COVER STORY

The changing face of hospital practice

Many primary care physicians are glad to turn over care to hospitalists. They've given up inpatient care to gain time for office and home.

By Ken Terry
Senior Editor

For primary care physicians, the hospital may soon become foreign territory. That's the clear message we got from a recent Medical Economics fax poll. Fully 61 percent of respondents are referring patients to hospitalists, and only 9 percent of those do so because they're required to.

In fact, primary care physicians are increasingly demanding that the institutions they're affiliated with start hospitalist programs—a big change from a few years ago, when doctors had to be persuaded to use the inpatient specialists. Many now realize they can earn more, work less, and do a better job for patients if they stay in the office. Moreover, they're satisfied with the care hospitalists give their patients; of those physicians who use hospitalists, 85 percent rate their care as excellent or good.

Because studies show that hospitalists can reduce lengths of stay, health care systems don't need to be urged twice to use them: More than half of all institutions now have inpatient services, estimates internist John R. Nelson III, director of the hospitalist practice at Overlake Hospital Medical Center in Bellevue, WA, and past co-president of the National Association of Inpatient Physicians.

The number of hospitalists has leaped to about 5,000, a tenfold increase over the last five years, and there's still a shortage in the field. One study predicts that there could be 19,000 hospitalists by the end of the decade. The figure might be even higher if the number of hospitalists co-managing surgical patients continues to grow, says internist Robert M. Wachter, associate chairman of the department of medicine at the University of California at San Francisco.

Inpatient care has become a losing proposition

FP Craig M.Wax of Mullica Hill, NJ, has a 20-minute drive from his office to each of his three hospitals. Until he started using hospitalists, he rounded on no more than three patients a day. That was a money-loser, especially with capitated patients. "It doesn't make sense to go to the hospital for a $10 per member per month capitation payment when I could be in the office trying to make enough to pay my staff," he says.

FP Edward J. Leins of Lubbock, TX, tells a similar tale. Until he signed on with a hospitalist group last January, he had been caring for 150 hospitalized patients a year. He'd be racing between his office and three hospitals to see five or six patients at any given time. Including rounds on his weekends off, he was working 90 hours a week. Now he's down to 55 hours a week, and the months from January through April were his best ever for number of patient encounters and collections.

If you're still getting significant income from hospitalized patients, you may worry that you'll miss that. But most doctors who refer to hospitalists find that they can make it up in the office. After starting to use hospitalists last October, internist Edward B. Blair Jr. of Alton, IL, opened his practice to new patients for the first time in six years. He now starts seeing patients at 8 am, half an hour earlier than before. "Seeing three extra people four days a week almost makes up for the financial hit of not seeing people in the hospital," he says.

Rounding on just a few patients didn't take a lot of Blair's time, but he dreaded the call duty and the often unpredictable timing of admissions. Now, he says, "I go home at night, and if the hospitalist or ER doc calls me, I can deal with it over the phone. If I'm cutting the grass, I don't have to run in, get cleaned up, and rush over to the hospital."

Primary care physicians also like the fact that hospitalists take ER call for them. "For lifestyle, it's fantastic," says Nashville FP David L. Boles. "Everything that required me to come in to the hospital has been taken over by the hospitalists."

While some patients object to hospitalists, most accept them, say physicians. Patients also prefer not to have their doctor run to the hospital while they're waiting for him in the office.

Some doctors feel guilty about their choice

Despite the seeming inevitability of the hospitalist trend, many physicians have lingering doubts about having other doctors care for their patients. "I started using hospitalists mainly because hospital work took too long for what it brought me in financial terms," says Boles. "Emotionally, though, I was torn, because I'd always practiced in the hospital and had that relationship with my patients."

Internist Toni J. Brayer of San Francisco sees no alternative to using hospitalists for her HMO patients because she doesn't get paid anything beyond her capitation rate for following them. "But I have patients who feel very abandoned when I don't make social visits to them," she laments. "I'm always having to do damage control afterward."

Internist Philip M. Blitz of Rocky River, OH, says he wouldn't refer to hospitalists even if there were any in his area. He doesn't want to hand over his patients to physicians who don't know them. Also, if he lost income to hospitalists, he'd have to expand his office hours to make up for it. That would be difficult, since he's director of an internal medicine residency program, he says.

Blitz likes to round on patients and have regular contact with his colleagues at the hospital. "You make more per hour in the office than in the hospital. But personally, I want to be out with my cohorts, and not be stuck in an office with no chance of keeping up with changes in medicine."

Toni Brayer would also rather not be confined to the office. "You don't get the same stimulation, the same interaction with your colleagues. You're divorced from the hospital. So apart from whether it's good or bad for patient care, it's really bad for internists."

Indeed, 55 percent of our fax poll respondents were concerned about losing their clinical skills—a fear that's especially acute among internists. "Their residency program is very hospital-based," says internist Mark V. Williams, president of NAIP and director of the Hospital Medicine Unit at Emory University School of Medicine in Atlanta. "But as time goes on, internists realize it's hard to work in the hospital and maintain an office-based practice with patients who are sicker than they used to be."

The same is true for family physicians. FP Patricia J. Roy of Muskegon, MI, still assists at surgery, so she's not worried about losing her basic inpatient skills. But she acknowledges that she's not on top of hospital formularies, ICU procedures, or inpatient best-practice guidelines. "Hospitalists are so much better informed than I am regarding those things," she says.

Over and above the question of clinical skills, many doctors perceive a loss of stature when their practice is confined to the office—44 percent of respondents to our fax poll say that using hospitalists would make them feel like less-complete physicians. "They're concerned that hospital work is what makes someone a real doctor in the eyes of patients and colleagues," says hospitalist John Nelson. "They sometimes worry that if they give that up, others might think of them as an allied professional, like a PA," he says.

Communication is key to physician satisfaction

When physicians contract with hospitalists, they expect to be kept apprised of their patients' progress. Yet 47 percent of the doctors who responded to our poll say that hospitalists don't always inform community physicians of admissions, discharges, or serious incidents involving their patients.

One reason for this communication gap is that many hospitalists are handling too many cases, says Emory's Williams. On average, hospitalists manage about 15 patients at a time, but that number can vary greatly from day to day. As a result, phone calls or faxes to primary care doctors may be sacrificed. New information technology can help overcome this obstacle, Williams says, but hospitals have been slow to adopt it.

Specialty status may also complicate the communication gap. It's common for pulmonologists/critical care specialists to set themselves up as hospitalists, since they're ICU experts and also have an internal medicine background. But some primary care physicians don't think these specialists are always tuned in to what's happening, because they bring in other consultants to handle problems outside their clinical area, and care can become disjointed. "With specialists taking care of patients, there's nobody watching the big picture," says Nashville FP David Boles.

How demand for hospitalists plays out

Since hospitalists came to Alton, IL, last October, half of the internists in town have begun using them, says Edward Blair. The hospitalist group, which started with two physicians, is already up to five and is looking for a sixth to meet the demand, he says.

Hospitalists can also make inroads in an area where a hospital, group or IPA requires doctors to use them. But that's rare, and most doctors don't like it. Internist Sharon J. Jones of San Pablo, CA, has to refer all of her patients in two IPAs to hospitalists. She complains that she's still on call and still has paperwork on these patients, but she doesn't get paid for admitting them because a hospitalist does that. "So we're still doing the work but we're not making any of the pay." On the other hand, Jones is satisfied with the hospitalists' care. And, like Toni Brayer, she keeps up her hospital skills by admitting her fee-for-service patients.

Once physicians have gotten used to hospitalists, in fact, it's hard to give them up. One of our poll respondents commented: "My hospital's program just folded after 18 months because of inadequate funding. The hospitalists will be missed. They took all indigent and ER backup patients from active staff and helped serve our overflow when on call."

What of the future? FP David Boles recalls that when he used to round on patients who were on monitored beds, specialists would sometimes use drugs he was unaware of. "If you're not up to date, you shouldn't be in the hospital," he says. "So I think there's potentially better care when a hospitalist takes over."

While studies to prove that aren't completed yet, UCSF's Robert Wachter is sure they'll show hospitalists' care is better. "As the data becomes clear regarding the quality advantages, the onus will fall on the primary care physician to demonstrate that he is able to achieve the same outcomes and efficiency that his colleague can by working with a hospitalist program." In short, says Wachter, physicians will be hard-pressed to find reasons for not using hospitalists.

Many, it seems, won't even want to try.

Economic incentives raise some questions

Some physicians fear that patients might get substandard care if hospitalists are economically motivated to shorten their hospital stays. "Efficient care in the hospital is not always to the benefit of the patient; it certainly is for the hospital," wrote one Midwestern FP who responded to our fax poll on hospitalists.

"The reports claiming good quality of care are usually measuring cost and length of stay rather than a true reduction in morbidity and mortality," wrote internist W.J. Dailey of Montgomery, AL. "I do not have an ethical bond to the hospital or the insurance company to reduce cost. I do have one with the patient to reduce morbidity."

The suspicions of these doctors have some basis in fact. Hospitals do have an incentive to discharge Medicare patients as soon as possible, and it's hospitals that employ or indirectly fund a large percentage of inpatient physicians. According to a survey by the National Association of Inpatient Physicians, 35 percent of hospitalists work directly for hospitals. University-based medical practices, often closely tied to academic teaching hospitals, employ another 11 percent. And hospitals also contract with some independent hospitalist groups and companies, which together account for 8 percent of the total.

Managed care organizations hire only 9 percent of hospitalists, but the groups that take risk from HMOs also have an incentive to restrain utilization. That would include some of the group practices that employ 23 percent of hospitalists.

Yet hospital and MCO funding of inpatient services is not what has led to the reduced length of stay among patients cared for by hospitalists, say observers. Noting that inpatient physicians usually receive a base salary plus a bonus based on productivity, internist and past NAIP Co-President John Nelson says, "They're not getting any different incentives than other doctors might have. Every study of hospitalists shows improved economic outcomes and efficiency, and in no case were the doctors paid to make it happen, or penalized if it didn't happen."

Ken Terry. The changing face of hospital practice.

Medical Economics

2002;16:72.