Beyond Making the Rounds

Hospitalists & Quality of Care under the ACA

This slideshow requires JavaScript.

By now, everyone knows the Affordable Care Act’s (“ACA”) motto is “increase quality, decrease costs.” As providers transition from the fee for service payment model to new payment systems that are tied to quality, one subset of providers will play a pivotal role in bringing health care into a new era: hospitalists.

Hospitalists (physicians who provide care solely to hospital inpatients) are poised to lead the way in ensuring that patient care is no longer a series of disconnected dots, but rather a continuum of ongoing service. As primary care providers (“PCPs”) and subspecialists increasingly limit time set aside for hospital visits, it is up to hospitalists to improve inpatient efficiency, manage patient expectations, and coordinate the overall inpatient experience. The unique nature of hospitalists, still a recently new specialty, makes meeting the lofty expectations of the ACA more attainable.

There are a number of ways that the ACA is emphasizing quality care: (1) integrating care through the creation of more Affordable Care Organizations, Patient Centered Medical Homes, and even electronic health records; (2) incentivizing positive patient outcomes, for example the Medicare Advantage program now issues bonus payments to plans with four or five star ratings, and CMS has expanded this to additional plans while also increasing bonuses and also rewarding plans for improvement in their star ratings; and (3) reducing cost through programs such as Medicare’s Hospital Readmissions Reduction Program, which is designed to ensure that hospitals only discharge patients when they are fully prepared and safe for continued care at home or at a lower acuity setting and penalizes hospitals with excessive rates of readmission within 30 days of discharge. Hospitalists are vital to hospitals wanting to ensure they receive the full amount of Medicare payments for several reasons including, but not limited to, those explained below.

Presence

Because hospitalists only work within the walls of a hospital, they have the undeniable appeal of simply being present when needed. In the past, a PCP would be taken away from his practice to make hospital rounds – leaving an inpatient waiting for the physician’s arrival and an outpatient waiting for his return. This practice led to unresponsiveness and unnecessary lulls in care. Now, because a hospitalist is located at the hospital 24/7, inpatients can be seen by a physician repeatedly throughout their stay. Likewise, a PCP is left with more time and energy to dedicate to outpatients, thus raising the quality of care in both settings.

The Home Field Advantage

As a result of this constant presence, hospitalists enjoy a familiarity with the hospital setting that PCPs may not. By knowing how a hospital is run on a day-to-day basis, hospitalists can improve integration and coordination of services provided by different departments while increasing efficiency, establishing protocol, and demanding accountability in the inpatient setting. Because the hospital is “home,” hospitalists are more likely to serve on committees or spearhead projects for the betterment of the hospital.

Accountability

Hospitals generally are limited in the control they can exercise over PCPs. Other than granting or denying hospital facility privileges, a hospital has little authority to manage behavior or measure performance. By employing directly or contracting with hospitalists to provide services, hospitals can ensure their rules and authority are followed. By sharing a unified vision and common principles, specific quality indicators can be more easily met.

A PCP’s Evolving Role for Inpatient Care

Of course, the industry cannot rely on hospitalists alone to meet ACA standards. It takes a village. PCPs still play a key role in establishing quality inpatient care. When a PCP has a patient admitted to the hospital, his role in the patient’s care has not ended. Instead, PCPs should see the inpatient stay as a momentary transition in care for which they are responsible for retaining oversight. PCPs should step up, not step back, to ensure continuity of care.

If a PCP is concerned about an aspect of a patient’s medical history or fact that the patient may not be forthcoming with, the PCP should alert the hospitalist to this information. While a hospitalist may be better equipped to care for a patient in the hospital, a PCP’s knowledge and history with a patient cannot be discounted. Often the admitting physician, a PCP is in the best position to know the patient’s current and past medical condition. PCPs should make their contact information known, both to hospitals and patients, so that hospitalists know how to reach them if the need arises.

No matter how great the care they offer to inpatients, an individual will never refer to a hospitalist as “my doctor.” Once out of the hospital, a patient can no longer call the physician or follow up with him for care. The PCP must be ready to resume his role fully and knowledgably.

After an inpatient is discharged, PCPs should expect a complete discharge summary. After all, like an emergency department doctor, a hospitalist’s role ends at the hospital’s door. PCPs will need to know test results, medications, and future treatment plans. PCPs should collaborate with hospitalists about when and how discharge summaries should be received. Fortunately, electronic health records (“EHR”) are greatly improving the ability for physicians to stay abreast of an inpatient’s care, even if they are not physically present in the hospital. As emphasis on EHR increases and more providers implement EHR systems in their practice, collaboration between PCPs and hospitalists will also increase. The better the information contained in the EHR, the easier it is to provide efficient and proper care after a hospital discharge.

To meet ACA demands, hospitalists and PCPs must work with, not against, each other. As demand for hospitalists rapidly increases, PCPs need to make sure they are on board with this emerging role in health care. It will take teamwork to stay afloat in the ACA’s waves of change. To ensure quality and continuity, we must have all hands on deck.

Hospitalists are vital to hospitals wanting to ensure they receive the full amount of Medicare payments …

Molly Nicol Lewis is an Associate of McBrayer, McGinnis, Leslie & Kirkland, PLLC. Lewis concentrates her practice in healthcare law and is located in the firm’s Lexington office. She can be reached at mlewis@mmlk.com or at (859) 231-8780.

This article is intended as a summary of federal law and does not constitute legal advice.