No doubt you may be well familiar with hospitalists that work in the hospital but there are those who also work for insurance carriers.  This article takes a look at a couple in southern California and how their work varies from the hospitalist who stays in the hospital all the time.  When working with senior Medicare Advantageimage plans the care sometimes takes place outside the walls of the hospital. 

CareMore Health Plan Invests in Business Intelligence for Acute and Chronic Illness Management

I have written here about CareMore a few times in the past and they have invested heavily in software management to streamline operations throughout.  I do have to say as far as being organized, they have come a long way since their start, which was pretty much all paper in the early days.  CareMore employs around 22 hospitalists. 

CareMore Live On TriZetto's Clinical CareAdvance System Algorithms - Healthcare Business Intelligence

There is a bit more pressure with readmitting here as business intelligence analytics are being reviewed after the fact and to coincide with Medicare’s goals on lowering the occurrences of a readmissions, algorithms for care and money spent are going to work.  One other company on the east coast Bravo, which uses an extensive network of hospitalists for Medicare supplement plans made a billion dollars profit! 

Bravo Health – Venture Capital Backed Medicare Senior Health HMO Carrier Sees Profits of 1 Billion for 2009

That last statement makes a point in the fact that there’s some very big profits with Medicare Advantage plans and their management.  Hospitalists for their portion in making their readmission goals get some bonuses paid.  Once more companies offering care and making big money by working with the government with Medicare Supplement plans and we all still worry so much about a “private” option?  Again you can see where the profits go in healthcare here and we still have hospitals struggling for their existence with over 50% in Los Angeles County operating in the red, we really need some balance here with the plans making big dollars and hospitals struggling

Tenet Commercial Hospital Admissions Down Over 5% – More Business Intelligence Analytics On The Way

On the other side of the coin we read about hospitals who are down with admissions so they must be keeping a number of readmissions down; however for the hospitals they have a certain amount of fixed costs to open the doors and keep it running, so on that end, they are running short on making end meet, so readmissions lowering in one area may be good, but if the hospitals don’t see enough patients the money will dry up and layoffs will continue.  BD 

On a typical morning, Sandip Patel, MD, a hospitalist employed by a health plan in Southern California, rounds on patients at the hospital, then meets with case managers and a medical director to review care plans and decide which patients will stay or go. 
In the afternoon, Dr. Patel may see recently discharged patients—those coded "red" or "yellow," based on medical complexity—at an integrated-care center, which is also owned and run by the health plan. Then he might head to a nursing home to check on patients discharged a week ago.

Dr. Patel considers himself an "extensivist" for CareMore, a Medicare Advantage plan in Southern California that started out as a medical group and IPA. The health plan’s care model is based on keeping hospitalists front and center throughout a range of patient settings, and providing physicians with resources—including disease management and home care programs. 

Because the health plan has hospitalists targeting "the highest risk Medicare patients," Dr. Patel says, "the profit motive coincides with the best interests of patients. We want to keep them as healthy as possible and out of the hospital, and we function like their second option for primary care."

"Readmission is our main focus as our extensivists follow patients during hospitalization and post discharge," says hospitalist Balu Gadhe, MD, CareMore’s senior medical officer. "Lowering readmission rates is within the purview of the hospitalists."  The plan’s goal, he adds, is for the extensivists—who are board-certified internists—to manage "that 15% to 20% of the frail population that utilizes 60% to 80% of the resources, giving them extra care and attention."

CareMore, for instance, provides "talking" pill boxes that remind patients to take their medications. The plan enrolls patients in its own disease-management programs, including one for heart failure that relies on telemonitoring and the use of wireless weight scales. Those initiatives, says Dr. Gadhe, have reduced readmissions for heart failure by 56%.image

Remote Monitoring Yields Healthier Patients – More EHR and PHR Integration In The Works And Privacy Issues Should Be Addressed

Dr. Patel admits that one big difference in being employed by a health plan, rather than a private hospitalist group or hospital, is that physicians have to make a case for why patients should remain in the hospital. "We must have stated goals and objectives and come up with efficient discharge-planning procedures," he says.

Hospitalist Balu Gadhe, MD, for instance, is the senior medical officer for CareMore, a Medicare Advantage plan in California and the Southwest that employs 22 hospitalists. According to Dr. Gadhe, hospitalists with the plan have a base salary that tops $200,000 a year, plus the potential for a bonus.

While those bonuses are tied to factors like accurate documentation, timely discharge summaries and patient satisfaction measures, incentives "are based on readmissions, first and foremost," Dr. Gadhe says. The plan’s goal is to have a 30-day readmission rate of only 15%. (The national average, according to studies, is closer to 20%.)
Hospitalists whose patients meet or beat that rate can get a bonus of up to 50% of their salary, says Dr. Gadhe. If, however, their patients’ readmission rate is "higher than that," he points out, "they do not get their admission bonus."

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HealthCare Partners, a large California multispecialty group, also assumes global risk for inpatient costs, professional fees and pharmacy expenditures for several national health plans that operate in California, and it has shared-risk arrangements with others.
The group’s 75 hospitalists care for the more than 600,000 patients in California for whom HCP "picks up the bills," says Manoj Mathew, MD, a lead hospitalist for the company.

Like other hospitalist groups, HealthCare Partners staffs a program that calls all discharged patients or caregivers within 72 hours. In addition, it’s piloting a medication-reconciliation program in which the PharmDs who also run the group’s anticoagulation clinics call discharged patients to review medications and make sure patients have the medications at home.

Dr. Mathew bristles at the notion that hospitalists could be induced by health plan dictates to hold back care. "I’m sure at times we all feel pressured to meet some sort of corporate expectation," he says, "but in the end it’s our decision how the patient’s cared for." That’s becoming easier, he adds, with standardized protocols and treatment plans.

Bravo Health, which operates Medicare Advantage plans in several states, has affiliated with outpatient practices to operate advanced care centers. Those centers, which are exclusively for plan members, will be fully staffed by hospitalists. The first center opened in Philadelphia last month, with others planned elsewhere on the East Coast.

Today's Hospitalist :: Health-plan hospitalists cut readmissions—by sometimes leaving the hospital

Related Reading:

CCHP Investing in Business Intelligence Algorithmic Processes with TriZetto Systems – Managed Care

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