Experts agree that comanagement arrangements are unlikely to be self-sustaining from billing revenues alone, and thus will need some kind of support. In some cases, specialist groups can contribute the needed support, but more likely it is up to the hospital’s administration, based on its commitment to keeping its surgeons happy and busy in the operating suite, and on outcomes documenting financial and other benefits.
Medicare currently pays surgeons a global fee to manage their patient’s care associated with the surgery. Hospitalist comanagers typically bill under different codes for managing the patient’s medical conditions. But in an era of heightened regulatory scrutiny, health reform, and increased bundling of payments, this approach could be in for some revision, says Michael Ruhlen, MD, MHCM, FACHE, SFHM, chief medical officer of Carolinas Medical Centers in Charlotte, N.C.
ACOs will receive a global fee and apportion it among all the providers involved in a given episode of care, perhaps returning to capitation as a method to accomplish the apportionment, Dr. Ruhlen says. Hospitalists now developing comanagement agreements with surgeons should be aware that such changes are on the horizon, requiring all of the parties involved to rethink how their agreements are structured. In such cases, clearly demonstrating the value of both parties’ contributions to comanagement will be essential, he says.
For The Cleveland Clinic’s Dr. Whinney, having a service agreement in place will help when physician reimbursement changes. “The thing you develop through these relationships is a sense of collegiality with your surgical colleagues, which is not something we’ve often seen before,” he says. “Particularly in large hospitals, where physicians don’t necessarily know each other, comanagement develops a true sense of collegiality.”
Felix Aguirre, MD, vice president of medical affairs for North Hollywood, Calif.-based IPC: The Hospitalist Company, says that a significant majority of hospitalized patients can benefit from an HM physician on the case.
“At IPC, we started with relationships [with the specialists], but as you go longer, you eventually move to more formal relationships, better defining what you are trying to do,” he says. “We’re still developing comanagement programs, and we’re trying to envision how they might relate to the readmission problem and to optimizing lengths of stay.”
Other industry leaders also ask how comanagement might contribute to the problem of hospital readmissions, perhaps with the hospitalist’s comanagement role continuing after the patient leaves the hospital. Others are exploring perioperative programs, broadly defined, with the hospitalist performing pre-operative assessments on an outpatient basis and helping to standardize processes and optimize the patient for surgery, thus reducing last-minute cancellations.