Hospital Med in the Land of Rocky Top

The Hospitalist. 2006 June;2006(06):

June 1, 2006 | The Hospitalist

He identified the hospitalist’s necessary skills as an ability to cooperate with community physicians, and an interest in improving processes to boost care quality and decrease costs. Methodist’s hospitalists have been independent contractors since the program’s inception. They receive hourly wages plus incentives based on productivity and metrics negotiated with hospital administrators.

Team Health recently rethought the model as potential recruits balked. In 2006 Methodist’s hospitalists became employees, with health benefits and defined contribution plans. Hospitalist Helen Bidawid, MD, says being employees improves recruiting because many doctors—particularly those just out of residency—find getting loans, buying health insurance, and other business associated with independent contractor status troublesome.

Symbiosis

Above: Methodist Medical Group’s average daily census climbed from 70 to 100 patients. The group has grown, too, from nine full-time employees in late October 2005 to a projection for 15 by first quarter 2006, and several intensivists to help by March.

The relationship of Methodist’s hospitalist program to Oak Ridge’s community physicians has changed over the years. Early on the group hired a hospitalist Dr. Garton describes as “very bright, knew his medicine, and would wow them in academia, but he antagonized the local docs. He left after one year and that was good because our census got low.”

Tact wasn’t that hospitalist’s long suit, and the community doctors who were uncomfortable with him didn’t refer many patients to the hospitalists. With the odd man out, hiring new hospitalists such as Joel Perkerson, MD, put the program back on track.

When Politics and Healthcare Collide

For decades TennCare, Tennessee’s Medicaid program, was seen as a national template of a generous Medicaid program for the indigent, those close to the poverty line, and the medically uninsurable. Until August 2005, that is, when Tennessee Governor Phil Bredeson cut more than 300,000 from the rolls, reduced or cut prescription drug coverage to 379,000, and trimmed millions of dollars from a program that consumed 26% of the state budget.

Slimmed down TennCare limits recipients to five prescription drugs paid for each month. Hospital administrators braced for an estimated 12% increase in uncompensated care in emergency departments due to chronic conditions that become acute due to inadequate access to medication. Although Tennessee tried to stretch a “safety net” under the sickest beneficiaries with a $57 million drug card subsidy and mail order pharmacy, those unable to pay for medication quickly flooded hospital emergency departments, including Methodist’s.

Dan Duzan, MD, who left an office-based practice a year and a half ago to join the Methodist Medical Group, saw the TennCare debacle coming. “It was the ‘go to’ program for beneficiaries, and it was not well run,” he says. “People got all the tests they wanted and all their prescriptions filled. The governor was either going to have to dissolve the program or put limits on it.”

Since August 2005 Dr. Duzan has seen a 10% to 15% increase in former TennCare beneficiaries who have decompensated with diabetes, heart failure, and other chronic illnesses. “When the TennCare changes were announced we didn’t know what the impact on us would be. Now we know,” he says. “Patients are not getting their meds. They get sick and come here, and there’s not much the hospital can do about it.”

Dr. Duzan doesn’t blame the governor: “He did what had to be done. It was either raise taxes—very unpopular here—or reduce care.”

Dr. Perkerson also sees a correlation between TennCare disenrollment and more work for Methodist’s hospitalists: “We see so many elderly on multiple medications. They can’t afford all their medications so their diabetes and/or CHF slips out of control.”—MP