Hospitalists have played a key role in highlighting the problems of a fragmented healthcare system, with its inadequate care transitions and follow-up, problems that long preceded the emergence of hospital medicine, Dr. Howell says.
“As a hospitalist, I want my service to try to make the world a better place and to fix the broken incentives that are now in place,” he says. “Whether or not you believe that hospital medicine has introduced its own dyssynchronies on transfers of care, it’s still our responsibility to try to improve the processes.”
Financial Accountability
Healthcare is moving toward integration of services, a process that muddies the waters somewhat when it comes to determining who is accountable for readmissions, says Nancy Foster, the American Hospital Association’s vice president of quality and patient safety policy.
“Every one of our members who is actively engaged in integration tells us that not all of those readmissions we might have thought preventable are,” she says, “but they were also surprised at how many we could prevent with better education and communication.”
The new penalties for readmissions are encouraging hospitals do a better job with their care transitions, Foster says. That pressure has helped hospitals to deliver better care, and hospitalists are a “critical piece of the puzzle.”
“When you get patients coming back, analyze what went wrong and reach outside your four walls to other providers,” Foster says. “Those are important opportunities for improvement.”
Rachel George, MD, MBA, SFHM, CPE, now system vice president for Presence Health in Chicago but formerly central business unit president for Brentwood, Tenn.-based Cogent Healthcare, says that when she was at Cogent, the company developed a readmissions playbook for its physicians. Cogent, which was acquired by Seattle’s Sound Physicians late last year, included readmissions in the quality conversations it had with its contracting hospitals, she says, although those conversations varied widely in terms of the resources dedicated to improving care transitions.
“How do you make sure the necessary communication happens?” Dr. George poses. “We believe everybody has a role, but in the hospital, the hospitalist is definitely the captain of the ship.
“It’s not as clear who is the captain of the ship when the patient goes home. Do we need to send someone out to the patient’s house to see what they have in their medicine cabinet?”
Ultimately, she says, it is up to the individual provider to use resources and implement processes that have been developed.
“Cogent always believed in quality as a business strategy, putting part of its payment at risk, but it was not clear that it could use incentives for readmissions rates for individual hospitalists. Hospitals’ incentives are undergoing evolution and are very different than physicians.’”
Randy Ferrance, DC, MD, FAAP, SFHM, medical director of the hospitalist service at Riverside Tappahannock Hospital in rural Virginia, says his hospital recently incorporated readmissions rates into the quality metrics that factor into the five-member hospitalist group’s collective bonus pay.
“The problem with readmissions incentives is who gets assigned the ‘blame,’” he says.
Incorporating readmissions into bonuses and penalties for hospitalist groups is likely to become an increasing trend, says Leslie Flores, MHA, SFHM, of Nelson Flores Hospital Medicine Consultants. She and partner John Nelson MD, MHM, are seeing that trend “as a bonus component in our clients’ incentive plans, whereas five years ago it was uncommon.”
SHM practice data support this observation, Flores says, with 46.1% of adult medicine hospitalist groups in 2013 reporting the use of readmissions rates as part of performance incentives.6