David M. Mitchell, MD, PhD

Let's think about what we need to do ourselves. We have to acknowledge that orders we write drive up health care costs.1 AMA President, Nancy H. Nielsen, MD, PhD

As the most prominent providers of inpatient care, hospitalists should be aware that, of the total annual expenditures on US healthcare ($2.3 trillion in 2007),2 approximately one‐third goes to hospital‐based medical care, over one‐half of which (57%) is covered by public funds through Medicare and Medicaid3; this high cost of healthcare is increasingly being blamed for unnecessarily burdening our economy and preventing our industries from being globally competitive. I believe that the high proportion of spending on inpatient care places hospitalists firmly in the center of the debate on how to reduce healthcare costs. It is well known that the United States spends about twice as much per capita as other industrialized countries on healthcare,4 without evidence of superior health outcomes.5 However, it is also known that remarkable local and regional variations in healthcare spending also exist within the US, again, without evidence of superior health outcomes in the higher‐spending regions.6 Both of these observations suggest that we are spending many healthcare dollars on things that evidently do not improve the health of our patients. How much of this waste is administrative, operational, or clinical is debatable and remains the focus of growing national healthcare reform efforts.711 However, from the hospitalist perspective, we should be especially wary of providing so‐called flat‐of‐the‐curve medicine, that is, a level of intensity of care that provides no incremental health benefit.12 The purpose of this editorial is to challenge hospitalists to collectively examine how much of our inpatient spending is potentially unnecessary, and how we, as specialists in inpatient medicine, can assume a critical role in controlling healthcare costs.

To illustrate the issue, consider the following clinical scenario, managed in different ways by different hospitalists, with approximate costs itemized in Table 1. The patient is an elderly woman who presents to the emergency room with syncope occurring at church. The first hospitalist takes time to gather history from the patient, family, eyewitnesses, and the primary care physician, and requests a medication list and outside medical records, which reveal several recent and relevant cardiac and imaging studies. He performs a careful examination, discovers orthostatic hypotension, and his final diagnosis is syncope related to volume depletion from a recently added diuretic as well as a mild gastroenteritis. The patient is rehydrated and discharged home from the emergency room in the care of her family, and asked to hold her diuretic until seen by her family physician in 1 or 2 days. The second hospitalist receives the call from the emergency room and tells the staff to get the patient a telemetry bed. He sees the patient 2 hours later when she gets to the floor. The family has gone home and the mildly demented patient does not recall much of the event or her past medical history. The busy hospitalist constructs a broad differential diagnosis and writes some quick orders to evaluate the patient for possible stroke, seizure, pulmonary embolism, and cardiac ischemia or arrhythmia. He also asks cardiology and neurology to give an opinion. The testing is normal, and the patient is discharged with a cardiac event monitor and an outpatient tilt‐table test scheduled.

Although the above scenarios purposely demonstrate 2 extremes of care, I suspect most readers would agree that each hospitalist has his or her own style of practice, and that these differences in style inevitably result in significant differences in the total cost of healthcare delivered. This variation in spending among individual physicians is perhaps more easily understood than the striking variations in healthcare spending seen when different states, regions, and hospitals are compared. For example, annual Medicare spending per beneficiary has varied widely from state to state, from $5436 in Iowa to $7995 in New York (in 2004), a 47% difference.13 Specific analysis of inpatient spending variations is presented in the Dartmouth Atlas of Health Care 2008, which reports healthcare spending in the last 2 years of life for patients with at least 1 chronic illness.14 While the average Medicare inpatient spending per capita for these patients was about $25,000, the state‐specific spending varied widely from $37,040 in New Jersey to $17,135 in Idaho. There was also significant variation in spending within individual states (ie, New York: Binghamton, $18,339; Manhattan, $57,000) and between similar types of hospitals (UCLA Medical Center, $63,900; Massachusetts General Hospital, $43,058). Yet there is no evidence that higher‐spending regions produce better health outcomes.6 Interestingly, the observed differences in spending within the US were primarily due to the volume and intensity of care, not the price of care, as has been seen in some comparisons of the US with other industrialized countries.8, 15 In overall Medicare expenditures, higher‐spending locations tended to have a more inpatient‐based and specialist‐oriented pattern of practice, with higher utilization of inpatient consultations, diagnostic testing, and minor procedures.6

Although the wide variation in spending observed is a bit baffling, the encouraging aspect of this data is that some places are apparently doing it right; that is, providing their patients with a much higher value per healthcare dollar. Ultimately, if the higher‐spending locations modeled the lower‐spending locations, we would have the potential to reduce overall healthcare costs by as much as 30% without harming health.9

What are the possible reasons that we are providing unnecessary care? There are both environment‐dependent and physician‐dependent reasons, which I will outline here. The first 3 reasons represent areas that would seem to require system‐wide change, whereas the remaining 7 reasons are perhaps more amenable to local and/or national hospitalist‐directed efforts.

• 1

  Working in a litigious environment promotes unnecessary testing and consultations with the intent of reducing our exposure to malpractice liability, so‐called defensive medicine.16

• 2

  A reimbursement system that is primarily fee‐for‐service encourages physicians to provide more care and involve more physicians in the care of each patient, with little or no incentive to spend less, a core problem that was recently highlighted in a public Society of Hospital Management (SHM) statement.17

• 3

  The lack of integrated medical record systems promotes waste by leading to duplicate testing, simply because we cannot easily obtain old records to confirm whether tests were previously done. Interestingly, data from the Commonwealth Fund conclude that US physicians order duplicate diagnostic tests (a test repeated within 2 years) at more than twice the rate of Canada and the United Kingdom, while the nation with the lowest rate of duplicate testing, The Netherlands, has the highest rate of electronic medical record use (98%).18

• 4

  Working with patients (or families) with high expectations who insist upon aggressive testing, treatment, and referral to specialists inflates spending, especially if associated with futile and expensive end‐of‐life care.

• 5

  The involvement of one or more specialists may subsequently lead to even more aggressive care ordered by each specialist.

• 6

  The availability and promotion of new technology (diagnostic testing, medical devices, etc.) may prompt us to make use of it simply because it is there, with or without evidence of a health benefit. Our natural curiosity or fascination with information, or our desire to do an overly complete evaluation, works against cost containment.

• 7

  Local trends or traditions within our specific work environment, as suggested by the variability data, may have a strong influence on our individual practice. In such a setting, inadequate knowledge of the cost‐effectiveness of various tests and treatment options likely leads to unnecessary health care spending.

• 8

  A hospitalist work environment in which a high patient load is carried will inevitably result in less time to gather a detailed history and obtain old records or other information that could help narrow a differential diagnosis and minimize unnecessary or duplicate testing.

• 9

  Preventable readmissions resulting from inadequate coordination of care add cost,19 a phenomenon highly dependent on efficient information systems and proper physician‐physician communication.20

• 10

  An overestimation of the need for inpatient evaluation and treatment (vs. outpatient) leads to unnecessary admissions and a longer average length‐of‐stay, each of which add dramatically to total healthcare costs. This is not only dependent on our individual threshold for admitting and discharging patients, but also on our efficiency in diagnosing and treating acute conditions. The fact that the average length‐of‐stay for congestive heart failure admissions, for example, ranges in different regions from 4.9 to 6.1 days (with costs of $9143 and $12,528, respectively)21 is enough to show that there is room for progress.

What joint efforts could be made to minimize unnecessary inpatient spending? The following are my personal opinions and suggestions (Table 2). Most importantly, I believe every physician deserves prompt and accurate feedback regarding their spending patterns, accompanied by valid comparisons to national and local standards, to demonstrate where they stand on the spectrum of healthcare spending. We are currently far behind other industries in our ability, as physicians, to evaluate what we are spending money on, how much, and why. If I knew, for example, that my spending was in the 95th percentile of all hospitalists in community hospitals similar to mine, I would be prompted to investigate where the differences were and why. In an informal survey of hospitalist colleagues, I found that the majority do not receive any data on the costs associated with their care, and are largely unaware of the actual cost of the inpatient tests they commonly order. Developing a secure, user‐friendly database of individual physician spending patterns relative to national and local standards could be a preliminary step, and would likely require a unified effort between government agencies, professional societies, hospitals, and the insurance industry. However, once available, the increased transparency and clarity of spending variations would hopefully prompt introspection and change. In the absence of hard data, however, individual self‐assessment on spending patterns could also be offered through the development of an online simulated case‐based examination in which a physician could gain a general idea of how his evaluation and treatment of a case scenario compares to his hospitalist colleagues, and to what degree each of his clinical decisions affects the overall cost of care. There are many excellent quality improvement tools offered through SHM but none that specifically address the cost of care.

Second, hospitalists need quick access to current evidence‐based guidelines regarding the true clinical value, or cost‐effectiveness, of testing and treatment for common inpatient conditions, including specific admission criteria. A single source or clearinghouse of guidelines, sponsored by SHM, may be particularly helpful, especially if it focuses on clarifying areas of highest variability in inpatient spending. In addition, I believe that, given the critically important interface between emergency medicine and hospital medicine, joint guidelines between the 2 groups would potentially be very helpful in controlling costs by limiting unnecessary admissions. Advocacy for comparative effectiveness research to establish validity in these guidelines will be fundamental22, 23; however, I suspect the common sense question: Will this added cost improve my patient's outcome? also needs to be applied more generously, since many individual clinical scenarios will not likely lend themselves to formal study. For discussion, some sample case scenarios are presented (Table 3).

Third, hospitalists could potentially benefit from the development of patient education materials, available through SHM, that address the cost‐effectiveness of common inpatient tests and treatments with the goal of decreasing patient demand for unnecessary testing. Education regarding advanced directives and end‐of‐life care decision‐making could be particularly valuable in minimizing futile care, as it is well‐documented that transitioning to palliative care as soon as it is appropriate reduces healthcare spending greatly during the end‐of‐life period.2427 At the same time, we need to be careful to reassure our patients that we are not trying to ration care, but are instead minimizing the risks and costs for them associated with unnecessary care. In my experience, most patients, if given appropriate time, attention, and education, are willing to accept the final recommendation of their physician.

Fourth, intensified federal and state advocacy in several areas could help reduce spending. For example, advocacy for medical liability reform may reduce the atmosphere of defensive medicine, although I suspect that because old habits die hard, it may take a full generation of decreased liability risk to actually change practice patterns. Advocacy for the development of a national, or at least more uniform, electronic medical record, may decrease duplicate testing and improve efficiency. Advocacy for value‐based reimbursement models may help dampen costs resulting from a predominantly fee‐for‐service environment.28

Fifth, and perhaps most fundamental to the future of our specialty, encouraging the broad professional development of hospitalists as a true specialists in inpatient medicine (based on the SHM Core Competencies,)29 could help minimize the unnecessary costs associated with specialist‐oriented care.6 With the desire to create, in the near future, a formal board‐certification in hospital medicine comes an obligation to develop broad knowledge and broad skill sets that are truly unique to our profession, whereas deferring to a specialist‐oriented pattern of care actually shrinks us down to something less than a traditional internist, rather than a unique entity.30 With our 24/7 focus on inpatient care, we should easily be able to demonstrate our superiority in safety, quality, and efficiency, all of which are closely linked to increased value per healthcare dollar. If, however, our focus is blurred by an overly productivity‐based practice, in which patient volume and procedures take precedence, we will not be able to claim any special value to the system.

Last, supporting efforts to improve coordination of care and transitions of care could reduce costs associated with unnecessary readmissions or posthospital complications. A recent policy statement from several professional societies, including SHM, highlights the importance of these transitions,20, 31 and within the past year, SHM has launched the successful Project BOOST (Better Outcomes for Older adults through Safe Transitions) to help in this effort.32

Unfortunately, there is an inherent problem with all of the above proposals: the assumption that physicians actually want to reduce healthcare spending. Since everyone who works in the medical industry benefits financially in some way from the current high levels of spending on healthcare, reducing spending is counterintuitive for many, and the incentives to spend more will likely persist until some form of spending targets or limits are set.33 Moreover, since physicians traditionally do not like to be told how to practice medicine, history would predict that, without attractive incentives, nothing will change. This is the fundamental and unfortunate dilemma that has apparently pushed us to the eleventh hour of a healthcare crisis.

Another concern with an extreme atmosphere of cost cutting is the risk of swinging too far in the opposite direction, focusing so intently on cost that we begin to compromise quality or access to care in order to achieve spending targets. Reassuringly, however, the data suggest that there is plenty of room for us to cut costs without harming health outcomes.

Despite these obstacles, during this historic time in US healthcare, I believe hospitalists have a unique and perhaps transient opportunity to demonstrate their singular commitment to rational healthcare spending and by doing so to gain significant influence in shaping the impending healthcare reforms. If we speak and act with one voice, with transparency, and with the proper data, we could be the first and only professional society to not only demonstrate our current pattern of spending, but also our potential for reducing spending and our plan on how to get there.

Let's think about what we need to do ourselves. We have to acknowledge that orders we write drive up health care costs.1 AMA President, Nancy H. Nielsen, MD, PhD

As the most prominent providers of inpatient care, hospitalists should be aware that, of the total annual expenditures on US healthcare ($2.3 trillion in 2007),2 approximately one‐third goes to hospital‐based medical care, over one‐half of which (57%) is covered by public funds through Medicare and Medicaid3; this high cost of healthcare is increasingly being blamed for unnecessarily burdening our economy and preventing our industries from being globally competitive. I believe that the high proportion of spending on inpatient care places hospitalists firmly in the center of the debate on how to reduce healthcare costs. It is well known that the United States spends about twice as much per capita as other industrialized countries on healthcare,4 without evidence of superior health outcomes.5 However, it is also known that remarkable local and regional variations in healthcare spending also exist within the US, again, without evidence of superior health outcomes in the higher‐spending regions.6 Both of these observations suggest that we are spending many healthcare dollars on things that evidently do not improve the health of our patients. How much of this waste is administrative, operational, or clinical is debatable and remains the focus of growing national healthcare reform efforts.711 However, from the hospitalist perspective, we should be especially wary of providing so‐called flat‐of‐the‐curve medicine, that is, a level of intensity of care that provides no incremental health benefit.12 The purpose of this editorial is to challenge hospitalists to collectively examine how much of our inpatient spending is potentially unnecessary, and how we, as specialists in inpatient medicine, can assume a critical role in controlling healthcare costs.

To illustrate the issue, consider the following clinical scenario, managed in different ways by different hospitalists, with approximate costs itemized in Table 1. The patient is an elderly woman who presents to the emergency room with syncope occurring at church. The first hospitalist takes time to gather history from the patient, family, eyewitnesses, and the primary care physician, and requests a medication list and outside medical records, which reveal several recent and relevant cardiac and imaging studies. He performs a careful examination, discovers orthostatic hypotension, and his final diagnosis is syncope related to volume depletion from a recently added diuretic as well as a mild gastroenteritis. The patient is rehydrated and discharged home from the emergency room in the care of her family, and asked to hold her diuretic until seen by her family physician in 1 or 2 days. The second hospitalist receives the call from the emergency room and tells the staff to get the patient a telemetry bed. He sees the patient 2 hours later when she gets to the floor. The family has gone home and the mildly demented patient does not recall much of the event or her past medical history. The busy hospitalist constructs a broad differential diagnosis and writes some quick orders to evaluate the patient for possible stroke, seizure, pulmonary embolism, and cardiac ischemia or arrhythmia. He also asks cardiology and neurology to give an opinion. The testing is normal, and the patient is discharged with a cardiac event monitor and an outpatient tilt‐table test scheduled.

Although the above scenarios purposely demonstrate 2 extremes of care, I suspect most readers would agree that each hospitalist has his or her own style of practice, and that these differences in style inevitably result in significant differences in the total cost of healthcare delivered. This variation in spending among individual physicians is perhaps more easily understood than the striking variations in healthcare spending seen when different states, regions, and hospitals are compared. For example, annual Medicare spending per beneficiary has varied widely from state to state, from $5436 in Iowa to $7995 in New York (in 2004), a 47% difference.13 Specific analysis of inpatient spending variations is presented in the Dartmouth Atlas of Health Care 2008, which reports healthcare spending in the last 2 years of life for patients with at least 1 chronic illness.14 While the average Medicare inpatient spending per capita for these patients was about $25,000, the state‐specific spending varied widely from $37,040 in New Jersey to $17,135 in Idaho. There was also significant variation in spending within individual states (ie, New York: Binghamton, $18,339; Manhattan, $57,000) and between similar types of hospitals (UCLA Medical Center, $63,900; Massachusetts General Hospital, $43,058). Yet there is no evidence that higher‐spending regions produce better health outcomes.6 Interestingly, the observed differences in spending within the US were primarily due to the volume and intensity of care, not the price of care, as has been seen in some comparisons of the US with other industrialized countries.8, 15 In overall Medicare expenditures, higher‐spending locations tended to have a more inpatient‐based and specialist‐oriented pattern of practice, with higher utilization of inpatient consultations, diagnostic testing, and minor procedures.6

Although the wide variation in spending observed is a bit baffling, the encouraging aspect of this data is that some places are apparently doing it right; that is, providing their patients with a much higher value per healthcare dollar. Ultimately, if the higher‐spending locations modeled the lower‐spending locations, we would have the potential to reduce overall healthcare costs by as much as 30% without harming health.9

What are the possible reasons that we are providing unnecessary care? There are both environment‐dependent and physician‐dependent reasons, which I will outline here. The first 3 reasons represent areas that would seem to require system‐wide change, whereas the remaining 7 reasons are perhaps more amenable to local and/or national hospitalist‐directed efforts.

• 1

  Working in a litigious environment promotes unnecessary testing and consultations with the intent of reducing our exposure to malpractice liability, so‐called defensive medicine.16

• 2

  A reimbursement system that is primarily fee‐for‐service encourages physicians to provide more care and involve more physicians in the care of each patient, with little or no incentive to spend less, a core problem that was recently highlighted in a public Society of Hospital Management (SHM) statement.17

• 3

  The lack of integrated medical record systems promotes waste by leading to duplicate testing, simply because we cannot easily obtain old records to confirm whether tests were previously done. Interestingly, data from the Commonwealth Fund conclude that US physicians order duplicate diagnostic tests (a test repeated within 2 years) at more than twice the rate of Canada and the United Kingdom, while the nation with the lowest rate of duplicate testing, The Netherlands, has the highest rate of electronic medical record use (98%).18

• 4

  Working with patients (or families) with high expectations who insist upon aggressive testing, treatment, and referral to specialists inflates spending, especially if associated with futile and expensive end‐of‐life care.

• 5

  The involvement of one or more specialists may subsequently lead to even more aggressive care ordered by each specialist.

• 6

  The availability and promotion of new technology (diagnostic testing, medical devices, etc.) may prompt us to make use of it simply because it is there, with or without evidence of a health benefit. Our natural curiosity or fascination with information, or our desire to do an overly complete evaluation, works against cost containment.

• 7

  Local trends or traditions within our specific work environment, as suggested by the variability data, may have a strong influence on our individual practice. In such a setting, inadequate knowledge of the cost‐effectiveness of various tests and treatment options likely leads to unnecessary health care spending.

• 8

  A hospitalist work environment in which a high patient load is carried will inevitably result in less time to gather a detailed history and obtain old records or other information that could help narrow a differential diagnosis and minimize unnecessary or duplicate testing.

• 9

  Preventable readmissions resulting from inadequate coordination of care add cost,19 a phenomenon highly dependent on efficient information systems and proper physician‐physician communication.20

• 10

  An overestimation of the need for inpatient evaluation and treatment (vs. outpatient) leads to unnecessary admissions and a longer average length‐of‐stay, each of which add dramatically to total healthcare costs. This is not only dependent on our individual threshold for admitting and discharging patients, but also on our efficiency in diagnosing and treating acute conditions. The fact that the average length‐of‐stay for congestive heart failure admissions, for example, ranges in different regions from 4.9 to 6.1 days (with costs of $9143 and $12,528, respectively)21 is enough to show that there is room for progress.

What joint efforts could be made to minimize unnecessary inpatient spending? The following are my personal opinions and suggestions (Table 2). Most importantly, I believe every physician deserves prompt and accurate feedback regarding their spending patterns, accompanied by valid comparisons to national and local standards, to demonstrate where they stand on the spectrum of healthcare spending. We are currently far behind other industries in our ability, as physicians, to evaluate what we are spending money on, how much, and why. If I knew, for example, that my spending was in the 95th percentile of all hospitalists in community hospitals similar to mine, I would be prompted to investigate where the differences were and why. In an informal survey of hospitalist colleagues, I found that the majority do not receive any data on the costs associated with their care, and are largely unaware of the actual cost of the inpatient tests they commonly order. Developing a secure, user‐friendly database of individual physician spending patterns relative to national and local standards could be a preliminary step, and would likely require a unified effort between government agencies, professional societies, hospitals, and the insurance industry. However, once available, the increased transparency and clarity of spending variations would hopefully prompt introspection and change. In the absence of hard data, however, individual self‐assessment on spending patterns could also be offered through the development of an online simulated case‐based examination in which a physician could gain a general idea of how his evaluation and treatment of a case scenario compares to his hospitalist colleagues, and to what degree each of his clinical decisions affects the overall cost of care. There are many excellent quality improvement tools offered through SHM but none that specifically address the cost of care.

Second, hospitalists need quick access to current evidence‐based guidelines regarding the true clinical value, or cost‐effectiveness, of testing and treatment for common inpatient conditions, including specific admission criteria. A single source or clearinghouse of guidelines, sponsored by SHM, may be particularly helpful, especially if it focuses on clarifying areas of highest variability in inpatient spending. In addition, I believe that, given the critically important interface between emergency medicine and hospital medicine, joint guidelines between the 2 groups would potentially be very helpful in controlling costs by limiting unnecessary admissions. Advocacy for comparative effectiveness research to establish validity in these guidelines will be fundamental22, 23; however, I suspect the common sense question: Will this added cost improve my patient's outcome? also needs to be applied more generously, since many individual clinical scenarios will not likely lend themselves to formal study. For discussion, some sample case scenarios are presented (Table 3).

Third, hospitalists could potentially benefit from the development of patient education materials, available through SHM, that address the cost‐effectiveness of common inpatient tests and treatments with the goal of decreasing patient demand for unnecessary testing. Education regarding advanced directives and end‐of‐life care decision‐making could be particularly valuable in minimizing futile care, as it is well‐documented that transitioning to palliative care as soon as it is appropriate reduces healthcare spending greatly during the end‐of‐life period.2427 At the same time, we need to be careful to reassure our patients that we are not trying to ration care, but are instead minimizing the risks and costs for them associated with unnecessary care. In my experience, most patients, if given appropriate time, attention, and education, are willing to accept the final recommendation of their physician.

Fourth, intensified federal and state advocacy in several areas could help reduce spending. For example, advocacy for medical liability reform may reduce the atmosphere of defensive medicine, although I suspect that because old habits die hard, it may take a full generation of decreased liability risk to actually change practice patterns. Advocacy for the development of a national, or at least more uniform, electronic medical record, may decrease duplicate testing and improve efficiency. Advocacy for value‐based reimbursement models may help dampen costs resulting from a predominantly fee‐for‐service environment.28

Fifth, and perhaps most fundamental to the future of our specialty, encouraging the broad professional development of hospitalists as a true specialists in inpatient medicine (based on the SHM Core Competencies,)29 could help minimize the unnecessary costs associated with specialist‐oriented care.6 With the desire to create, in the near future, a formal board‐certification in hospital medicine comes an obligation to develop broad knowledge and broad skill sets that are truly unique to our profession, whereas deferring to a specialist‐oriented pattern of care actually shrinks us down to something less than a traditional internist, rather than a unique entity.30 With our 24/7 focus on inpatient care, we should easily be able to demonstrate our superiority in safety, quality, and efficiency, all of which are closely linked to increased value per healthcare dollar. If, however, our focus is blurred by an overly productivity‐based practice, in which patient volume and procedures take precedence, we will not be able to claim any special value to the system.

Last, supporting efforts to improve coordination of care and transitions of care could reduce costs associated with unnecessary readmissions or posthospital complications. A recent policy statement from several professional societies, including SHM, highlights the importance of these transitions,20, 31 and within the past year, SHM has launched the successful Project BOOST (Better Outcomes for Older adults through Safe Transitions) to help in this effort.32

Unfortunately, there is an inherent problem with all of the above proposals: the assumption that physicians actually want to reduce healthcare spending. Since everyone who works in the medical industry benefits financially in some way from the current high levels of spending on healthcare, reducing spending is counterintuitive for many, and the incentives to spend more will likely persist until some form of spending targets or limits are set.33 Moreover, since physicians traditionally do not like to be told how to practice medicine, history would predict that, without attractive incentives, nothing will change. This is the fundamental and unfortunate dilemma that has apparently pushed us to the eleventh hour of a healthcare crisis.

Another concern with an extreme atmosphere of cost cutting is the risk of swinging too far in the opposite direction, focusing so intently on cost that we begin to compromise quality or access to care in order to achieve spending targets. Reassuringly, however, the data suggest that there is plenty of room for us to cut costs without harming health outcomes.

Despite these obstacles, during this historic time in US healthcare, I believe hospitalists have a unique and perhaps transient opportunity to demonstrate their singular commitment to rational healthcare spending and by doing so to gain significant influence in shaping the impending healthcare reforms. If we speak and act with one voice, with transparency, and with the proper data, we could be the first and only professional society to not only demonstrate our current pattern of spending, but also our potential for reducing spending and our plan on how to get there.

Let's think about what we need to do ourselves. We have to acknowledge that orders we write drive up health care costs.1 AMA President, Nancy H. Nielsen, MD, PhD

As the most prominent providers of inpatient care, hospitalists should be aware that, of the total annual expenditures on US healthcare ($2.3 trillion in 2007),2 approximately one‐third goes to hospital‐based medical care, over one‐half of which (57%) is covered by public funds through Medicare and Medicaid3; this high cost of healthcare is increasingly being blamed for unnecessarily burdening our economy and preventing our industries from being globally competitive. I believe that the high proportion of spending on inpatient care places hospitalists firmly in the center of the debate on how to reduce healthcare costs. It is well known that the United States spends about twice as much per capita as other industrialized countries on healthcare,4 without evidence of superior health outcomes.5 However, it is also known that remarkable local and regional variations in healthcare spending also exist within the US, again, without evidence of superior health outcomes in the higher‐spending regions.6 Both of these observations suggest that we are spending many healthcare dollars on things that evidently do not improve the health of our patients. How much of this waste is administrative, operational, or clinical is debatable and remains the focus of growing national healthcare reform efforts.711 However, from the hospitalist perspective, we should be especially wary of providing so‐called flat‐of‐the‐curve medicine, that is, a level of intensity of care that provides no incremental health benefit.12 The purpose of this editorial is to challenge hospitalists to collectively examine how much of our inpatient spending is potentially unnecessary, and how we, as specialists in inpatient medicine, can assume a critical role in controlling healthcare costs.

To illustrate the issue, consider the following clinical scenario, managed in different ways by different hospitalists, with approximate costs itemized in Table 1. The patient is an elderly woman who presents to the emergency room with syncope occurring at church. The first hospitalist takes time to gather history from the patient, family, eyewitnesses, and the primary care physician, and requests a medication list and outside medical records, which reveal several recent and relevant cardiac and imaging studies. He performs a careful examination, discovers orthostatic hypotension, and his final diagnosis is syncope related to volume depletion from a recently added diuretic as well as a mild gastroenteritis. The patient is rehydrated and discharged home from the emergency room in the care of her family, and asked to hold her diuretic until seen by her family physician in 1 or 2 days. The second hospitalist receives the call from the emergency room and tells the staff to get the patient a telemetry bed. He sees the patient 2 hours later when she gets to the floor. The family has gone home and the mildly demented patient does not recall much of the event or her past medical history. The busy hospitalist constructs a broad differential diagnosis and writes some quick orders to evaluate the patient for possible stroke, seizure, pulmonary embolism, and cardiac ischemia or arrhythmia. He also asks cardiology and neurology to give an opinion. The testing is normal, and the patient is discharged with a cardiac event monitor and an outpatient tilt‐table test scheduled.

Although the above scenarios purposely demonstrate 2 extremes of care, I suspect most readers would agree that each hospitalist has his or her own style of practice, and that these differences in style inevitably result in significant differences in the total cost of healthcare delivered. This variation in spending among individual physicians is perhaps more easily understood than the striking variations in healthcare spending seen when different states, regions, and hospitals are compared. For example, annual Medicare spending per beneficiary has varied widely from state to state, from $5436 in Iowa to $7995 in New York (in 2004), a 47% difference.13 Specific analysis of inpatient spending variations is presented in the Dartmouth Atlas of Health Care 2008, which reports healthcare spending in the last 2 years of life for patients with at least 1 chronic illness.14 While the average Medicare inpatient spending per capita for these patients was about $25,000, the state‐specific spending varied widely from $37,040 in New Jersey to $17,135 in Idaho. There was also significant variation in spending within individual states (ie, New York: Binghamton, $18,339; Manhattan, $57,000) and between similar types of hospitals (UCLA Medical Center, $63,900; Massachusetts General Hospital, $43,058). Yet there is no evidence that higher‐spending regions produce better health outcomes.6 Interestingly, the observed differences in spending within the US were primarily due to the volume and intensity of care, not the price of care, as has been seen in some comparisons of the US with other industrialized countries.8, 15 In overall Medicare expenditures, higher‐spending locations tended to have a more inpatient‐based and specialist‐oriented pattern of practice, with higher utilization of inpatient consultations, diagnostic testing, and minor procedures.6

Although the wide variation in spending observed is a bit baffling, the encouraging aspect of this data is that some places are apparently doing it right; that is, providing their patients with a much higher value per healthcare dollar. Ultimately, if the higher‐spending locations modeled the lower‐spending locations, we would have the potential to reduce overall healthcare costs by as much as 30% without harming health.9

What are the possible reasons that we are providing unnecessary care? There are both environment‐dependent and physician‐dependent reasons, which I will outline here. The first 3 reasons represent areas that would seem to require system‐wide change, whereas the remaining 7 reasons are perhaps more amenable to local and/or national hospitalist‐directed efforts.

• 1

  Working in a litigious environment promotes unnecessary testing and consultations with the intent of reducing our exposure to malpractice liability, so‐called defensive medicine.16

• 2

  A reimbursement system that is primarily fee‐for‐service encourages physicians to provide more care and involve more physicians in the care of each patient, with little or no incentive to spend less, a core problem that was recently highlighted in a public Society of Hospital Management (SHM) statement.17

• 3

  The lack of integrated medical record systems promotes waste by leading to duplicate testing, simply because we cannot easily obtain old records to confirm whether tests were previously done. Interestingly, data from the Commonwealth Fund conclude that US physicians order duplicate diagnostic tests (a test repeated within 2 years) at more than twice the rate of Canada and the United Kingdom, while the nation with the lowest rate of duplicate testing, The Netherlands, has the highest rate of electronic medical record use (98%).18

• 4

  Working with patients (or families) with high expectations who insist upon aggressive testing, treatment, and referral to specialists inflates spending, especially if associated with futile and expensive end‐of‐life care.

• 5

  The involvement of one or more specialists may subsequently lead to even more aggressive care ordered by each specialist.

• 6

  The availability and promotion of new technology (diagnostic testing, medical devices, etc.) may prompt us to make use of it simply because it is there, with or without evidence of a health benefit. Our natural curiosity or fascination with information, or our desire to do an overly complete evaluation, works against cost containment.

• 7

  Local trends or traditions within our specific work environment, as suggested by the variability data, may have a strong influence on our individual practice. In such a setting, inadequate knowledge of the cost‐effectiveness of various tests and treatment options likely leads to unnecessary health care spending.

• 8

  A hospitalist work environment in which a high patient load is carried will inevitably result in less time to gather a detailed history and obtain old records or other information that could help narrow a differential diagnosis and minimize unnecessary or duplicate testing.

• 9

  Preventable readmissions resulting from inadequate coordination of care add cost,19 a phenomenon highly dependent on efficient information systems and proper physician‐physician communication.20

• 10

  An overestimation of the need for inpatient evaluation and treatment (vs. outpatient) leads to unnecessary admissions and a longer average length‐of‐stay, each of which add dramatically to total healthcare costs. This is not only dependent on our individual threshold for admitting and discharging patients, but also on our efficiency in diagnosing and treating acute conditions. The fact that the average length‐of‐stay for congestive heart failure admissions, for example, ranges in different regions from 4.9 to 6.1 days (with costs of $9143 and $12,528, respectively)21 is enough to show that there is room for progress.

What joint efforts could be made to minimize unnecessary inpatient spending? The following are my personal opinions and suggestions (Table 2). Most importantly, I believe every physician deserves prompt and accurate feedback regarding their spending patterns, accompanied by valid comparisons to national and local standards, to demonstrate where they stand on the spectrum of healthcare spending. We are currently far behind other industries in our ability, as physicians, to evaluate what we are spending money on, how much, and why. If I knew, for example, that my spending was in the 95th percentile of all hospitalists in community hospitals similar to mine, I would be prompted to investigate where the differences were and why. In an informal survey of hospitalist colleagues, I found that the majority do not receive any data on the costs associated with their care, and are largely unaware of the actual cost of the inpatient tests they commonly order. Developing a secure, user‐friendly database of individual physician spending patterns relative to national and local standards could be a preliminary step, and would likely require a unified effort between government agencies, professional societies, hospitals, and the insurance industry. However, once available, the increased transparency and clarity of spending variations would hopefully prompt introspection and change. In the absence of hard data, however, individual self‐assessment on spending patterns could also be offered through the development of an online simulated case‐based examination in which a physician could gain a general idea of how his evaluation and treatment of a case scenario compares to his hospitalist colleagues, and to what degree each of his clinical decisions affects the overall cost of care. There are many excellent quality improvement tools offered through SHM but none that specifically address the cost of care.

Second, hospitalists need quick access to current evidence‐based guidelines regarding the true clinical value, or cost‐effectiveness, of testing and treatment for common inpatient conditions, including specific admission criteria. A single source or clearinghouse of guidelines, sponsored by SHM, may be particularly helpful, especially if it focuses on clarifying areas of highest variability in inpatient spending. In addition, I believe that, given the critically important interface between emergency medicine and hospital medicine, joint guidelines between the 2 groups would potentially be very helpful in controlling costs by limiting unnecessary admissions. Advocacy for comparative effectiveness research to establish validity in these guidelines will be fundamental22, 23; however, I suspect the common sense question: Will this added cost improve my patient's outcome? also needs to be applied more generously, since many individual clinical scenarios will not likely lend themselves to formal study. For discussion, some sample case scenarios are presented (Table 3).

Third, hospitalists could potentially benefit from the development of patient education materials, available through SHM, that address the cost‐effectiveness of common inpatient tests and treatments with the goal of decreasing patient demand for unnecessary testing. Education regarding advanced directives and end‐of‐life care decision‐making could be particularly valuable in minimizing futile care, as it is well‐documented that transitioning to palliative care as soon as it is appropriate reduces healthcare spending greatly during the end‐of‐life period.2427 At the same time, we need to be careful to reassure our patients that we are not trying to ration care, but are instead minimizing the risks and costs for them associated with unnecessary care. In my experience, most patients, if given appropriate time, attention, and education, are willing to accept the final recommendation of their physician.

Fourth, intensified federal and state advocacy in several areas could help reduce spending. For example, advocacy for medical liability reform may reduce the atmosphere of defensive medicine, although I suspect that because old habits die hard, it may take a full generation of decreased liability risk to actually change practice patterns. Advocacy for the development of a national, or at least more uniform, electronic medical record, may decrease duplicate testing and improve efficiency. Advocacy for value‐based reimbursement models may help dampen costs resulting from a predominantly fee‐for‐service environment.28

Fifth, and perhaps most fundamental to the future of our specialty, encouraging the broad professional development of hospitalists as a true specialists in inpatient medicine (based on the SHM Core Competencies,)29 could help minimize the unnecessary costs associated with specialist‐oriented care.6 With the desire to create, in the near future, a formal board‐certification in hospital medicine comes an obligation to develop broad knowledge and broad skill sets that are truly unique to our profession, whereas deferring to a specialist‐oriented pattern of care actually shrinks us down to something less than a traditional internist, rather than a unique entity.30 With our 24/7 focus on inpatient care, we should easily be able to demonstrate our superiority in safety, quality, and efficiency, all of which are closely linked to increased value per healthcare dollar. If, however, our focus is blurred by an overly productivity‐based practice, in which patient volume and procedures take precedence, we will not be able to claim any special value to the system.

Last, supporting efforts to improve coordination of care and transitions of care could reduce costs associated with unnecessary readmissions or posthospital complications. A recent policy statement from several professional societies, including SHM, highlights the importance of these transitions,20, 31 and within the past year, SHM has launched the successful Project BOOST (Better Outcomes for Older adults through Safe Transitions) to help in this effort.32

Unfortunately, there is an inherent problem with all of the above proposals: the assumption that physicians actually want to reduce healthcare spending. Since everyone who works in the medical industry benefits financially in some way from the current high levels of spending on healthcare, reducing spending is counterintuitive for many, and the incentives to spend more will likely persist until some form of spending targets or limits are set.33 Moreover, since physicians traditionally do not like to be told how to practice medicine, history would predict that, without attractive incentives, nothing will change. This is the fundamental and unfortunate dilemma that has apparently pushed us to the eleventh hour of a healthcare crisis.

Another concern with an extreme atmosphere of cost cutting is the risk of swinging too far in the opposite direction, focusing so intently on cost that we begin to compromise quality or access to care in order to achieve spending targets. Reassuringly, however, the data suggest that there is plenty of room for us to cut costs without harming health outcomes.

Despite these obstacles, during this historic time in US healthcare, I believe hospitalists have a unique and perhaps transient opportunity to demonstrate their singular commitment to rational healthcare spending and by doing so to gain significant influence in shaping the impending healthcare reforms. If we speak and act with one voice, with transparency, and with the proper data, we could be the first and only professional society to not only demonstrate our current pattern of spending, but also our potential for reducing spending and our plan on how to get there.

As a hospitalist of about 6 years, I enjoy hospital medicine and hope, over the course of my career, to see it develop into an increasingly respected, diverse, and influential specialty. There is abundant evidence that this is occurring, primarily through the praiseworthy efforts of the leadership and members of the Society of Hospital Medicine (SHM). Efforts to prove our value to inpatient care and align ourselves with quality improvement, as promoted early in the hospitalist movement,2 are coming to fruition. However, I would like to raise a flag of concern; and this is based on my experience working as a hospitalist in 10 community hospitals in 5 states, including positions as a locum tenens hospitalist, staff hospitalist, medical director of a hospitalist group, and full‐time teaching hospitalist for a community hospital residency program. I believe that hospitalists, particularly those working in community hospitals (approximately 80% of all hospitalists),3 are currently at a critical crossroad, with the option of either actively expanding their clinical, administrative, and quality improvement roles or allowing these roles to stagnate or atrophy. As in any career, we are, like Alice, perched on a mushroom, one side of which will make us grow taller and the other side of which will make us grow shorter. Which side are we choosing in our careers as hospitalists?

Hospitalists currently have numerous opportunities to expand their clinical, administrative, and quality improvement roles and responsibilities (Table 1), and these opportunities are in full alignment with the mission statement of SHM: to promote the highest quality of care for all hospitalized patients.4 My concern is that, for one reason or another, hospitalists in some settings are shrinking away from roles that they could or should fill, and this is a trend that I believe could affect our specialty adversely over time and that we, as an organization, should find ways to prevent. Although family medicine and traditional internal medicine physicians who work in the hospital face similar challenges, if we as hospitalists wish to qualify one day as board‐certified hospital medicine specialists, we are obligated to develop knowledge and skill sets that are truly unique to our profession.5 Holding to this goal, we cannot settle into a narrow comfort zone. I believe that the development of the hospital medicine core competencies by SHM6 was an important step in helping us define our intended reach, but even so, what are the specific growth factors or inhibitors that are influencing the expansion or shrinking of hospitalists and hospital medicine groups?

On the basis of my observations, I believe that this problem is due in large part to a misalignment of incentives. Specifically, I believe that the expansion of hospitalist roles and responsibilities is often counteraligned with the bottom‐line productivity goals of the group. That is, to maintain high productivity, a hospitalist has a tendency to minimize his or her role in ways that save time. For example, there may be a tendency to overuse subspecialty consultations, which can take away some of the burden of complex clinical decision making, or to quickly transfer patients that are sicker and require more time to a higher level of care (if available). There may also be a tendency to avoid performing inpatient procedures (a significant part of the core competencies) because of time constraints and the demands of a higher census. Excessively rapid rounding results, and this diminishes other claimed benefits of the hospitalist model of care: patient satisfaction, safety, quality, and communication. Length‐of‐stay measures also suffer as productivity exceeds the limits of efficient care. Moreover, in such a productivity‐based environment, there is certainly no incentive for hospitalists to become enthusiastically involved in hospital committees, education, or quality improvement efforts, all of which are critical to the development of hospital medicine as a unique subspecialty. In essence, the incentive to expand one's role as a hospitalist in such a setting is almost completely absent, and I believe that this puts the future influence and reach of our specialty at significant risk.

Particularly as hospitals face increasing scrutiny about their quality and safety, and especially as the costs of hospital care increase and reimbursements threaten to decline, the value of hospitalists to the hospital has become different from that of all other physicians. Their value lies not in sheer productivity but in their ability to improve the cost, quality, efficiency, and safety of inpatient care simultaneously. If hospitalists settle into or are forced into a lesser role, hospital medicine will not be worthy of consideration as a unique subspecialty. Some of the remaining roles of the shrunken hospitalist may, at some point and in some settings, shift to nonphysicians,7 with a decline in the ratio of physicians to mid‐level providers in hospital medicine programs, and the jobs of some hospitalists will be effectively eliminated. Market forces will lead to improved training of mid‐level providers, allowing hospitals to fill inpatient care needs in a more cost‐effective way.

Having worked with some very capable nurse practitioners in 4 different community hospitals, I believe that a well‐trained mid‐level provider, with appropriate physician backup, can effectively manage many of the typical general medical admissions and surgical consultations seen in a community hospital setting. I admit that this may not be the case in larger referral centers or academic medical centers.

In developing and defining this new specialty and also in training new physicians for the field, we do not want to lose this transient opportunity to define ourselves as broadly as possible, pushing beyond traditional internal medicine to new areas of inpatient care and management and managing more complex conditions than a traditional primary care physician would typically manage, conditions that have always fallen within the broad spectrum of inpatient internal medicine (Table 2). If we instead develop a tendency to admit, consult, and walk away and do not have the time or appropriate incentives to expand our roles in other important ways (noted in Table 1) because of a focus on productivity, what is our specialty destined to become?

That said, how can incentives be restructured to encourage hospitalists to expand their universe? Perhaps the simplest way of influencing the incentive structure of hospital medicine programs is more selectivity in the choice of jobs: seeking out jobs that offer us clear incentives (typically financial) to expand our universe by rewarding efforts to improve the quality, safety, and efficiency of inpatient care. According to the SHM 20052006 survey, about two‐thirds of responding hospital medicine programs reimbursed their physicians with a mix of salary and productivity/performance bonuses, with productivity being the dominant incentive (more than 80%). However, bonuses based on quality/efficiency measures were also being rewarded (about 60%), as well as bonuses for committee or project work (about 25%). Of all responding groups, that leaves about 60% of programs with no financial incentives for quality/efficiency measures. There is certainly room for progress in this area, and we can influence the process positively by requesting that such incentives be added to our contract before making a final commitment to a job or by negotiating changes to our current incentive structure at the time of contract renewal. This would be in the best interest of our individual careers as well as our specialty.

As we consider different job opportunities, we may also wish to consider the possible effect of the employment model on the incentive structure. Although it may seem logical that hospital‐employed groups would have broader goals than independent groups and thus might be more motivated to provide proper incentives, I do not believe that this is the case universally. Conversely, private groups who might be expected to focus more on productivity measures may actually offer excellent growth‐promoting incentives. In either case, careful consideration of the incentive structure is warranted when we choose to work in a given employment model.

Perhaps another way of encouraging hospitalists to expand their role would be through a program of national recognition, potentially established by SHM, that would allow individual hospitalists to formally claim specialization in a particular area of hospital medicine and benefit from such distinctions. For example, a hospitalist that was particularly proficient with inpatient procedures could submit documentation of procedures completed in a given time period and subsequently receive a formal designation as a certified procedural hospitalist or something similar. Alternatively, a hospitalist who preferred to focus on quality improvement efforts could submit information regarding his involvement with quality improvement initiatives and results and, on the basis of defined criteria, receive a formal designation as a quality improvement hospitalist. This approach could apply to any area of focus, and more than one designation could be achieved by each hospitalist. As the specialty of hospital medicine matures, these designations (similar to academic rank) could eventually correlate with salary ranges or incentive bonuses as hospitals learned to value the diverse skills of individual hospitalists.

Discouraging overconsultation of subspecialists while concurrently encouraging the broadening of our clinical skills is particularly difficult to address. The only solution to this issue that I can imagine would be to somehow align physician reimbursement more closely to the actual complexity of and time spent in managing patients with multiple comorbidities. Currently, the actual hospitalist physician reimbursement for subsequent visits of patients, with or without subspecialists involved, likely does not vary much. However, if hospitalists knew their extra effort in managing more complex conditions would be reimbursed differently (ie, billing for critical care time), they would certainly tend to broaden their practice to the benefit of their careers and the future of the specialty.

In summary, I believe that misaligned incentives are causing some hospitalists to underestimate their potential; this has the potential to adversely affect the future of the specialty of hospital medicine. I hope that this opinion will serve to generate discussion on the potential origins of and solutions to this problem and ultimately promote the future expansion of our hospital medicine universe, so that we do not find ourselves in Alice's predicament:

As a hospitalist of about 6 years, I enjoy hospital medicine and hope, over the course of my career, to see it develop into an increasingly respected, diverse, and influential specialty. There is abundant evidence that this is occurring, primarily through the praiseworthy efforts of the leadership and members of the Society of Hospital Medicine (SHM). Efforts to prove our value to inpatient care and align ourselves with quality improvement, as promoted early in the hospitalist movement,2 are coming to fruition. However, I would like to raise a flag of concern; and this is based on my experience working as a hospitalist in 10 community hospitals in 5 states, including positions as a locum tenens hospitalist, staff hospitalist, medical director of a hospitalist group, and full‐time teaching hospitalist for a community hospital residency program. I believe that hospitalists, particularly those working in community hospitals (approximately 80% of all hospitalists),3 are currently at a critical crossroad, with the option of either actively expanding their clinical, administrative, and quality improvement roles or allowing these roles to stagnate or atrophy. As in any career, we are, like Alice, perched on a mushroom, one side of which will make us grow taller and the other side of which will make us grow shorter. Which side are we choosing in our careers as hospitalists?

Hospitalists currently have numerous opportunities to expand their clinical, administrative, and quality improvement roles and responsibilities (Table 1), and these opportunities are in full alignment with the mission statement of SHM: to promote the highest quality of care for all hospitalized patients.4 My concern is that, for one reason or another, hospitalists in some settings are shrinking away from roles that they could or should fill, and this is a trend that I believe could affect our specialty adversely over time and that we, as an organization, should find ways to prevent. Although family medicine and traditional internal medicine physicians who work in the hospital face similar challenges, if we as hospitalists wish to qualify one day as board‐certified hospital medicine specialists, we are obligated to develop knowledge and skill sets that are truly unique to our profession.5 Holding to this goal, we cannot settle into a narrow comfort zone. I believe that the development of the hospital medicine core competencies by SHM6 was an important step in helping us define our intended reach, but even so, what are the specific growth factors or inhibitors that are influencing the expansion or shrinking of hospitalists and hospital medicine groups?

On the basis of my observations, I believe that this problem is due in large part to a misalignment of incentives. Specifically, I believe that the expansion of hospitalist roles and responsibilities is often counteraligned with the bottom‐line productivity goals of the group. That is, to maintain high productivity, a hospitalist has a tendency to minimize his or her role in ways that save time. For example, there may be a tendency to overuse subspecialty consultations, which can take away some of the burden of complex clinical decision making, or to quickly transfer patients that are sicker and require more time to a higher level of care (if available). There may also be a tendency to avoid performing inpatient procedures (a significant part of the core competencies) because of time constraints and the demands of a higher census. Excessively rapid rounding results, and this diminishes other claimed benefits of the hospitalist model of care: patient satisfaction, safety, quality, and communication. Length‐of‐stay measures also suffer as productivity exceeds the limits of efficient care. Moreover, in such a productivity‐based environment, there is certainly no incentive for hospitalists to become enthusiastically involved in hospital committees, education, or quality improvement efforts, all of which are critical to the development of hospital medicine as a unique subspecialty. In essence, the incentive to expand one's role as a hospitalist in such a setting is almost completely absent, and I believe that this puts the future influence and reach of our specialty at significant risk.

Particularly as hospitals face increasing scrutiny about their quality and safety, and especially as the costs of hospital care increase and reimbursements threaten to decline, the value of hospitalists to the hospital has become different from that of all other physicians. Their value lies not in sheer productivity but in their ability to improve the cost, quality, efficiency, and safety of inpatient care simultaneously. If hospitalists settle into or are forced into a lesser role, hospital medicine will not be worthy of consideration as a unique subspecialty. Some of the remaining roles of the shrunken hospitalist may, at some point and in some settings, shift to nonphysicians,7 with a decline in the ratio of physicians to mid‐level providers in hospital medicine programs, and the jobs of some hospitalists will be effectively eliminated. Market forces will lead to improved training of mid‐level providers, allowing hospitals to fill inpatient care needs in a more cost‐effective way.

Having worked with some very capable nurse practitioners in 4 different community hospitals, I believe that a well‐trained mid‐level provider, with appropriate physician backup, can effectively manage many of the typical general medical admissions and surgical consultations seen in a community hospital setting. I admit that this may not be the case in larger referral centers or academic medical centers.

In developing and defining this new specialty and also in training new physicians for the field, we do not want to lose this transient opportunity to define ourselves as broadly as possible, pushing beyond traditional internal medicine to new areas of inpatient care and management and managing more complex conditions than a traditional primary care physician would typically manage, conditions that have always fallen within the broad spectrum of inpatient internal medicine (Table 2). If we instead develop a tendency to admit, consult, and walk away and do not have the time or appropriate incentives to expand our roles in other important ways (noted in Table 1) because of a focus on productivity, what is our specialty destined to become?

That said, how can incentives be restructured to encourage hospitalists to expand their universe? Perhaps the simplest way of influencing the incentive structure of hospital medicine programs is more selectivity in the choice of jobs: seeking out jobs that offer us clear incentives (typically financial) to expand our universe by rewarding efforts to improve the quality, safety, and efficiency of inpatient care. According to the SHM 20052006 survey, about two‐thirds of responding hospital medicine programs reimbursed their physicians with a mix of salary and productivity/performance bonuses, with productivity being the dominant incentive (more than 80%). However, bonuses based on quality/efficiency measures were also being rewarded (about 60%), as well as bonuses for committee or project work (about 25%). Of all responding groups, that leaves about 60% of programs with no financial incentives for quality/efficiency measures. There is certainly room for progress in this area, and we can influence the process positively by requesting that such incentives be added to our contract before making a final commitment to a job or by negotiating changes to our current incentive structure at the time of contract renewal. This would be in the best interest of our individual careers as well as our specialty.

As we consider different job opportunities, we may also wish to consider the possible effect of the employment model on the incentive structure. Although it may seem logical that hospital‐employed groups would have broader goals than independent groups and thus might be more motivated to provide proper incentives, I do not believe that this is the case universally. Conversely, private groups who might be expected to focus more on productivity measures may actually offer excellent growth‐promoting incentives. In either case, careful consideration of the incentive structure is warranted when we choose to work in a given employment model.

Perhaps another way of encouraging hospitalists to expand their role would be through a program of national recognition, potentially established by SHM, that would allow individual hospitalists to formally claim specialization in a particular area of hospital medicine and benefit from such distinctions. For example, a hospitalist that was particularly proficient with inpatient procedures could submit documentation of procedures completed in a given time period and subsequently receive a formal designation as a certified procedural hospitalist or something similar. Alternatively, a hospitalist who preferred to focus on quality improvement efforts could submit information regarding his involvement with quality improvement initiatives and results and, on the basis of defined criteria, receive a formal designation as a quality improvement hospitalist. This approach could apply to any area of focus, and more than one designation could be achieved by each hospitalist. As the specialty of hospital medicine matures, these designations (similar to academic rank) could eventually correlate with salary ranges or incentive bonuses as hospitals learned to value the diverse skills of individual hospitalists.

Discouraging overconsultation of subspecialists while concurrently encouraging the broadening of our clinical skills is particularly difficult to address. The only solution to this issue that I can imagine would be to somehow align physician reimbursement more closely to the actual complexity of and time spent in managing patients with multiple comorbidities. Currently, the actual hospitalist physician reimbursement for subsequent visits of patients, with or without subspecialists involved, likely does not vary much. However, if hospitalists knew their extra effort in managing more complex conditions would be reimbursed differently (ie, billing for critical care time), they would certainly tend to broaden their practice to the benefit of their careers and the future of the specialty.

In summary, I believe that misaligned incentives are causing some hospitalists to underestimate their potential; this has the potential to adversely affect the future of the specialty of hospital medicine. I hope that this opinion will serve to generate discussion on the potential origins of and solutions to this problem and ultimately promote the future expansion of our hospital medicine universe, so that we do not find ourselves in Alice's predicament:

As a hospitalist of about 6 years, I enjoy hospital medicine and hope, over the course of my career, to see it develop into an increasingly respected, diverse, and influential specialty. There is abundant evidence that this is occurring, primarily through the praiseworthy efforts of the leadership and members of the Society of Hospital Medicine (SHM). Efforts to prove our value to inpatient care and align ourselves with quality improvement, as promoted early in the hospitalist movement,2 are coming to fruition. However, I would like to raise a flag of concern; and this is based on my experience working as a hospitalist in 10 community hospitals in 5 states, including positions as a locum tenens hospitalist, staff hospitalist, medical director of a hospitalist group, and full‐time teaching hospitalist for a community hospital residency program. I believe that hospitalists, particularly those working in community hospitals (approximately 80% of all hospitalists),3 are currently at a critical crossroad, with the option of either actively expanding their clinical, administrative, and quality improvement roles or allowing these roles to stagnate or atrophy. As in any career, we are, like Alice, perched on a mushroom, one side of which will make us grow taller and the other side of which will make us grow shorter. Which side are we choosing in our careers as hospitalists?

Hospitalists currently have numerous opportunities to expand their clinical, administrative, and quality improvement roles and responsibilities (Table 1), and these opportunities are in full alignment with the mission statement of SHM: to promote the highest quality of care for all hospitalized patients.4 My concern is that, for one reason or another, hospitalists in some settings are shrinking away from roles that they could or should fill, and this is a trend that I believe could affect our specialty adversely over time and that we, as an organization, should find ways to prevent. Although family medicine and traditional internal medicine physicians who work in the hospital face similar challenges, if we as hospitalists wish to qualify one day as board‐certified hospital medicine specialists, we are obligated to develop knowledge and skill sets that are truly unique to our profession.5 Holding to this goal, we cannot settle into a narrow comfort zone. I believe that the development of the hospital medicine core competencies by SHM6 was an important step in helping us define our intended reach, but even so, what are the specific growth factors or inhibitors that are influencing the expansion or shrinking of hospitalists and hospital medicine groups?

On the basis of my observations, I believe that this problem is due in large part to a misalignment of incentives. Specifically, I believe that the expansion of hospitalist roles and responsibilities is often counteraligned with the bottom‐line productivity goals of the group. That is, to maintain high productivity, a hospitalist has a tendency to minimize his or her role in ways that save time. For example, there may be a tendency to overuse subspecialty consultations, which can take away some of the burden of complex clinical decision making, or to quickly transfer patients that are sicker and require more time to a higher level of care (if available). There may also be a tendency to avoid performing inpatient procedures (a significant part of the core competencies) because of time constraints and the demands of a higher census. Excessively rapid rounding results, and this diminishes other claimed benefits of the hospitalist model of care: patient satisfaction, safety, quality, and communication. Length‐of‐stay measures also suffer as productivity exceeds the limits of efficient care. Moreover, in such a productivity‐based environment, there is certainly no incentive for hospitalists to become enthusiastically involved in hospital committees, education, or quality improvement efforts, all of which are critical to the development of hospital medicine as a unique subspecialty. In essence, the incentive to expand one's role as a hospitalist in such a setting is almost completely absent, and I believe that this puts the future influence and reach of our specialty at significant risk.

Particularly as hospitals face increasing scrutiny about their quality and safety, and especially as the costs of hospital care increase and reimbursements threaten to decline, the value of hospitalists to the hospital has become different from that of all other physicians. Their value lies not in sheer productivity but in their ability to improve the cost, quality, efficiency, and safety of inpatient care simultaneously. If hospitalists settle into or are forced into a lesser role, hospital medicine will not be worthy of consideration as a unique subspecialty. Some of the remaining roles of the shrunken hospitalist may, at some point and in some settings, shift to nonphysicians,7 with a decline in the ratio of physicians to mid‐level providers in hospital medicine programs, and the jobs of some hospitalists will be effectively eliminated. Market forces will lead to improved training of mid‐level providers, allowing hospitals to fill inpatient care needs in a more cost‐effective way.

Having worked with some very capable nurse practitioners in 4 different community hospitals, I believe that a well‐trained mid‐level provider, with appropriate physician backup, can effectively manage many of the typical general medical admissions and surgical consultations seen in a community hospital setting. I admit that this may not be the case in larger referral centers or academic medical centers.

In developing and defining this new specialty and also in training new physicians for the field, we do not want to lose this transient opportunity to define ourselves as broadly as possible, pushing beyond traditional internal medicine to new areas of inpatient care and management and managing more complex conditions than a traditional primary care physician would typically manage, conditions that have always fallen within the broad spectrum of inpatient internal medicine (Table 2). If we instead develop a tendency to admit, consult, and walk away and do not have the time or appropriate incentives to expand our roles in other important ways (noted in Table 1) because of a focus on productivity, what is our specialty destined to become?

That said, how can incentives be restructured to encourage hospitalists to expand their universe? Perhaps the simplest way of influencing the incentive structure of hospital medicine programs is more selectivity in the choice of jobs: seeking out jobs that offer us clear incentives (typically financial) to expand our universe by rewarding efforts to improve the quality, safety, and efficiency of inpatient care. According to the SHM 20052006 survey, about two‐thirds of responding hospital medicine programs reimbursed their physicians with a mix of salary and productivity/performance bonuses, with productivity being the dominant incentive (more than 80%). However, bonuses based on quality/efficiency measures were also being rewarded (about 60%), as well as bonuses for committee or project work (about 25%). Of all responding groups, that leaves about 60% of programs with no financial incentives for quality/efficiency measures. There is certainly room for progress in this area, and we can influence the process positively by requesting that such incentives be added to our contract before making a final commitment to a job or by negotiating changes to our current incentive structure at the time of contract renewal. This would be in the best interest of our individual careers as well as our specialty.

As we consider different job opportunities, we may also wish to consider the possible effect of the employment model on the incentive structure. Although it may seem logical that hospital‐employed groups would have broader goals than independent groups and thus might be more motivated to provide proper incentives, I do not believe that this is the case universally. Conversely, private groups who might be expected to focus more on productivity measures may actually offer excellent growth‐promoting incentives. In either case, careful consideration of the incentive structure is warranted when we choose to work in a given employment model.

Perhaps another way of encouraging hospitalists to expand their role would be through a program of national recognition, potentially established by SHM, that would allow individual hospitalists to formally claim specialization in a particular area of hospital medicine and benefit from such distinctions. For example, a hospitalist that was particularly proficient with inpatient procedures could submit documentation of procedures completed in a given time period and subsequently receive a formal designation as a certified procedural hospitalist or something similar. Alternatively, a hospitalist who preferred to focus on quality improvement efforts could submit information regarding his involvement with quality improvement initiatives and results and, on the basis of defined criteria, receive a formal designation as a quality improvement hospitalist. This approach could apply to any area of focus, and more than one designation could be achieved by each hospitalist. As the specialty of hospital medicine matures, these designations (similar to academic rank) could eventually correlate with salary ranges or incentive bonuses as hospitals learned to value the diverse skills of individual hospitalists.

Discouraging overconsultation of subspecialists while concurrently encouraging the broadening of our clinical skills is particularly difficult to address. The only solution to this issue that I can imagine would be to somehow align physician reimbursement more closely to the actual complexity of and time spent in managing patients with multiple comorbidities. Currently, the actual hospitalist physician reimbursement for subsequent visits of patients, with or without subspecialists involved, likely does not vary much. However, if hospitalists knew their extra effort in managing more complex conditions would be reimbursed differently (ie, billing for critical care time), they would certainly tend to broaden their practice to the benefit of their careers and the future of the specialty.

In summary, I believe that misaligned incentives are causing some hospitalists to underestimate their potential; this has the potential to adversely affect the future of the specialty of hospital medicine. I hope that this opinion will serve to generate discussion on the potential origins of and solutions to this problem and ultimately promote the future expansion of our hospital medicine universe, so that we do not find ourselves in Alice's predicament: