A Midwest Partnership
Quite likely things are different in Minnesota than they are on either coast. People are polite, know how to work together, and are respectful about consuming resources. Or as Tom Anderson, MD, a HealthPartners Medical Group (HPMG) hospitalist says: “In Minnesota affable usually beats good.” Fortunately, the 25 physician members of the hospitalist team who belong to the 580-member HPMG, are beyond affable and good. By many measures they are excellent, and they are shaping the field of hospital medicine.
At the heart of the HPMG hospitalist program’s quality are its people. Burke Kealey, MD, HPMG’s assistant medical director, helped start the program in 1997, recruiting young, energetic, and personable physicians who liked practicing big city hospital medicine, Midwestern style. “Our hospitalist program was one of the early ones operating before the term ‘hospitalist’ was well-known,” says Dr. Kealey.
The hospitalists are employed neither by an academic medical nor a community hospital. Instead, they are members of a 580-multispecialty physician group that anchors HealthPartners Network, an organization that consistently ranks among The National Committee for Quality Assurance’s (NCQA) top five health plans regionally and top 10 nationally. Yet excellence has its price, as the perverse incentives of the U.S. healthcare system reveal. Mary Brainerd, HealthPartner’s CEO, comments that although the company consistently ranks high, it gets paid thousands of dollars less per patient by Medicare than poor performing plans.
“The way Medicare is set up, it actually punishes you for being good,” says Brainerd, referring to Medicare’s rules that qualify hospitals to receive additional payments each time a patient returns for more treatment—even if their return was caused by sub-par diagnosis and treatment. Under Medicare’s incentives, hospitals and doctors who order unnecessary tests, provide poor care, or even make patients worse often receive higher payments than those who provide efficient, high-quality care. That doesn’t stop HPMG from doing things correctly.
With the physician group employing both clinic and inpatient physicians, it’s more straightforward getting metrics and incentives aligned than in a healthcare environment where the outpatient physician’s loss may be the hospitalist’s gain—or vice versa. “Working closely with clinic and ER doctors decreases length of stay, improves clinical outcomes, and decreases costs,” says Dr. Kealey. “That helps the whole medical group.”
Another major contributor to clinical excellence goes beyond HPMG. Using the Minnesota mindset, HPMG’s physicians work with the area’s other medical heavyweights, the Mayo Clinic (Rochester, Minn.) and the Allina Medical Group (Minneapolis), forging a consensus on best practices and evidence-based guidelines (www.icsi.org). An example of HPMG’s outpatient and inpatient physician collaboration is their approach to CHF. After both groups tackled the job of operationalizing “perfect” CHF care in a one-day Rapid Design Workshop, “perfect treatment” outcomes rose from 22% in January 2005 to 50% in March 2005.
Nuts and Bolts
Scheduling logistics is among the challenges a hospitalist program’s manager faces, and Dr. Kealey and his colleagues have—through experience—done well. Each hospitalist selects a block schedule (either one week on, one week off or 14 days straight for 24 weeks). They also serve two night shift weeks (6 p.m.—8 a.m.), although residents run things at night. Hospitalists reconfigure their schedules every six months, helping to avoid burnout. Geographic deployment is another energy saver. Each hospitalist works in one or two units, allowing them to know patients, family, and the nursing staff well. It also cuts the nine-story hospital down to a size.
To communicate effectively, physicians use electronic technology. Voice pagers connect all HPMG physicians. Other devices sound alerts, allow for co-management of patients with chronic diseases, quick referrals to specialists within the group, in-box messaging, and a discharge summary to the primary physician in six to eight hours.
