Tuesday, December 28, 2010

Hospitalists at the close of 2010: how are we doing and where are we headed?

St. Louis City Hospital

Hospitalists and outcomes
Boosters of the hospitalist movement have been saying for years that the hospitalist model of care resulted in cost savings. Until this year that claim was not evidence based. Although several studies and systematic reviews had suggested improved efficiency attributable to hospitalist care one of the largest and methodologically best studies on the model showed no difference in efficiency attributable to hospitalist care. But after making a brief splash in the blogs in 2005 it was conveniently tossed into the memory hole. A large new study out this year appears to have tipped the balance of evidence in favor of the hospitalist model by showing reduced length of stay, with an increase in the magnitude of the effect over time through the study period.

There were two items of interest in this year's literature in the related field of comanagement. When hospitalists served as attending physicians for patients admitted with GI bleeds (and thus comanaged the patients alongside the gastroenterologists) costs were higher and there was a borderline statistically significantly higher rate of readmissions in a study I discussed here. Another study just out this month looked at the experience with comanagement of neurosurgical patients at UCSF, which I noted here. According to the results of that study, although the perceived value of comanagement was high, objectively the service appeared to be value neutral.

Current recession and health care reform
Hospitalist salaries have continued to climb, with no sign of moderation, right through the recession. Hospitalists are being paid what the market demands and this is driven by a shortage in the work force. This was documented in the first ever combined MGMA-SHM survey, the results of which I referenced here. The trend will eventually moderate, but no one knows when or at what level. It will likely continue as long as hospitalists remain in short supply. An early influx of hospitalists seeking jobs came from traditional general internists making a career move. That pipeline is likely to run dry soon. Among IM trainees leaving residency, although many take temporary hospitalist positions before landing a subspecialty fellowship or making other definitive plans, the percentage of graduates seeking a hospitalist career is relatively small. Meanwhile, according to 2010 American Hospital Association survey data, 43% of hospitals were making efforts to increase the number of employed hospitalists.

It's anybody's guess what the impact of health care reform will be. It is in a shambles now and we don't know what it will look like in its final form. However, if currently developing economic pressures continue hospitals will need hospitalist programs in order to survive. Although the number is likely much smaller now, according to survey data from almost two years ago nearly half of hospitals did not have hospitalists. So until this growing niche is saturated hospitalist salaries are likely to continue to climb. On the other hand hospitalist jobs could be negatively impacted if large numbers of hospitals are shuttered by health care reform. While that's an outcome that may seem desirable to some policy makers it's not a likely scenario in the near term.

The evolving (or devolving) hospitalist job description
As I said in a post earlier this year, My how we've changed. Cultural and economic shifts have altered the hospitalist's job description over the past decade, and it's not for the better:

Hospitalist skill set, year 2000

Management of CAP and HCAP
Management of sepsis
Management of venous thromboembolism
Management of DKA, adrenal crisis and other endocrine-metabolic emergencies
Management of COPD, asthma and ARDS, including ventilator management
Management of renal, fluid and electrolyte problems
Management of acute decompensated heart failure
Management of toxicologic emergencies
Providing consultation for complex and difficult diagnostic problems
Providing consultation for medical complications in surgical, subspecialty and general medical patients

Hospitalist skill set, year 2010

Tweaking Press Ganey
Tweaking clinical documentation (DRGs)
Creative coding
Bed control
Admitology, roundology and dischargology for surgical and subspecialty patients
Cosmetic charting (performance measures)
Secretarial (CPOE)

No comments: