The health care industry is experiencing a system-wide overhaul of the care of the hospitalized patient. Over the last year or two, numerous articles in the medical literature have discussed a growing trend in inpatient care: groups of hospitalists - physicians who specialize in the care of inpatients - are becoming increasingly visible both in academic and community hospitals.1.2

The attention received by the hospitalist movement may be well deserved. As clinicians see the potential for improvement in the quality of patient care, fiscal personnel are realizing dramatic cost savings with hospitalist groups.

Much of the exuberance displayed by health plan and hospital administrators regarding the hospitalist phenomenon, however, is not shared by traditional primary care physicians who are leery of a system that fractures the patient-physician relationship at a time when patients need a familiar provider’s presence the most.3 Regardless, the new modality continues to grow — and with it a steady stream of converts.

Definition of a Hospitalist
Wachter defines hospitalists as “physicians who spend at least 25% of their time in a hospital setting, where they serve as the physicians of record after accepting ‘handoffs’ of hospitalized patients from primary care providers, returning these patients to the primary physician at the time of hospital discharge.”4 This definition is well suited to those practicing in an academic setting where diverse interests and substantial non-clinical time are the norm. However, the experience of non-academic hospitalists is in many ways different. An alternative definition which would encompass hospitalists as a whole is offered: A hospitalist is a general internist, medical subspecialist, or family practitioner who is predominantly engaged in the care of inpatients on acute medical wards and intensive care units and who acts as a consultant on surgical patients through a dedicated on-site approach with limited outpatient responsibilities.

Factors in the Development of Hospitalist Practices
The concept of physicians who are dedicated to inpatient care is not new. The age-old “house doctor” has existed predominantly in community hospitals, serving many of the same off-hours functions that house staff perform in teaching settings. This individual was typically not fully residency-trained and did not view the position as a career path. The advent of groups of board-certified generalists and/or subspecialists who focus on hospitalized patients and efficiency of care on acute medical wards is a trend that began within the past decade.

Many identify the ascendency of managed care as the primary force behind the proliferation of hospitalists.4 It is argued that the increased efficiency and resultant decrease in resource utilization gained from the division of inpatient and outpatient responsibilities is leading the growth of this model. There is mounting evidence to support this theory in mature markets, as the experience of Kaiser Northern California, The Scripps Clinic, and the Park Nicollet Clinic have demonstrated.5,6,7

However, those who have seen hospitalist groups flourish in areas with little managed care weigh factors unrelated to financial benefits as the impetus for the division of inpatient and outpatient responsibilities.8,9 One such factor is the medical information and technology explosion. For example, physicians are having an increasingly difficult time juggling complex regimens for the outpatient treatment of diabetes or asthma with the ability to manage the complicated infectious disease dilemmas of inpatients. Finally, a large number of hospitalist groups have been initiated to relieve medical staffs of the responsibilities of “unassigned” patients needing admission, as well as night time and other off-hours duties for inpatient care. This has stemmed in part from a desire for a more predictable lifestyle and call schedule.

Hospitalists in 1997
There are hospitalists spread across the majority of regions of the United States, transcending any one type of payer system. It is estimated that there are roughly 1,200 to 1,500 hospitalists in the USA and that this number will grow rapidly in coming years. There is a great deal of heterogeneity in hospitalist groups around the country: some work as hospital employees, some are health maintenance organization or managed care organization employees, and some are members of a private practice. The majority of hospitalists are general internists. Medical subspecialists such as intensivists, pulmonologists, and infectious disease specialists, along with pediatricians and family practitioners make up the balance.
 

The Value (Quality/Cost) Equation
The implications of the hospitalist movement for quality enhancement and cost containment exist not only for the acute patient setting but across the continuum of care. The institution of hospitalist groups has generally led to reductions in hospital charges of roughly 15%-20% regardless of local market characteristics.8,9,10,11 As hospitalists get better at what they do, further decreases in utilization are being seen.12 What is underappreciated is the value imparted by increasing primary care provider availability and efficiency in the outpatient setting,13 by maximizing use of skilled nursing facilities, sub-acute units, and home care through timely discharge, and by increasing attention to patient satisfaction.

However, many questions still remain about the cost of hospitalists to the health care system. Are inpatient costs simply being shifted to sub-acute, skilled nursing, or outpatient settings? If a patient is sent to a sub-acute unit two days earlier under a hospitalist, does that patient consume proportionately more resources in the sub-acute setting due to increased acuity of illness? Are readmission rates higher? At this time, definitive answers do not exist.

Indeed, much of the promise of hospitalist groups lies in their potential to transform the acute medical ward. That which was once an afterthought for physicians with a busy office practice is becoming a locus of multi-disciplinary efficiency through the development of critical paths, continuous quality improvement initiatives, measurement of outcomes, and other collaborative efforts. The close knit and onsite nature of hospitalist groups allows for leadership in these areas.

Who Will Be the Hospitalists of the Future?
It is argued that intensivists make the best hospitalists because they are best suited to care for severely ill patients. Intensivists also possess the non-critical care skills needed to care for the majority of hospitalized patients so that general internist-hospitalists, for example, are needed only in a setting where intensivists are fully occupied with ICU duties, such as in large tertiary care centers.14

Some predict that in the future, hospitals will consist of nothing more than an intensive care unit, a step-down unit or two, and a rehabilitation facility run by physicians with critical care expertise, physician extenders, and case managers. The viewpoint of the entire hospital as the sovereign domain of the intensivist raises a variety of concerns, however. Will acute medical wards truly be phased out of existence? Some see a limit to the amount of services that can be provided in the home setting,5 thus favoring the continued existence of acute medical wards. There may be a point where it will be cheaper to have patients in a hospital receiving intravenous antibiotics and wound care, for example, than it will be to have a nurse and therapist travel to each individual’s home. With this scenario, a system of hospitalists who are generalists focusing on the acute medical ward will complement the hospitalist-intensivist who concentrates on the ICU.

Furthermore, can society afford to train hospitalists for two or three years post-residency? Will intensivists be able to maintain their skills in both the care of the ICU patient and the complicated inpatient who is not critically ill? It follows that there will be a need for general internists, pulmonologists, other medical subspecialists and family practitioners to be hospitalists in various regions, reflecting the heterogeneity of local health care markets and community needs. It is becoming increasingly clear that hospitalism is a unique intellectual discipline accessible from a variety of backgrounds.

Effect on Community Hospitals
The impact of a hospitalist program on a community hospital cannot be underestimated. As inpatient utilization continues to decline and competition among hospitals intensifies, the presence or absence of a hospitalist group will be a major factor in determining the continued success of some community hospitals and the demise of others. At a time when many smaller community hospitals are being pushed to the margins of viability, a program that potentially enhances quality and cuts costs has tremendous implications.
 

Consider what occurs when a community hospital closes. Patients formerly in the hospital’s catchment area will be sought after by the remaining hospitals. Primary care physicians who are now distant from an inpatient facility will preferentially send their patients to a facility that has hospitalists while they retain their outpatient practice.

Consider further the impact of hospital report cards on determining continued viability. Report cards are becoming highly publicized15 and have been associated with changed in hospital admission rates.16 In the future, they will be based on determinations of quality in addition to an institution’s reputation and whether or not it is regarded as a “center of excellence.” The presence of physicians dedicated to the improvement of inpatient care will potentially have a substantial impact on a hospital's “final grade.”

Effect on Academic Centers
Academic medical centers are experiencing increased pressure under managed care to contain costs while continuing to carry out their mission of teaching and research. Further pressure is being applied as cuts in residency positions and the attendant loss of federal revenues occurs. Programs such as the Health Care Finance Administration’s (HCFA’s) $400 million deal with New York teaching hospitals to cut 20%-25% of residency positions over the next seven years presage a widespread movement.
Since teaching hospitals rely heavily on residents for inpatient care, alternatives will need to be devised. The most logical and cost-effective way to fill this void may be to construct teams of hospitalists to care for inpatients who were formerly under the care of residents.

The potential benefits to house staff are significant under a hospitalist model. Instead of having teaching attendings who spend only a month or two on the wards each year, hospitalists as teaching attendings are more in touch with the practical aspects of inpatient care in addition to being more available for resident interaction. Wachter’s group at UCSF has demonstrated that under a hospitalist program, house staff teaching is at least as good as the traditional model.4

Finally, the prospects for cost containment are substantial. UCSF’s experience has demonstrated significant cost savings with comparable outcomes between the hospitalist and traditional groups.4

Conclusion
We are presently in the early stages of the hospitalist movement. Legitimate concerns about continuity of care and the true value of hospitalist groups exist. However, the impact these groups will have on their institutions both for quality enhancement and cost containment will be profound in the years to come.

References
1. Wachter R.M, Goldman L. The emerging role of hospitalists in the American health care system. N Engl J Med 1996;335:514-17.
2. Speer T. The Balancing Breed: Is It Time for a New Class of Inpatient Specialist? Hospitals and Health Networks, February 5, 1997, p. 44-46.
3. Brunton S. Are Hospitalists a Good Idea? Physician’s Weekly, March 17, 1997, Vol. XIV, No. 11.
4. Wachter R. The Emerging Role of Hospitalists in the American Healthcare System: presented April 11, 1997 in San Francisco at “Management of the Hospitalized Patient in the Managed Care Era,” UCSF School of Medicine.
5. Sager A, Socolar D, Imprudent and Impatient: Are Hospitals Closing Too Fast and for Insufficient Reason? Boston Globe; April 27, 1997:E1.
6. Terry K. Discharging primary care doctors from hospital rounds. Med Econ; 1996;11:65-81.
7. Likosky W. The emerging role of hospitalists in the delivery of inpatient care - a panel discussion. Society of Critical Care Medicine Annual Symposium, February 7, 1997.
8. Nelson J. Inpatient-only practice: where did it come from and where is it going. Today’s Internist, January/February 1997:35-6.
9. Hospital Peer Review: Emerging MD specialty can help you cut costs, optimize. Amer Health Consult. May 1997, Vol 22, No. 5, pp 61-72.
10. Moore JD. The inpatient’s best friend: hospitalists specialize in managing care of the very ill. Mod Healthcare, February 3, 1997, pp. 54-62.
11. Lindblad P. Hospital-based internists - hospital care of the future? HMO Practice, September, 1996, p. 123-4.
12. Whitcomb W. Mercy Internal Medicine Service: unpublished data.
13. Cobaugh DS. Why we dropped most inpatient visits. Medical Economics, February 13,1995.
14. Gipe B. The original hospitalists. Mod Healthcare. April 28, 1997, p. 25.
15. America’s best hospitals. US News & World Report. April 30,1990: 51-85.
16. Hargadon, T. Personal communication.

- By Winthrop F. Whitcomb, MD

Dr. Whitcomb is the Director of Inpatient Medical Service at Mercy Hospital in Springfield, Massachusetts.

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