Hospitalist Positioning And Politics Public Version

Positioning your program for success

Meeting your hospital’s expectations

Hospitalist Executive Leadership Summit

December 3, 2010

Michael Wagner, MD FACP

Chief, Internal Medicine and Adult Primary Care

Michael Wagner MD FACP December 2010

V=Q/CMichael Wagner, MD FACP

Positions• Chief, Internal Medicine and Adult Primary Care, Tufts Medical Center 2008‐

present• Chief Executive Officer, EmCare Inpatient Services 2003‐8• Chief, General Internal Medicine, Tufts‐New England Medical Center 1999‐2003• Regional Medical Director, Cove Healthcare 1998‐1999• Internal Medicine Residency Program Director and Director of Medical Education,

St. Mary’s Hospital and University of Rochester 1992‐1997• Internist, New England Medical Center 1990‐1992• Chief Resident, Dartmouth‐Hitchcock Medical Center 1989‐1990• MD Georgetown University School of Medicine, 1986Current Roles• Associate Professor of Medicine, Tufts University School of Medicine• Vice Chair, institutional Review Board, Tufts Medical Center and Tufts University

Health Sciences • Physician Advisor, Information Technology Tufts Medical Center• Chair, Managed Care and Quality Committee, Tufts Medical Center Physician

OrganizationDisclosures• None

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V=Q/CConflict model: Thomas ‐ Kilmann

(Thomas – Kilmann)


V=Q/CPositioning your program – Goals of presentation

• Review some key concepts driving health reform

• Traditional drivers for hospitalists program development

• Outline current program metrics

• Review primary care situation

• Outline hospitalist program position in ACO environment


V=Q/CCouple concepts

• Value proposition– Value is proportional to quality– Value is inversely proportional to cost

• Triple aim (IHI)– Improve health outcomes– Enhance the patient experience– Reduce (or hold) health care expenditures

• Variation in care


V=Q/CValue proposition


V=Q/CVariation

Dartmouth Atlas


V=Q/CCurrent state view of hospitalist medicine

• Clinical drivers

• Business drivers

• Medical management focus

• Hospitalist world view


V=Q/CIdeal program (from an administrator)

• Program is free – no subsidy (after all don’t physicians get paid for their services?)

• The physicians are well trained and from prestigious programs

• The physicians are highly engageable– They go to meetings and are pleasant and helpful– They answer nursing questions and take their suggestions

• Patients are satisfied and would refer their friend or family toour hospital

• The physicians don’t ask for the hospital to buy anything


V=Q/C

• Unassigned call

• Referrals from primary care physicians

• Primary care physicians satisfaction

• Specialty physician satisfaction

• Reduce complexity– Reduce the number of physicians practicing inpatient medicine

• Quality – Execute quality programs– Documenting success

Clinical Drivers


V=Q/C

• Inpatient volume– Maintain current and attract new staff physicians– Support specialty physicians– Market to local non‐aligned MDs to use hospital to care for patients– Marketing to patients benefits of dedicated onsite coverage

• Quality– Enhanced reimbursement tied to achieving quality outcomes

• Utilization management– Enable part time providers to focus on their outpatient practices and reduce the number of low

volume providers practicing in the hospital– Leverage a single group to pay attention to hospital needs– Achieve specific average length of stay and cost per case budgetary goals

• RN satisfaction– Improve RN job satisfaction– Reduce RN turnover

• Outpatient volume– Improve productivity of employed outpatient physicians

Business Drivers


V=Q/CMedical Management Focus

• Effective Utilization Management– Reduce complexity– Reduce LOS variation– Appropriate lab, radiology and pharmacy utilization

– Implement “Best Practices”

• Increase Hospital Revenue per Day– Enhance throughput – Increase CMI– Reduce denials/denied days

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V=Q/CHospitalist Medicine – Ideal conditions

Jan 200913

Investment - >$90,000 / FTE hospitalist

Unassigned patients and primary care overload

Reproducible and scalable clinical model

MD Workforce


V=Q/CGrowth in numbers of hospitalists

14

Source: Society of Hospital Medicine


V=Q/CGrowth in relationship to established specialties

Jan 200915

30,000 hospitalistsestimated by 2010

Source: AAMC


V=Q/CHospitalist world view

Metrics• Time to admit • Time of discharge• Length of stay• # and % observation• Case mix index• Denials• Core Measures• AHRQ

- Safety measures- Quality measures

• Nursing satisfaction• PCP satisfaction• Patient satisfaction


V=Q/CDissatisfaction with primary care

• Burden– Non‐visit clinical work without support– Administrative paperwork– Technology

• Compensation

• Respect

• Role models

• Control

Jan 200917


V=Q/CChoices

18

Hospitalist Medicine Primary Care Medicine

The generalist


V=Q/CChoice: Primary Care vs. Hospital Medicine

Primary Care IM Hospital Medicine

Full time work commitment 18.75 days/month 15 shifts/month

Patient encounters per day 20‐30 pts per day 15‐18 pts per shift

Average compensation $150,000‐$180,000/yr $180,000‐$220,000/yr

Overhead Office, staff, equipment, supplies, billing, medical malpractice

Billing and medical malpractice

Non‐visit clinical work >100 documents/day Minimal

Administrative work Common ‐Prior authorizationsReferrals, FMLA, PT‐1, Disability forms, etc

Minimal ‐Inpatient payment denials

Panel size 1,500 to 2,500 0

Workday Controlled by schedule Controlled by patient need

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V=Q/CSnapshot of work generated

Based on EMR data from January 15, 2008 to January 15, 2009

Document type

Total number of documents since

January 2008

Average number per day for all of GMA

Ratio compared to office visit volume

Number compared to average volume of 20 patients per day

Office Visit 63,932 256 1.00 20

Coumandin 9,058 36 0.14 3 Phone Note 75,103 300 1.17 23 Rx Refill 20,861 83 0.33 7

Letter - Results 39,310 157 0.61 12 Medication list 14,845 59 0.23 5 External Correspondence 18,726 75 0.29 6 Internal Correspondence 10,241 41 0.16 3 Other letter 39,543 158 0.62 12

Lab Report 258,036 1,032 4.04 81 Imaging Report 17,115 68 0.27 5 Pathology Report 4,052 16 0.06 1

Hospital Admission* 3,530 14 0.06 1 Emergency Report* 9,002 36 0.14 3

Totals (excluding office visit) 519,422 2,078 8 162 Other notes* 87,631 351 1.37 27


V=Q/CIT overload and disintegration

• Logician

• Soarian

• PatientKeeper

• RelayHealth

• Quantia

• RCO/Envision

• Standing Stone

• Email

• Fax

• Phone

• NEQCA registry

• Intranet (phone book, Up to Date)

• Clinic electronic health record

• Hospital clinical repository

• Physician billing system

• Patient portal

• Physician education website

• Patient scheduling system

• Warfarin management system

• General communication

• Legacy system

• Legacy system

• Managed care quality monitoring

• Information resources


V=Q/CPrimary Care Capacity

Dartmouth Atlas


V=Q/CWhat we think about capitation or risk

• Starts with a “network” of primary care physicians

• Population is determined by those physicians

• Estimation of utilization risks and variability based on historical data and projections

• Management of:– Clinical events – preventable and inevitable– Utilization of network and out of network resources – leakage – The claims process– Attributing shared savings/risks to MD or pod level– Funds flow– Adjudication complaints/appeals


V=Q/CHospitalist revised world view


V=Q/CWhere does the hospitalist fit in an ACO

• Reduce out of network utilization

• Reduce unnecessary acute care utilization – Readmissions– Diversion to lower levels of care

• Meeting inpatient quality goals

• Collaborating on traditional outpatient quality goals– Diabetes– Hypertension– CVD lipid management

• Service line management

Hospitalist Positioning And Politics Public Version

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