At HM18 in Orlando, the Society of Hospital Medicine’s CEO Larry Wellikson, MD, MHM, challenged our thinking by sharing a slide with the attendees that effectively and accurately captured the current environment. Today’s largest retailer, Amazon, owns no inventory; today’s largest taxi company, Uber, owns no cars; and today’s largest provider of accommodations, Airbnb, owns no real estate.
This powerful statement captures a transformative way of thinking, functioning, and thriving that has rapidly evolved over the past decade in the United States. And yet, health care fundamentally functions very similarly to how it did 10 years ago. I think we can all acknowledge that this is not a sustainable way to advance.
With megamergers dominating the health care landscape in 2017, the industry has become consolidated to weather the economic challenges ahead. Hospital contribution margins have been declining, forcing systems to critically evaluate how they deliver value-based care. In addition, the joining of forces between Amazon, Berkshire Hathaway, and JPMorgan further illustrates the pressures employers are experiencing with costs in the market.
What can we in hospital medicine do to proactively respond to, and shape, the evolving U.S. health care landscape?
If I had a crystal ball and could predict the future, I would say hospital medicine will be functioning very differently in 10 years to respond to today’s challenges.
The acute becomes more acute
When I started working as a hospitalist more than a decade ago, in a tertiary/quaternary academic medical center, the patients were severely ill with multiple comorbidities. Yet, in the span of 10 years, we care for many of those diagnoses in the ambulatory setting.
Reflecting on the severity of illness in my patients when I was recently on the medicine wards, I have to admit the patients now have a significantly higher burden of disease with twice as many comorbidities. As medicine has advanced and we have become more skilled at caring for patients, the acuity of patients has exponentially increased.
As this trend continues, hospitalists will need greater training in critical care components of hospital-based care. While we may comanage some of these patients with critical care, our skill sets need to intensify to address the growing needs of our patient population.
“Bread and butter” moves to lower-acuity settings and home
As our ability to manage patients advances, and the existing inpatient beds are occupied by sicker patients, the common hospital medicine diagnoses will move to skilled nursing facilities, long-term acute care settings, and ultimately home.
Delivery systems will have to create robust networks of home health and home services to actively manage patients with accountability. This provides an opportunity for hospitalists to manage acutely ill patients in less intense settings of care, and the emergence of telehealth will help facilitate this.
In a Feb. 6, 2018 article in JAMA – “Is it Time for a New Medical Specialty?” – Dr. Michael Nochomovitz and Dr. Rahul Sharma argue that, with rapid advances in technology and the establishment of telemedicine, a new specialty – the virtualist – will need to formally emerge (JAMA. 2018;319:437-8. While telehealth has been successfully utilized for the delivery of acute care in remote regions, as well as the delivery of basic services for common diagnoses, it is not robustly and broadly integrated into all aspects of care delivery.
As we move from the hospital setting to less acute settings of care and home-based care, providers need specific training and skill sets in how to manage and deliver care without the patient in front of them. This includes knowledge of how to remotely manage acutely ill patients who are stable and do not require a hospitalization, as well as effectively managing day-to-day issues that arise with patients.