Hospitalists take over, and hospitals save money
KLP Note: It is this man I met but didn't know who he was while in the hospital....I will speak again of him in a day or two....In the meantime, everyone should check and see how this will affect them.....
Friday, January 4, 2008
Puget Sound Business Journal (Seattle) - by Brad Broberg Contributing Writer
Puget Sound Business Journal (Seattle) - January 7, 2008
seattle.bizjournals.com
Photo: Dan Schlatter
Hospitalist Dr. John Nelson speaks with Tom Murray at Overlake Hospital Medical Center in Bellevue, where Murray has had a procedure to return his heart to normal rhythm.
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As a hospitalist, Dr. John Nelson belongs to the fastest-growing medical specialty in the country -- even if the average person doesn't know a hospitalist from a hospital gown.
"Everybody in medicine has heard of (hospitalists), but I almost never encounter a patient who has," said Nelson, who directs the hospitalist practice at Overlake Hospital Medical Center in Bellevue and co-founded the Society of Hospital Medicine.
Hospitalists are doctors -- typically internists -- who care for patients while they are in the hospital. Not before. Not after. Just during their hospital stay. 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.
When Nelson helped form the Society of Hospital Medicine in 1997, there were around 1,000 hospitalists in the United States. Today, there are 20,000 -- a number that is expected to climb to 30,000 by 2010.
Practiced in scattered locations for a number of years, the concept caught fire in the mid-1990s when the changing dynamics of health care created a need for new strategies. That's also when the term hospitalist was coined in a New England Journal of Medicine article.
"That's when I realized what I was: a hospitalist," said Dr. Per Danielsson, medical director of the adult hospitalist program at Swedish Medical Center in Seattle. "I never liked the term, though. It's a little bureaucratic."
If the name is debatable, enthusiasm for the concept is less so. Over the past decade, hospital after hospital has added a hospitalist team.
"It's a natural evolution," said Danielsson.
As a result, the number of primary care doctors who continue to manage the care of their patients while they are in the hospital is dwindling.
"I don't know if it will ever go to zero, but it's close," said Nelson. "It's almost down to zero in metro Seattle."
Overlake is a typical example. Only four or so of the 60 primary care doctors who admit patients to that hospital continue to care for them during their hospital stay, said Nelson. The rest turn their patients over to Overlake's team of 15 hospitalists.
It's not a matter of hospitals giving primary care docs the boot, said Dr. Kathryn Beattie, chief medical officer at Valley Medical Center in Renton.
"It's the physician's choice," she said. "We still have physicians who really enjoy inpatient medicine and don't want to give that up. But the trend is away from that."
Reasons for the trend abound, starting with dollars and cents.
"There wouldn't be this explosive growth of (hospitalists) if it didn't make financial sense -- that's just a fact," said Danielsson.
While hospitalists cannot point to any studies that quantify the financial carrots, it's easy to see where savings can occur. It starts with the time hospitalists save primary care doctors by sparing them repeated trips to the hospital to make rounds.
In the past, those trips -- as many as three a day -- made more sense as primary care doctors tended to admit more of their patients to the hospital. Today's emphasis on preventive medicine and reliance on outpatient treatment has changed that. A primary care doctor might be managing only one or two hospital cases at any given time.
"It's not cost-effective to see such a small percentage of patients in the hospital," said Overlake's Nelson.
Fewer hospitalized patients also means fewer opportunities for primary care physicians to maintain the expertise needed to meet the increasingly complex demands of hospital medicine -- a threat to both quality of care and the bottom line.
It's a matter of practice makes perfect, and hospitalists get more practice caring for hospitalized patients than do most primary care doctors. What's more, the presence of hospitalists 24/7 ensures that there is always a doctor in the house, which speeds decisions about everything from tests to medication to discharge.
The potential result? Shorter stays and -- since reimbursement is based on diagnosis rather than length of stay -- the promise of improved margins. A study released last year by a Tufts University professor found that hospital stays were a half-day shorter if managed by a hospitalist.
"The pace of inpatient (medicine) is quicker now," said Dr. Paul Sutton, assistant chief of medical services at the University of Washington Medical Center in Seattle. "The goal is to identify and correct problems ... as quickly as possible. There's such a premium on efficiency."
All of that efficiency does, however, exact a toll. Over time, some patients develop close relationships with their primary care doctors. Being handed over to a hospitalist they've never met can be disconcerting.
"The biggest source of anxiety may stem from not knowing if (the hospitalist and primary care doctor) are talking with each other," said Dr. Chris Kodama, leader of the hospitalist team at Mary Bridge Children's Hospital and Health Center in Tacoma.
Ideally, they do talk to each other -- regularly, said Kodama. In addition, primary care doctors are welcome to make "social visits" to the hospital, providing support to patients and families, as well as conferring with hospitalists.
It also helps to remind people that the handoff between primary care doctors and hospitalists is not unprecedented, said Nelson. It's the same handoff primary care doctors make with other specialists such as cardiologists and neurosurgeons. Besides, many patients don't even have a primary care doctor -- which points out another problem hospitalists are addressing.
In the past, primary care doctors were expected to take turns being on call to treat "unassigned" hospital patients. That model worked fine until the growing number of unassigned patients entering hospitals -- often through the emergency room and with little or no insurance -- placed a heavier and heavier load on primary care doctors. Now, hospitalists are lifting that burden.
Unlike previous generations, few primary care doctors setting up shop today expect to provide inpatient care.
"That is a bygone era," said Dr. Robert Bessler, co-founder and president of Sound Inpatient Physicians (SIP) in Tacoma.
While most hospitalists work directly for hospitals, many others work for groups such as SIP. Founded in 2001, SIP now employs 340 doctors in 26 hospitals in six states. The company's biggest challenge is finding enough hospitalists to meet the demand.
"There are four jobs for every qualified hospitalist right now," said Bessler.
Most medical schools do not offer distinct tracks for hospitalists because doctors gain extensive hospital experience during their residencies. Even so, the growing number of medical students planning to become hospitalists is prompting the UW to consider adding such a track, Sutton said, to provide a sharper focus on hospital medicine.
Last year, hospitalists were pleased to learn the American Board of Internal Medicine will begin formally credentialing the specialty, one more sign that the future is now for hospitalists.
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