Pair of CXCR4 molecules
Credit: Raymond Stevens
Scripps Research Institute

A team of researchers has uncovered the structure of a cell surface receptor, CXCR4, which guides blood and immune cell movement throughout the body.

CXCR4 is also found on the surface of the human immunodeficiency virus (HIV), and helps the virus to enter blood cells.

The receptor is part of a group of about 700 proteins known as G protein-coupled receptors (GPCRs).

The team, led by Raymond C. Stevens, PhD, of Scripps Research Institute in La Jolla, California, and senior author of the study, already found the structures of two other GPCRs: the adrenergic receptor and A2A adenosine receptor.

CXCR4 belongs to a different group of GPCRs, one that binds to protein molecules called chemokines, responsible for steering blood and immune cells where they are needed.

The team used GPCR biochemistry, receptor stabilization, and X-ray crystallography to capture the first visual of a chemokine receptor bound to a ligand.

Unlike the adrenergic receptor and the A2A adenosine receptor, CXCR4 likes to form dimers.

“The dimerization observation was very intriguing,” said Dr Stevens. “We solved 5 different crystal structures in multiple crystal forms, and each one had the same dimer interface. It has long been debated how GPCRs might dimerize, if they did at all. This is the first solid observation about a consistent structural GPCR dimer.”

The team believes preventing dimerization might provide a new way to block CXCR4, which results in the release of hematopoietic stem cells from bone marrow into the bloodstream.

Currently, plerixafor injection is the only drug on the market that blocks CXCR4. Therapy that assists in the release of hematopoietic stem cells to the bloodstream is very useful following stem cell transplant.

Drugs that block CXCR4 are also useful in treating HIV infection.

Their findings were published in the October 7 issue of Science.

Pair of CXCR4 molecules
Credit: Raymond Stevens
Scripps Research Institute

A team of researchers has uncovered the structure of a cell surface receptor, CXCR4, which guides blood and immune cell movement throughout the body.

CXCR4 is also found on the surface of the human immunodeficiency virus (HIV), and helps the virus to enter blood cells.

The receptor is part of a group of about 700 proteins known as G protein-coupled receptors (GPCRs).

The team, led by Raymond C. Stevens, PhD, of Scripps Research Institute in La Jolla, California, and senior author of the study, already found the structures of two other GPCRs: the adrenergic receptor and A2A adenosine receptor.

CXCR4 belongs to a different group of GPCRs, one that binds to protein molecules called chemokines, responsible for steering blood and immune cells where they are needed.

The team used GPCR biochemistry, receptor stabilization, and X-ray crystallography to capture the first visual of a chemokine receptor bound to a ligand.

Unlike the adrenergic receptor and the A2A adenosine receptor, CXCR4 likes to form dimers.

“The dimerization observation was very intriguing,” said Dr Stevens. “We solved 5 different crystal structures in multiple crystal forms, and each one had the same dimer interface. It has long been debated how GPCRs might dimerize, if they did at all. This is the first solid observation about a consistent structural GPCR dimer.”

The team believes preventing dimerization might provide a new way to block CXCR4, which results in the release of hematopoietic stem cells from bone marrow into the bloodstream.

Currently, plerixafor injection is the only drug on the market that blocks CXCR4. Therapy that assists in the release of hematopoietic stem cells to the bloodstream is very useful following stem cell transplant.

Drugs that block CXCR4 are also useful in treating HIV infection.

Their findings were published in the October 7 issue of Science.

Pair of CXCR4 molecules
Credit: Raymond Stevens
Scripps Research Institute

A team of researchers has uncovered the structure of a cell surface receptor, CXCR4, which guides blood and immune cell movement throughout the body.

CXCR4 is also found on the surface of the human immunodeficiency virus (HIV), and helps the virus to enter blood cells.

The receptor is part of a group of about 700 proteins known as G protein-coupled receptors (GPCRs).

The team, led by Raymond C. Stevens, PhD, of Scripps Research Institute in La Jolla, California, and senior author of the study, already found the structures of two other GPCRs: the adrenergic receptor and A2A adenosine receptor.

CXCR4 belongs to a different group of GPCRs, one that binds to protein molecules called chemokines, responsible for steering blood and immune cells where they are needed.

The team used GPCR biochemistry, receptor stabilization, and X-ray crystallography to capture the first visual of a chemokine receptor bound to a ligand.

Unlike the adrenergic receptor and the A2A adenosine receptor, CXCR4 likes to form dimers.

“The dimerization observation was very intriguing,” said Dr Stevens. “We solved 5 different crystal structures in multiple crystal forms, and each one had the same dimer interface. It has long been debated how GPCRs might dimerize, if they did at all. This is the first solid observation about a consistent structural GPCR dimer.”

The team believes preventing dimerization might provide a new way to block CXCR4, which results in the release of hematopoietic stem cells from bone marrow into the bloodstream.

Currently, plerixafor injection is the only drug on the market that blocks CXCR4. Therapy that assists in the release of hematopoietic stem cells to the bloodstream is very useful following stem cell transplant.

Drugs that block CXCR4 are also useful in treating HIV infection.

Their findings were published in the October 7 issue of Science.

A new Archives of Internal Medicine study that shows the use of multiple anti-thrombotics increases the risk of bleeding in atrial fibrillation (AF) patients compared with warfarin monotherapy shouldn't change hospitalists' prescribing patterns, according to one physician.

Kurt Pfeifer, MD, FACP, program director of the Internal Medicine Residency program at Medical College in Milwaukee, says the research is important, as it adds to the knowledge base on the potential dangers of combining aspirin, warfarin, and clopidogrel. But even in cases where bleeding risks can be tripled, Dr. Pfeifer suggests hospitalists keep an eye on the risk-reward curve.

"It comes back to: Ask yourself, Do [patients] have a reason to be on it?" says Dr. Pfeifer, an associate professor who stays current on bleeding-risk research. "If they do, you better have a real reason for not putting them on it."

The study concluded that all combinations of the three medications in AF patients are associated with increased risk of both fatal and nonfatal bleeding (Arch Intern Med. 2010;170(16):1433-1441). The cohort study noted that "dual warfarin and clopidogrel therapy and triple therapy carried a more than 3-fold higher risk than did warfarin monotherapy."

Dr. Pfeifer doesn't discount the information, but notes that he would likely only discourage the use in patients with a particularly high risk for bleeding. However, he thinks the study is also a good reminder that HM practitioners should communicate the risks and therapies to both patients and their PCPs.

"It's important to know what the risks are, but it doesn't take away from what the indicators are," he says. "In most of these situations, I think you can feel better that you’ve academically addressed it."

A new Archives of Internal Medicine study that shows the use of multiple anti-thrombotics increases the risk of bleeding in atrial fibrillation (AF) patients compared with warfarin monotherapy shouldn't change hospitalists' prescribing patterns, according to one physician.

Kurt Pfeifer, MD, FACP, program director of the Internal Medicine Residency program at Medical College in Milwaukee, says the research is important, as it adds to the knowledge base on the potential dangers of combining aspirin, warfarin, and clopidogrel. But even in cases where bleeding risks can be tripled, Dr. Pfeifer suggests hospitalists keep an eye on the risk-reward curve.

"It comes back to: Ask yourself, Do [patients] have a reason to be on it?" says Dr. Pfeifer, an associate professor who stays current on bleeding-risk research. "If they do, you better have a real reason for not putting them on it."

The study concluded that all combinations of the three medications in AF patients are associated with increased risk of both fatal and nonfatal bleeding (Arch Intern Med. 2010;170(16):1433-1441). The cohort study noted that "dual warfarin and clopidogrel therapy and triple therapy carried a more than 3-fold higher risk than did warfarin monotherapy."

Dr. Pfeifer doesn't discount the information, but notes that he would likely only discourage the use in patients with a particularly high risk for bleeding. However, he thinks the study is also a good reminder that HM practitioners should communicate the risks and therapies to both patients and their PCPs.

"It's important to know what the risks are, but it doesn't take away from what the indicators are," he says. "In most of these situations, I think you can feel better that you’ve academically addressed it."

A new Archives of Internal Medicine study that shows the use of multiple anti-thrombotics increases the risk of bleeding in atrial fibrillation (AF) patients compared with warfarin monotherapy shouldn't change hospitalists' prescribing patterns, according to one physician.

Kurt Pfeifer, MD, FACP, program director of the Internal Medicine Residency program at Medical College in Milwaukee, says the research is important, as it adds to the knowledge base on the potential dangers of combining aspirin, warfarin, and clopidogrel. But even in cases where bleeding risks can be tripled, Dr. Pfeifer suggests hospitalists keep an eye on the risk-reward curve.

"It comes back to: Ask yourself, Do [patients] have a reason to be on it?" says Dr. Pfeifer, an associate professor who stays current on bleeding-risk research. "If they do, you better have a real reason for not putting them on it."

The study concluded that all combinations of the three medications in AF patients are associated with increased risk of both fatal and nonfatal bleeding (Arch Intern Med. 2010;170(16):1433-1441). The cohort study noted that "dual warfarin and clopidogrel therapy and triple therapy carried a more than 3-fold higher risk than did warfarin monotherapy."

Dr. Pfeifer doesn't discount the information, but notes that he would likely only discourage the use in patients with a particularly high risk for bleeding. However, he thinks the study is also a good reminder that HM practitioners should communicate the risks and therapies to both patients and their PCPs.

"It's important to know what the risks are, but it doesn't take away from what the indicators are," he says. "In most of these situations, I think you can feel better that you’ve academically addressed it."

Hospitalist leader Adam Singer, MD, is to be formally named physician executive of the year on Oct. 26 by the Medical Group Management Association (MGMA), a national association of 21,500 administrators and leaders of physician group practices. Dr. Singer, who learned of the award last month, is the first hospitalist honoree.

The award recognizes physician executives who have exhibited outstanding leadership and achieved exceptional performance in healthcare delivery.

Dr. Singer, 50, who is founder, CEO, and chief medical officer of IPC: The Hospitalist Company, took the North Hollywood, Calif.-based company public in 2008. A founding member of SHM, Dr. Singer's award represents a milestone in the growing acceptance of HM as a medical business and of its business model, says Dan Fuller, president of IN Compass Health of Alpharetta, Ga.

“We’re seeing more attention to hospitalist compensation models, payment incentives, and recognition of the need to align these with both productivity and quality,” says Dr. Fuller, a member of SHM's Practice Management Committee. The award “is great for Adam, but really exciting for our movement.”

Steven Deitelzweig, MD, chair of hospital medicine for Ochsner Health System in New Orleans and chair of SHM’s Practice Management Committee, says the MGMA honor reflects growing recognition of the role hospitalists will play in the changing business of hospital care under Affordable Care Act reforms. “Hospitalists will be the ones senior hospital leaders come to for help in figuring out healthcare reform,” he says.

Dr. Singer says the award recognizes his success, as a physician, and as an entrepreneur, and is a "signpost for hospital medicine as a whole. They're recognizing HM not just as a medical specialty that has emerged in recent years, but our success as a business," he says. "HM is a business, at least as we practice it at IPC. We've shown that it can be profitable as a standalone medical service, without requiring subsidization."

Hospitalist leader Adam Singer, MD, is to be formally named physician executive of the year on Oct. 26 by the Medical Group Management Association (MGMA), a national association of 21,500 administrators and leaders of physician group practices. Dr. Singer, who learned of the award last month, is the first hospitalist honoree.

The award recognizes physician executives who have exhibited outstanding leadership and achieved exceptional performance in healthcare delivery.

Dr. Singer, 50, who is founder, CEO, and chief medical officer of IPC: The Hospitalist Company, took the North Hollywood, Calif.-based company public in 2008. A founding member of SHM, Dr. Singer's award represents a milestone in the growing acceptance of HM as a medical business and of its business model, says Dan Fuller, president of IN Compass Health of Alpharetta, Ga.

“We’re seeing more attention to hospitalist compensation models, payment incentives, and recognition of the need to align these with both productivity and quality,” says Dr. Fuller, a member of SHM's Practice Management Committee. The award “is great for Adam, but really exciting for our movement.”

Steven Deitelzweig, MD, chair of hospital medicine for Ochsner Health System in New Orleans and chair of SHM’s Practice Management Committee, says the MGMA honor reflects growing recognition of the role hospitalists will play in the changing business of hospital care under Affordable Care Act reforms. “Hospitalists will be the ones senior hospital leaders come to for help in figuring out healthcare reform,” he says.

Dr. Singer says the award recognizes his success, as a physician, and as an entrepreneur, and is a "signpost for hospital medicine as a whole. They're recognizing HM not just as a medical specialty that has emerged in recent years, but our success as a business," he says. "HM is a business, at least as we practice it at IPC. We've shown that it can be profitable as a standalone medical service, without requiring subsidization."

Hospitalist leader Adam Singer, MD, is to be formally named physician executive of the year on Oct. 26 by the Medical Group Management Association (MGMA), a national association of 21,500 administrators and leaders of physician group practices. Dr. Singer, who learned of the award last month, is the first hospitalist honoree.

The award recognizes physician executives who have exhibited outstanding leadership and achieved exceptional performance in healthcare delivery.

Dr. Singer, 50, who is founder, CEO, and chief medical officer of IPC: The Hospitalist Company, took the North Hollywood, Calif.-based company public in 2008. A founding member of SHM, Dr. Singer's award represents a milestone in the growing acceptance of HM as a medical business and of its business model, says Dan Fuller, president of IN Compass Health of Alpharetta, Ga.

“We’re seeing more attention to hospitalist compensation models, payment incentives, and recognition of the need to align these with both productivity and quality,” says Dr. Fuller, a member of SHM's Practice Management Committee. The award “is great for Adam, but really exciting for our movement.”

Steven Deitelzweig, MD, chair of hospital medicine for Ochsner Health System in New Orleans and chair of SHM’s Practice Management Committee, says the MGMA honor reflects growing recognition of the role hospitalists will play in the changing business of hospital care under Affordable Care Act reforms. “Hospitalists will be the ones senior hospital leaders come to for help in figuring out healthcare reform,” he says.

Dr. Singer says the award recognizes his success, as a physician, and as an entrepreneur, and is a "signpost for hospital medicine as a whole. They're recognizing HM not just as a medical specialty that has emerged in recent years, but our success as a business," he says. "HM is a business, at least as we practice it at IPC. We've shown that it can be profitable as a standalone medical service, without requiring subsidization."

John Harney, COO at University of Colorado Hospital, moved west in 2008 after working at New York University Hospitals Center. The East Coast hospital had used a grant to establish a palliative-care program and witnessed immediate results.

“We truly believed it resulted in reductions in length of stay, as well as humanistic benefits,” Harney says. “When I came out to Colorado, I was pleasantly surprised at the breadth and depth of the programs here.”

Harney says he believes HM is a logical place to advance palliative care to the next level, as most HM groups already possess an in-house presence and commitment to efficient throughput. Hospital administrators will be concerned with consistency, routines, and protocols, he says, as well as the palliative-care service’s commitment to quality improvement. Those same administrators appreciate the need for program and salary support, although he advises palliative-care advocates to do their homework and develop a viable business plan.

“Hospital administrators will quickly figure out the math,” Harney says. “If you’re coming to speak to us, you need to have your numbers in order. You also need some monitoring in place.”

The initial salvo should include confirmation that HM group leaders have done their homework: surveyed their HM staff and discussed the idea with oncologists and other specialists. “It’s also helpful to have real champions in nursing and social work,” Harney says. “It’s never easy to get financial support for a new program, but if you have those ducks lined up, it goes better.”

John Harney, COO at University of Colorado Hospital, moved west in 2008 after working at New York University Hospitals Center. The East Coast hospital had used a grant to establish a palliative-care program and witnessed immediate results.

“We truly believed it resulted in reductions in length of stay, as well as humanistic benefits,” Harney says. “When I came out to Colorado, I was pleasantly surprised at the breadth and depth of the programs here.”

Harney says he believes HM is a logical place to advance palliative care to the next level, as most HM groups already possess an in-house presence and commitment to efficient throughput. Hospital administrators will be concerned with consistency, routines, and protocols, he says, as well as the palliative-care service’s commitment to quality improvement. Those same administrators appreciate the need for program and salary support, although he advises palliative-care advocates to do their homework and develop a viable business plan.

“Hospital administrators will quickly figure out the math,” Harney says. “If you’re coming to speak to us, you need to have your numbers in order. You also need some monitoring in place.”

The initial salvo should include confirmation that HM group leaders have done their homework: surveyed their HM staff and discussed the idea with oncologists and other specialists. “It’s also helpful to have real champions in nursing and social work,” Harney says. “It’s never easy to get financial support for a new program, but if you have those ducks lined up, it goes better.”

John Harney, COO at University of Colorado Hospital, moved west in 2008 after working at New York University Hospitals Center. The East Coast hospital had used a grant to establish a palliative-care program and witnessed immediate results.

“We truly believed it resulted in reductions in length of stay, as well as humanistic benefits,” Harney says. “When I came out to Colorado, I was pleasantly surprised at the breadth and depth of the programs here.”

Harney says he believes HM is a logical place to advance palliative care to the next level, as most HM groups already possess an in-house presence and commitment to efficient throughput. Hospital administrators will be concerned with consistency, routines, and protocols, he says, as well as the palliative-care service’s commitment to quality improvement. Those same administrators appreciate the need for program and salary support, although he advises palliative-care advocates to do their homework and develop a viable business plan.

“Hospital administrators will quickly figure out the math,” Harney says. “If you’re coming to speak to us, you need to have your numbers in order. You also need some monitoring in place.”

The initial salvo should include confirmation that HM group leaders have done their homework: surveyed their HM staff and discussed the idea with oncologists and other specialists. “It’s also helpful to have real champions in nursing and social work,” Harney says. “It’s never easy to get financial support for a new program, but if you have those ducks lined up, it goes better.”

They have grown up in an era of reality television and hyperbolic politics. They prefer news alerts and fantasy football on their handhelds to daily newspapers and leather-bound novels. They text, they text, they text.

The generation known as millennials—those who were born in the years 1982 to 1995—is a breed unto itself. Millennials have grown up in the information age, are adept with new technologies, and have been trained under the umbrella of duty-hour guidelines that protect both the patient and the physician.

So when you hire a millennial for your hospitalist group, you’d better be clear about your expectations. “Millennials are looking for jobs that provide flexibility—time with family, time with friends, time to do other things,” says Troy Ahlstrom, MD, FHM, CFO of Traverse City-based Hospitalists of Northern Michigan and a member of SHM’s Practice Analysis committee. “There is nothing wrong with that, except that the baby boomers look at millennials and say, ‘Gosh, you slugs don’t want to work.’ ”

Dr. Ahlstrom says the influx of millennials into HM in recent years has had a significant impact on group administration—namely, an increase in use of 24/7 on-site coverage. The State of Hospital Medicine: 2010 Report Based on 2009 Data shows 68% of hospitalist groups provide on-site coverage at night. SHM’s 2007-2008 survey data showed only 53% of HM groups provided on-site coverage at night; the 2005-2006 figure was 51%. (Although the 2010 report includes a small percentage of truly academic hospitalist groups and, therefore, probably pushes the on-site coverage a little higher than in past years, Dr. Ahlstrom says he expects the trend toward on-site coverage at night to continue in the near future.)

“Baby boomers are perfectly fine with the idea of working more. They grew up working those horrifically long shifts, 36 hours straight,” Dr. Ahlstrom says. “The millennials would rather have clearly defined shifts, with nocturnists around to work the nights. Or maybe they get to be the nocturnist and work the nights. That’s the trend with younger physicians: They are more interested in seeing that split, where the days and nights are clearly set off.”

Then again, not all physicians, young or old, are against the idea of working long hours. And plenty of well-seasoned physicians are more than happy to have a nocturnist around, “but not if it’s going to cost them a lot of money or productivity,” Dr. Ahlstrom says.

They have grown up in an era of reality television and hyperbolic politics. They prefer news alerts and fantasy football on their handhelds to daily newspapers and leather-bound novels. They text, they text, they text.

The generation known as millennials—those who were born in the years 1982 to 1995—is a breed unto itself. Millennials have grown up in the information age, are adept with new technologies, and have been trained under the umbrella of duty-hour guidelines that protect both the patient and the physician.

So when you hire a millennial for your hospitalist group, you’d better be clear about your expectations. “Millennials are looking for jobs that provide flexibility—time with family, time with friends, time to do other things,” says Troy Ahlstrom, MD, FHM, CFO of Traverse City-based Hospitalists of Northern Michigan and a member of SHM’s Practice Analysis committee. “There is nothing wrong with that, except that the baby boomers look at millennials and say, ‘Gosh, you slugs don’t want to work.’ ”

Dr. Ahlstrom says the influx of millennials into HM in recent years has had a significant impact on group administration—namely, an increase in use of 24/7 on-site coverage. The State of Hospital Medicine: 2010 Report Based on 2009 Data shows 68% of hospitalist groups provide on-site coverage at night. SHM’s 2007-2008 survey data showed only 53% of HM groups provided on-site coverage at night; the 2005-2006 figure was 51%. (Although the 2010 report includes a small percentage of truly academic hospitalist groups and, therefore, probably pushes the on-site coverage a little higher than in past years, Dr. Ahlstrom says he expects the trend toward on-site coverage at night to continue in the near future.)

“Baby boomers are perfectly fine with the idea of working more. They grew up working those horrifically long shifts, 36 hours straight,” Dr. Ahlstrom says. “The millennials would rather have clearly defined shifts, with nocturnists around to work the nights. Or maybe they get to be the nocturnist and work the nights. That’s the trend with younger physicians: They are more interested in seeing that split, where the days and nights are clearly set off.”

Then again, not all physicians, young or old, are against the idea of working long hours. And plenty of well-seasoned physicians are more than happy to have a nocturnist around, “but not if it’s going to cost them a lot of money or productivity,” Dr. Ahlstrom says.

They have grown up in an era of reality television and hyperbolic politics. They prefer news alerts and fantasy football on their handhelds to daily newspapers and leather-bound novels. They text, they text, they text.

The generation known as millennials—those who were born in the years 1982 to 1995—is a breed unto itself. Millennials have grown up in the information age, are adept with new technologies, and have been trained under the umbrella of duty-hour guidelines that protect both the patient and the physician.

So when you hire a millennial for your hospitalist group, you’d better be clear about your expectations. “Millennials are looking for jobs that provide flexibility—time with family, time with friends, time to do other things,” says Troy Ahlstrom, MD, FHM, CFO of Traverse City-based Hospitalists of Northern Michigan and a member of SHM’s Practice Analysis committee. “There is nothing wrong with that, except that the baby boomers look at millennials and say, ‘Gosh, you slugs don’t want to work.’ ”

Dr. Ahlstrom says the influx of millennials into HM in recent years has had a significant impact on group administration—namely, an increase in use of 24/7 on-site coverage. The State of Hospital Medicine: 2010 Report Based on 2009 Data shows 68% of hospitalist groups provide on-site coverage at night. SHM’s 2007-2008 survey data showed only 53% of HM groups provided on-site coverage at night; the 2005-2006 figure was 51%. (Although the 2010 report includes a small percentage of truly academic hospitalist groups and, therefore, probably pushes the on-site coverage a little higher than in past years, Dr. Ahlstrom says he expects the trend toward on-site coverage at night to continue in the near future.)

“Baby boomers are perfectly fine with the idea of working more. They grew up working those horrifically long shifts, 36 hours straight,” Dr. Ahlstrom says. “The millennials would rather have clearly defined shifts, with nocturnists around to work the nights. Or maybe they get to be the nocturnist and work the nights. That’s the trend with younger physicians: They are more interested in seeing that split, where the days and nights are clearly set off.”

Then again, not all physicians, young or old, are against the idea of working long hours. And plenty of well-seasoned physicians are more than happy to have a nocturnist around, “but not if it’s going to cost them a lot of money or productivity,” Dr. Ahlstrom says.

MGMA analyst David Litzau discusses the new compensation and productivity report, and gives advice on how best to use benchmarking data in your practice

Click here to listen to the audio file

MGMA analyst David Litzau discusses the new compensation and productivity report, and gives advice on how best to use benchmarking data in your practice

Click here to listen to the audio file

MGMA analyst David Litzau discusses the new compensation and productivity report, and gives advice on how best to use benchmarking data in your practice

Click here to listen to the audio file

David Dupray, a 60-year-old uninsured coffee shop owner from Bar Harbor, Maine, had been having left leg pain on ambulation for four years. His cardiologist recommended stent placement for left iliac artery stenosis. The estimated bill: approximately $35,000.

Unable to afford the procedure, Dupray began searching the Web for affordable medical care overseas. His physician suggested Thailand. Within days, Dupray had an appointment with a cardiologist halfway around the world—at Bumrungrad Hospital in Bangkok, Thailand. Dupray spent two days in the hotel-like hospital, had three stents placed in his leg arteries, and completed a cardiac stress test. The total bill: $18,000.

“I will never go to a hospital in the U.S.,” says Dupray, who represents a growing number of Americans searching for affordable healthcare in the global marketplace.

With rising U.S. healthcare costs and millions of Americans uninsured or underinsured, more American patients are seeking affordable, high-quality medical care abroad—known as “medical tourism.” In 2007, an estimated 750,000 Americans traveled abroad for medical care; the number is expected to increase to 6 million by the end of this year.¹ On the flip side, only a little more than 400,000 nonresidents visited the U.S. in 2008 for the latest medical care.1 Globally, the medical tourism industry is estimated to grow into a $21 billion-a-year industry by 2012, with much of the growth expected from Western patients traveling overseas for affordable care.²

“As hospitalists, we have been seeing increasing numbers of patients going overseas for urgent and elective procedures, as it is a general perception the medical treatment overseas is less expensive,” says Joseph Ming Wah Li, MD, SFHM, director of hospital medicine at Beth Israel Deaconess Medical Center in Boston and SHM president-elect.

Physicians in U.S. hospitals encounter potential medical tourists all the time. Some are uninsured or underinsured. Some have insurance carriers that limit or exclude coverage for certain procedures and treatments. Even those with insurance sometimes struggle to pay deductibles, copays, and their costs after insurance has paid its part. Others are uncomfortable with the language barriers and cultural differences of U.S. hospitals and physicians.

Medical tourism also lures patients who are citizens of countries (e.g. Canada, the United Kingdom) that offer universal healthcare, Dr. Li says.³ For example, more expatriates from India and Malaysia are traveling to their native countries for medical care, as they receive affordable and quicker medical care while visiting family.

Hospitalists routinely care for patients requiring essential cardiac or orthopedic surgeries—conditions that are common in the medical tourism trade. With medical tourism growing in scope and popularity, it is essential that hospitalists are prepared to discuss with their patients the pros and cons of traveling for medical care. Hospitalists should be able to:

• Identify patients who might benefit from medical tourism;
• Know where and how to look for an accredited overseas facility; and
• Explain to patients the potential travel risks and complications, including insurance coverage and legal restrictions in destination countries.

A basic understanding of the industry and the issues can help guide your patients through medical decisions and help you care for those who have returned from a medical trip.

click for large version

Big Menu, Discount Prices

Medical tourism offers a wide range of medical services performed in hospitals on nearly every continent, with a wide range of costs for certain procedures (Table 1, p. 26). Most surgeries cost 50% to 90% less than the average cost of the same surgery at a U.S. hospital. Many in the medical tourism industry say these types of savings have brought once-unaffordable surgery within the reach of most Americans, regardless of insurance status. For example, cardiac bypass surgery on average costs $144,000 in the U.S.; it costs about $8,500 in India.

The reasons the costs are so much less at overseas hospitals, as compared with U.S. costs, are many:

• Lower wages for providers;
• Less expensive medical devices and pharmaceutical products;
• Less involvement by third-party payors; and
• Lower malpractice premiums.⁴

For example, the annual liability insurance premium for a surgeon in India is $4,000; the average cost of a New York City surgeon’s liability insurance premium is $100,000.⁵

Brazil, Costa Rica, and Mexico are attractive destinations for cosmetic and dental surgeries; Singapore, Malaysia, Thailand, and India have emerged as hubs for cardiac and orthopedic surgeries (Table 1, above).⁶

The growth in medical tourism led the Joint Commission in 1999 to launch Joint Commission International (JCI), which ensures that offshore hospitals provide the highest-quality care to international patients (see “Ultra-Affordable Prices and No Decline in Quality of Care,” p. 28). JCI has accredited 120 overseas hospitals that meet these standards.

“Overseas hospitals are always keen in partnering with U.S. hospitals,” Dr. Li says. Collaborations, such as Johns Hopkins International Medical Center’s partnership with International Medical Clinic Singapore, and Partners Harvard Medical International’s affiliation with Wockhardt Hospitals in Mumbai, India, have helped facilitate the accreditation process and alleviate U.S. patient concerns.

Overseas hospitals not only offer greatly discounted rates than insurer-negotiated U.S. prices, but many of the international hospitals also report quality scores equal to or better than the average U.S. hospital’s.⁷

click for large version

Before You Book a Trip …

How do patients find overseas facilities? It’s as easy as a click of the mouse.

“Our survey shows 75 percent of patients located offshore hospitals through the Internet,” says Renee-Marie Stephano, president of the Medical Tourism Association, a nonprofit group based in West Palm Beach, Fla., that was established in 2007 to promote education, transparency, and communication in the medical tourism community. Patients use overseas hospital websites, international medical coordinators, and medical tourism companies, such as PlanetHospital.com and MedRetreat.com, to find facilities and providers, and to coordinate medical travel.

“Medical tourism is currently unregulated,” Stephano says. “One of our goals is to certify medical tourism facilitators to create the best standard of practice.”

In 2007, the American Medical Association (AMA) published medical tourism guidelines to help healthcare entities engaged in overseas medical care.⁸ (Download a PDF of the guidelines at www.ama-assn.org/ama1/pub/upload/mm/31/medicaltourism.pdf.) The AMA suggests that:

• Medical care outside the U.S. should be voluntary, and patients should be informed of their legal rights and recourses before agreeing to travel outside the U.S.;
• Before traveling, local follow-up care should be arranged to ensure continuity of care;
• Patients should have access to physician licensing, facility accreditation, and outcomes data for both;
• Medical record transfers should follow HIPAA guidelines; and
• Patients should be informed of the potential risks of combining surgical procedures with long flights and vacation activities.

Patient Concerns

Hospitalists are highly focused on a patient’s quality of care; the same can be said of some overseas hospitals that attract large numbers of medical tourists. “I think the service and quality of care provided at our hospital compares favorably with the very best American hospitals,” says Kenneth Mays, senior director of hospital marketing and business development at Bumrungrad Hospital in Bangkok.

That might be so, but the growth of medical tourism also raises concerns stateside. With sleek websites making it easy for U.S. patients to schedule procedure vacations from their kitchen tables, many U.S. physician and watchdog groups worry about patient safety, privacy, liability, and continuity of care. Although most international hospitals and physicians provide outcomes data, rarely do the benchmarks compare directly with U.S. hospital quality and safety data.

“Quality comparisons are difficult, even within U.S. hospitals, as hospitals use different methodologies to collect data,” says Stephano. “Patients have to rely on JCI accreditation, surgeon experience, volume, and outcomes to decide.”

Recent studies echo the Medical Tourism Association’s claim: Increased cardiac surgery volume at Apollo Hospitals—an 8,500-bed healthcare system with 50 locations throughout India—and Narayana Hospital in Bommasandra, India, has lowered costs, with similar, or even lower, mortality rates compared with the average U.S. hospital.^7,9 Other challenges like getting medical records exist even within U.S. hospitals, so emerging platforms like Google Health and Microsoft Vault, where medical records can be uploaded at the touch of a button, “will benefit patients and providers,” Dr. Li says.

The Medical Tourism Association envisions U.S.-based physicians offering follow-up care to medical tourism patients. “Currently, we encourage patients to follow up with their primary-care physician,” Stephano says.

Dr. Li says malpractice is always a concern when traveling overseas; however, he also notes the legal system in the U.S. is strong enough “to handle any medical malpractice.” That said, a patient who experiences a poor medical outcome as the result of overseas treatment might seek legal remedies, but the reality is that malpractice laws are either nonexistent or not well implemented in some destination countries. That makes malpractice claims on overseas procedures a dicey proposition.

“Patients receiving overseas treatment need to realize that they are agreeing to the jurisdiction of the destination country,” Stephano says. Other risks associated with extended travel include exposure to regional infectious diseases and poor infrastructure in the destination country, which could undermine the benefits of medical travel.

Cost-saving benefits have led some U.S. insurance companies to begin integrating overseas medical coverage. For example, Blue Cross Blue Shield of South Carolina offers incentives for patients willing to obtain medical care overseas at JCI-approved hospitals. BCBS then waives deductibles and copays, and several other insurers have launched similar pilot programs.¹⁰ “We will see more of these changes,” Stephano says, “to cut costs and remain competitive.”

Immediate Impact

In 2008, U.S. healthcare spending was $2.3 trillion.¹¹ A 2005 Institute of Medicine report suggests that 30% to 40% of current U.S. healthcare expenditure is wasted.12 U.S. lawmakers, employers, hospitals, and consumers are scrambling to find ways to reduce healthcare costs and improve efficiency. Medical tourism seems to benefit a select few Americans, only lowering U.S. healthcare spending by 1% to 2%.¹²

Medical tourism revenue generated in destination countries currently is limited to the private sector, but that might change soon. Government funding for healthcare initiatives in such countries as India, Brazil, and Thailand is declining. Some entrepreneurial physicians and hospitals are looking to medical tourism to fill the funding gap.

Medical tourism likely will continue to grow; so too will the legal, quality, and insurance protections for patients. Efficient resource utilization might help reduce U.S. healthcare costs, and improved distribution of destination-country resources might help improve infrastructure and access to better healthcare for their own citizens.

With their leadership skills and expertise, hospitalists can play a major role in reducing healthcare costs.

However, what actual reforms healthcare legislation brings to medical tourism remain to be seen. TH

Dr. Thakkar is a hospitalist and assistant professor in the division of hospital medicine at Johns Hopkins University School of Medicine in Baltimore.

References

1. Medical tourism: Consumers in search of value. Deloitte Consulting LLP website. Available at: www.deloitte.com/dtt/cda/doc/content/us%5Fchs%5FMedicalTourismStudy(1).pdf. Accessed Sept. 13, 2010.
2. Pafford B. The third wave—medical tourism in the 21st century. South Med J. 2009;102(8):810-813.
3. Kher U. Outsourcing your heart. Available at: http://proquest.umi.com/pqdweb?did=1041533291&Fmt=7&clientId=5241&RQT=309&VName=PQD. Accessed Sept. 13, 2010.
4. Forgione DA, Smith PC. Medical tourism and its impact on the US health care system. J Health Care Finance. 2007;34(1):27-35.
5. Lancaster J. Surgeries, side trips for “medical tourists.” The Washington Post website. Available at: www.washingtonpost.com/wp-dyn/articles/A497432004Oct20.html. Accessed Sept. 13, 2010.
6. Horowitz MD, Rosensweig JA, Jones CA. Medical tourism: Globaliz-ation of the healthcare marketplace. MedGenMed. 2007;9(4):33.
7. Milstein A, Smith M. Will the surgical world become flat? Health Aff (Millwood). 2007;26(1):137-141.
8. New AMA guidelines on medical tourism. AMA website. Available at: www.ama-assn.org/ama1/pub/upload/mm/31/medicaltourism.pdf. Accessed March 26, 2010.
9. Anand G. The Henry Ford of heart surgery. Wall Street Journal website. Available at: online.wsj.com/article/SB12587589288795811.html.
10. Einhorn B. Outsourcing the patients. Business Week website. Available at: www.businessweek.com/magazine/content/08_12/b40760367 77780.htm. Accessed Sept. 13, 2010.
11. . Hartman M, Martin A, Nuccio O, Catlin A, et al. Health spending growth at a historic low in 2008. Health Aff (Millwood). 2010;29(1): 147-155.
12. Milstein A, Smith M. America’s new refugees—seeking affordable surgery offshore. N Engl J Med. 2006;355(16):1637-1640.

David Dupray, a 60-year-old uninsured coffee shop owner from Bar Harbor, Maine, had been having left leg pain on ambulation for four years. His cardiologist recommended stent placement for left iliac artery stenosis. The estimated bill: approximately $35,000.

Unable to afford the procedure, Dupray began searching the Web for affordable medical care overseas. His physician suggested Thailand. Within days, Dupray had an appointment with a cardiologist halfway around the world—at Bumrungrad Hospital in Bangkok, Thailand. Dupray spent two days in the hotel-like hospital, had three stents placed in his leg arteries, and completed a cardiac stress test. The total bill: $18,000.

“I will never go to a hospital in the U.S.,” says Dupray, who represents a growing number of Americans searching for affordable healthcare in the global marketplace.

With rising U.S. healthcare costs and millions of Americans uninsured or underinsured, more American patients are seeking affordable, high-quality medical care abroad—known as “medical tourism.” In 2007, an estimated 750,000 Americans traveled abroad for medical care; the number is expected to increase to 6 million by the end of this year.¹ On the flip side, only a little more than 400,000 nonresidents visited the U.S. in 2008 for the latest medical care.1 Globally, the medical tourism industry is estimated to grow into a $21 billion-a-year industry by 2012, with much of the growth expected from Western patients traveling overseas for affordable care.²

“As hospitalists, we have been seeing increasing numbers of patients going overseas for urgent and elective procedures, as it is a general perception the medical treatment overseas is less expensive,” says Joseph Ming Wah Li, MD, SFHM, director of hospital medicine at Beth Israel Deaconess Medical Center in Boston and SHM president-elect.

Physicians in U.S. hospitals encounter potential medical tourists all the time. Some are uninsured or underinsured. Some have insurance carriers that limit or exclude coverage for certain procedures and treatments. Even those with insurance sometimes struggle to pay deductibles, copays, and their costs after insurance has paid its part. Others are uncomfortable with the language barriers and cultural differences of U.S. hospitals and physicians.

Medical tourism also lures patients who are citizens of countries (e.g. Canada, the United Kingdom) that offer universal healthcare, Dr. Li says.³ For example, more expatriates from India and Malaysia are traveling to their native countries for medical care, as they receive affordable and quicker medical care while visiting family.

Hospitalists routinely care for patients requiring essential cardiac or orthopedic surgeries—conditions that are common in the medical tourism trade. With medical tourism growing in scope and popularity, it is essential that hospitalists are prepared to discuss with their patients the pros and cons of traveling for medical care. Hospitalists should be able to:

• Identify patients who might benefit from medical tourism;
• Know where and how to look for an accredited overseas facility; and
• Explain to patients the potential travel risks and complications, including insurance coverage and legal restrictions in destination countries.

A basic understanding of the industry and the issues can help guide your patients through medical decisions and help you care for those who have returned from a medical trip.

click for large version

Big Menu, Discount Prices

Medical tourism offers a wide range of medical services performed in hospitals on nearly every continent, with a wide range of costs for certain procedures (Table 1, p. 26). Most surgeries cost 50% to 90% less than the average cost of the same surgery at a U.S. hospital. Many in the medical tourism industry say these types of savings have brought once-unaffordable surgery within the reach of most Americans, regardless of insurance status. For example, cardiac bypass surgery on average costs $144,000 in the U.S.; it costs about $8,500 in India.

The reasons the costs are so much less at overseas hospitals, as compared with U.S. costs, are many:

• Lower wages for providers;
• Less expensive medical devices and pharmaceutical products;
• Less involvement by third-party payors; and
• Lower malpractice premiums.⁴

For example, the annual liability insurance premium for a surgeon in India is $4,000; the average cost of a New York City surgeon’s liability insurance premium is $100,000.⁵

Brazil, Costa Rica, and Mexico are attractive destinations for cosmetic and dental surgeries; Singapore, Malaysia, Thailand, and India have emerged as hubs for cardiac and orthopedic surgeries (Table 1, above).⁶

The growth in medical tourism led the Joint Commission in 1999 to launch Joint Commission International (JCI), which ensures that offshore hospitals provide the highest-quality care to international patients (see “Ultra-Affordable Prices and No Decline in Quality of Care,” p. 28). JCI has accredited 120 overseas hospitals that meet these standards.

“Overseas hospitals are always keen in partnering with U.S. hospitals,” Dr. Li says. Collaborations, such as Johns Hopkins International Medical Center’s partnership with International Medical Clinic Singapore, and Partners Harvard Medical International’s affiliation with Wockhardt Hospitals in Mumbai, India, have helped facilitate the accreditation process and alleviate U.S. patient concerns.

Overseas hospitals not only offer greatly discounted rates than insurer-negotiated U.S. prices, but many of the international hospitals also report quality scores equal to or better than the average U.S. hospital’s.⁷

click for large version

Before You Book a Trip …

How do patients find overseas facilities? It’s as easy as a click of the mouse.

“Our survey shows 75 percent of patients located offshore hospitals through the Internet,” says Renee-Marie Stephano, president of the Medical Tourism Association, a nonprofit group based in West Palm Beach, Fla., that was established in 2007 to promote education, transparency, and communication in the medical tourism community. Patients use overseas hospital websites, international medical coordinators, and medical tourism companies, such as PlanetHospital.com and MedRetreat.com, to find facilities and providers, and to coordinate medical travel.

“Medical tourism is currently unregulated,” Stephano says. “One of our goals is to certify medical tourism facilitators to create the best standard of practice.”

In 2007, the American Medical Association (AMA) published medical tourism guidelines to help healthcare entities engaged in overseas medical care.⁸ (Download a PDF of the guidelines at www.ama-assn.org/ama1/pub/upload/mm/31/medicaltourism.pdf.) The AMA suggests that:

• Medical care outside the U.S. should be voluntary, and patients should be informed of their legal rights and recourses before agreeing to travel outside the U.S.;
• Before traveling, local follow-up care should be arranged to ensure continuity of care;
• Patients should have access to physician licensing, facility accreditation, and outcomes data for both;
• Medical record transfers should follow HIPAA guidelines; and
• Patients should be informed of the potential risks of combining surgical procedures with long flights and vacation activities.

Patient Concerns

Hospitalists are highly focused on a patient’s quality of care; the same can be said of some overseas hospitals that attract large numbers of medical tourists. “I think the service and quality of care provided at our hospital compares favorably with the very best American hospitals,” says Kenneth Mays, senior director of hospital marketing and business development at Bumrungrad Hospital in Bangkok.

That might be so, but the growth of medical tourism also raises concerns stateside. With sleek websites making it easy for U.S. patients to schedule procedure vacations from their kitchen tables, many U.S. physician and watchdog groups worry about patient safety, privacy, liability, and continuity of care. Although most international hospitals and physicians provide outcomes data, rarely do the benchmarks compare directly with U.S. hospital quality and safety data.

“Quality comparisons are difficult, even within U.S. hospitals, as hospitals use different methodologies to collect data,” says Stephano. “Patients have to rely on JCI accreditation, surgeon experience, volume, and outcomes to decide.”

Recent studies echo the Medical Tourism Association’s claim: Increased cardiac surgery volume at Apollo Hospitals—an 8,500-bed healthcare system with 50 locations throughout India—and Narayana Hospital in Bommasandra, India, has lowered costs, with similar, or even lower, mortality rates compared with the average U.S. hospital.^7,9 Other challenges like getting medical records exist even within U.S. hospitals, so emerging platforms like Google Health and Microsoft Vault, where medical records can be uploaded at the touch of a button, “will benefit patients and providers,” Dr. Li says.

The Medical Tourism Association envisions U.S.-based physicians offering follow-up care to medical tourism patients. “Currently, we encourage patients to follow up with their primary-care physician,” Stephano says.

Dr. Li says malpractice is always a concern when traveling overseas; however, he also notes the legal system in the U.S. is strong enough “to handle any medical malpractice.” That said, a patient who experiences a poor medical outcome as the result of overseas treatment might seek legal remedies, but the reality is that malpractice laws are either nonexistent or not well implemented in some destination countries. That makes malpractice claims on overseas procedures a dicey proposition.

“Patients receiving overseas treatment need to realize that they are agreeing to the jurisdiction of the destination country,” Stephano says. Other risks associated with extended travel include exposure to regional infectious diseases and poor infrastructure in the destination country, which could undermine the benefits of medical travel.

Cost-saving benefits have led some U.S. insurance companies to begin integrating overseas medical coverage. For example, Blue Cross Blue Shield of South Carolina offers incentives for patients willing to obtain medical care overseas at JCI-approved hospitals. BCBS then waives deductibles and copays, and several other insurers have launched similar pilot programs.¹⁰ “We will see more of these changes,” Stephano says, “to cut costs and remain competitive.”

Immediate Impact

In 2008, U.S. healthcare spending was $2.3 trillion.¹¹ A 2005 Institute of Medicine report suggests that 30% to 40% of current U.S. healthcare expenditure is wasted.12 U.S. lawmakers, employers, hospitals, and consumers are scrambling to find ways to reduce healthcare costs and improve efficiency. Medical tourism seems to benefit a select few Americans, only lowering U.S. healthcare spending by 1% to 2%.¹²

Medical tourism revenue generated in destination countries currently is limited to the private sector, but that might change soon. Government funding for healthcare initiatives in such countries as India, Brazil, and Thailand is declining. Some entrepreneurial physicians and hospitals are looking to medical tourism to fill the funding gap.

Medical tourism likely will continue to grow; so too will the legal, quality, and insurance protections for patients. Efficient resource utilization might help reduce U.S. healthcare costs, and improved distribution of destination-country resources might help improve infrastructure and access to better healthcare for their own citizens.

With their leadership skills and expertise, hospitalists can play a major role in reducing healthcare costs.

However, what actual reforms healthcare legislation brings to medical tourism remain to be seen. TH

Dr. Thakkar is a hospitalist and assistant professor in the division of hospital medicine at Johns Hopkins University School of Medicine in Baltimore.

References

1. Medical tourism: Consumers in search of value. Deloitte Consulting LLP website. Available at: www.deloitte.com/dtt/cda/doc/content/us%5Fchs%5FMedicalTourismStudy(1).pdf. Accessed Sept. 13, 2010.
2. Pafford B. The third wave—medical tourism in the 21st century. South Med J. 2009;102(8):810-813.
3. Kher U. Outsourcing your heart. Available at: http://proquest.umi.com/pqdweb?did=1041533291&Fmt=7&clientId=5241&RQT=309&VName=PQD. Accessed Sept. 13, 2010.
4. Forgione DA, Smith PC. Medical tourism and its impact on the US health care system. J Health Care Finance. 2007;34(1):27-35.
5. Lancaster J. Surgeries, side trips for “medical tourists.” The Washington Post website. Available at: www.washingtonpost.com/wp-dyn/articles/A497432004Oct20.html. Accessed Sept. 13, 2010.
6. Horowitz MD, Rosensweig JA, Jones CA. Medical tourism: Globaliz-ation of the healthcare marketplace. MedGenMed. 2007;9(4):33.
7. Milstein A, Smith M. Will the surgical world become flat? Health Aff (Millwood). 2007;26(1):137-141.
8. New AMA guidelines on medical tourism. AMA website. Available at: www.ama-assn.org/ama1/pub/upload/mm/31/medicaltourism.pdf. Accessed March 26, 2010.
9. Anand G. The Henry Ford of heart surgery. Wall Street Journal website. Available at: online.wsj.com/article/SB12587589288795811.html.
10. Einhorn B. Outsourcing the patients. Business Week website. Available at: www.businessweek.com/magazine/content/08_12/b40760367 77780.htm. Accessed Sept. 13, 2010.
11. . Hartman M, Martin A, Nuccio O, Catlin A, et al. Health spending growth at a historic low in 2008. Health Aff (Millwood). 2010;29(1): 147-155.
12. Milstein A, Smith M. America’s new refugees—seeking affordable surgery offshore. N Engl J Med. 2006;355(16):1637-1640.

David Dupray, a 60-year-old uninsured coffee shop owner from Bar Harbor, Maine, had been having left leg pain on ambulation for four years. His cardiologist recommended stent placement for left iliac artery stenosis. The estimated bill: approximately $35,000.

Unable to afford the procedure, Dupray began searching the Web for affordable medical care overseas. His physician suggested Thailand. Within days, Dupray had an appointment with a cardiologist halfway around the world—at Bumrungrad Hospital in Bangkok, Thailand. Dupray spent two days in the hotel-like hospital, had three stents placed in his leg arteries, and completed a cardiac stress test. The total bill: $18,000.

“I will never go to a hospital in the U.S.,” says Dupray, who represents a growing number of Americans searching for affordable healthcare in the global marketplace.

With rising U.S. healthcare costs and millions of Americans uninsured or underinsured, more American patients are seeking affordable, high-quality medical care abroad—known as “medical tourism.” In 2007, an estimated 750,000 Americans traveled abroad for medical care; the number is expected to increase to 6 million by the end of this year.¹ On the flip side, only a little more than 400,000 nonresidents visited the U.S. in 2008 for the latest medical care.1 Globally, the medical tourism industry is estimated to grow into a $21 billion-a-year industry by 2012, with much of the growth expected from Western patients traveling overseas for affordable care.²

“As hospitalists, we have been seeing increasing numbers of patients going overseas for urgent and elective procedures, as it is a general perception the medical treatment overseas is less expensive,” says Joseph Ming Wah Li, MD, SFHM, director of hospital medicine at Beth Israel Deaconess Medical Center in Boston and SHM president-elect.

Physicians in U.S. hospitals encounter potential medical tourists all the time. Some are uninsured or underinsured. Some have insurance carriers that limit or exclude coverage for certain procedures and treatments. Even those with insurance sometimes struggle to pay deductibles, copays, and their costs after insurance has paid its part. Others are uncomfortable with the language barriers and cultural differences of U.S. hospitals and physicians.

Medical tourism also lures patients who are citizens of countries (e.g. Canada, the United Kingdom) that offer universal healthcare, Dr. Li says.³ For example, more expatriates from India and Malaysia are traveling to their native countries for medical care, as they receive affordable and quicker medical care while visiting family.

Hospitalists routinely care for patients requiring essential cardiac or orthopedic surgeries—conditions that are common in the medical tourism trade. With medical tourism growing in scope and popularity, it is essential that hospitalists are prepared to discuss with their patients the pros and cons of traveling for medical care. Hospitalists should be able to:

• Identify patients who might benefit from medical tourism;
• Know where and how to look for an accredited overseas facility; and
• Explain to patients the potential travel risks and complications, including insurance coverage and legal restrictions in destination countries.

A basic understanding of the industry and the issues can help guide your patients through medical decisions and help you care for those who have returned from a medical trip.

click for large version

Big Menu, Discount Prices

Medical tourism offers a wide range of medical services performed in hospitals on nearly every continent, with a wide range of costs for certain procedures (Table 1, p. 26). Most surgeries cost 50% to 90% less than the average cost of the same surgery at a U.S. hospital. Many in the medical tourism industry say these types of savings have brought once-unaffordable surgery within the reach of most Americans, regardless of insurance status. For example, cardiac bypass surgery on average costs $144,000 in the U.S.; it costs about $8,500 in India.

The reasons the costs are so much less at overseas hospitals, as compared with U.S. costs, are many:

• Lower wages for providers;
• Less expensive medical devices and pharmaceutical products;
• Less involvement by third-party payors; and
• Lower malpractice premiums.⁴

For example, the annual liability insurance premium for a surgeon in India is $4,000; the average cost of a New York City surgeon’s liability insurance premium is $100,000.⁵

Brazil, Costa Rica, and Mexico are attractive destinations for cosmetic and dental surgeries; Singapore, Malaysia, Thailand, and India have emerged as hubs for cardiac and orthopedic surgeries (Table 1, above).⁶

The growth in medical tourism led the Joint Commission in 1999 to launch Joint Commission International (JCI), which ensures that offshore hospitals provide the highest-quality care to international patients (see “Ultra-Affordable Prices and No Decline in Quality of Care,” p. 28). JCI has accredited 120 overseas hospitals that meet these standards.

“Overseas hospitals are always keen in partnering with U.S. hospitals,” Dr. Li says. Collaborations, such as Johns Hopkins International Medical Center’s partnership with International Medical Clinic Singapore, and Partners Harvard Medical International’s affiliation with Wockhardt Hospitals in Mumbai, India, have helped facilitate the accreditation process and alleviate U.S. patient concerns.

Overseas hospitals not only offer greatly discounted rates than insurer-negotiated U.S. prices, but many of the international hospitals also report quality scores equal to or better than the average U.S. hospital’s.⁷

click for large version

Before You Book a Trip …

How do patients find overseas facilities? It’s as easy as a click of the mouse.

“Our survey shows 75 percent of patients located offshore hospitals through the Internet,” says Renee-Marie Stephano, president of the Medical Tourism Association, a nonprofit group based in West Palm Beach, Fla., that was established in 2007 to promote education, transparency, and communication in the medical tourism community. Patients use overseas hospital websites, international medical coordinators, and medical tourism companies, such as PlanetHospital.com and MedRetreat.com, to find facilities and providers, and to coordinate medical travel.

“Medical tourism is currently unregulated,” Stephano says. “One of our goals is to certify medical tourism facilitators to create the best standard of practice.”

In 2007, the American Medical Association (AMA) published medical tourism guidelines to help healthcare entities engaged in overseas medical care.⁸ (Download a PDF of the guidelines at www.ama-assn.org/ama1/pub/upload/mm/31/medicaltourism.pdf.) The AMA suggests that:

• Medical care outside the U.S. should be voluntary, and patients should be informed of their legal rights and recourses before agreeing to travel outside the U.S.;
• Before traveling, local follow-up care should be arranged to ensure continuity of care;
• Patients should have access to physician licensing, facility accreditation, and outcomes data for both;
• Medical record transfers should follow HIPAA guidelines; and
• Patients should be informed of the potential risks of combining surgical procedures with long flights and vacation activities.

Patient Concerns

Hospitalists are highly focused on a patient’s quality of care; the same can be said of some overseas hospitals that attract large numbers of medical tourists. “I think the service and quality of care provided at our hospital compares favorably with the very best American hospitals,” says Kenneth Mays, senior director of hospital marketing and business development at Bumrungrad Hospital in Bangkok.

That might be so, but the growth of medical tourism also raises concerns stateside. With sleek websites making it easy for U.S. patients to schedule procedure vacations from their kitchen tables, many U.S. physician and watchdog groups worry about patient safety, privacy, liability, and continuity of care. Although most international hospitals and physicians provide outcomes data, rarely do the benchmarks compare directly with U.S. hospital quality and safety data.

“Quality comparisons are difficult, even within U.S. hospitals, as hospitals use different methodologies to collect data,” says Stephano. “Patients have to rely on JCI accreditation, surgeon experience, volume, and outcomes to decide.”

Recent studies echo the Medical Tourism Association’s claim: Increased cardiac surgery volume at Apollo Hospitals—an 8,500-bed healthcare system with 50 locations throughout India—and Narayana Hospital in Bommasandra, India, has lowered costs, with similar, or even lower, mortality rates compared with the average U.S. hospital.^7,9 Other challenges like getting medical records exist even within U.S. hospitals, so emerging platforms like Google Health and Microsoft Vault, where medical records can be uploaded at the touch of a button, “will benefit patients and providers,” Dr. Li says.

The Medical Tourism Association envisions U.S.-based physicians offering follow-up care to medical tourism patients. “Currently, we encourage patients to follow up with their primary-care physician,” Stephano says.

Dr. Li says malpractice is always a concern when traveling overseas; however, he also notes the legal system in the U.S. is strong enough “to handle any medical malpractice.” That said, a patient who experiences a poor medical outcome as the result of overseas treatment might seek legal remedies, but the reality is that malpractice laws are either nonexistent or not well implemented in some destination countries. That makes malpractice claims on overseas procedures a dicey proposition.

“Patients receiving overseas treatment need to realize that they are agreeing to the jurisdiction of the destination country,” Stephano says. Other risks associated with extended travel include exposure to regional infectious diseases and poor infrastructure in the destination country, which could undermine the benefits of medical travel.

Cost-saving benefits have led some U.S. insurance companies to begin integrating overseas medical coverage. For example, Blue Cross Blue Shield of South Carolina offers incentives for patients willing to obtain medical care overseas at JCI-approved hospitals. BCBS then waives deductibles and copays, and several other insurers have launched similar pilot programs.¹⁰ “We will see more of these changes,” Stephano says, “to cut costs and remain competitive.”

Immediate Impact

In 2008, U.S. healthcare spending was $2.3 trillion.¹¹ A 2005 Institute of Medicine report suggests that 30% to 40% of current U.S. healthcare expenditure is wasted.12 U.S. lawmakers, employers, hospitals, and consumers are scrambling to find ways to reduce healthcare costs and improve efficiency. Medical tourism seems to benefit a select few Americans, only lowering U.S. healthcare spending by 1% to 2%.¹²

Medical tourism revenue generated in destination countries currently is limited to the private sector, but that might change soon. Government funding for healthcare initiatives in such countries as India, Brazil, and Thailand is declining. Some entrepreneurial physicians and hospitals are looking to medical tourism to fill the funding gap.

Medical tourism likely will continue to grow; so too will the legal, quality, and insurance protections for patients. Efficient resource utilization might help reduce U.S. healthcare costs, and improved distribution of destination-country resources might help improve infrastructure and access to better healthcare for their own citizens.

With their leadership skills and expertise, hospitalists can play a major role in reducing healthcare costs.

However, what actual reforms healthcare legislation brings to medical tourism remain to be seen. TH

Dr. Thakkar is a hospitalist and assistant professor in the division of hospital medicine at Johns Hopkins University School of Medicine in Baltimore.

References

1. Medical tourism: Consumers in search of value. Deloitte Consulting LLP website. Available at: www.deloitte.com/dtt/cda/doc/content/us%5Fchs%5FMedicalTourismStudy(1).pdf. Accessed Sept. 13, 2010.
2. Pafford B. The third wave—medical tourism in the 21st century. South Med J. 2009;102(8):810-813.
3. Kher U. Outsourcing your heart. Available at: http://proquest.umi.com/pqdweb?did=1041533291&Fmt=7&clientId=5241&RQT=309&VName=PQD. Accessed Sept. 13, 2010.
4. Forgione DA, Smith PC. Medical tourism and its impact on the US health care system. J Health Care Finance. 2007;34(1):27-35.
5. Lancaster J. Surgeries, side trips for “medical tourists.” The Washington Post website. Available at: www.washingtonpost.com/wp-dyn/articles/A497432004Oct20.html. Accessed Sept. 13, 2010.
6. Horowitz MD, Rosensweig JA, Jones CA. Medical tourism: Globaliz-ation of the healthcare marketplace. MedGenMed. 2007;9(4):33.
7. Milstein A, Smith M. Will the surgical world become flat? Health Aff (Millwood). 2007;26(1):137-141.
8. New AMA guidelines on medical tourism. AMA website. Available at: www.ama-assn.org/ama1/pub/upload/mm/31/medicaltourism.pdf. Accessed March 26, 2010.
9. Anand G. The Henry Ford of heart surgery. Wall Street Journal website. Available at: online.wsj.com/article/SB12587589288795811.html.
10. Einhorn B. Outsourcing the patients. Business Week website. Available at: www.businessweek.com/magazine/content/08_12/b40760367 77780.htm. Accessed Sept. 13, 2010.
11. . Hartman M, Martin A, Nuccio O, Catlin A, et al. Health spending growth at a historic low in 2008. Health Aff (Millwood). 2010;29(1): 147-155.
12. Milstein A, Smith M. America’s new refugees—seeking affordable surgery offshore. N Engl J Med. 2006;355(16):1637-1640.

If imitation is the sincerest form of flattery, then hospitalists have a lot to crow about. For the same reasons that sparked the original hospital medicine movement, HM’s specialist colleagues are flocking to the HM model.

“I switched because your impact with consultation is limited,” says geriatrician-hospitalist Jeffrey Farber, MD, assistant professor of geriatrics and palliative medicine and director of the Mobile Acute Care for the Elderly Service (MACE) at Mount Sinai Hospital in New York City. As the former director of the Department of Geriatrics’ consult service, Dr. Farber adds, “I like being able to call the shots and direct the care.”

He’s not the only one. Neurologists, surgeons, and even dermatologists and otolaryngologists have been establishing inpatient services based on the HM model. While many of these programs first begin in the academic setting, where resident work-hour limits necessitate faculty coverage, community hospitals increasingly are turning to specialist hospitalists to address patient-safety and treatment-innovation issues.

According to a leading surgical hospitalist, more than 250 such programs exist throughout the country.

Shaun Frost, MD, FACP, SFHM, chair of SHM’s Membership Committee and SHM’s Emergency Medicine Task Force, an SHM board member, and regional medical director for Brentwood, Tenn.-based Cogent Healthcare, views the growth of specialty hospitalist programs as a positive development. “In many ways, [this trend] is confirmatory regarding the key reasons for creation of the hospital movement,” he says.

For example, mirroring the performance of adult inpatient hospitalist programs, pediatric hospitalist programs have now documented improved throughput, increased efficiency, and increased patient satisfaction, especially when such programs combine pediatric emergency department and pediatric inpatient coverage.¹

“We’ve all been inspired by the success of the medical hospitalist model, and we want to acknowledge and credit them for being the trailblazers and pioneers who are leading the way,” adds John Maa, MD, FACS, assistant professor in the Department of Surgery, assistant chair of the Surgery Quality Improvement Program, and director of the Surgical Hospitalist Program at the University of California at San Francisco (UCSF). Dr. Maa and colleagues introduced the surgical hospitalist program at UCSF in July 2005.

It used to be that neurologists didn’t have to get out of bed at night for most strokes. But with innovations in stroke treatments, that’s all changed. It really helped to give birth to the neurohospitalist movement.

—David Likosky, MD, FHM, neurohospitalist, stroke program director, Evergreen Hospital Medical Center, Seattle

What’s Driving the Trend?

The impetus for adopting and adapting the HM model varies across medical specialties. For some, it was necessity; for others, it was a way to extend coverage or streamline the hospital stay; and for still others, it was a matter of personal choice.

“We couldn’t continue in the old paradigm and deliver safe care, because it was traditionally resident-dependent,” says Dr. Maa, explaining that the 80-hour resident workweek restriction mandated by the Accreditation Council for Graduate Medical Education (ACGME) “annihilated” the old-school model.

The goal in organizing the Society of Dermatology Hospitalists (SDH), according to SDH cofounder Lindy P. Fox, MD, assistant professor of clinical dermatology and director of the hospital consultation service at UCSF, was to ensure 24/7 coverage by a dedicated group of dermatologists whose skill set is focused on inpatient care, and who, because of their involvement with the university hospital, are probably more comfortable with the nuances of inpatient dermatologic care than their outpatient-based colleagues. The SDH currently has 20 members representing about 15 academic programs.

Innovations in stroke treatment caused a “sea change” for the field of neurology, says David Likosky, MD, SFHM, hospitalist and stroke program director at Evergreen Hospital Medical Center in Seattle. Dr. Likosky, who is board-certified in neurology and internal medicine, says the HM model allows neurohospitalists to enjoy a work-life balance.

“It used to be that neurologists didn’t have to get out of bed at night for most strokes. But with innovations in stroke treatments, that’s all changed,” Dr. Likosky says. “It really helped to give birth to the neurohospitalist movement.”

A recent survey on the current scope of neurohospitalists’ practice presented by Dr. Likosky and colleagues at the American Academy of Neurology found that 8% of those surveyed were full-time neurohospitalists. The number might seem small, but it might be a matter of perception. The same study showed 73% of neurologists surveyed listed inpatient neurology care as their primary practice focus.²

Another driver for the neurohospitalist movement was that it became unfeasible to staff inpatient neurology services with physicians who maintained offices “across town,” observes S. Andrew Josephson, MD, director of the neurohospitalist program and inpatient neurology at UCSF. “Stroke is just one example of a disease that has so many emergent therapies that hospitals decided they needed a neurologist on site to make those types of treatment decisions.”

At a quaternary-care center such as UCSF, the requirements for otolaryngology expertise have increased exponentially, says Andrew H. Murr, MD, FACS, vice-chair of the Department of Otolaryngology/Head and Neck Surgery at UCSF. “For instance, our hospital has a huge transplant volume. Often, patients are on immuno-compromising medications that create the specter of fungal sinusitis,” he says. “We also get called to the operating room or ICU when patients have breathing problems and require surgical airways or other complicated intubation schemes. All of these problems require a lot of time, effort, and special expertise.”

Since September of last year, Dr. Murr’s department has been using office space adjacent to the hospital as headquarters for a full-time otolaryngologist whose sole responsibility is to cover inpatient work. Increased complexity of otolaryngologic-related problems, increased ED commitment, and a simple matter of logistics prompted the move. The Department of Otolaryngology moved 10 minutes away from the hospital, so literally running across the street for an otolaryngology consult was no longer an option.

Today, the hospital duty is linked to the department’s call schedule. Dr. Murr anticipates the department soon will establish a full-time faculty position to create a hospitalist niche within the department.

Usefulness Affirmed

Dr. Farber

Good results already have been demonstrated for the hospitalist model in other specialties. In the first two years of the surgical hospitalist program at UCSF, response times for surgical consultations averaged less than 20 minutes; the average wait for patients with acute appendicitis to undergo surgery was cut in half; and the number of billable consults rose by almost 200%.³

Heidi Wald, MD, MSPH, FHM, a 2009 Health and Aging Policy Fellow, and two hospitalist colleagues studied the impact of hospitalist programs on acute-care geriatrics and found a paucity of geriatric-care approaches.⁴ “The employment of geriatrics-trained clinicians by hospitalist programs is one approach to supporting generalist-hospitalists and inclining group culture toward clinical geriatric concerns,” the authors wrote. “Programs that purposefully hired geriatricians and gerontology nurse-practitioners used them to staff geriatrics services.”

Dr. Wald, assistant professor of medicine in the division of Health Care Policy Research and a hospitalist at the University of Colorado Denver, says trends in patient demographics and patient-safety initiatives will drive the proliferation of more geriatrician-hospitalists and geriatrics-focused services in the future. “The median age of the hospital population is increasing,” she notes, “and there are not enough geriatricians to deal with every elderly patient.”

Mount Sinai’s Dr. Farber is in the process of submitting for publication two years’ worth of data about the MACE service at Mount Sinai, which will evaluate the effect of MACE on costs, length of stay, and rehospitalization rates.

Variations on a Theme

The dermatology HM model at UCSF more closely resembles a consultative practice model. UCSF’s dermatology hospitalists do not admit patients. Still, says SDH’s Dr. Fox, because of their conversance with inpatient care and round-the-clock availability, dermatology hospitalists are invaluable. They help colleagues “puzzle out” the causes of cutaneous manifestations of system disease, quickly initiate state of the art treatment for hospital-acquired skin conditions, and improve outcomes for hospitalized patients with skin diseases.

“We see our charge as being multifold,” Dr. Fox explains. “We provide continuity of care for patients who are frequently hospitalized; we keep up with the medical literature; we are comfortable with and know the nuances of hospital operations; and we provide education to residents, house staff, and colleagues.”

In Denver, the Acute Care for the Elderly (ACE) service operated by the internal-medicine hospitalist group has only informal ties to the Department of Medicine’s Geriatrics Division, Dr. Wald says. Although not a closed geriatric-care unit, the service concentrates elderly patients on one inpatient service and introduces the tenets of geriatric care—multidisciplinary approach, functional assessment, early discharge planning, mitigating the hazards of hospitalization, and patient and family-centered care—into a hospitalist milieu.

Surgical hospitalist models also vary by setting, and continue to evolve as surgeons examine processes to determine what works and what doesn’t. At UCSF, the original model relied on surgeons taking call for seven days running. “You probably couldn’t do that continuously for your career,” says Dr. Maa, who worked the seven-day call schedule for 3 1/2 years.

The program has been modified so that the surgical hospitalists now work three- or four-day stretches.

Another successful variation involves one surgeon taking all the daytime shifts, while others rotate in for the PM shifts and weekends.

A Win-Win for Hospitalists?

Does the proliferation of specialty hospitalists create competition for patients? That could be a possibility, says Dr. Frost, should other specialty hospitalists become interested in providing care for the “bread and butter” pathologies.

“For instance, if neurohospitalists were interested in evaluating and managing patients with TIAs (transient ischemic attacks), or cardiohospitalists were interested in managing patients with low-risk chest pain, then there could be some competition,” Dr. Frost says. Although possible, he senses it isn’t a likely scenario.

What’s more likely, according to neurohospitalist Dr. Likosky, is cross-fertilization between specialties, where hospitalists who interface with their specialty colleagues gain the benefit of on-site, in-service education. “Many hospitalists feel that they were not adequately trained in neurologic illnesses, and yet, by default, they have become the first-line providers of inpatient neurologic care nationally,” Dr. Likosky says. “The neurohospitalist model is a way of getting at that issue. I don’t think that we are in competition. I think we are welcome partners.”

Dr. Likosky and fellow neurohospitalists Dr. Josephson and W. David Freeman, MD, assistant professor in the department of neurology and critical care at the Mayo Clinic College of Medicine in Jacksonville, Fla., offered the first neurology precourse in April at HM10 in Washington, D.C., and more and more hospitalist meetings are including neurohospitalist courses on their schedules.

Increased education also is a benefit of Mount Sinai’s adaptation of the MACE concept, Dr. Farber says. Because the hospitalist-run MACE patients are located throughout the hospital, the team conducts nursing grand rounds to educate other hospital staff about geriatrics-centered HM principles.

This represents a transformation of the way an academic medical center is structured. We’ve traditionally prioritized research ahead of patient care, but this model is inverting that. It is patient-centered, making them the priority.

—John Maa, MD, FACS, assistant professor, Department of Surgery; assistant chair, Surgery Quality Improvement Program; director, Surgical Hospitalist Program, University of California at San Francisco

Economies of Scale

Dr. Fox, the dermatology hospitalist, is the first to admit that UCSF’s practice model probably works best in a large, tertiary-care, academic medical center. However, the potential exists for extension into rural settings with telemedicine models and trained physician assistants or nurse practitioners, she notes.

Dr. Farber agrees the HM model is adaptable to a variety of medical specialties; he foresees geriatric hospitalists working in community settings. “Even in smaller hospitals with fewer discharges, there will be a sizable subset of admissions of patients at risk for high utilization of resources,” he says. “Many of Medicare’s hospital-acquired conditions are geriatrics-related, such as catheter-associated urinary tract infections, central-line infections, and falls. The investment [in geriatrician-hospitalist teams] could be justified if you track the outcomes of these high-risk patients over time and see whether you’re reducing length of stay, direct costs, and readmissions.”

Dr. Likosky says the benefits of the neurohospitalist model closely mirror those of the HM model, and although volumes are lower, the benefits “remain significant even in relatively small hospitals.” His American Academy of Neurology (AAN) survey backs up this observation: Neurohospitalists were about evenly split between academic and private settings (49% and 51%, respectively). “Unlike dermatology, neurologic diagnoses are very common as either a primary or secondary reason for admission to the hospital,” Dr. Likosky says.

In the community setting, surgical hospitalist programs provide a new answer for ED call coverage, Dr. Maa says. Surgical practices often approach the medical center leadership to negotiate a stipend, then contribute salary support so that a new surgeon can be recruited to join the practice. This physician—usually a younger surgeon—then is hired in the role of a surgicalist so that timely patient care and surgeon availability can be ensured.

In rural settings, however, even this model might not be feasible, Dr. Maa says, because surgical practices could be comprised of only one or two surgeons. “We will have to think differently about telemedicine, telesurgery, and having ERs equipped with video monitors so that the ED physician can examine the patient while a surgeon, at a remote centralized area, can provide input,” he says.

Adoption of the hospitalist model by other specialties shows no sign of slowing down. That’s good news for HM and patient care, Dr. Maa says.

“This represents a transformation of the way an academic medical center is structured,” he adds. “We’ve traditionally prioritized research ahead of patient care, but this model is inverting that. It is patient-centered, making them the priority, and answers the question, ‘How can we reconfigure what we have to take better care of patients?’ And that’s why I think we’ll succeed.” TH

Gretchen Henkel is a freelance writer based in California.

References

1. Krugman SD, Suggs A, Photowala HY, et al. Redefining the community pediatric hospitalist: the combined pediatric ED/inpatient unit. Ped Emerg Car. 2007;23(1):33-37.
2. Likosky D. Is it time for neurohospitalists? Neurology. 2009;72(9):859-860.
3. Maa J, Carter JT, Gosnell JE, et al. The surgical hospitalist: a new model for emergency surgical care. J Am Coll Surg. 2007;205(5):704-711.
4. Wald H, Huddleston J, Kramer A. Is there a geriatrician in the house? Geriatric care approaches in hospitalist programs. J Hosp Med. 2006;1(1):29-35.

Unique Factors Propel Proliferation of “ists” at Washington Hospital

By Gretchen Henkel

Dr. Farber

“Ists” are multiplying at Providence Regional Medical Center in Everett, Wash. (PRMCE), about 25 miles north of Seattle. The medical hospitalist team manages 90% of the hospital’s medical patients and comprises 34 FTEs, with nocturnists and a palliative-care service; other in-house services include general surgery hospitalists, critical-care hospitalists, orthopedic hospitalists, neurology hospitalists, pediatric hospitalists, and obstetrics hospitalists.

So many “ists” under one roof is unusual for a community-based medical center. One reason for the trend is a highly successful hospitalist program that’s caused other specialists to take notice of the increase in quality metrics and job satisfaction.

“For some reason, we were blessed with an early decision by the hospitalists to acculturate themselves with the hospital’s mission,” says Joanne C. Roberts, MD, FACP, chief of the division of medicine, hospice, and palliative medicine at PRMCE.

The medical hospitalists quickly instituted standardization, quality, and utilization measures, and tied their performance to incentives, says HM medical director Jefferey S. Winningham, MD. For example, every hospitalist is required to leave voicemails for referring physicians upon admittance and discharge of their patients. A 95% compliance rate—validated by surveys of referring physicians—yields bonuses for the HM team.

Quality scores have increased dramatically since 2003, when the hospitalist program took off. PRMCE chief medical officer Larry Schechter, MD, says that the hospitalists’ success has increased the willingness of other specialists to adopt the HM model for delivering inpatient care.

Another factor in the swift adoption of specialist hospitalists: Except for the intensivist service—recipient of the American Association of Critical-Care Nurses’ 2008-2009 Beacon Award for Care Excellence—most of PRMCE’s programs are staffed with physician members of Everett Clinic, a large multispecialty group. “The secret of this community is the large medical groups,” Dr. Roberts says. “Everybody plays well together, especially at the senior leadership level.”

Fewer administrators means nimble decision-making, Dr. Schechter notes. Hospitalists’ internal teamwork is continuously reinforced through bimonthly team meetings; with hospital administrators in steering committee meetings, the hospitalist program has “set a high bar and brought the community together,” Dr. Winningham says.

As PRMCE grows—a new, 12-story tower is set to open in 2011—the hospital is poised to attain its mission of becoming a regional referral center. “To deliver quality at the lowest cost is a really serious enterprise,” Dr. Roberts says, “so getting the hospitalists engaged in that value proposition has been challenging but delightfully fun.”

If imitation is the sincerest form of flattery, then hospitalists have a lot to crow about. For the same reasons that sparked the original hospital medicine movement, HM’s specialist colleagues are flocking to the HM model.

“I switched because your impact with consultation is limited,” says geriatrician-hospitalist Jeffrey Farber, MD, assistant professor of geriatrics and palliative medicine and director of the Mobile Acute Care for the Elderly Service (MACE) at Mount Sinai Hospital in New York City. As the former director of the Department of Geriatrics’ consult service, Dr. Farber adds, “I like being able to call the shots and direct the care.”

He’s not the only one. Neurologists, surgeons, and even dermatologists and otolaryngologists have been establishing inpatient services based on the HM model. While many of these programs first begin in the academic setting, where resident work-hour limits necessitate faculty coverage, community hospitals increasingly are turning to specialist hospitalists to address patient-safety and treatment-innovation issues.

According to a leading surgical hospitalist, more than 250 such programs exist throughout the country.

Shaun Frost, MD, FACP, SFHM, chair of SHM’s Membership Committee and SHM’s Emergency Medicine Task Force, an SHM board member, and regional medical director for Brentwood, Tenn.-based Cogent Healthcare, views the growth of specialty hospitalist programs as a positive development. “In many ways, [this trend] is confirmatory regarding the key reasons for creation of the hospital movement,” he says.

For example, mirroring the performance of adult inpatient hospitalist programs, pediatric hospitalist programs have now documented improved throughput, increased efficiency, and increased patient satisfaction, especially when such programs combine pediatric emergency department and pediatric inpatient coverage.¹

“We’ve all been inspired by the success of the medical hospitalist model, and we want to acknowledge and credit them for being the trailblazers and pioneers who are leading the way,” adds John Maa, MD, FACS, assistant professor in the Department of Surgery, assistant chair of the Surgery Quality Improvement Program, and director of the Surgical Hospitalist Program at the University of California at San Francisco (UCSF). Dr. Maa and colleagues introduced the surgical hospitalist program at UCSF in July 2005.

It used to be that neurologists didn’t have to get out of bed at night for most strokes. But with innovations in stroke treatments, that’s all changed. It really helped to give birth to the neurohospitalist movement.

—David Likosky, MD, FHM, neurohospitalist, stroke program director, Evergreen Hospital Medical Center, Seattle

What’s Driving the Trend?

The impetus for adopting and adapting the HM model varies across medical specialties. For some, it was necessity; for others, it was a way to extend coverage or streamline the hospital stay; and for still others, it was a matter of personal choice.

“We couldn’t continue in the old paradigm and deliver safe care, because it was traditionally resident-dependent,” says Dr. Maa, explaining that the 80-hour resident workweek restriction mandated by the Accreditation Council for Graduate Medical Education (ACGME) “annihilated” the old-school model.

The goal in organizing the Society of Dermatology Hospitalists (SDH), according to SDH cofounder Lindy P. Fox, MD, assistant professor of clinical dermatology and director of the hospital consultation service at UCSF, was to ensure 24/7 coverage by a dedicated group of dermatologists whose skill set is focused on inpatient care, and who, because of their involvement with the university hospital, are probably more comfortable with the nuances of inpatient dermatologic care than their outpatient-based colleagues. The SDH currently has 20 members representing about 15 academic programs.

Innovations in stroke treatment caused a “sea change” for the field of neurology, says David Likosky, MD, SFHM, hospitalist and stroke program director at Evergreen Hospital Medical Center in Seattle. Dr. Likosky, who is board-certified in neurology and internal medicine, says the HM model allows neurohospitalists to enjoy a work-life balance.

“It used to be that neurologists didn’t have to get out of bed at night for most strokes. But with innovations in stroke treatments, that’s all changed,” Dr. Likosky says. “It really helped to give birth to the neurohospitalist movement.”

A recent survey on the current scope of neurohospitalists’ practice presented by Dr. Likosky and colleagues at the American Academy of Neurology found that 8% of those surveyed were full-time neurohospitalists. The number might seem small, but it might be a matter of perception. The same study showed 73% of neurologists surveyed listed inpatient neurology care as their primary practice focus.²

Another driver for the neurohospitalist movement was that it became unfeasible to staff inpatient neurology services with physicians who maintained offices “across town,” observes S. Andrew Josephson, MD, director of the neurohospitalist program and inpatient neurology at UCSF. “Stroke is just one example of a disease that has so many emergent therapies that hospitals decided they needed a neurologist on site to make those types of treatment decisions.”

At a quaternary-care center such as UCSF, the requirements for otolaryngology expertise have increased exponentially, says Andrew H. Murr, MD, FACS, vice-chair of the Department of Otolaryngology/Head and Neck Surgery at UCSF. “For instance, our hospital has a huge transplant volume. Often, patients are on immuno-compromising medications that create the specter of fungal sinusitis,” he says. “We also get called to the operating room or ICU when patients have breathing problems and require surgical airways or other complicated intubation schemes. All of these problems require a lot of time, effort, and special expertise.”

Since September of last year, Dr. Murr’s department has been using office space adjacent to the hospital as headquarters for a full-time otolaryngologist whose sole responsibility is to cover inpatient work. Increased complexity of otolaryngologic-related problems, increased ED commitment, and a simple matter of logistics prompted the move. The Department of Otolaryngology moved 10 minutes away from the hospital, so literally running across the street for an otolaryngology consult was no longer an option.

Today, the hospital duty is linked to the department’s call schedule. Dr. Murr anticipates the department soon will establish a full-time faculty position to create a hospitalist niche within the department.

Usefulness Affirmed

Dr. Farber

Good results already have been demonstrated for the hospitalist model in other specialties. In the first two years of the surgical hospitalist program at UCSF, response times for surgical consultations averaged less than 20 minutes; the average wait for patients with acute appendicitis to undergo surgery was cut in half; and the number of billable consults rose by almost 200%.³

Heidi Wald, MD, MSPH, FHM, a 2009 Health and Aging Policy Fellow, and two hospitalist colleagues studied the impact of hospitalist programs on acute-care geriatrics and found a paucity of geriatric-care approaches.⁴ “The employment of geriatrics-trained clinicians by hospitalist programs is one approach to supporting generalist-hospitalists and inclining group culture toward clinical geriatric concerns,” the authors wrote. “Programs that purposefully hired geriatricians and gerontology nurse-practitioners used them to staff geriatrics services.”

Dr. Wald, assistant professor of medicine in the division of Health Care Policy Research and a hospitalist at the University of Colorado Denver, says trends in patient demographics and patient-safety initiatives will drive the proliferation of more geriatrician-hospitalists and geriatrics-focused services in the future. “The median age of the hospital population is increasing,” she notes, “and there are not enough geriatricians to deal with every elderly patient.”

Mount Sinai’s Dr. Farber is in the process of submitting for publication two years’ worth of data about the MACE service at Mount Sinai, which will evaluate the effect of MACE on costs, length of stay, and rehospitalization rates.

Variations on a Theme

The dermatology HM model at UCSF more closely resembles a consultative practice model. UCSF’s dermatology hospitalists do not admit patients. Still, says SDH’s Dr. Fox, because of their conversance with inpatient care and round-the-clock availability, dermatology hospitalists are invaluable. They help colleagues “puzzle out” the causes of cutaneous manifestations of system disease, quickly initiate state of the art treatment for hospital-acquired skin conditions, and improve outcomes for hospitalized patients with skin diseases.

“We see our charge as being multifold,” Dr. Fox explains. “We provide continuity of care for patients who are frequently hospitalized; we keep up with the medical literature; we are comfortable with and know the nuances of hospital operations; and we provide education to residents, house staff, and colleagues.”

In Denver, the Acute Care for the Elderly (ACE) service operated by the internal-medicine hospitalist group has only informal ties to the Department of Medicine’s Geriatrics Division, Dr. Wald says. Although not a closed geriatric-care unit, the service concentrates elderly patients on one inpatient service and introduces the tenets of geriatric care—multidisciplinary approach, functional assessment, early discharge planning, mitigating the hazards of hospitalization, and patient and family-centered care—into a hospitalist milieu.

Surgical hospitalist models also vary by setting, and continue to evolve as surgeons examine processes to determine what works and what doesn’t. At UCSF, the original model relied on surgeons taking call for seven days running. “You probably couldn’t do that continuously for your career,” says Dr. Maa, who worked the seven-day call schedule for 3 1/2 years.

The program has been modified so that the surgical hospitalists now work three- or four-day stretches.

Another successful variation involves one surgeon taking all the daytime shifts, while others rotate in for the PM shifts and weekends.

A Win-Win for Hospitalists?

Does the proliferation of specialty hospitalists create competition for patients? That could be a possibility, says Dr. Frost, should other specialty hospitalists become interested in providing care for the “bread and butter” pathologies.

“For instance, if neurohospitalists were interested in evaluating and managing patients with TIAs (transient ischemic attacks), or cardiohospitalists were interested in managing patients with low-risk chest pain, then there could be some competition,” Dr. Frost says. Although possible, he senses it isn’t a likely scenario.

What’s more likely, according to neurohospitalist Dr. Likosky, is cross-fertilization between specialties, where hospitalists who interface with their specialty colleagues gain the benefit of on-site, in-service education. “Many hospitalists feel that they were not adequately trained in neurologic illnesses, and yet, by default, they have become the first-line providers of inpatient neurologic care nationally,” Dr. Likosky says. “The neurohospitalist model is a way of getting at that issue. I don’t think that we are in competition. I think we are welcome partners.”

Dr. Likosky and fellow neurohospitalists Dr. Josephson and W. David Freeman, MD, assistant professor in the department of neurology and critical care at the Mayo Clinic College of Medicine in Jacksonville, Fla., offered the first neurology precourse in April at HM10 in Washington, D.C., and more and more hospitalist meetings are including neurohospitalist courses on their schedules.

Increased education also is a benefit of Mount Sinai’s adaptation of the MACE concept, Dr. Farber says. Because the hospitalist-run MACE patients are located throughout the hospital, the team conducts nursing grand rounds to educate other hospital staff about geriatrics-centered HM principles.

This represents a transformation of the way an academic medical center is structured. We’ve traditionally prioritized research ahead of patient care, but this model is inverting that. It is patient-centered, making them the priority.

—John Maa, MD, FACS, assistant professor, Department of Surgery; assistant chair, Surgery Quality Improvement Program; director, Surgical Hospitalist Program, University of California at San Francisco

Economies of Scale

Dr. Fox, the dermatology hospitalist, is the first to admit that UCSF’s practice model probably works best in a large, tertiary-care, academic medical center. However, the potential exists for extension into rural settings with telemedicine models and trained physician assistants or nurse practitioners, she notes.

Dr. Farber agrees the HM model is adaptable to a variety of medical specialties; he foresees geriatric hospitalists working in community settings. “Even in smaller hospitals with fewer discharges, there will be a sizable subset of admissions of patients at risk for high utilization of resources,” he says. “Many of Medicare’s hospital-acquired conditions are geriatrics-related, such as catheter-associated urinary tract infections, central-line infections, and falls. The investment [in geriatrician-hospitalist teams] could be justified if you track the outcomes of these high-risk patients over time and see whether you’re reducing length of stay, direct costs, and readmissions.”

Dr. Likosky says the benefits of the neurohospitalist model closely mirror those of the HM model, and although volumes are lower, the benefits “remain significant even in relatively small hospitals.” His American Academy of Neurology (AAN) survey backs up this observation: Neurohospitalists were about evenly split between academic and private settings (49% and 51%, respectively). “Unlike dermatology, neurologic diagnoses are very common as either a primary or secondary reason for admission to the hospital,” Dr. Likosky says.

In the community setting, surgical hospitalist programs provide a new answer for ED call coverage, Dr. Maa says. Surgical practices often approach the medical center leadership to negotiate a stipend, then contribute salary support so that a new surgeon can be recruited to join the practice. This physician—usually a younger surgeon—then is hired in the role of a surgicalist so that timely patient care and surgeon availability can be ensured.

In rural settings, however, even this model might not be feasible, Dr. Maa says, because surgical practices could be comprised of only one or two surgeons. “We will have to think differently about telemedicine, telesurgery, and having ERs equipped with video monitors so that the ED physician can examine the patient while a surgeon, at a remote centralized area, can provide input,” he says.

Adoption of the hospitalist model by other specialties shows no sign of slowing down. That’s good news for HM and patient care, Dr. Maa says.

“This represents a transformation of the way an academic medical center is structured,” he adds. “We’ve traditionally prioritized research ahead of patient care, but this model is inverting that. It is patient-centered, making them the priority, and answers the question, ‘How can we reconfigure what we have to take better care of patients?’ And that’s why I think we’ll succeed.” TH

Gretchen Henkel is a freelance writer based in California.

References

1. Krugman SD, Suggs A, Photowala HY, et al. Redefining the community pediatric hospitalist: the combined pediatric ED/inpatient unit. Ped Emerg Car. 2007;23(1):33-37.
2. Likosky D. Is it time for neurohospitalists? Neurology. 2009;72(9):859-860.
3. Maa J, Carter JT, Gosnell JE, et al. The surgical hospitalist: a new model for emergency surgical care. J Am Coll Surg. 2007;205(5):704-711.
4. Wald H, Huddleston J, Kramer A. Is there a geriatrician in the house? Geriatric care approaches in hospitalist programs. J Hosp Med. 2006;1(1):29-35.

Unique Factors Propel Proliferation of “ists” at Washington Hospital

By Gretchen Henkel

Dr. Farber

“Ists” are multiplying at Providence Regional Medical Center in Everett, Wash. (PRMCE), about 25 miles north of Seattle. The medical hospitalist team manages 90% of the hospital’s medical patients and comprises 34 FTEs, with nocturnists and a palliative-care service; other in-house services include general surgery hospitalists, critical-care hospitalists, orthopedic hospitalists, neurology hospitalists, pediatric hospitalists, and obstetrics hospitalists.

So many “ists” under one roof is unusual for a community-based medical center. One reason for the trend is a highly successful hospitalist program that’s caused other specialists to take notice of the increase in quality metrics and job satisfaction.

“For some reason, we were blessed with an early decision by the hospitalists to acculturate themselves with the hospital’s mission,” says Joanne C. Roberts, MD, FACP, chief of the division of medicine, hospice, and palliative medicine at PRMCE.

The medical hospitalists quickly instituted standardization, quality, and utilization measures, and tied their performance to incentives, says HM medical director Jefferey S. Winningham, MD. For example, every hospitalist is required to leave voicemails for referring physicians upon admittance and discharge of their patients. A 95% compliance rate—validated by surveys of referring physicians—yields bonuses for the HM team.

Quality scores have increased dramatically since 2003, when the hospitalist program took off. PRMCE chief medical officer Larry Schechter, MD, says that the hospitalists’ success has increased the willingness of other specialists to adopt the HM model for delivering inpatient care.

Another factor in the swift adoption of specialist hospitalists: Except for the intensivist service—recipient of the American Association of Critical-Care Nurses’ 2008-2009 Beacon Award for Care Excellence—most of PRMCE’s programs are staffed with physician members of Everett Clinic, a large multispecialty group. “The secret of this community is the large medical groups,” Dr. Roberts says. “Everybody plays well together, especially at the senior leadership level.”

Fewer administrators means nimble decision-making, Dr. Schechter notes. Hospitalists’ internal teamwork is continuously reinforced through bimonthly team meetings; with hospital administrators in steering committee meetings, the hospitalist program has “set a high bar and brought the community together,” Dr. Winningham says.

As PRMCE grows—a new, 12-story tower is set to open in 2011—the hospital is poised to attain its mission of becoming a regional referral center. “To deliver quality at the lowest cost is a really serious enterprise,” Dr. Roberts says, “so getting the hospitalists engaged in that value proposition has been challenging but delightfully fun.”

If imitation is the sincerest form of flattery, then hospitalists have a lot to crow about. For the same reasons that sparked the original hospital medicine movement, HM’s specialist colleagues are flocking to the HM model.

“I switched because your impact with consultation is limited,” says geriatrician-hospitalist Jeffrey Farber, MD, assistant professor of geriatrics and palliative medicine and director of the Mobile Acute Care for the Elderly Service (MACE) at Mount Sinai Hospital in New York City. As the former director of the Department of Geriatrics’ consult service, Dr. Farber adds, “I like being able to call the shots and direct the care.”

He’s not the only one. Neurologists, surgeons, and even dermatologists and otolaryngologists have been establishing inpatient services based on the HM model. While many of these programs first begin in the academic setting, where resident work-hour limits necessitate faculty coverage, community hospitals increasingly are turning to specialist hospitalists to address patient-safety and treatment-innovation issues.

According to a leading surgical hospitalist, more than 250 such programs exist throughout the country.

Shaun Frost, MD, FACP, SFHM, chair of SHM’s Membership Committee and SHM’s Emergency Medicine Task Force, an SHM board member, and regional medical director for Brentwood, Tenn.-based Cogent Healthcare, views the growth of specialty hospitalist programs as a positive development. “In many ways, [this trend] is confirmatory regarding the key reasons for creation of the hospital movement,” he says.

For example, mirroring the performance of adult inpatient hospitalist programs, pediatric hospitalist programs have now documented improved throughput, increased efficiency, and increased patient satisfaction, especially when such programs combine pediatric emergency department and pediatric inpatient coverage.¹

“We’ve all been inspired by the success of the medical hospitalist model, and we want to acknowledge and credit them for being the trailblazers and pioneers who are leading the way,” adds John Maa, MD, FACS, assistant professor in the Department of Surgery, assistant chair of the Surgery Quality Improvement Program, and director of the Surgical Hospitalist Program at the University of California at San Francisco (UCSF). Dr. Maa and colleagues introduced the surgical hospitalist program at UCSF in July 2005.

It used to be that neurologists didn’t have to get out of bed at night for most strokes. But with innovations in stroke treatments, that’s all changed. It really helped to give birth to the neurohospitalist movement.

—David Likosky, MD, FHM, neurohospitalist, stroke program director, Evergreen Hospital Medical Center, Seattle

What’s Driving the Trend?

The impetus for adopting and adapting the HM model varies across medical specialties. For some, it was necessity; for others, it was a way to extend coverage or streamline the hospital stay; and for still others, it was a matter of personal choice.

“We couldn’t continue in the old paradigm and deliver safe care, because it was traditionally resident-dependent,” says Dr. Maa, explaining that the 80-hour resident workweek restriction mandated by the Accreditation Council for Graduate Medical Education (ACGME) “annihilated” the old-school model.

The goal in organizing the Society of Dermatology Hospitalists (SDH), according to SDH cofounder Lindy P. Fox, MD, assistant professor of clinical dermatology and director of the hospital consultation service at UCSF, was to ensure 24/7 coverage by a dedicated group of dermatologists whose skill set is focused on inpatient care, and who, because of their involvement with the university hospital, are probably more comfortable with the nuances of inpatient dermatologic care than their outpatient-based colleagues. The SDH currently has 20 members representing about 15 academic programs.

Innovations in stroke treatment caused a “sea change” for the field of neurology, says David Likosky, MD, SFHM, hospitalist and stroke program director at Evergreen Hospital Medical Center in Seattle. Dr. Likosky, who is board-certified in neurology and internal medicine, says the HM model allows neurohospitalists to enjoy a work-life balance.

“It used to be that neurologists didn’t have to get out of bed at night for most strokes. But with innovations in stroke treatments, that’s all changed,” Dr. Likosky says. “It really helped to give birth to the neurohospitalist movement.”

A recent survey on the current scope of neurohospitalists’ practice presented by Dr. Likosky and colleagues at the American Academy of Neurology found that 8% of those surveyed were full-time neurohospitalists. The number might seem small, but it might be a matter of perception. The same study showed 73% of neurologists surveyed listed inpatient neurology care as their primary practice focus.²

Another driver for the neurohospitalist movement was that it became unfeasible to staff inpatient neurology services with physicians who maintained offices “across town,” observes S. Andrew Josephson, MD, director of the neurohospitalist program and inpatient neurology at UCSF. “Stroke is just one example of a disease that has so many emergent therapies that hospitals decided they needed a neurologist on site to make those types of treatment decisions.”

At a quaternary-care center such as UCSF, the requirements for otolaryngology expertise have increased exponentially, says Andrew H. Murr, MD, FACS, vice-chair of the Department of Otolaryngology/Head and Neck Surgery at UCSF. “For instance, our hospital has a huge transplant volume. Often, patients are on immuno-compromising medications that create the specter of fungal sinusitis,” he says. “We also get called to the operating room or ICU when patients have breathing problems and require surgical airways or other complicated intubation schemes. All of these problems require a lot of time, effort, and special expertise.”

Since September of last year, Dr. Murr’s department has been using office space adjacent to the hospital as headquarters for a full-time otolaryngologist whose sole responsibility is to cover inpatient work. Increased complexity of otolaryngologic-related problems, increased ED commitment, and a simple matter of logistics prompted the move. The Department of Otolaryngology moved 10 minutes away from the hospital, so literally running across the street for an otolaryngology consult was no longer an option.

Today, the hospital duty is linked to the department’s call schedule. Dr. Murr anticipates the department soon will establish a full-time faculty position to create a hospitalist niche within the department.

Usefulness Affirmed

Dr. Farber

Good results already have been demonstrated for the hospitalist model in other specialties. In the first two years of the surgical hospitalist program at UCSF, response times for surgical consultations averaged less than 20 minutes; the average wait for patients with acute appendicitis to undergo surgery was cut in half; and the number of billable consults rose by almost 200%.³

Heidi Wald, MD, MSPH, FHM, a 2009 Health and Aging Policy Fellow, and two hospitalist colleagues studied the impact of hospitalist programs on acute-care geriatrics and found a paucity of geriatric-care approaches.⁴ “The employment of geriatrics-trained clinicians by hospitalist programs is one approach to supporting generalist-hospitalists and inclining group culture toward clinical geriatric concerns,” the authors wrote. “Programs that purposefully hired geriatricians and gerontology nurse-practitioners used them to staff geriatrics services.”

Dr. Wald, assistant professor of medicine in the division of Health Care Policy Research and a hospitalist at the University of Colorado Denver, says trends in patient demographics and patient-safety initiatives will drive the proliferation of more geriatrician-hospitalists and geriatrics-focused services in the future. “The median age of the hospital population is increasing,” she notes, “and there are not enough geriatricians to deal with every elderly patient.”

Mount Sinai’s Dr. Farber is in the process of submitting for publication two years’ worth of data about the MACE service at Mount Sinai, which will evaluate the effect of MACE on costs, length of stay, and rehospitalization rates.

Variations on a Theme

The dermatology HM model at UCSF more closely resembles a consultative practice model. UCSF’s dermatology hospitalists do not admit patients. Still, says SDH’s Dr. Fox, because of their conversance with inpatient care and round-the-clock availability, dermatology hospitalists are invaluable. They help colleagues “puzzle out” the causes of cutaneous manifestations of system disease, quickly initiate state of the art treatment for hospital-acquired skin conditions, and improve outcomes for hospitalized patients with skin diseases.

“We see our charge as being multifold,” Dr. Fox explains. “We provide continuity of care for patients who are frequently hospitalized; we keep up with the medical literature; we are comfortable with and know the nuances of hospital operations; and we provide education to residents, house staff, and colleagues.”

In Denver, the Acute Care for the Elderly (ACE) service operated by the internal-medicine hospitalist group has only informal ties to the Department of Medicine’s Geriatrics Division, Dr. Wald says. Although not a closed geriatric-care unit, the service concentrates elderly patients on one inpatient service and introduces the tenets of geriatric care—multidisciplinary approach, functional assessment, early discharge planning, mitigating the hazards of hospitalization, and patient and family-centered care—into a hospitalist milieu.

Surgical hospitalist models also vary by setting, and continue to evolve as surgeons examine processes to determine what works and what doesn’t. At UCSF, the original model relied on surgeons taking call for seven days running. “You probably couldn’t do that continuously for your career,” says Dr. Maa, who worked the seven-day call schedule for 3 1/2 years.

The program has been modified so that the surgical hospitalists now work three- or four-day stretches.

Another successful variation involves one surgeon taking all the daytime shifts, while others rotate in for the PM shifts and weekends.

A Win-Win for Hospitalists?

Does the proliferation of specialty hospitalists create competition for patients? That could be a possibility, says Dr. Frost, should other specialty hospitalists become interested in providing care for the “bread and butter” pathologies.

“For instance, if neurohospitalists were interested in evaluating and managing patients with TIAs (transient ischemic attacks), or cardiohospitalists were interested in managing patients with low-risk chest pain, then there could be some competition,” Dr. Frost says. Although possible, he senses it isn’t a likely scenario.

What’s more likely, according to neurohospitalist Dr. Likosky, is cross-fertilization between specialties, where hospitalists who interface with their specialty colleagues gain the benefit of on-site, in-service education. “Many hospitalists feel that they were not adequately trained in neurologic illnesses, and yet, by default, they have become the first-line providers of inpatient neurologic care nationally,” Dr. Likosky says. “The neurohospitalist model is a way of getting at that issue. I don’t think that we are in competition. I think we are welcome partners.”

Dr. Likosky and fellow neurohospitalists Dr. Josephson and W. David Freeman, MD, assistant professor in the department of neurology and critical care at the Mayo Clinic College of Medicine in Jacksonville, Fla., offered the first neurology precourse in April at HM10 in Washington, D.C., and more and more hospitalist meetings are including neurohospitalist courses on their schedules.

Increased education also is a benefit of Mount Sinai’s adaptation of the MACE concept, Dr. Farber says. Because the hospitalist-run MACE patients are located throughout the hospital, the team conducts nursing grand rounds to educate other hospital staff about geriatrics-centered HM principles.

This represents a transformation of the way an academic medical center is structured. We’ve traditionally prioritized research ahead of patient care, but this model is inverting that. It is patient-centered, making them the priority.

—John Maa, MD, FACS, assistant professor, Department of Surgery; assistant chair, Surgery Quality Improvement Program; director, Surgical Hospitalist Program, University of California at San Francisco

Economies of Scale

Dr. Fox, the dermatology hospitalist, is the first to admit that UCSF’s practice model probably works best in a large, tertiary-care, academic medical center. However, the potential exists for extension into rural settings with telemedicine models and trained physician assistants or nurse practitioners, she notes.

Dr. Farber agrees the HM model is adaptable to a variety of medical specialties; he foresees geriatric hospitalists working in community settings. “Even in smaller hospitals with fewer discharges, there will be a sizable subset of admissions of patients at risk for high utilization of resources,” he says. “Many of Medicare’s hospital-acquired conditions are geriatrics-related, such as catheter-associated urinary tract infections, central-line infections, and falls. The investment [in geriatrician-hospitalist teams] could be justified if you track the outcomes of these high-risk patients over time and see whether you’re reducing length of stay, direct costs, and readmissions.”

Dr. Likosky says the benefits of the neurohospitalist model closely mirror those of the HM model, and although volumes are lower, the benefits “remain significant even in relatively small hospitals.” His American Academy of Neurology (AAN) survey backs up this observation: Neurohospitalists were about evenly split between academic and private settings (49% and 51%, respectively). “Unlike dermatology, neurologic diagnoses are very common as either a primary or secondary reason for admission to the hospital,” Dr. Likosky says.

In the community setting, surgical hospitalist programs provide a new answer for ED call coverage, Dr. Maa says. Surgical practices often approach the medical center leadership to negotiate a stipend, then contribute salary support so that a new surgeon can be recruited to join the practice. This physician—usually a younger surgeon—then is hired in the role of a surgicalist so that timely patient care and surgeon availability can be ensured.

In rural settings, however, even this model might not be feasible, Dr. Maa says, because surgical practices could be comprised of only one or two surgeons. “We will have to think differently about telemedicine, telesurgery, and having ERs equipped with video monitors so that the ED physician can examine the patient while a surgeon, at a remote centralized area, can provide input,” he says.

Adoption of the hospitalist model by other specialties shows no sign of slowing down. That’s good news for HM and patient care, Dr. Maa says.

“This represents a transformation of the way an academic medical center is structured,” he adds. “We’ve traditionally prioritized research ahead of patient care, but this model is inverting that. It is patient-centered, making them the priority, and answers the question, ‘How can we reconfigure what we have to take better care of patients?’ And that’s why I think we’ll succeed.” TH

Gretchen Henkel is a freelance writer based in California.

References

1. Krugman SD, Suggs A, Photowala HY, et al. Redefining the community pediatric hospitalist: the combined pediatric ED/inpatient unit. Ped Emerg Car. 2007;23(1):33-37.
2. Likosky D. Is it time for neurohospitalists? Neurology. 2009;72(9):859-860.
3. Maa J, Carter JT, Gosnell JE, et al. The surgical hospitalist: a new model for emergency surgical care. J Am Coll Surg. 2007;205(5):704-711.
4. Wald H, Huddleston J, Kramer A. Is there a geriatrician in the house? Geriatric care approaches in hospitalist programs. J Hosp Med. 2006;1(1):29-35.

Unique Factors Propel Proliferation of “ists” at Washington Hospital

By Gretchen Henkel

Dr. Farber

“Ists” are multiplying at Providence Regional Medical Center in Everett, Wash. (PRMCE), about 25 miles north of Seattle. The medical hospitalist team manages 90% of the hospital’s medical patients and comprises 34 FTEs, with nocturnists and a palliative-care service; other in-house services include general surgery hospitalists, critical-care hospitalists, orthopedic hospitalists, neurology hospitalists, pediatric hospitalists, and obstetrics hospitalists.

So many “ists” under one roof is unusual for a community-based medical center. One reason for the trend is a highly successful hospitalist program that’s caused other specialists to take notice of the increase in quality metrics and job satisfaction.

“For some reason, we were blessed with an early decision by the hospitalists to acculturate themselves with the hospital’s mission,” says Joanne C. Roberts, MD, FACP, chief of the division of medicine, hospice, and palliative medicine at PRMCE.

The medical hospitalists quickly instituted standardization, quality, and utilization measures, and tied their performance to incentives, says HM medical director Jefferey S. Winningham, MD. For example, every hospitalist is required to leave voicemails for referring physicians upon admittance and discharge of their patients. A 95% compliance rate—validated by surveys of referring physicians—yields bonuses for the HM team.

Quality scores have increased dramatically since 2003, when the hospitalist program took off. PRMCE chief medical officer Larry Schechter, MD, says that the hospitalists’ success has increased the willingness of other specialists to adopt the HM model for delivering inpatient care.

Another factor in the swift adoption of specialist hospitalists: Except for the intensivist service—recipient of the American Association of Critical-Care Nurses’ 2008-2009 Beacon Award for Care Excellence—most of PRMCE’s programs are staffed with physician members of Everett Clinic, a large multispecialty group. “The secret of this community is the large medical groups,” Dr. Roberts says. “Everybody plays well together, especially at the senior leadership level.”

Fewer administrators means nimble decision-making, Dr. Schechter notes. Hospitalists’ internal teamwork is continuously reinforced through bimonthly team meetings; with hospital administrators in steering committee meetings, the hospitalist program has “set a high bar and brought the community together,” Dr. Winningham says.

As PRMCE grows—a new, 12-story tower is set to open in 2011—the hospital is poised to attain its mission of becoming a regional referral center. “To deliver quality at the lowest cost is a really serious enterprise,” Dr. Roberts says, “so getting the hospitalists engaged in that value proposition has been challenging but delightfully fun.”