Medicolegal Issues

Hospital Med in the Land of Rocky Top


 

If a busy doctor is a happy doctor, then the hospitalists in the Methodist Medical Group at Methodist Hospital in Oak Ridge, Tenn., are ecstatic. Chris Frost, MD, the hospital medicine group’s chief hospitalist and medical director, has seen the group’s average daily census climb to 70, then 90, and now 100 patients. Fortunately, the group is growing, too, from nine full-time employees in late October 2005 to 12 before year-end, a projection for 15 by first quarter 2006, and several intensivists to help by March.

The hospital itself has grown as well: It’s in the midst of a $40 million renovation and expansion started in 2004. By August 2006, Methodist Medical will have 230 new private rooms, 12 beds in a new acute care unit, and an emergency department twice the size of its predecessor.

As a 24/7 hospitalist program, we help the medical community to be more profitable by enabling them to see more patients in the office and doing more procedures in the hospital. Better communication between physicians, patients, and their families benefits everyone and, we hope, will grow Methodist’s market share.

—Chris Frost, MD

How It Started

Methodist Medical Group has been shaped by Oak Ridge’s traditions and demographics. Nestled between the Great Smokey and Cumberland Mountains, Oak Ridge was one of three research and production sites for the Manhattan Project (an effort by the United States, in conjunction with Canada and the United Kingdom to develop nuclear weapons). At its height, Oak Ridge had 75,000 inhabitants. Now its population is 28,000, with a Medicare age group that comprises 42% more of its population than the average Tennessee city. It continues as a magnet for scientists, and its physicians—both office-based and hospitalists—form a close-knit community.

Methodist Medical Center of Oak Ridge Above: Methodist Medical Group’s average daily census climbed from 70 to 100 patients. The group has grown, too, from nine full-time employees in late October 2005 to a projection for 15 by first quarter 2006, and several intensivists to help by March.

Methodist Hospital is in the midst of a $40 million renovation and expansion that started in 2004. By August 2006, Methodist Medical will have 230 new private rooms, 12 beds in a new acute care unit, and an emergency department twice the size of its predecessor.

CONTACT Methodist Medical Center of Oak Ridge

990 Oak Ridge Turnpike

Oak Ridge TN 37831-2529

865/481-1000

Web site: www.mmcoakridge.com

Given its dynamics and demographics, when Oak Ridge’s primary care physicians asked Methodist Hospital in 1993 for help in admitting their patients, the hospital responded affirmatively. Hospital President Jan McNally, BSN, MHA, recalls how things unfolded. “Dr. Richard Dew, a highly respected primary practice physician with a busy office, wanted to change his life. His son had died and he decided to close his office, but he wanted to stay in medicine in Oak Ridge. He agreed to practice inpatient medicine at Methodist,” she explains. “The beauty of it was that he was universally respected. Barriers to the program fell because the admitting doctors and the patients all knew him.”

When Dr. Dew retired in 2002, Anthony Garton, MD, who closed his solo practice to join Dr. Dew as Methodist’s second hospitalist, stayed on. Dr. Garton became a hospitalist because “office procedures just brought me to break even financially. Only the things I did that didn’t have office overhead, such as being medical director at a nursing home and doing physicals for Boeing, made sense financially.” Dr. Garton, who worked with a nephrology group for 13 years, made a smooth transition to a hospitalist career.

VITAL STATISTICS:

Methodist Medical Center of Oak Ridge

Beds: 301

Physicians: 175 in 30 specialties

Employees: 1,300

Parent Company: Covenant Health, Knoxville, Tenn.

Web site: www.covenanthealth.com

Structure: Methodist Medical Center of Oak Ridge is one of five acute care hospitals in east Tennessee within the Covenant Health network.

From the hospitalist program’s inception, Methodist turned to Team Health, Inc., of Knoxville, an outsourcer of medical personnel, for staffing. Team Health Vice President Kenneth Burns saw a natural fit; his firm already supplied Methodist’s emergency department physicians.

“We understood the problems faced by Methodist’s ED docs,” says Burns. “Patients got stuck there and couldn’t be admitted rapidly to inpatient floors.”

He identified the hospitalist’s necessary skills as an ability to cooperate with community physicians, and an interest in improving processes to boost care quality and decrease costs. Methodist’s hospitalists have been independent contractors since the program’s inception. They receive hourly wages plus incentives based on productivity and metrics negotiated with hospital administrators.

Team Health recently rethought the model as potential recruits balked. In 2006 Methodist’s hospitalists became employees, with health benefits and defined contribution plans. Hospitalist Helen Bidawid, MD, says being employees improves recruiting because many doctors—particularly those just out of residency—find getting loans, buying health insurance, and other business associated with independent contractor status troublesome.

Symbiosis

Above: Methodist Medical Group’s average daily census climbed from 70 to 100 patients. The group has grown, too, from nine full-time employees in late October 2005 to a projection for 15 by first quarter 2006, and several intensivists to help by March.

The relationship of Methodist’s hospitalist program to Oak Ridge’s community physicians has changed over the years. Early on the group hired a hospitalist Dr. Garton describes as “very bright, knew his medicine, and would wow them in academia, but he antagonized the local docs. He left after one year and that was good because our census got low.”

Tact wasn’t that hospitalist’s long suit, and the community doctors who were uncomfortable with him didn’t refer many patients to the hospitalists. With the odd man out, hiring new hospitalists such as Joel Perkerson, MD, put the program back on track.

When Politics and Healthcare Collide

For decades TennCare, Tennessee’s Medicaid program, was seen as a national template of a generous Medicaid program for the indigent, those close to the poverty line, and the medically uninsurable. Until August 2005, that is, when Tennessee Governor Phil Bredeson cut more than 300,000 from the rolls, reduced or cut prescription drug coverage to 379,000, and trimmed millions of dollars from a program that consumed 26% of the state budget.

Slimmed down TennCare limits recipients to five prescription drugs paid for each month. Hospital administrators braced for an estimated 12% increase in uncompensated care in emergency departments due to chronic conditions that become acute due to inadequate access to medication. Although Tennessee tried to stretch a “safety net” under the sickest beneficiaries with a $57 million drug card subsidy and mail order pharmacy, those unable to pay for medication quickly flooded hospital emergency departments, including Methodist’s.

Dan Duzan, MD, who left an office-based practice a year and a half ago to join the Methodist Medical Group, saw the TennCare debacle coming. “It was the ‘go to’ program for beneficiaries, and it was not well run,” he says. “People got all the tests they wanted and all their prescriptions filled. The governor was either going to have to dissolve the program or put limits on it.”

Since August 2005 Dr. Duzan has seen a 10% to 15% increase in former TennCare beneficiaries who have decompensated with diabetes, heart failure, and other chronic illnesses. “When the TennCare changes were announced we didn’t know what the impact on us would be. Now we know,” he says. “Patients are not getting their meds. They get sick and come here, and there’s not much the hospital can do about it.”

Dr. Duzan doesn’t blame the governor: “He did what had to be done. It was either raise taxes—very unpopular here—or reduce care.”

Dr. Perkerson also sees a correlation between TennCare disenrollment and more work for Methodist’s hospitalists: “We see so many elderly on multiple medications. They can’t afford all their medications so their diabetes and/or CHF slips out of control.”—MP

Methodist Hospital is in the midst of a $40 million renovation and expansion that started in 2004. By August 2006, Methodist Medical will have 230 new private rooms, 12 beds in a new acute care unit, and an emergency department twice the size of its predecessor. Above: Methodist Medical Group’s average daily census climbed from 70 to 100 patients. The group has grown, too, from nine full-time employees in late October 2005 to a projection for 15 by first quarter 2006, and several intensivists to help by March.

Methodist Hospital is in the midst of a $40 million renovation and expansion that started in 2004. By August 2006, Methodist Medical will have 230 new private rooms, 12 beds in a new acute care unit, and an emergency department twice the size of its predecessor.

Dr. Perkerson left an office practice he had been in for 12 years. “I was drowning in paperwork, and it was so frustrating,” he says. “I couldn’t get my homework done or help my son, who was struggling academically.”

Having been both an office- and a hospital-based physician in Oak Ridge, he says it’s too hectic to do both. Being a hospitalist is challenging enough.

“It’s like the movie ‘Field of Dreams.’ Build it, and they will come. Demand keeps growing for our services and we all work a lot of hours,” he says, crediting the increasing load both to Dr. Frost’s leadership, which has made the subspecialists comfortable with the hospitalists’ management of medically complex patients, and to ex-TennCare patients flooding the emergency department. (See “When Politics Collide with Healthcare,” p. 38.)

Under Dr. Frost’s direction (he took over as medical director in 2003 after being recruited as assistant medical director), the hospitalist program has thrived. Dr. Frost has built relationships with Oak Ridge’s subspecialists, particularly pulmonologists, hematologists, oncologists, gastroenterologists, and orthopedists. Typical of Dr. Frost’s leadership is his response to Oak Ridge’s only pulmonary group imploding from six physicians to two. The hospitalists now admit all the group’s patients and Dr. Frost worked with Team Health to recruit intensivists for those very ill patients.

“I’m very pleased with the growth of the hospitalist program,” says Dr. Frost. “We feel empowered that more and more primary care doctors and subspecialists are allowing us to admit and take an active role in managing their patients.”

Tackling one problem that has bedeviled other hospitalist programs, Jan McNally has added a mechanism to ensure cooperation from referring doctors. She expects referring subspecialists to come for consults ASAP when a hospitalist calls.

“We must have that commitment from specialists,” she says. “We have about 15 percent who are laggards, but we will impose disciplinary action if they don’t come when called.”

Dr. Frost favors specialists willing to turn their patients over to the hospitalists in order to improve care quality. He diligently writes care guidelines, focuses on core measures, has deepened discussion of end-of-life care issues, and built such strong esprit de corps that the hospitalists willingly work long and irregular schedules until more physicians arrive. Helen Bidawid, MD, who has been a Methodist hospitalist for about a year, enjoys the hospitalist group, doesn’t mind pitching in to support her colleagues, and says “we function very well together. We watch out for all of our patients, share our responsibilities, and ask each other for help.”

Dr. Bidawid, who was in a non-supportive hospitalist group before her current position, asked herself before she arrived at Methodist: “’Will I be nurtured here or thrown to the wolves?’ Fortunately, I found a very supportive environment.”

With the course set, Dr. Frost still has challenges ahead. There’s growing patient volume, more complex cases to co-manage, carve-outs such as cardiology, neurology, and stroke care, and TennCare disenrollees to contend with.

“Our goal is to add value to Methodist Medical Center,” he says. “As a 24/7 hospitalist program, we help the medical community to be more profitable by enabling them to see more patients in the office and doing more procedures in the hospital. Better communication between physicians, patients, and their families benefits everyone and, we hope, will grow Methodist’s market share.” TH

Marlene Piturro is based in New York.

Quality Counts

Table 1: Core Measure Compliance Above: Methodist Medical Group’s average daily census climbed from 70 to 100 patients. The group has grown, too, from nine full-time employees in late October 2005 to a projection for 15 by first quarter 2006, and several intensivists to help by March.

click for large version

Table 1: Core Measure Compliance Above: Methodist Medical Group’s average daily census climbed from 70 to 100 patients. The group has grown, too, from nine full-time employees in late October 2005 to a projection for 15 by first quarter 2006, and several intensivists to help by March.

click for large version

Methodist Medical ranks #1 in Tennessee on its compliance with Medicare core measures. Coletta Manning, RN, MHA, Methodist’s director of outcomes management, provided these data to show how they did it: (Table 1)

Manning cites this caveat in interpreting the data: When a patient is admitted and a diagnosis associated with a core measure is not made until the second day of hospitalization, the case isn’t considered in compliance. An example is abdominal pain that on further examination turns out to be caused by a myocardial infarction. If that were the case, the core measure of giving aspirin immediately would not be met because the diagnosis was not made within the first 24 hours of admission. “We get dinged sometimes,” says Manning.

Internally, the hospitalists measure their performance on compliance with the group’s own care design (critical pathway) utilization. Dr. Frost is pleased with the hospitalists’ growing acceptance of care designs and is working with Team Health on a sophisticated computer system to help the hospitalists use

Next Article:

   Comments ()