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Use of mandatory hospitalists blasted

College, others protest plans that force doctors to give up inpatient care

From the May 1999 ACP-ASIM Observer, copyright 1999 by the American College of Physicians-American Society of Internal Medicine.

By Phyllis Maguire

Internists' worst fears about the hospitalist movement appear to be coming true in south Florida and other parts of the country.

In February, Prudential HealthCare-South Florida told its 3,000 physicians that it would soon require them to transfer the acute care of their patients to hospitalists. Starting March 15, hospitalists began caring for Prudential members in nine hospitals and a dozen sub-acute facilities. The remaining 31 hospitals that contract with Prudential are scheduled to begin using hospitalists for inpatient care by June 15.

Although Prudential's program is one of the country's most far-reaching efforts to use mandatory hospitalists--it could affect 230,000 patients in one geographical area--patients and physicians elsewhere are facing similar situations as the hospitalist movement gathers steam.

Humana Inc., for example, has implemented policies in 11 of its markets that preclude some of its physicians from caring for their hospitalized patients. In addition, 10 health plans owned by Cigna Corp. have introduced hospitalist policies, although officials aren't sure how many are mandatory. Many individual hospital systems around the country are also opting for hospitalist care.

While the general idea of hospitalists has received a mixed reaction from physicians, the medical community stands together in opposing the mandatory handoff of patients.

In April, the College and 23 other physician groups sent a letter to Prudential, Cigna, the Blue Cross and Blue Shield Association and the American Association of Health Plans calling mandatory hospitalist programs "bad public policy" and "bad for individual patients."

Jamie S. Barkin, FACP, the College's Governor for the Florida Chapter, reported that physicians were shocked by Prudential's news that they would have to hand over care of their hospitalized patients. "We think it's a further erosion of the patient-physician relationship and promotes the further isolation of the physician to his or her office," Dr. Barkin said.

In a separate letter to Prudential in March, Harold C. Sox, MACP, then College President, reminded Prudential that efforts to limit patients' choice of physicians typically backfire against the managed care industry. Lanny R. Copeland, MD, president of the American Academy of Family Physicians, objected in another letter to the health plan, claiming that Prudential's mandatory program was an arbitrary attempt "to artificially limit the scope of our specialty."

In its initial letter to physicians, Prudential officials tried to defuse the issue by pointing out what it saw as advantages of the hospitalist model: Admissions are simplified and primary care physicians no longer have to interrupt their outpatient practice to make hospital visits. The letter went on to state that the new policy will allow doctors to "devote themselves to what they do best: ambulatory care and preventative medicine."

In subsequent meetings with irate physicians, Helio De Leon, MD, Prudential's medical director in south Florida, tried to explain that the insurer's hospitalist policy was not, in fact, mandatory. Instead, physicians who meet utilization criteria established by the actuarial firm Milliman & Robertson could qualify to opt out of the hospitalist program and continue to admit and care for their own patients. But in a telephone interview, Dr. De Leon acknowledged that at least 80% of Prudential's physician panel probably would not qualify to provide inpatient care and would have to hand that care over to hospitalists.

Threat to internal medicine?

While physicians who contract with Prudential in south Florida will bear the immediate brunt of the new program, critics charge that internal medicine as a whole is being threatened. In a Feb. 16, 1999, Annals of Internal Medicine supplement on hospitalists, Dr. Sox wrote that internists will have a much harder time distinguishing themselves from family physicians and nurse practitioners if they are stripped of their ability to provide inpatient care. In a telephone interview concerning Prudential's new policy, Dr. Sox explained that internists are being hit hard by mandatory hospitalist policies since their core strength is their ability to provide patient care across the full range of care settings.

"Our unique contribution is to take care of patients that other physicians don't want to care for because of the complexity of their problems," Dr. Sox said. "If we get cut out of the opportunities of inpatient medicine, it's going to be a huge problem."

In part to protect the interests of internists, the College formally affiliated last year with the National Association of Inpatient Physicians (NAIP), a medical association of hospitalists. The NAIP, which was established in 1997 and has 1,000 members (there are about 3,500 hospitalists now practicing nationwide), supports only voluntary patient transfers, which is also the College's position. "A mandatory system doesn't allow for the natural progression of evaluating the hospitalist model and deciding whether that would be a good thing for you to use for your patients," said Winthrop F. Whitcomb, ACP-ASIM Member, NAIP's co-president. "It immediately creates a situation where a would-be referring physician resists it."

That resistance destroys the working relationship between hospitalists and primary care physicians, which is the key to a successful hospitalist program. In mandatory models, for example, inpatient physicians have less of an incentive to communicate with the primary care physician. "They know that they're going to get the referral, no matter what," Dr. Whitcomb pointed out. In voluntary systems, however, hospitalists--like any other consultant--must develop good relationships with referring physicians based on communication and service.

"We want that group to thrive," Dr. Sox said of the NAIP, adding that roughly 90% of hospitalists are internists. The goal of the College's affiliation with the NAIP, he explained, is to ensure that hospitalists are sensitive to the needs of internists who transfer patients to them and to present a united physician front to any hospital system or health plan that seeks to impose mandatory transfers. "It should be harder for the mandatory hospitalist model to get a serious foothold if both internists and hospitalists are opposed to it," Dr. Sox said.

Cost savings

But as health plans see potential cost savings in hospitalist models, more are willing to test physician and patient acceptance of hospitalist policies.

Cigna Corporation, for example, has introduced hospitalist programs in about a quarter of its 40 plans, according to a company spokesperson. That spokesperson could not identify how many of those policies were mandatory and explained that individual plans decide how to implement the policies.

Humana maintains hospitalist programs in 11 urban markets, including five of its plans in Florida. Nationally, Humana's hospitalist programs affect 400,000 enrollees in both commercial and Medicare populations. Humana officials were quick to point out, however, that those handoffs are voluntary and that only physicians who are "severe outliers" as far as utilization of hospital services are required to transfer patients to hospitalists. According to Jerry D. Reeves, MD, Humana's senior vice president and chief medical officer, the percentage of those physicians affected by mandatory transfers is "very low"--nowhere near the 80% figure cited by Prudential officials.

Yet Dr. Reeves spoke of physicians as already being divided into two camps: hospitalists, and those he called "ambulatory care specialists."

"The number of physicians who are really skilled in both areas is diminishing rapidly, because of the huge demands placed on physicians in both the hospital care setting--where patients are sicker than they used to be--and in outpatient care because of the complexities of the administrative load," he said.

Humana is convinced that hospitalists provide superior clinical, patient satisfaction and financial outcomes, according to Dr. Reeves. He claimed that in markets where Humana has used hospitalists, hospital days for patients decreased between 7% and 38%, time spent in skilled nursing facilities decreased 20% and patient satisfaction scores improved 10%. Clinical outcomes, in terms of re-admit rates, remained the same.

"Patients are spending less time with complications requiring skilled nursing facilities or acute hospitalization, and they are having better continuity of care," said Dr. Reeves. He added that Humana is so happy with hospitalists that it intends to roll out similar programs in several more markets this year.

A growing number of management companies that specialize in placing hospitalists are making it easier for health plans and hospitals to implement hospitalist policies. About a dozen such companies in the country provide the capital and administration needed to maintain hospitalist programs; Prudential's program in south Florida, for instance, will be administered by IntensiCare Corporation, which is based in southern California.

Different models

Not everyone is considering hospitalist programs like Prudential's. Hospital officials, who have to deal with the resistance of primary care physicians on a day-to-day basis, are more willing to rely on voluntary models. And even hospitalist management companies have already found that imposing mandatory models in individual hospitals can alienate local physicians and lead to disastrous results.

"One of the challenges for management companies is to get buy-in from the local medical staff," said the NAIP's Dr. Whitcomb, "To get buy-in, it's a lot easier to have a voluntary system." As a result, analysts say, most locally-based hospitalist programs are likely to remain voluntary.

Physicians have created their own hospitalist programs, independent of any directives from health plans or hospitals. In 1994, for example, Park Nicollet Clinic in Minnesota implemented a hospitalist program to remedy what its physicians saw as admission delays and inefficient patient care. The group's 73 internists and 10 family physicians were given a choice of whether they wanted to continue to provide inpatient care; one-third of the internists chose to become strictly office based. Internist Richard B. Freese, ACP-ASIM Member, senior vice president of the group, said that the program has been successful because it was created and implemented by physicians. "The absolute key was that it was designed at the grassroots level," he said.

And some Kaiser Permanente physicians have also designed their own hospitalist programs to pre-empt what they believed was the impending arrival of hospitalists who weren't familiar with the Kaiser Permanente system or their patients. One of the three service areas in Kaiser Permanente's Mid-Atlantic region, which covers Maryland and the District of Columbia, implemented such a program in 1994. The group has 10 hospitalists working at two hospitals; physicians can choose either to hand their inpatients over to a hospitalist or provide their own inpatient care.

Brian F. Reagan, ACP-ASIM Member, one of the first Kaiser Permanente physicians in the area to embrace the hospitalist model, said that while many of the group's primary care physicians use hospitalists to care for inpatients, many primary care doctors still remain on call one weekend a month and some nights, and they also cover for hospitalists who are on vacation. "You don't want to lose those hospital skills," Dr. Reagan said, "and doctors shouldn't give them up."

Resistance

Doctors elsewhere agree, and some have taken steps to ensure that they are not forced to give up their inpatient skills. Some health plans have encountered such fierce resistance to mandatory models that they have actually changed their policies. Last year in Philadelphia, for instance, when a Medicaid HMO tried to implement a mandatory hospitalist program, it met a wall of protest from local and statewide medical groups, consumer advocates and physicians from several city hospitals.

Representatives from Thomas Jefferson University Hospital led the opposition. "It could have had a dramatic impact on the nature of our teaching programs," said Jeffrey L. Lenow, MD, JD, medical director of JeffCare, which is Jefferson's physician hospital organization. "It also had legal consequences that no one thought through. Any time you introduce a break in continuity, if there's an adverse outcome, you're on the hook."

Taking the position that they would never compromise and accept a forced hospitalist program, the hospitals convinced the HMO to rescind its policy.

Others have found that when direct pressure doesn't work, legislative safeguards may. Last November, Blue Cross and Blue Shield of Kansas City decreed that only hospitalists could admit patients enrolled in their HMO plans from the emergency room of the North Kansas City Hospital and care for them while they were hospitalized. According to a letter sent to the health plan by Stephen E. Vilmer, MD, president of the Missouri State Medical Association (MSMA), the program interfered with the physician-patient relationship--and violated Missouri state law.

A comprehensive managed care bill passed by the Missouri state legislature in 1997 stipulated that health plans must disclose benefit limitations to their members. The state medical association argued that Blue Cross and Blue Shield had not notified its subscribers when they purchased their policies that their primary care physician would be limited to providing only outpatient services.

The strategy worked and the health plan switched to a voluntary hospitalist model, but the damage had been done. According to Patrick J. Mills, MSMA's director of health care finance, the hospital medical staff was so incensed by the plan's tactics that very few of them opted to use hospitalists. In contrast, Mr. Mills said, a voluntary hospitalist program initiated by doctors in another area hospital met with much less physician resistance and much more success.

"This came top-down," he said, referring to Blue Cross and Blue Shield's aborted mandate, "as opposed to the way it should be: bottom-up and optional, not mandatory."

In Florida, the College's chapter is also seeking legislative solutions, according to Robert J. Harvey, the chapter's executive director. It hopes that language it has crafted and sent to Rep. Durell Peaden Jr., MD, the Republican state representative who chairs the Florida legislature's health services committee, may become an amendment to one of the several managed care bills Rep. Peaden has introduced.

To back up that local effort, the College is strengthening coalitions with other medical organizations, seeking information from chapter Governors about hospitalist policies in their states and expressing its objections to national managed care trade associations--efforts that may intensify in the months ahead.

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