Sunday, November 23, 2008

Hospitalists and the economy

I can already hear the buzz at SHM 2009. How will the recession affect the hospitalist movement? How should hospitalists be compensated in tough economic times? And, one more time, How can we measure and demonstrate our value?

The past few weeks have seen some interesting and provocative posts on this subject. Adam Singer, author of The Hospitalist Blog, thinks the economic woes of hospitals will trickle down to hospitalists. His solution? If I read him correctly, he thinks hospitalist programs should become “self sufficient” and subsist entirely (or almost entirely) from their billing revenues:

Herein lays the opportunity for hospitalist groups of all types to seize this moment and reevaluate their business models with the goal of reducing their dependency on hospital subsidy dollars to sustain their practices. There are some situations where obtaining hospital stipends are totally appropriate, such as providing on-site night coverage or caring for a disproportionate share of indigent patients, but these situations are more the exception than the rule. Focus on finding opportunities and staffing models for your practice that will generate enough profit so that your practice is self-sustaining. Better to view your hospital subsidy as a luxury that your practice could live without if you had to, rather than as a necessity that you need in order to survive. It can be done.

I’m skeptical as to how that can be done. I think he plans to explain in installment three.

Bob Wachter’s prognosis, though not quite so pessimistic, is guarded:

My own feeling is that we should accept our share of any shared pain. If budgets are being cut across our institution, we should participate in reasonable belt tightening.

(Do ya think hospital CEOs should participate too, Bob?) ;)

What disturbs me just a wee bit in both posts is the characterization of hospitalist compensation. Referring to the difference between what programs are paid and the fees they produce, Adam uses the term “subsidy” and Bob talks about “support payments.” It implies most programs don’t really “earn their keep.” The usual workaround for that uncomfortable notion invokes all the mental gymnastics about hospitalists’ “value.”

Sure, hospitalist programs bring a great deal more to health care systems than the fees they generate. Much of that value, though, is intangible. It can’t be measured. Here’s the value test: imagine waking up some morning to find that your hospital’s hospitalist program has imploded.


Anonymous said...

If my hospitalist program had to exist only on billing revenues, we would not ber able to see any uninsured patients.

Maybe that's possible if you have a town full of PCPs who don't want to come to the hospital?

Otherwise, who needs the hopsitalists, and who sees the uninsured pts who show up needing care?

Anonymous said...

why is that different than any other practice? it would be no good if the internal medicine practices imploded as well?

i might make the case that if any one group had to implode, the hospitalist group might be the easiest one to deal with? certainly not trauma, anesthesia, neurosurgery, cardiology. in this day and age, i don't think radiology would be easy to go without as we have gotten complacent with physican exams. and for medicolegal purposes. the primary care guys would have to start readmitting some, the specialists would have to readmit some, the er would be dealing with a lot more than previously. what do you think? (thanks for an interesting exercise)

R. W. Donnell said...

Anon 1117:

It is true with other specialties, as you say, that their value is based on more than the RVU's they bring in. Internal medicine doctors are not getting paid for their true value, the specialty is imploding and health care is suffering the consequences.

PookieMD said...

The value that hospitalists bring is intangible, indeed. As so to anonymous, I ask: what PCPs want to come back to the hospital? Most are glad to get the hospitalized patients off their backs--it is nearly impossible to see 25 clinic patients and do rounds on seriously ill hospitalized patients. Thinking that PCPs will come back and solve the problem of reimbursement smacks of magical thinking.