Medicolegal Issues

A Midwest Partnership


Quite likely things are different in Minnesota than they are on either coast. People are polite, know how to work together, and are respectful about consuming resources. Or as Tom Anderson, MD, a HealthPartners Medical Group (HPMG) hospitalist says: “In Minnesota affable usually beats good.” Fortunately, the 25 physician members of the hospitalist team who belong to the 580-member HPMG, are beyond affable and good. By many measures they are excellent, and they are shaping the field of hospital medicine.

At the heart of the HPMG hospitalist program’s quality are its people. Burke Kealey, MD, HPMG’s assistant medical director, helped start the program in 1997, recruiting young, energetic, and personable physicians who liked practicing big city hospital medicine, Midwestern style. “Our hospitalist program was one of the early ones operating before the term ‘hospitalist’ was well-known,” says Dr. Kealey.

The hospitalists are employed neither by an academic medical nor a community hospital. Instead, they are members of a 580-multispecialty physician group that anchors HealthPartners Network, an organization that consistently ranks among The National Committee for Quality Assurance’s (NCQA) top five health plans regionally and top 10 nationally. Yet excellence has its price, as the perverse incentives of the U.S. healthcare system reveal. Mary Brainerd, HealthPartner’s CEO, comments that although the company consistently ranks high, it gets paid thousands of dollars less per patient by Medicare than poor performing plans.

“The way Medicare is set up, it actually punishes you for being good,” says Brainerd, referring to Medicare’s rules that qualify hospitals to receive additional payments each time a patient returns for more treatment—even if their return was caused by sub-par diagnosis and treatment. Under Medicare’s incentives, hospitals and doctors who order unnecessary tests, provide poor care, or even make patients worse often receive higher payments than those who provide efficient, high-quality care. That doesn’t stop HPMG from doing things correctly.

With the physician group employing both clinic and inpatient physicians, it’s more straightforward getting metrics and incentives aligned than in a healthcare environment where the outpatient physician’s loss may be the hospitalist’s gain—or vice versa. “Working closely with clinic and ER doctors decreases length of stay, improves clinical outcomes, and decreases costs,” says Dr. Kealey. “That helps the whole medical group.”

Another major contributor to clinical excellence goes beyond HPMG. Using the Minnesota mindset, HPMG’s physicians work with the area’s other medical heavyweights, the Mayo Clinic (Rochester, Minn.) and the Allina Medical Group (Minneapolis), forging a consensus on best practices and evidence-based guidelines ( An example of HPMG’s outpatient and inpatient physician collaboration is their approach to CHF. After both groups tackled the job of operationalizing “perfect” CHF care in a one-day Rapid Design Workshop, “perfect treatment” outcomes rose from 22% in January 2005 to 50% in March 2005.

Being an HPMG hospitalist allows physicians to pursue many avenues of clinical and process improvement, including national initiatives and teaching

Nuts and Bolts

Scheduling logistics is among the challenges a hospitalist program’s manager faces, and Dr. Kealey and his colleagues have—through experience—done well. Each hospitalist selects a block schedule (either one week on, one week off or 14 days straight for 24 weeks). They also serve two night shift weeks (6 p.m.—8 a.m.), although residents run things at night. Hospitalists reconfigure their schedules every six months, helping to avoid burnout. Geographic deployment is another energy saver. Each hospitalist works in one or two units, allowing them to know patients, family, and the nursing staff well. It also cuts the nine-story hospital down to a size.

To communicate effectively, physicians use electronic technology. Voice pagers connect all HPMG physicians. Other devices sound alerts, allow for co-management of patients with chronic diseases, quick referrals to specialists within the group, in-box messaging, and a discharge summary to the primary physician in six to eight hours.

As for compensation, physicians receive a base salary, set at 80% of SHM’s annual average for the Midwest, accounting for 65% of pay. Of the balance, productivity as measured by relative value units (RVUs) accounts for 40%, with 20% each for high marks on patient and provider satisfaction surveys, and the medical director’s discretion.

Myriad Opportunities

The HPMG hospitalist program offers opportunities to pursue many professional paths, as its SHM award roster shows. SHM’s Award for Outstanding Service in Clinical Medicine to HPMG Hospitalists have included:

  • 2002 Rusty Holman, Outstanding Service in Hospital Medicine;
  • 2003 Burke Kealey, Clinical Excellence; and
  • 2005 Shaun Frost, Clinical Excellence.

Adding depth to the program involves embracing physicians on unusual career paths, such as Tom Anderson, MD, one of HPMG’s family practice hospitalists. After finishing training at Ramsey County Hospital of St. Paul, Minn., which became Regions Hospital in 1997 (and where Dr. Kealey also trained), Dr. Anderson joined a seven-doctor rural practice in Iron Range, Wis.

“It was in a hard-working blue collar town, and we were throwbacks,” says Dr. Anderson, “doing all our own obstetrics, covering the ER, helping surgeons. I was a real person in that community. Everyone knew each other from the church or hardware store.” If the doctors wanted to change anything, they talked over doughnuts and coffee, deciding how it would affect them and their patients. Dr. Anderson loved the work, but wanted more family time than the all-consuming rural practice allowed.

A recruiting call from Dr. Kealey changed everything. Dr. Kealey calls Dr. Anderson “a bright and shining star, someone who sits in the front row and asks all the questions.”

Dr. Anderson joined HPMG’s hospitalist team in 2004, enjoying the one-week-on/one-week-off schedule and the continuity of care afforded by a large team. “This is a big busy hospital,” he says. “The patients are really sick, and we plan our 12-hour shift around them.” He starts with a 7 a.m. huddle of nurses and physicians to plan the day by prioritizing patient needs, reviewing orders, arranging time to talk to specialists, and visiting all patients. “By 9 a.m. we’ve planned the day, including 3 p.m. patient discharges. I like prioritizing what has to be done, and defining what has to be fixed.”

Rick Hilger, MD, board certified in internal medicine and pediatrics, is on another mission. After residency at the University of Minnesota Medical School (Duluth), he became Regions Hospital’s chief resident and then stayed on. He wanted a pediatrics hospitalist practice, which proved impractical because 95% of Regions’ pediatric cases now go to another hospital. “Down the line I’d like a 50/50 adult/peds mix, but that’s hard to accomplish in a hospitalist program,” he says.

Still looking for a challenge, Dr. Hilger chose the Institute for Healthcare Improvement’s “100K Lives” initiative, becoming the lead physician for Region’s rapid response team to prevent unnecessary code-blue calls. With the hospitalists’ geographic deployment to specific units that meant planning who would respond to codes and how that would be communicated. Dr. Hilger encouraged administration to hire full-time employees to field a rapid response team and created a pre-code team.

“At least 30%-40% of patients code outside the ICU,” he says. “We’ve observed that they often have unstable vital signs six to eight hours before coding. We’ve cut through administrative minutiae and red tape so that patients don’t sit there with unstable vitals for long.”

The pre-code team—an ICU trained nurse and respiratory therapist—are alerted to those signs and respond in five minutes or less, 24/7. The rest of the team is alerted via pagers, with hospitalists fielding an average of three calls per day.

Other hospitalists find their special niches. Shaun Frost, MD, is breaking ground in peri-surgical care in orthopedics, urology and neurology, and is active in process improvement teams. Howard Epstein, MD, leads the palliative care team, while John Degelau, MD, chief of hospital medical at North Memorial, pursues his interest in geriatrics. Rich Mahr, MD, is the physician champion for electronic health records.

So being an HPMG hospitalist allows physicians to pursue many avenues of clinical and process improvement, including national initiatives and teaching. Dr. Anderson sums up what HPMG is about: “I joined this group because of its passion for medicine. When we get older we’ll look back and say that we had our moment, our time to give it 100%.”

Dr. Kealey calls them “an energized creative group. Everyone wants to go to national meetings and to keep ahead of the pack, to ask what’s next to learn?” TH

Writer Marlene Piturro regularly writes practice profiles for The Hospitalist.

Pursuing Perfection—Prepared Practice Teams

Administrators and clinicians at HealthPartners knew they excelled at patient care when compared with national benchmarks, but believed they could do better.

“We were on a plateau and weren’t going higher,” says Beth Waterman, vice president of primary care and clinic operations. In 2001 she raised the bar by applying for a $50,000 Robert Wood Johnson Foundation “Pursuing Perfection” Phase I grant. According to Sue Knudson, senior director of Health Partners, the foundation awarded dozens of pilot project grants to providers in the United States, Canada, and Europe, attracting many organizations with different approaches to improving care quality. After a pilot project, HPMG was one of only seven grantees in 2002-2004’s Phase II $1.9 million grants, with which HealthPartners developed a planned care model.

HealthPartners’ new model started with the recognition that even though its physicians provided highly integrated care across settings, they weren’t sure if the patients saw care as smooth or fragmented. To start improving things Waterman and Knudson brought together 200 HealthPartners staff for a two-day Rapid Design Workshop. They mapped workflow processes that moved patients through the system, identified stumbling blocks to smooth handoffs from pre-visit through after-care, and called the reengineered path “the planned care model.”

Under this model prepared practice teams streamlined care by closing gaps in pre-visit, visit, post-visit, and between-visit care. For example, all patients now receive calls to have lab work done pre-visit, providers are more consistent writing after-visit summaries for patients, and clinic nurses round with hospitalists to coordinate after-care. To further make care patient-centered, HealthPartners is pilot-testing a subset of its larger electronic medical records (EMR) system for their patients called “My Chart.”

Unlike many other Pursuing Perfection grantees that focused on individual disease states, HealthPartners stayed disease-neutral. “At first there was some confusion about not working on clinical pathways,” says Waterman, “but we didn’t want to make transformational change one disease at a time. We haven’t regretted that decision at all.”

Although planned care isn’t generally disease-specific, HPMG focused on heart failure for Phase III, running from 2004-2006. Its task is to redefine how the team manages heart failure along the care continuum. Using a rapid design team of 20 people, the group tackled issues such as operationalizing the roles of cardiologists and primary care physicians in one day. The team reviews the literature on the stages of CHF and how it will be co-managed by specialist and primary physician, embedding CHF guidelines in the EMR, writing a co-management protocol for admitting CHF patients, and revising inpatient order sets and work flows. —MP

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