Adam D. Singer, MD, ACP Member, is anything but a new hospitalist. He first joined a hospitalist practice in 1991 and founded IPC, the hospitalist company of which he is now chairman and chief executive officer, in 1995.
ACP Hospitalist recently caught up with Dr. Singer and got his perspective on current trends and future possibilities for hospitalists and their field.
Q: The hospitalist workforce—and your company—have been growing consistently for years. Can that continue much longer?
A: Yeah, we're definitely short doctors and extenders everywhere. There is still huge demand. Nobody knows how deep this rabbit hole goes. We still find facilities every now and then that don't have a program, which is really hard to believe. There are a lot of programs that only see emergency room unassigned patients, leaving behind the 75% of patients directly admitted. There's plenty of demand.
We're finding a lot of [hospitalist] groups are also hitting walls because of their growth. We do a lot of acquisitions because those groups don't have any technology, they're not collecting properly—five doctors working with no management. These groups hit a wall management-wise and need a more professional infrastructure.
Q: The latest data on hospitalist practice show that subsidies from hospitals are common (supporting 80% of groups, according to the Society of Hospital Medicine/MGMA's “State of Hospital Medicine: 2010 Report Based on 2009 Data”) and increasing. Any predictions on the future of hospital subsidies?
A: You're seeing a delayed impact [on the survey data]. Right now many hospitals are offloading their previously employed groups. There isn't a day that goes by that we're not getting a call here: “Can you take over my previously employed group? It's costing me three million. They are under performing clinically. I'm not getting the results I would expect.” Any of the other [large hospitalist companies] are going to tell you the same thing. That's the number one source of new business now.
I don't think hospitals should be paying anything, other than for specific reimbursed tasks or duties that they ask us to perform. The higher the per-FTE (full-time equivalent) subsidy goes, the sooner you're going to see the whole system collapse. It's not economically viable. This happened in the ‘90s, when hospitals were buying up all the primary care groups. The whole system imploded and it all got re-outsourced.
Q: What do you see in the future for these kinds of hospitalist groups?
A: It's problematic. I'm sure they're good people and they're good doctors, but they've been put into a system to be a postal worker—paid $200,000 a year to work 16 days a month, and to limit the number of patients they see. Eventually those doctors will have to work full time.
The issue with the shift model isn't so much how many patients they are seeing a day. They say, “I see 20 patients a day, and still have to be subsidized.” It's how many days they're working. If you're only working 16 days a month, you can't make it. If you work 22 days or 23 days a month, which is like the rest of the world, then you'd have another six or seven days of billings, another 33% of revenue, so maybe you could even reduce the amount of work you're doing per day. Because, by the way, you have twice as many people working, because half the people aren't off. And by the way, that meeting for improving quality the first Tuesday of every month, you can go to it.
I understand there are some people that love [shift models], but it's a non-viable way of running your business. This is not episodic care like an ER, where you can have people plugged into a shift and the dollar per encounter is much higher. We're not ER medicine, but half the hospitals in the world work this way.
Q: How do you convince physicians to change their style of practice?
A: You just have to hit them 15 ways, because you don't know which of those ways will hit each person. Sometimes it's all about patient care: “If it's not about my patient, I won't listen.” Some people, it's always economics: “If I can't make more money by doing this, I'm not going to do it.” Doing the right thing actually pays well, so you win either way.
Some people will never get there. Of the doctors we lose each year [at IPC], two-thirds are leaving for some reason unrelated to us, such as planned fellowship training or a desire to pursue outpatient medicine, but that other third comprise a lot of providers that just will not change their ways. Even the youngest, fresh, green person has got seven years of being told and convinced of what they are. Most of our doctors have three, four years' experience before we hire them, so we're really overcoming an 11-year history.
Q: Should residencies be teaching more of these non-clinical skills?
A: The problem with residency teaching hospitalist concepts is it takes three years to learn how to be an internist. There is a core amount of knowledge you need to know—heart failure, pneumonia, these basic medical conditions. How you put these concepts of how to be a hospitalist into a three-year residency is very hard. There are unique core competancies to this emerging new specialty, such as how to build teams, lead teams, be a member of team, process reengineering and economics, to mention a few. There just is not enough time to do it all.
Q: Speaking of new concepts, IPC has recently been acquiring physician practices that operate in skilled nursing facilities. Why?
A: The way it was 20 years ago, you're in the hospital until you're well enough to go home. Then managed care came and said, “Get the length of stay down.” We compressed length of stay and patients who were not ready to go home went to the nursing home. It was out of sight, out of mind. Then the world changed. We are now looking at cost all the way until they are better, not just hospital costs. All of a sudden we realized we were sending these people to a nursing home, and who was taking care of them? The doctors were primary care doctors, generally older, who on a Friday would show up at the nursing home. If anything went wrong during that week, the nurse would call the doc, the doc would say, “I'm not going to get there until Friday. Send them to the ER.”
Q: Why should hospitalists take on the role of caring for these patients?
A: The need for care in nursing homes is literally what the hospital used to be like 10 years ago, in terms of acuity of patients. So we started building post-acute hospitalists: They're rounding every day in the nursing home, not just once a week. Their career is to figure out how to make those facilities more efficient.
We started building protocols for how to hand off patients from IPC hospitalists to IPC post-acute hospitalists and start building relationships to prevent readmissions or unplanned discharges. Nursing home care is about unplanned discharges; when you send that patient back [to the hospital], they have to hold the bed open, so they're losing a lot of money with this flow and patients are getting horrible care. In every one of our cities, we have post-acute hospitalists and acute care hospitalists, so patients get good care, length of stay goes down, and total costs go down.
We've always had post-acute hospitalists even from the first days of our practice, but it has never been as much of an initiative. Now I think we are the largest post-acute hospitalist group in the country. Everybody's doing it now. All of the bigger people that get hospital medicine are building post-acute presence now. It looks to me exactly like 1991 all over again, when I formed my first practice. It's the same demand.
Q: How hard is it to recruit physicians for these jobs?
A: [In the past] nobody wanted to go there. Being a fully trained doctor from a reasonable program, the idea of going to a nursing home would be a failure. Nobody wanted to do it, but now all the primary care docs are saying, “I don't want to be a hospitalist. I can't make it in outpatient anymore and I really don't want to do that. Maybe there's a middle ground.” So we're finding this new population of docs who are wanting to do this important work.
Q: IPC has also expanded into behavioral health. How does that fit into the hospitalist model?
A: What it fits into is quality of care. Almost 25% of seniors go from a hospital to some post-acute facility. In the nursing home, not surprisingly, over 50% of the patients who make it there are diagnosed with clinical depression.
That leads to a host of problems, the biggest of which is that they refuse their treatment in the nursing home. If you refuse therapy for three days in a nursing home, your entire stay is disallowed. So getting patients motivated and engaged and less depressed, so they can participate in therapies, is important so they can get the therapy, and is important economically so their stay will be covered by Medicare. It isn't just behavioral health. It's also wound care, which is a huge issue for these patients. They are getting bedsores, which is a huge disaster clinically for the patient and a huge disaster economically for the facilities, as well as a liability nightmare.
When we started building our strategy, we thought about that. Now you've really got to, if you're going to give quality care, manage the patient through an episode of illness, from when they're sick until they're all the way back home and out of the woods. When you look at that from the hospitalist viewpoint, you've got the acute care hospitalist, the post-acute care hospitalist, behavioral health component, the wound care, and they're all facility-based people. So we can manage it similarly on the same patient population. It makes sense for us to take all those pieces on. Behavioral health and wound care are still more in their infancy and experimental. We've definitely proved the model with post-acute and acute. We know that readmission rates are much less, that lengths of stay are less, when we combine the two.
Q: What are the biggest challenges of moving into these new areas?
A: The biggest problem is the electronic health record (EHR) needs of the post-acute provider. These are considered primary care physicians. They have to use an EHR in order to be paid in full, but they are not office-based doctors where you can get an EHR. By the same token, these nursing homes are way behind. We have nursing homes literally today that still don't have a fax machine.
We're trying to figure out an electronic record for our post-acute providers. For acute providers, it's on the hospital. The post-acute providers need that tool. A thing we're developing is putting our IPC-Link EHR on an iPad. Providers who move through multiple facilities in a day, they bring their technology on an iPad. We're developing a lot of tools that we didn't have to develop before. Once we have them, we'll be ready to roll out a lot of really cool programs, and be able to bring these post-acute providers into the modern age.
Q: One last prediction: What do you think will happen with accountable care organizations (ACOs)?
A: The reform world has scared everybody into doing irrational stuff. They're building ACOs. Before ACOs, it was bundled fees. These things come and they go. We're part of many ACOs right now. We're supposed to be out there trying to provide high-quality care at low cost and that's what we're trying to do. There isn't any direct payment mechanism yet. You still bill Medicare, you still do your same work and a year later, if that patient's still assigned to the same ACO and if your costs are less than some number, extra money comes into the ACO. Quite frankly, I don't care if I don't get a penny of that. I just want to be paid for the work upfront.
I know that's heresy among these people who believe there's all this money. I don't believe there's all this money. The point is there's too much being spent, so the idea that you're going to get more money—does that make sense?
These models where you have bonuses for reducing utilization are not good. That's managed care all over again. Every time something bad happens, I'm going to be accused of not providing the care for money.