Topic # 1: Who should be the attending?

As you know, at Evergreen Healthcare, we are doing both OB and emergency GYN from the ED.  We also were trying to work more closely with the perinatalogists.  On occasion we have been asked to admit an OB patient from the perinatal office.  This is usually a patient that the perinatalogist is consulting on and the patient does not have a primary OB at Evergreen, but now wants to deliver at Evergreen or the perinatalogist feels she need to be admitted.  The question is who is the attending in these cases? Should it be the OB hospitalist or the perinatalogist?  I am getting some push back from my hospitalists on this.  My hospitalists feel that if the perinatalogist saw the patient first, then he or she should manage the care.  On the other hand, I feel we should maybe help out the perinatalogists in these cases and let them just consult.

-Terry Pheifer M.D.

Evergreen Healthcare

12040 NE 128th Street

Kirkland, WA  98034

OBX guidelines for Inpatient Care with OB Hospitalist

* The MFM on call will serve as the back up for the hospitalist and will come in to the hospital to evaluate patient if requested by the hospitalist.

* The MFM on call will assist the hospitalist for C/S if needed, or back up for delivery if the hospitalist is otherwise occupied or for twin deliveries.

* OBX C/S deliveries >23 wks and <28 wks, and medically complicated deliveries will be attended by MFM on call (excluding IUFD, induction terminations)

* The Hospitalist will cover other unscheduled OBX deliveries.

* The Hospitalist will cover IUFD or induction termination deliveries

* MFM will continue to provide consultation to OB¹s as requested; these consultation requests will not be delegated to OB hospitalist.

* Transports will be accepted and managed by MFM, with initial evaluation of the patient done by OB hospitalist, with report to MFM.  All undelivered antepartum transport patients will have MFM note/plan of care on chart within 24 hours of arrival at hospital.

* Any Hospitalist patients will be considered OBX inpatients and AM rounds will include perinatologist and hospitalist rounding on the service.  MFM note and plan of care must be placed on chart for all:

1. Preterm or medically complicated patients

2. Patients with active medical problems

3. Patients whose condition is considered medically unstable or requiring

    consultation from other medical specialists

* Hospitalist can round on postpartum and stable antepartum patients with report to MFM.

* Comprehensive US, Doppler studies, multiples done by MFM,

* Repeat US, Limited US done by hospitalist as requested

* Rescue cerclages will be placed by MFM.

Our group is part of the MFM group (Obstetrix Medical Group) and we have MFM back up to OB hospitalists for all patients on the service.  I am the medical director of Obstetrix medical group and the medical director of OB at Good Samaritan.

-Alan Fishman

Obstetrix Medical Group

San Jose, CA

8/27

Our group of OB hospitalists has had a contract from the hospital for 4 years to care for high risk antepartum transfers, and patients who arrive in the ER or OB triage > 12 weeks. Our income derives from monies the hospital used to pay residents to moonlight after hours + up to a certain amount from monies derived from charges made to the patients and/or their insurance carrier/Medicaid. We also assist the private doctors at C/S and see their patients when requested, time allowing. Our inpatient census varies from about 10 to 25 patients and averages about 15.

There are 6,000 deliveries per/year. There is a level 3 NICU. The hospital has more than recouped their money from the increased NICU revenue, as they have been able to actively market the NICU to attract more antepartum transfers. It has been a win-win situation. All of the hospitalists really enjoy their work, the nurses appreciate having physicians there 24/7 and the private doctors really, really like not having to see drop-ins or high risk transfers plus we are there for the rare times they cannot make a delivery or have a sudden unexpected OB catastrophe. I'm sure the hospital enjoys having happy staff plus the enhanced NICU revenues.

I do not know how many deliveries per year a hospital would have to have to make our type program work but I am sure someone could work that out.

-Bill Griffin, MD

Dallas, TX

 Questcare Obstetrics in Dallas Texas - This service is offered to the staff physicians we work with, on a "limited" basis. If an ob-gyn staff physician wants us to do this on a regular basis, we have a separate "Extended & Additional Services" agreement between Questcare and the physician. These services are billed to the physician directly, not the patient, not the patient's insurance. This has made the physicians very happy, and it doesn't disturb the global reimbursement to the physicians. Many physicians have become extremely disgruntled with hospitalists billing the patient, or their insurance, because of the impact it has on the global fee. We have had no problem invoicing the physicians for the extended and additional services, and they appreciate the freedom it gives them. We have had no problems collecting these fees from the physicians. Needless to say, the agreement is extremely detailed as far as services provided and how the billing process works. In short, it's an hourly charge + a delivery charge.

-Wayne L. Farley, Jr., DO, FACOG

Regional Medical Director-Questcare Obstetrics

OB-GYN Hospitalists

12221 Merit Drive  #530

Dallas, Texas  75251

p 214.217.1900

f 214.217.1901

E-mail  wfarley@questcare.net