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Secondly, consider what can realistically be done to make a hospitalist program a viable service to the provider community and members? There are financial, political and quality of care issues that must be considered in the equation. For example, no referrals to the hospitalist equal failure before it starts. Find the catalyst that will persuade the physician community and the members that using a hospitalist program is a good thing. Will the ER physicians promote the program and refer the patients? Will the specialists promote the program if it means that the PCP will be available for pre-op exams? Will the PCP support the program if there is a relief from night and weekend coverage? Will the member push the program because of physician availability in the off-hours? Will the hospital support the program? Do the discharge planners for the hospital support the program?

Understanding the political, economic and satisfaction issues in the organization and community and then solidifying the base of support for the hospitalist program is a crucial step once the goals of the program have been determined.

At the point where the goals of the hospitalist program are clearly spelled out, the political and socio-economic factors driving the success of the program are understood and the likelihood of success is calculated, it is time to begin the crucial make vs. buy decision process.

Make vs. Buy Decisions

Make:

1. You have enough talented and interested Internal Medicine physicians to do the job.

2. Your PCPs agree to stay in their offices and not go to the hospitals.

3. You have a leader who can educate, train and lead the hospitalists so as to reduce the LOS and admissions to the hospital.

4. You can use the internal team to redirect admissions to many different hospitals or does the team want one location that is near and convenient to the office practice?

5. You have a MIS system set up to allow efficient reporting and tracking of performance and information to the PCPs.

6. You have an incentive program built in to get maximum improvement or is it business as usual?

7. You have enough manpower to be able to flex for holidays and illness.

8. You will hire full-time MDI to work in the program realizing some shared gains from the improved performance will pay their salary as well as what FFS will bring in. If no increased returns are forthcoming, then this is a very expensive program for the convenience factor of FPs and senior IMs, as their salary will go down to cover the cost.

Buy:

1. The track record and reference check of the hospitalist program are good.

2. The satisfaction surveys of both physicians and members is high.

3. The hospital has a strong incentive to work with the hospitalist program to reduce LOS. Avoid relationships with hospitalist programs that have a financial linkage to the hospital that will encourage admissions and reduce the effectiveness of the program.

4. You have the support of enough senior MDs to help defray the cost of the per diems in exchange for no more on-call.

Finally, just having a hospitalist does not make a good program. It needs to fill a need or solve a problem (real or perceived). Also, it needs a push from someone to reach critical mass and become self-sustaining.

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