Hospitalists reduce costs, but jury is still out on how they improve care
Early data show benefits extend to patient outcomes
If you want to crank up the heat in a gathering of doctors, just mention the word "hospitalist," referring to the growing number of physicians dedicated to inpatient care. On average, the use of hospitalists reduces costs and length of stay (LOS) by 20%, but do they improve care?
According to the National Association of Inpatient Physicians (NAIP) in Philadelphia, "hospitalist" is a job description rather than a certified specialty. Hospitalists come primarily from the specialties of internal medicine and pediatrics. If the idea hasn’t hit your area yet, it may come soon. By NAIP’s count, there were approximately 300 hospitalists in 1995; today, there are 4,000 across the country.
In theory, the notion of an on-site doctor has considerable appeal. He or she would be available day or night for emergencies. LOS would diminish. Procedures could be standardized, and unassigned patients would receive more efficient care. Hospitalists would have more expertise in inpatient procedures through sheer repetition, which could reduce errors now that primary care physicians spend less time in the hospital. According to American Medical Association figures, primary care physicians now average 9.6 patient visits on rounds each week; in 1985, the average was 22.
As with any new wrinkle, though, the appearance of hospitalists evokes a lot of skepticism. One concern is the quality of communication between the hospitalist and the primary care physician at both ends of the inpatient stay. Another is interruption of the doctor-patient relationship when the patient is most ill. In the absence of convincing improvements in patient outcomes, some question the real motivation behind the movement.
Many a slip when theory goes to work
One insurance carrier, Humana, based in Louisville, KY, has developed some experience with hospitalists. The company accumulated its program in the San Antonio, TX, market between 1994 and 1996. According to Humana’s spokeswo man, Mary Sellers, approximately 10% of the carrier’s 6.1 million members use hospitalists for inpatient care. It makes the most sense in urban areas, she explains. In rural and smaller communities, primary care physicians can handle both inpatient and outpatient care. (In the chart, "Four Practice Models for Hospitalist Services," you’ll find descriptions of hospitalist models and their strengths and pitfalls, p. 115.)
Convincing primary care physicians that hospitalists are good for them — or for their patients — is no easy feat, however. In the Rockford, IL, area, where 20% of the market is at full capitation, the introduction of hospitalists is up for consideration at SwedishAmerican Health System. Robert Klint, MD, president and CEO of the facility, surmises that prime targets for affirmative votes might be general internists who drive 45 minutes to see hospitalized patients as well as those who are near retirement and weary of midnight treks to emergency rooms. But, Klint wonders, what’s going to attract the doctor who faces income losses from hospital visits?
Patients would have their objections as well, he adds. "The public wants a choice of doctors, so how would people react to being transferred away from their doctor when they get sick?"
That interference in the doctor-patient relationship could cut both ways, cautions a 1998 statement on the hospitalist movement issued by the Kansas City, MO-based American Academy of Family Physicians (AAFP). Patient satisfaction might suffer if the patient becomes attached to the hospitalist and is forced to sever the tie when he or she goes home, the statement says.
Still, Humana reports that in its poll, 86% of the Medicare beneficiaries who used hospitalist services say they would choose a similar care model again.
Physicians are often reluctant to accept hospitalists at first, concedes Sellers. But, she continues, "the majority of physicians see the value after they have been in the program for a time." While participation in Humana’s hospitalist programs is optional, Sellers candidly explains that the persuasion to join is intense. "If primary care physicians can demonstrate that they can come up with the same clinical outcomes as hospitalists, we encourage them to continue inpatient care as well as outpatient — if they are that superhuman!"
Humana’s criteria are based on complication rates, length of stay, availability for consultation with specialists, and feedback from nurses and patients.
Cornel Lupu, MD, a Miami-based general internist, expresses doubts about whether hospitalists can maintain the cost benefits they’re showing at this point. "I don’t think they’re going to save money by doing less testing because their feet are held to the same fire as ours. Everybody seems to forget that we are all being watched constantly," he says. His doubts don’t stop there, either.
Supposedly, the community and hospital physicians share responsibility for continuity of care. When the hand-off from community to hospital works as it should, the hospitalist faxes or e-mails admission notes to the community-based doctor within 12 to 24 hours. Similar time frames apply for detailed discharge summaries. "The most important thing the outpatient physician wants is a phone call on both ends of the hospitalization," asserts NAIP’s co-president, Winthrop F. Whitcomb, MD.
Lupu retorts, "In my personal experience with hospitalists, I have yet to receive meaningful information on my patients’ inpatient care!"
Weak communication links raise questions about accountability, Lupu points out. "Hospital ists will get better lengths of stay than we have now because they will push patients out sicker than they are now! But when something goes wrong, I suspect we’ll be blamed, even if the decision was made in the hospital — and even if we were not part of the decision." The use of hospitalists provides fertile ground for medical and legal problems to develop, he fears. "And the primary care doctor or the internist will end up with the blame."
Doctors on the West Coast share Lupu’s discontent. The chief complaint about hospitalists, according to a recent survey by the California Academy of Family Physicians in San Francisco, is poor communication between primary care physicians and hospitalists.
The point is not lost on the California Academy, which advises its members to investigate the mechanisms for continuity of care and patient satisfaction when they consider the switch to a hospitalist program.
In a word, it’s still too early to say whether patients do better when hospitalists take care of them. However, early data suggest that outcomes might improve as time goes on. For example, in a study of 144 Humana myocardial infarction patients in Kansas City, MO, 68% received beta blockers under the care of hospitalists. Compare that to the Cooperative Cardiovascular Project study of 201,752 eligible patients, in which 34% received the medication.1
Yet, Whitcomb says frankly, "The jury is still out whether the quality of care improves in a hospitalist system." However, he notes, hospitalists tend to introduce and support processes that are known to improve patient outcomes. By virtue of their availability, hospitalists can participate in team projects with nurses, pharmacists, social workers, chaplains, and case managers on care decisions and guideline development.
The burgeoning number of hospitalists leads Lupu to wonder where health systems find people with that much expertise in inpatient care. "In Israel and Europe, they train and pass exams in hospital-based medicine," he notes. In the United States, at this stage anyway, "It’s another source of income for an internist who has not built a busy practice," he observes.
Klint confesses he is unconvinced that a desire for better patient outcomes drives the hospitalist movement. "If nobody knows about the quality produced by this new service," he observes, "I have to assume it’s a matter other than patient outcomes. When I’m studying something like this and I don’t know what’s driving it, I follow the money."
Reference
1. Gottlieb SS, McCarter RJ, Vogel RA. Effect of beta-blockade on mortality among high-risk and low-risk patients after myocardial infarction. N Engl J Med 1998; 339:489-497.
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