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Square dance

July 2009

Immediately after reading Dr. Gawande’s seminal piece about the regional disparity between high utilization health care systems and places like the Mayo Clinic, I hopped a ride on Today’s Hospitalist’s private jet and made a beeline to Idaho.

My task: to interview a hospitalist medical director from a low utilization hospital. After all, I hail from New Jersey, and although my hospitalist program is excellent, we are in a state that collectively ranks No. 1 in health care expenditures (or dead last in efficiency, if you take Medicare’s perspective). So here’s my story–most of which, I’m pretty sure, I imagined, but could well be true (especially the part about the Today’s Hospitalist private jet).

Upon landing, I met with John Q. Hospitalist (JQH) from Idaho General Hospital. We immediately hit it off, in no small part because we were both delighted to realize that the square dance was the official dance of each of our states (true; you can look it up). But there was scant time for pleasantries–I had some intrepid reporting to do.

My first question got to the reason for my visit: “How can you manage to keep your costs so low compared to us East Coasters? Take, for example, the typical septic 90-year-old in the ICU. Between the intensivist consult for respiratory failure, the ID consult for pneumonia, the cardiology consult for borderline troponins, the renal consult for ATN and all the resulting, prerequisite procedures and tests–I mean holy cow, that is a lot of spending, and it is only Monday.”

JQH: “Well, slow down there with all those consults. We have hospitalists here in Idaho. We are of course skilled enough to manage most of this. And a 90-year-old on a ventilator? Well, we’re not going to see that too often.”

Me: “Oh, perhaps I didn’t make myself clear. I, too, am a hospitalist. In fact, in case you hadn’t realized, most of the care on the East Coast has transitioned to this model. Further, every hospitalist I know is extremely skilled at identifying which problem needs what consultants.”

JQH: “Sounds like a different kind of hospitalist than we are used to having. You see, we have consultants, but not that many. They are kind of a precious resource that we reserve for the most difficult cases.

“Sepsis, well, most of us can handle that. And aren’t you familiar with the recently presented SHM abstract at the 2009 meetings that showed no mortality difference between those cared for by intensivists and hospitalists? And of course, there was the study that showed increased mortality by patients cared for by intensivists vs. non-intensivists. Moreover, one study didn’t find any difference between neurologists and hospitalists in treating hospitalized stroke. Bottom line, I believe we can deliver much of the hospital care for less with the same results.”

Me: “I’m impressed. You guys clearly know what you are doing. But you mention you don’t see a lot of 90-year-olds on respirators. Why not? Too many farm accidents leading to an early demise?”

JQH: “Not exactly. You see, our patients have very reasoned expectations out here. If they wouldn’t subject their horse to some procedure, they certainly would not allow their mother to go through it. You might even say we are a bit more European in our attitudes about end-of-life care, which is probably not what you city slickers would expect.”

Me: “So you do less and your patients expect less. Pretty simple.”

JQH: “You forgot to mention that our patients do just as well.”

Me: “But lawyers must have a field day with all this underutilization of resources every time there is a bad outcome!”

JQH: “Not so much. I looked it up, and while your state has five times the population as ours, you have twenty times the malpractice claims paid.”

Well played, JQH. A few more exchanged pleasantries, and I headed back to the Today’s Hospitalist jet.

I must say, the whole experience was more than a bit disconcerting. No doubt, it bothered me to know that we spent twice as much as the docs at Idaho General do for the same outcomes.

But it also worried me was that a hospitalist in Idaho did not sound all that much like a hospitalist in New Jersey. They ran ventilators, managed MIs that didn’t need intervention by themselves, and rarely considered the need for a consultant for many bread-and-butter infections that required hospitalization.

So what are the take-home points from my imaginary (or not) journey? One, like most hospitalists, I could not agree more with Dr. Gawande’s message. Clearly, there is something amiss if care can be delivered for half as much with the same results in the same country. Controlling health care costs, at least in part, means controlling this differential.

However, given the politics, it is not surprising that various special interest groups are disseminating scare-tactic talking points such as “rationing of health care” and “a bureaucrat between you and your doctor.” This, coupled with the often myopic instinct for self-preservation on the part of all entities involved, makes change far from a done deal.

Two, if reimbursement and incentive structures are changed to try to curb procedural and subspecialty utilization, hospitalists may very well be asked to practice to the full extent of their training. I suspect this will not be a problem for many hospitalists who currently practice in low-utilization areas.

For the rest of us, it could be more interesting, what with hospitalist medicine’s widely disparate scope of practice. All the more reason for us to forge ahead with our own specialty boards.

Finally, and perhaps paradoxically, the lack of health care reform has been instrumental to the growth of our specialty. The need for doctors who are at least somewhat accountable for hospital expenditures is no small reason why we went from zero to 30,000 almost overnight. Perverse financial incentives have help drive our growth while hospitals have been desperately trying to control costs.

But the playing field is likely to change, and hospitalists would be wise to not expect that health care reform is guaranteed to improve our profession’s stead. That’s especially true if new regulations encourage us to be even better at more things, no matter where we practice.