“If you reward PCPs for doing what’s right, then somebody has to pay for it,” he says. “The specialists are going to pay for it. If what happens is epidemiologically fine, that we lower the census … where is the money coming from?”
For the well-positioned HM group, the money will come from the savings it can prove to hospital administrators, says Dr. Centor, a nationally recognized voice in the debate on the value of hospitalists. He and Dr. Wellikson agree that hospitalists should be viewed as even more valuable to a hospital in financial trouble.
“Good hospitalists demonstrate their value with pay-for-performance-type things, with the avoidance of events, getting involved in quality committees,” Dr. Centor says. “A really good hospitalist program is worth its weight in gold and makes the hospital money. If you’re in a hospitalist group that is just churning out patients and isn’t involved in quality and isn’t considered good clinically, then you might be in danger.”
Integration Model
At Boston Medical Center, hospitalists have a more secure place—even in worsening economic times—through a vertical integration program that uses physicians hired through the Department of Family Medicine. The doctors split time between community health centers and hospital inpatient units, and work directly with hospitalists led by Jeffrey Greenwald, MD, HM director and associate professor of medicine at Boston University School of Medicine.
Larry Culpepper, MD, MPH, chairman of family medicine at Boston University School of Medicine and Boston Medical Center, says the vertical integration helps the family medicine physician and hospitalist to find efficiencies. “It has huge advantages,” Dr. Culpepper says. “They’re closely tied to the hospital this way. They’re not out in the community health center getting burned out and drifting away from mainstream medicine. … They see—face to face—the urologist or the cardiologist. They’ve got great communication that helps both ways.”
Collaborative programs are likely to crop up more in the next 12 to 18 months as HM leaders look for creative ways to justify their hospital support. More than 90% of HM groups receive hospital support payments, and the average subsidy is nearly $900,000 per year, according to SHM’s “2007-2008 Bi-Annual Survey on the State of Hospital Medicine.” Dr. Wellikson says hospitalists are establishing initiatives to demonstrate their value, but independent experts say more empirical data is needed to quantify that value.
“Many studies report that hospitalist care is associated with shorter lengths of stay and reduced costs,” say the authors of a recent study in the New England Journal of Medicine.1 “However, most studies were single-center, observational studies, and the results of the few available randomized trials have been mixed.”
Dr. Wellikson says recognition of the symbiotic relationship between hospitals and the hospitalists that work there is a major step in and of itself. HM leaders need to recognize and appreciate the litany of current statistics tied to hospitals. He frequently quotes recent hospital data that show 65% of institutions experienced both a drop in elective procedures and an uptick in charity care.
Combine that information with fact that many hospitals saw credit ratings downgraded and investment portfolios trimmed to the tune of $1 billion, and it’s clear hospitalists need to be cognizant of the threats to their livelihood. That means HM and hospitals need to work together, Dr. Wellikson says, to make both businesses financially viable. Thought leaders who take a long-term view, one that aligns HM fortunes with hospitals’ fate, would be in the strongest position moving forward, he says.
“In any cycle in any industry, you have fat times and lean times,” he says. “You have to manage in both times, and this is the first lean time. … Eventually, this recession will pass and the strong hospitals will survive. The better hospitalists will survive, because they’re going to be more valuable to their institution.” TH