Can the new trend toward hospitalists help you?

Practices benefit from hiring dedicated specialists

It’s a Sunday night in the emergency department (ED). One of your practice’s patients comes in with a blinding headache. It might be nothing, but it also might be serious. "The attending ED physician is going to work the patient up to the max to cover his or her liability," says Dennis Collins, MD, a physician at Bay Care Medical, a San Francisco-based medical practice.

The problem is that your practice is at-risk for the days spent by your patients in the hospital. So how can you keep those days down and still ensure the best possible care when your doctors aren’t there?

Some practices have found hiring a hospitalist is the answer. "If you are trying to manage capitated patients, this is a good strategy," says Collins, who works with a hospitalist.

Jeff Milburn, senior vice president at Colorado Springs (CO) Health Partners, a 60-physician multispecialty practice, agrees. He hired his first hospitalist last fall. Since then the number of hospital days has dropped by about 20% over the same period a year ago. "I’m not sure that the hospitalist is the reason," he admits. "It could be an actuarial blip. But I know that more likely than not, we will be adding more hospitalists in the future."

More practices are going this route. Advocates for Primary Care, a primary care management group based in Washington, DC, has affiliated hospitalists with several of its practices, including one 250-physician group in San Francisco. William Condrell, MD, chief medical officer for Advocates, says that with 37,000 fully capitated patients in that practice, hiring hospitalists seemed like an obvious move.

"It’s so easy to cut inpatient costs using a hospitalist," says Condrell. Currently, inpatient hospital care is not always managed by your practice, he says. There are other admitting and attending physicians involved. By hiring someone whose sole responsibility is to manage the care of your patients when they are in the hospital, you can regain control over inpatient costs.

Condrell says hospitalists make a single person the "point man" for care. That person is forced to justify to the practice and the payer that a patient needs the care he or she is receiving. For instance, Condrell says some physicians will refuse to release a patient if that patient’s ride home doesn’t come. "That’s not an acceptable reason to pay for another day," he says. In most cases, there are taxis available, or you can call a friend or relative to take the patient home.

Another way hospitalists save money is by making use of the large pool of information available in the hospital setting. For example, if a patient is well enough to go home as long as there is home care and other community support, a hospitalist is more likely to know about those services than a typical family practitioner, says Condrell. "If a doc doesn’t know about community support for a patient, he or she won’t send the patient home. The physician won’t take that risk. But the hospitalist knows about home care agencies, home infusion companies, and other services, so we can send the patient home."

It’s about quantity, not quality

Milburn says there was some resistance among his physicians when the idea was first floated. "The family practitioners loved it," he says. "The internists are more reluctant to refer patients to a hospitalist."

But in explaining the program to physicians, you can allay their fears by assuring them that they are still welcomed, even encouraged to see their patients in the hospital and make suggestions about their treatment. But now they don’t have to go to the hospital daily and try to rush around and see all their patients. They can go three or four days a week, he says, freeing up more time for the office, when they can treat patients and earn more money.

"Your physicians need to understand that no one is saying they are worse physicians than the hospitalists," Condrell says. "It is all about time and quantity of attention. And if they say, Fine, then why should we ever go to the hospital to see the patients?’ you have to remind them, they are getting paid to take care of these people, even in the hospital, even if another physician is managing their care there."

Another selling point is to suggest to physicians that if a hospitalist system is created for their own practices, they are less likely to be forced to accept one created by payers, who are increasingly hiring hospitalists to keep inpatient costs in check.

Milburn says you can ease the transition by beginning slowly. "Start with an inside person — one of your internists who can do this part time and spend part time in a normal practice situation."

Milburn thinks in the future, he will further smooth the ruffled feathers of internists by starting a hospitalist rotation among them.

Condrell agrees that finding someone inside the practice who finds the job appealing can give you an inside track to having this new system accepted.

Milburn also suggests that your hospitalist conduct an informal marketing campaign once he or she starts. "Our guy went out of his way to introduce himself to our physicians," he says. "We don’t require our physicians to refer to him, but he is open to feedback and has made a real effort. My gut says this is a good thing, and even though it’s still evolving, I think we will probably be expanding it."

"The program works for practices because there is finally someone responsible for watching the costs," says Condrell. "And it works for patients because someone is there every day, providing care that the primary care physician can’t. Hospitalists do rounds three or four times a day. They get the test results immediately; they can order IV and antibiotics when needed. Patients get better care more often, not because the hospitalists are better doctors, but because the patients get closer attention."

 • William Condrell, MD, Chief Medical Officer, Advocates for Primary Care, Washington, DC. Telephone: (202) 333-3999.

Jeff Milburn, Senior Vice President, Colorado Springs (CO) Health Partners. Telephone: (719) 538-2900.

Dennis Collins, MD, Bay Care Medical, San Francisco. Telephone: (415) 437-4354.