Hospitalists and the price of medical efficiency

Click to enlarge.

If you’re admitted to a hospital these days, responsibility for your care is likely to be handed off from your family doctor to a specialist known as a “hospitalist” — a physician employed by the hospital whose specialty is knowing how to coordinate and deliver the hospital’s services most efficiently.

“Hospitalist” was a new and rare specialty 15 years ago, but there are more than 30,000 practitioners now.  A Google search shows many hospitals here in the Rochester area advertising for hospitalists.  It is a lucrative specialty.  A 2011 survey shows that 99 percent receive more than $100,000 a year in total compensation and roughly two-thirds receive more than $200,000.

Compensation of hospitalists in 2011.  Click to enlarge.

It seems to me this is another example of how managers of institutions prioritize maximizing efficiency of the system rather than maximizing service to the individual.  For example, you spend time on the phone waiting for customer service representatives to return your call because, if there were enough of them to return your call promptly, they would have down time in which they didn’t take calls.  Electric utility systems have less and less reserve generating capacity, because that capacity is idle except in emergencies.  Many colleges and universities prefer to maximize enrollment even if it means less attention by the individual teacher to the individual student.

I first became aware of the “hospitalist” profession while visiting a friend in San Antonio over the Christmas holidays, and reading an article in the San Antonio Current.  The reporter described a case in which a family has filed a lawsuit about a loved one who died under hospitalist care without being able to see the family or the family doctor.  His article pointed out that:

The University of Texas Medical Branch in Galveston (UTMB) began researching concerns with the hospitalist paradigm after geriatric specialists noticed hospitalists were not fully communicating with primary care physicians about patient histories and hospital stays.

A study published in the August 2 issue of Annals of Internal Medicine found that Medicare patients under hospitalist care checked out of hospitals sooner than those managed by primary care physicians. However, the hospitalist patients were more likely to be readmitted, costing $1.1 billion in added payments for 120,000 Medicare patients.

Yong-Fang Kuo, a co-author of the study, told the Current that the hospitalist model encourages early discharge to cycle more patients through hospitals. “The shorter stay means more beds are open and, if beds open, that means you can admit more patients,” she said.

Reduced waste and greater efficiency is a good thing, not a bad thing, but I fear the hospitalist is likely to be more concerned with getting me in and out of the hospital in the shortest possible time than giving me the best possible care.  Of course there is a balance to be made here.  To give me a level of care equivalent to that of a Saudi prince or a Fortune 500 CEO would be prohibitively expensive.  The goal should be to set a standard of efficiency, and give the best possible individual care within that standard, not to set a (very) minimum standard of care and maximize efficiency and revenue within that standard.

With or without hospitalists, modern medicine is growing more impersonal.  My relationship with my primary care physician, whom I see for 20 to 30 minutes once a year, is not like my boyhood relationship with my family doctor, who had a close personal knowledge of my parents and me.  During my hospital stays, the main health care workers who’ve been concerned with me as a human being, rather than just for my physical body, were the nurses and aides.

I don’t have good answers to this.  Doctor Zimmerman, my family’s doctor of 60 years ago, lived a life of self-sacrifice, making house calls all day and in the evening seeing patients in his office, which was in his home.  I would not ask anyone to live like this today.  To some extent the impersonality of modern medicine is due to technological advances, without which I would not be alive.  I don’t have a good answer for this.  I would be interested in a second opinion.

Click on Hospitalists: high-tech, high-turnover medicine for the full San Antonio Current article.

Click on The Hospitalist Model of Care for an article by Robert Wachter, one of the original advocates for “hospitalist” as a profession.  The chart at the top of this post is taken from that article.

Click on Survey Results Compare Hospitalist Earnings in 2011 for the source and context of the hospitalist compensation chart on the Better Health group medical blog.

Click on Today’s Hospitalist for the blog of Today’s Hospitalist magazine.

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3 Responses to “Hospitalists and the price of medical efficiency”

  1. Anne Tanner Says:

    A related question is what role the GP or family doctor plays now. My physician never wants to see me. If I call with an ailment it’s diagnosed by whoever answers the phone and I can pick up meds at the pharmacy. If I mention that I’ve never had a bone density test, I’m sent–not referred– to the radiology department of a hospital to get one IF I WANT IT. If I break a bone I’m sent to emergency. So far, I’ve seen her once in my life and that seems fine to her. I kept her because others have said that if you are hospitalized, she’s great. Now if she isn’t going to be taking care of me then, either, I guess my question is, what does she do with all this free time? Write academic papers?

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    • philebersole Says:

      I don’t have any complaints about my primary care physician as an individual; he seems to take an intelligent and caring interest in me when I see him once a year. I am satisfied with my own medical care, at least so far.

      I don’t think he has a lot of time to waste. As I see it, that’s not the problem. I think he is under the same kinds of pressure as a customer service representative in call center. The HMO wants him to get his patients in and out within a fixed amount of time.

      I once called to reschedule an appointment, then five minutes late I realize I didn’t need to schedule and called back. Too late. My slot had already been given to somebody else. That’s a system in which the main imperative is maximum utilization of resources.

      I sometimes think it would be better to make nurse practitioners the primary caregivers. The nurse practitioner, who could take care of routine matters and refer you to a physician or specialist when needed. You could ramp up the supply of nurse practitioners so that you wouldn’t have any problem seeing your primary caregiver when you needed it. But for this to work, you’d have to change the imperatives of the system—-to get rid of financial incentives that are unrelated to the needs of patients.

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  2. Nirav Patel Says:

    I am a former primary care doctor and now only work urgent care. The system has really broken the basic contract. When I decided to enter the field, I incorrectly thought the patient and I were on the same team. The insurance middleman while creating some efficiency in the system now also creates conflict between the doctor and the patient.
    Doctors have to decide between working for free and providing the best care they can. It will be a rare individual who can provide service with sacrifice for strangers. We all do it for our families and friends but the new system makes the patient behave more like customers (shop for the best deal, complain to the manager, allow themselves to be marketed to).
    This new patient satisfaction i.e. Customer service will be the final straw I think. The numbers of people willing to go through 7+ years of education for a customer service job will definitely dwindle.
    Nurse practitioners are probably the answer. Physicians are already cutting back hours worked to pursue other goals which might just include catching up on sleep!. Unless slavery is re-instituted, several hundred thousand patients will have no choice but to see nurse practitioners or physician assistants.

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