Inpatient specialists help cut costs, reduce LOS
Inpatient specialists help cut costs, reduce LOS
Hospitalists partner with case managers
If you’re still having trouble achieving physician buy-in for your critical pathways and other quality improvement efforts, take heart. Help might soon be on the way in the form of a new breed of hospital doctors.
Hospitalists sometimes called hospital-based internists, inpatient specialists, or admitting doctors work full-time in the hospital, caring for patients too ill to be treated on an outpatient basis. Increasingly, hospitals and health plans are bringing them on board as a way to achieve high-quality, cost-effective care.
And they’re getting results. At Mercy Hospital in Springfield, IL, hospitalists have helped cut inpatient costs by 20% and reduced length of stay by an average of one day across the board. (See bar graphs showing raw data on length of stay and cost per case at Mercy, below.) Meanwhile, at Park Nicollet Medical Group in Minneapolis, costs per stay have also dropped by 20%, with length of stay falling by an average of half a day since the introduction of hospitalists. For both institutions, patient satisfaction has remained high, with 97% of patients at Mercy reporting that they are either satisfied or very satisfied with the care they’ve received.
Essentially, hospitalists manage the care of hospitalized patients in roughly the same way that primary care physicians manage outpatients, says Winthrop Whitcomb, MD, one of 11 hospitalists at Mercy. Hospitalists there treat all unassigned hospital admissions, as well as night admissions. They also accept assignments from community physicians who may be too busy managing patients in their offices to spend much time in the hospital. They coordinate consultations with other physicians, schedule inpatient procedures, and help guide patients through the process of care.
"The biggest thing is that hospitalists maintain a continuous presence in the hospital," says John R. Nelson, MD, an internist and hospitalist based in Gainesville, FL, who founded his hospitalist group practice, Inpatient Medical Services, in 1988. "By being there all the time, it’s easier to respond to things in a more timely way and to shepherd a patient through the system more efficiently." Nelson adds that because they spend all their time caring for patients in the hospital, hospitalists should be more proficient at caring for patients with hospital illnesses than other physicians.
Ideal test marketers’ for pathways
Should case managers worry that hospitalists will usurp their role in coordinating patient care? On the contrary, Nelson says. They can be an important resource in helping you achieve your quality objectives.
"I think hospitalists are the ideal physician members of case management programs," says Nelson. "They’re the ideal ones to be the first to use new protocols and critical pathways and help to troubleshoot and debug them. You have a group of doctors who can be the ideal test marketers for the programs you want to see implemented in your hospital."
Because hospitalists spend all their time in the hospital, there’s a greater potential for interaction with nurse case managers, Nelson adds. That familiarity can lead to greater levels of trust and cooperation than case managers sometimes experience with other physicians.
"My heart and soul are in the hospital," says Nelson. "A traditional internist or primary care doctor’s heart and soul are in the office. A lot of PCPs [primary care physicians] view what they do in the hospital as something they have to do to keep their office going. Obviously, a doctor like that is not going to be as inclined to expend a great effort to go and change the way he does things in the hospital. I don’t think hospitalists can magically solve all the problems, but I think they’re going to be predisposed to play ball a little more."
Whitcomb adds that because most primary care physicians see their acute patients either early in the morning or after hours, they can miss out on face-to-face encounters with case managers. "Hospitalists are around during regular business hours, when case managers are around," he says. "So we develop professional relationships with these people that aren’t developed otherwise."
Case managers at Park Nicollet have welcomed the arrival of hospitalists, because now they have a better understanding of who’s managing a given patient day to day, says Thomas Schmidt, MD, an internist and medical director for quality resources and utilization management at Park Nicollet. "Because inpatient specialists are in the hospital all day long, case managers’ access to them is much better," he says. "Say you have a patient who can go to a nursing home at 4 p.m., but the doctor’s not going to see her again until tomorrow. With a hospitalist, you don’t have to worry about trying to track down a physician that you missed on rounds who’s now back at the office. The communication and the access to the physician taking care of patients markedly improved with hospitalists on site all the time."
Nelson argues that case managers don’t have the time to learn the idiosyncrasies and practice patterns of every physician on staff. "There’s just too many of them. You’re not going to see that doctor’s patients too terribly often. That’s not true for us," he says. "We have so many patients that case managers are dealing with them every single day. And if we know one another better, I think we’ll be happier and more efficient."
The hospitalist system benefits patients and facility alike, because the doctor in control decides what resources are consumed. Hospitalists tend to deviate less from standards than their colleagues in office practice, so they become highly skilled in utilization management, says Nelson. They generally manage laboratories aggressively, ordering fewer, more precise tests than colleagues in more traditional practices.
"Hospitalists give good medical care in a cost-effective manner," says Nelson. "The fees charged by Inpatient Medical Services tend to be slightly lower than those of internists in traditional practice in this part of the country our overhead is lower but that has little to do with the cost-effectiveness of the hospitalist. You have to whittle down utilization of hospital resources to save real money."
For example, hospitalists may feel more comfortable than other physicians in ordering only one CT scan rather than two during an episode.
"Eliminating one CT scan saves $600," says Nelson. "In addition, length of stay is decreased with the patient going home half a day earlier. All this adds up to cost savings because the hospital can charge the full DRG without consuming as many resources as expected."
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