Those Who Do

The Hospitalist. 2008 February;2008(02):

February 1, 2008|The Hospitalist

Hospitalist Bradley Rosen, MD, has become something of a celebrity lately. Dr. Rosen, assistant director of the Procedures Center at Cedars-Sinai Medical Center in Los Angeles, is making news as the prime example of physicians carving new turf by becoming experts in performing medical procedures.

But it’s his center’s eye-popping statistics that are generating interest from patient safety groups and hospitals around the country. Dr. Rosen has documented a complication rate of less than 1% for procedures performed at the center. Published data for similar procedures done elsewhere sets the rate at between 3% and 5%.

The statistics don’t surprise Dr. Rosen. “The more you do something, the better you are going to be at it, and the better you are able to deal with the unexpected,” he explains.

Stories on proceduralists have also generated interest from hospitalists, who wonder if becoming experts in procedures can make them a more valuable part of the healthcare team and make their jobs more varied.

The future growth of proceduralist services and centers will come from being closely associated with and staffed by hospitalists.

—Bradley Rosen, MD, assistant director, Procedures Center, Cedars-Sinai Medical Center, Los Angeles

Safety Advantages

The evolution of proceduralists is first and foremost a patient safety measure. Many internists have given up doing procedures, concerned that they don’t do enough of them to stay proficient. In a study published in The Annals of Internal Medicine, internists reported that they do 50% fewer procedures today than they did 18 years ago. And the American Board of Internal Medicine has reduced the number of procedures required for certification, saying internists should focus on core procedures they are likely to do frequently. Proceduralists are moving in to fill the void.

Also driving the proceduralist movement is concern that residents don’t get enough experience in doing today’s more complicated procedures and are being trained by other residents.

“Unfortunately, training in procedures hasn’t progressed much from when I was a resident,” says Joseph Li, MD, director of the hospital medicine program at Beth Israel Deaconess Medical Center in Boston and assistant professor of medicine at the Harvard Medical School. “When I had to do a thoracentesis, for example, a junior resident was teaching me, and we would get three or four kits because I knew that I would screw up. We had no notion of cost, and although I felt bad sticking a patient a bunch of times, it was the way it worked in the teaching hospital. Unfortunately that is still the way it’s done in the overwhelming majority of medical schools today.”

Do Procedures Pay?

It’s a great idea, but can you make money from it?

That’s the question many hospitals and hospitalists groups ask when they hear about the evolving proceduralists trend. The answer is, it depends.

Proceduralists are so new that statistics on the financial feasibility of this practice are hard to come by. Like many things in medicine, the financial benefits may be long in coming and hard to measure. But one thing is for sure: It’s generated a lot of interest on the part of hospitals trying to stretch reimbursements and curb expenses.

It’s almost universally agreed that a private physician could not make enough money doing only procedures to make a living. Dr. Rosen asserts that physicians would have to do more procedures than are practical or possibly safe to generate a sufficient income. However, with procedures reimbursed at a higher rate than patient consultations, some combination of the two might increase a physician’s income.

Proceduralists at Cedars-Sinai Medical Center in Los Angeles are faculty members of the medical school and receive a salary and bonuses from the hospital, Dr. Rosen says.

For hospitals, the financial picture is more complicated. To set up a procedure center, hospitals have to invest in physicians’ salaries, space in the facility, nursing support, supplies, and data collection and management. In return, the hospital can bill for procedures in addition to facility fees. Dr. Rosen says this can add up to “a sizable chunk of change.”

Whether a hospital can make money with a procedures center depends on the local political cultural and economic environment, Dr. Rosen says. “Is there enough volume for at least one proceduralist to stay busy? Is the hospital used to doing procedures and how hard would it be to get it set up? And who’s doing procedures now? Would they be resistant to a proceduralist service or would they welcome it? It’s a business decision, and I think a business plan has to be developed at each hospital. One size doesn’t fit all.”

An increase in efficiency and patient safety may be the most convincing reason for hospitals to embrace proceduralists. Increasingly, payers are demanding that hospitals demonstrate quality through pay-for-performance measures, Dr. Li points out.

For example, the Centers for Medicare and Medicaid Services has said it will no longer pay to treat many hospital-acquired infections and complications beginning in October. In some parts of the country, Blue Cross Blue Shield offers an incentive payment to hospitals reducing their central line infection rates, Dr. Li says. Having dedicated proceduralists who could demonstrate a decreased central line infection rate could mean the difference between a hospital getting reimbursed or having to absorb the additional costs of treating for an infection. At forward-looking hospitals, hospitalists are partnering with hospitals to develop systems to increase the quality of care, Dr. Li says.

“If you don’t have a system in place to document your quality efforts in the future, you’re going to have more expenses that you’re not going to get reimbursed for,” Dr. Li says. “What’s happening with payers may ultimately drive the financial future of proceduralists.”—BD