The term "hospitalist" was coined a mere decade ago even though the role began being filled in the early 1990s. In the years since, their numbers have exploded. Today hospital medicine is one of the fastest-growing medical specialties, and salaries are on the rise.
Hospitals that have implemented hospitalist programs have done so for a variety of reasons, from the burden on primary-care physicians to improving quality and lowering costs. Whether hospitalists actually help accomplish these and other goals is difficult to determine, but a new study by healthcare research company Solucient shows mixed preliminary results.
The Evanston, Ill.-based company compiles an annual 100 Top Hospitals study, and the results on hospitalists were released exclusively to Modern Healthcare in conjunction with the 100 Top list.
Hospitals that use hospitalists may experience shorter lengths of stay and improved mortality rates, according to the research. However, they do not have markedly lower costs, better patient safety or fewer complications. That said, hospitals appear to be forging ahead, expanding hospitalist programs and starting new ones.
The term "hospitalist," which refers to a physician who takes care of hospital patients in place of their own primary-care doctors, was introduced in 1996 in a New England Journal of Medicine article by Robert Wachter and Lee Goldman. In the mid-90s, there were about 800 hospitalists nationwide. By 2005, that number had jumped to 15,000, and by 2010, there may be as many as 30,000, according to the Society of Hospital Medicine, a professional association for the specialty.
Large community hospitals and teaching hospitals are more likely than smaller ones to have hospitalists, Solucient found, with more than 50% of teaching hospitals using at least one hospitalist, but only one in 10 community hospitals having one. Hospitals of all types and sizes that have hospitalist programs, however, are more likely than their peers to be top performers and make it into the 100 Top, according to the Solucient study. The 100 Top hospitals are selected for their superior performance in quality, finances, operations and growth.
"The higher the intensity of hospitalist use, the more likely you are to be selected a 100 Top hospital," says Jean Chenoweth, senior vice president of the performance improvement and 100 Top Hospitals programs at Solucient. "That holds across the board, with all types and within each class." For its 100 Top list, Solucient divides hospitals into five categories: major teaching hospitals, which have 400 or more beds and high levels of physician education and research; teaching hospitals, which have 200 or more beds; large community hospitals (250 or more beds); medium community hospitals (100 to 249 beds); and small community hospitals (25 to 99 beds).
The data for Solucient's analysis of hospitalist care were culled from the 2004 100 Top database and the American Hospital Association's 2003 annual survey database, which asked respondents whether hospitalists provided care for patients in their hospitals, and if so, how many full- and part-time hospitalists they had. Among the study's limitations was its small sample size: Only 857 hospitals answered the AHA's second question.
In addition, the Solucient study looked only at correlations between hospitalist care and factors such as mortality rates, quality and cost. It did not examine whether there was a cause-and-effect relationship. Thus it is possible that other factors besides the use of hospitalists may be contributing to better or worse performance in the areas studied.
"Not only should someone be careful about getting too excited about what the findings are, but someone should also not be getting too excited about what the findings aren't," says Dave Foster, Solucient's chief scientist. "Absence of proof of a connection ... between two factors is not the same as proof of an absence."
Still, many hospitals are buying into the hospitalist model as a way to solve specific problems. The reasons a community hospital may have for hiring hospitalists can be very different from those of an academic medical center.
Easing residents' burden
The University of Michigan Hospitals and Health Centers in Ann Arbor is one large academic medical center that relies on hospitalists to ease the burden on its residents. The 785-bed center, which has appeared on the 100 Top list four times (See chart, p. 9), began its program in 2002 with four hospitalists.
Today there are 28, and that number is likely to grow, says Scott Flanders, an associate professor of medicine and the director of the hospitalist program. Flanders, who is also on the board of the Society of Hospital Medicine, estimates that for the year that began July 1, hospitalists will take care of roughly one-third of the 15,000 internal medicine patients admitted to the University of Michigan hospitals.
The university began its program to increase the availability of physicians to patients and to free up subspecialists, Flanders says. Before the hospitalists came on board, the doctors who were taking care of patients were running back and forth to labs and other responsibilities and were not necessarily dedicated entirely to hospital medicine.
"It was the assumption that this would likely be better for patient care, and it was our hope that it would improve the resident educational experience up on the wards and improve some of the efficiency of patient care, which became increasingly important as hospitals filled up and got closer to capacity," Flanders says.
The recent federal mandates for shorter resident work hours have propelled the program's growth, he says. "Our hospital has just gotten busier and busier, fuller and fuller; patients have gotten more and more complex, and our residents have been overworked."
Kenneth Pituch heads up the University of Michigan's pediatric hospitalist program at its C.S. Mott Children's Hospital, which has also grown from two full-time and two part-time hospitalists in 1999 to 10 full- and part-time hospitalists today. Pituch says his program's experience reflects one of Solucient's findings: that hospitals with hospitalists have shorter lengths of stay.
For example, at the university's children's hospital, the hospitalists can perform routine circumcisions on newborn boys around-the-clock, an advantage that has reduced the length of stay of baby boys dramatically, he says.
The program has also been doing better than expected financially, Pituch says. When it began the pediatric hospitalist program, the university had planned to subsidize half of the program's budget, but for the past two years it has had to subsidize only 20%, or even less, Pituch says. The Society of Hospital Medicine, in a survey released in May, found that 97% of hospitals surveyed contributed financial support to their hospital medicine groups in 2005, at an average rate of $50,000 to $60,000 per full-time hospitalist per year.
Connections between hospitalist programs and the cost of care appear to be difficult to measure. Solucient found no clear relationship between use of hospitalists and lower expenses per discharge in its study. The study's authors concede that this was a surprising finding, perhaps attributable to the nature of the data.
Much of the early hype about hospitalist programs focused on the financial efficiencies they could deliver, but the University of Michigan's Flanders suggests that focusing on efficiency and cost alone is simplistic.
"I think the big message is the benefits of a good hospitalist program go so far beyond that," he says. "You basically have people that now live in the hospital, see it as their home, and take ownership in that. ... It's very different from the old model, where you had people who were renters, if you will."
Still, efficiencies are possible and do play into hiring decisions, says David Rice, the director of the division of inpatient medicine at 517-bed Scott & White Memorial Hospital in Temple, Texas, another teaching hospital that has been a 100 Top hospital for the past three years.
"In the long run, from a business point of view, if you can get by with one less cardiologist, that could pay for two or three hospitalists," Rice says. "That's not saying good or bad about one or the other. That's just the truth."
Nevertheless, he says, it's difficult to pinpoint how much hospitalists have saved the hospital. "Having a hospitalist here 24/7 absolutely improves efficiency," Rice says. "We've seen a decreased length of stay and are trying to document a decrease in cost compared with the teaching staff." Rice also says that it is difficult to document any improvement in performance because of the difficulties in measuring quality and safety. "Everyone is absolutely convinced that it's there," he says, "but showing that in a data format, a study format, has been fairly difficult for us."
That has not dampened support for the hospitalist program though.
Scott & White now has 12 hospitalists and is looking for at least two more, Rice says. The program began 10 years ago with two doctors. Now, hospitalists care for about one-quarter of the hospital's patients.
Middlesex Hospital, in Middletown, Conn., is a medium-size community hospital that was a 2004 100 Top hospital. Its hospitalist program began in 1998 with about two full-time physicians and has since grown to 10 full-time and three part-time physicians, as well as two full-time and one part-time physician assistants.
Lengths of stay improve
The initial impetus for the program came in part from the broad geographic area served by the 168-bed hospital, says Jesse Wagner, chief of the hospitalist service at Middlesex. Physicians who sometimes had to drive 30 to 45 minutes to see patients at the hospital favored the program from the outset. While there was a group who said they would never use hospitalists, "that lasted about 30 days," recalls Susan Menichetti, vice president of administration at the hospital.
Wagner says length of stay improved by a half-day to a full day after the program had been in place for two years. As for whether hospitalists contribute to improved patient safety, Menichetti says that while data may be lacking, hospitalists at Middlesex have been instrumental in implementing the Leapfrog Group's 27 patient-safety measures and other initiatives at the hospital.
"They are a key group in making any of these safety measures doable and consistent," she says. "Because we had the service, it was much easier to institute those safety measures across the board."
Beaumont Hospital-Troy (Mich.) is a teaching hospital that has been a 100 Top hospital six times in total and in each of the past four years. The 254-bed hospital has a very high ratio of hospitalists to beds, Solucient's Chenoweth says. Jason Batke, a hospitalist at Beaumont, says he is not surprised by Solucient's finding that length of stay and mortality levels are better at hospitals that use more hospitalists than their peers.
"I think these things come together," he says. "We're able to expedite things like testing. If a test result comes back, if a doctor sees the patient at 6 a.m. or 7 a.m., if they're at the office they might not see the test result until the end of the day. The hospitalist would see it (more quickly) and possibly let that patient go home that day."
Besides moving things along, hospitalists also spend more time around sicker people than outpatient physicians do. "If you're there and more readily available," Batke says, "you're able to address emergencies that come up." This in turn may have a positive effect on mortality rates, he suggests. "That's what we want to see -- people getting better."
Although Solucient found that small community hospitals did not use hospitalists as frequently as teaching or larger community hospitals do, some smaller hospitals are trying to get in on the action. Chestatee Regional Hospital in Dahlonega, Ga., is one of them. Rob Followell, the 49-bed hospital's chief executive officer, says that when he first began talking about the possibility of a hospitalist program a couple of years ago, some physicians were reluctant. "Two years ago, physicians on my medical staff were less likely to want to turn over the care of their patients to another physician," he says.
Since then, though, financial pressures on physicians have mounted, and the climate might be ripe for change. "It's more and more difficult for them to maintain their level of income," Followell says. "The best way is for them to be in their office seeing patients."
Not necessarily a money-saver
Followell says he hopes to have a hospitalist program in place by the end of the year, even though he does not see it as a money-saver. What he does hope for is improved critical pathways and disease management, more teamwork between physicians and the hospital staff, and increased admissions from physicians in outlying areas. "You don't make any money sitting in traffic as a physician," he says.
There are several national companies that help hospitals set up hospitalist programs. IPC-The Hospitalist Co. is the largest. Based in North Hollywood, Calif., the private company was founded in 1995 and now employs about 500 physicians in 13 states, says Adam Singer, the company's chairman and CEO. While he would not provide specific financial figures, he says the company's profits and revenue have grown 30% every year for the past eight years.
Reacting to the Solucient data, Singer explains that the quality of hospitalist programs varies widely. The bad programs are simply internists without offices. A real hospitalist, though, "is really about driving a medical system to improve the quality and efficiency of the system." The ones that perform better, he says, have hospitalists managing more beds.
While hospitalists may not reduce a hospital's costs, Singer says better documentation and standardization may well help a hospital get better reimbursement for those costs. "Their job is to communicate and bring the team together," he says, "to be the captain of the ship."
Hospitalists are not the answer to every hospital's problems though, he says. "There are some overzealous expectations on a hospitalist movement that isn't well-defined yet," he says. "This is an embryonic specialty, and expectations probably exceed what we can deliver right now."
It is also difficult to find trained hospitalists, he says, because so many are fresh out of their residencies. The growth of the movement may also soon put pressure on outpatient physicians, because there will be fewer of them if more people are choosing to become hospitalists, he suggests.
Still, Singer is banking on the fact that hospital medicine will keep growing and not turn out to be simply a fad. He is hopeful that IPC will go public within a year, he says.
Salary data seem to back up the notion that hospitalists are in demand. Salaries for hospitalists rose 4.1% to an average $182,279 in 2006 from $175,041 in 2005, according to Modern Healthcare's annual physician compensation survey (July 17, p. 26), a greater jump than the 3.9% increase for all physicians and perhaps even a force behind a 7% jump in salaries for internists.
Rachel Canning says she was the first hospitalist UCLA Medical Center hired in 2001. Canning, who now is a hospitalist at 258-bed Kaiser Permanente Oakland (Calif.) Medical Center, says in the three years she's been with Kaiser, the program has increased from 10 people to 30.
"It's clear from the administration's perspective that they're willing to hire more and help us grow because we do so much," she says. That includes patient education, helping coordinate care with surgeons and communicating with patients' primary-care doctors.
Canning says there are times when patients may not understand why they are seeing a hospitalist instead of their regular doctor, or when they may not trust a hospitalist's decisions. But what makes the job appealing to her, she says, is also what makes it beneficial to patients. "It's a real luxury for patients and it's a luxury for us, too, that you can see a patient for five minutes or an hour, or when their family calls up you can actually talk to them," she says. "I can't picture myself doing anything else."
