"You need specialists who are world experts in small slivers of their work and whose expertise is very, very deep," Wachter says. "And then you need connectors and coordinators. It is really, really tricky. From the patient's experience, you probably want as much one-stop shopping as you can get so you don't have 20 different messages that are invariably going to conflict. On the other hand, do I as a patient really not want the subspecialist to see me, and have everything go through a conduit of someone who is not as well versed in a subspecialty? The interaction has to be somewhere in between that."
Beyond the need for general care, the demands on the care team to reach measures from the competing acronyms of quality overseers keeps fueling the proliferation of hospitalists, who by the nature of being employed are more accountable for participation.
Baptist Health South Florida now employs 26 hospitalists, who work with a handful of community hospitalists from a managed care plan. "Because they are employees, they have their goals and measures to meet. We watch every hospitalist's length of stay—we don't want it too short or too long—their patient satisfaction, and other outcomes such as how they manage deep vein thrombosis. It has really been beneficial to us. They have patient satisfaction above the 90th percentile, and our quality outcomes with them are proving to be really good. We like that model and we are going to stick with it."
Wachter calls the old model of the community primary care physician coming and going "inherently stupid." And given the demands for more integration around quality—not to mention pressure on readmissions, bundling, value-based care—care teams of the future will require more "ists," not fewer.
"I don't just think of it in terms of the hospitalist being a member of that direct patient care team. There is this other set of teams, which is the organizational and managerial team that is tasked with thinking about how to make the system work better, to look at data, to analyze whether it is working better and when it is not. That also requires a new kind of team and new kinds of expertise."
Two care teams won't work anymore. Having one team of physicians, nurses, and therapists in the ambulatory setting that is essentially disconnected to a mirrored one in the hospital is the type of redundancy and outright waste that healthcare can't afford any longer.
Deconstructing each team and melding them into one asks a healthcare system to redefine its role, and to undergo difficult physician alignment issues for which there is yet no clear revenue path. Despite the cliff, a few systems are taking large leaps toward a more horizontal care team now to have the flexible infrastructure for a healthcare revenue stream built more on value and outcomes later.