Critical Care Plus: Hospitalist ER Involvement Lowers Facility Costs

Uninsured and underinsured patients better screened

Two California-based hospitalist groups say their involvement in emergency room care for unassigned patients lowers hospitals’ unreimbursable costs by assisting in triage, thus reducing the number of unnecessary admissions.

Alan Puzarne, CEO of Cogent Health Care of Laguna Beach, Calif, says hospitalist physicians help move people through the ER more quickly, triage those patients who need to be hospitalized, and help less ill patients find alternatives for treatment.

"More people are uninsured today, and more are using the ER to access care," Puzarne says. "ERs are absolutely over capacity and hospitals are full."

A recent report from the Institute of Medicine says uninsured patients are less likely to receive preventive care services and care for chronic conditions than insured patients. Puzarne notes that the number of Americans without health insurance has risen sharply since the mid-1990s, and more than 40 million people are currently uninsured.

According to the American Hospital Association, hospitals provided $21.6 billion of uncompensated care in 2000, often to uninsured or underinsured patients without primary care physicians. Such patients often use ERs for routine care. Puzarne points out that when these patients are not triaged appropriately they can be admitted unnecessarily, filling beds in hospitals that are already overcrowded.

"Hospitalist involvement helps ER physicians decide who among their patients needs to be hospitalized, thus effectively increasing the facility’s capacity without adding more beds," Puzarne says.

James S. Potyka, MD, FACEP, medical director for the emergency department physician group for Baptist Health System in San Antonio, TX, says his system includes 38 ER physicians who cover five hospitals and see more than 140,000 patients per year. It began using Cogent hospitalists in December 2001.

Potyka observes that many physicians are reluctant to take care of indigent or uninsured patients because they tend to have more complications, a mindset Potyka says hospitalists don’t seem to have. He adds that hospitalists’ presence offers cost saving benefits even with patients who have insurance and a primary care physician.

"If I were using a group of internists who didn’t really want to come to the hospital they might admit patients just because they didn’t want to come to the hospital," Potyka says. "A lot depends on the quality of the emergency physician group and on the on-call physicians, but the hospitalist is already there."

Weston G. Chandler, MD, FACP, President of Pacific Hospitalist Associates and director of the hospitalist program at Hoag Memorial Hospital in Newport Beach, CA, says one of the fastest growing parts of the hospitalist movement is contracting for unassigned patients through the ER. Chandler says the hospitalists his group provides evaluate patients in the emergency room and expedite the ER work-up from an internal medicine standpoint.

"They may order a few more tests, find the patient does not need to be hospitalized and arrange for them to be seen as outpatients, avoiding admission altogether," he says. Chandler adds that hospitals generally contract with hospitalists for all unassigned patients who come through the ER, many of whom have insurance but no primary care physician.

Chandler estimates he redirects care for about 10% of the patients he sees in conjunction with ER physicians. "For those patients who don’t have insurance there’s an obvious cost savings involved," Chandler notes. "At Hoag, we’re also seeing an increasing number of private, fee-for-service patients because their primary care physicians know we’re available 24/7."

(For more information, contact Alan Puzarne at [888] 646-7763, James Potyka, MD, at [210] 495-9860, and Weston Chandler, MD, at [877] 742-4624.)

New Privileging Standard Addresses Emergency Situations

A new hospital standard from the Joint Commission on Accreditation of Healthcare Organizations addresses the problem of privileging physicians quickly when disaster strikes. The issue was raised recently in light of last year’s terrorist attacks and the threat of more to come.

The new standard addresses the privileging of volunteer Licensed Independent Practitioners (LIPs) during emergencies. Standard MS.5.14.4.1 states: "In circumstances of disaster(s), in which the emergency management plan has been activated, the chief executive officer or medical staff president or their designee(s) may grant emergency privileges." The Joint Commission reports that while the use of volunteers is not mandated, the standard provides a means for hospitals to use volunteers in emergencies.

In a statement released with the new standard, the Joint Commission explains that the standard outlines acceptable sources of identification of volunteer LIPs, including a current license to practice, a current picture hospital I.D. accompanied by the LIP’s license number, or verification of the volunteer practitioner’s identity by a current hospital or medical staff member. The standard is effective immediately.

"This standard was created following JCAHO’s debriefing of health care personnel involved in last year’s Houston, Tex, flood and in response to the terrorist attacks in New York City and Washington, DC," the accrediting body reports. "These personnel identified a specific need for rapid access to clinicians to assist in meeting patient care demands in emergencies."