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Annual Session News

Can the hospitalist movement live up to its potential

From the May 1998 ACP Observer, copyright 1998 by the American College of Physicians.

By Deborah Gesensway

SAN DIEGO—The concept of having general internists who take care of patients only in the hospital may be a clever idea, but it won't be a great idea until research proves its worth. That was the message of the keynote speaker at the first meeting of the National Association of Inpatient Physicians (NAIP), held last month in conjunction with Annual Session.

"Can the hospitalist movement live up to its promise?" John Eisenberg, MACP, administrator of the federal Agency for Health Care Policy and Research (AHCPR), asked the more than 200 hospitalists and other health care providers attending the one-day meeting. Earlier this year, NAIP agreed to become an affiliate of ACP; the College co-sponsored the day-long meeting, "Transforming the Acute Hospital Setting."

Dr. Eisenberg said the enthusiasm today about the hospitalist movement—NAIP estimates there are now about 2,500 to 3,000 hospitalists in practice, up from a handful a few years ago—reminds him of the excitement that the "gatekeeper" model generated a decade ago. "It had a lot of promise, but there were problems," he said.

Because there was no research to analyze whether the gatekeeper model could be made to work well for patients, physicians and delivery systems, Dr. Eisenberg said, it has not been able to survive patient dissatisfaction and is losing support. Many health plans are now backing away from requiring primary care gatekeepers for their enrollees.

NAIP co-founder John R. Nelson, ACP Member, a hospitalist in Gainesville, Fla., acknowledged that a major challenge currently facing hospitalists is overcoming the misconception that HMOs invented the idea of inpatient-only primary care doctors. With the current public backlash against managed care, hospitalists will have to guard against being discredited as simply another managed care ploy to save money.

"We aren't just moonlighters or house doctors," said Winthrop F. Whitcomb, ACP Member, NAIP's other co-founder. Hospitalists are seeking to transform the acute care setting so that physicians no longer have to leave the medical care of their hospitalized patients in the hands of procedural subspecialists, he said.

Dr. Eisenberg acknowledged that hospitalists have the potential to improve continuity of care; improve communication with families, nurses and specialists; become specialists in end-of-life care; develop protocols and information systems in hospital systems; and improve the lives of outpatient-based primary care physicians. By improving the day-to-day activities of all internists, he said, hospitalists could actually help attract more physicians to general internal medicine.

"I think you've got a lot of good hypotheses," Dr. Eisenberg told the audience, adding that AHCPR is interested in funding research proposals to scientifically test these assertions.

Exploring strategy

Hospitalists at the NAIP meeting also explored many of the logistical and political issues facing them.

For example, doctors at the conference agreed that it can be difficult to make a living in an all-inpatient primary care practice. The average hospitalist can only treat 10 to 15 patients a day, and they do few billable procedures. Hospitals, however, are finding that hospitalists help them save money by cutting average lengths-of-stay.

"It's absolutely essential to gainshare with our hospital or with the health plan," Dr. Whitcomb said. "But how do we do it?" Perhaps just as importantly, hospitalists need to understand the anti-kickback laws so that any incentive-sharing plan set up won't run afoul of investigators looking for fraud and abuse in the health care system.

According to Rulon F. Stacey, president and CEO of Poudre Valley Health System in Fort Collins, Colo., to avoid payment schemes that resemble hospital kickbacks, hospitalists need to make sure that incentive systems reward groups, not individuals. For example, Mr. Stacey, who has had experience setting up hospitalist systems in two very different markets, said that incentives should not be directly related to one physician's care of one patient.

New data

At the conference, NAIP organizers also released preliminary data from a survey trying to describe the make-up of hospitalists. The survey found that 55% of hospitalists were generalists and 45% were subspecialists.

The average age of respondents was 40, and 81% were men. A third of the respondents said they were employed by a medical group, a quarter worked for a hospital, and 16% were employed by a managed care organization. About a quarter reported that they maintained some outpatient practice. More than half—54%—worked in a teaching setting.

Respondents earn an average salary of $145,000 and work an average of 58 hours per week. Nearly all—95%—said they were somewhat or very satisfied with their profession.

For information about becoming a member of NAIP call 800-843-3360.

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