Hospitalists poised to help with reform

0 | Health Care Delivery, Workforce, Health Reform

Dr. Kent Palmberg, right, and Dr. Greg Chediak discuss Stormont-Vail HealthCare's hospitalist program. The Topeka hospital was the first in the state to start such a program, which allows primary care physicians to hand-off the treatment of their patients to generalists and specialists who only work in the hospital setting.

Dr. Kent Palmberg, right, and Dr. Greg Chediak discuss Stormont-Vail HealthCare's hospitalist program. The Topeka hospital was the first in the state to start such a program, which allows primary care physicians to hand-off the treatment of their patients to generalists and specialists who only work in the hospital setting.

— Dr. Matt Voth doesn’t carry a pager home from the hospital. He doesn’t need to.

Voth is one of a growing number of physicians who choose to practice exclusively in hospitals. Hospitalists work regular shifts. They attend to emergencies and otherwise care for the patients of other physicians.

Voth said his job as a laborist, which refers to hospital-based obstetric care, has provided an opportunity to work as an obstetrician while maintaining his lifestyle away from work. Voth is employed by Via Christi, working at its East Harry Street hospital here and will also work at Via Christi’s soon-to-open hospital on the city’s west side.

“I knew I loved OB in medical school the best – it was what I was happiest doing,” he said. “But I was always worried about the lifestyle. So many OB’s I’ve seen work so many hours away from their families that it really worried me.”

An October 2008 article in the Journal of the American Medical Association, among others, has estimated that the United States will experience a shortage of as many as 44,000 primary care physicians by 2025, a result of an aging population and too few physicians who are choosing primary care over specialized medicine.

At the same time, millions will enter the health care system as they gain access to health insurance, putting additional pressure on an already stressed structure.

Hospitalists are considered a key player in the efforts to provide care for those patients and implement new quality standards that will be set as a result of the health care legislation that was signed into law earlier this year.

Generalists to hospitalists

Most hospitalists are trained in general medical fields such as internal medicine, family medicine and pediatrics, said Dr. Lisa Vansaghi, director of the internal medicine residency program at the University of Kansas Medical Center.

Authors of a New England Journal of Medicine article from March 2009 estimated that by 2006 almost 20 percent of the nation’s internists were hospitalists.

“A lot of (medical students) are now choosing internal medicine residencies because they want to be hospitalists,” Vansaghi said. “As a third year medical student, they rotate with hospitalists on the wards. They like the fact that it’s intense and stimulating to take care of sick patients. They like the shift schedule, the fact that when they’re here, they’re here, and they’re not on a pager.”

This year, of 18 residents, about half will enter hospital medicine, she said. Six will stay at the KU hospital. There are a few specialized hospital medicine fellowships available for physicians who seek further training, Vansaghi said, but physicians who take that path are in the minority.

“The job market is such that, at least for internal medicine, there are many more jobs out there both for primary care and hospital medicine than there are graduates,” she said. “Especially for hospital medicine – I get three or four e-mails every day from recruiters. There’s a huge need.”

A 2008 survey of 155 Kansas hospitals found that 18 community hospitals and eight specialty hospitals used hospitalists, said Cindy Samuelson, a spokeswoman for the Kansas Hospital Association.

There are 91 Kansas members of the Society for Hospital Medicine, the advocacy group for the profession, said Brendon Shank, a society spokesman.

The median salary for hospitalists trained in internal medicine, according to the Medical Group Management Association’s Physician Compensation and Production Survey: 2009 Report Based on 2008 Data, is $210,250.

More predictable, but not without trade-offs

The most widely discussed drawback to the hospitalist model is the interruption of the relationships between primary care providers and their patients.

Traditionally, primary care physicians visit their hospitalized patients early in the morning and later in the evening, spending the hours between in their offices.

Hospitalists are on the hospital floor for longer stretches at a time, are available when family members are present, and can make a patient’s hospital stay more efficient. Studies published in the Journal of the American Medical Association have found that hospitalists can reduce costs by about 13 percent and the average length of stay by about 17 percent.

“I really miss having that ongoing relationship, seeing women through their entire pregnancy and delivery,” said Dr. Brooke Grizzell, a Wichita laborist who practices with Voth at Via Christi. “But for me, I have to look at what is best for my family. I feel like I’m still helping to provide safe, quality care, but I’m also able to do what I need to do for my family.”

“I have many patients that I have bonded with and loved, but none of them could replace my kids and my wife,” Voth said. “It’s a trade-off. I had to give up my patients, but that could never replace my time with my family. I get the best of both worlds.”

Patients generally report positive reactions to hospitalists.

“For most women who are in labor, which is such an emotional event, when they’re ready to deliver, if I have to step in – I can’t think of a time when a mother cared,” Voth said. “Most of the time they say they don’t want to wait.”

Stormont-Vail HealthCare in Topeka surveys all patients served by hospitalists, said Dr. Kent Palmberg, the hospital’s senior vice president and chief medical officer, asking questions about the patient’s satisfaction, the professionalism of the physician, and how well the program was explained.

Patients consistently give high marks to the program, he said.

All of the physicians said that strong communication between primary care providers and hospitalists was the foundation of a good hospitalist program.

Via Christi in Wichita, for instance, requires all hospitalists and primary care providers to have a plan for communicating what happened during the patient’s hospital stay.

Electronic health records have helped tremendously, said Dr. Hewitt Goodpasture, vice president for clinical quality and patient safety at Via Christi, but there’s always room for improvement.

“It’s a real challenge and something we’re continually working on,” he said. “If the hospitalist is trying to hand off to a physician in an office but is only getting phone mail when they call, that’s not a good hand-off.”

New standards

As the entire health care system prepares for changes coming as a result of the new federal health reform , hospitalists will be on the front lines of some of the most immediate changes.

“Health care reform is really going to put an increasing demand on expectations for a more organized and systematic approach, a consistent application of best practices,” Goodpasture said. “It will really put pressure on for more systematic care. It’s good in one way and not so good in another, where doctors will lose individualization a little bit. But I think overall, it’s a benefit.”

One concern, Palmberg said, is a federal proposal to stop paying for certain readmissions to hospitals.

“Hospitalists see patients who keep coming back,” he said. “They come in, we get them all tuned up and send them back home and then they come back in three weeks. The care continuum now doesn’t end when they leave the hospital. They need follow-up care.”

The Stormont-Vail hospitalist staff is looking at all of the patients who suffer from congestive heart failure, one of the categories of readmissions that would no longer be reimbursed by the government.

One possible solution is to direct those patients to a special clinic focused only on the condition, Palmberg said.

“As an accountable care organization, it’s important to take good care of a patient in the hospital, but it’s just as important to keep them out,” he said. “There’s never been an incentive to do that before. That’s not a bad thing.”










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