Cardiology Hospitalist Programs Becoming a Reality

From St. Louis Today:

The first cardiology hospitalist program in the St. Louis area recently began at St. John’s Mercy Heart and Vascular Hospital allowing more focused care for hospitalized heart patients by board-certified cardiologists available throughout the day.

Patricia Cole, MD, an interventional cardiologist, is the director of inpatient cardiology services at St. John’s Mercy leading the new group. Mary Carolyn Gamache, MD, FACC, recently joined Mercy as the second cardiology hospitalist. She has been practicing with Metro Heart Group of St. Louis since 1995. Along with the cardiologists, three nurse practioners will also be a constant presence for patients and families.

On-site interventional "cardiology hospitalists" may improve door-to-balloon times during acute heart attacks, but will also place additional pressure on community-based interventional cardiologists to join forces with hospitals since their ability to expand their practices with new acute patients will be severely limited as a result.

The path to "cardiology proceduralist" continues.

-Wes

The Rise of Specialty Hospitalists

It started as just a figment of the hospitalist movement years ago when I saw an ad in Florida advertising for a cardiology hospitalist. Now it seems the trend is continuing to other specialties like neurosurgical, orthopedic, OB-GYN, and ENT hospitalists.

In the new construct of health care reform ahead, will specialists evolve to mere proceduralists?

If so, should we insist our hospitalist colleagues obtain additional specialty training and board certification in their chosen "specialty" fields? Or is a mere "label change" of the hospitalist title enough to assure quality care for our patients?

This trend toward lower-cost, less-trained individuals subsuming titles of "specialists" so hospitals can meet their bottom lines leaves me lukewarm regarding patient care quality. Yet ironically, I suspect that 90% of things we do day to day in my field will be managed fine by this construct.

It's just the other 10% of cases that aren't routine that I remain concerned about. It's like that old Harry Callahan line spoken by Clint Eastwood in the movie Dirty Harry:

I know what you're thinking. "Did he fire six shots or only five?" Well, to tell you the truth, in all this excitement I kind of lost track myself. But being as this is a .44 Magnum, the most powerful handgun in the world, and would blow your head clean off, you've got to ask yourself one question: Do I feel lucky? ... Well, do ya, punk?

-Wes

The Eroding Physician Brand

It came as a Twitter 'follow' this morning from '@coldfeet65,' a self-proclaimed 'Nurse Practitioner Hospitalist.'

I had never heard this term before.

Does it mean a Nurse Practitioner who cares for Hospitalists? Or is it a Hospitalist who is a Nurse Practitioner? Or maybe it's a Nurse Practitioner who helps Hospitalists? (Honestly, I think I know which one she means, but you get my point.)

Perhaps this is a prescient glimpse to health care of the future, where our more typical nurse and doctor labels are supplanted by more and more monikers that serve to confuse, rather than clarify, each of our roles in health care delivery. As specialists in cardiology, we've seen a similar trend with cardiology hospitalists.

But we should be clear what this means to the patients and doctors going forward.

No doubt most people in America still expect to see a doctor when they come to the hospital. Increasingly, it appears that might not be the case. Your doctor might be a robot while a nurse (aka, nurse practitioner) will be the one providing the hands-on care in the inpatient setting. Is that a good thing?

Honestly, I'm not sure.

No one argues that the costs in health care need to be cut. No doubt the Central Authority has deemed that doctor salaries will be a big part of that effort. Already, 20 states have cut physician Medicaid payments for fiscal year 2010 and, given the current economic pressure on our states both now and after they start feeling the financial impact of the "Affordable" Care Act in 2019, this trend is not likely to improve anytime soon. As a result, we are seeing that the world is full of "creative solutions" to our health care access crisis and the evolution to Nurse Practitioner Hospitalists might be one of these.

But what are Doctors of Medicine becoming as a result? Are our current cohort of primary care doctors becoming little more than nurse managers and fact-checkers of mandated protocols, treatment guidelines, and care directives?

Hopefully not.

But increasingly it appears that those without a hands-on, invasive skills in medicine (like surgery) are being marginalized in the health care models going forward. This trend now appears to even be affecting the much-heralded inpatient hospitalist care model as the doctor shortage intensifies. Consequently, the image of "doctor" as we knew it is changing, not only for what patients can expect to encounter when they come to a hospital, but for the type (and caliber) of the doctor we attract to our profession going forward.

-Wes

Running on Empty

"In sixty-nine I was twenty-one and I called the road my own
I don't know when that road turned onto the road I'm on.

Running on, running on empty
Running on, running blind
Running on, running into the sun
But I'm running behind."

-Jackson Browne

"We're stretched so thin, right now. No new hires in sight. Look at this list of patients: twenty-two of 'em, all over 70, eight "new's" among them, every one with tons of medical issues. Didn't get out of here until 10:30 last night. Then back at it at 8 (am) this morning. I'm telling you, I hate it. Hate it. There just doesn't ever seem to be an end in sight. We're just a bunch of "f**in' employees, and no one gives a damn."

I sat stunned. I knew him from before. His job had taken it's toll. This wasn't the guy I knew earlier. I really didn't know how to respond, but did suggest that maybe hospitalist medicine wasn't for him.

I had been there once. Like a fly buzzing against a pane of glass, persistently buzzing, buzzing, unable to escape, able to see the sun on the other side of the window, but no matter how hard I buzzed against that window, I could never make it outside. The forces against me were just too great. But it's right there! Can't you see it? If I just work a little harder. Hey, others can do this job, so I must just be doing something that I can fix. What can be so hard about this? Hell, I've got a medical degree! I'm smart enough to figure this out!

But only after the fly stopped buzzing against the window to noted that there was an open door right next to him, was he ever able to reach the great outdoors.

But woe to the fly that doesn't make the change...

... for if he keeps buzzing against the window, he'll die.

-Wes

When the Hospitalist Service is Capped

It's the fastest growing "specialty" service in medicine: hospitalist medicine. These are the doctors who limit their practice to the care and management of patients admitted to the hospital. It has been wildly popular because it adds a shift-like work schedule to medical care for physicians while supposedly preserving their personal life. It also moves patients through the hospital faster, shortening length of stays. As one of our more esteemed hospitalist bloggers likes to boast: it's a "WIN-WIN!"

At least until the hospitalist service gets too busy.

It seems now that hospitalists services are limiting the number of patients they admit per day in response to their overwhelming "popularity." It's something akin to capping resident medical student ward services - they stop accepting patients when their census gets too full. I learned this today when a patient I was trying to manage with heart failure was just not turning the corner and needed to be admitted for more agressive inotropic therapy.

Finding an admitting physician becomes an interesting exercise when the patient's primary care doctor no longer admits to the hospital (or is on vacation as was the case today) and the hospitalist service is no longer accepting patients because they're "capped" and you're trapped in a busy clinic.

What becomes the pop-off valve? You guessed it: the Emergency Room. Even though the patient absolutely, positively does not need the Emergency Room.

So much for cost savings.

It appears hospitalist services are increasingly finding themselves overwhelmed with admissions and the promise of a reasonable lifestyle can be assured by either limiting the number of patients admitted to each hospitalist or hiring more of them. But new hires are becoming tougher to justify in this "do more with less" economic time in medicine. As a result, it appears existing hospitalists are quickly finding they've hit the peak speed of their clinical-care gerbil wheels.

In a 1999 National Association of Inpatient Physicians (NAIP) survey, 25% of hospitalists were at risk for burnout, and 13% were in fact burned out. While these burnout rates were significantly lower than those documented in similar surveys of intensivists and emergency medicine physicians at the time, others suggested that his rate could increase as the field matured.

News flash: At least at some hospitals, it looks like we're there.

-Wes

References:
Robert M. Wachter, MD; Lee Goldman, MD, MPH
The Hospitalist Movement 5 Years Later. JAMA. 2002;287:487-494.

Hoff TH, Whitcomb WF, Williams K, Nelson JR, Cheesman RA. Characteristics and work experiences of hospitalists in the United States. Arch Intern Med. 2001 Mar 26;161(6):851-8.

Specialists Become Hospitalists: The Consolidation Continues

From Columbus, Ohio:

In the past, hospitals hired primarily family doctors who would refer patients to the facility for medical tests. Now, hospitals are employing more specialists.

For example, having a neurologist or cardiologist on staff allows quicker patient consults than waiting for a private-practice doctor to come to the hospital.

"The reason we even employ specialists is to provide inpatient coverage on our floors in the hospital," said Cindy Sheets, senior vice president ambulatory services for Mount Carmel Health System.

Another reason specialists are consolidating with hospital systems is the high cost of bringing on other experienced specialists that have insurance "tails" from their former practice. These insurance "tails" assure continued malpractice insurance coverage on patients from their former practice as they start employment (and new malpractice insurance coverage) with their new group.

Not only do doctors need portability of their own health insurance from one job to the next, they need portability of their malpractice insurance, too.

-Wes

Addendum: Another example in Asheville, NC.

The First Real Hospital Quality Measure

How many hospital measures exist for physicians today? Answer "119." (Somehow I count 134, but hey, what's the difference)

Now, how many hospital measures exist for hospitals today? Answer: 35.

But these quality measures for hospitals, are really clinical measures for physicians, so all told, physicians now have 155 quality measures to which they must conform, should they want to be paid.

The bottom line is that hospital quality measures, as they exist today, are really more physician quality measures.

But hospitalists are paid by hospitals, and as such, have now become a "hospital quality standard." Same with nocturnists - hospitalists that do the night shift. Heck, these used to be medical students and residents, but because of the ever-growing concern over sleep deprivation in medicine, residents' hours may soon be restricted to 56 hours a week. With the growing realization of the paucity of care delivery after hours, coupled with the reality of the need for 24/7 care, hospitals are now in the position to differentiate themselves with a measure that can actually affect outcomes.

So, here's my proposal for the first real hospital quality measure (always looking for ways to cut the bureaucracy):

Does the hospital employ full time hospitalist and nocturnist services?

The next might be clinical nursing staff to patient census ratios.

Once we stop confusing hospital quality measures with physician quality measures, we might get somewhere.

-Wes

Cardiology Hospitalist: A New Career Path?

Cardiology Hospitalist?

Will provide direct clinical support, evaluating ED patients for admissions, follow-up care, expediting discharges, assisting with cardiac emergencies, completion of CORE measures, coordinating care teams of house staff and nursing staff. Plenty of opportunity to attend cardiology conferences, lectures, grand rounds.

Opportunty, certainly, but I've never seen any hospitalists attend our cath conferences or most medical conferences for that matter... they're just too busy "expediting discharges."

Sneaky marketing, though, but I'd suggest that the potential "cardiology hospitalist-to be" look at this position with some skepticism.

-Wes

"My Doctor" Becomes "The Doctor"

Happy's going to be happy today.

My fellow blogger, Happy Hospitalist, who has added more to our understanding of the economics of our health care crisis than many others after his blog appeared this year, gets to toot his horn a bit more. After all, hospitalists had yet another retrospective, observational study released today in the mighty New England Journal of Medicine that justifies the subspecialty economically.

So it's official: hospitals like hospitalists. And hospitalists like hospitals. Yep, it's a "WIN-WIN" as Happy likes to say.

Now I don't have the time to go into all of the limitations of the study design as reported, but some of the fanciest statistics in the world were used to overcome the admitted limitations of the trial. This certainly didn't thwart the editors and peer reviewers in the Journal from publishing this work - after all there were lots and lots of data. (*Sigh*) But if were to naively accept the results of the study, the bottom line from the authors' analysis suggested that hospitalists save about $268 dollars (less than the cost of a single echocardiogram) and shave off about half a day of hospital time compared to what an general internist or family practitioner could muster without a change in hospital mortality.

Now, don't get me wrong, I think that hospitalists are here to stay. They offer lots of advantages to patients, being omni-present in the hospital and all. But there are some things that our embattled primary care physicians and patients will lose a bit more of because of this economic inevitability: their doctor-patient relationship. Patients no longer are cared for by "my doctor," but rather "the doctor."

And that doctor changes often.

You see, the hospitalist movement requires the "handoff" of the patient from the "primary care" physician to the hospitalist when they enter the hospital. And once in the hospital (what the authors failed to mention), is that at least weekly, and usually nightly, another hospitalist assumes that patient's care. A whole set of re-learning occurs. As though the patient is moving down an industrial assembly line with a different machine applying a few more welds to the final body part.

So patients are left to wonder who, exactly, is their doctor this week or this evening while in the hospital. Whom do they call to find out the results of a test? Whom do they call to discuss an upcoming therapy? Will their (outpatient) doctor have a say in the decisions of day to day care? (Sorry, not really.)

The economics for the field of primary care will also be affected. More and more primary care physicians find they can't compete economically with the salaries of hospitalists. After all, hospitalists have to pay little to no overhead, except their malpractice which is often subsidized by their hospital employer. Additionally, hospitalists' are often incentivised to minimize length of stay with additional bonuses too.

Which leads to the question, where does that extra money paid to hospitalists come from?

A primary care doctor in the outside world must rely on the old economics of the broken Medicare reimbursement system that feeds them mainly a declining "professional" fee for an outpatient office visit. They cannot refer to their own x-ray facility or lab facility due to the Stark II self-referral law that bans such practices. The hospitalists, however, enjoy a slight competetive edge with their income supplied by the omnipotent hospitals who can collect the much larger Medicare "technical" fees from the many procedures ordered by hospitalists and use these funds to support their slightly higher salaries. These incentives are effectively a legal loophole that skirts the well-known Stark II self-referral law. All perfectly legal: after all, they're just "employees" on salary receiving "productivity" bonuses.

So, the primary care doctors are losing a bit more control over their patients and a bit more revenue erosion relative to their hospitalist peers. Patients meanwhile are seeing slightly shorter hospital stays and a more attentive physician presence in the hospital, but are left not knowing who's managing their care.

It's a strange new world of medicine these days - all in the name of efficiency and economics.

-Wes