As the acuity of hospitalized patients rises along with the number of seniors enrolling in Medicare-risk HMOs, financial pressures will force a reconsideration of the historical approach to acute care coverage. The inevitable clinical logic of providing legitimate in-house 24-hour coverage for the highest risk patients will be forced into play by the financial realities of the times. key decisions that result in huge expenditures, e.g., who is admitted to the ICU, which antibiotics re used, which imagining modalities are warranted, who should be resuscitated in the event of an arrest, etc., cannot be made effectively over the phone at 3:00 a.m.

Clinicians and administrators who are interested in succeeding with managing inpatient care should pay close attention to the model at the St. Francis Medical Center in Pittsburgh, Pennsylvania. Dr. John Hoyt, who is the current President of the Society of Critical Care Medicine, heads a group of seven Board Certified Critical Care specialists who have practiced at St. Francis in one form or another for the last 12 years. As of January 1, 1996, the group entered into a new contract with the Hospital wherein they provide in-house 24-hour coverage for critically ill patients.

St. Francis has 750 beds, 42 of which are designated for critical care (22 medical-surgical, 8 cardiac, and 12 cardiac surgery). Additionally there are about 60 telemetry beds referred to as "step-down" and a four-bed intermediate care unit. The hospital is not a trauma or transplant center but performs about 1,000 open heart procedures annually.

The Group's daily census averages around 16-18 patients. The critical care physicians function as automatic co-attendings for patients admitted to the medical-surgical ICU and frequently consult on patients admitted to the other units. Rounds are made on every patient twice per day and detailed progress notes are dictated at least twice per patient per day. About 50% of the patients have other consultants involved in their care, most commonly nephrology for dialysis and infections disease for antibiotic recommendations. About 70% of the patients have a critical fellow assigned to them from the University of Pittsburgh program.

The call schedule is structured around a seven day rotation in which the day attending covers the service from 8 am to 5 pm and on the seventh day covers for a straight 24-hour period. The night attending comes in at 5 pm; each member of the Group takes three of four nights in house each month (the Group's ages range is from 32 to 52!). About 68% of the payer mix is Medicare and at present there is very little managed care. The Group contracts out its billing, employs 2.5 office staff, and receives a small portion of its income from the Hospitals as a guarantee against reduced collections. Each member of the Group generates income for the corporation in additional ways, i.e., teaching, critical care transport, research, and ER coverage.

The Group is collecting data regarding its performance. Thus far 7, 600 patients have been entered into an APACHE II database. The predicted mortality rate for these patients was 23% with an observed rate of 17%; the predicted ICU length of stay was 4 days and the observed was 3 days.

This practice model for inpatient coverage could be implemented at almost any facility with modification that would take volume and payer mix into account. Patients and the attending staff at St. Francis have access to unique talent around the clock. Likewise, payers and administrators have a direct link to a contracted provider group for questions concerning utilization and cost. In communities where the physician oversupply is causing an emigration of skills, groups who are willing to rotate in house call cal remain viable by adopting a similar mode. Generalists (i.e. Internists and Family Physicians) who increasingly are under pressure to see more outpatients will also be incentivized to restructure the delivery of inpatient care in order to relieve the stress of outpatient volume and improve the overall efficiency of services offered through their managed-care organizations.

- by Bruce T. Gipe , MD

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