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

1. Positioning your program for success
Meeting your hospital’s expectations
Hospitalist Executive Leadership Summit
December 3, 2010
Michael Wagner, MD FACP
Chief, Internal Medicine and Adult Primary Care

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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
• None
Michael Wagner MD FACP December 2010
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Conflict model: Thomas ‐ Kilmann
(Thomas – Kilmann)
Michael Wagner MD FACP December 2010

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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 environment
Michael Wagner MD FACP December 2010

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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

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Value proposition
Michael Wagner MD FACP December 2010

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Variation
Dartmouth Atlas
Michael Wagner MD FACP December 2010

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Current state view of hospitalist medicine
• Clinical drivers
• Business drivers
• Medical management focus
• Hospitalist world view
Michael Wagner MD FACP December 2010

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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 anything
Michael Wagner MD FACP December 2010

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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 success
Michael Wagner MD FACP December 2010

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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 physicians
Michael Wagner MD FACP December 2010

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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 days
Michael Wagner MD FACP December 2010
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Hospitalist Medicine – Ideal conditions
Unassigned patients and
primary care overload
Investment - >$90,000 / FTE hospitalist
Reproducible and scalable
clinical model
MD Workforce
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Michael Wagner MD FACP December 2010
Jan 2009

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Growth in numbers of hospitalists
Source: Society of Hospital Medicine
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Michael Wagner MD FACP December 2010

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Growth in relationship to established specialties
30,000 hospitalists
estimated by 2010
Source: AAMC
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Michael Wagner MD FACP December 2010
Jan 2009

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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 satisfaction
Michael Wagner MD FACP December 2010
• Patient satisfaction

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Dissatisfaction with primary care
• Burden
– Non‐visit clinical work without support
– Administrative paperwork
– Technology
• Compensation
• Respect
• Role models
• Control
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Michael Wagner MD FACP December 2010
Jan 2009

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Choices
Hospitalist Medicine Primary Care Medicine
The generalist
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Michael Wagner MD FACP December 2010

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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
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Michael Wagner MD FACP December 2010

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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, 2009
Michael Wagner MD FACP December 2010

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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 resources
Michael Wagner MD FACP December 2010

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Primary Care Capacity
Michael Wagner MD FACP December 2010 Dartmouth Atlas

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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/appeals
Michael Wagner MD FACP December 2010

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Hospitalist revised world view
Michael Wagner MD FACP December 2010

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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 management
Michael Wagner MD FACP December 2010