Published in the April 2005 issue of Today’s Hospitalist
Robert Berenson, MD, remembers the day in 1988 when, in a slow simmer of frustration, he walked into an administrator’s office at Capitol Hill Hospital and suggested hiring a few dedicated inpatient physicians to help reduce the gross inefficiency and wildly varying hospital care patterns.
“We couldn’t get patients out of the hospital because of the inefficiency,” recalls Dr. Berenson, who was the hospital’s head of utilization review at the time, “and it occurred to me that if we had some physicians coordinating care and bringing some discipline to the process, we might be able to get them out far sooner. My argument to the administrator was that it was in the hospital’s interest to have those physicians.”
Little did he know that the remedy he was proposing would become a model of care that is catching on like wildfire throughout the country, or that up to 10,000 U.S. physicians would be referring to themselves as hospitalists, a term that would not be invented for another eight years.
“I’d never have speculated that less than 20 years later, things would be where they are now, or that the hospitalist [model] would become a standard in about six years,” says Dr. Berenson, co-author of a study that examined the market trends driving hospital medicine published in the February Journal of General Internal Medicine. “It’s amazing how quickly markets respond to real or perceived needs.”
That study, in fact, paints a fascinating portrait of how the symbiotic relationship between hospital medicine and the market has helped make hospital medicine the fastest growing specialty in the United States.
The study, which examined the growth of hospital medicine in 12 U.S. cities, sheds light on not only the furious pace of change among hospitalist programs, but how the marketplace in those cities has embraced “and at times shaped “hospital medicine.
The growth of hospital medicine has been so phenomenal that it has surprised even veteran hospitalists like Robert Wachter, MD, the man who helped coin the term hospitalist in 1996. “I’m not terrible with crystal balls,” says Dr. Wachter, who directs the hospitalist group at the University of California, San Francisco, “but I can’t say that I would have predicted all that has happened.”
“In the early days,” he explains, “I had a sense that if a field materialized, very good generalists would see their roles as caring for patients in the hospital and developing a closer-than-usual relationship with the institution to provide patient care coordination and make system support better.” While Dr. Wachter suspected other roles would evolve over time, he never imagined they would change at the current pace. “All of that has happened,” he says, “and to some extent faster than I would have expected.”
It was that pervasiveness of the hospitalist model that prompted researchers from the Center for Studying Health System Change to research and write the article that was published earlier this year. “This article wasn’t on our list,” explains Dr. Berenson, who is a senior fellow at the Urban Institute in Washington. “It wasn’t a topic we were looking for, but it came up everywhere we went.”
The researchers kept stumbling across the pivotal role that hospital medicine plays in medicine today as they conducted a regular update of the center’s community tracking study. As part of that study, researchers make bi-annual site visits to 12 representative U.S. markets to research trends in health care. The communities range from large urban areas like Seattle and Phoenix to mid-sized communities like Lansing, Mich., and Greenville, S.C.
“We never thought that the hospitalist [movement] was important in understanding markets,” Dr. Berenson explains, “but we found out that it was an important development.”
After researchers realized just how pervasive hospital medicine had become, they decided to retrospectively comb through interviews with hospital administrators, health plan executives and the leaders of medical groups to write the article, which covers developments between 2001 and 2003. While the project took a retrospective approach, researchers were able to put together a snapshot of inpatient medicine.
Some of the researchers’ findings will hardly be news to hospitalists. The team found that while most hospitals initially brought in hospitalists to care for unassigned patients on general medicine wards and to cover for community-based primary care physicians, that role is changing as the field evolves.
They saw hospitalists getting involved in a wide range of roles and settings, from pre- and post-op surgical care and pediatric NICU consults to adult ICU specialty services such as neurology. They also found that in some hospitals, inpatient physicians are backing up or standing in for intensivists. That trend, says Hoangmai Pham, MD, MPH, the study’s chief author and senior health researcher at the center, “is making certain physicians feel very threatened.”
What really struck Dr. Pham, however, was the stunning variation among hospitalist programs and their origins, not only from one community to the next, but from one facility to another. “There were some very idiosyncratic local circumstances that generated [hospitalist] practitioners or programs in some communities,” she says.
And in many circumstances, the fortunes of hospitalists and hospitalist programs have been related to the local market. As an example, Dr. Pham describes how the entrance of a large hospitalist program in Orange County, Calif., allowed several community hospitals that did not have the resources to hire hospitalists on their own to put a program in place.
That development, combined with the high penetration of capitated health plans, helped push Orange County into the No. 1 spot nationwide in hospitalist-model penetration. In that part of California, nearly 90 percent of medical inpatients are cared for by hospitalists.
(In communities around the country, researchers noted, that figure varies from a low of 5 percent to the more common 50- to 75-percent range in areas with mature programs.)
In other regions, the growth of hospital medicine was driven by malpractice concerns, rising health care costs and constraints on bed capacity, which produced a concerted effort to improve patient throughput. And throughout all of the markets studied, the push for patient safety improvement “and pressure from purchaser coalitions to implement new systems of care “helped facilitate the growth of hospitalists.
“On the employer side,” Dr. Pham says, “people are at the moment very grateful that hospitalists are there.”
At the community level, the biggest growth push came from the sector that propelled the early growth of hospitalists: community physicians who are finding that the management of both office and inpatient practice is growing economically untenable.
Of even greater interest to Dr. Pham was what she calls the “organic” nature of hospitalist medicine’s evolution. As evidence, she points to the variation in programs, staffing models and individual roles assumed by hospitalists.
“The medical profession has historically been so compulsive and controlling about how its practitioners enter the workforce and organize,” she explains, “and that’s definitely not how the hospitalist field has evolved.” While the growth curve of hospital medicine may be bucking convention, Dr. Pham “and many of the individuals interviewed by the researchers “viewed that trend as a good thing.
“We didn’t see deep concerns out there about program variation or the organic manner in which inpatient medicine has evolved,” she says. “It has allowed for a lot of flexibility in how these relationships have been set up.”
“Health care is like politics,” Dr. Pham continues. “It’s very local in terms of what a community needs. Hospitalists have been such a malleable workforce that they’ve been able to adapt. That’s no small reason for their success and growth.”
That flexibility gives hospitalists the ability to be much more sensitive to the needs of their local markets. Martin Buser, MPH, a founding partner of Hospitalist Management Resources LLC, a hospitalist consulting firm with offices in San Diego and Colorado Springs, Colo., says that a staple of early hospitalist programs featured something known as the “rounder” model. It was a favorite of health plans in managed-care heavy markets like southern California because hospitalists could see a maximum number of patients.
But Mr. Buser says even in the southern California strongholds of managed care, that model is starting to fade because of market considerations. “Hospitals are realizing that they don’t want flyby rounds care that simply turfs off patients to other specialists,” he explains. That’s why more hospitals are starting to opt for what he describes as “fourth-generation models” that are hospital-based and hospital-dedicated. “These physicians are available to see patients several times a day and interact completely with the medical staff.”
“Basically, hospitals are looking for hospitalists who are on the chief-of-staff path,” Mr. Buser says. “They want that return from their programs.”
Even in the tight-utilization environment of markets like Los Angeles and Phoenix, he notes, hospitals are abandoning high-volume coverage models. They are instead favoring programs that focus on clinical pathways and evidence-based approaches to improve patient throughput.
That’s exactly the path that Monarch HealthCare has elected to take with its hospitalist programs. The 1,700-member independent physician association, which cares for 160,000 patients under risk contracts, started a basic hospitalist model in 1998 in which physicians rotated among the 18 hospitals where Monarch patients are admitted. Today, Monarch is scrapping that model in favor of dedicated programs with dedicated hospitalists covering its core facilities, says Monarch president Jay Cohen, MD.
“That’s the evolution we have undergone in the last seven years as we have tried to respond to a very challenging business,” Dr. Cohen says, referring to Orange County’s notoriously low reimbursement rates and extraordinarily high managed care penetration. “The coverage model worked for awhile, but we’re trying to move to a more sophisticated model.”
Leap of faith
Perhaps what’s most interesting of all is that although they lack any hard evidence that hospital medicine is paying off, hospital administrators and physician leaders in some mature hospitalist markets have plowed forward with expansions of and modifications to their hospitalist programs.
“We really don’t know if this is working out for us or not from a quality or return on investment perspective because we don’t have any empirical data or statistics to support it or the information systems to track [results],” admits Azhar Qureshi, MD, vice president of clinical quality for the 12-hospital St. Joseph Health System in Orange, Calif. “That’s the frustration.”
His system created a hospitalist program five years ago, both because of demand from physicians and because of demands from purchasers. “We think it’s a good thing to do,” he says, “but we can’t answer the question of the extent to which it’s paying off “or what the trade-off is in the amount of resources we have spent.” Despite that lack of data, the program has expanded since its launch.
On the other side of the country, Massachusetts General Hospital finds itself in a similar position. Officials there say they have a sense that hospital medicine is helping, but they admit that they have no data to back up that hunch.
Larry Ronan, MD, who directs one of the institution’s hospitalist groups, says the service “works out well for those who need it,” but that the hospital hasn’t been able to “study it with enough numbers to make any conclusions.”
Dr. Ronan’s program, like many, originally was put in place to take care of unassigned patients and to cover physicians within the hospital. To those ends, it’s been a success and, he suspects, economically beneficial to some extent since its creation in 2001.
While he is pleased that the hospitalist movement is expanding its focus to encompass big-picture issues such as safety enhancement and systems improvement, his sense is that most hospitals are still turning to hospitalist programs, at least initially, to improve their cost structures. “It’s usually an economic reason,” he says.
Economics or explosion of knowledge?
John Nelson, MD, one of the specialty’s pioneers, disagrees that economic considerations alone are driving hospital medicine’s growth. While he acknowledges that many recent articles, including the study by Dr. Pham and colleagues, focus on the fiscal advantages of hospital medicine, he thinks the specialty transcends its economic impact.
“Even in the absence of economic forces, we would be seeing this growth,” contends Dr. Nelson, who directs the Overlake Hospital Medical Center hospitalist program in Bellevue, Wash.
He argues that the exploding medical knowledge base, combined with many hospitals’ focus on reducing errors and improving quality, would have produced an inevitable surge in the growth of hospitalist programs even without economic considerations.
“After all,” he explains, “it’s hard for a physician to know the latest guidelines for treating pneumonia in the hospital and at the same time, the most recent recommendations for target cholesterol levels in outpatients. There’s just more to know, and it makes sense for a doctor to pick a site for practice and become more expert in that one.”
Peter Lindenauer, MD, medical director of clinical and quality informatics at Baystate Health System in Springfield, Mass., agrees that recognition of the knowledge divide is contributing to hospitalists’ growth, but he quickly adds that he has seen the model deliver both quality and cost improvement.
“Our internal data has consistently shown that our hospitalists provide care that is less costly than expected based on risk-adjustment models, and that adherence to common quality measures is better,” he says. As proof, he points to a study in the 2003 Annals of Internal Medicine that found Baystate’s hospitalists had better outcomes and slightly lower costs in caring for heart failure patients than the system’s nonhospitalists.
Further, Dr. Lindenauer, like others who have closely observed the field’s growth, is convinced that inpatients’ high acuity, coupled with the increasing implementation of sophisticated IT systems such as computerized order entry, will ensure that the hospitalist model prevails.
“It’s becoming harder and harder to be a casual visitor to the hospital, as not only the complexity of patients has increased but also the pressure to do more in a shorter period of time,” he says. “And of course the technology bar has been raised. What physicians need to know to practice in a hospital anymore is increasing all the time.”
Bonnie Darves is a freelance writer specializing in health care. She is based in Lake Oswego, Ore.