Hospitalists and PCPs: A delicate balance

Key Points

Jeffrey K. Pearson, a family physician in San Marco, CA, has to send his managed care patients to a hospitalist because his IPA, which contracts with a hospitalist group, won't pay him extra to round on HMO patients. He doesn't have to refer his other patients to hospitalists-yet he does.

"I love hospital work," Pearson explains. "But it got to the point where I just didn't have the time. If I got an admission during the day, I couldn't leave my office; if it was at night, I'd be at the hospital for five hours. I was just getting beaten down."

FP Joel Dickerman of Cascade, CO, tells a similar story. At one time, he rounded on patients every morning. Then, because of pressure to discharge patients sooner, he found himself going to the hospital three times a day. "But it was impossible to do that and run a busy office practice," Dickerman says. Now he uses hospitalists instead.

However you feel about hospitalists, they're not going away. Here's what's happening in the field and a look at how the rapid growth of this medical specialty is likely to affect you-if it hasn't already.

The hospitalist landscape

There are now about 20,000 hospitalists, four times as many as there were in 2002. Nearly half of all US hospitals have them, and the percentage tops 70 percent among larger institutions. According to internist Robert Wachter, who heads the hospitalist program at the University of California, San Francisco, the only thing that's preventing the field from growing even faster is a shortage of qualified candidates.

About a third of hospitalists work directly for hospitals, and 20 percent are on the faculty of academic medical centers, says internist Patrick Cawley, president of the Society of Hospital Medicine (SHM). Most of the others are associated with local hospitalist groups and regional or national hospitalist companies. Only 1 percent work for HMOs, compared with 9 percent in 2002.

The number of multispecialty groups that employ hospitalists has also declined, Cawley reports. The rapid growth in the field is occurring in hospitalist groups.

Many physicians believe that hospitals control hospitalists, whether or not they employ them, and that is often the case. Wachter estimates that hospitals pay or subsidize the salaries of 80 to 90 percent of hospitalists.

One reason for their support is that hospitalists have been found to reduce the length of stay by 10 to 20 percent-which could mean big savings for the facilities that employ them. A study released in December, however, found that hospitalist care had "modestly lower costs" than inpatient care handled by internists-and no real savings over FP-directed inpatient care.

On average, hospitalists maintain or improve the quality of care, Cawley says. The recent study found similar outcomes, whether patient care was overseen by hospitalists or PCPs.

But working to improve efficiency isn't hospitalists' only function. They often engage in teaching activities and usually take ED call, admitting unassigned and indigent patients. These poorly reimbursed activities explain why hospitals have to subsidize them, Cawley says.