Evolution of the hospitalist

When Rob Olson, MD, a solo practice obstetrician-gynecologist in Bellingham, Wash., sat in on a presentation about the emergence of hospitalists in his speciality a few years ago, a light bulb went off.

If there was an obstetrician-hospitalist program in his area, he wouldn't have to run to the hospital for emergencies, which was disruptive to patients in his office as well as his quality of life. Patients with an obstetrical crisis would not have to wait for him to rush out of his office, drive to the hospital, park and then find them. They could be cared for by an obstetrician who was in the hospital all the time.

“What I heard described in the lecture was exactly what I wanted to do,” Dr. Olson said. “I put my practice up for sale.” He is now an independently contracted obstetrician-hospitalist and founder of the Society of OB/GYN Hospitalists.

Dr. Olson is among a growing number of physicians who are showing that hospitalist work isn't just for family and internal medicine physicians. Although the specialties might be different, hospitalists say physicians throughout the community need to be involved closely in determining how hospitalist programs are structured to improve care and hospital-physician alignment while not damaging the finances of office-based doctors. Physicians should decide how patient information will be communicated between settings, who will do what, how reimbursement will be handled and what the protocols for certain procedures will be.

“There are clear benefits, and there are clear detractions,” said John Wachtel, MD, an obstetrician-gynecologist in private practice in Menlo Park, Calif., who has presented on this topic at meetings of the American Congress of Obstetricians and Gynecologists. “And for a program to be successful, it has to be economically feasible for everyone.”

Hospitalist programs are expanding to include neurologists, orthopedic surgeons, pediatricians, general surgeons and numerous other specialties. They provide emergency department coverage, assist in the operating room and round on patients but don't have office-based practices. They are employed by hospitals or large groups, although some, like Dr. Olson, work independently.

Why hospitalists?

According to the Society of Hospital Medicine, 34,799 physicians identified themselves as hospitalists in 2012. The organization does not break numbers down by specialty, but there are indications that specialist-hospitalists are growing more prominent. They were the subject of an SHM meeting in 2011 and an American Hospital Assn. meeting in 2012. The American Academy of Neurology and the American Academy of Pediatrics have hospitalist sections. Typing various specialist-hospitalist titles into job search engines brings up hundreds of listings.

“Any speciality with a large outpatient volume and a relatively small inpatient volume is ripe for adopting this model,” said John Nelson, MD, a partner with Nelson Flores Hospital Medicine Consultants and SHM's co-founder. “And things are moving very quickly.”

Mark Williams, MD, runs a nocturnist program as part of the division of hospital medicine at Northwestern University's Feinberg School of Medicine in Chicago. Hospitalists who work only at night tend to earn more money for fewer hours worked. Photo by Ted Grudzinski/AMA

This seems to be moving forward with minimal pushback. Hospitalists were the subject of a contentious debate at the 1997 American Academy of Family Physicians annual policy-setting meeting, and an editorial published in the Aug. 1, 1998, American Family Physician was headlined, “Hospitalist concept: another dangerous trend.” But early experience with primary care hospitalists may have made specialists more at ease with the idea.

Hospitalist is “not the dirty word that it used to be,” said Lori Heim, MD, a hospitalist in Laurinburg, N.C., and a past president of AAFP. “People realized that there is a way to do it well, and there were advantages.”

Hospitals get the benefit of call coverage and closer alignment with physicians, which is considered particularly crucial in the age of health system reform. It may be easier to recruit an office-based physician to an area if there is a robust hospitalist program. Specialist-hospitalists are being viewed in some quarters as a way to reduce readmissions as well as costs within an accountable care organization.

“Hospitals are under tremendous pressure to improve quality and provide value,” said Robert Wachter, MD, professor and chief of the division of hospital medicine at the University of California, San Francisco. “They are looking at all sorts of ways to achieve these goals.”

On the physician side, changes in medicine have made it less practical for doctors in some specialties to have both an office- and hospital-based practice. For example, in obstetrics, there is a greater call to increase attempts at vaginal birth after a cesarean, but the time involved is significant. The need to closely monitor acute stroke patients after receiving tissue plasminogen activator may strain an office-based neurologist. In the case of the pediatric-hospitalist, physicians caring for children are spending more time in the office managing chronic conditions and other special needs and may have their days constrained to provide high-quality care for hospitalized patients.

The ortho-hospitalist emerged because a greater percentage of orthopedic surgeries can be cared for in the outpatient setting, and the number of elective procedures such as a hip and knee replacement is growing. This means an orthopedic surgeon does not need emergency trauma cases to maintain an economically viable practice, and having an ortho-hospitalist in the area means devoting more time to cases that may be more lucrative.

“We do not get paid for driving a car,” said John Cherf, MD, MPH, who is on the faculty of practice management meetings run by the American Academy of Orthopaedic Surgeons. “And for most orthopedic surgeons, the least efficient use of time is in the hospital. Most are very happy to give up inpatient work.”

Meanwhile, all specialties have been affected by generational differences, which mean younger physicians are putting a higher priority on work-life balance and are less willing to take call. Resident work-hour restrictions also have created a need for other physicians to fill the gap.

Financial considerations

But to make this setup economically viable and beneficial for all involved, office-based physicians should be invested closely in the planning of specialist-hospitalist programs. Participation in any hospitalist program on the part of patients and physicians should be voluntary, according to American Medical Association policy. Such programs should be implemented with the formal approval of the organized medical staff.

“The hospital and the physicians need to talk about what they really want out of it and what the goals are,” Dr. Nelson said. “It's very easy for the hospital to have one thing in mind and for the doctors to have another.”

The most important issue, say office- and hospital-based physicians, is to devise effective communication between doctors in both settings. Disrupting continuity of care is a constant concern of office-based and hospitalist physicians, and this issue is often a high priority in guidance from medical societies. Communication may be as simple as passing on photocopied records or as complex as providing access to a Web portal or electronic health records.

“You need to have a setup that ensures the flow of information,” said David Likosky, MD, founding chair of AAN's neuro-hospitalist section.

Another key question to consider is where the duties of an office-based physician end and those of a hospitalist begin. A hospitalist program usually does not mean an office-based physician will never go to the hospital, but the visits most probably will be less frequent. Who does what — and when — needs to be spelled out.

“There will be some situations where patients have very complex needs, and an office-based physician will need to come in and help with aspects of the patient's care,” said Jack Percelay, MD, MPH, chair of AAP's committee on hospital care. “That patient is still part of your practice.”

The next question is how payment from insurers for hospitalist services will be handled. In many cases, the hospital will receive the remittances then pay the hospitalist as an employee or independent contractor, but this may be more complicated if payments are bundled. For example, in the case of obstetrics, prenatal care and delivery may be paid out as one global fee. In some communities, office-based obstetricians collect that and then pay the hospital for the services of an obstetrician-hospitalist. In some situations, the hospital and office-based physicians bill for the respective services they provide.

“The economics of it have to be worked out very carefully,” said Dr. Wachtel, an adjunct clinical professor at Stanford University in California.

Hospitals and physicians, whether office- or hospital-based, need to agree on care protocols. This should allow care delivered in a consistent way but differ when appropriate.

“If you're going to have a successful hospitalist program, you're going to set up clinical guidelines or protocols that everybody has discussed and agreed to in advance,” Dr. Wachtel said. “You cannot have the patient getting very different recommendations about what to do for a particular problem.”

Physicians need to agree on how patients are informed that they may be cared for by a hospitalist rather than their own physician exclusively, if they have one in a particular speciality. Physicians say this has become easier as the hospitalist model has grown more widespread.

“This is the reality in today's world,” said C. Brent Boles, MD, a solo practice obstetrician-gynecologist in Murfreesboro, Tenn., who helped establish the obstetrician-hospitalist program in his area and regularly informs his patients how it works. “Patients usually understand.”