The utility of dedicated inpatient physicians is receiving increased attention. (1,2.3.)

This type of practice is growing rapidly in many markets, especially where there is a significant managed care presence. It may seem natural for physicians to think of this model as one that has been thrust upon them by the business people in charge of managed care organizations. However, thinking this way runs the risk that the many benefits of an inpatient coverage model will be ignored.

A group of Gainesville, Florida internists (Inpatient Medical Services, Inc.) started an inpatient-only private practice in 1987 which has grown from one doctor at one hospital to five doctors who now cover two acute care facilities (Columbia North Florida Regional Medical Center and Alachua General Hospital, both of which have about 250 beds and 16-20 ICU beds). The group’s five physicians are all young (the age range is 29-37) and are all board certified Internists. The group’s growth has occurred in an area which has relatively little managed care (their payer mix is 62% Medicare, 13% indemnity, 1% Medicaid, 3% discounted fee-for-service, and 21% other).

Potential benefits to patients, hospitals, and other physicians can be derived from an inpatient-only practice and have a great deal to do with the manner in which the program is structured. Inpatient Medical Services has several unconventional features. Of these, the physician’s schedule may be the most important.

A Unique Schedule for Physicians
Most published reports of inpatient practices describe a system of office-based internists rotating hospital coverage for periods of one or more weeks, during which time they do not see outpatients. An alternative schedule would allow for a group of in inpatient physicians to “cover” the hospital in 24-hour shifts, in much the same way that emergency room physicians work. In this model a physician would conduct rounds on all patients on the service and see all new admissions and consultations during his shift, and a colleague would assume these responsibilities on the next day (or shift). Both of these systems provide for hospital coverage and the greatest amount of predictability in the doctor’s schedule.

The potential lack of continuity between the outpatient and inpatient setting is one of the biggest obstacles to high-quality care for inpatient practices. Because of this, Inpatient Medical Services attempts to maximize the continuity between patient and doctor for each episode of hospital care. Physicians conduct rounds 7 days each week and rotate call for all of the new admissions or consults for each day. Thus a given patient typically sees the same doctor daily for the entire length of stay, even if it is several weeks. Each doctor takes time off in one-week blocks every 3 to 6 weeks.

In 1995 the group managed about 2,500 admissions, performed about 600 consultations, and had a daily census which ranged between 6 and 20 patients. Specific data regarding the utilization of consultations from specialists was not available; however, the Internists in the Group are comfortable performing independent management of uncomplicated myocardial infarctions, strokes, and short-term respiratory failure, and as a result they tend to utilize fewer specialty consultations.

Most admissions come from the emergency room; others are either transfers from other emergency rooms or hospitals, or office admissions. The group dictates a discharge summary on the day of discharge and has as one of its primary goals making sure that a copy of the discharge summary arrives at the attending physician’s office before the patient does for follow-up care. Calls to the patients are made within 10 days of discharge in order to follow up on their status and to clarify any questions regarding the plan for further care.

Another advantage of full-time inpatient work is that the physician can focus his or her skills and CME efforts on illnesses which commonly require inpatient care. These skills can be developed best by practicing inpatient medicine full-time, rather than through periodic “rotations” to the inpatient service. Additionally, the inpatient doctors get to know hospital personnel and services quite well, which leads to an ability to guide the patient “through the system” more efficiently.

Strong Support From Patients and Physicians
The practice has been quite well received by patients and physicians in the community. During the late 1980’s the idea of an inpatient practice was quite new, but it was welcomed as a good way to care for many of the medical patients that arrived at the hospital without an attending physician on staff. These patients were happy to have a hospital doctor to complement their office doctor near home, which was often some distance away.

Many office-based physicians have chosen to refer to the inpatient service, allowing them to spend more time in the office where they are more efficient. In the last few years an increasing number of new primary care physicians have started office practices without taking on hospital responsibilities. By having an inpatient service, the hospital has an ideal tool for recruiting such physicians and increasing their local primary care base.

While the growth of the practice has been encouraged by strong support from the local physician community, some have expressed concern that it poses a threat to their own hospital work. Most of these anxieties have been short-lived since no doctor is required to refer to the inpatient service. A two-man pulmonary group at one hospital was concerned about losing referrals. These concerns were alleviated by having the pulmonary doctors share in the workload of the inpatient service.

Many Benefits for Hospitals
In addition to attracting primary care doctors to the hospital, the practice attracts referrals from doctors in outlying communities. The group has formed strong associations with many of these doctors, resulting in steady referrals. The hospitals benefit from this arrangement since the local market offers several options in hospital care and doctors will refer to the one that has physicians who will most readily accept patients.
Reports from large health care systems (e.g. Park Nicollet and Mullikin4) describe large reductions in length of stay and cost of care with the advent of inpatient physicians. Length of stay for the Group has been shorter (averaging 10% less than the rest of the State) and initial data regarding the cost of care is encouraging, showing reduced charges at both facilities. Systems to accurately track costs in order to provide more meaningful comparisons are being developed.

Satisfied Inpatient Physicians
The five doctors in the Group have found this style of practice to be very rewarding. Some satisfaction has come from successfully starting an inpatient-only private practice in the absence of a prototype. The rapid growth of practices like this in the last few years is seen as a confirmation that what some regarded as untenable in the 1980’s was actually a good idea and ahead of its time.

Advantages for the physician include an alternative work schedule allowing for a generous number of weeks off each year, and exceedingly low overhead (generally less than 10%). There are no employees to manage, and a contract billing service handles collections. Additionally there is the potential for short-term employment for new physicians in the community who may wish to eventually establish a more traditional practice.

Not Created by Managed Care
While inpatient practice and managed care enjoy a close association, our experience in Gainesville has shown that this model is a practice style which benefits the patients, hospitals, and doctors associated with it. These benefits, not managed care, are the reason for the development of this model. It is likely that inpatient practice models would have evolved out of their own merits even without the advent of managed care, which appears to be accelerating their growth by encouraging greater efficiency and quality.

References
1. Wachter TM, Goldman L. The emerging role of “hospitalists” in the american health care system. NEJM 1996;335:514-5.
2. Gipe B. A pennsylvania model for in-house acute care physician services: improving patient performance and outpatient stress. Cost & Quality 1996;2:6.
3. Brandner J. Will hospital rounds go the way of the house call? Managed Care, July 1995:19-28.
4. Kilgore C. Some internists bid farewell to rounds. Int Med News. March 1, 1995;1,33.

-by John Nelson, MD

Dr. Nelson is an inpatient physician in Gainesville , Florida.

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