Hospitalists Seek Parity With Hospitals

Healthcare reform is setting off a multitude of repercussions throughout the U.S. healthcare system, not least of which is the changing relationship between physicians and hospitals.

In last September's HealthLeaders Media's intelligence report, Physician Alignment in an Era of Change, many survey respondents said they believed that hospital and physician relationships would continue to be strained in the wake of healthcare reform. They also said that hospitals planned to employ a greater percentage of physicians over the next several years.

With more employment, and increasing strain, it is clear that physicians and hospitals will continually need to work on alignment issues. One of the most significant areas of potential change in those relationships may involve hospitalists, whose numbers are increasing.

Even though there may be stress with physicians, hospitals view hospitalists as valuable partners in improving quality of care, and rightfully so. In a recent report, more than half—57% - of C-suite leaders in California expected to increase their hospitalist programs within the next two years, according to a study in the Journal of Hospital Medicine.

That's no surprise to Adam Singer, MD, chairman and CEO of IPC the Hospitalist Company, based in North Hollywood, CA was one of the pioneers in the hospitalist development in the 1990s.

Singer was honored in October as the Physician Executive of the Year by the Medial Group Management Association and the American College of Medical Practice Executives. Singer's company, IPC, The Hospitalist Company, is a provider of management services to hospitalist practices to more than 500 facilities, with employment of more than 1,000 affiliated healthcare providers.

It was the first award for a hospitalist from the groups. Indeed, with increasing numbers of hospitalists, they are in a position to become clinical leaders who drive improvements within hospitals, Singer says. The results could be a mutually beneficially relationship for better patient care.

Singer is an unabashed enthusiast for hospitalists, saying those physicians are in a potentially better position to take care of patients "then a doctor going back and forth to an office."

Back in the 1990s, Singer began his own hospitalist journey. "I took on those contracts for physicians where I would manage their entire population of patients, whenever patients showed up at the hospital," he says. Singer says he was among "pulmonologists trying to grab market share for (pulmonary) practice."

Over the past decade, the number of hospitalists has increased to more than 30,000; have increased, and the need for hospitalists is  expected to grow in the wake of healthcare reform. A report cited by The Hospitalist this fall shows that median compensation for adult hospitalists is $215,000 per year.  And many hospitalists are happy about hospital subsidy programs that are used to buttress hospitalist programs.

But within the healthcare system, there are concerns. "A highly functioning hospitalist program can help hospitals operating more efficiency," writes Ron Greeno, MD, in Healthcare Financial Management. "Yet despite the potential hospitals have to positively affect hospital operations in the areas of quality, safety and finance, hospitalist programs do not always generate expected returns."

The reason, Greeno writes, is often linked to how a hospital funds such a program, with hospital subsidies linked to hospitalist productivity but not necessarily on their ability to make hospital care more efficient or better, he adds.

Singer appears to embrace some of those concerns as well, and notes that many hospitals have a difficult time establishing a well-balanced partnership with hospitalists, particularly in their failure to align goals and objectives of the hospitalist group with the hospital.

The subsidy program for hospitalists also ironically seems to have a detrimental impact on hospitalists' efforts to have a greater say or become partners in their health care facilities.

 "It is unclear if many hospitals are willing to give doctors a stake in performance," he says. "The reason is that today most hospitals that employ or even contract with hospitalists are having to pay a subsidy to begin with. In essence, they are paying for the performance up front in anticipation that a hospitalist program will produce results that are in excess of that subsidy. I see very little upside to these subsidies being offered today."

Singer has been fighting the subsidy arrangements for years. Back in 2003, he told Today's Hospitalist saying he believes that "anything that smacks of financial support and prevents hospitalist programs from flying solo financially is a bad thing."

"It's hard to build a new specialty when the underlying assumption is that it's not financially viable—that hospital medicine requires a subsidy to exist," Singer stated seven years ago.

He feels the same way today.

Aside from the subsidy issues, Singer has called for certain strategies to be initiated by hospitalists to be treated fairly "at the table."

For that to happen, hospitalists need to take clinical leadership, as well as ensuring a stake in hospital performance, in all ways: clinically, operationally and financially. While there have been inroads in many areas, there isn't enough, Singer insists.

To make inroads into being a complete part of a hospital, hospitalists need to develop clinical leadership, he says. "Hospitalists should be totally involved in the committee structure of the facility. They should be aspiring to be chief of staff of that hospital.  They have been clinically involved in every level of the building."

"Doctors haven't figured out how to align with hospitals," he says.

So despite all these years of growth among hospitalists and health care systems, some basic issues need to be resolved, such as whether they are partners in treating patient care, and hospitalists are still trying to find their identity. Singer says healthcare reform may begin to help the process, but no one knows for sure.

The award-winning hospitalist says the term itself may be sort of a misnomer. "It is not that I do not like the term hospitalist," he says. "The issue is that we continue to evolve toward an environment of inpatient and outpatient only doctors. The generic term 'hospitalist' does not describe how many of these doctors identify themselves."