Housestaff coverage in a nonteaching community hospital.

Housestaff coverage in community hospitals that have approved graduate medical education programs is primarily funded by Medicare. This funding is through both "direct" and "indirect" medical education payments.[1] Studies that have compared residency budgets and revenues with those of replacement delivery systems with no educational mission have shown a projected net reduction in hospital income in the nonteaching environment.[2,3] Other studies have compared productivity and financial outcomes of staffing models having inpatients assigned to a resident (teaching) or staff (nonteaching) service.[4-6] In these studies, when hospital charges and length of stay were factored into the equation, a distinct fiscal advantage was realized with the staff service. Indeed, Simmer et al.[4] had shown a 1.7-day lower average length of stay in the nonteaching service. In our institution, this would equate to a $737,000 cost savings per year.

Many community hospitals without graduate training programs, which therefore do not receive a Medicare subsidy, have medical housestaff coverage. In the pre-DRG era, the expense of maintaining a paid housestaff was offset by immediate patient access to a physician or allied health professional. The arrangement allowed hospitals to attract and retain attending physicians and their patients. The advent of prospective payment has provided additional reasons for maintaining medical housestaff coverage. The new emphasis is on reduction of hospital costs through reduction of length of stay.

Although in our hospital the average length of stay has decreased over the past year through a variety of measures aimed at the attending physician, it still remains unacceptably high. Intuitively, physician managers and hospital administrators would agree that they could have a greater impact on housestaff physicians than on attending physicians in reducing the length of stay. Lending credence to this concept was a study by Manheim et al. that demonstrated that, when housestaff members were randomly placed in an educational program that trained them to be cost conscious, they were found to have significantly lower per patient costs and length of stay than the control group.[7]

History

Housestaff coverage at Park Ridge Hospital began with its predecessor, the Park Avenue Hospital, in the late |60s. Recognizing the need to have a cadre of housestaff physicians to provide basic medical coverage, Park Avenue Hospital recruited 10-12 physicians. In those days, basic medical services included routine histories and physicals as well as responding to medical crises and/or emergencies. Additionally, housestaff physicians provided most of the medical management for physicians whose skills were most adapted to outpatient management. Park Avenue Hospital as well as the early Park Ridge Hospital administration and medical staff were never interested in a teaching program. The reasons variably set forth for this stance were that the physicians felt threatened by an educational program and administration likewise felt threatened by the administrative policies that an educational policy would mandate.

Most of the housestaff physicians came from abroad, with the majority originating from India and being recruited through various training programs in England. As a result of changes in federal immigration policies in the early 1970s, the free flow of these physicians markedly decreased. Park Ridge Hospital looked toward allied health care practitioners to fill in the void. The first attempt was to employ nurse practioners. However, this met with significant medical staff opposition and therefore did not succeed. In the late |70s, the hospital maintained its housestaff coverage with foreign medical graduates; however, these physicians tended to be of irregular and inconsistent quality.

During the late |70s and early |80s, the hospital embarked upon a program to have a smaller cadre of well-qualified physicians and at the same time began an effort toward a heavier reliance on primary care nursing. In the early |80s, the hospital began to rely more on the newly credentialed and licensed physician assistants. After almost 30 years of housestaff coverage, the type of service provided remained essentially unchanged. What had changed, however, was competition for patients in the community and the advent of DRGs. For a variety of reasons, including a desirable hospital location, ease of patient and visitor access, all private rooms, and an improving reputation for high-quality care, Park Ridge Hospital remained an attractive place for patients to receive their medical care.

The hospital's high occupancy rate reflected the census throughout the Rochester community. Coupled with the favorable occupancy rate, however, was an unacceptably high length of stay. The initial premise, therefore, of housestaff coverage to maintain market share had become less convincing. In an era of continually shrinking health care dollars and increased cost of providing service, the $1 million plus price tag to provide housestaff coverage needed to be critically evaluated. It became necessary not only to economize, but also to re-look and reshape the traditional concept of housestaff coverage.

Methods

In August 1992 a project team composed of senior medical and administrative personnel was formed at the direction and sponsorship of the President of the Park Ridge Health Systems. This group was entitled the "Hospital Coverage Project Team" and its mandate was to develop a house staff coverage plan. Following the process of total quality management (TQM), the goal was to develop a system of coverage utilizing appropriate expertise with clearly defined roles that were sustainable, efficient and effective. The timetable given to complete the task was five months. Implementation was to begin at the completion of the plan.

Process

The team met on a weekly basis from the first week of August 1992, with most meetings scheduled for two hours. The TQM process was rigidly followed. The ground rules were set, and it was agreed that a quorum consisted of five of the six principal members of the team. The development of the "as is" and "desired state" statements were followed by a fishbone analysis of the problem. From the key issues identified, an output statement was developed. Customer requirements were identified by members of the committee who had explored the requirements of their respective departments. The project team agreed that the housestaff service would be reorganized. Three "products" or levels and types of service would be offered to the hospital medical staff - a minimum "standard hospital coverage" that would be available to all patients as well as two levels of "enhanced coverage" that would be available to a selected number of physicians and patients. This enhanced level of care would fall under the aegis of either "case management" or "consultative services." The case management services would be provided pursuant to a letter of agreement with attending physicians.

Results

Standard Services

Beginning as soon as possible, all patients who are admitted to the hospital would receive standard house coverage:

* History and physical exam and orders on each new admission.

* Crisis intervention, defined as a response to a therapeutic dilemma or a change in status whereby the patient would suffer harm if there was no intervention.

* Length of stay issues intervention as circumstances may warrant in times of bed availability crises or in response to issues in delay of discharge.

Physicians whose patients only receive "standard services" would be responsible for any orders or interventions not listed above. Examples are daily medication orders, adjustment of heparin infusions, adjustment of insulin doses, follow-up of all laboratory tests, completion of discharge paper work, ancillary requisitions, etc.

Case Managed Services 

Physicians may request a more comprehensive level of inpatient care (consistent with resource availability) under a formalized agreement between attending physicians and the case management team. Case management incorporates activities listed as standard services as well as daily rounding, including progress notes, follow-up of medical testing, therapeutic interventions, and discharge summaries. The formal agreement with attending physicians will require them to work in collaboration with and be actively involved in the management and plan of care of their patients with the case management team including:

* Priority communication with house staff and family.

* Prompt, documented, comprehensive continuum of care.

* Aggressive resource management, including:

* Estimation of a discharge date and of potential problems, such as being unable to return to home or a referring facility.

* Early discharge initiatives where appropriate by using available resources both efficiently and expeditiously.

It is also assumed that attending physicians will contribute to the educational requirements of the housestaff. Defaults in adhering to the obligations of the agreement for case management will be referred to the director of the housestaff for resolution. Letters of agreement may be invalidated in cases of noncompliance by an attending physician.

Consultative Services

All patients who receive standard services or who are case managed are eligible to receive consultative medical services from housestaff physicians at the request of the primary attending physician. These services are the same as the traditional consultative serves that may be requested by any credentialed physician. Examples of consultative services that the house physician would be able to render are:

* Diagnostic procedures.

* Hyperalimentation.

* Geriatric assessment.

* Medical consultations on psychiatric patients.

* Preoperative medical consults.

As with the normal consultative process housestaff physicians, at the request of primary attending physicians, may either consult only, consult and follow, or consult and take over.

Additional Services

Housestaff physicians will accept any unassigned or otherwise uninsured patients who are admitted to Park Ridge Hospital.

Organizational Arrangement

and Support

It is anticipated that all of the housestaff will be employed by the Park Medical Group, an independent multispecialty group closely associated with Park Ridge Hospital. Their services, in turn, will be contracted out to the hospital. The Park Medical Group will provide the levels of services described here and will be totally responsible for operational management. No direct billing will occur for patients who receive the standard services or who are case managed. All consultative services will be billed in the usual manner and according to the policies of the Park Medical Group.

The ultimate goal is to have all patients in the hospital under a system of case management. The benefits of this arrangement include quality improvement, decreasing length of stay, and improved customer satisfaction. To the extent that this new house coverage results in a reduction in the length of stay, the Park Ridge Health System agrees to underwrite its full cost. The continued commitment of hospital resources to support case management will be possible only to the extent that direct economic benefits are realized. Evaluation mechanisms will be established to measure the impact of case management interventions and are essential to demonstrate the anticipated success of these efforts.

Discussion

Housestaff coverage in a community hospital, viewed from a financial perspective, may have a variable economic influence. In a teaching program, direct and indirect medical education subsidies from Medicare have a positive economic impact. However, calculated variables, such as size of housestaff, percentage of Medicare patients, attending productivity, length of stay, and total charges, can either individually or in aggregate negate any fiscal advantage of a training program. In a nonteaching community hospital setting, the expense to maintain a housestaff takes on more significance, as costs are directly borne by the hospital. The trade-off in this case, however, may be the following:

* Attending productivity increases, as less time is spent teaching.

* Length of stay can be reduced by more aggressive and efficient management of hospital resources.

* Housestaff reduction of total hospital charges can be accomplished by a variety of ways including:

* Prescribing the least expensive, equivalent drugs.

* Adhering to clinical guidelines, with standardization of care.

* Avoidance of duplicative testing.

* Emphasis on outpatient management and care where appropriate.

Because of the changing economic environment, Park Ridge Hospital found itself with a housestaff coverage plan that was nonsustainable, inefficient, and often ineffective. Through the process of total quality management, we have developed a system that addresses these issues through team building with attending physicians and through case management.

Andrew Conti, MD, FACP, was Chairman, Department of Medicine, Park Ridge Hospital, Rochester, N.Y., and Adjunct Assistant Professor of Medicine, School of Medicine and Dentistry, University of Rochester. He is now Director of Primary Care, Internal Medicine, Maimonides Medical Center, Brooklyn, N.Y., and Assistant Professor, State University of New York Health Science Center, Brooklyn. He is a member of the College's Societies on Group Practice and on Corporate Medicine and of its Forums on Entrepreneurism and on Medical Informatics.

References

[1.] Medicare Provider Reimbursement, reg. 413.86, Commerce Clearing House Inc., 1991

[2.] Kahn, N., and others. "Financial Analysis of a Family Practice Residency Threatened with Closure." Family Medicine 24(1):49-52, Jan. 1992.

[3.] Barnett, P., and others. "Cost-Benefit Analyses of California Family Practice Residencies." Journal of Family Practice 28(5):567-72, May 1989.

[4.] Simmer, T., and others. "A Randomized, Controlled Trial of an Attending Staff Service in General Internal Medicine." Medical Care 29(7 Suppl):js31-40, July 1991.

[5.] Dunn, P., and others. "The Effect of Resident Involvement on Community. Hospital Charges." Journal of General Internal Medicine 4(2):115-20, March-April 1989.

[6.] Campbell, C., and others. "The Effects of Residency Training Programs on the Financial Performance of Veterans Affairs Medical Centers." Inquiry 28(3):288-99, Fall 1991.

[7.] Manheim, L., and others. "Training House Staff to Be Cost Conscious. Effects of an Educational Intervention on Charges and Length of Stay." Medical Care 28(1):29-42, Jan.1990.