Tag Archives: length of stay

An overview at one year

One year at our newest site in Wilkes-Barre has come and gone and with it, a lot of changes. Starting fresh at a facility that simply hasn’t been progressive in the transition from fee-for-service to pay-for-performance has not been easy. Taking a facility where specialists run the show and transitioning to hospitalists who can manage in a more cost effective and efficient manner was initially met with resistance by many specialists. Perhaps we came on too strong initially, since, after all, this whole hospitalist thing came as a complete culture shock to them. Fortunately, we were able to show an ever increasing split between our data metrics versus the private physician community. That included length of stay, case mix index, and others. Those differences add up to millions of dollars to the hospital when extrapolated over time, and that’s why the administration has been totally supportive of trying to promote the growth of our program.
It isn’t an easy task. What do you say to the worst offenders in the hospital, the ones with the extra-long lengths of stay who waste resources and cost the hospital money? “Well doctor, we want you to give your patients to the hospitalists because we can save money and they do a better job”. Not exactly a way to endear yourself to the medical staff. Economics does speak volumes these days, though, and the hospital does indeed want us to grow because we simply do a better job of inpatient care. By better, they mean more efficient and more cost effective. When we do a better job, people get out of the hospital faster & that saves the hospital lots of money. Larger than that, I think that the higher quality issue is far more important. Hospitalists are supposed to be able to provide care that is better, as in up to date, accurate and effective care. Our group meets every month and has a journal club. We review the latest literature & keep up with the latest standards of care. We work hard to provide the highest quality of care possible and all of our staff are always encouraged to keep up with the latest news in the medical literature. That’s the ‘better’ type of care that I think about. Interesting though, most data suggest that higher quality of care is actually more cost effective as well, so being a top notch doctor usually means being a more cost effective one as well. It has been gratifying that this has been noticed and the administration has given us their full support to continue to expand.
Year two will bring a different set of challenges as we continue to grow. We want to start to put our stamp on the inpatient process and really start to transform things. We have talked about improving patient flow from the ED, geographic rounding, better handoffs, team rounds with nursing, and a host of changes that will result in better communication and better patient care. If we do that, the ‘better’ care becomes more cost-effective care, and the entire hospital benefits in addition to the patients. That’s the brass ring of being a hospitalist. We love the challenge of getting there.

Reducing readmissions…oops!

     On April 15th, AIM just wrapped up one of its many QI projects, this one looking at decreasing readmission rates for four major diagnoses (MI, CHF, COPD, & pneumonia) through 4 specific interventions. It was a great project, involving many people over multiple disciplines. We added staff to provide more in depth discharge planning at the bedside. The pharmacists were involved making phone calls after discharge to go over med issues & also did med rec prior to discharge. Home health visits for every patient enrolled in the project also took place. So far, it looks like we will have reduced the rates of readmissions for CHF, MI, pneumonia, & COPD by about 25-30%!

    Here’s the rub: we didn’t do our hospital any favors & in fact, cost them revenue. The ‘problem’ was that our baseline readmission rates were not excessive, around the national average of 18% or so. We were never going to be hit with readmission penalties. What we did, basically, is cost our hospital business. So, was it the right thing to do? I don’t think there is anyone who wouldn’t agree that this project & these interventions were very good things to be doing. This is a prime example of just how difficult the transition from fee-for-service to pay-for-performance will be. Hospitals are not going to embrace these changes if it hurts the bottom line, no matter how much better it is for patient care. ACO’s & other programs are looking at improving the overall health of the population. In all of these models, the hospital is the cost center and the area to take the biggest hits. As a hospitalist, I have been thinking about the somewhat sad realization that if we succeed in these endeavors, then the need for hospitalists will diminish considerably. All for the greater good? Maybe. Then again, we are talking about government programs here. At the rate our government moves, I will be long retired before health care ever becomes that efficient. I hope we get there, though….eventually.