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In the aftermath of the recent shuttering of Colorado’s oldest newspaper, The Rocky Mountain News, a couple of colleagues and I were discussing how unlikely it seemed just a few months ago that this could happen. It wasn’t long until we made the theoretical leap to what it would take for our hospitalist group to go out of business. Of course, this seems highly unlikely, but then again, the closing of a 150-year-old metropolitan newspaper seemed a preposterous proposition.

In the course of this discussion, we conjured myriad internal or external factors that could adversely affect our program. Although this was a tangential, lunchtime discussion, it did reverberate against the tuning fork of a faltering U.S. economy, especially regarding the financial sector and the automotive industry.

The possibility of primary-care physicians seeing insured inpatients and leaving hospitalists with a largely uninsured population would be a game-changer.

With that as a frame, I thought I’d take a dip into Paranoia Pond and look at potential threats to the HM model. Let me start by saying that I believe—deeply—in the hospitalist movement, the strides we’ve made, and the bright path that lies before us. I am not stating that any of these potential perils will put hospitalists out of business. However, the list below includes several risks that, if not properly mitigated, could alter our future course.

Here are 10 potential threats to the HM business model that you should keep an eye on:

1. Failure to Embrace QI

Those who fundamentally improve outcomes will write the future of medicine. Hospitalists are perfectly positioned—and expected—to do this. I believe most hospital CEOs think this is part of the contract: funding for quality. A failure to live up to our end of the bargain puts us at great risk. If your group isn’t able to demonstrate measurable improvements in processes and clinical outcomes, then you are at risk of losing hospital funding. As the economy recedes further and hospital reimbursement is more closely tied to quality, this will quickly move beyond a potential threat to a reality.

2. Lack of New Data to Support the HM Model

A corollary of No. 1 is our ability to show how we work. This burden, by and large, falls to my academic colleagues. After a rash of early studies showed the benefits of the hospitalist model, more recent data has been less convincing. This doesn’t mean we aren’t improving outcomes; rather, it means we aren’t always measuring and proving it. HM must get past the easy-to-measure endpoints, such as length-of-stay reduction and cost savings, to more meaningful endpoints, such as readmission rates, mortality, and clinical improvements. Ultimately, HM depends on robust, published data that clearly illustrate our benefit to hospitals and patients. Anything short of that intensifies the pressure to achieve No. 1.

3. Decreased Admissions

Our mother ship is under fire. Each wound our hospitals suffer is a wound to us. Erosion of hospital margins likely will translate to decreased levels of support. Nearly 40% of hospitals are experiencing a decrease in admissions. Coupled with economy-induced increases in the number of uninsured patients, this looms as a major threat to our future stability.

4. Elective Procedures

Thirty-one percent of hospitals have witnessed a decrease in lucrative, elective procedures. It began with the rise of procedural centers (e.g., surgery, gastroenterology, radiology) and is being exacerbated by the wheezing U.S. economy. Each 1% increase in unemployment results in roughly 2.5 million Americans losing their employer-provided health benefits. That means fewer elective procedures, which directly threatens the profitability of HM groups who depend on co-management revenue.

5. Recruitment

For years, HM has battled a workforce shortage, which has stifled growth and pushed providers to the verge of exhaustion. This problem persists despite offers of lucrative salaries, significant free time, and specialty status. The continuing workforce shortage should serve as a call to arms to improve recruitment into the field. An inability to increase the flow of providers will limit growth and tax the hospitalists we have in place. Ultimately, we will retard our progress toward achieving the improved outcomes articulated in No. 1.

6. Retention

We must address burnout and career satisfaction issues. Although exact numbers are tough to come by, it’s clear that many hospitalists are exhausted and overworked. This should not come as a surprise, considering we are a rapidly growing field constantly tasked with seeing more patients and solving all of a hospital’s problems. However, an inability to keep our current workforce sated and in HM jobs will amplify the workforce shortage.

7. PCPs Return

One interesting theory is that the floundering economy could prompt primary-care physicians (PCPs), whose hospital exodus we backfilled, to return to inpatient care in order to supplement their income. This isn’t likely to happen unless outpatient providers see such a drop in business that they cannot field a large-enough insured panel of patients to make ends meet. The possibility of PCPs seeing insured inpatients and leaving hospitalists with a largely uninsured population would be a game-changer. In the face of a large PCP shortage, however, this seems an unlikely scenario.

8. PCP Payment Reform

It is more likely our primary-care colleagues will get an ever-so-deserved pay raise. This is central to the proposed medical-home model and a key point of many healthcare reform plans. To stay competitive, hospitalists might also see a resultant pay increase. Anything short of this could further strain HM recruitment, as working hospitalists and new grads might migrate back toward primary-care jobs.

9. Bundling

It’s too early to know the effects of the proposed bundling of physician and hospital payments into one fee, which would compensate both hospitals and physicians. On the one hand, it could be a boon, as HM efficiency could be rewarded in ways not currently allowed. On the other hand, if hospitals continue to struggle financially and we are completely dependent upon bundled payments for our revenue, it could be a financial calamity.

10. Healthcare Reform

Without a clear sense of President Obama’s plans for healthcare reform, it’s tough to predict the future. We could try to paint numerous rosy scenarios that derive from a plan that includes a universal payor, improved access, and increased technology. However, it’s possible this reform would hamstring our efforts through reduced reimbursement, increased regulation, and cumbersome federal mandates.

Final Thought

I believe HM is strong and will overcome future threats. But it pays to consider and mitigate the hazards we might confront. Still, after much deliberation, I just cannot conceive of a reasonable scenario that results in a future without hospitalists.

Then again, Henry Ford probably felt the same about cars. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of hospital medicine and the hospitalist training program, and as associate program director of the Internal Medicine Residency Program.

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