Question: We work with a large orthopedic group. We would like to propose a more formal structure to this. We are interested in building business and partnerships. Do you know of any articles or references to support hospitalists doing this, or any sources to show the orthopedic group we can and would improve outcomes and their work life and workload?
Julie Lepzinski, director,
hospitalist medicine group,
Dr. Hospitalist responds: I commend you and your hospitalist group for taking the initiative to develop a relationship with your orthopedics colleagues. Many hospitalist groups are exploring such relationships with not only orthopedists but also with other surgical and medical subspecialists.
As you mentioned, the opportunity exists to improve your group’s income and improve orthopedist work life. More importantly, there is a real opportunity to improve the medical care of patients admitted to the hospital primarily with orthopedic problems.
There are published data from an academic medical center on a hospitalist-orthopedics co-management model. Huddleston, et al., studied the effect of such a co-management model on the care of patients after elective hip and knee arthroplasty at the Mayo Clinic.1 They found that “the co-management medical hospitalist-orthopedic team model reduced minor postoperative complication rates with no statistically significant difference in length of stay or cost. The nurses and surgeons strongly preferred the co-management hospitalist model.”
This study would seem to support your notion that orthopedists may prefer the involvement of hospitalists in the care of their patients. Hospitalist involvement reduced minor complications (urinary tract infections, fever, electrolyte abnormalities). However, investigators did not find that hospitalist co-management reduced major postoperative complications (death, myocardial infarction, renal failure requiring hemodialysis) or intermediate ones (heart failure, pulmonary embolus, ileus, pneumonia).
Mayo Clinic hospitalists also studied the impact of a hospitalist-orthopedist co-management model of the care on elderly patients admitted to their hospital with hip fracture.2 Phy, et al., found that, “In elderly patients with hip fracture, a hospitalist model decreased time to surgery, time from surgery to dismissal and length of stay without adversely affecting inpatient deaths or 30-day readmission rates.” This study demonstrated that hospitalist co-management can decrease hospital length of stay in this population of patients.
We should recognize the obvious limitations of these studies. They were done at a single large academic institution with a largely Caucasian population at the turn of the century (2000-2001), early in the hospitalist movement. The hospitalist movement has matured, with approximately 20,000 hospitalists in the country. I hope we will soon see more robust data coming from multicenter trials that include a more diverse population of patients as well as a mix of community and academic institutions.
Start an HMG?
Question: We own a medical clinic in Arizona and are thinking of starting a hospitalist group as a separate business entity. Are you aware of any recommended reading or articles on how to start one, if it’s profitable, and in what shape or form? And most important--regarding the current trends and projections--I wonder if the need has changed, as most hospitals reduce their number of vendors.
Shawn Toloui, president and owner,
1st Care Medical Clinic,
Dr. Hospitalist responds: These are the kind of questions people have been asking since the term “hospitalist” was coined in 1996. Over the past decade, we have seen an explosion in the number of hospitalists in the country. Few folks in the 1990s thought there would be 20,000 hospitalists today.
If I understand you correctly, you are concerned that because many hospitals are reducing their numbers of vendors, this may have an adverse effect on the need for hospitalists. Hospitals will engage in business relationships with hospitalists as long as the hospitalists can bring solutions to problems and fulfill needs. To understand this better, let’s examine the reasons the numbers of hospitalists have grown over the past decade.
Costs: When Medicare started paying hospitals based on diagnosis-related groups (DRGs) in the early ’80s, this forced hospitals to “manage” patients’ length of stay. The DRG system pays a fixed fee regardless of the length of stay but allows for an adjusted higher payment based on a hospital’s case mix index (a measure of how “sick” patients are in a given hospital).
This reimbursement system encourages hospitals to take care of ill patients but also to “manage” their length of stay. It is difficult for doctors to manage any hospitalized patients from outpatient offices, let alone sick patients. Hospitals and payers found that hospitalists are able to manage sick patients and reduce costs, mostly by being available to admit, manage, and discharge patients in a timely manner. This increased throughput of patients also allows hospitals to put another patient in a bed sooner, bringing additional revenue.
Quality: By serendipity, the hospitalist movement coincided with the quality movement. Hospitalists have helped reduce variations in care by working locally to develop and implement clinical-care pathways. Hospitalists have also served as partners for hospitals to achieve compliance with payer quality mandates.
For example, in 2003, Medicare began requiring hospitals to report a handful of diagnosis-based quality measures it called the Core Measures. The number of measures continues to grow. In 2007, Medicare tied hospital reimbursement to performance on the Core Measures. I hear from hospital administrators that they find it easier to educate and work with a small group of hospitalists, rather than a large medical staff, to achieve optimal results on these measures.
Satisfaction: The exodus of primary care physicians (PCPs) from the hospital has fueled much of the growth in hospital medicine. PCPs have found it increasingly difficult to care for hospitalized patients while juggling the demands of a busy outpatient practice. In hospitalists, nurses have found a physician partner who is available physically to work with them in the care of acutely ill patients.
PCPs and nurses have been very satisfied with the hospitalist model of care. Although provider satisfaction is important, satisfaction in healthcare begins and ends with patients. Despite the discontinuity of care of meeting a new provider during hospitalization, patients have been satisfied with hospitalist care. Patients view hospitalists as providers available to provide for their acute needs while also communicating with the patients’ outpatient providers to understand their long-term needs.
I expect the number of hospitalists to grow over the next decade, albeit at a slower pace as most programs begin to fill their available positions. SHM believes the numbers of hospitalists will grow to 40,000.
There are a number of resources that can help you understand how to develop, manage, and grow a hospitalist program. I suggest you visit the “Practice Resources” section of the SHM Web site at www.hospitalmedicine.org. In particular, I recommend the “Best Practices in Managing a Hospital Medicine Program,” held twice a year. The spring program is held in conjunction with the SHM Annual Meeting in San Diego, April 3-5. The fall program is held in conjunction with the University of California, San Francisco’s “Management of the Hospitalized Patient” course in San Francisco. Also, the book Hospitalists: A Guide to Building and Sustaining a Successful Program by SHM Senior Vice President Joe Miller and SHM cofounders John Nelson, MD, and Winthrop F. Whitcomb, MD, is a must read for anybody looking to build a hospitalist program. TH
- Huddleston JM, Long KH, Naessens JM, Vanness DJ, Larson D, Trousdale R, Plevak M, et al. Medical and surgical comanagement after elective hip and knee arthroplasty. Ann Intern Med. 2004 July 6;141(1):28-38.
- Phy MP, Vanness DJ, Melton JL, Hallong K, Schleck C, Larson DR, Huddleston PM. et al. Effects of a hospitalist model on elderly patients with hip fracture. Arch Intern Med. 2005;165:796-801.