“We want to go beyond the stereotype of the internal-medicine trained physician drudging through the hospital as an eternal extension of residency,” says Dr. Chmelik. “Family physicians excel at end-of-life issues and the biopsychosocial model of healthcare, both of which are very important in a hospital.”
Another addition to Dr. Chmelik’s black bag is her expert consulting on obstetric and pediatric patients; she can easily handle issues such as hypertension in a postpartum patient or post-appendectomy asthma in a child.
The Financial Tightrope
The University of Florida’s CHFM is closely tied to SAGH, a 75-year-old, 367-bed community hospital that serves as its training ground for residents and hospitalist fellows. Although SAGH is a vital part of Gainesville’s medical scene, its financial status has been shaky for some time.
In 2002, Moody’s Investor Service gave SAGH a negative rating, which was upgraded to stable in 2003.The upgrade of SAGH’s $312 million of outstanding debt issued by Alachua County Health Facilities Authority kept the wolf from the door temporarily. Talk persists that SAGH is in trouble, however, and a Gainesville group, the Health Care Is a Human Right Coalition, asserted in July 2006 that the hospital lacked leadership and that “there are no published plans to keep SAGH open beyond 2010.” SAGH spokesman Ralph Ives says, “Nothing could be further from the truth.” He points to SAGH’s investment in an 82-bed pediatric hospital in a renovated wing with its own hospital medicine group as an affirmation of the institution’s future.
Like other hospitals struggling with public payers and lots of unassigned patients, SAGH’s hospitalist program improves the hospital’s financial health by serving large numbers of patients cost-effectively. Conversely, hospitalist programs can sink because of inattention to financial basics. Early in SAGH’s history, the hospitalists were overwhelmed with a burgeoning census, leaving coding and billing for clerical staff to figure out at day’s end. This delayed billing and often failed to capture the correct diagnostic codes and level of severity for each patient encounter. As the program matured, the hospitalists and hospital administration agreed that physicians would do the coding themselves as they rounded. That change saved on the back end of clerical work and got the charges in promptly.
Each month, Swilley and the hospitalists review individual and group coding patterns, payer mix, the amount billed to each carrier, the amount of time bills spend in accounts receivable, and the services that have been denied. Hospitalists also receive daily reports on their charges and tips on improving coding. For example, if they’ve reviewed documents, Swilley reminds them to code that activity, just as she does a hospitalist who was swamped in the ED at 10 p.m. and left coding his encounters until 1 a.m., thereby losing one day of service. “A hospital is a business. Our hospitalists work hard; I teach them to work smarter and to pay attention to the bottom line,” says Swilley.
Being diligent about financial productivity matters greatly when it’s time for the CHFM department to negotiate with the hospital for its annual subsidy, which Dr. Curry says is about $500,000.
“When we present our budget, we include billing expenses, overhead, salary, and fringe benefits,” says Swilley. “The more detail we have on the number of patient encounters, [our] productivity, and the revenues we generate, the better position we’re in to get support.”
Like most other hospitals, SAGH struggles with tight reimbursement versus the need for an attractive physical plant. To that end, in 1998 it became the first hospital in Florida to adopt the Planetree model, which advocates patient-driven healthcare, serving body, mind, and spirit. “We’ve always been a deeply compassionate hospital,” says Lynne Mercadante, RN, SAGH’s director of Medical Staff Services, “and Planetree is a natural extension of our looking into our hearts and minds about treating the whole person.”