As USC Verdugo Hills Hospital implements an exclusive physician contract for pulmonary/critical care services in its intensive care unit, a debate over the pros and cons of exclusivity is playing out locally.
In January, the hospital began a pilot program in which ICU patients would be treated exclusively by on-duty or on-call intensive care doctors — also called intensivists — belonging to Pasadena-based Foothill Pulmonary and Critical Care Consultants Medical Group.
The hospital’s chief medical officer, Dr. Armand Dorian, said there’s an overwhelming amount of data and literature on the success rates of “closed” ICU units.
“‘Closed’ means that you have one quarterback running the show,” Dorian said. “That doesn’t mean you don’t have other players involved, but you have one person calling the plays.”
If patients with serious chronic health conditions — more likely to have a preexisting relationship with their own pulmonary/critical care physician — are admitted into the ICU and request their regular doctor, that physician may visit but cannot write or change orders without approval of the intensivist on duty.
Also under the new program, community doctors credentialed to act as intensivists who are not part of Foothill Pulmonary cannot bill for any time spent seeing patients in the unit.
Physician feedback was solicited in an Aug. 23 letter signed by USC Verdugo Hills Hospital Chief of Staff Dr. Steven Hartford and Chief Executive Keith Hobbs, explaining hospital and medical staff were “considering making the arrangement permanent.”
A handful of local doctors, many who’ve treated La Cañada patients in the ICU for decades, wrote letters claiming a closed unit would restrict physician access and patient choice. Among them was Steven Taback, a pulmonologist and critical care specialist who’s practiced locally since 1992.
“Your administrative policy excludes members of the medical staff with impeccable service records from caring for their patients and prevents members of the community from having access to the doctors who have loved and cared for them for many years,” Taback wrote in a Sept. 14 letter.
“How does this promote a nurturing, therapeutic environment for anyone?” he asked.
Michael Klein, a gastroenterologist and doctor of internal medicine who’s practiced locally for 46 years, submitted a letter to Hartford on Sept. 1 expressing his concern newly contracted intensivists might deny a patient’s request to see his or her regular critical care doctor, or treat them without their consent.
“What kind of physician would take on a contract that would damage a colleague’s career?” he asked in an interview. “If mom’s had the same pulmonary doctor for 10 years and he’s willing to see her, shouldn’t she be in charge?”
Administrators see benefits
While a request for an interview with Dr. Hartford was not answered, Dorian and Hobbs spoke in an-person interview. They explained the genesis of the pilot program and why the hospital’s Medical Executive Committee decided in late September to make the move permanent.
Dorian said when administrators looked at the ICU they came up against some “sub-optimal” statistics.
In the final quarter of 2016, the average patient stay in the unit was 7.15 days. Seven months into the pilot program, with in-house intensivists in place, the average length of stay dropped to 3.81 days. The incidence of bacterial infections from central line insertions and of clostridium difficile (C.diff) contamination also declined during the pilot study.
Administrators attribute the improvements to the more centralized, consistent care model provided by an exclusive contract, which keeps a specialized physician on site during the day and on call with a five-minute mandated response time at night. Hobbs said the transition reflected a changing trend in critical care.
“We are going to continue to look at how to move the needle to improve the quality of care,” Hobbs added, referring to that mission as the hospital’s true north. “That change inevitably will always cause somebody to raise a question — but as long as you’re improving the quality of care, who’s not going to want to go with that model?”
Dorian said when the hospital put out a request for proposals in 2016 seeking specialist physician groups to contract for exclusive ICU services first under the pilot program, Taback’s own Glendale-based firm, Consultants for Lung Diseases Medical Group, Inc., was one of the bidders who submitted a proposal.
Ultimately, Foothill Pulmonary was chosen over Taback’s group and other contenders, including a group of USC physicians.
“To complain morally and saying we’re doing a disservice, when you’re offering yourself up to get the contract makes no sense,” the chief medical officer said.
Physicians seek inclusion
Taback acknowledged he informally submitted a quote for full exclusive services and also put forth a hybrid model that would let qualified community doctors take turns being the on-site/on-call intensivist on any given day, while allowing other critical care physicians to continue to make rounds and bill accordingly.
He said he’s not against on-duty intensivists, just the exclusion of other doctors.
As the co-medical director of Providence St. Joseph Medical Center’s 40-bed ICU in Burbank, Taback helped establish a hybrid intensivist program similar to the one he proposed for USC Verdugo Hills Hospital.
Now, St. Joseph contracts with Manhattan Beach-based Benchmark Hospitalists, which administratively supports regular pulmonary critical care doctors as they make rounds and act as on-site intensivists on a rotational basis.
“Instead of doing it independently, we’re organized and working together,” Taback said. “It’s a little bit more laborious … but there’s been no backlash. And, more importantly, patients get to see the doctors they want to see.”
Although Dorian and Hobbs maintained closed ICUs are an increasing trend, other area hospitals employ slightly different intensivist models.
Glendale Adventist, for example, uses intensivists from partnering Loma Linda University Medical Center as supervisors in its 50-bed ICU but still allows critical care physicians to see and treat patients.
Dr. Arby Nahapetian, Adventist’s regional chief medical officer, said doctors and intensivists are mandated to consult with one another about a patient so the individual’s history in and outside of the ICU is consistently tracked.
“You get ICU specialists there with 24/7 boots on the ground, but a primary doctor who knows the patient best is allowed to follow along and contribute — it’s the best of both worlds,” Nahapetian said.
While USC Verdugo Hills Hospital’s ICU will remain closed in an exclusive contract with Foothill Pulmonary, administrators plan to reconvene with physicians after a one-year period to review data.
“If it ends up going the opposite direction, we’ll modify it again,” Hobbs said. “But if it shows great outcomes, we’ll all look around the room and go, ‘OK, that was a great decision.’”