January 12, 2017

Over the last few years, we have seen a massive consolidation of physician practices into bigger groups or as part of a vertical integration with HMOs, MSOs or hospital-owned networks. With this wave of change, we have also seen the growth of hospitalists in these hospital networks and groups. While to some extent this may improve efficiency of service and economies of scale, there may be certain downsides to this approach.
Some of these limitations are:

  • Lack of communication:
  • This seems to be the biggest deficiency since the hospitalists did not know the patients or families beforehand and have no information on their prior histories. With the advent of shared IT platforms, some of these concerns may be alleviated; however, the human interaction is missing and many patients still want their primary physicians to visit them in the hospital and communicate with them and the hospitalist. It is quite often that admitted patients call their primaries to enquire what is going on with them in the hospital. Recently one of our patients died in the hospital, yet we did not know that patient had passed away until a chance meeting with one of the family members several weeks later.

  • Quality of care:
  • This is the most fearsome casualty. As the lack of communication continues, patients are discharged with inappropriate or contradictory discharge medication lists, and some of these lapses may be fatal. For example, a patient of ours was recently discharged on Coumadin, and the Home Healthcare did not show up for two weeks to see the patient. By the time the patient received attention, she was in critical condition with a hemoglobin of 5 and an INR of more than 100.

  • Customer service:
  • Patient satisfaction is very low, no matter how excellent the service, if communication is not good. Patients start feeling like they have been vulnerable and abandoned in alien surroundings with 'unfriendly' personnel while multiple procedures are being performed on their bodies without due explanation.

  • Financial Viability:
  • As quality of care deteriorates, the number of readmits increases, unnecessary procedures multiply, and patient follow-up is compromised. Furthermore, complication rates and ER visits increase, along with a heavy reliance on consultants to manage the case, and healthcare costs go up. The malpractice risk is greater, and preventable injuries to patients escalate.

  • Healthcare Indicators:
  • Thus, the entire group suffers in its utilization, quality of care, compliance, clinical integration, and disease and care management. Such a group would find it very difficult to retain its providers or align the community with its operations and growth.

Having delineated some of these real, practical issues that we have dealt with among our patients, what have we done? Or is the hospitalist program irredeemable?
These are the measures we undertook and are still refining:

  • Patient continuity and discharge coordinator:
  • We hired our own navigator for our inpatients to communicate with our patients, their families, and physicians, to assist in any issues or concerns if they came up, get the primary care records to the hospitalists, assist with discharge planning, and get the discharge summaries to the primaries. The coordinator also ensured that the patients had her phone number for any assistance needed post discharge, that the discharge summaries reached the primaries within two days and that the patient was seen within seven days of discharge.

  • Involvement of care management and utilization management:
  • Our utilization management teamed up with the discharge coordinator to ensure that 23-hour observations were appropriate and converted if needed, that procedures and consults done on inpatients were medically necessary, and that we communicated with allour hospitalists and primaries about the program.

  • Tracking:
  • If you do not measure, you do not treasure. Once we started tracking data about our utilization, length of stay, readmits, etc., we saw the needle move and an improvement in our numbers. Patients felt empowered and appreciated.

  • Monthly Meetings:
  • Our utilization management team and medical director met with hospital case management on a monthly basis, and with our physicians to ensure that this initiative was a team effort and that everyone had a stake in it.

  • Customer Satisfaction Questionnaire:
  • We plan to introduce this to patients to see what our areas of improvement are and how we truly measure up. I believe this measurement will soon be mandatory in any aspect of healthcare, for it is already being forced by the government.

  • Integration, Clinical and Administrative:
  • In essence, we brought compliance, quality management, care management, and physicians together. The integration of data, patient information, customer service, healthcare utilization, and outpatient follow up with SNFs, HHCs, ALFs, and other long term facilities remains our goal.

Was there an improvement?

  • Improvement in Awareness:
  • There was an increase in awareness of what the issues involved are and a constant desire to improve.

  • Improvement in Numbers:
  • There was a significant improvement in utilization and patient service.

  • Reduction in Mortality and Morbidity:
  • In terms of reduced complication-rate, I believe that such a system is the only way on a macro-level to prevent patient injury.

  • Numbers over quality:
  • The biggest concern is that such an objective reporting of indicators should not cloud patient care and quality of care. Physicians should not become heartless calculators who are only concerned with report cards, but they should be concerned foremost for what is the right thing to do for their patients. This can only be avoided by constant communication and training, and measuring patient satisfaction against UM indicators.

As far as I am concerned, the consolidation of medicine and medical practices is here to stay. So are the hospitalist programs and intensivist programs. How we turn them into opportunities for better patient care and reduced wastage and improved services is up to us. It is still a process we can define with constant attention to quality, compliance, and utilization.

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