In late September, I had the honor (or honour, I guess) of speaking at the 5th Annual Canadian Hospitalist Conference, held in beautiful Vancouver. It was an eye-opener.
About 150 hospitalists from all over Canada were there, and they really are delightful people: enthusiastic, energetic, and really jazzed about doing something new and important.
Whereas in the U.S., hospital medicine was initially catalyzed by the economic advantages that accrued to managed care organizations and hospitals for safely shortening LOS and lowering hospital costs, those haven’t been the key issues in Canada. Instead, family physicians – their dominant providers of primary care – have all-but-fled from Hospital-World, leaving a gaping hole.
Who filled the gap? In the U.S., nearly 90% of hospitalists are internists, mostly general internists who found the opportunity to focus on hospital care attractive. However, in Canada, there are very few general internists – the tradition (as in the UK) is for internists to be consultants to family physicians and teaching attendings in academic hospitals; the primary care docs are nearly all FPs. The relatively small number of internists in Canada rarely stay “general”: most differentiate into subspecialists, particularly drawn to the more highly reimbursed procedural specialties like cardiology and GI. (Note to Michael Moore: so it’s not that different).
So, it was family physicians who morphed into hospitalists in Canada, and nearly all of the conference attendees were FPs. Even though family medicine training in Canada is a bit more inpatient-oriented than it is in the U.S., folks generally agreed that two years of family medicine is not the ideal hospitalist training recipe, particularly since FPs get relatively little ICU and peri-operative experience. We brainstormed about what a 3rd year Canadian “hospitalist fellowship” might look like, perhaps followed by some kind of hospitalist certification. There is precedent for this in Canada: a fair number of emergency physicians are FPs who received an additional year of post-FP-residency emergency medicine training.
In addition to this FP/internist difference, the other thing I found interesting was the flow of dollars. Here, there were striking similarities to the American story, but some profound differences. Similarities: primary care physicians began to find providing non-procedural, coordinative care of sick inpatients unattractive. A group of physicians, finding this an appealing niche, embraced this role. And the dollars available to pay them from the traditional forms of billing were insufficient to create sustainable positions. (That, of course, is a big “duh”: if the dollars were plentiful, the other docs wouldn’t have willingly left the building).
Here’s where the stories diverged. In the U.S., this dynamic led hospitalists to identify the hospital as the critical deep pocket: the stakeholder that (because of DRGs, and, more recently, because of the quality and safety imperative) had a sufficient interest in hospitalists to potentially open the piggybank. You remember the course in college: Return-On-Investment 101.
In Canada, hospitals don’t really have the money to do this, nor the market-based incentives that lead to these kinds of ROI decisions. So who was the deep pocket? Well, under a single payer system, “It’s the Government, Stupid.”
This situation creates one of the main raisons d’etre of Canadian hospitalist confabs: to strategize amongst themselves regarding their government service agreements – agreements that are struck either with the provincial governments (thought they’re hard to get to) or the regional health authorities constructed to be intermediaries.
With this complexity, Canadian hospitalists quickly recognized the need for unique approaches to plead their case effectively. First of all, they identified the importance of public support, which led them to develop an aggressive media strategy. Several people commented on the key role of “stories in the newspaper” about the value of hospitalists or the lack of alternatives to hospitalist care.
The second difference was the fact that the docs were out of their league when it came to negotiating with the government. In the U.S., most of us who run hospitalist programs have had challenging negotiations with our hospital CMO, CFO, or CEO, arguing for the resources needed to build an effective, thriving program. Imagine a world in which these discussions were not with your hospital leaders, but rather with provincial legislators or bureaucrats.
At the Vancouver conference reception, the crowd hushed when one person entered the room – a chatty and irreverent middle-aged man whose longish blonde hair made him look like a surfer dude a few waves past his prime. As he walked toward me, several people whispered to me that this man, Murray Tevlin, might well be the most important figure in the Canadian hospitalist field. Who was he, I wondered? A brilliant diagnostician, a superb administrator, perhaps a mesmerizing lecturer…
No, he was the hospitalists’ lawyer, who had used his entire bag of tricks to secure a better hospitalist contract from the province (“these young docs are too nice,” he told me): a charm offensive, mediagenic sound bites, and – when it didn’t look like British Columbia was going to blink (the health minister bellowed that the province would not be “held for ransom on this issue”) – a bit of brinksmanship, in the form of a near-walkout in June, 2006. The result: a reasonable contract that the Canadian hospitalists are largely satisfied with.
Although I’d take the Canadian healthcare system over ours in a heartbeat, I found myself in the unusual position – in the healthcare policy world, at least – of being glad I lived in America when it came to hospitalist negotiations. I’ll take sitting down with my Chief Medical Officer, who knows me and my group extraordinarily well, to facing a government health minister or a provincial bureaucrat (“so, what exactly is a hospitalist?”) any day. The Canadians are to be congratulated on pushing the ball downfield under these circumstances, and I look forward to watching and learning from their continued successes.