Author Archive for Kirk Mathews, MBA
Kirk Mathews is the CEO, principal, and founder of Inpatient Management, Inc., a national hospitalist management company in St. Louis. Prior to cofounding Inpatient Management in 1997, he was senior vice president of Cejka & Company, responsible for managing one of the nation's largest physician recruiting enterprises with a search portfolio of over 300 clients. His experience includes management, sales, operations, recruiting strategy, physician compensation and benefits planning and design, and employment contract design and negotiations. In 1989, he served as vice president of Clayton Medical Associates after serving as senior recruiting consultant with Jackson & Coker, the nation's largest physician recruiting firm at the time. Mathews received his B.S. in accounting and MBA from Northwest Missouri State University. Mathews is a member of the the Society of Hospital Medicine.
Greeley Medical Staff Institute and bundled payments
I recently had the privilege of speaking at the Greeley Medical Staff Institute Symposium in Naples, Florida, November 8-9, and found the experience to be both very enjoyable and educational. I really enjoyed serving on the opening plenary session panel discussion regarding healthcare reform. I was amazed at the prophetic abilities of the organizers in having the panel speak about reform exactly nine hours after the House of Representatives passed the 1,990-page bill! I had the honor of sharing the podium with Dr. Jon Burroughs of the Greeley Company and Dr. John Maa, one of the nations thought leaders on surgicalists. The session was moderated by Dr. Rick Sheff, executive director of the Greeley Company.
One of the questions posed was regarding the effect of the proposed “bundled payments.” Predictably, this has proven to be a very volatile topic amongst physicians. The Phoenix Group, of which I am a member, published a white paper earlier this year on the topic. The first draft stated that “healthcare reform legislation holds the potential for a cataclysmic uprooting of the traditional fee-for-service payment system.” In final form the word cataclysmic was removed. I suppose “cataclysmic” is in the eye of the beholder, but one thing is clear: The current bill is designed to change how providers get paid, and even how their businesses are structured and aligned and, ultimately, how care is rationed. Consider the following:
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The “one-visit follow-up clinic”
A frequent impediment to reducing length of stay with the unassigned (or “no-doc”) patients is the lack of an outpatient physician with whom the patient can get an appointment. In many, many places around the country, primary care physicians have overflowing practices and cannot take on the unassigned patient very easily.
One solution to this dilemma is what I call the “one-visit follow-up clinic”. At Inpatient Management Inc., we are about to launch our first such clinic. The idea works like this: we, as the hospitalist team, will provide one follow-up visit to patients who do not have a primary care physician. The clinic might see patients two half-days per week, depending on volume, and can be staffed by a nurse practitioner with supervision from one of the hospitalists.
Recent physician recruitment survey
Merritt Hawkins & Associates recently released their 2009 Review of Physician and CRNA Recruiting Incentives report and revealed some interesting, but not particularly surprising, trends. This review is based on the physician and CRNA search assignments that Merritt Hawkins & Associates conducted during the 12-month period from April 1, 2008 to March 31, 2009. I look at some of the numbers with a bit of skepticism since this is totally a report of its own internal data. However, it does seem to affirm some trends that are evident in the marketplace. Here are some highlights of interest to hospitalists:
Great demand for hospitalists!
Hospitalists are third on its list of most sought after physicians, right behind family practice, which is number one by a long shot, and number two, internal medicine. The report correctly points out that since many internal medicine physicians are pursuing hospitalist positions, the demand for traditional internists is on the rise. Personally, I am of the opinion that the practice of traditional (outpatient and inpatient) internal medicine faces possible extinction over the next 10 years or so.
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Reform: Quality, Cost and Access… Access to what?
I have been extremely interested in watching the debate on health ______ reform. I intentionally did not fill in the blank because this has become a bit of a moving target. Of course, this debate began as a discussion on healthcare reform. But somewhere along the line, someone changed the terminology. Now, we no longer hear President Obama discuss healthcare reform, but health insurance reform. I am perfectly okay with this term because I believe it more accurately depicts what the current proposals have become.
Most would agree that early on in the reform debate, three main issues were identified as being central to any meaningful reform—quality, cost, and access. The current bills under consideration in both the House and the Senate contain some elements of all three. However, they all place heavy emphasis on access and do precious little to address quality and almost nothing to address cost (except increase the cost, but that is another blog post). But these bills also beg the question: Access to what? Access to actual healthcare or access to health insurance? Clearly, if you study these bills, they are more focused on providing access to health insurance, and thus, the appropriate shift in the terminology by President Obama and others.
Accountable Care Organizations and hospitalists
A recent article in the American Medical News Web site discusses Accountable Care Organizations (ACOs) as a potential element in healthcare reform.
Don’t feel bad if you have not heard of this delivery model. It is not yet in practice in any significant way. However, look for several demonstration projects to start during the next year or two.
Basically, ACOs are an integrated delivery system (including hospitals, primary care physicians, specialists, and probably some other providers as well) which will coordinate care across the organization in a manner designed to improve quality and decrease costs. Medicare reimbursement would most likely remain fee-for-service. However, reimbursement would probably have a “withhold” that could be returned in the form of a bonus (resulting from meeting quality benchmarks and cost savings). It will be up to an administrator to distribute the savings bonus amongst the various provider elements of the ACO.
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Are concierge hospitalists coming?
I recently had the opportunity to have lunch with a member of the board of directors of a company called MDVIP and was fascinated by their business model. MDVIP helps primary care physicians transition from a traditional practice model to a concierge practice. This company was featured in a recent article on CNNmoney.com.
Here are some of the basics of MDVIP as I understand them:
- The patient pays an annual retainer of approx. $1,500 or $125 per month
- The practice limits the number of patients to between 300—600
- The physician is accessible to any patient around the clock by cell phone and will even meet the patient in the emergency room when an emergency arises
- The patient keeps his or her health insurance in place
- The patient must take an annual “Mayo Clinic” level physical, and the practice focuses on wellness and prevention
Wherefore art thou tort reform?
By Kirk Mathews, MBA
The more I hear about healthcare reform or “health insurance reform,” the less I hear about tort reform and the more crazed I become! I have written before (Can real health reform happen without tort reform?) about the added costs from defensive medicine. So I nearly blew a gasket, when driving down the interstate recently, I spotted a billboard that read something like this:
Have you ever had Tendonitis? Ever had problems with your Achilles tendon? Ever taken Levaquin? Then call Dewey, Cheatem, and Howe so we can sue on your behalf!
Do hospitalists improve the quality of care? YES!
I read, with great interest, two newspaper stories from The Wall Street Journal and the Los Angeles Times that reference a research piece published in the regarding Archives of Internal Medicine hospitalists and quality of care. The study concluded that after adjusting for several factors, care was 21% better for heart attack patients when hospitalists were involved, 11% for pneumonia patients, and no statistically significant difference for congestive heart failure patients.
However, the research could not prove a direct cause and effect relationship between the use of hospitalists and the better quality of care. Other factors such as ratio of nurses to patients (the more nurses, the better the care) clouded the ability to isolate one factor as the cause of the improved care.
Resident hospitalists in teaching hospitals
It has been very interesting to me to watch the explosive growth of the hospitalist movement. Among the most interesting has been the use of hospitalists in teaching institutions. At some of these hospitals, the residents ARE the hospitalists that primarily serve unassigned patients. However, many (if not most) teaching hospitals also have a large number of private practice physicians on their medical staffs; this is where it can get interesting.
In my experience, private practice physicians often hesitate, if not outright refuse, to have residents see their patients because of their concerns regarding quality, patient satisfaction, or the permanent loss of the patient to faculty practice plan physicians. In these cases, there is a segment of the medical staff that does not have access to a hospitalist program unless it uses the residency program’s “hospitalists”. Sometimes, this will cause the medical staff to send their patient to other hospitals where they can access a hospitalist program without concern.
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Consultation: What code to use?
How familiar are you with the proper use of consultation codes? If your answer is “not very,” you are not alone. But get ready: CMS is proposing to change the way we must document and code for consultations and transfer of care. One of the proposed changes in its 2010 inpatient physician payment rule is to eliminate payment for consultation codes. The rationale includes ongoing confusion about the use of consultation codes. Quite frankly, I believe this is one time they are correct: There IS confusion, or at least a great amount of variability in coding and documentation of consultations.
The CMS proposal will instruct providers to use “initial visit” E&M codes when providing consultations. A hospitalist would bill an admission code for the initial visit and a new modifier will be created for the admitting physician. Since consultation codes have historically been paid at a higher rate than initial visit codes, the proposal could have a negative impact on physician incomes. To counter-balance this, CMS is proposing a modest increase in work RVUs for initial hospital visits.
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Is gainsharing in sight?
The July issue of Today’s Hospitalist includes a very interesting Q&A session with Andrew Knoll, MD, JD, on the topic of gainsharing. The article centers on an opinion issued by the Office of Inspector General (OIG) last fall that perhaps indicates a relaxed future view of gainsharing. I believe this is an idea whose time has come. Many hospitalists have long been frustrated that the financial benefits of their hard work in improving the efficiency and quality of care have largely been enjoyed by the hospitals in which they serve.
The OIG opinion was favorable toward a hospital that shared a pay-for-performance bonus (received from an insurer) with its medical staff members. The bonus was paid for achieving quality improvement goals though the exact goals were was not disclosed. This is potentially good news for hospitalists, but we should remain cautious with our optimism.
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Primary care and healthcare reform: Where do we fit in?
In the healthcare reform discussion, one thing that most people agree on is the need to revamp primary care and primary care reimbursement. One congressional committee has published a Discussion Draft on the House healthcare reform bill.
This bill calls for increasing Medicare reimbursement by 5% (10% if the physician practices in an area defined as a health professional shortage area) for primary care services. These services are defined as evaluation and management services, including new and established patient office visits, and “other physicians services as the Secretary determines are associated with ensuring accessible, continuous, coordinated, and comprehensive care for individuals enrolled under this part.”
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