Under Pressure

The Hospitalist. 2009 May;2009(05):

May 1, 2009 | The Hospitalist

Dr. Maynard blames some of the current friction between hospitals and hospitalists on HM’s growth—estimated at 28,000 physicians and still growing—and the lagging increases in Medicare, Medicaid, and private insurer reimbursement. A new reimbursement system is at the top of Obama’s agenda for national healthcare reform; however, the economy has slowed the advance of those initiatives. Obama has set aside roughly $20 billion in stimulus funding to encourage EMR programs.

Other plans are likely to gain momentum in coming months, with the expected confirmation of Kansas Gov. Kathleen Sebelius as secretary of the U.S. Department of Health and Human Services.

“You can’t grow and grow, and not grow the amount of money needed,” Dr. Maynard says.

Return of the PCP

Another oft-discussed threat to the HM model is the potential return of primary-care physicians (PCPs) to the hospital. PCPs pulling back to focus on their private outpatient practices helped birth the HM movement. Many of the nation’s uninsured forego primary care and instead seek care in the ED, which often leads to hospital admission and HM care. If PCPs return to the hospital, it could mean a decrease in hospitalist patient census.

Don’t Back Down

Threats to the HM business model paint a hazy picture of an industry in struggle, but while the challenges to the industry are serious, the impact on individual hospitalists is more clouded. In fact, experts say, the demand for hospitalists puts HM practitioners in the driver’s seat—if they can take advantage of the situation. Here’s how:

Provide data points on specific cost savings. It’s difficult for hospital administrators to justify losing physicians who prove they save the institution money. As the economy tightens, those savings may be harder to quantify, which is why HM leaders are pushing for creativity in cost savings.
Remember it’s a buyer’s market. There is no shortage of open hospitalist positions, and the more jobs that are available in hospitals, the more difficult it can be for institutions to retain their top talent. That can be a bargaining tool.
Realize size matters. While large HM groups clearly benefit from economies of scale, smaller groups can have the nimbleness to quickly adjust to a hospital’s needs. Some HM leaders believe there is an opportunity for new groups to form, offering to start new programs for lower costs than more-established groups.

“It’s a unique kind of situation,” says Dr. Wellikson. “Many of the things that will happen will play into the favor of individual hospitalists.”—RQ

The plight of the unemployed, which has ballooned to more than 500,000 per month since December 2008, is another consideration. Will PCPs need to fill an encounter gap when millions of American families lose their employee-funded medical benefits? And what about the billions being set aside to open new community health centers, which theoretically would siphon potential PCP patients—and revenue? Will these centers push PCPs to resume caring for hospitalized patients?

“The only threat to HM is if we had major healthcare reform that included comprehensiveness, that included something to make it worthwhile for the PCPs to take care of their patients in the hospital,” says Robert M. Centor, MD, FACP, associate dean and director of the division of general internal medicine at Huntsville Regional Medical Campus in Alabama. “For more and more family physicians … it doesn’t make financial sense to travel to the hospital.”

Gene “Rusty” Kallenberg, MD, chief of family medicine at UC San Diego’s School of Medicine, points out PCPs can hurt hospitalists without returning to the hospital. More patients treated in primary care means fewer patients whom hospitalists can charge. Should Obama extend healthcare coverage to the estimated 47 million uninsured people in the U.S., patients once treated in the ED and admitted through HM programs likely would seek primary care before heading to the hospital, further limiting billing opportunities for HM groups. The irony, Dr. Kallenberg says, is that what is best for the patient isn’t necessarily best for the industry—HM included—that treats them.