Under Pressure

The Hospitalist. 2009 May;2009(05):

May 1, 2009|The Hospitalist

Hospitalist Stephanie Jackson, MD, medical director of patient safety at Sacred Heart Medical Center in Eugene, Ore., was preparing for SHM’s meeting with lawmakers in Washington, D.C., in March. As a member of SHM’s Public Policy Committee, she knew the annual powwow with Congressional leaders would be particularly sensitive this year as the economy continues to crater, healthcare reform hangs in political purgatory, and HM advocates look to insulate the industry from growing pressures.

But while she was prepping to tackle national issues, Dr. Jackson was dealing with serious problems closer to home. Her own hospital administrators were preparing to slash the safety initiatives she was championing, including an ambitious new bar-coding system to reduce medication errors and a long-planned information technology upgrade, from the budget. Hospital executives held emergency financial meetings two weeks running. At the time, Sacred Heart had less than 70 days’ cash on hand, compared with its usual 350-day buffer. In essence, the threat to her HM program had sprouted up so severely and quickly that Dr. Jackson was too busy batting them down to travel 3,000 miles to talk about the issues.

“It’s hard to leave when your organization is not doing well,” she says. “You need to be home. Our whole mission is to provide safe, high-quality, compassionate patient care. When budget cuts are made, it will affect patient care. There’s absolutely no way it can’t.”

Major Threats

HM is enduring its first recession since the specialty was established in the mid-1990s. As the national economy teeters and hospitals falter, threats to HM’s future continue to emerge. Leaders say the biggest threats are:

Hospital closings. Two Chicago hospitals, Lincoln Park and Michael Reese, recently closed their doors, placing hundreds of healthcare professionals in the unemployment line. More hospitals are floundering financially, and as institutions close, they will eliminate job opportunities for HM groups to provide services. Then again, demand for hospitalists remains high, so even out-of-work practitioners have options. “There’s still going to be so much more demand for good hospitalists than there is supply that, if I was going to quit academic study and get a job as a hospitalist, I’d be pretty confident,” says Dr. Centor, the associate dean at the Huntsville Regional Medical Campus in Alabama.
Hospitals reducing HM program subsidies. As administrators struggle to balance budgets because of declining revenues and rising charity-care costs, payments to HM programs focusing on QI and nonessential care practices are fodder for cutbacks. “We’re appreciated nine months out of the year,” says UC San Diego’s Dr. Maynard, “and three months of the year, it’s budget hell.”
Cutting HM programs altogether. This is seen as the least likely scenario, given how entrenched hospitalists have become in most institutions. However, most are expecting a slowdown in the expansion of current programs and the creation of new ones. One notable exception is the recent announcement that pediatric hospitalists from The Children’s Hospital of Philadelphia would provide 24/7 coverage at the University Medical Center of Princeton in New Jersey.—RQ

It’s the new HM paradigm: a landscape in which hospitalists confront a growing confluence of threats to their livelihood. The pressures are rooted in the economic downturn, as hospitals nationwide face sagging revenues and daily fights to raise capital as investors lower their investment ratings. Questions abound:

Will more primary-care physicians (PCPs) return to hospitals to supplement their practices, siphoning encounters from HM groups?
Will an infusion of government money into community health centers draw patients away from hospital stays?
Will HM’s workforce expansion continue as hospitals close or lose the ability to pay competitive subsidies? Even the Federal Reserve, in its latest Beige Book survey, reported falling patient volumes for elective procedures and an increase in emergency services.
Will the very real fears of physician overload and burnout—and the possible departure of qualified hospitalists for other specialties or careers—grow as institutions cut ancillary medical staff and put more duties on the HM checklist?