Academyhealth 2013 How are Rural Hospitals Using Hospitalists?
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In this study, we focused on the following research questions: 1) Which rural hospitals use hospitalists, and how do they differ from those that do not?; 2) Why are small rural hospitals using hospitalists and how are they being used?; and 3) What impact is hospitalist use having on rural hospital quality of care, finances, and recruitment and retention of primary care physicians?
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Academyhealth 2013 How are Rural Hospitals Using Hospitalists?
- 1. How are Rural Hospitals Using Hospitalists? Michelle Casey, MS Peiyin Hung, MSPH Ira Moscovice, PhD AcademyHealth | June 2013 Supported by the Office of Rural Health Policy, Health Resources and Services Administration, PHS Grant No. U1CRH03717
- 2. Background and Objectives ⢠Paucity of research with rural context â Unclear whether prior research findings are generalizable to smaller rural facilities â Hospitalists may be part-time with additional responsibilities ⢠Study objectives were to examine: â How hospitalists are being used in rural hospitals â Which rural hospitals are using hospitalists
- 3. Trends in Hospitalist Use 2005-2010 8% 11% 14% 16% 18% 21% 26% 32% 41% 44% 56% 61%63% 69% 75% 79% 81% 85% 2005 2006 2007 2008 2009 2010 CAHs All Other Rural Hospitals Urban Hospitals Data Source: AHA Annual Surveys
- 4. Data Sources ⢠Primary data from a national phone survey of rural hospitals May-August 2011 â Survey sample: Rural hospitals with <100 beds using hospitalists in AHA annual survey â Respondents: Hospital CEOs (2/3) and clinical/administrative staff (1/3) â Response rate: 86.4% (N=402) â Statistical analysis of quantitative survey data and qualitative analysis of open-ended responses ⢠Secondary data from American Hospital Association Annual Surveys FY 2010
- 5. Primary Reasons for Using Hospitalists Requests from physicians, 26.6% Improve care quality / continuity, 19.3% Cover unassigned patients, 6.9% Alleviate physician shortage, 6.6% Cover call/reduce workload for physicians, 16.4% Allow physicians to focus on clinical practice, 10.3% Recruit & retain physicians, 8.6%
- 6. Hospitalist Specialties 82% 57% 24% 6% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% Internal Medicine Family Practice PAs and/or NPs Emergency Medicine Percentofsurveyhospitals
- 7. Additional Care Provided by Hospitalists Care Settings by Hospitalists Percent of hospitals Hospital Outpatient Department 30% Primary care in clinic or physician office 30% Emergency Department 17%
- 8. Perceived Quality Impacts Positive, 84.4% Positive & negative, 9.8% Hospitalists: ⢠Are available when needed & quick to respond, spend more time with patients ⢠Improve quality, patient safety measures, communication with nurses, teamwork ⢠Possess expertise, ability to handle more acute patients ⢠Provide consistent, standardized care; use evidence-based medicine No change, 5.8%
- 9. Perceived Financial Impacts No change, 5.8% Positive, 44.6% Both positive & negative, 16.9% Negative, 32.6% ⢠Increased admissions ⢠Improved primary care physician productivity, ability to treat higher- acuity patients ⢠Reduction in patient complications, avg. length of stay, transfers
- 10. ⢠Costs more than revenue generated ⢠Hospital has to subsidize hospitalist program ⢠High costs of hospitalistsâ salaries or contracts Perceived Financial Impacts No change, 5.8% Positive, 44.6% Both positive & negative, 16.9% Negative, 32.6%
- 11. Perceived Recruitment / Retention Impacts Easier, 74.4% No change, 25.4% ⢠PCPs donât want to do inpatient care or want flexibility in doing it ⢠Reduced call, more work/life balance for PCPs ⢠New candidates are only interested in places with hospitalists Harder 0.6%
- 12. Which Facilities Are Using Hospitalists? ⢠Data â AHA Annual Survey 2010 â Medicare payment classification data from University of North Carolina at Chapel Hill ⢠Sample: Rural hospitals (n=1,462) ⢠Multivariate logistic regression model calculated probabilities of hospitalist use given a hospital characteristic
- 13. Measures ⢠Dependent variable â Binary hospitalist use variable â 27% of rural hospitals had missing value ⢠Explanatory variables â Inpatient days â Medicare payment classification â Total primary care physicians with admitting privileges â System membership â Ownership â Census Divisions
- 14. Probability of Hospitalist Use by Small Rural Hospitals Variables Est. Std. Err. P-value Medicare Payment Classification [Reference = Rural PPS] Critical Access Hospital (CAH) -9.2% 3.7% 0.012 Medicare Dependent Hospital (MDH) -8.6% 4.4% 0.054 Sole Community Hospital (SCH) -3.7% 3.8% 0.331 Rural Referral Center (RRC) 5.0% 4.6% 0.271 Total Inpatient Days [Reference = Quartile 1] Quartile 2 (2,188 â 4,212) 15.6% 3.4% <.001 Quartile 3 (4,213 â 9,259) 24.3% 3.8% <.001 Quartile 4 (>9,259) 37.2% 5.5% <.001
- 15. Regression Results cont. Variables Est. Std. Err. P-value Total Primary Care Physicians 3.8% 1.1% <.001 Total Primary Care Physicians2 -0.1% 0.1% 0.048 System Member 4.6% 2.2% 0.039 Ownership (Reference = Public/Government) Private Non-Profit 7.5% 2.5% 0.002 For-Profit 6.8% 4.2% 0.107
- 16. Conclusions ⢠Hospitalist use by rural hospitals increased threefold, 2005-2010 ⢠In rural hospitals, hospitalists: â Are family physicians and non-physician providers as well as internists â Frequently play multiple roles â also providing outpatient, emergency, and/or primary care ⢠Hospitalists can help address workforce shortages in rural areas
- 17. Conclusions cont. ⢠Financial impact of hospitalist use is more complex than costs vs. revenue: â Enhance recruitment, retention and efficiency of PCPs â Care for unassigned and uninsured patients ⢠Likelihood of hospitalist use varies by: â Type of Medicare reimbursement (prospective payment vs. cost-based) â Inpatient volume
- 19. Medicare Payment Classification ⢠Critical Access Hospitals â 25 or fewer beds â 101% of reasonable costs for inpatient, outpatient and swing bed care. ⢠Sole Community Hospitals â located either 35 miles from similar hospitals â receive the higher of the federal PPS rate or an updated hospital- specific rate based on historical costs. ⢠Medicare Dependent Hospitals â fewer than 100 beds and more than 60% of inpatient discharges or days covered by Medicare â received the PPS rate plus 75% of the difference between the PPS rate and an updated rate based on their historical costs. ⢠Rural Referral Centers â have a combination of high case mix intensity and specialist supply â more than 275 beds â reimbursed using urban PPS rates.
- 20. Survey Respondents and Non-Respondents Hospital Characteristics Survey Respondents with Hospitalist Programs (N = 329) Non- Respondents (N = 73) Staffed inpatient hospital beds 25 or fewer beds* 140 (42.6%) 13 (25.0%) 26 â 50 beds 72 (21.9%) 14 (26.9%) 51 â 100 beds 117 (35.6%) 25 (48.1%) Ownership Government, non-federal* 71 (21.6%) 19 (36.5%) Private not-for-profit*** 229 (69.6%) 24 (46.2%) For-profit 29 (8.9%) 9 (17.3%) Census Region Northeast 53 (16.1%) 5 (9.6%) Midwest* 94 (28.6%) 7 (13.5%) South*** 116 (35.3%) 35 (67.3%) West 66 (20.1%) 5 (9.6%) System Member* 164 (50.0%) 34 (65.4%) *p<0.05 **p<0.01 ***p<0.01
Hinweis der Redaktion
- Acknowledge my colleagues who worked on this study, ORHP for funding the study, the Survey Research Center at the University of Minnesota and the 329 rural hospitals that participated in our survey.
- Some studies have found reductions in costs & LOS but results inconsistent. Most of them were done in academic or large urban hospitals. Generalizability of these studies to smaller rural facilities unclear. In rural hospitals, hospitalist may be part-time role with additional responsibilities (e.g., ER coverage) and NP or PA may function in hospitalist role. Our study focused on smaller rural hospitals Critical Access Hospitals and other rural hospitals with less than 100 beds. purposes.
- Before getting into our survey results, it is important to show the overall trend of hospitalist use by rurality. The use of hospitalists increased across all types of hospitals from 2005 to 2010. But it was relatively in the slow pace in critical access hospitals. Unfortunately, most research on hospitalist program implementation and outcomes has mainly focused on teaching and large urban hospitals.
- We surveyed 402 hospitals, including critical access hospitals and other rural hospitals with less or equal to 100 beds using hospitalists in 2008 AHA survey. Of them, 350 hospitals responded but 21 hospitals indicated that they did not use hospitalists at the survey period. The rest of 329 small rural hospitals was analyzed/ Survey topics included: length of time used and primary reasons for using hospitalists characteristics of hospitalist practice and hospitalists perceived impact of hospitalist use on quality of care, hospital finances, recruitment and retention, patient and physician satisfaction *Critical Access Hospitals, which have 25 or fewer beds, receive 101% of reasonable costs for inpatient, outpatient and swing bed care. To better understand rural hospitalsâ survey responses, especially regarding their reasons for using hospitalists and the financial characteristics of hospitalist use  on the hospital, we analyzed the relationship between hospitalist use, inpatient volume, and Medicare payment classifications for all rural hospitals, using secondary data from the FY 2010 AHA Annual Survey.
- Open-ended question. Most common reason â 27% of responses - PCPs on medical staff either requested or required that the hospital set up a hospitalist program. One CEO described it as â PCPs said get a hospitalist program or weâre out of here! 2nd reason â 16% cover call, give physicians time off, for work-life balance, and especially on weekends to spend time with family. A number of respondents specifically mentioned need to reduce workload for aging PCPs. 3rd reason - 14% to improve quality of care and continuity of care. "We have a significant ICU but were unable to staff overnight in a manner that was safe and effective. We were going through long overnight stints with no physician on the floor." "We felt it would improve clinical quality of acute inpatient care and enhance primary care by enabling those doctors to focus 100% on ambulatory care." Other important reasons included allowing physicians to focus on practices, recruitment and retention, coverage of patients who were admitted to the hospital without a physician, having too few medical staff and a desire to increase census, reduce transfers and care for more complex patients.
- Literature indicates vast majority of hospitalists in urban settings are internists. We found internists well-represented in rural hospitals, but family physicians are also important. When we grouped the surveyed hospitals by combinations of specialties used, 42% use both internists and family physicians while 41% use internists and no family physicians, and 15% use family physicians and no internists. These groupings may include PAs, NPs, or other specialties. Very few hospitals have neither IMs or FPs.
- Hospitalists in rural hospitals frequently play multiple roles â providing outpatient, emergency, and/or primary care.
- We asked survey respondents to indicate whether the use of hospitalists had positive impact, negative impact, both positive and negative or no change in terms of quality and hospital finances. Assessments of the impact of hospitalist use on quality were very positive with 85% of hospitals reporting positive impacts on quality, 10% both positive and negative impacts, and 6% no change. No respondents reported only negative impacts on quality. Respondents then asked open-ended question about how the impact had been positive or negative. The most common positive impacts, in order were: Hospitalists are available when needed; respond quickly; spend more time with patients Improved quality and patient safety measures Hospitalist expertise, ability to handle more acute patients Provide consistent, standardized care; use evidence-based medicine, protocols Improved communication with nurses and better teamwork For the 32 hospitals that described negative as well as positive impacts, more than half described the negative impacts as being that patients want to see own primary care physician. A few also mentioned problems with locums, contract staff
- Assessments of the financial impact of hospitalist use were more mixed than impact on quality 45% reporting a positive financial impact One-third both positive and negative financial impacts 17% a negative financial impact 6% no change in financial status
- Assessments of the financial impact of hospitalist use were more mixed than impact on quality 45% reporting a positive financial impact One-third both positive and negative financial impacts 17% a negative financial impact 6% no change in financial status
- Three-quarters of hospitals (74%) reported that the use of hospitalists made it easier for the hospital to recruit and retain primary care physicians and one-quarter indicated that there was no change. Only 2 hospitals indicated that hospitalists made it harder to recruit and retain.
- Critical Access Hospitals, which have 25 or fewer beds, receive 101% of reasonable costs for inpatient, outpatient and swing bed care. Sole Community Hospitals, which are located either 35 miles from similar hospitals or where closer hospitals are inaccessible, receive the higher of the federal PPS rate or an updated hospital-specific rate based on historical costs. Until the program recently expired, Medicare Dependent Hospitals with fewer than 100 beds and more than 60% of inpatient discharges or days covered by Medicare received the PPS rate plus 75% of the difference between the PPS rate and an updated rate based on their historical costs. Rural Referral Centers, which have a combination of high case mix intensity and specialist supply, more than 275 beds, or a high volume of referrals, are reimbursed using urban PPS rates.
- Previous research found a significant positive relationship between the number of hospital beds and hospitalist use. Inpatient volume can vary significantly for rural hospitals of similar bed size, so we used inpatient hospital days as a measure of the potential demand for hospitalist services. We were also interested in testing whether rural hospitalsâ Medicare payment classification is significantly related to the likelihood of using hospitalists. Our interest was based on suggestions in the literature that prospectively paid hospitals would be more likely to benefit financially from using hospitalists than hospitals paid on a per diem basis (Gregory 2003; Coffman and Rundall 2005), as well as research showing that rural hospital financial performance varies significantly by Medicare payment classification (Holmes et. al. 2010).
- Model also controlled for primary care physicians with hospital privileges, system membership, ownership and census division
- Hospitalist use appears to offer many potential benefits to rural hospitals, but benefits may need to be balanced against negative financial impacts, especially for hospitals with low inpatient volume
- http://www.hsr.umn.edu/rhrc/