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Despite their booming numbers, hospitalists face growing pains

From the May 2001 ACP-ASIM Observer, copyright © 2001 by the American College of Physicians-American Society of Internal Medicine.

By Phyllis Maguire

How hospitalists are shaping residency training

Atlanta—While the hospitalist movement continues to enjoy explosive growth—and perhaps more importantly, acceptance by internists—the emerging specialty faces some challenges in the coming years to sustain that growth.

At a state-of-the-union address on the hospitalist movement during Annual Session, Robert M. Wachter, FACP, explained that physicians today not only are comfortable working with hospitalists, but that they are actually driving the specialty’s growth by demanding that their hospitals or group practices contract with hospitalists.

Dr. Wachter, who is president of the National Association of Inpatient Physicians (NAIP) and coined the term "hospitalist" in a 1996 New England Journal of Medicine article, explained that physicians’ growing acceptance of hospitalists comes in part from the economic advantages the specialty offers. He cited research showing that physicians who refer their inpatients to hospitalists can see their incomes rise between $20,000 and $47,000.

Dr. Wachter (left) discusses with session attendees how hospitalists can benefit office-based physicians.

Despite these advantages, he said, the hospitalist movement must still overcome some barriers, some of them financial. For example, because hospitalists can’t bill for many of the services they provide—such as multiple visits with patients and separate family meetings—the physicians or institutions they work with typically subsidize their salaries. And while hospitalists help the bottom line of many physicians, certain subspecialties still view the emerging specialty more as a threat than an opportunity.

Growth

Dr. Wachter, associate chair of the department of medicine at the University of California, San Francisco, estimated that 4,500 hospitalists now practice nationwide. The field is growing so quickly that there are more hospitalist positions available than there are physicians to fill them.

Just a few years ago, he said, many internists mistrusted hospitalists, in part because health plans attempted to force them to work with hospitalists. Today, however, physicians are embracing the specialty because many don’t want to manage a shrinking number of inpatients.

Twenty years ago, Dr. Wachter explained, general internists might spend as much as 40% of their workday managing 10 or 12 hospitalized patients. In California, where he practices, that percentage has shrunk to 10%, with an average census of one. A growing number of primary care physicians are realizing that commuting to see one patient a day may be inefficient—and expensive.

"A major driver here is the increasing demands on our time," he explained, "and the recognition that we can't be in two places at once."

Using hospitalists can also provide some distinct financial advantages for office-based physicians. Dr. Wachter cited research from The Advisory Board, a Washington-based consulting group, which found that capitated physicians who give up hospital rounds can earn just under $47,000 more each year. (The research assumes that the physicians can fill the time not being spent on rounds with more patient visits.)

The same study found that fee-for-service physicians who forego inpatients would lose close to $30,000 in hospital fees. However, they would gain more than $53,000 in additional office fees, producing a net increase of more than $23,000.

Dr. Wachter pointed to evidence that the hospitalist model is indeed "a better mousetrap" when it comes to costs. Several studies have shown that institutions that use hospitalists have seen a 15% drop in both hospital costs and length of stay.

Evidence of a quality advantage is emerging as well, he said, although more sensitive quality measurements are needed. One study he cited found that using hospitalists led to a 54% decrease in re-admissions. Unpublished studies presented at the NAIP annual meeting preceding Annual Session found a 33% decrease in inpatient mortality at a community teaching hospital.

Part of that success comes from the variety of roles that hospitalists fill. Dr. Wachter noted that while most now rotate in intensive care units, many have taken over triage in emergency rooms and are increasingly the physician of record for surgical patients, a trend that could have enormous implications for the field's growth. Hospitalists are also becoming more prominent in end-of-life care and are taking leadership roles on hospital committees.

Reimbursement issues

While financial considerations are helping drive the growth of the hospitalist movement, reimbursement remains in flux. Because hospitalists rarely pay for themselves through billing Medicare or other payers, their pay usually must be subsidized by a hospital or group practice.

"It's not a procedure-based specialty. Its goals are instead to move patients through a complicated system more efficiently," Dr. Wachter explained. "Much of what hospitalists do—calling primary care physicians, meeting with families or case managers, seeing patients several times a day—is not reimbursed."

When hospitals have tried to make hospitalists pay their own way, he said, they have created unsustainable workloads. Some programs have also tried to use incentives linked to costs and length of stay, but they typically run afoul of gainsharing regulations. As a result, many hospitalist programs are moving to straight salaries.

Most hospitals now accept that 20% to 45% of hospitalists' salaries, which average $150,000, needs to be subsidized. If a hospitalist bills $80,000, some entity—usually a hospital, managed care company, medical group or a combination of all three—has to ante up the rest.

The selling point is return on investment. "Our program at UCSF saved about $10 million and 5,000 bed days in the last five years because of hospitalists," Dr. Wachter said. "The return on investment is at least five-to-one."

A reasonable hospitalist census is between 11 and 15, he added. "Certainly in some places hospitalists manage 20 patients, which may be OK if none are in the ICU and length of stay is fairly long," Dr. Wachter said. "But if your census is consistently in the high teens, you're shooting yourself in the foot in terms of efficiency and burnout."

He said that a census of less than 10 makes it hard to justify a program, and that a hospitalist's annual admissions should range between 400 and 700.

Continuity and other issues

As the hospitalist movement matures, old problems have faded and new concerns have evolved. Dr. Wachter identified the following factors that may affect the relationship between hospitalists and other physicians:

  • Continuity of care. The fact that patients are "handed off" to hospitalists was always considered the specialty's Achilles' heel. Critics frequently charged that the disruption would compromise care.

    But in the past few years, Dr. Wachter said, more physicians have realized that hospitalists bring their own kind of continuity. Because they remain in the hospital, they can follow a patient to the ICU, for instance, or track down X-rays and meet with consultants and family members.

    "No matter how committed a primary care doctor is," Dr. Wachter said, "if he has an office full of patients, he can't do any of these things.

    Most hospitalist schedules—with 10 days on and several days off, for example—maximize the probability that patients will have only one physician in the hospital. And most hospitalists and primary care physicians have worked out a system of communication to guard against what Dr. Wachter called "a voltage drop" of discontinuous care, with phone calls exchanged at admission and discharge.

    Office-based physicians have also made the hand-off smoother by staying in touch with patients through phone calls or social visits, letting patients know they are following their care.

  • Patient satisfaction. Critics once claimed that patients would balk at being cared for by a new physician and that patient satisfaction under hospitalists would nosedive. While there are few published data, Dr. Wachter said, surveys suggest that patients accept the fact that different specialists take care of them in different settings. As an example, he pointed to the emergency room, where another site-specific specialty has emerged.

    Dr. Wachter acknowledged that some studies have shown that patients are uncomfortable with a new physician, but other patients find that availability more than makes up for the lack of familiarity. And research from the Park Nicollet Clinic in Minnesota found that outpatient satisfaction actually increased under hospitalist programs, because primary care physicians were more available for office visits.

  • Physician satisfaction. While more than half of primary care physicians say that patients "might get better care" with hospitalists, two factors seem to directly affect physician attitudes: familiarity with hospitalists and whether or not hospitalist use is mandatory.

    Dr. Wachter explained that surveys bear out the position of the NAIP and the College: Physicians are satisfied with the hospitalist model as long as it is not shoved down their throats.

    While more primary care physicians are embracing the model, Dr. Wachter said, some subspecialists still have concerns. Infectious disease specialists, for instance, who used to be routinely consulted for pneumonia admissions, are finding those consults drying up under hospitalists.

    Many procedure-based subspecialists, however, like hospitalists because they free up more beds. (Dr. Wachter presented data that showed that using hospitalists can lead to hospital discharges of a half-day to almost a full-day earlier.) Neurosurgeons, for instance, are pleased that pneumonia patients get discharged sooner, opening up more beds for their own highly reimbursed procedures.

  • Interpersonal issues. Finally, Dr. Wachter said that some sticky interpersonal issues remain. One physician in the audience commented that he finds some hospitalists guilty of an off-putting elitism when dealing with primary care physicians. Dr. Wachter agreed that many physicians have that perception, but he countered that some hospitalists think other physicians view them as little more than super-residents.

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How hospitalists are shaping residency training

Because the use of hospitalists is growing fastest within academic medical centers, it is changing internal medicine training—and the career choices of a growing number of internists.

Robert M. Wachter, FACP, associate chair of the department of medicine at the University of California, San Francisco, said that residents at his hospital have a 75% chance of working with an attending who is a hospitalist. In some centers around the country, that probability is 100%.

"Inpatient training is very quickly shifting to being run by hospitalists," said Dr. Wachter, who is also president of the National Association of Inpatient Physicians. "It is having a big impact on role-modeling and may markedly influence the credibility of the field."

As evidence, he pointed to a survey with 1997 data showing that while 90% of hospitalists were internists, only 60% of them had generalist backgrounds. By 1999, internists continued to account for 90% of all hospitalists, but 74% of them had been trained in general internal medicine.

When hospitalist programs first emerged in the mid-to-late 1990s, Dr. Wachter explained, many pulmonary/critical care specialists were pulled from intensive care units to fill hospitalist slots. Since 1997, however, more internists have chosen a distinct hospitalist track, letting critical care specialists go back to critical care.

"The hospitalist model is a morphing together of acute care with generalism," Dr. Wachter said. "For many internal medicine trainees, that's exactly what they want to do."

He emphasized that the specialty’s growth will not threaten the value of internal medicine training for primary care physicians. Generalist training gives physicians a much greater ability to manage complicated illnesses, Dr. Wachter explained, even if a time comes when general internists stop caring for hospitalized patients.

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