Twenty years in, the hospitalist landscape is shifting—and prompting new debates

NYT reports on complexity of balancing quality, productivity

See the Advisory Board's take on this story.

The drive for efficiency in health care has led to a boom in hospitalists—and growing pains for the profession as hospitals seek to increase efficiency and demonstrate high quality outcomes, Noam Scheiber reports for the New York Times.

Hospital medicine emerged two decades ago as a managed care-driven innovation: rather than losing office time to rounds, internists could stay at their offices while hospitalists took over in-hospital care. The change allowed internists to see more patients and hospitals to improve throughput and care quality by having hospitalists handle intake and discharge while also developing expertise in the sort of complicated and layered conditions often exhibited by hospital patients.

The model caught on, with number of U.S. hospitalists growing from about 11,000 in 2003 to about 50,000 in 2015. But the shift toward value-based care has meant more documentation work for hospitalists and less time with patients, Scheiber writes—a trade-off that hospital operations consultant Adam Higman says has reduced readmission rates overall but perhaps taken a toll on individual patient care.

Hospitals seek to increase efficiency, quality

Meanwhile, hospitals are pursuing strategies to increase efficiency and create incentives for better care in hospital medicine that they've seen success with in other specialties.

What's the right ratio of hospitalists to patients?

Many hospitals are outsourcing hospital medicine, with about 25% to 30% of hospitalists working for multistate management companies in recent years, according to the Society of Hospital Medicine. And hospitals increasingly are tying hospitalist income to clinical outcomes, such as performance on hospital-acquired infection rates and other ACA-related criteria, says Dr. Robert Wachter, chief of the division of hospital medicine at the University of California-San Francisco.

Hospitalists express concerns

Wachter notes that “tying everything to financial incentives” risks "stomping on [hospitalists'] intrinsic motivation" a concern echoed by hospitalists at Oregon's PeaceHealth Sacred Heart Medical Center, some of whom are profiled in the Times. One says that "our licenses, our livelihoods, our professions" are at stake in every patient interaction, providing sufficient motivation to produce high-quality outcomes.

How to position your hospitalist program for success

The Sacred Heart hospitalists recently formed a union—among the first of its kind nationwide—partially in response to a proposal to outsource the center's hospitalists and concerns about the possibility of being asked to increase the number of patients they saw each day.

Sacred Heart decided not to pursue the outsourcing idea and has focused on negotiating a contract with the hospitalist union. Administrators and hospitalists have made progress in some areas, such as addressing physicians' desire to provide more input on staffing. But hospitalists continue to object to other proposed changes, the Times reports, including increasing their number of annual shifts and tying physician compensation to performance targets like patient satisfaction and length of stay (Scheiber, New York Times, 1/9).

The Advisory Board's take

Julie Riley, Physician Executive Council

Hospital leaders should keep several key trends and best practices in mind as they look to get the most out of their hospitalist program.

For example, hospital leaders are increasingly recognizing that a high-performing hospitalist program is no longer just a tool for efficiency. According to a survey we conducted last year, hospitalists now care for more than half of the hospital's patients, and their performance impacts about 80% of the hospital's value based performance metrics. This makes hospitalists an inflection point for overall hospital performance.

However, in our research we found that the hospitalist program often isn't fully aligned with hospital strategy. The challenge is that alignment is about more than performance incentives or accountability; it's about shared priorities between both groups. High-performing hospitalist programs all have one thing in common—they have a shared understanding with hospital leaders about what the program can achieve, and the resources they need to do so.

The Society of Hospital Medicine has worked to codify traits of successful programs in the Key Principles and Characteristics of an Effective Hospital Medicine Program. We've taken that research and created a user-friendly gap assessment tool—available here—that hospital and hospital medicine leaders can use to develop greater alignment.

We also encourage you to join us for our webconference tomorrow on ownership culture, where we'll interview John Nelson, one of the experts quoted by the New York Times.

Finally, hospital leaders can learn more about how to capture the full value of the hospitalist program at their organization at our upcoming national meeting in Dana Point, California.


Next in the Daily Briefing

How three hospitals are tackling the deadly problem of alarm fatigue

Read now