And then came the hospitalists

The 20th century has been a time of tremendous change for the medical profession. What began as a cottage industry in which house calls by family physicians were commonplace is now dominated by multi-billion dollar corporations trying to gain their share of an industry that is worth $1 trillion and represents approximately 14% of the U.S. economy. Among the trends that have taken place during this time is the movement toward physician specialization - the latest example of which is the managed care-driven rise of the hospitalist.

Most medical specialization was spawned from an increasingly vast amount of medical knowledge in very distinct areas. Keeping up-to-date on the latest medical breakthroughs in every area proves not only an impossibility from an information standpoint but it is also impractical. After all, family physicians may run across a particular disease only once or twice in their careers. However, the medical profession's latest specialization - the hospitalist - resulted from physicians looking for better ways to use their time.

Throughout the '80s and '90s, one of the most pronounced health care trends in the country was the movement of the delivery of health care away from the hospital setting. Patients were shifted from this high-cost setting toward less costly ambulatory settings. The result was that physicians had fewer patients admitted to the hospital at any given point in time.

Having fewer patients in the hospital, however, did not save much time for the average practitioner because it did not eliminate one of the most time-consuming aspects of hospital rounds - going to and from the hospitals. To free up time-hungry physicians, larger practices starting dividing up hospital round duty; physicians began checking on each other's patients. This is the basic idea that gave birth to the hospitalist.

Hospitalists dedicate their time to caring for patients admitted to a hospital facility. Most are internists – up to 90%, according to industry sources. Although hospitalists were first used approximately 10 years ago, the trend has taken off in the last two years. Groups that solely concentrate in this subspecialty are still quite rare, according to the National Association of Inpatient Physicians, a trade association created in the last year to represent hospitalists. Today, there are more than 2,000 hospitalists practicing in the United States.

Hospitalists earn an average of $145,000 - more than many of their primary-care colleagues. Although primary care physicians increasingly rely on hospitalists, they have also become the new specialists' biggest critics. Some primary care physicians contend that using hospitalists can disrupt the continuity of care. Managed care organizations, on the other hand, are among hospitalists' biggest proponents.

Managed care likes the idea

Managed care organizations recognize the benefit of hospitalists to the health care system. Staff-model health maintenance organizations, for example, can reduce costs by using hospitalists because they cut the time primary care physicians spend in the hospital looking after small numbers of patients. These savings can be realized in all types of models using capitation as well for the same reason.

Hospitalists also reduce expenditures on hospital stays. For example, when patients are admitted to a hospital for tests that ultimately prove negative, they must remain there until their physicians sign their discharge papers. Depending on the time of day and the physicians' schedules, patients who would otherwise return home may spend needless nights in a hospital because their physicians are unavailable. If patients are under the care of a hospitalist, their discharges could be made soon after the test results came back, thereby reducing the length of their hospital stays and eliminating unnecessary costs. Humana estimates that its hospitalist program reduced hospital length of stay for its Medicare patients by 9%, which saved the company more than $22 million.

Many patients like hospitalists. Although some may initially find it disconcerting to be turned over to a new physician, others note that they prefer the increased availability of hospitalists. These physicians also tend to have more experience with certain illnesses, such as pneumonia, because they treat these conditions much more frequently than office-based physicians who may only see a few incidents per year. Additionally, the patients' primary care doctors, who now have more time to focus on patients in the practice setting, are kept informed of all major decisions made about their patients in the hospital and are sent discharge summaries.

Hospitalists have a promising role to play in controlling costs in tomorrow's health care system. However, like all medicine, the quality of care provided will hinge on the information available to hospitalists, the coordination of care and the skill these physicians possess. PR