Hospitalist Positioning And Politics Public Version

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Review the value of a hospitalist program and discuss emerging landscape with development of ACO

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Hospitalist Positioning And Politics Public Version

  1. 1. Positioning your program for successMeeting your hospital’s expectationsHospitalist Executive Leadership SummitDecember 3, 2010Michael Wagner, MD FACPChief, Internal Medicine and Adult Primary Care
  2. 2. V=Q/C Michael Wagner, MD FACP Positions • Chief, Internal Medicine and Adult Primary Care, Tufts Medical Center 2008‐ present • Chief Executive Officer, EmCare Inpatient Services 2003‐8 • Chief, General Internal Medicine, Tufts‐New England Medical Center 1999‐2003 • Regional Medical Director, Cove Healthcare 1998‐1999 • Internal Medicine Residency Program Director and Director of Medical Education,  St. Mary’s Hospital and University of Rochester 1992‐1997 • Internist, New England Medical Center 1990‐1992 • Chief Resident, Dartmouth‐Hitchcock Medical Center 1989‐1990 • MD Georgetown University School of Medicine, 1986 Current Roles • Associate Professor of Medicine, Tufts University School of Medicine • Vice Chair, institutional Review Board, Tufts Medical Center and Tufts University  Health Sciences  • Physician Advisor, Information Technology Tufts Medical Center • Chair, Managed Care and Quality Committee, Tufts Medical Center Physician  Organization Disclosures • NoneMichael Wagner MD FACP December 2010 2
  3. 3. V=Q/C Conflict model:  Thomas ‐ Kilmann (Thomas – Kilmann)Michael Wagner MD FACP December 2010
  4. 4. V=Q/C Positioning your program – Goals of presentation • Review some key concepts driving health reform • Traditional drivers for hospitalists program development • Outline current program metrics • Review primary care situation • Outline hospitalist program position in ACO environmentMichael Wagner MD FACP December 2010
  5. 5. V=Q/C Couple concepts • Value proposition – Value is proportional to quality – Value is inversely proportional to cost • Triple aim (IHI) – Improve health outcomes – Enhance the patient experience – Reduce (or hold) health care expenditures  • Variation in care Michael Wagner MD FACP December 2010
  6. 6. V=Q/C Value propositionMichael Wagner MD FACP December 2010
  7. 7. V=Q/C Variation Dartmouth AtlasMichael Wagner MD FACP December 2010
  8. 8. V=Q/C Current state view of hospitalist medicine • Clinical drivers • Business drivers • Medical management focus • Hospitalist world viewMichael Wagner MD FACP December 2010
  9. 9. V=Q/C Ideal program (from an administrator) • Program is free – no subsidy (after all don’t physicians get paid  for their services?) • The physicians are well trained and from prestigious programs • The physicians are highly engageable – They go to meetings and are pleasant and helpful – They answer nursing questions and take their suggestions • Patients are satisfied and would refer their friend or family to our hospital • The physicians don’t ask for the hospital to buy anythingMichael Wagner MD FACP December 2010
  10. 10. V=Q/C Clinical Drivers • Unassigned call • Referrals from primary care physicians • Primary care physicians satisfaction • Specialty physician satisfaction • Reduce complexity – Reduce the number of physicians practicing inpatient medicine • Quality  – Execute quality programs – Documenting successMichael Wagner MD FACP December 2010
  11. 11. V=Q/C Business Drivers • Inpatient volume – Maintain current and attract new staff physicians – Support specialty physicians – Market to local non‐aligned MDs to use hospital to care for patients – Marketing to patients benefits of dedicated onsite coverage • Quality – Enhanced reimbursement tied to achieving quality outcomes • Utilization management – Enable part time providers to focus on their outpatient practices and reduce the number of low  volume providers practicing in the hospital – Leverage a single group to pay attention to hospital needs – Achieve specific average length of stay and cost per case budgetary goals • RN satisfaction – Improve RN job satisfaction – Reduce RN turnover • Outpatient volume – Improve productivity of employed outpatient physiciansMichael Wagner MD FACP December 2010
  12. 12. V=Q/C Medical Management Focus • Effective Utilization Management – Reduce complexity – Reduce LOS variation – Appropriate lab, radiology and pharmacy  utilization – Implement “Best Practices” • Increase Hospital Revenue per Day – Enhance throughput  – Increase CMI – Reduce denials/denied daysMichael Wagner MD FACP December 2010 12
  13. 13. V=Q/C Hospitalist Medicine – Ideal conditions Unassigned patients and primary care overload Investment - >$90,000 / FTE hospitalist Reproducible and scalable clinical model MD Workforce 13Michael Wagner MD FACP December 2010 Jan 2009
  14. 14. V=Q/C Growth in numbers of hospitalists Source: Society of Hospital Medicine 14Michael Wagner MD FACP December 2010
  15. 15. V=Q/C Growth in relationship to established specialties 30,000 hospitalists estimated by 2010 Source: AAMC 15Michael Wagner MD FACP December 2010 Jan 2009
  16. 16. V=Q/C Hospitalist world view Metrics • Time to admit • Time of discharge • Length of stay • # and % observation • Case mix index • Denials • Core Measures • AHRQ - Safety measures - Quality measures • Nursing satisfaction • PCP satisfactionMichael Wagner MD FACP December 2010 • Patient satisfaction
  17. 17. V=Q/C Dissatisfaction with primary care • Burden – Non‐visit clinical work without support – Administrative paperwork – Technology  • Compensation • Respect • Role models • Control 17Michael Wagner MD FACP December 2010 Jan 2009
  18. 18. V=Q/C Choices Hospitalist Medicine Primary Care Medicine The generalist 18Michael Wagner MD FACP December 2010
  19. 19. V=Q/C Choice: Primary Care vs. Hospital Medicine Primary Care IM Hospital Medicine Full time work commitment 18.75 days/month 15 shifts/month Patient encounters per day 20‐30 pts per day 15‐18 pts per shift Average compensation $150,000‐$180,000/yr $180,000‐$220,000/yr Overhead Office, staff, equipment,  Billing and medical  supplies, billing, medical  malpractice malpractice Non‐visit clinical work >100 documents/day Minimal Administrative work Common ‐ Minimal ‐ Prior authorizations Inpatient payment  Referrals, FMLA, PT‐1,  denials Disability forms, etc Panel size 1,500 to 2,500 0 Workday Controlled by schedule Controlled by patient  need 19Michael Wagner MD FACP December 2010
  20. 20. V=Q/C Snapshot of work generated Total number of Average number Ratio compared Number compared to documents since per day for all of to office visit average volume of 20 Document type January 2008 GMA volume patients per day Office Visit 63,932 256 1.00 20 Coumandin 9,058 36 0.14 3 Phone Note 75,103 300 1.17 23 Rx Refill 20,861 83 0.33 7 Letter - Results 39,310 157 0.61 12 Medication list 14,845 59 0.23 5 External Correspondence 18,726 75 0.29 6 Internal Correspondence 10,241 41 0.16 3 Other letter 39,543 158 0.62 12 Lab Report 258,036 1,032 4.04 81 Imaging Report 17,115 68 0.27 5 Pathology Report 4,052 16 0.06 1 Hospital Admission* 3,530 14 0.06 1 Emergency Report* 9,002 36 0.14 3 Totals (excluding office visit) 519,422 2,078 8 162 Other notes* 87,631 351 1.37 27 Based on EMR data from January 15, 2008 to January 15, 2009Michael Wagner MD FACP December 2010
  21. 21. V=Q/C IT overload and disintegration  • Logician  • Clinic electronic health record • Soarian • Hospital clinical repository • PatientKeeper • Physician billing system • RelayHealth • Patient portal  • Quantia • Physician education website • RCO/Envision • Patient scheduling system • Standing Stone • Warfarin management system • Email • General communication • Fax • Legacy system • Phone • Legacy system • NEQCA registry • Managed care quality monitoring • Intranet (phone book, Up to Date) • Information resourcesMichael Wagner MD FACP December 2010
  22. 22. V=Q/C Primary Care CapacityMichael Wagner MD FACP December 2010 Dartmouth Atlas
  23. 23. V=Q/C What we think about capitation or risk • Starts with a “network” of primary care physicians • Population is determined by those physicians • Estimation of utilization risks and variability based on historical  data and projections • Management of: – Clinical events – preventable and inevitable – Utilization of network and out of network resources – leakage  – The claims process – Attributing shared savings/risks to MD or pod level – Funds flow – Adjudication complaints/appealsMichael Wagner MD FACP December 2010
  24. 24. V=Q/C Hospitalist revised world viewMichael Wagner MD FACP December 2010
  25. 25. V=Q/C Where does the hospitalist fit in an ACO • Reduce out of network utilization • Reduce unnecessary acute care utilization  – Readmissions – Diversion to lower levels of care • Meeting inpatient quality goals • Collaborating on traditional outpatient quality goals – Diabetes – Hypertension – CVD lipid management • Service line managementMichael Wagner MD FACP December 2010

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