A bumpy ride ahead for the hospitalist movement?

As a member of the Society of Hospital Medicine I have the opportunity to view archived presentations of SHM 2008. Last night I watched the lecture by Institute for Healthcare Improvement CEO Donald M. Berwick, MD and the panel discussion immediately preceding. It was both fascinating and disturbing.

A recurring theme was that health care providers with competing agendas are seeking bigger and bigger pieces of a shrinking financial pie. How will hospitalists fare in the competition, particularly with Medicare’s impending move toward bundling of payments and even a proposal for combining payment to the hospital and the physicians for episodes of care? The panel, coming just short of considering it a fait accompli, would do well to remember a little history. Just such a proposal was floated in 1984: the Kennedy-Gephardt bill. Among other provisions it sought to:

Attempt to "improve' PPS further by including inpatient physician services within DRG payments to hospitals. "It will be the responsibility of the hospitals and the physicians providing the care to allocate the payment.'

Thank goodness it died. But if after 24 years it’s resurrected hospitalists will finally be employees in every sense of the word. Tension between white coats and suits will mount. Does it mean the bubble of increasing hospitalist salaries will burst?

Two answers emerged from the panel. The first was nebulous: hospitalists must demonstrate “value”. What does that mean, exactly? As hospitalists we think our model has value, but how is it measured? Not only is it vague, but, as the panel pointed out, it’s a shifting target. Early in the movement we thought we could demonstrate value in terms of reduced costs and better outcomes. But research on those metrics during the ensuing years was disappointing. Moreover, according to an abstract presentation at the meeting, the move toward hospitalist shift work and the resulting fragmentation of care during hospitalization may be eroding any slim advantage the model had in cost savings. So what’s left that we can demonstrate as value? Patient satisfaction in an age of consumer driven and “patient centered” care? Research suggests we’re value neutral in that area. So the latest buzz seems to be that hospitalists will take advantage of the fact that other doctors are fleeing the building faster than you can say “code brown”. That means admitting all comers, doing “everything” and functioning outside our training and comfort zones, essentially becoming “house doctors”. It's sure to create job satisfaction and burnout issues, already a problem for the movement.

The other answer was more down to earth: the bubble will burst the morning CEOs wake up and realize that there is no longer a shortage of hospitalists. Don’t expect that to happen for decade or so according to the panel. One thing we can all agree on---it’ll be a bumpy ride.