His study at UCSF found just the opposite: no clinical improvement but a net cost benefit. “We were a little disappointed in some ways, but in other ways not surprised because there are very few data out in the community that suggest comanagement improves any outcomes,” Dr. Auerbach says. Among complicated neurosurgery patients, the strongest determinants of outcome might be beyond the scope of hospitalist-aided medical care.
With hospitals nervously eyeing their bottom lines, however, any financial improvement that does not adversely affect quality can still be seen as a positive development, and Dr. Auerbach says his study was the first to demonstrate that benefit. At UCSF Medical Center, at least, comanagement has proven compelling enough to spur plans for extending the service to orthopedic surgery patients.
Regardless of the care model, other studies suggest that specific interventions at key moments can yield substantial savings. A small, randomized controlled study led by hospitalists at Johns Hopkins University in Baltimore, for example, supports the idea that “simply showing providers the cost of some diagnostic tests at the time of order entry can affect behavior.”10 Although the study didn’t focus exclusively on hospitalists, experts say they’re in the best position to take the lead in curbing unnecessary costs.
“Hospitalists, I think, have a better understanding of the impact of resource utilization on the total cost of care and can be more prudent in the use of technologies,” says Kenneth Epstein, MD, MBA, FHM, FACP, chief medical officer for Traverse City, Mich.-based Hospitalist Consultants Inc. One reason is that hospitalists aren’t beholden to any specific technology, whether endoscopies or cardiac catheterization.
I’m hoping they can point to this analysis and say, “Look, here’s what L.A. County did. They were able to show a net increase in revenue from this hospitalist service.”
—Scott Lundberg, MD, assistant medical director, Olive View-UCLA Medical Center, Sylmar, Calif.
Mark Graban, author of the book “Lean Hospitals: Improving Quality, Patient Safety, and Employee Satisfaction,” says hospitalists can play another critical role in controlling costs by mapping out and simplifying the discharge processes. He recalls how hospitalists helped coordinate the effort by one of his hospital clients to prevent discharge delays that would have unnecessarily kept patients in the hospital for an additional night or two.
“That length-of-stay reduction, especially in a fixed-reimbursement setting, can have a huge financial impact,” Graban says. “And, inarguably, it’s the right thing to do for the patient, because it’s patients that are medically ready to be discharged. It gets them home and it reduces their increased risk of picking up infections or being involved in hospital errors.”
Focusing on patient safety could translate into big cost savings under the new Medicare system that penalizes providers for certain hospital-acquired conditions, such as skin ulcers and urinary tract infections, Dr. Epstein says. “There’s an emphasis by hospitalists in understanding the system and being willing to put energy into things like documenting ‘present on admission,’ which then has a huge impact on the hospital,” he says. Close monitoring of patients and developing standardization of care can likewise minimize the risk of conditions, such as catheter-associated infections, from cropping up in the hospital.
Dr. Meltzer says his own research suggests that experienced hospitalists are most effective at controlling costs. “So a program that is structured in such a way as to hire or retain experienced hospitalists is likely to have a higher cost savings than one that doesn’t,” he says.
In a broader sense, the maturation of the HM model and more widespread adoption of effective methods by practitioners might be boosting the overall impact of hospitalist care. A study that examined nearly 2 million Medicare admissions over six years found that the effects of the hospitalist care model on LOS became progressively more pronounced over time, from an average reduction of only 0.02 inpatient days in 2001-2002 to a decrease of 0.35 days by 2005-2006.11
