Hospitalist physicians are here to stay. The value they bring to hospital systems is undeniable. The steady rise in the hospitalist salary over the last decade says so. For the most part, internal medicine and family medicine physicians have created their own dividing lines. Many doctors in my field have decided they are either going to practice medicine in the clinic or they are going to practice medicine in the hospital. Fewer and fewer doctors have chosen to do both. This is a lifestyle and practice management decision that every physician has an obligation define for themselves and patients should not feel slighted or insulted when their doctor chooses not to see them in the hospital. This is how hospital care is delivered in 2012.
Some nonbelievers point to a perceived lack of hospitalist continuity of care as one failure of the hospitalist movement. As the theory goes, an outpatient doctor who has taken care of you for years will know you and your history best. Fortunately for patients, that is simply not always the case. Many hospitalist patients are well known to the admitting service. Most patients in the hospital have been there before. Hospitalists have EHR systems to rapidly review previous admission records. These records often give a more complete picture of the patient's story than the fractured outpatient experience spread among many doctors' offices, radiology suites and outpatient laboratories.
Hospitalists often know their patients' history well because of their extensive hospital database. Five percent of America's population spends 50% of the health care dollars. A great part of a hospitalist practice is built on God's promise that chronic disease is unstable when given enough time to express itself in a patient's daily life experience outside the magic force field of the controlled hospital environment. This is why heart failure 30 day readmission rates will never be zero even when offered free heart medications. 2014 isn't going to fix our health care spending problem. It's going to make it worse.
The last decade has seen a rapid expansion in the percent of hospitals using hospitalists. With 60% of hospitalized patients now being seen by a hospitalist, one has to wonder what role these patients' outpatient internists and family medicine doctors have to fill. Research suggests that patients who are discharged from the hospital are less likely to be readmitted to the hospital if they are seen sooner rather than later by their outpatient internist or family medicine physician. These doctors are playing an important role in reducing readmission rates to the hospital. Contractually defining one's role in reducing hospital readmissions is a golden opportunity for outpatient physicians to increase their revenue stream. The last comprehensive compensation survey confirmed that hospitalist subsidy/support payments are now over $130,000 per hospitalist per year. Why? Because hospitalists are worth their weight in gold.
If you are an outpatient internist or family medicine doctor, it's time to listen to The Happy Hospitalist. If you utilize a hospitalist service, you need to understand that their service is going to generate shorter average length of stays with no increase in readmissions or mortality than if you admitted your patients. Hospitalists will get your patients home quicker and less sicker. Don't be offended though. This is a compensation opportunity for you to consider.
It's going to be your job to keep them out of the hospital for that golden 30 day window that has been graciously defined for us by the Medicare National Bank. If you are an independent practicing physician, however, you could care less, but you should. Why? Because you have officially become valuable to all hospital systems in your area. It's time to ask hospitals for your own Readmission Avoidance Subsidy (RAS) to compensate you for a higher intensity of service required to keep patients out of the hospital.
CMS has their recovery audit contractors (RAC). It's time you started a RAS program and tell hospitals that their return on investment will go straight to their bottom line. It's time you left the revenue constraints of the colossal evaluation and management (E&M) failure and start earning revenue from sources that perceive your service as valuable. What do you have to lose? The worst they could say is no. You could even use the RAS as a bargaining chip to decide which local hospital you want to send your patients to. Hospitals that are willing to provide for you the resources to avoid readmission should be preferred over hospitals that don't.
Providing this service means you will have to maintain close contact with your discharging hospitalist physician. You will have the motivation to interrupt your daily office monotony, stop what you're doing and rush to the waiting call of your hospitalist, who has been on hold for five minutes waiting eagerly to discuss the details of your patient's hospital stay. Having great hospitalist handoffs to the outpatient physician requires time from both ends. Hospitalists must stop what they are doing to navigate obstructive voice mail systems and call centers with obstructive hours of availability only to find the patient's primary outpatient physician is often not available or too busy to take the call. Hospitalist handoffs are often handcuffed by the process we are given to practice in.
To make matters worse, many outpatient physicians simply do not want to be contacted by phone when their patients are discharged. As a matter of interest, we recently took a survey of our referring physician base to understand what contact process was preferable to them on the day of their patient's discharge. With a 98% response rate of over 100 physicians, we discovered nearly 65% of our outpatient referring physicians requested that no hospitalist contact them by phone when their patient was discharged.
That was shocking, yet enlightening. Our personal contact with them is simply not important to them in the continued management of their patients after hospital discharge. What does this say? It says our phone calls offer no value to them. It says that our phone calls to them are an intrusion into their daily workflow. I can understand that and I empathize deeply with them. Constant interruptions to my daily and nightly work flow are a patient safety issue. It says that for nearly two out of three outpatient family medicine doctors and internists, my day of discharge phone call is just annoying and offers no value.
That places even more importance on the structure of the discharge system process. Hospitals that are proactive in creating processes that help primary care physicians navigate the complexities of post hospital discharge management will win. Others will get stuck caring for readmissions that do nothing be take profit away from the bottom line. What's the cost going to be? Nobody knows. CMS is on a mission to stop paying for care. They are cloaking their mission in verbal jargon that generates great sound bites for the media but the end result is just the same. They are going to continue expanding their mandates to stop paying for care. And hospitals are either going to have to stop accepting Medicare or they are going to have to continue to play the game.
I believe engaging outpatient physicians with readmission avoidance subsidies would go along way to winning the game. Hospitals already pay physicians to be on call. Perhaps it's time they started to pay physicians to keep patients out of the hospital as well. I suspect, until that day comes, most of the outpatient doctors will continue to avoid hospitalist interruptions and hospitalist handoffs will be handcuffed in the interest of physician satisfaction.
