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“Wallflowers at the dance”

May 2010

I keep hearing that doctors don’t make good businesspeople. While there may be some truth to that, those of us who have practiced medicine over the past 10 years recognize that doctors are, in fact, a resourceful lot. Faced with falling reimbursement for procedures or for patients seen, doctors are already acting on the fact that they need to do a great deal more than they used to to generate the same amount of revenue.

Lower reimbursement is only one of many factors that have led to increased utilization. Add to that the following drivers: patient demand, more sophisticated and expensive tests, and, as all doctors can attest, the tendency to do more prophylaxis against litigation. Dr. Sandeep Jauhar, author of “Intern: A Doctor’s Initiation,” wrote an excellent essay in the New York Times], which chronicles how the current climate has led to increased orders for inpatient tests and procedures. It will strike a chord with hospitalists who observe this phenomenon on a daily basis.

Yet, to some extent, hospitalists find ourselves wallflowers at the dance, mere onlookers to the payer-provider pas-de-deux. Put another way, for a “value-added” specialty, the idea of seeing more patients to create more revenue amounts to cutting off our nose to spite our cost-saving face.

Give us more than 20 patients a day, and we become nothing more than rounders, not physicians who can provide efficient, efficacious care. And unlike many of our subspecialist colleagues, we don’t really have the option to do more procedures to boost our bottom line. I doubt that patients will be interested in having us administer botox during their third echocardiogram for decompensated CHF.

Improved charge capture is one meaningful and realistic way for us to increase revenue. Based on the growth of companies that provide charge-capture services, I’d assume that most hospitalist programs have already adapted or are planning to adapt this technology.

Then there’s the ability to move into other niche services. In my first program, for instance, we partnered with the hospital wound care program to supervise hyperbaric therapy.

But aside from being paid appropriately for the work we already do, I believe our only option for significantly better funding remains a bigger subsidy from hospitals. The most recent SHM data seem to bear that out: The average subsidy per hospitalist now stands at around $100,000.

So what is the endpoint for hospitalists in this era of decreasing revenue for hospitals and physicians? No question, we will continue to be asked to do more, as any increase in subsidy comes hand-in-hand with amplified expectations.

But being asked to be more productive is potentially problematic. I suspect that many hospital administrators will have trouble understanding the line in the sand that divides better revenue from productivity that comes at the expense of our ability to provide “value added” care. Further, I doubt that all employers will have the good sense and foresight to determine what is and is not a sustainable career in terms of workload.

To be sure, we are not the ones driving utilization; hopefully, we’re just the opposite. I think we will continue to be asked to try to moderate utilization growth within the hospital. And I believe that our success as a profession will ultimately be defined by our ability to control costs, not generate revenue. This, I think, may put us on a potential collision course with some of our consultant colleagues.

What will this mean for the field in the long run? No firm answers yet, but being on the “sidelines” certainly has proved to be interesting!