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Our identity crisis

August 2011

The recent Annals of Internal Medicine article that suggests that hospitalists increase overall costs to the health care system may be enough to throw our specialty into a full-blown identity crisis.

While I am not well-versed in Erikson’s stages of psychosocial development, it is hard not to draw the analogy between the confused adolescent and the newly flummoxed post-Annals hospitalist. If I am not a doctor who increases efficiency and decreases costs, then who am I? Is it no longer safe to walk past a full-length mirror adorned in our white coats without an eerie sensation that the image looking back at us is not who we thought we were all along?

Before attempting to resolve my newfound ego collapse, it is probably worth noting that the study had its limitations. For example, while I’m sure those at Annals know more about peer review than I do (I believe my last journal club just had its 10-year anniversary), one does wonder what to make of data drawn between 2001 and 2006, well before the maturity of our field. Further, as Joe Li notes, this study does not address quality of care, supposedly our strength.

And truth be told, I read only the article abstract, being of the Stephen Colbert school that does not allow facts to potentially subvert what my gut knows to be true.

But for the sake of argument, let’s assume the study is bull’s-eye dead-on. We cost more without appreciable return on that investment. We are hardly the first innovation in health care to fit that bill. If internists are generic Aricept 10mg, then maybe we are the brand name “improved” Aricept 23mg. New dose, perhaps improved cognition, but no overall improvement in function and more toxicity, all at a much higher price. What’s not to like?

After all, at least on the macro level, health care costs continue to outpace the growth of just about everything except the growth of the hospitalist movement. Shouldn’t we expect that 30,000-plus hospitalists mean that health care costs will finally start to level off?

The short answer is “no,” not at least with the financial models that still exist. After all, we may be hospitalists, but we still play in a fee-for-service world. Even though many programs give more than lip service to quality, compensation is still largely based on how many you treat, not how many you treat well.

Further, health care has only recently begun to reward coordinated care and to no longer view the bounceback patient as anything less than a guaranteed annuity. So while we may create an efficient system within the hospital, our efforts may be stymied once patients are discharged. We can extend our efficiencies only so far in a system that has not traditionally found value in the post-discharge process.

Finally, some good news: Despite our alleged start-up costs, the health care cost curve simply can’t be bent without hospitalists. Hospital care is too complex to be left to physicians who have only a transient relationship with the hospital. In the future, there is no doubt that we will be on the frontlines, likely in concert with ER physicians, redirecting lower acuity admissions to subacute facilities or home care.

Efficiency for patients hospitalized in a value-based purchasing world will continue to be incentivized. The discharge process will become increasingly seamless and coordinated in the era of bundled care with 30-day readmission windows.

You may say I am a dreamer. To quote John Lennon, “I am not the only one.” Hospital administrators, hardly the type for idle daydreams, don’t shell out $130K in subsidy to each of us without imagining a future in which that investment in our infrastructure pays large dividends.

No one should be naive enough not to believe that much of our growth and success is predicated on the “If not us, then who?” doctrine. Simply put, the subspecialists turfed inpatient care to us right after many traditional internists turfed it to them beginning in earnest in the late 1990s. Point being that our development was equal parts “last man standing” and “grand plan of reform.” Either driver is a cost center, not a profit center.

That disclaimer aside, when I look in the mirror, I still see a hospitalist who is efficient, cost effective and handsome (granting that beauty is in the eye of the beholder). While the initial investment in our field may have yet to demonstrate a stellar ROI, you have to spend money to make money (or, in our case, create efficiency).

So back to to the identity crisis analogy: Experts think that those who emerge from this developmental stage with a strong sense of self are well equipped to face adulthood with confidence and certainty (compliments of the wiki-page on identity crisis). These are traits that will no doubt be required as health care continues it inevitable journey to cost control.