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Their use expands even as debate broadens
They go by a number of names. By some accounts, their numbers are swelling. To some players in the health care industry, they represent a promising means to more closely control costs. To others, their presence signifies a dangerous rift in the close relationship between patient and primary physician.
Hospitalists — inpatient physicians, hospital managers, inpatient consultants, admitting officers — are definitely in the news. In the business press, The Wall Street Journal recently called them the "new breed of doctors taking full charge of stays in the hospital." Meanwhile, an entire volume of the American College of Physicians’ Annals of Internal Medicine was recently devoted to a review of the hospitalist movement in the United States.
Even though the role of hospitalists in the nation’s health care system seems destined to grow, a sometimes-heated debate over this model of care remains under way. In this issue of Healthcare Benchmarks, we’ll present some facts and benchmarkable data about hospitalists and the controversy engendered by their emergence. Next month, we’ll take a closer look at how a number of health care organizations have used this model to their — and their patients’ — benefit.
Simply stated, "A hospitalist is a physician dedicated to the care of hospitalized patients," according to the National Association of Inpatient Physicians (NAIP). "Hospitalists coordinate all aspects of an inpatient’s care, including regular visits to the bedside, ordering tests and medications, integrating recommendations from the specialists, and updating the family until discharge when care is transferred to the patient’s primary physician."
Hospitalist is a job description, according to NAIP co-president, Winthrop F. Whitcomb, MD, "although I think that ultimately it will become a recognized specialty." About 55% of practicing hospitalists are trained in general internal medicine, he notes. Another 35% are trained in a subspecialty such as critical care or pulmonary medicine, about 6% in family practice, and the remainder mostly in pediatrics.
The number of hospitalists is growing, and that growth has been explosive. According to Whitcomb, NAIP estimated that some 300 doctors were practicing hospitalists in 1995; by mid-1999, that figure had grown to 4,000. "By the time things level out in the next decade," he says, "we estimate that there will be approximately 20,000 practicing hospitalists nationally."
Hospitalists work from a variety of platforms. A survey of 400 NAIP members at the end of 1997 showed that 35% of them were employed by a medical group, he says. Meanwhile, some 23% were employed by hospitals, 14% by HMOs, and another 12% by freestanding, hospitalist-only medical groups.
Since first emerging in northern California in the early 1990s, the hospitalist model for inpatient care has gained a lot of ground, according to Robert M. Wachter, MD, in the department of medicine at the University of California, San Francisco. "In the Bay area, you pretty much cannot find a hospital now that doesn’t use hospitalists for at least part of their inpatient care," he notes.
Elsewhere, the hospitalist movement has taken root in a variety of markets, he says. "In general, you are seeing it happen a bit more quickly in markets that have more competitive environments where there is a lot of managed care," such as Los Angeles, San Diego, and Minneapolis. "But at the same time, I have been struck by the fact that you also see this model of care in markets where there is almost no managed care, such as some rural areas," he notes.
Advantages touted for patients, physicians
Proponents of the hospitalist model focus many of their arguments on economics. "On average, most places that have developed hospitalist programs have seen decreases in patient care costs and [length of stay] of about 20%," says Wachter.
Other major advantages of the hospitalist model, as published in a 1998 report by the Council on Medical Service of the American Medical Association titled "The Emerging Use of Hospitalists," include:
- Improved quality of care and clinical outcomes in the inpatient setting due to the increased expertise and experience of hospitalists, particularly with respect to severely ill patients.
- Improved efficiency and patient satisfaction in the inpatient setting because the hospitalist is available throughout the entire day to see hospitalized patients and to assess potential admissions from the emergency room.
- Improved quality, efficiency, and patient satisfaction in the outpatient setting because the practice of the office-based physician is not interrupted by inpatient rounds and midday emergencies with hospitalized patients, and time is not wasted traveling to and from the hospital.
- Enhanced accountability and investment in the hospital quality improvement process due to the hospitalist being located in the hospital for a considerable portion of each day.
There are a number of potential disadvantages to the hospitalist model — one of which, in the eyes of many, undermines all the purported benefits. "When the primary physician doesn’t follow the patient into the hospital, the continuity of care is negatively affected," according to Lanny Copeland, MD, president of the American Academy of Family Physicians.
This is a valid concern, says Whitcomb. "The handoff of the patient from primary physician to hospitalist upon admission is definitely the weak link in the chain," he notes. "When care is transferred from one physician to another, there is typically a voltage drop’ in information that goes along with the patient.
Copeland also has other concerns. "Cost savings [resulting from hospitalist use] have been talked about, but I have seen no figures to substantiate it as cost-effective," he says. "Indeed, I sometimes wonder if a hospitalist that does not know a patient — despite having discussed the patient with the primary physician — may be more inclined to order more in the way of studies and tests."
While the jury may still be out on whether the hospitalist model saves health care payer dollars, "Managed care companies are looking at preliminary data showing hospitalists cut costs by roughly 10% to 25%," says Whitcomb. As a result, many MCOs, primarily in Texas, Missouri, and Florida, "are requiring their primary care physicians to hand off hospital care, effectively mandating the use of hospitalists."
This approach has caused a backlash on the part of primary care physicians and organized medicine, according to Whitcomb. This is unfortunate, he says. "It is critical that primary physicians be vested in the success of the hospitalist model because it is a good model for outpatient as well as inpatient care," says Whitcomb.
"When primary physicians hand off to hospitalists, it changes the way they practice office medicine. We’ve seen data showing that access, wait times, and patient satisfaction in outpatient settings improve with the use of hospitalists because of the increased availability of primary physicians who aren’t making trips to the hospital any more," he says.
The key to making the hospitalist model work in today’s health care system is to make the "handoff at the hospital" voluntary, which is the official NAIP position, according to Whitcomb.
"The primary physician has to endorse the hospitalist to the patient, introduce the patient to what is going on, and assure the patient that there will be continued communication between the primary physician and the hospitalist," he explains. Cooperation between the two caregivers is essential to avoiding the "voltage drop" phenomenon. At the same time, "this cooperation will not occur under the mandatory’ hospitalist model."
There may be lessons to learn from the past. Today’s hospitalist debate mirrors questions raised earlier this century about the use of emergency room physicians, says Norm Jacobson, MD, chairman of San Antonio-based Hospital Inpatient Management Systems, a company that provides hospitalists to health care organizations.
"Many doctors were initially very threatened by the introduction of ER physicians; they thought they would lose patients and revenues. But it was the right thing to do from a quality standpoint," he notes. It took a few years for the doctors’ fears to prove unfounded, adds Jacobson, "and now ER physicians are a centerpiece of the way health care is delivered in our country today."
[For more information, contact:
• The National Association of Inpatient Physicians, Independence Mall West, Sixth St. at Race, Philadel-phia, PA 19106. Telephone: (215) 351-2740 or (800) 843-3360. Web site: http://www.acponline.org.
• Robert M. Wachter, MD, University of California San Francisco, Department of Medicine, P.O. Box 0120, 505 Parnassus Ave., San Francisco, CA 94143. Telephone: (415) 476-5632.
• American Academy of Family Physicians, 880 Ward Parkway, Kansas City, MO 64114. Telephone: (816) 333-9700. E-mail: firstname.lastname@example.org. Web site: http://www.aafp.org.
• Norm Jacobson, MD, Chairman, Hospital Inpatient Management Systems, 8-38 Wurzbach Road, Suite 360, San Antonio, TX 78229. Telephone: (210) 614-0500.]