For the last 20 years, Hospitalist Medicine has evolved beyond a means of providing general medical care to hospitalized patients. While the primary purpose of hospitalists has remained the same, the role of the hospitalist has continued to evolve at an unprecedented rate. As the fastest growing specialty in United States history, hospitalists are helping hospitals to meet the demands of continually changing payor policies and creating a more team-based care delivery model. The increasingly specialized nature of hospitalist medicine has also begun to put pressure on hospitals to adapt while balancing the needs of the patient, the physician, and the overall cost of the hospitalist services.
As high acuity inpatient volumes increased in the early 1990’s, hospitals developed hospitalist programs to provide day-to-day general treatment services. Today, hospitalists not only provide general inpatient care but they also are increasingly involved in hospital committees devoted to patient quality and coordination of care efforts. Recognizing that the hospitalist specialty inherently creates a discontinuity of care by adding one more physician to a patients care team, hospitalists have continually led technology initiatives and multidisciplinary care team efforts to increase the quality and cohesiveness of patient care. As a specialty that is able to follow a patient throughout hospitalization, hospitalists have a unique vantage point that is able to pull together the patient’s entire treatment plan. However, as demand for the specialty continues to grow, hospitalists are having an increasingly difficult time balancing their clinical and administrative services.
Studies have found a large portion of hospitalists believe that in the last month they have exceeded safe patient workloads. Typical benchmark recommendations state that an ideal patient workload is 10 to 15 patient encounters per hospitalist (15 being the most common), but this depends on several factors including case mix index, teaching status of the hospital, admitting vs consultative services, and the presence of advance practice clinicians. Physician to patient ratio is going to become an increasingly important focus for hospitals going forward, as the increasing hospitalist workload is associated with clinically meaningful increases in length of stay and costs. However, it is important to note that there is not a significant association between workload and inpatient mortality, 30-day readmission, or patient satisfaction. Inconsistent patient volumes are outside of a hospitalists’ control, which is why shift-based compensation is more common than production compensation for this specialty.
In order to continue improving quality metrics associated with patient care, hospitalists will increasingly focus on balancing the appropriate resources to maximum efficiency within a care team. The utilization of advance practice clinicians will continue to increase within the hospitalist specialty, and will allow physicians to carry a heavier patient load. Additionally, the association between hospitalists, specialists, and pharmacists will continue to grow as the country continues to shift towards population health. To ensure that a hospital has the appropriate balance of providers, the importance of tracking physician to patient rates and ensuring that physicians are not overloaded with patient volumes will continue to grow. It will also be important that hospitals have action plans for high volume days in order to avoid increased length of stay or increased costs.
An increasing trend within the hospitalist specialty is the implementation of specialty-trained hospitalist physicians. These specialized hospitalists come from several backgrounds and can focus on anything from pediatrics to oncology. Hospitals are increasingly utilizing these specialized hospitalists to provide onsite inpatient services 24/7/365, rather than utilizing call coverage schedules. This specialist-based model has been tested and proven effective in both pediatrics and obstetrics for several years, with pediatric physicians now representing 10% of all hospitalists. However, the venture into more specialized care is only beginning to be tested. This trend is driven by several factors including quality, financial, and physician factors. The increasing importance of quality based reimbursement metrics such as 30-day readmission rates has several hospitals turning to these models to ensure an appropriate level of treatment. Additionally, the transition to specialized hospitalists is being driven by physician preferences, which are putting pressure on hospitals to decrease call coverage burden in order to better recruit and retain new physicians. The standard shift model and minimal call coverage requirements associated with hospitalist medicine has increasingly attracted physicians coming out of medical school.
While pediatrics and obstetrics were a natural direction for hospitalist medicine, other specialties such as orthopedics, neuro, general surgery, and oncology have continued to evolve at large specialty hospitals. A five-year pilot program by Sutter Medical Center utilized general surgery hospitalists at a non-trauma facility and found that it resulted in decreased length of stay, decreased hospital costs, decreased complications, and a downward trend in readmissions. All of these results were in spite of an increase in overall patient acuity, which was potentially driven by specialized hospitalist being more willing to perform surgery than an on-call physician would be. Another notable pilot out of M.D. Anderson utilized oncology hospitalists to treat high acuity inpatients with multiple comorbidities. This allowed the historically oncology focused facility to better care for patients that have health issues that go beyond oncology.
A large problem that is expected to continue is the fact that the majority of hospitalists do not bring in adequate income from professional services alone to cover expenses. The support cost per hospitalist continues to increase, with the average at about $150,000 per full time equivalent. This cost can vary based on the presence of advanced practice clinicians and the academic status of the facility. However, the support costs for hospitalists are not expected to decrease in the future. Therefore, it is imperative that hospitalists continue to contribute to the quality and efficiency of hospitals. It is important to note that several studies draw a correlation between the utilization of hospitalists’ decreased length of stay and cost per patient. This will also continue to drive the use of quality based compensation metrics for hospitalists.
Going forward hospitals will continue to test specialty hospitalists to adapt to changing reimbursement trends, patient needs, and physician lifestyles. However, in order to maintain the growth trajectory of the specialty, hospitalists will continue to work towards utilizing technology and care teams to ensure a continuity of care while increasing the hospitals quality and minimizing the overall cost of care.