In a move that healthcare advocates and a local nurses' union say they find troubling and suspicious, the prospective buyer of Jersey City's Christ Hospital has asked that the sale of the hospital be expedited so that the deal concludes by the end of this year. In an Aug. 12 "letter of intent" addressed to Christ President and CEO Peter A. Kelly, a vice president representing Prime Healthcare Services lists several terms of the sale agreement between Christ Hospital and Prime, the California-based company negotiating to buy the facility. Among the terms enumerated is the agreement that "the closing of this transaction would occur as soon as is commercially reasonable after all conditions to the closing?have been satisfied, but in no event later than Dec. 31, 2011." The following month, on Sept. 13, Kelly sent an 18-page letter to the Office of the New Jersey Attorney General requesting that the department approve Prime's purchase of Christ Hospital by Dec. 31.
A ll Jessica wanted was a doctor who would treat her like everyone else. A doctor who was comfortable with her self-identification as queer - a term sometimes used as an umbrella for any variation of lesbian, gay, bisexual, or transgender orientation. But it wasn't until she moved to Boston, in her 30s, that she was ready to even try to look for one. Before that, "the only office I went to was the dentist,'' said the Jamaica Plain resident, who asked to be identified only by her first name to protect her privacy. Despite overall strides in the attitudes toward people who identify as lesbian, gay, bisexual, or transgender many argue that the medical community has lagged behind.
Fifteen years ago, hospitals and physicians began to warm to a revolutionary idea: hospital-based physicians could provide the same, or a better level of care to a patient in the hospital as a primary care physician. Today, hospitalists now work in every major hospital across the country.
Today, a similarly revolutionary idea is taking hold in hospitals, an idea that is changing the way hospital and healthcare leaders look at the caregivers that staff their hospitals. Doctors in nearly every specialty are choosing to adopt the hospitalist model of practice.
In addition to the "legacy" hospitalist fields of adult and pediatric medicine, specialties like neurology, general surgery, obstetrics, psychiatry, orthopedics, gastroenterology, cardiology, and others are, in some settings, choosing to organize themselves into a hospitalist model of practice.
There are even dermatology and ENT hospitalists. Look at recruitment advertisements in the back of medical publications and you'll see pitches for some of these positions. There are no precise statistics available to document the number of doctors in each specialty currently practicing in the hospitalist model. But there is a lot of anecdotal and indirect evidence.
A Web site devoted to obstetric hospitalists ("laborists") currently lists 134 such practices. The Neurohospitalist Society already has an affiliated journal, The Neurohospitalist, entering its second year of publication.
While the current number of hospitalist practitioners in most fields is still a tiny fraction of all the doctors in each specialty, it appears almost certain to grow in coming years. While the majority of inpatient general medical and pediatric care in the United States is now provided by hospitalists, it is unclear whether other specialties will find themselves in the same place eventually.
In some locales most inpatient care in a particular specialty may continue to be provided by doctors in a traditional (inpatient and outpatient) practice model, while in others the hospitalist model will predominate in inpatient care.
Some of the forces behind this growth across specialties are the same as those that led adult and pediatric inpatient medicine to adopt the model. For example, practitioners in any specialty may have difficulty being reliably available to patients in both the inpatient and outpatient setting during a work day, and it can be challenging to keep up with the knowledge base and skill set in each setting.
Other drivers of adoption vary by locale and specialty. For example, unlike many specialties, mid- to late-career general surgeons seem most interested in work as a surgical hospitalist, rather than those early in their career. They often say that they've always enjoyed inpatient surgical care but found it to be an intrusion on their ability to maintain a robust referral stream of private patients.
By leaving their private office practice, and in many cases becoming employed by a hospital, they are relieved of the burden of operating a practice and are often provided with a better call schedule and work-life balance, which extends their careers.
Hospitals are typically supportive of developing a hospitalist model in many specialties even though it appears that all specialties require some funding from a hospital or other source. A common scenario is that a hospital has historically paid on-call stipends to doctors in a given specialty and gotten poor responsiveness and service in return.
By reallocating the dollars spent on call coverage to instead support a hospitalist practice in that specialty, and often adding some additional money, the hospital can support a hospitalist model that promises improved on-call service and potentially better engagement around quality of care goals and other initiatives.
Depending on the particular specialty and the hospital's baseline performance, there may be an opportunity to improve the efficiency of care and market share/patient volume to yield a net positive return on the hospital's financial investment in the program. But even if the program operates at a net financial loss, a hospital may find it a valuable way to respond to things like the needs of existing medical staff and address emergency department on-call problems.
The growth of hospital-focused practice in so many specialties raises a number of issues including the overall value of the care for patients under this model, malpractice liability, and physician training and career longevity. It is reasonable to be optimistic about these things, but important to measure them through future research and not take good results for granted.
Research shows quality of care under the medical hospitalist model generally compares favorably to or improves upon the traditional model. But an August 2011 study showed that reductions in inpatient cost of care resulting from the medical hospitalist model are more than offset by higher costs after discharge, so the net cost to the whole healthcare system is higher.
There are likely to be complex trade-offs and some unforeseen consequences in each specialty, but many hospitals won't be able to wait to adopt the model until robust data proves its value.
Like the original hospitalist specialties of adult general medicine and pediatrics, adoption of a hospital-focused model of practice by many specialties has the potential to change the way hospitals provide care.
Hospitals and healthcare leaders that begin that change today will be able to look back on 2011 as the year they improved care and efficiency at the same time.
John Nelson, MD, MHM, is a hospitalist at Overlake Hospital and a Partner at Nelson Flores Hospital Medicine Consultants. He may be reached at john.nelson@nelsonflores.com
University Hospitals, the region's second largest health system, is trimming $100 million during the next two years as it prepares for a future of declining state and federal reimbursements. The health system, whose network of hospitals and clinics employs about 16,000, has "no plans for major layoffs," said Dr. Achilles Demetriou, COO of University Hospitals. "But constantly, we look at efficiencies and moving people around in parts of the organization depending on performance," Demetriou said, adding "if a unit is performing better than others, we may shift." While Demetriou declined to provide specifics, he described the initiative as a "transformation" and not just cost-cutting. UH executives, he said, were looking at expanding some areas that could improve revenues and keeping others flat by managing costs. And money may be saved by changing models of care, he said. Leaders at the system are asking where the best place may be for a patient to get the best care at the best cost. For instance, they are asking if a physician is always needed or whether a nurse practitioner might be better for a job, Demetriou said.
Blue Shield of California says it will give customers in the state a $283-million credit on their insurance premiums, saying it is fulfilling a promise to return money to policyholders when its net income exceeds 2% of revenue. The action, on top of a similar $167-million credit announced in June and returned this month, was driven partly by the weak economy. The San Francisco nonprofit insurer says it has spent less than expected on claims because people have cut back on medical care. "People are really struggling to make ends meet," Blue Shield Chief Executive Bruce Bodaken said in an interview Thursday. "As people have less discretionary spending, they're deciding that maybe they will put off that hip or knee replacement until they can afford it." Individual policyholders will see their December bills credited $135 on average, while a family of four will get a $420 average credit, reducing their annual insurance costs by 4.5%. Although Thursday's action affects only nearly 2 million of Blue Shield's policyholders in California, other consumers could be getting similar paybacks under President Obama's healthcare overhaul approved last year. Under the regulations, insurers must spend at least 80% of consumer premiums on medical care and not reserve that income for administrative costs or profit.
The Nemours Foundation's Wilmington-area offices have lost three computer backup tapes containing sensitive personal and financial information on about 1.6 million patients, employees and other people associated with the four-state children's health care provider. The lost tapes do not contain detailed medical records, and patients' treatment information is stored on the tapes in a coded format, according to John Grabusky, spokesman for the foundation that operates the Alfred I. duPont Hospital for Children north of the city. The tapes do include patient billing and employee payroll data, including name, address, date of birth, Social Security number, insurance information and direct-deposit bank account information. The Nemours Foundation's Wilmington-area offices have lost three computer backup tapes containing sensitive personal and financial information on about 1.6 million patients, employees and other people associated with the four-state children's health care provider. Most of the information on the tapes dates from 1994 to 2004 and was generated at the Nemours facilities in Delaware, Pennsylvania, New Jersey and Florida. That includes the children's hospital's many pediatricians' offices.