Keys to hospitalist success: Right docs, incentives, tools

How Cogent developed its model

How do you ensure a successful hospitalist program? You find the right physicians, incentivize them the right way, and give them the tools they need to meet their goals, says Ron Greeno, MD, FCCP, chief medical officer for Cogent Healthcare in Los Angeles. "It’s our formula for success."

This model has been developed over a period of more than 10 years, notes Greeno, co-founder of the organization, which was started by four hospitalist groups in the early 1990s.

"We knew there was tremendous potential," he recalls. "Hospitals had been trying to standardize care at the best practice level; that’s a very lofty goal but hard to do with a medical staff of 400 to 500 physicians."

On the other hand, he says, if you put a large group of patients in the hands of a small group of physicians all working together, "there’s a tremendous opportunity for that group to say, Here’s the way we do it,’ using evidence-based medicine to determine best practices. It can drive how an institution operates in taking care of patients."

To develop their model, the Cogent co-founders brought in people who understood operations, communications, and IT systems, as well as financial people to figure out how to pay for the model.

"The first thing the operations people did was time-motion studies," Greeno recalls. "They calculated that the percentage of our time we spent doing things that had to be done by a doctor was only 35%."

Ensuring efficiency

The money, it was determined, would be created by the efficiency of the program. The model includes the right tools: support personnel such as nurse coordinators. "We also put systems in place so a lot of things we work on intensively are much easier for a doctor to do — such as communicating to the PCP [primary care physician] when the patient goes home," says Greeno.

On the day of discharge, Cogent has a service center the physicians can call using an 800 number. "The information is dictated in a database format, giving the PCP all the information they need to know — diagnosis, procedures, meds, consultants," he says. "It takes our docs about 2½ minutes, and they’re done."

The physicians are paid for the quality of the work they do. "We pay them a salary, but then we incent them to work hard and grow the program," explains Greeno.

This profit-sharing methodology calls for bonuses based on quality metrics agreed to with the hospital in the contract. They might include patient satisfaction, PCP satisfaction, or readmission rates below certain levels. "Some are even tied to making sure the patients get correct meds," he adds. "In several contracts, we can measure compliance with discharge med protocols."

In addition, Cogent gathers data on how the hospital could do a better job. "Whether it’s different services, more operating rooms, or more cath labs, whatever it is that helps us do a better job taking care of patients," says Greeno. "The hospital can use the information to decide what they can do for the docs to help them take better care of the patients."

Cogent uses its information as a data-capture tool; Cogent staff can look at matching diagnosis with meds, for example. On their discharge notes, they can look at ordering patterns, consultant use, or complications. "This is a huge opportunity to gather data for quality," Greeno notes.

Under the Cogent model, "docs spend their time doing what they want to do and what you need them to do," says Greeno. "Say you go from 35% efficiency to 78%, allowing your docs to spend twice as much time with their patients; how can that not benefit everybody?"

In the end, he summarizes, "it’s all about intelligent design of the workflow of the hospitalist team and putting in place what you need to maximize patient care."