Joseph A. Miller Healthcare Consultant September, 2002

1. The Hospitalist Movementin Massachusetts The Quiet Revolution In Healthcare Joseph A. Miller Healthcare Consultant September, 2002

2. Key Messages from the Report Good news: • The Hospitalist movement has moved into the mainstream in Massachusetts Bad news: • Hospitalist programs are about to receive more scrutiny

3. Definition of a Hospitalist • Term defined in 1996 NEJM article by Wachter/Goldman from UCSF • Hospitalists are hospital-based physicians that manage medical inpatients • An alternative to inpatient management by an office-based PCP

4. Why are there Hospitalists? Hospital motivations: • Vehicle for managing “unassigned” patients • Cost savings for DRG cases PCP motivations: • Managing fewer, sicker inpatients • Stress of commuting to/from hospital • More revenue in seeing patients in office

5. Hospitalist Research • Wachter/Goldman follow-up article in January 2002 JAMA reviewed 19 published studies on hospitalist programs • “Empirical research supports the premise that hospitalists improve inpatient efficiency without harmful effects on quality or patient satisfaction.”

6. Concerns re: Hospitalists • Discontinuity of care: the communications between PCP and hospitalist • Patient dissatisfaction: a new MD is now managing the case • PCP dissatisfaction: loss of authority; turf issues of PCP vs. hospitalist • Provider communications: hospital is no longer the meeting place for MDs

7. The Hospitalist Movementin Massachusetts The Quiet Revolution In Healthcare

8. Joseph A. Miller Credentials • 25+ years healthcare industry experience • Focus: implementing/reporting on innovation • Disease management, electronic medical records • Outcomes analysis, case-mix adjustment • eHealth, managed care initiatives • 5 years experience in survey research • Partner at consulting firm responsible for research • Products: reports, articles, seminars, conferences

9. Hospitalist Research Background • What was the motivation for this research? • Personal experience with a family member • Who provided support to the research? • Winthrop Whitcomb, M.D., Mercy Medical Center • Joseph Li, M.D., Beth Israel Deaconess Med. Center • What is the unique contribution of the research? • 1st analysis of the impact of hospitalist medicine on a defined community

10. Target Population • 75 acute care hospitals in the state • 27 academic hospitals (average: 342 beds) • 48 community hospitals (average: 148 beds) • 18 “major” medical groups in the state • 3 primary care groups (average: 18 MDs) • 15 multi-specialty groups (average: 94 MDs)

11. Survey Methodology • For hospitals/medical groups without hospitalist programs • 1-page fax back survey completed by Chief Medical Officer • For hospitals/medical group with hospitalist programs • 15-20 minute phone survey with Director of the Hospitalist Program

12. Response Rate • Hospitals without hospitalist programs • 39 of 47 responded (83%) • Hospitals with hospitalist programs • 26 of 28 responded (93%) • Major medical groups • 16 of 18 responded (89%)

13. Data Analysis Issues • Not all hospitalist programs are hospital-based • There are medical group-based programs • A hospitalist program can support >1 hospital • More likely to apply to medical group-based programs • There are adult and pediatric hospitalist programs • A hospital or medical group can operate 2 hospitalist programs

14. The Hospitalist Movementin Massachusetts The Quiet Revolution In Healthcare

15. Table of Contents60-page report • Executive Summary • Ch 1: The Emergence of the Hospitalist Movement • Ch 2: Research Methodology • Ch 3: Overview of the Hospitalist Movement in MA • Ch 4: Reasons for Starting Hospitalist Programs • Ch 5: Characteristics of Hospitalists • Ch 6: Staffing of Hospitalist Programs • Ch 7: Types of Patients Seen by Hospitalists • Ch 8: Roles & Responsibilities of Hospitalists • Ch 9: Hospitalist Communications with PCPs & Patients • Ch 10: Hospitalist Marketing to PCPs • Ch 11: Conclusions & Observations

16. Examples of detailed findings • Characteristics of patients seen by hospitalists • 38% unassigned; 67% seniors • Average patient load seen by hospitalists • Hospital-based programs: 10.5; Medical group programs: 17.0 • Profile of an average hospitalist • 37 year old general internist, slightly more likely to be male (60%) than female (40%). • Marketing efforts by hospital-based programs • 54% no direct marketing (“word of mouth”) • 32% direct marketing (meetings, visits, mailings) • 14% no marketing (have a waiting list of PCPs)

17. Examples of Mass. programs • The largest hospitalist programs in Mass are at UMass Memorial Medical Center (20 MDs, 14 FTEs), the South Shore Hospitalists group practice (17 MDs, 13 FTEs), and Brigham & Women’s/ Faulkner (13 MDs, 10 FTEs). • The increased inpatient load of summer tourists was the impetus for developing hospitalist programs at Martha’s Vineyard Hospital and Nantucket CottageHospital • Adrienne Bennett M.D, Chief of the service at Newton-Wellesley Hospital has implemented a unique approach to round-the-clock coverage. Hospitalists are “on” 14 consecutive days and “off” for 7 days. When they are on, MDs are in the hospital 10-12 hours and available by pager for the remainder of the day.

18. Research Results • 5 major conclusions: • GROWTH: The number of hospitalist programs and hospitalists in Mass. has grown rapidly over the last 6 years • IMPACT: These programs have had a surprisingly significant impact on the delivery of inpatient care in the state • MORE GROWTH & IMPACT: The impact of hospitalist programs in Mass. will continue to grow rapidly over the next 5 years • SEGMENTATION: Hospitalist programs can be segmented into three categories each with distinct characteristics • MATURATION: The hospitalist movement in Mass. is in its early stages and will likely mature over the next 5-10 years

19. Conclusion 1:Growth

20. Conclusion 2:Impact • Hospitalists coordinate care for an estimated 42% of the 1.8M medical inpatient days in Mass. • It took managed care plans over 25 years to achieve a 40% penetration of the Mass. healthcare marketplace. • Hospitalist programs have achieved that result in 6 years.

21. Conclusion 3:More growth & impact • Existing hospitalist programs in Mass. expect to grow in size by 12% in the next year (i.e., add 24 physicians). • 15 Mass. hospitals (virtually all community hospitals) that currently do not have hospitalist programs have active plans to implement one in the next 12-18 months. • 11 hospitals are interested in hospitalist programs, but have no active plans to implement one. • By 2005 hospitalists will coordinate care for two-thirds of the medical inpatient days in Massachusetts.

22. Conclusion 4:Segmentation • Academic hospital-based programs • Community hospital-based programs • Medical group-based programs

23. Academic hospital-based programs • Leading the hospitalist movement in Massachusetts • 52% have programs vs. 23% for community hospitals • Teaching is an important priority for these programs • These hospitals often care for very sick patients • Hospitalists’ role often requires significant coordination with a range of sophisticated specialists • Because of house staff/specialization: • Hospitalists rarely perform procedures • Hospitalists less likely to see patients in ICU, CCU, or ED

24. Community hospital-based programs • Represent the growth market for new hospitalist programs • Virtually all hospitals with active plans to implement hospitalist programs in the next 2 years are in this category • Hospitalists have multi-dimensional responsibilities • Admit some patients, admit and round on other patients, perform consultations, do medical procedures, and see patients in the ICU, CCU, and ED • More likely to provide 24 hour, round-the-clock coverage and to employ administrative and/or clinical support staff

25. Medical Group-based programs • Almost 90% of major Medical Groups have programs • Many programs support multiple hospitals • Cost savings are a strong motivation for using hospitalists • Often at financial risk (e.g., capitation) for inpatient services • Programs good at integrating care across multiple settings • PCPs and hospitalists are partners in the medical group • PCP can explain hospitalist role to the patient before admission • The hospitalist can easily and frequently communicate with the PCP and other MDs in the group (e.g, using an EMR) • Smooth patient transfers to ECFs and rehab facilities because groups often have contractual relationships with these providers

26. Conclusion 5:Maturation

27. The Diffusion of Innovation • Enthusiasts – explorers, willing to experiment with break-through ideas. Little fear of failure; not intimidated by the pains/hassles of being 1st. • Visionaries – courageous exploiters, willing to take a chance. Visionaries seeking to gain the benefits of being an early adapter. • Pragmatists – practical users who will adapt an innovation if there is convincing evidence that it works. • Conservatives – the “wait and see” population of users. They want to be sure that the innovation delivers on its promises. • Skeptics – the group that stubbornly resists the innovation. Skeptics not only avoid change, they actively oppose it. • The “CHASM” – the difficult passage from adaption by visionaries to adaption by pragmatists – the movement of an innovation into the mainstream. Many innovations do not successfully cross the chasm

28. Conclusion 5:Maturation • The hospitalist movement in Mass. is crossing the chasm • As hospitalist programs move into the mainstream: • Visibility will increase – “hospitalist” will become a household word. • Hospitals, physicians, etc. will demand that hospitalist programs show value: i.e., that they are proven, predictable, measurable, integrated, and comprehensive. • Scrutiny by industry experts and the general public will put a spotlight on hospitalist program strengths and weaknesses... PEOPLE WILL HAVE OPINIONS! • Hospitalists will be more actively engaged in classic industry conflicts re: money and turf.

29. What I plan to do • Facilitate the movement of the Massachusetts hospitalist movement into the mainstream • Raise awareness of the hospitalist movement among policymakers and the general public • Identify, describe, and communicate best practices of hospitalist programs

30. For more information:Joseph A. MillerHealthcare Consultant Website: http://hospitalist.thecog.org Phone: 781-768-2501Email: josephamiller@yahoo.com