"The clinical part of practicing medicine should not be the part of medicine that should be considered an art," he says. "The part of medicine that will remain an art will be in managing physician-patient relationships, managing the health care team, and managing communications throughout the course of a hospitalization."
Greeno says small or solo practices will likely become extinct under an ACO model in which physicians have to become risk-bearing entities to some degree. They may be able to stay independent through independent practice associations, for example, but with a payment methodology that pushes people and institutions to take bundled risk and maybe even capitation under the ACO structure, physicians will have to belong to some type of organization, he says, further driving the trend toward physician employment by hospitals or companies like Cogent. Further, the ability of physicians to make care decisions about a wide variety of patients has become more difficult due to the simple fact that physicians simply can't keep best practice information in their head even if they are current on their specialty.
"It's all about standardization if we're going to make hospitals remotely safe or remotely efficient," Greeno says. "I've practiced for 30 years and the amount of information available to use in patient decisions has exploded. You can't keep that information in your head. You can keep where to find that information. That's about it."
The expense of healthcare services and, more important, the rate of inflation associated with those services, means physicians have to move toward limiting what they do to those actions that are known to actually work, he says.
As part of an organization that is accountable to its hospital clients for meeting certain cost and quality targets, Greeno looks forward to more standardization among physicians. In fact, Cogent's business model essentially is bundling, at least as far as Medicare reimbursement is concerned. Under its business model, the hospital pays Cogent in part based on the number of physicians it provides, but a large portion of its compensation comes from how well physicians meet quality and safety targets, and how well they coordinate care with other members of the hospital's medical staff, regardless of whether those doctors, nurses, and ancillaries are employees of the hospital. Such metrics are also used to determine individual physician compensation.
"We take the Part B dollars that are invested by the hospital in the program and create an incentive model that drives better quality and higher patient satisfaction," he says. "We've essentially been bundling payments, even though no official bundling methodology exists from Medicare."
Gaps in structures
As ACOs mature, companies like Cogent might become more attractive to hospitals that don't choose to set up accountability with physicians through employment. Currently, many hospitals already contract out the hospitalist function because they don't have to deal with the downsides of physician employment but do reap the benefits of standardization driven by a company that has thousands of physicians in a variety of care settings throughout the country. That allows hospitals to take advantage of the current institutional knowledge of many hospital systems without the capital investment required to replicate the complex patient information systems required for care standardization. Those same hospitals are realizing that other pieces of the in-hospital physician staff can also be outsourced, such as physicians who take care of patients in the emergency department and so-called intensivists, who take care of patients in the ICU.
"The same infrastructure we wrap around a group of hospitalists to improve their performance can easily be applied to docs working in the ICU," Greeno says. "The average hospital in this country will not be able to staff their ICU solely with ICU-trained docs. So this service will include some combination of critical care people who will be supplemented with hospitalists. Integration between the hospitalist and critical care program not only makes sense in continuum of care, but also makes sense in terms of providing an alternative physician staff model."
With a shortage of physicians in general, Greeno says such cross-training will become essential as ACOs mature. If that takes care of the hospital, however, there's much more work to do on the outpatient side, says CSC's Enders.
"If we just focus on the high-risk groups to start, among the challenges are the creation or expansion of sites of care that are conveniently located and staffed to make it easy for patients to have access to care," he says.