Until recently, most primary care doctors cared for their patients both in and out of the hospital, but with the emergence of hospitalists, hospital medicine has morphed into a calling all its own.
Most things happen most of the time for a reason.
Over the past several years Medicare was paying hospitals not on a "cost plus" basis, and not by the number of days the patient spends in the hospital, but based on "DRG's" - Diagnosis Related Groups. In other words, whether a patient with Pneumonia will spend in the hospital 3 days or 7, the hospital will get paid the same amount of money.
Hospitalists help streamline the management of the admissions, they are on site all day, not just for a short time like office based doctors as they make their daily rounds before or after their office hours. Hospitalists are in a better position to react promptly to new test results and other information. Overall, the so called "length of stay" tends to be shorter when a Hospitalist is in charge of the admission. Is the care better? Overall, I'd say, probably yes. Many office based doctors over the years fall out of touch with acute care management - more than they may realize.
Hospitalist programs are - to my knowledge, just about always - subsidized by the hospitals. Most of what they do falls under the category of "evaluation and management" - also known as "cognitive services", or "visits". While many procedures are still paid well, "visits" are not. It is not unusual for a hospital to subsidize their hospitalists programs to the tune of $100K per physician annually - or sometimes more.
Why would hospitals do that, and how can they afford it? 1) they save money on the length of stay. 2) Having such a program puts them into a better competitive situation compared to other hospitals, since they all compete for referrals from local physicians.
Moreover, people generally do not recognize that over the last few decades as a result in advances in medications and procedures a lot of "business" moved away from hospitals and into the realm of outpatient healthcare. People after gallbladder surgery used to spend as much as a couple of weeks recovering in the hospital. Nowadays, after a laparoscopic cholecystectomy it is not unusual to discharge the patient the same or the next day. Cataracts used to be an inpatient procedure - not anymore. New antibiotics are more effective, allowing doctors to avoid admissions. Even things like the Hospice movement took away thousands of "end of life" admissions from hospitals.
And so forth. And yet, at the same time, the funding for Medicare Parts "A" (hospitals) and "B" (Physicians) is still based on historic numbers. In other words, while I do not consider hospitals to be overpaid, they ARE *relatively* overfunded in relation to Part "B". Paying big bucks for Hospitalists makes economic sense to them.
How do I know all this? Because I've been on both sides of the divide. After 25 years in office practice, for the past 2 1/2 years I am a Hospitalist. Even while in practice I participated in running a large medical group, AND a hospital. Could probably write a book about all this, except... who will read it?... :)
Overall, my view on the future of healthcare in this country is rather guarded. Mostly, that is because in the coming years the ageing baby boomers will require a huge amount of medical services, while additional funding will simply not be forthcoming. |
