I’m just back from the annual meeting of the Society of Hospital Medicine and, as usual, I was blown away. I’ve not seen a medical society meeting that is remotely like it.
As Win Whitcomb, who co-founded SHM, wrote to me, the meeting is “a mix of love, deep sense of purpose, community, mission, changing-the world, and just plain sizzle,” and I completely agree. I was also amazed by the size: having hosted the first hospitalist meeting in 1997, with about 100 people, seeing an audience of 3,600 fill a Las Vegas mega-ballroom was just plain awesome.
This enthusiasm did not equal smugness. Folks know that change is the order of the day, and with it will come upheaval and some unpleasantness. But the general attitude I sensed at the meeting was that change is likelier to be good for patients – and for the specialty – than bad. Whether this will ultimately be true is up in the air, but the mindset is awfully energizing to be around.
Here, in no particular order, is my take on a few of the issues that generated hallway buzz during the SHM meeting.
The Closing of Hospitals
While much is uncertain in the era of health reform, the number of hospitals is clearly going to shrink, perhaps by a lot. A healthcare system that tolerated the inefficiency of having two mediocre 125-bed hospitals in adjacent towns will no longer do so: one 200-bed hospital will be left standing when the dust settles.
The betting is that 10-20% of hospital bed capacity will be taken out of the system in the next few years. It could be even more, depending on the answers to several questions. Will electronic monitoring and telemedicine allow increasing numbers of sick patients to be cared for at home or in sub-acute settings?
Will payments for non-hospital care (home care, SNFs) be enough to expand their capacity to care for acutely ill patients?
Will ACOs, bundling, and other similar interventions truly flourish? Will a shift to population health and a new focus on wellness make a dent in the prevalence of chronic disease?
Sarah Jones was an anomaly in contemporary healthcare. Despite shifting alliances between physicians, hospitals, and insurance companies, she had been under the care of the same physician for over 20 years. Over this time, patient and physician had gotten to know each other well and had developed a fine relationship. Mrs. Jones had always assumed that, should she ever need to be admitted to the hospital, this relationship would pay big dividends, ensuring that her medical decision making would be based on long acquaintance and strong mutual understanding.
When the dreaded day came that she finally needed inpatient care, however, her hopes were dashed. Her physician explained to her that he no longer sees hospitalized patients. Instead she would be under the care of a team of physicians known as hospitalists. When she arrived, the hospitalist on duty introduced herself and told her that she would be the physician responsible for her care, while colleagues would be responsible during off hours. Unlike her regular physician, who would have been on hand only once or perhaps twice per day, the hospitalists would always be in house and ready to address her needs.
Mrs. Jones was surprised and disappointed to discover that her primary physician would not be involved in her hospital care. She had always assumed that she would be able to rely on their longstanding relationship for counsel and support. She imagined that if she were facing some really important decision, such as whether or not to proceed with a risky operation or how to manage her own end-of-life care, it would make a huge difference to know that she could count on a physician she knew well. Instead her hospital-based physician was a complete stranger.
Mrs. Jones’ experience is far from unique. In the past 15 years or so, medicine has seen the birth of hospitalists, a new breed of physicians who care only for hospitalized patients. There are now over 30,000 hospitalists in the US. From a patient’s point of view, such physicians offer a number of advantages. In many hospitals, a specialist in hospital medicine is always on duty, day or night. Moreover, because such physicians work only in the hospital, they are often more familiar with the hospital’s standard procedures, information systems, and personnel.
It is not difficult to see why hospital medicine might be so attractive to young physicians. For one thing, it provides them with a high degree of control over their working hours. They come on and off shift at regular times, and do not bear patient care responsibilities outside these hours. In addition, they are usually employed by the hospital, which means that they do not need to attend to a host of practice management issues that self-employed physicians confront. They can also focus on acute-care, in-hospital medicine, avoiding the challenges associated with long-term care of chronic-disease patients.
Some non-hospitalist physicians also find the rise of hospital medicine attractive. They do not need to travel to one or more hospitals each day to see patients, which takes considerable time and generates little revenue. They do not need to work so hard at staying abreast of changes in hospital procedures and technologies, which often vary from institution to institution, as do requirements for acquiring and maintaining hospital medical staff privileges. And finally, they can focus their energies on outpatient care, avoiding the more acutely life-threatening and complex situations associated with hospitalization.
Everybody hates curbside consults – the informal, “Hey, Joe, how would you treat asymptomatic pyuria in my 80-year-old nursing home patient?”-type questions that dominate those Doctor’s Lounge conversations that aren’t about sports, Wall Street, or ObamaCare. Consultants hate being asked clinical questions out of context; they know that they may give incorrect advice if the underlying facts and assumptions aren’t right (the old garbage in, garbage out phenomenon). They also don’t enjoy giving away their time and intellectual capital for free. Risk managers hate curbside consults because they sometimes figure into the pathogenesis of a lawsuit, such as when a hospitalist or ER doctor acts after receiving (non-documented) curbside guidance and things go sideways.
There is some evidence to support this antipathy. A recent study published in the Journal of Hospital Medicine examined 47 curbside consultations by hospitalists, in which formal consults by different hospitalists (unaware of the details of the curbside encounter) were performed soon thereafter. Conducted by a team of researchers from the University of Colorado, the study found that the information given to the curbside consultant was incomplete or inaccurate roughly half the time, and that management advice offered via the two forms of consultation differed 60 percent of the time. (In those cases in which the consultant was given inaccurate or incomplete information, the advice differed more than 90 percent of the time!) This is not the first warning about the dangers of such consults (see also here and here), and it won’t be the last.
I have been taking a vacation from blogging as I try to get through a very busy academic quarter. But my last blog, “My Son the Electrician” elicited a lot of comments and I have always wanted to follow up. And today I see that the Chicago Sun Times has generously quoted me, in particular noting how I liken physicians to entrepreneurs. Lest anyone get the wrong impression, let me briefly explain what I mean.
Like entrepreneurs, physicians launch their careers by making large investments – up to ten years of post-graduate training. Such investments do not come with a guarantee. Entrepreneurial physicians – those who own their own practices or work in small partnerships, must build their practices and maintain relationships with other physicians. All successful physicians, whether entrepreneurs or employees, enjoy personally and professional satisfying careers and comfortable, sometimes more than comfortable, incomes. But only physicians entrepreneurs have ultimate responsibility for their practices and their patients.
I just returned from the Society of Hospital Medicine’s annual meeting in Dallas. Seeing more than 2,000 hospitalists in one place is remarkable, since I remember the days when we all fit into a mid-sized conference room at a Holiday Inn.
I have clearly assumed the mantle of elder statesman at these meetings. I find this odd, since my idea of an elder statesman is UCSF’s former chair of medicine, Lloyd Hollingsworth (“Holly”) Smith, a man of unbelievable accomplishment and grace. Holly is now in his late 80s, and every year we ask him to say a few words at our department’s annual faculty dinner. Holly is the best after-dinner speaker I know – his comments, always insightful and hilarious, are increasingly peppered with “old guy” references (my recent favorite: “I’ve now reached the age of – when I reach down to tie my shoes, I ask myself, ‘Is there anything else I need to do as long as I’m down here?’ before I get up.”)
I’m not complaining: for the past decade, I’ve had the honor of giving a closing keynote address at the annual hospital medicine meeting. In this week’s talk, I reflected on the history of the hospitalist field, in the 15 years since Lee Goldman and I coined the term in the New England Journal of Medicine.
This kind of reflection is useful because, in a world in which we’re all drinking out of a huge information hose, it’s easy to focus on the short term and lose track of the arc of history. Self-help guru Tony Robbins had it right when he said, “Most people overestimate what they can do in a year, and underestimate what they can do in a decade.” Our 15-year history proves that.Continue reading…
I recall with fondness many meetings in 1996-98, when the hospitalist field was still in its infancy. We had invented a new medical specialty, and our gatherings were vibrant and purposeful. We were determined to remake the healthcare system, learn from each other’s triumphs and disasters, and chart a course that would improve the care of hospitalized patients. These were heady times.
I experienced déjà vu last week in a nondescript conference room at a San Francisco airport hotel, where the Society of Hospital Medicine and the American Hospital Association gathered a dozen folks to discuss specialty hospitalists. Representing the “traditional” hospitalist field (I never thought I’d say that) were SHM CEO Larry Wellikson, SHM co-founder John Nelson, SHM president-elect Joe Li, pediatric hospitalist Erin Stucky, and me. We were joined by AHA Senior Vice President John Combes. But the real stars were six leading physicians in new subspecialty hospitalist fields: a neurohospitalist (Dave Likosky), two surgical hospitalists (John Maa and Leon Owens), two ob-gyn hospitalists (Rob Olson and Ken Jacobs), and even an ENT hospitalist, Matt Russell. Here’s what I learned:
The Neurohospitalist: “The Neurologists Have Left The Building”
At my yearly hospital medicine CME course, I ask the 600 attendees what topics they believe they need to learn more about. The top answer is always neurology. Why? Because most neurologists are perfectly content to remain in their offices seeing headaches and neuropathy; few want the pressure and hassle of managing acute strokes or status epilepticus. When the neurologist “has left the building,” which is most of the time, medical hospitalists are left to pick up the pieces.
I had heard something about this, but couldn’t find it. A colleague here finally tracked it down. The story is about Caremore, a California based organization. Hospitalists generally are internal medicine doctors based in the hospital; but here they care for frail elderly members at high risk of hospital admission or readmission in skilled nursing facilities and in outpatient settings both before and after a hospital stay. Here’s an article on the AHRQ Innovations Exchange website.
A Medicare Advantage plan expanded the role of its employed hospitalists, using them to continue following and caring for recently discharged members until their condition stabilizes, as well as other members at high risk of a hospital admission. Known as “extensivists” and supported by sophisticated information technology (IT) systems, these physicians generally split their time between the hospital, where they round on a small group of members each day, and an outpatient clinic, where they see recently discharged members and other members at high risk of an admission. Once or twice a week, these physicians also see members in SNFs.
The program reduced readmission rates and has led to low LOS (lengths of stay) and to below-average inpatient utilization in a high-acuity population.
Is this worth considering more broadly? What are the conditions for success? I welcome your thoughts.
Paul Levy is the President and CEO of Beth Israel Deconess Medical Center in Boston. Paul recently became the focus of much media attention when he decided to publish infection rates at his hospital, despite the fact that under Massachusetts law he is not yet required to do so. For the past three years he has blogged about his experiences in an online journal, Running a Hospital, one of the few blogs we know of maintained by a senior hospital executive.
Hospitals aren’t the first businesses hurt when the economy sours, but they get hurt nonetheless, as an article in last week’s NY Times points out. But hospitalists have never lived through a massive downturn. What happens to them when the economy tanks?
Let’s start with hospitals. Unlike new cars and Starbucks drinks – “discretionary” purchases (though I really do need my morning mocha!) that tend to dematerialize when household budgets tighten, hospitals are likely to get busier in tough times. We’re already seeing people having to choose between their statin and their supper – some of them will end up in our Emergency Departments. Folks who lose their jobs may lose their health insurance, and with it their access to primary care and prevention. They too may ultimately pay the price in hospital admissions for out-of-control diabetes or hypertensive heart failure.
The bottom line is that people will keep getting sick, no matter where the Dow is. In fact, they may get sicker as the economy worsens, and when they do, they’ll end up on our doorsteps.
But volume and profitability don’t march hand-in-hand, and in difficult economic times they tend to march in opposite directions. The problem is captured by that old ironic lament: “We lose money on every case but make it up on volume.” As government budgets tighten, Medicaid and Medicare cuts are inevitable. Beth Israel Deaconess CEO Paul Levy estimates that Medicaid cuts in Massachusetts will cost his hospital 7 million dollars this year, cutting his operating margin nearly in half. These payment cuts, coupled with more patients with no insurance at all, mean that more beds will be filled with no- or poor-paying patients, hammering our hospitals’ bottom lines.
Hospitals live off sources of income other than clinical revenues, but these too will be squeezed. Philanthropic dollars – a crucial fuel source for hospital improvements – are drying up, as the “B” in billions in certain trust funds gets replaced with an “M”. Many hospitals are finding that the bonds they counted on to finance their new Cardiac Wing are no longer available or affordable (though here in California the voters thankfully passed significant hospital construction bond measures, including one to rebuild San Francisco General Hospital and another for statewide Children’s Hospital construction).
Finally, in academic hospitals, research dollars have nowhere to go but down, as NIH budgets are cut and the endowments of research foundations dwindle like your 401(k).
Overall, its not a pretty picture for the average hospital. But at least people are buying what we’re selling, even if they’re not paying us enough. If you’re in the hospital business and getting depressed, think about what it must feel like to be at GM.
Now let’s turn to hospitalists. Since hospitalists earn most of their pay (50-80%, on average) from clinical billings, these dollars will go down for all of the above reasons. But the key variable is the other 20-50%, which generally comes from support payments from hospitals. If you’re a hospitalist, you can bet that your hospital, pleading poverty, will try to cut this portion. And it won’t be an idle plea: they have only so much money to go around and they can’t cut nursing salaries, already-pledged construction budgets, or any number of other fixed costs.
Sounds like hospitalists are in for a tough ride. But not so fast…
Managed care – which got de-fanged over the past decade when the public came to associate its cost-cutting with poor quality – is likely to get re-fanged, with increasing pressure to shorten LOS and decrease hospital costs. Many hospitals look to their hospitalists to help improve their throughput, and there is strong evidence that they are right to do so. Primary care physicians will be busier than ever in the office and even less likely to come to the hospital, creating further hospitalist demand. Surgeons will want to spend more of their time in the OR, increasing their desire for hospitalist co-management. The Institute of Medicine will soon release a report on housestaff duty hours, and Those-In-The-Know are predicting further ratcheting down, perhaps abolishing the still-legal 30-hour overnight shifts.
Meanwhile, the pressure to improve quality and safety continues to grow, with more public reporting, regulatory oversight, and pay-for-performance/no-pay for no-performance. The measures will also become more diverse and complex, making them harder to “game” and increasing the pressure to truly transform the care delivery process. Hospitalists are likely to be critical to the success of these efforts.
All in all, hospitalists remain in an enviable position to weather the budgetary storms. In many organizations (including mine), hospitalists now help care for over 50% of the inpatient census, and make up a wildly disproportionate fraction of leaders in quality, safety, IT, and medical education. The market for hospitalists remains uber-competitive – hospitals recognize that an unhappy hospitalist can leave work on Friday and have a new and desirable job across town on Monday… assuming that the competing hospital doesn’t need to fill a weekend shift! In other words, the negotiating position of hospitalists remains strong, even if they’re vying for a share of a shrinking pie.
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. But my usual admonition to hospitalists remains unchanged: We and our programs simply must be – and must be seen to be – indispensable. Hospitalist leaders need to argue that cuts that are too draconian are not only not in their own interest, they are not in the hospital’s interest. These arguments should be data driven and respectful – it is always a good idea to try to put oneself in the shoes of the person on the other side of the table to understand his or her predicament, and to search for win-win opportunities.
Finally, if hospitals believe that other organizational models might be successful in performing certain functions at an acceptable quality at lower cost (such as using NPs or PAs instead of hospitalists on certain services), I urge them to give it a try. A field like hospital medicine – whose raison d’être was “value improvement” over traditional models of inpatient care – can’t fight efforts to try other ways to achieve the same ends, at least not without a heavy helping of hypocrisy. In my experience, in institutions with strong hospitalist programs, senior leaders recognize the model’s value and will be highly reluctant to muck with it. But there is nothing wrong with a little experimentation, as long as the results are measured and acted upon.
It will be a rough patch for everybody, and hospitalists will be no exception. But if you run a hospitalist group, the pain your group experiences will be attenuated if you’ve made yourselves indispensable and have demonstrated that you are great stewards of resources, inveterate problem solvers, and model organizational citizens.
If you haven’t, yesterday was a good time to get started.