Pat Cawley, MD, is the hospitalist program director and founder of the academic hospitalist group at the Charleston-based Medical University of South Carolina’s Hospital. He has a hard time focusing on hospitalist group efficiency, though, when he’s still flat-out recruiting.
“Demand for hospitalists is still way outstripping supply,” says Dr. Cawley. “We currently have nine hospitalists and plan to add five more this year, but we could actually use 10 more.”
The South Carolina market is competitive, with other hospitals planning to establish hospitalist medicine programs and vying with Dr. Cawley’s program for fresh physicians. Medical University Hospital’s hospitalist group started in July 2003 with four physicians and has kept growing. The hospitalists spend most of their time functioning as a teaching service and also cover a long-term acute-care facility at another hospital.
Defining efficiency in South Carolina’s booming market is secondary to recruiting and incorporating new physicians as team members. Dr. Cawley uses average daily census (ADC) as an efficiency benchmark: 15-20 patients per hospitalist is productive, although many doctors are comfortable at 12.
“We looked at our learning curve, about 10-12,” points out Dr. Cawley. “We think 15-20 is better, although some places are reporting an ADC of 22. But after a certain point, performance doesn’t appear to improve.”
A big problem with improving hospitalist group efficiency, according to Dr. Cawley, is hospital inefficiency: “Lack of IT to get lab results quickly, not enough nursing and secretarial support for admissions and discharges, policies on contacting the primary doc versus having a standing order for a procedure—all decrease efficiency.”
He’d also like his hospital administrators to allow nurses to pronounce death (common in community hospitals but less so in AMCs). “The power of hospitalists is to challenge the hospital’s inefficiencies, to break down the barriers to more efficient practices,” adds Dr. Cawley. “Many institutions need huge culture change, and hospitalists must lead the way.”
A close watcher of hospitalist performance, Scott Oxenhandler, MD, medical director of the Memorial Hospitalist Group in Hollywood, Fla., heads a hospitalist group he started in June 2004 that now has 23 physicians and two nurse practitioners. Memorial Hospital also has two other private hospitalist groups. While Dr. Oxenhandler’s group handles unassigned patients (55%) and Medicaid/Medicare patients (45%), the other hospitalist groups have captured the more lucrative business of managed care and other commercially insured patients.
—Per Danielsson, MD, medical director, Swedish Medical Center Adult Hospitalist Program, Seattle
Dr. Oxenhandler says efficiency is a complicated issue involving several key components. “Following evidence-based medicine protocols and CMS core measures are fairly straightforward [ideas] for all of us,” he says, “but financial measures are more complex.”
He has taken aim at adjusted variable costs per discharge on lab tests, pharmacy, and radiology, “three areas where I know that our group can improve,” he adds.
As for how hard and how efficiently a hospitalist works, Dr. Oxenhandler is taking a closer look at that as his group and the field mature. “We know that average daily census can be deceiving and RVUs [relative value units] are more relevant to efficiency but not perfect,” he says. “Another factor is tenure with the hospitalist group. For the physician to excel and to mature clinically, he or she needs to stay with a hospitalist group long enough to improve readmission rates and to get a sense of how to better manage clinical resources.’’
Dr. Oxenhandler describes a patient presenting with heart failure and anemia to show how a hospitalist’s clinical skills might mature. After several days of repeated hemoglobin studies indicating anemia, the hospitalist might refer the patient—once stabilized and discharged—to his primary physician for an outpatient work-up for possible colon cancer—rather than do so during the hospitalization.