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Hospitalists and Their Role in Health Care Reform

The Health Care Reform Bill ratified by Congress in April 2010 emphasizes better care for patients at reduced cost. It also ushers in the emphasis on a new medical specialty: the hospitalist. Defined as a physician who specializes in hospital medicine, the hospitalist is largely responsible for patient care in the hospital setting, but also focuses on the administrative duties of medical treatment. This includes coordination of physicians and other personnel in caring for the patient in the hospital setting, monitoring and planning the patient’s transition from hospital to home care, and facilitating the efficient use of hospital resources.

Evolution of the Hospitalist

The hospitalist became a prominent figure in 1996, after Robert Wachter introduced the term in a New England Journal of Medicine article, years before the primary physician began to feel the squeeze of the health care crisis. Hospitalists perform the fastest growing medical specialty. In 1996, the United States had nearly 800 hospitalists. Today, roughly 30,000 hospitalists serve in 5,000 hospitals nationally.

Before hospital care evolved into what it is under today’s HMO systems, most hospitals did not employ primary-care physicians. Doctors were usually independent practitioners or affiliated with small offices, and would treat their patients in hospitals only if hospitalization was necessary (surgery and childbirth are primary examples). In fact, the system called for outpatient physicians to be physicians-of-record when their patients were hospitalized.

This system worked well until the 1980s, when Medicare changed the way in which it reimbursed hospitals. Before 1983, hospitals were paid based on the number of days patients were hospitalized. By moving to a system of diagnosis-related groups (DRGs), hospitals were instead paid by particular treatments (i.e., $9,000 for congestive-heart-failure treatment or $2,500 for childbirth).

Since reimbursement was now fixed by treatment type, hospitals were under pressure to shorten stays and lower costs. Also, with technological advancements and sophisticated screening techniques, patients that would have been hospitalized for long stays (heart-attack patients, for example) were discharged within days. Further, doctors would earn less for extra time spent with hospitalized patients.

This change meant that doctors would have fewer patients in the hospital, with more being treated out of doctors’ offices. Those in the hospital were very ill and often in need of constant care, but the physicians-of-record were commonly unavailable because of growing patient demands in the doctors’ offices. This conundrum created the need for a new type of specialist, one who could stay at the hospital each day managing patients and coordinating care, and returning patients (along with care recommendations and information) to their primary care doctors at discharge.

Why the Hospitalist Is a Good Idea

Studies on hospitalist care have largely been positive. All have shown that hospitalists decrease hospital stays for patients, lead to significant reductions in resources and most importantly, cut costs. In a 2002 American Medical Association (AMA) article, Wachter reported that hospitalists save hospitals billions of dollars yearly.

Hospitalists have grown into important cogs because of their flexibility in addition to their availability. In May 2010, The New York Times highlighted Dr. Subha Airan-Javia, a University of Pennsylvania hospitalist who split time between providing clinical care and developing cost-saving computer programs. Because of improvements in medical-student and resident training, hospitalists are now focal points in teaching hospitals that emphasize inpatient medicine.

Proponents of the hospitalist model believe that hospitalists will continue to diminish hospital liability, reduce costly readmissions and lead to fewer medical-malpractice claims. Since neglect or miscommunication is the impetus for many lawsuits, having a doctor who specializes in day-to-day care and communication should reduce the potential for mistakes given the long hours of a typical hospital schedule. In fact, some argue that the use of hospitalists has played a role in the steady decline of medical-malpractice insurance premiums.

Perhaps most important is the hospitalist’s effect on patients. A main concern about the hospitalist model was how the patient would react to someone other than his or her primary-care doctor. However, surveys indicate that patients are generally satisfied and comfortable with hospitalist care.

While patient safety will always be a major concern, the coordination of care and communication hospitalists provide is a critical element in how health care will work under the new reform laws. Since the Health Care Reform Bill calls for significant penalties for readmissions, hospitalists will be instrumental in identifying high-risk patients, detailing discharge and follow-up requirements, and making themselves available for further questions from patients and families.

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