It is ironic and somewhat amazing that many hospitalized adult patients in the United States undergo significant periods of time in each 24-hour period during which their physician management is coordinated by phone only. This is often true regardless of whether the patient is connected to a mechanical ventilator in the ICU, or is on the medical-surgical ward receiving intravenous therapy. In the era of healthcare reform the acuity level of hospitalized patients will only continue to increase as efforts are made to ensure that as much care as possible is delivered in the outpatient setting. This rising acuity level in the inpatient population will make continuous on-site physician management even more important as hospitals, payers, and medical groups seek to control costs.

A huge portion of what physicians learn about inpatient care comes from the crucible of staying in-house while on-call during medical school and residency. The long hours of confinement in the hospital provide a concentrated learning experience that is painful, and yet at the same time, essential to the process of managing inpatient care. At the conclusion of postgraduate training, a very small percentage of physicians take jobs which require that they stay in-house while on call.

There is little data to prove that in-house physician coverage (for areas other than the Emergency Department) has an impact on either cost or quality. It makes intuitive sense that if a talented clinician were actively involved in the hospital around the clock - using clear guidelines to assist in the decisions to admit, transfer, consult, and to utilize expensive tests and imaging modalities -that there would be an improvement in almost any measure of care or cost. There are signs that this type of approach is beginning to take hold, especially in markets with a high managed-care penetration.

According to Dr. Rich Freese, the Medical Director for Internal Medicine at the Park Nicollet Clinic in Plymouth, Minnesota, the implementation of a hospital-based physician program has had a significant impact on utilization. Park Nicollet is a large practice consisting of about 400 physicians, which in 1993 affiliated with Methodist Hospital in an effort to form an integrated system. Methodist Hospital has a Family Medicine training program and the residents provide care for about 20% of the Park Nicollet inpatient census. In July, 1996, an Internal Medicine residency program will start at Methodist as well.

The group's inpatient census at Methodist runs from 60-80 patients. In January of 1994 the group began looking at ways to simplify and streamline the management of their huge inpatient census, a significant portion of which was paid for via capitation. The inefficiency of having the inpatient census divided between so many primary care physicians led to the creation of the unique call schedule shown in figure 1. It took almost two years of planning to arrive at this schedule. Physicians in the group were given the option of not participating in the in-house rotation - about one-third of the group's Internists and two-thirds of the Family Physicians opted out and in turn took more time in the outpatient setting. The inpatient rotation lasts for two weeks at a stretch, the physician who covers the midnight to 7 am shift has no outpatient responsibility for the next day, and each quarter each physician either covers the daytime inpatient rotation for a two week period or takes 12 evening or night shifts. The inpatient service averages 15 patients per doctor, about 10% of the patients are in the ICU or CCU, 30% are in the step-down unit, and 60% are on the medical-surgical wards. Consultants are used for invasive procedures and to assist with the management of complex patients.

A number of impressive outcomes have been realized by implementing this model. Charges for the twelve most expensive DRGs are down 25% due to a 0.5 day average reduction in length of stay, and specialist consultation has been reduced by 43%. According to Dr. Freese, the new schedule is not perceived as being more or less difficult than the prior; however, it is appreciated as being more predictable since taking call is confined to either inpatient or outpatient care.

Most groups do not have the concentrated volume of physicians and inpatients at one hospital that is seen with the Park Nicollet/Methodist system. However, the trend is to merge and integrate, and this trend, in combination with the simple clinical logic behind 24-hour in house coverage for patients who are at the highest risk for both resource consumption and poor clinical outcomes due to their level of acuity, will undoubtedly produce more examples of the Park Nicollet model.

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Park Nicollet Call Schedule