A group of specialists in a new independent practice association in California is challenging the primary-care physician's role as medical gatekeeper for hospitalized patients.
These critical-care specialists-also called "intensivists"-want to establish themselves as inpatient-care gatekeepers, allowing the primary-care physician to remain as gatekeeper for outpatient care.
One could argue that specialists who devise new roles for themselves in the managed-care system have simply seen the handwriting on the wall: "Evolve or die." But forward-thinking critical-care specialists argue that even under fee-for-service medicine, where specialists were higher on the food chain, inpatient acute care was not effectively delivered.
Once a patient was admitted to the intensive-care unit under fee-for-service, "everybody could dip in, and everybody did dip in....It seems every cell of the body had its own specialist," said Bruce T. Gipe, M.D., president of the IPA, Marina Del Rey, Calif.-based Primary Critical Care.
The 35-doctor IPA was incorporated last year out of a network of pulmonary, critical-care and emergency medicine physicians.
Primary Critical Care is the end product of "the concern by some specialists about what's happening around them and their interest in having some say in the contracting process," instead of having the process totally controlled by primary-care physicians, Gipe said.
If critical inpatient-care management was flawed under the old system, under managed care it makes even more sense to put a critical-care doctor in charge of hospitalized patients, Gipe said.
"There are tremendous potential opportunities at this time for specialists who are willing to take risk for the sickest and most expensive patients who historically have had an (inadequate) process of care," Gipe said.
The way critical inpatient care is now generally delivered is disorganized and wasteful, he said. Patients are usually admitted to a hospital under the supervision of a primary-care doctor, an internist or generalist "who defaults immediately to subspecialty consultants for management of the case," Gipe said.
Primary-care physicians have their hands full with a large volume of outpatient care, leaving them little time and energy to supervise hospitalized patients, and they often don't have the clinical expertise to care for hospitalized patients, Gipe said. This is particularly true because the emphasis on outpatient care has resulted in hospitalizing only the sickest patients, he said.
"Any blip in a patient's physiologic screen results in another (specialist) getting involved," he added.
By contrast, a gatekeeper with some experience in specialist fields would make fewer referrals, Gipe argues.
Primary Critical Care has developed guidelines "for deciding where a patient needs to go in the hospital and then quickly getting them out." For example, not every acutely ill patient needs to be sent to the emergency room. And if they are sent, many might not need intensive treatment or even need to be admitted at all.
"When we are called by the emergency room, we'll go and see the patient," rather than simply telling the ER to admit the patient, he said. "That adds a level of scrutiny that has a tremendous potential to avoid overadmitting.
"The concept of managing critical care has really not evolved in pace with the rest of managed care," although critical care makes up about 30% of a hospital's budget, he said.
Key decisions are being made about acutely ill patients "without ever seeing the patient, and that's expensive," Gipe said. "Our argument is that had the doctor gone in to personally evaluate the patient, he may not have shotgunned the panel of tests over the phone, practicing so-called defensive medicine."
So far, the IPA has credentialed 35 physicians affiliated with almost 20% of the acute-care facilities in California, or about 100 of the 500 hospitals in the state.
To be credentialed, a physician has to be board-certified in a specialty as well as in critical care. There are about 7,000 board-certified critical-care doctors in the country, Gipe said, but most don't have jobs as hospital-based critical-care doctors. Instead, they may have a pulmonary practice or other practice with some contracts to do critical-care work.
Gipe said the practice of putting critical-care doctors in charge of inpatient care "has been popping up all over the country." But he believes that so far his group is the only specialty IPA focused on critical care.
The IPA has been marketing itself to HMOs; large multispecialty groups like Birmingham, Ala.-based MedPartners/
Mullikin and Pasadena, Calif.-based Huntington Provider Group; other IPAs; and hospitals. It recently signed its first contract with Inpatient Consultants, a primary-care IPA in Burbank, Calif., to cover out-of-area services, Gipe said.
Primary Critical Care physicians are at risk for critical-care services while a patient is hospitalized and are paid from the capitated fee received by a medical group or hospital.
Under a typical contract, critical-care gatekeepers would either be at a hospital on a 24-hour basis or arrive at the hospital within 30 minutes of being called. They would assume responsibility for the patient's care while in the emergency room, intensive-care unit or medical-surgical area. They would perform medical services as they are qualified to do so or they would call in other specialists.
"We do not represent ourselves as clinicians who never use other specialists. We do represent ourselves as clinicians who think before we use other specialists, and we use specific guidelines and criteria to order a consult, test or therapy," Gipe said.
Many large provider groups have started adopting the practice of basing an "intensivist" at some hospitals they own or contract with, said Jim Hillman, executive director of Seal Beach, Calif.-based Unified Medical Group Association, a trade group that represents large physician groups. However, those groups have selected physicians from among their own members rather than contracting with an IPA for hospital-based services.
Hillman says he hates the word "gatekeeper" and prefers to think of intensivists as coordinators of hospital care. They take over for the primary-care physician while the patient is in the hospital. "There are no downsides to this," Hillman said, because there are many advantages to having an intensivist as the supervising physician at the hospital round the clock.
Patients say they like this practice better than the old way, when a doctor would be available to patients only when making rounds before going back to his or her office, Hillman said.
And both Hillman and Gipe said there's evidence that using hospital-based intensivists has improved quality while reducing costs.