Ibe Mbanu, MD, MBA, MPH, became medical director of the adult hospitalist department at Bon Secours St. Mary’s Hospital in Richmond, Va., about six months ago. Since then, he’s been besieged by a torrent of reform-based challenges he says make his job exponentially more difficult than that of medical directors just a few years ago.
Accountable-care organizations (ACOs), value-based purchasing, and discussions about bundled payments for episodic care are changing rapidly, and as a new administrator in a group with 24 hospitalists and three nonphysician providers (NPPs), he felt he needed to attend his first SHM annual meeting to keep up.
“The landscape in health care is rapidly evolving, at a frantic pace,” Dr. Mbanu says. “I essentially came here to just try to get a condensed source of information on how to manage the changes that are coming through the pipeline, and how to effectively run my department.”
Managing a practice is a challenge, and many of the more than 2,700 attendees at HM13 said the four-day confab’s focus on the topic was a major draw. From a rebooted continuing medical education (CME) pre-course appropriately named “What Keeps You Awake at Night? Hot Topics in Hospitalist Practice Management” to dozens of breakout sessions on the topic, it’s clear that successful practice management is a concern for many hospitalists.
“Before, the drivers were pretty clear,” Dr. Mbanu says. “Volume, productivity. Now we’re switching more toward a business model that’s changing from volume to value. Trying to adapt to that change is pretty challenging.
“Now it’s critical to really understand the environment.”
One particularly hot topic this year was the trend of hospitalists taking on more comanagement responsibilities for patients previously managed by other specialties, including neurology, surgery, and others. Frank Volpicelli, MD, a first-year hospitalist and instructor at New York University (NYU) Langone Medical Center in New York, was one of three members of his HM group that attended the “Perioperative Medicine: Medical Consultation and Co-Management” pre-course. This summer, his group is going to establish a presence in the preoperative clinic.
“We hope very strongly that we can prevent some complications, identify patients that we should be following when they come into the hospital, and help the surgeons out,” he says. “No. 1, keep them in the [operating room] more, and No. 2, get in front of some of the complications that they are less comfortable managing.”
Ralph Velazquez, MD, senior vice president of care management for OSF Healthcare System in Peoria, Ill., isn’t so sure comanagement of more and more patients is the best practice-management model moving forward. For example, as physician compensation is tied more to how much their care costs to deliver, a hospitalist comanaging a surgical patient’s elective knee replacement could be financially penalized for the cost of that person’s stay, despite having nothing to do with the most expensive portion of the bill.
“You have a financial model that says do more billings, but as you start developing analytics … you may see there is no difference between the model that’s doing more billing, in terms of improving quality, and the one that is doing less,” Dr. Velazquez says. “So if you’re getting the same amount of quality, and the only thing you’re doing is generating more cost by doing more billing, you need to reevaluate your strategy.”
He believes some patients benefit from comanagement, but HM groups have to be diligent in seeking them out.
“We look for simple solutions and one-size-fits-all,” he adds. “Comanagement in complex patients—definitely there’s a need for that. Comanagement in noncomplex patients, elective patients—there’s no need for that. It’s just additional cost. I don’t think it’s going to produce any value.”
John Colombo, MD, FACP, a 30-year veteran of internal medicine who moved to HM a few years ago when one of the hospitals he worked at asked him to launch a hospitalist group, thinks bundled payments might alleviate that value conundrum. Then again, he’s not quite sure. That’s why attended his first annual meeting.
“I found it difficult starting a new program from scratch,” says Dr. Colombo, of Crozer Keystone Health System in Drexel Hill, Pa. “Even with the materials available, there’s not a lot of ‘how to do it’ out there. There’s no ‘Starting Hospitals for Dummies’ book.”
Dr. Colombo spent much of his meeting focused on recruiting, compensation, bonus structures, and scheduling concerns. He said all are important in the hospital-heavy metropolitan Philadelphia region where he works. Plus, with departures and retirements at other programs in his health system, Dr. Colombo went from no HM experience three years ago to being in charge of four HM programs.
“The biggest thing is, I wanted to make sure I hadn’t stepped in something that I shouldn’t have already,” he adds. “There’s many different ways to do things. So I’ve learned a few different ways. I found value.”
Another way to discover value in running a practice is looking at the business side of the house, says Denice Cora-Bramble, MD, MBA, chief medical officer and executive vice president of Ambulatory & Community Health Services at the Children’s National Medical Center in Washington, D.C.
Dr. Bramble says many hospitalists need to understand that while clinical care is what brought them to medicine, their future paychecks depend on recognizing how to provide that care in a way that demonstrates business value.
“When you finish residency, if you have not intentionally sought out those courses or those seminars, you need to recognize that as a blind spot,” she says. “You need to fill that toolkit as it relates to the business side of medicine.
“You don’t necessarily have to know all the answers, but you need to know the right questions to ask,” she says.
Dr. Bramble adds that hospitalist leaders should take advantage of certificate programs, leadership courses, basic budgeting classes, or anything that gives them added education about the economics of healthcare.
“It all comes down to demonstrating your outcomes, demonstrating the value that you bring to that institution,” she says. “And with health-care reform, I think hospitalists are uniquely positioned to be able to partner with other areas of the hospital to look at this value-based approach.”
Gary Gammon, MD, FHM, the newly named medical director of the Hospitalist Service at FirstHealth Moore Regional Hospital in Pinehurst, N.C., is doing his part to demonstrate value to his administrators. While his group does multidisciplinary rounds on patients, one of his questions for the pre-course faculty was to make sure that system of rounding is an evidence-based practice. He’s also looking for ways to establish more hegemony to his practice to ensure the rounds are effective, regardless of which physicians and others are participating.
The feedback he received was that most people view multidisciplinary rounds as a best practice. Now, Dr. Gammon can feel more authoritative that he and his 32 hospitalists and 12 extenders are practicing HM the way it should be practiced.
“I wanted to hear just what I heard, which is the leaders in the community feel that it’s helping, feel that it’s the right thing to do, feel that there’s objective data,” he says. “This is the stuff that makes me say, ‘OK, I’ve got the same problems everybody else has.’”
Richard Quinn is a freelance writer in New Jersey.