The Next Phase: Doing it Cheaper
To be fair, HM is not all about the money. Even in the early days, it was recognized that at its pinnacle HM was about improving the patient experience—higher quality, safety, and satisfaction. That said, it was Medicare’s diagnosis-related group (DRG) that drove the model forward. To be clear, there were other factors that helped propel the HM movement: staffing issues, the rise in complexity of care, many PCPs and specialists willingly leaving the hospital. But in the end, the bottom line drove many hospital administrations to adopt the HM model.
Most hospital care is reimbursed via prospective payment, which means hospital reimbursement is, in a sense, determined upon admission. Every dollar of that DRG payment that isn’t spent is pocketed by the hospital as profit. As expected, specialists in hospital care were able to significantly reduce the length of hospital stay, costs of care, and, ultimately, save hospitals many dollars for each dollar of investment.
And to be clear, there was nothing unsavory about this. It wasn’t done through rationing care or reducing access, but rather through systematically reducing some of the estimated 30% waste in healthcare. This was shown in numerous studies, with a 2002 report estimating average savings at about 13% per patient cared for in the HM model.2
The Current Phase: Doing it Better
Pretty impressive, but mostly unsatisfying. Yes, as a group director that has negotiated for nearly a decade with hospital administrators, I’m well aware of the power of cost savings. Yet, I didn’t go into medicine to save money. I did so to help patients, enhance their experience, and improve outcomes. And indeed, there are data that hospitalists do this. Two 2002 papers showed that hospitalist groups could reduce readmission rates as well as inpatient and 30-day mortality.3,4 A paper in 2004 showed that pairing hospitalists with orthopedic surgeons could reduce perioperative complications.5
Couple these studies with anecdotal experience and perusal of any issue of the Journal of Hospital Medicine, and its clear that hospitalists are fulfilling their promise of doing it better. But we have a long way to go. We must continue to innovative and create better, safer systems of care until we can be confident that not a single one of our patients is avoidably harmed by healthcare. That is the kind of care you’d want for your family member, for yourself.
Our Legacy, TBD
And here we are now, looking forward to the next 15 years. For many hospitalists, this will represent the twilight years of their careers. For others, it’ll be the formative years. What mark will we leave?
Clearly, the premium on patient safety and quality is increasing, morphing from word to deed as we speak. And hospitalists will find themselves in the middle of the fray. The healthcare reform alphabet soup calls for equal parts VBP and ACO, with a pinch of EHR, and a dash of PFP—boiled in a cost reduction. But more than ingredients, it requires a chef—someone to orchestrate the great change that is necessary in American healthcare.
Whether it’s leading inpatient safety, improving the quality of hospital care, bridging post-discharge transitions, or reducing readmissions, someone is required to tend these fires.
And I believe HM’s legacy will be forged in these flames of change. There is no single group as well positioned to impact the outcomes that matter most to healthcare reform now than hospitalists. In most hospitals, we will touch the majority of patients, control the spending of the majority of dollars, and be directly responsible for the majority of outcomes. This is an unfathomable position to be in for a specialty that is yet old enough to drive. Yet this is where we find ourselves.