Topic # 3: Antepartum care

Do other hospitalist programs have an outpatient clinic?  If so, do you see both antepartums and postpartums?  If not, what is your system for referral and follow-up?

-Jody Tochterman MD

Sacred Heart Medical Center

Spokane, WA

I think it is a mistake for the Hospitalist to manage inpatients other than just post partum patients.  The folks at Good Samaritan Hospital in San Jose have an excellent policy for this.  Basically all such patients are placed on the MFM service and the Hospitalist may admit them but the MFM comes in the next AM and writes orders, progress notes and assumes management.  There is also a policy for what diagnoses require an immediate on site evaluation by the MFM.  Write Alan_Fishman@pediatrix.com if you want more information.

-Tom Garite, M.D.

In our program, the hospitalist is the attending, and the perinatologist the consulting.  This clarifies relationships, allows the hospitalist to charge for rounding, etc., and for the perinatologists to charge for additional consults if status changes.  The perinatologist, hospitalist, charge nurse, and resident (if applicable) round together daily, and the perinatologists appear prn otherwise.  In most cases the hospitalist delivers.  This creates

a very effective management team.

-Duncan Neilson, MD

Legacy Health System, Portland, Oregon

I would think it is fine to admit perinatal patients as long as the communication is good- where I was recently the perinatal group did not usually deliver their patient- the hospitalist generalist did. We had issues with good communication about the perinatal issues on occasion.

-Alison Madden

In our programs, we are the attending. We work closely with the perinatologists, but they don¹t want to do deliveries. They are very supportive and readily available for consultation and as a result we have also developed active maternal transport/transfer programs, which is extremely beneficial to the hospitals NICU. In one of our hospitals our presence has been the key factor and component in developing a congenital birth defect transport/transfer program. This has proven to be a boom for the hospital, the perinatologists, the neonatal specialty surgeons, the NICU, our program, and the patients!

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

Regional Medical Director-Questcare Obstetrics

OB-GYN Hospitalists

Dallas, Texas 75251

Our hospitalists admit OB and Gyn ER walk-ins and they are admitted under the name of the hospitalist who admits and are considered patients of our group.  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.

-Alan Fishman MD

Good Samaritan

San Jose, CA

Do other hospitalist programs have an outpatient clinic?  If so, do you see both antepartums and postpartums?  If not, what is your system for referral and follow-up?

-Jody Tochterman MD

Sacred Heart Medical Center

Spokane, WA

Again I think it is a mistake for hospitalists to have an antepartum service. This could result a fear over competition for cases by the primary doctors in the hospital and torpedo the hospitalist program.  Better to either admit them all to the perinatal service or have a panel of on call generalists for this.  The hospitalist could admit them then the MFM or the on call generalist could see them in the morning.

-Tom Garite, M.D.

In our program the hospitalists have no outpatient clinic responsibilities. This prevents the appearance of competition with the community physicians for patients.  I'm sure this will play out differently in different settings.

-Duncan Neilson, MD

Legacy Health System, Portland, Oregon

We also offer an extended services contract. This is a contract between the physician and us directly that creates a call partner situation with a price tag on our services. This is most popular with solo practitioners. We have several physicians that utilize this on a regular basis. They really appreciate it. It¹s a good deal for them and us, and it doesn¹t disrupt their global reimbursement as we bill them, not their patient¹s insurance.

If we perform gyn surgery on their patient, we do bill the patient¹s insurance.

We provide the ante-partum care for all of our patients with MFM consultation as indicated. We will provide ante-partum care for the patients of other physicians, but that requires an extended services agreement between Questcare and the physician. It¹s important to remember  the hospitalist program and the hospital have a contractual agreement that details services provided by the hospitalist program. Services being provided outside the scope of the contract, without some form of reimbursement, could be interpreted as the hospital providing (paying for) services to their staff physicians. This, of course, could have legal implications and hence the reason we created the additional services agreement.

 -Wayne L. Farley, Jr., DO, FACOG

Regional Medical Director-Questcare Obstetrics

OB-GYN Hospitalists