DB'S MEDICAL RANTS

Internal medicine, American health care, and especially medical education

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In which the Happy Hospitalist drinks the Kool-Aid

Happy states:

The fact that hospitals see value in hospitalists is a striking indication that hospital internists/FP’s save money when a head of the ship takes control. Insurance companies don’t see the benefit of prevention because it happens years down the road when most of their premium paying customers have moved on. For them to pay more now only to have another insurance company reap the benefits of prevention would be counter productive to their bottom line. Hospitals see the benefit here and now. And that’s why hospitalist salaries are soaring above their respective counterparts.

There are several possibilities for the willingness of hospitals to pay hospitalist salaries.  Happy suggests that they save the hospital money.  Some early studies suggest that, while others studies show no difference.

Let me postulate a couple of other motivations.  At teaching hospitals (note that they are the largest employers of hospitalists), the increasing number of adult medicine patients requires new physicians for patient care.  They cannot rely on house staff to provide all the patient care, and meet all the demand for admission.  Thus, hospitalists become the safety net for training programs.  Now many groups have taken those positions and expanded beyond patient care.  They have become important contributors to quality and safety programs for the hospital.  These programs are becoming increasingly important for hospital payment.

Another reason fo hospitalist growth is demand from primary care physicians and surgeons.  Hospitalist programs make hospitals more competitive, thus increasing admission rates.  We all know that patient volume drives hospital income.

While I find Happy’s idea intriguing, hospitalists should have no leadership advantage over combo physicians (those who do both inpatient and outpatient.)  Unfortunately, being a combo physician is very time consuming, without being financially rewarding.  Physicians do better financially when focusing on either inpatient or outpatient.  That is a shame.

The value of excellent outpatient physicians is not just in prevention.  Outstanding internists and family physicians can decrease hospitalization and referral rates through excellent in chronic disease management and outpatient diagnostic evaluations.  Outstanding outpatient physicians limit health care costs by limiting (appropriately) consultation and expensive diagnostic testing, because they think before they refer.  That is the concept behind the patient centered medical home.

I have no objections to hospitalist salaries.  Hospitalists have made themselves valuable to hospitals in many ways.  I do have objections to the current payment system for outpatient physicians.

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