The Hospital Medicine Movement
The evolution, or more appropriately the revolution, of providing physician care to patients during their hospital stay is a remarkable and valuable example of how healthcare has adapted to meet the needs of the patient and those who care for those patients. Born of the quest for quality and efficiency, hospital medicine has proven its ability to transform satisfaction and performance in a large segment of hospital-based healthcare delivery system, while simultaneously relieving primary care physicians (PCPs) of the increasing burden of the inpatient portion of their practices. Hospital medicine directly impacts inpatient hospital processes to simultaneously improve the patient experience and utilization of hospital resources. In a time of significant advances in medicine, new technology, evidence and information, and a focus on quality and efficiency, it is interesting to see how something as simple as a basic reassignment of responsibilities can have a significant effect on patient care as well as overall hospital performance.
The hospital medicine movement continues to grow based largely on its ability to impact value-based purchasing from a cost, satisfaction, and quality perspective. As hospital medicine continues to become more available, new questions arise about the most effective options for implementation and management. It is opening up new challenges and opportunities for refining processes of inpatient care and uncovering new avenues for improving that care through better interdepartmental relationships.
As the specialty becomes more mainstream, hospital medicine is capturing the serious attention of practice management companies interested in diversifying into this area. This chapter explains the history and development of hospital medicine as well as the reasons, advantages, and challenges facing those who have an interest in providing this service. For emergency physicians interested in diversifying their practices, hospital medicine is among the best options available.
Hospital Medicine as a Specialty
As defined by the Society of Hospital Medicine (SHM), hospital medicine physicians or “hospitalists” are physicians whose primary professional focus is the general medical care of hospitalized patients. The role of the hospitalist is to coordinate care for the inpatient portion of the hospital stay often referred to as inpatient services. The specialty is broad in scope and can support multiple specialties, but the majority of hospitalists have trained in internal medicine or family practice. Hospital medicine fellowships are increasing in number each year, though hospitalist medicine is not yet recognized as a distinct subspecialty requiring additional training or certification. The hospitalist's role starts with the patient's evaluation after being informed by the emergency physician (PCP in the case of direct admissions) that admission is required. The hospitalist then works to provide the most appropriate treatment, monitors the patient's progress, provides daily care supervision, manages postdischarge planning and follow-up, and ultimately discharges the patient to the next level of care. In the best of practices, the hospitalist also keeps the PCP informed of the patient's care. The specialty has also evolved into a variety of subspecialty areas listed in Table 48-1.
Table 48-1 Hospital Medicine Subspecialties |Favorite Table|Download (.pdf)
Table 48-1 Hospital Medicine Subspecialties
Adult inpatient care
Pediatric inpatient care
Inpatient care for surgical patients
Intensive care unit care
Night care for inpatients
The History of Inpatient Care
Historically, patient care in the inpatient setting was managed by a PCP (usually an internal medicine, family medicine, or pediatric physician) who checked on hospitalized patients as time allowed while balancing their own office practice. As major payers began paying a fixed diagnosis-related group (DRG) rate (a predetermined allowance for days and fees based on diagnosis), hospitals began looking more closely at the quality and efficiency of their inpatient management compared to their peers and to the guidelines set by Medicaid and Medicare for length of stay (LOS), utilization, and costs. If a patient stayed longer and cost more than the guidelines allotted, the additional cost of care would have to be absorbed by the hospital. Hospitals quickly began to explore and implement methods to improve their efficiency and processes. The goals of the hospitals were to first find methods to more efficiently move the patient through their stages of treatment and care and then to manage the patient discharge more effectively. By accomplishing these goals, the hospital could ensure that the patient was moved out of the inpatient bed at the appropriate time and into a more suitable care setting for the next stage of care. As Doctor Robert Cates wryly noted, “Some healthcare systems don't need a ‘hospitalist,’ they need a ‘dischargist.’”1
A number of questions arose. How could efficient care occur when the managing physicians only intermittently “dropped in” to round on their patients before or after business hours? Would it be more efficient and produce better quality to have practitioners continuously available and committed to the inpatient population as a full-time practice?
The term “hospitalist” was coined in 1996,2 so it is still a relatively new specialty. The hospitalist field normally requires board certification in a primary care specialty. All the physicians that become specialists in hospital medicine typically work only in the hospital and do not have a practice outside of the hospital.
Considered by many to be the fastest-growing medical specialty in the United States, hospital medicine continues to increase in popularity because of the cost-saving effects of reducing LOS and improving utilization (Figure 48-1). Increasingly, hospital administrators understand and value the advantages of having a hospital medicine group. Experience has shown LOS is less or can be lowered with a hospitalist managing the inpatient when compared to a PCP.
Hospitalists are the fastest growing medical specialty in the United States.
In the last few years, the demand for hospitalist medicine has grown rapidly. In 2011, there were approximately 50,0001 hospitalist positions for an estimated 30,000 available hospitalists.3-4 The low supply and increasing demand for hospitalists drives increasing salaries. As shown in the Hospitalist Annual Pay chart (Figure 48-2), the salary curve has taken a sharp turn upward. Fortunately, among a typical group of internal medicine residents, about half of the class state that they are going to subspecialize with the other half preparing to be hospitalists.
Hospitalist annual pay—salaries (does not include bonuses).
Despite the predictable initial resistance to this new role and the conservative adoption process into hospital planning and budgets, hospitalists have increased satisfaction for patients, families, referring physicians, hospital staff, ancillary services, and more. As recognition of the value as well as acceptance of the “cost” of providing hospitalist services has grown, so has the understanding of the extensive beneficial external effects.
In addition, most hospitalist programs have effectively “won over” those PCPs who originally resisted the concept. Hospitalists allow primary care practitioners to concentrate on their outpatient practices and, in many cases, enjoy better “quality of life,” since time is not spent going to and from the hospital (often several times a day) to evaluate and treat inpatients from their practice. In addition, effective hospitalist programs reduce LOS by the hospitalists' constant presence and focus on the patient. It is hard for practicing internists and family practice physicians to duplicate the hospitalists' results.
Advantages of a Hospital Medicine Program
Even though the initial start-up of a hospitalist program results in upfront costs, the hospitalist program can deliver a positive return on investment (ROI) through a multitude of benefits and advantages.
The hospitalist helps improve care by providing greater accessibility to care for the patient, communicating with family members, and providing effective coordination with the patient's PCP, subspecialists, case management, lab, x-ray, and more. With the increasing demands of healthcare reform and value-based purchasing, hospitalist medicine will continue to play a larger role in care management and utilization.
The constant availability and communication with stakeholders improves continuity of care, clinical quality, the effectiveness and momentum of the healing process, patient satisfaction, physician satisfaction, and the cost of care. Hospital medicine fills the gap of providing consistent, quality physician care to patients in the hospital, while managing the patient stay to decrease costs.
In a value-based purchasing environment, a well-run hospitalist program can improve quality and services while reducing LOS, reducing cost-per-case due to efficient management of resources, and improving utilization. With a significant impact on communication and core measures, the hospitalists can support hospital initiatives such as improving HCAHPS results. Hospitalists can also save the hospital from penalties that could result from inappropriate admissions and costly readmissions.
The advantages of a properly managed hospitalist program can include all of the advantages noted in Box 48-1.
Box 48-1 Advantages of Effective Hospital Medicine Programs |Favorite Table|Download (.pdf)
Box 48-1 Advantages of Effective Hospital Medicine Programs
- LOS reductions
- Decreased cost per case
- Reduction in readmission rates and penalties
- Fewer patient tests
- Higher patient/family satisfaction
- Greater availability to a physician—in the hospital 24 × 7
- Improved quality measures
- Core measure compliance
- Improved HCAHPS scores