Emerging Trends -- Hospitalists In Florida

Alex Ommaya
Alex Ommaya is a Research Analyst for Blue Cross Blue Shield of Florida.

Much of our health care expenditures are driven by the costs of hospital care. Inpatient care is roughly 34% of national healthcare expenditures.1 Employers spend roughly 30 to 40% of their employee health care benefit dollars on inpatient care, and health care costs add roughly 10% to payroll costs.2 Inpatient care is of concern for patients, as one study found that medical errors are responsible for injury in 1 out of every 25 patients, with 14% of those injured dying each year.3 These quality concerns are also illustrated by lengths of stay that are 40 percent higher for the same conditions in the Northeast than those in Western states.4 Another example includes the use of beta-blockers after heart attack, which has been shown to reduce mortality by 43 percent. But, in a study of Medicare patients in New Jersey, only 21 percent of eligible patients received beta-blockers. 5 The hope is that a new breed of specialists, hospitalists, can add to the quality of care that is received by patients in inpatient settings while increasing efficiency and lowering costs.

A hospitalist specializes in inpatient medicine, and has been defined as a physician who spends at least 25% of their time caring for the hospitalized patients of primary care physicians (PCPs).6 The hospitalist hands back care of the patient to the PCP after discharge from the hospital. Hospitalists have been used by some health systems and health plans to manage the inpatient care of patients for primary care physicians. Because hospitalists work more routinely in an inpatient setting they have potentially improved knowledge of the operating procedures, greater familiarity with hospital staff, and increased accessibility to patients. Additionally, hospitalists may have more experience and thus improved outcomes in treating conditions that necessitate inpatient care.

Some heath systems implemented hospitalist models in the early 90s, e.g. Kaiser Permanete and Park Nicollet. For health plans, most of the initial growth in hospitalist programs was in-group model plans. Within Florida, many hospitals have independently instituted hospitalist programs on a voluntary basis. Some health plans have established voluntary programs, such as Blue Cross and Blue Shield of Florida and United Health Care. Some health plans such as Kaiser Permanete and Humana have established mandatory programs.

Several studies have shown the promise of hospitalist programs in reducing length of stay and readmission rates. They have also noted concerns, which are ongoing issues related to implementing a hospitalist program. In one study length of stay was reduced 1 day, median cost was decreased $587, and the 14 day readmission rate decreased from 9.9 to 4.6 readmissions per 100 compared to admissions before the hospitalist program.7 Craig et al recently reported the experience of Kaiser Permanete's hospitalist program in 16 Northern Californian hospitals.8 The authors noted implementation challenges such as overcoming reluctance of physicians to relinquish inpatient care responsibilities and communication between staff in inpatient and outpatient settings. A trend in lower mean length of stay was noticed in facilities with a hospitalist program (3.8 vs. 3.2 days). No difference was seen in readmission rates. Primary care physicians were encouraged to make "social visits" to their patients but the authors noted that this practice has not been widespread.

Communication regarding patient progress and breaks in continuity of care have been cited as the major problems related to the hospitalist model.9 Sox cites the mandatory hand-off, practiced by some health plans, as a major issue which exacerbates problems related to communication and continuity of care. Sox also notes that hospitalists do not have the prior experience of the PCP regarding compliance, response to illness and therapeutics, mental health issues, etc. Additionally, there may be confusion about end of life care, advance directives, and other wishes of the patient communicated to the PCP. There is also a concern that hospital based physicians may be more aggressive and technology oriented thus tending toward over-utilization of services.

Although the results of studies of hospitalist programs have been promising, to fully appreciate the effectiveness of hospitalists programs more studies, which appropriately control for temporal, environmental, and patient severity confounds, need to be conducted. There are many factors that impact length of stay, readmission rate, and charges noted in the studies above. Rigorous study design and non-biased methods of sampling will improve the ability to assess the impact of hospitalists programs. Additionally quality, outcome, and patient and physician satisfaction measures should be evaluated in future studies.

A recent survey of members of the National Association of Inpatient Physicians sheds some light on the characteristics of practicing hospitalists.10 This survey however, because it utilized a convenience sample should not be regarded as representative of all practicing hospitalists, merely those who belong to the association. The average age was 40 years and 81% were male. Eighty nine percent received training in internal medicine with 38% reporting some subspecialty training. Roughly 60% followed more than 11 patients at one time. Few hospitalists provided daily progress reports to the primary care physician (14%) or contacted the PCP before ordering an expensive test or starting a new medication. Approximately 24% stated that the use of hospitalists was mandatory by PCPs. Compensation was tied to financial incentives such as patient satisfaction, length of stay, or overall cost for 43% of those surveyed.

Also growing with the hospitalist movement are hospitalists firms, which set up hospitalist programs and provide a communication infrastructure between PCPs and hospitalists. Five of these growing companies employing roughly 500 physicians responsible for over 1.5 million lives were recently profiled in American Medical News.11 Two of them, Hospitalists Inc. and Hospital Inpatient Management System operate in Florida.

The success or failure of the Hospitalist movement hinges on acceptance by patients and their attending physicians. As we have experienced the institutionalization of emergency room and intensive case specialists, might this be another emerging specialty that becomes commonplace? Currently the medical marketplace views hospitalist programs as beneficial to patients and physicians. Patients who are seen by hospitalists are taking advantage of physicians who have an increase familiarity with issues related to inpatient care. Primary care physicians who use a hospitalist have more time to focus on their outpatient practice.

REFERENCES

  1. Diamond HS, Goldberg E, Janosky JE. The Effect of Full Time Faculty Hospitalists on the Efficiency of Care at a Community Teaching Hospital. Annals of Internal Medicine. 1998; 129; 197-203.
  2. Craig DE, Hartka L, Likosky WH, Caplan WM, Litsky MA, and Smithey J. Implementation of a Hospitalist System in a Large Health Maintenance Organization: The Kaiser Permanente Experience. Annals of Internal Medicine. 1999; 130: 350-359.
  3. Sox HC. The Hospitalist Model: Perspectives of the Patient, the Internist, and Internal Medicine. 1999; 130: 368-372.
  4. Lindenauer PK, Pantilat SZ, Katz PP, Wachter RM. Hospitalists and the Practice of Inpatient Medicine: Results of a Survey of the National Association of Inpatient Physicians. Annals of Internal Medicine. 1999; 130; 343-349.
  5. American Medical News. Hospitalists Firms Gain Popularity. American Medical News. April 5, 1999; p. 13-14.
  6. Levit K, Cowan C, Braden B, Stiller J, Sensenig A, Lazenby H. National Expenditures in 1997: More Slow Growth. Health Affairs. 1998; 17(6); 99 - 110.
  7. Milstein A. An Employer's Perspective on Hospitalists as a Source of Improved Health Care Value. Annals of Internal Medicine. 1999; 130; 360-363.
  8. Leape L. Error in medicine. JAMA. 1994; 272: 1851-1857.
  9. Graves E and Gillum B. National hospital discharge survey: annual summary, 1994. Vital and Health Statistics. 1997; 13:1-146.
  10. Soumerai SB, McLaughlin TJ, Spiegelman D, et al. Adverse outcomes of underuse of beta-blockers in elderly survivors of acute myocardial infarction. JAMA. 1997; 277(2): 115-121.
  11. Wachter RM. Hospitalits fan winds of change, and inpatient care won't be the same. Managed Health Care. 1998; 8(1); 36-39.

While the Duval County Medical Society has attempted to make the information in this and other associated documents as accurate as possible, it gives no guarantee as to the accuracy or currency of any individual item. The information in this and other documents does not necessarily reflect the views of the Duval County Medical Society.

July 1999 / Jacksonville Medicine

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