospital medicine, at least in risk contracts. “We want the same people treating patients in the hospital to see them in the clinic,” she says. That way, hospitalists can detect changes in patient status.
Primary care physicians, on the other hand, may see patients only monthly, “and they may not know what’s a true baseline, which could lead to more hospitalizations,” she says. “Hospitalists could tell with more finesse the little changes that may or may not be within normal, so they could exert much tighter control over when patients need to be hospitalized.”
Dr. Kumar would also like hospitalists to eventually follow high-risk patients out of the hospital into SNFs before patients go on to high-risk clinics. Her rationale may sound familiar to those who were suspicious of the hospitalist movement when it first started.
“If different physicians keep taking over different parts of high-risk patients’ care,” she says, “you’re going to lack complete knowledge of those patients at all times.” With hospitalists filling the role of primary physicians for such patients, Dr. Kumar adds, “you really have control over where the patient is going.”
Are the IPA’s hospitalists on board with such a broad role? “They have to be,” she says, “because they’ll be running it.”
ACROSS THE COUNTRY, the Central Maine ACO has just signed up for its second three-year stint in Medicare’s Shared Savings Program. But unlike hospitals and medical groups in southern California, those in Maine have virtually no background in capitation.
But they’re getting up to speed. John Dickens, MD, MPH, the former director of the hospitalist program at Central Maine Medical Center in Lewiston, is now medical director of the Central Maine ACO and holds the title of chief transformation officer for the hospital. He estimates that at least 40% of the hospital’s medical patients are ACO patients, either from Medicare or commercial insurers.
Dr. Dickens points out that patients in the ACO have some specific resources available to them. EMTs affiliated with the ACO, for instance, now make home visits to some high-risk patients, while the ACO pays for some telehealth and home health resources that ACO patients may need to stay out of the hospital.
But when it comes to the hospitalists, who are employed by the hospital, he says, “We’ve chosen to treat every patient the same. The hospitalists don’t label patients in the hospital as ACO patients. Instead, we look at patients based on risk.”
Hospitalists’ first new priority is to collaborate with care management to identify high-risk patients prior to discharge and to help them get home rather than to a post-acute care facility. ACOs that can safely discharge patients home, after all, can save themselves the cost of post-acute care.
“We think we need to focus more on that: the prevention side of hospital medicine,” he says. Their next priority, he notes, is to go after “the low-hanging fruit of low-value care” to reduce waste, treatment variations and the use of non-evidence-based care.
The hospitalist group “with 16 physicians and six NPs/ PAs “has already tackled open-ended telemetry orders by putting in pop-up alerts on the health system’s EHR. They’re reducing the number of discretionary orders for nebulizers, incentive spirometers and acapellas, and now put end dates on their orders for IV fluids.
They’re doing away with constant testing for the 90-year-olds who come to the hospital with a small heart attack. “You’re never going to do an intervention, so why poke them nine times to see how high their cardiac enzymes go?” They’re also putting an end to orders for echocardiograms for patients whom doctors already know have poor cardiac function.
“Doing another one is not going to change your management or treatment whatsoever, so you are just using up resources,” Dr. Dickens says. “One of the simple things I tell people: Don’t order tests just because you’re interested.”
To change physician ordering behavior, the medical center relies on utilization data around five disease states (pneumonia, heart failure, stroke, cellulitis and COPD), as well as a red/green electronic dashboard displaying the use of target labs, diagnostics, X-rays and meds. Dr. Dickens says that the IT department is able to supply that utilization data within six weeks.
A big part of his new role as chief transformation officer will be making sure that published metrics are shared with providers in all departments and seeing that low-value care is a constant topic at group meetings.
Ironically, Dr. Dickens notes, the hospitalists launched their cost-cutting quality efforts in 2011, long before their ACO participation.
“We started talking about eliminating unnecessary care variations, and we made good progress,” he explains. “In one year, we cut $1 million in costs just by ordering fewer phlebotomies.” The hospitalists also championed adding charge data to many of the more common orders. “When you pull up an order for a chest X-ray and see what it’s going to cost patients, it gives you a purposeful pause,” says Dr. Dickens. “You think about what the impact is going to be on the patient.”
But as the person clinically directing those earlier efforts, he got too busy with the expanding hospitalist program.
“We could see all our numbers “like for charges per case “coming down, but then the numbers came back up again,” Dr. Dickens says. “We were doing really good ACO hospital-based care five years ago, and now we’re getting back to it again. Now, that sense of urgency is back.”
ONE OF THE COUNTRY’S FIRST ACOS to join Medicare’s Shared Savings Program, Seton Health Alliance in Austin, Texas, has also been one of the most successful.
That’s according to Norman Chenven, MD, the founder and CEO of Austin Regional Clinic, the multispecialty group that has partnered with Seton Healthcare, which has more than a dozen hospitals, to form the ACO. The ACO’s Medicare contract covers about 13,000 lives, and it has other patients in several commercial ACO contracts.
“In 2014,” says Dr. Chenven, “the ACO had approximately $10 million in shared savings, so $5 million of that came to the ACO.” He chalks a large part of those savings up to the hospitals’ ability to be “much more precise” in targeting who really needs to go to a post-acute care facility and who doesn’t.
Mauricio A. Sardan, MD, one of Seton Medical Center Austin’s 23 hospitalists and one of the group’s co-chief hospitalists, is also the medical director for Seton’s bundled payments for care improvement (BPCI) program.
To increase their ability to target where patients need to go after discharge, “we try to narrow the number of SNFs, inpatient rehab facilities and home health agencies in the network,” Dr. Sardan explains. “That makes it easier for us to have regular meetings with their representatives to make sure they identify our patients, apply clinical protocols and know what we expect in terms of information coming back to the hospital.”
The hospitalists also have helped integrate care within the hospital, launching what they call “Continuity of Care” programs. That program for heart failure has been in effect for four years.
As soon as heart failure patients are admitted, they are transferred to the cardiac floor, where a multidisciplinary team follows heart failure patients exclusively. Dr. Sardan runs the unit, and the team meets twice daily, at 9 a.m. and 2 p.m. Since 2012, readmission rates for that unit have dropped from 23% to 15%.
Dr. Sardan points out that other hospitalists don’t rotate through the unit. However, he adds, “my goal is for all the hospitalists to learn the skills that these changes in health care now demand from us, not just seeing patients and managing volume, but also being responsible for the continuity of these patients’ care and pulling all the players together.”
Dr. Sardan says that he sees hospitalists evolving into what he calls “a bundle-ist.”
“The bundle-ist is a hospitalist who’s actually learned the skills to put systems together,” similar to what has taken place in the heart failure unit. The medical center, which is participating in the BPCI’s heart failure bundle, also began participating on Oct. 1 in the BPCI bundle for hip and knee replacements.
“Obviously, that’s a different kind of population with different clinicians” than on the heart failure unit, Dr. Sardan notes. “But we’re creating a similar process in terms of putting all the players “doing rounds with pharmacy, case managers, physical therapists, nurse navigators from the joint program “in one place. That will help coordinate both inpatient care and the transition to the proper level of care with one of our narrow list of providers.”
Dr. Sardan notes that his hospitalist colleagues have embraced the bundle-ist concept. The challenge is continuing to practice medicine in what he calls “the sandwich period.”
“Fee-for-service is still the current way that we get paid, and final and clean ways of hospitalist reimbursement are not yet clear,” Dr. Sardan points out. While hospitalist compensation has for years been pegged to productivity, “We’re now telling hospitalists, ‘You don’t need to see 20 patients. Just see 15 and you’ll get paid the same.’ What we need to figure out is where hospitalists need to invest that extra time in care coordination and integration. That’s a big challenge.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.