When Long Island Jewish Medical Center wanted to improve its financial performance two years ago, it introduced a hospitalist program. Now the program oversees one-quarter of the New York hospital's patients--and it has cut costs and boosted patient satisfaction.
Long Island Jewish is part of a trend across the country to establish hospitalist programs. Dubbed "the new inpatient specialists," hospitalists are physicians who manage the care of hospitalized patients. An estimated 3,000 of them are in practice, with approximately two to three more joining the ranks every week, says Winthrop Whitcomb, M.D., co-founder of the National Association of Inpatient Physicians, a specialty society for hospitalists.
Meanwhile, private firms, venture capital investors and managed-care companies are taking a risk on hospitalists' promise, spurring the movement along at a rapid pace.
With hospital care accounting for about 5% of the gross national product, hospitalist programs are being formed in response to an industrywide interest in optimizing efficiency.
The program at Long Island Jewish has achieved more comprehensive results than hospital executives anticipated. For example, it has cut patients' length of stay by 10% to 15% and reduced cost per patient by $600 to $800.
It also has improved patient satisfaction, says Steven Walerstein, M.D., associate chairman of medicine and director of inpatient services of Long Island Jewish. "Patients and families are particularly pleased about having somebody who is constantly available to answer questions and discuss their case throughout the course of the day," Walerstein says.
Today, Long Island Jewish employs eight hospitalists to manage about 25% of its medical services, or a projected 2,300 patients in 1998.
The hospitalist concept isn't new; in fact, inpatient physicians have existed in some form for many years. But the creation of the formal title "hospitalist" in April 1997 by a pioneer of the movement and the launch of the NAIP early this year have brought such doctors into the spotlight.
The driving force behind the hospitalist movement has been managed care's effect on the shifting focus of medical practice. With patients being pushed out of the hospital earlier--and in a sicker condition--outpatient physician practices have become busier. This shift leaves less time for primary-care physicians to spend with their hospitalized patients, creating the need for an inpatient physician counterpart to perform primary-care functions in the hospital, Whitcomb says.
Without a hospitalist, inpatient care might aptly be illustrated by a revolving door: One specialist comes in, treats the patient and leaves, then another does the same, and so on. Communication gaps exist among all involved--including patients and their families.
Hospitalists are leading an initiative to coordinate patient care and eliminate such communication gaps.
For example, at Mercy Hospital in Springfield, Mass., the hospitalist team meets with the physician coming off the night shift each morning for 45 minutes to discuss the cases of all new admissions from the day before. This helps weave together the patient's story and fill communication gaps among physicians, correcting crucial flaws with the current system, says Whitcomb, who also is director of inpatient services and hospitalists for Mercy.
Whitcomb says the hospitalist movement's main focus is improving patient care.
"This is not about managed care," he says. "It's not an HMO thing. This is about more efficient, better-outcome healthcare. It has been spurred on by HMOs because, coincidentally, it saves money too. It's a more rational healthcare delivery system, and it just turns out that it ends up costing less."
One way hospitalists can improve outcomes is by activating care guidelines that previously had not been implemented effectively, Whitcomb says.
For example, when Mercy's hospitalists determined many patients were not receiving proper, timely respiratory treatment, the team organized respiratory therapists, pulmonologists and hospitalists to develop and implement a related protocol. As a result, the number of patients who did not receive treatment or whose treatment was delayed dropped threefold.
"The bottom line is that it's more efficient because of the ability to focus resources behind a fewer number of providers," Whitcomb says. "If you think about it, hospitals are amazing places. They handle thousands of different doctors, admissions, diagnoses. The process variability that hospitals have to handle is unbelievable. Hospitalists reduce process variation."
For doctors to buy into the hospitalist concept, says Adam Singer, M.D., chief executive officer of Burbank, Calif.-based IPC-The Hospitalist Co., inpatient physicians should practice full time in the hospital. Singer founded the hospitalist outsourcing company in 1995; it now manages and employs about 40 physicians and has annual revenues of $7 million. It recently received $5.5 million in financing from major venture capital funds and investment banks.
Singer says IPC is using the funding to expand its management team, continue information technology development and enter new markets.
As opposed to full-time inpatient physicians, part-time hospitalists maintain an outpatient practice in addition to their inpatient responsibilities. Singer says this creates conflicts because primary-care physicians are concerned their patients will be taken away from them by hospitalists who also treat outpatients.
The full-time model solves that problem. "It's a real partnership," Singer says. "You need (primary-care physicians) to refer your patients to. We've become a referral source for them."
Also, he adds, the hospitalist concept is based on the ability of physicians to focus solely on inpatient care, which they can't do if they maintain outpatient practices. Singer says he believes the part-time model, while currently common, will die out as the hospitalist movement moves forward.
Managed-care companies, enthusiastic about the positive results that can be achieved, are implementing hospitalist programs in their HMOs and PPOs. Whitcomb is concerned managed-care companies may tend to establish mandatory hospitalist programs, which the medical field views unfavorably.
In a mandatory program, when a patient is admitted to the hospital, he or she is automatically assigned to a hospitalist. Thus, primary-care physicians are not reimbursed for seeing their patients. Primary-care doctors feel displaced and want themselves and their patients to have the right to choose.
At its June 14-18 delegates meeting, the American Medical Association voted in favor of voluntary use of hospitalists. The NAIP, the American Society of Internal Medicine and the American College of Physicians also support voluntary use.
Singer says the real risk of using hospitalists is the potential for information cutoff. Whereas the primary-care physician is versed in a patient's complete medical history, the hospitalist generally sees the patient for the first time upon hospital admission.
He notes, however, that the focus of hospital care is stabilizing patients; everything else can be done on an outpatient basis. For that reason, he says, there's no need for complete historical knowledge. And, he says, when a patient is admitted, the hospitalist contacts the patient's physician immediately. The doctor would inform the hospitalist at that point about any imperative information. Plus, Singer says, hospitalists are well-acquainted with chronically ill patients who are frequently admitted to the hospital. "We know them just as well because we keep readmitting them," he says.
Singer stresses that it's imperative to avoid communications breakdowns between the inpatient physician and the primary-care doctor after patient discharge.
To address this problem, in 1997 Singer and his cousin Robert Singer designed and developed IPC-LINK, an information technology solution for hospitalist practices. Within seconds of patient discharge, the program downloads pertinent information about hospital care to the patient's primary-care physician. IPC's physicians use the program, and Singer recently made it available to outside hospitalists.
Some opponents of mandatory programs also believe patients want to be cared for by the doctor they already know and feel comfortable with.
Singer disagrees. "Patients are very satisfied," he says. "Rarely do we hear a complaint that they want their doctor to come in. They don't care."
Jerry Reeves, M.D., chief medical officer for Humana, Louisville, Ky., echoes Whitcomb's testimonial. While acknowledging that the managed-care company's hospital inpatient management system has improved its bottom line, he says patients in the program have a higher satisfaction level than other enrollees.
The goal of Humana's program is to improve continuity of care, decrease variation, and improve service and outcomes of care. "And we have been successful on all fronts," he says.
Singer has a theory as to why: "When you're healthy, your issue is choice. When you're sick, you're simply saying, 'Help me.' You want someone there explaining, meeting with your family. A (primary-care physician) can't deliver that because he's in the office. When you're in pain or you feel lousy, you just want someone to take care of you."
