A More Perfect Union


It used to be so simple. The relationship between doctors and hospitals was a straightforward quid pro quo.

Hospitals granted privileges to physicians to admit and treat their patients, and the physicians returned the favor by assuming unpaid responsibilities like taking call, providing care to uninsured or emergency patients, and serving on administrative committees.

The hospital was like a friendly club whose members exchanged benefits for duties—a win-win situation. No more.

“You used to be part of a fraternity,” explains Win Whitcomb, MD, director of performance improvement at Mercy Medical Center in Springfield, Mass., and a co-founder of SHM. “There were social rewards. There was opportunity for collegial interchange.”

Economic pressure has taken that all away. “The pace of care has greatly intensified, and the financial reward system has deteriorated significantly,” Dr. Whitcomb continues. “We treat larger numbers of uninsured patients with chronic unmanaged illnesses that require intervention. The reward system for physicians to take call and fulfill their obligation to the hospital no longer matches the responsibility.”

To illustrate the change, Dr. Whitcomb offers an example: “We have some days of the month where the call roster for general surgeries has vacancies. A month ago we had to send a patient to another hospital for an appendectomy.”

It is not an isolated instance. “Every hospital is struggling with the fact that many physicians don’t view unassigned call as a part of membership on the staff; they want to be paid for it,” says SHM President Patrick Cawley, MD, executive medical director of the Medical University of South Carolina (MUSC). And extra “pay” for services that used to be rendered gratis is one thing today’s strapped hospitals can little afford.

Committee staffing is another area undergoing change. Attending physicians are simply declining the duty. Neal Axon, MD, a hospitalist and assistant professor of medicine and pediatrics at MUSC, has seen the transformation firsthand. At one hospital his service covered, he saw the following: “At the first staff meeting there were 50 people; there was food, liquor. It was social and attendance was mandatory. You had to make three or four meetings a year to be on medical staff at this hospital.” But then, he says, attendance waned, and in the last year “dropped off precipitously.”

The old ways don’t work so what will replace them? “The point is that both physicians and hospitals need to put something on the table to collaborate,” Dr. Cawley says. “Many are saying that the hospital-physician relationship needs to change, but everyone is still feeling their way through it. What does it mean?”

SHM’s CEO Larry Wellikson, MD, sees a layered structure ahead. “Clearly the system is evolving into three kinds of physicians who use the hospital,” he says. “We are not advocating for it—just saying what it is. This is what is evolving, and hospital staffs need to see this is coming.” His three kinds of physicians are categorized by their relationship to the hospital.

The home team: “The first group is those physicians who work only at the hospital,” he says. “Their professional life is with the hospital as an institution: hospitalists, ER doctors, critical care physicians, and sometimes the anesthesiologists and radiologists. The hospital is the location of their work and provides the tools to do their job. If the hospital works well, they can do their job well. If hospital is dysfunctional, they can’t work well.”

He describes their relationship to the hospital with an anecdote: “When I was regular physician who came to the hospital just to see my patient, if they couldn’t find the chart I would scream and yell about that one patient.” Every physician faced with a missing chart thinks of it as an individual problem. “But now as a hospitalist, I try to fix the system, because all my patients are affected,” he says. “Hospitalists are on the inside trying to make it work.”

Important visitors: The second group, whom Dr. Wellikson calls important visitors, has a totally different relationship with the hospital. These are the cardiologists, orthopedic surgeons, and other medical specialties. “They are very important,” he says. “But they use the hospital intermittently and are not as tightly connected to it.”

Even so, they desire a high-quality hospital for their patients and will be willing to help set performance standards to achieve it. But their interest may not extend to patients who are not their own. “If the hospital says you have to also take care of free patients, they may choose not to,” Dr. Wellikson notes. “In fact, sometimes they have their own outpatient centers,” making them direct competitors as their competing practices sap revenue from money-making patients and procedures—all the while sending the sickest and costliest patients to the hospital.

Office-based physicians: The last of Dr. Wellikson’s groups is office-based physicians. These are the doctors who once made daily morning and evening rounds of their hospitalized patients but are now infrequently found at the bedside. “They are the physicians who don’t come to the hospital anymore: primary care physicians, endocrinologists, rheumatologists, neurologists, physicians who do all their surgery as outpatient procedures,” Dr. Wellikson explains.

Clearly the system is evolving into three kinds of physicians who use the hospital.

—Larry Wellikson, MD, CEO of SHM

This upheaval is due to tectonic shifts in both medical economics and lifestyle preferences. “Because the reimbursement for care has gone down, physicians have to see more patients to make the same amount of money,” explains Dr. Wellikson. Turning their hospitalized patients over to hospitalists allows office-based physicians to maximize their income and optimize their time.

“It increases satisfaction, limits the hours you spend in the hospital, and puts some boundaries on your work day,” Dr. Cawley says.

“Doctors want more a predictable lifestyle,” Dr. Whitcomb says. In fact, their absence is already a fait accompli in many community hospitals.

As Dr. Axon succinctly puts it: “The primary care doc has left the building.”

Dr. Cawley believes the new system is a relief to many office-based physicians. “Some do miss going to the hospital and seeing other physicians to network with them. Some miss taking care of their acute in-care patients. But I think most are relieved to not have to go to hospital. They say, ‘No, things are better this way.’”

With so many other physicians withdrawing from hospitals to their offices and clinics, Dr. Wellikson believes hospitalists will become increasingly crucial to the institution’s operation and governance. “Now the home team is going to be more active; how you staff, how you make the hospital more efficient,” he says. “The inside physicians will be much more interactive. That’s why hospital medicine has grown so rapidly.”

The explosive expansion of hospital medicine as a specialty is a direct result of the need to increase efficiency and quality standards in this new hospital atmosphere.

In addition, good home teams create a milieu in which other physicians—the important visitors (cardiologists, surgeons, orthopedists)—will want to work. “My job (as a hospitalist) is to create an environment where you can come in and do your surgery,” Dr. Wellikson points out.

The home team offers something else too: medical expertise. Providing post-operative care is not cost-effective for many surgeons. “The surgical specialists are not paid to manage medical issues,” Dr. Cawley says. “It takes time and if somebody else can manage it, that’s great.” That somebody is often a hospitalist. “There is a quality-control aspect as well,” he adds. “With hospitalists focusing on medical issues, the result is better patient care.”

Melding these groups of physicians with disparate interests and responsibilities is the next challenge for hospital leadership. It is a challenge fraught with potential pitfalls. As Dr. Wellikson explains, “The biggest obstacle is that physicians don’t do change very well.”

Administrators will turn to their institution’s hospitalists (both hospital-employed and contracted) to effect these changes and ensure overall standards and efficiency.

“I think hospitalists are in a position to bridge the gap between administrators and medical staff,” says David Yu, MD, medical director of hospitalist services at Decatur Memorial Hospital in Illinois. “I think that’s why there will be more and more hospitalists in leadership positions. That’s why hospitalists are unique: they have their feet in both worlds.”

Dr. Wellikson believes the home team will step up to the plate and take over many of the leadership duties of the new hospital.

Kenneth Patrick, MD, the ICU director of Chestnut Hill Hospital in Philadelphia, sounds a more cautionary note. Dr. Patrick, a trained hospitalist and intensivist, believes the demise of the old “hospital privilege” model is dissolving ties between physicians and their workplace. “I think younger physicians will be much more transient and more concerned with their position, work hours, and pay,” he says.

He sees a young workforce—whether hospital or office-based—as more disengaged than physicians used to be. “They will meet hospital standards, but not be actively involved in developing them,” he believes. That will be left to a small group of hospital-based physicians “who will voluntarily come forward because it is their civic responsibility. It would be nice if more physicians would work on committees, but they look at them like jury duty and they don’t want to serve.”

Dr. Patrick

“The question everyone asks is ‘What’s in it for me?’” Dr. Yu says. He notes a common sticking point: the requirement for increased documentation, which often means more work for doctors. “I think administrators are going to be in shock if they think practitioners are going to line up and say, ‘Well that’s great for the hospital.’”

The key to cooperation, says Dr. Yu, is the linking of changes to mutual benefit and patient welfare: “The administrators have to communicate that in the long run everyone will gain and it will ultimately lead to better patient care. You have to share your vision, inspire, motivate, and develop a culture of providing quality care. It’s easier said than done, but it’s the essence of medical care.”

What about patients? How do they react when a group of strangers takes over their hospital care rather than the primary care physician they often have gotten to know and trust for years? “Wanting your doctor present is counterbalanced by not having your doctor in the house,” Dr. Axon says. “Now you can see a physician anytime during the day.” And most patients are glad for the tradeoff. Dr. Yu has found the same dynamic with his patients at Decatur Memorial Hospital. “I can just count on one hand patients who were not happy the primary care physician wasn’t there,” he says. “Patients are more concerned with having their problems solved than with who is solving them.” And he makes sure his hospitalist staff never undermines the office based physicians. “We always say we are not better physicians, we are just more available.”

While they may have left the hospital, office-based physicians still will be a large presence in it by advocating for their patients. “If my whole currency is, ‘Do I have hospital privileges?’ then all my decisions are based on that,” Dr. Wellikson says.

Armed with the power of their patient referrals, office-based physicians will be able to demand that hospitals show proof of performance—thus becoming their patients’ ombudsmen. “I’m your shopper for the best healthcare, so the hospital has to step up to the plate and make sure it gets the business,” Dr. Wellikson explains. “They want standards because their patients need the best treatment, and they will have a choice of which hospital to put their patients into. If I now have a choice of three hospitals, I am looking to see that you are the Lexus of healthcare for my patients.”

Looking out for their patients’ interests is not the only way office-based physicians will continue to affect hospitals. As in-patient revenue declines, hospitals must look to the outpatient side to make up the difference. “The hospital is lucky if they break even on the inpatient side; they get the vast majority of money on the outpatient side: testing and procedures that private attendings are sending to the hospital,” Dr. Yu says.

He cautions against alienating those private practitioners by forcing change that is not mutually beneficial. “If you alienate them, you might lose money because they can send their patients to a different institution,” he warns. “These are the same doctors that never admit patients but do order the outpatient ultrasounds, blood tests, and therapies that are all money makers for the hospital. Why would you want to alienate these physicians?”

Dr. Patrick agrees: office-based physicians and hospitalists need each other. “I have to work with the primaries,” he says. “They are my source of referrals.”

There is another group that hospitals must learn to court, according to Dr. Axon: its own hospitalists. “I think you will see more innovative solutions to problems of recruiting hospital-based physicians to perform these functions,” he says. “For that to happen, the doctors will need to get more out of it. Many hospitalist groups are in a quandary; they are expected to do all these extra things, but pay is closely liked to clinical production and the number of patients they see. Those incentives will have to be aligned.”

All of which increases the reliance on—and importance of—those physicians who do work in the hospital—the home team. As Dr. Yu puts it: “I think the hospitalist model, whether you like or hate it, is the wave of the future.” TH

Carol Berczuk is a journalist based in New York.

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