Hospitalists: A Little Slice of Mayo

Much has been made of the superior performance – on both cost and quality – of integrated healthcare organizations like the Mayo and Geisinger Clinics. But since the defining characteristic of these standout systems is at least 50 years of integrated history, few believe that the rest of us – namely the docs and hospitals that provide the bulk of American healthcare – can quickly achieve such seamless integration, even if the perfect bill emerges from the Congressional sausage factory.

And it’s increasingly clear that the perfect bill will not be coming out of Washington this year.

Is hope lost? Is it possible to create tighter integration between hospitals and doctors without a legislative Attaboy? Can healthcare organizations and physicians be incented to deliver the highest quality, safest, most reliable, most patient-centric care at the lowest possible cost without Atul Gawande reading the findings of the Dartmouth Atlas into the Congressional Record?

I think they can, if they have a strong hospitalist program.

I know that some accuse me of seeing hospitalists as the answer to every question (“What did you have for breakfast today, Bob?” “Oh, hospitalists.”). They’re not. They won’t do anything to tackle the excesses of the McAllen, Texas’s of the nation, where most of the shenanigans take place in the netherworld of doctor-owned clinics and surgi-centers. And – although many hospitalists now staff inpatient specialty services like orthopedics and neurosurgery – it is unlikely that they’ll be in a position to tamp down procedural overutilization driven by the specialists.

And I am painfully aware that there are some crummy hospitalist programs out there, capable of perpetuating, even expanding, some of the ills the movement was meant to heal.

Yet I’ve seen many hospitalist programs that have created little islands of Mayo-like practice: with strong hospital-physician partnerships, appropriate focus on both quality and costs, thoughtful balancing of individual and group benefit, real passion for systems improvement, and exemplary physician-nurse teamwork. And I’ve seen these things in organizations that, from the outside, look like the rest of American healthcare. How can that be?

The answer lies largely in the economics. More than 90% of hospitalists receive financial support from their hospitals (about one-third of hospitalists are directly employed by the hospital, the rest weave the hospital support into other employment models), and relatively few hospitalists are paid under the unfettered fee-for-service model that promotes relentless overutilization.

Precisely the opposite – by accepting support from their hospital, hospitalists find themselves in a uniquely well-balanced incentive environment. Although many receive a productivity bonus, their dominant incentive is that of their hospital: they see the world through a DRG-tinged lens that rewards shorter lengths of stay and lower inpatient costs.

(A brief word of explanation. While most insurers pay hospitalists just like they pay other doctors [namely, for piecework], this fee-for-service revenue stream is blended with the hospital’s support dollars to create a paycheck based on salary, or a salary-plus-bonus. Under this model, the hospitalists’ incentives are aligned with the hospital’s DRG-generated incentive to conserve resources, since these savings partly account for the hospital’s willingness to support this particular group of doctors.)

Moreover, since hospitals are the target of most robust quality reporting, pay-for-performance, and patient safety mandates, hospitalists share their worldview on these issues as well. If I’m getting money from my hospital, I damn well better help the hospital achieve excellent performance on publicly reported hospital quality data, “no pay for errors”, Joint Commission National Patient Safety goals, patient satisfaction scores, readmission rates, and the other scary things that keep my hospital CMO up at night.

In other words, well-organized hospitalist programs share their hospital’s accountabilities.

The result of this set of incentives is that hospitalists should be the best behaved doctors in the building. In my own program at UCSF, we’re just finishing our yearly negotiations with our medical center leadership over their support for the clinical parts of our program (we also have robust research and educational enterprises that support themselves in other ways). I’m acutely aware that there are many things that my hospital can do with its money other than support my group. My arguments for hospital dollars hinge on things that seem like reasonable goals for all of American healthcare: we provide high quality, safe, patient satisfying care; we meet reasonable efficiency targets; we work hard and make defensible salaries; and we are enthusiastic and effective citizens of our organization. At the Mayo Clinic – which I’ve been privileged to visit several times – that’s how everybody thinks. In most hospitals, it is decidedly not how the fiercely independent physicians have been conditioned to approach their work.

This is why I’m enthusiastic about any policy maneuvers that promote this kind of integration and shared accountability. When these things are successfully achieved, I’ve seen how it changes the nature of practice – not only at the Cleveland Clinics and Kaiser Permanentes of the world, but at hundreds of other hospitals that share none of these organizations’ storied pedigrees and cultural DNA, but do have well functioning hospitalist programs.

The importance of a strong hospitalist program extends beyond direct changes in clinical care. Such programs may help model a new system of less dysfunctional hospital-physician relationships. When the market or policymakers finally get around to forcing hospitals and medical staffs into each other’s metaphorical arms, both parties are more likely to embrace the lessons of their own successful hospitalist program than of bright but distant supernovas like the Mayo Clinic.

10 Responses to “Hospitalists: A Little Slice of Mayo”

  1. MKirschMD August 31, 2009 at 1:50 pm #

    Your term ‘seamless integration’ is apt as this is a necessary component of hospitalist medicine that must occur after the patient is discharged home. This was not addressed in your piece. Under hospitalism, the admitted patient is treated by a physician he has never seen. Obviously, the clinical nuances, known to the primary care out-pt physician, are not known to the hospital doctor. Similarly, a hospital discharge summary is a sterile document, which might not convey important clinical subtleties to the out-pt physician. When the primary physician reclaims the patient afterwards, he might not be adequately apprised of the patient’s clinical status. In addition, patients are often discharged with many medical loose ends remaining. It is easy to imagine that some of these may be missed in the hand-off process. Can the system work? Yes, but the players in the game need to strive for a seamless medical transition and not just focus on issues of efficiency and economics. http://www.MDWhistleblower.blogspot.com

  2. menoalittle September 1, 2009 at 5:57 am #

    Bob,

    In your formative years, you, as the resident, were the hospitalist. The handoffs generally went no further away than the clinic, and you frequently spoke with the clinic doc, your fellow resident. The discharge summaries were thoughtful and detailed partly from the peer pressure of other residents.

    Fast forward to 2009. Does any one know the patient? The hand off from hospitalists consist of patients suffering premature discharge sent back with many pages of disjointed EMR generated minute detail, lab reports with user unfriendly formats, medicine lists inadequately reconciled with admission medicine lists, and inaccurate discharge summaries.

    Lest I forget, there are handoffs of train wrecks being transferred to LTACs and SNFs with boxes of computer generated pages of useless and irrelevant EMR gibberish, but the gibberish is readable. Does any one take the time to read it?

    Best regards,

    Menoalittle

  3. Phil Vaidyan September 5, 2009 at 3:52 pm #

    Let us get energized to fight and win this just fight worth fighting for. Let us work hard to get a real health care reform. Let us not get subdued by nonsense, lies and bigotry.

  4. adblouky September 7, 2009 at 12:03 am #

    Re-reading your lunch club post, I might ask if laproscopic cholecystectomies are now overused, or were open cholecystectomies underused? How do you know? If we paid surgeons a yearly salary independent of the number of surgeries they perform, I imagine the number of surgeries they would perform would go down. Would that indicate that they are now churning, or would it suggest that they are just lazy and see no need to work so hard and expose themselves to malpractice risks and endless utilization audits?

    None of us are free of bias; ultimately it’s all a matter of context. I don’t criticize you for having your own, but it’s not a compliment that your biases are so evident, either.

  5. retiredpath September 7, 2009 at 1:59 am #

    I agree with the others’ remarks about the transition to the outpatient setting, given my experiences with my elderly mother. Fortunately as an M.D. I acted as the water carrier for the transition, but it was not facilitated by the hospital at all, nada.
    It is for this reason I hold the unpopular viewpoint that all players’ payment must be bundled together, inside and outside the hospital; M.D. and non-M.D.’s alike. Otherwise all the nuance will be lost, along with, inevitably, some lives.

  6. Evinx September 10, 2009 at 9:05 pm #

    The problem with everyone screaming for healthcare reform is that they think THEIR views are correct. Why are we all so arrogant? Sorry, physicians are not exception. Great doctors with altruistic intentions still may not be able for formulate successful policies. This applies doubly for the political class which in turn, is tremendously affected by special interest groups.

    Many of the problems we have today were created by govt policies (tax) and regulations (mandates, community rated pricing, etc).If we could eliminate 90% of the mandates, eliminate the distortions caused by the income tax treatment, and allow insurance to be sold in the same way as auto insurance is, prices would come tumbling down + incentives to efficiencies and performance would go up.

    The key is let’s have some Respect for markets! None of us knows best. A little more freedom would unleash evolutionary forces to improve healthcare for all of us.

  7. Matthew Carr MD September 12, 2009 at 2:08 am #

    The hospitalist issue us very complex. In my hospital we were told that hospitalists are masters of getting things done quiickly and efficiently cause the are “alwyas there” Instead most hospitalists strectch themselves pretty thin to make a decent living and to many the job is but one temporary step to private office practice.
    The thing that concerns me the most howevrer is the potentiial conflicts of interest,. To secure their jobs they must discharge quicker and avoid epensive procedures if the patient is under an drg. Who is advocating for the patient?? We know what the private hospitals advocate for, and now their doctor is endentured to the hospital.
    I can not tell you how many times our hospitalists run across a problem while a pt is in the hospital (heme pos stool, Creatinine if 2.0, density on a chest x ray, heart murmur, anemia, ) and decide to push the workup to the outpt follow-up that does not exist. Indeed if an extensive workup is advised to the HMO primary, a complaint may be lodged against the hospitalist. They quickly learn. In my view the hospitalist system thus far leaves a lot to be desired. Bye the way, process change is usually done to please the outside docs that bring their private pts to the hospital, rarely to make the hospitalists more efficient.
    I would say however that most dedicated hospitalists are quite well trained. They probably deserve better than they are getting
    M L Carr MD

  8. Bob Wachter September 18, 2009 at 3:58 am #

    The following is from my old friend Rich Savel, an intensivist who helps run the medical ICU at Montefiore Medical Center in the Bronx (rhsavel@gmail.com):

    “I think intensivists need to be mentioned here too. Good intensivists share the passion of patient safety in the hospital along with hospitalists. Indeed, smoothing over the transition between the ICU and the floor, or the even murkier transition between the ICU and the progressive care unit, can be another area where hospitalists and intensivists can work together. If there were more people trained like I am (former hospitalist turned intensivist) with boards in IM and Crit Care, there would be more jobs that combine hospitalist and intensivist work. I believe this would make care for patients even better, provide more opportunities for QI projects, as well as clinical research, and tighten the bond between our specialties.”

  9. Gerald W. Roller, MD IM, Rheu.; Geriatrics ( retired MD in 1999 after 37 1/2 years. October 28, 2009 at 4:14 pm #

    I believe we should have a payment system based upon a specific amount to be made in a
    lifetime of work. EG: $5,000,000. The “less trained in speciality” ( e.g. 3 or 4 years) would
    work longer at patient/doctor than would the “greater trained specialty” (e.g. 5-7 years)
    and as a result the ‘specialist’ would generate a greater income during his years of practice, yet
    in the end (say at age 65 or after 35 years of work) both would have made the same amount
    of money ( income). The final amount would of necessity have to change from time to time
    as economic times change also. ( e.g. a gallon of gasoline in 1960 was about 50 cents, yet now it is $2.47 .) My rational is that it is just as important to diagnose and treat diabetes, or hypertension
    as it is to do a coronary bypass or a colon cancer removal.The surgeon oftentimes depends upon
    a family practice or internist to send him/her the patients. Example: I once saw a young person
    on a Sunday for non-specific complaints; I saw him later in the evening and diagnosed appendicitis.
    I was paid $25 and the surgeon $125, yet he spent 30 minutes at most with the patient, and I
    had spent approximately 1 hour.
    Such a means of pay could be translated into much of the medical field, even to the point
    of limiting income from drug sales…with excess above a level going to upgrade, educate,
    medical personell and patients. Thanks, GWR

  10. jewelllo March 6, 2010 at 8:55 am #

    good article

Leave a Reply