Question: Before hospitalists, who cared for hospitalized patients?
Answer: Generalists—in other words, internists, family physicians, pediatricians.
Q: How much did that system cost hospitals?
A: Nothing, or very little. In some cases, support dollars were available for weekend, night, or uninsured patient coverage, but by and large this system cost hospitals little. Physicians admitted their patients to the hospital because the alternatives (sending a hypoxic pneumonia patient home from clinic, turning out the office lights and hoping the patient survived the night, or bringing the patient home with them) offered uncomfortable ethical, malpractice, or alimony consequences. So doctors admitted these patients to the hospital and visited them daily.
Q: The average amount of support per hospitalist is $131,564, or about $1.7 million per HM group seeing adult patients. The bulk of those dollars come from the hospital. If we assume that the people running hospitals are smart, then why would those smart businesspeople pay $1.7 million for something they used to get for free?
A: Because there is something they get in return for that money. Or, perhaps, something they think they are getting in return for those dollars.
A: I often go through this exercise with the residents in our hospitalist training program when we discuss the drivers of the HM movement. I usually discuss the reasons why a hospital should fund these groups; it always seems like such a no-brainer to me.
Enter a recent news item from Montana. The story from the Helena Independent Record (see “Unsustainable Growth?” p. 1) noted that a multispecialty group practice in Helena announced they were no longer admitting their patients to a local hospital in protest over a new hospital policy to charge the clinic practice. The fee was to defray some of the costs of the HM program. A hospital representative was quoted as saying “physicians are responsible for obtaining hospital coverage for their own patients, not the hospital.”
I can’t really argue with the logic of that statement. Surely a clinic has responsibility to ensure that their patients get cared for while they are inpatients. If an internist is going to see a patient in the clinic and admit them to the hospital, shouldn’t an internist then see the patient in the hospital?
If I’m a hospital CEO, the answer is no.
To retrench a bit, yes, I’d want a board-certified internal-medicine (or pediatric or family medicine) physician to see the hospitalized patient. But in the process, I wouldn’t want them to only practice internal medicine. That was the model hospitals had 25 years ago—a model that cost them very little, a model that they played a large part in exterminating. The fact that most hospitals are willing to pay millions or more per year to not have that system tells me that they don’t want that system.
Q: So, what do hospitals want?
A: Hospitalists, not internists in the hospital.
What’s the difference? Well, it’s a perception issue. Many, if not most, believe that all it takes to be a great hospitalist is to show up for your shift, provide great care to your 15 patients, and go home. That is, the job is defined by the clinical effort—the internist part. Although there is tremendous benefit to this and I recognize its importance (and let’s not forget the weekend, night, and holiday coverage), this sells us short and puts our financial stability in peril.