Are Hospitalists Helpful to LTC Patients?

by Marlene Piturro, PhD, MBA

The term "hospitalist" was coined six years ago and applied to several hundred like-minded physicians who had staked out their turf as doctors who manage inpatient care. Today there are more than 5,000 hospitalists, roughly the same number as critical care physicians. Their charge is to manage inpatient care, becoming the patient's primary care provider (PCP) during the hospital stay. In addition to patient care, hospitalists focus on finding ways to reduce length of stay (LOS), eliminate unnecessary tests and procedures, improve outcomes, and otherwise enhance hospital efficiency.

By most accounts they have met their goals. Robert Wachter, MD, Associate Chairman of the University of California-San Francisco's Department of Medicine and an early champion of UCSF's hospitalist program, said that such programs cut costs by 10%-20%. They do this without compromising care quality, according to Dr. Wachter, and reduce average LOS by half a day, saving the institution approximately $1,000 per patient.

But what is the impact on the frail elderly in long-term care? Are they getting short shrift from such reduced inpatient stays?

Hospital Discharge

Steven Levenson, MD, CMD, a Multi-Facility Medical Director in Towson, MD, and Chair of Caring's Editorial Board, noted that hospitalists can be effective if they work closely with LTC facilities. However, "there's only so much they can do when they send the frail elderly out of hospitals so fast," he cautioned, citing concerns over instability from comorbidities, increased difficulty in diagnosis and treatment when patients are mentally impaired, and barely having time to manage the primary condition before hospital discharge.

Teresa Jones, MD, Medical Director of IPC, a North Hollywood, California-based hospitalist group with 200 physicians in seven markets, might disagree. "We don't want patients to bounce back [to the hospital]. We're conscientious about returning patients successfully to where they came from." Dr. Jones, working in Phoenix with 36 hospitalist physicians in 20 facilities, including several skilled nursing facilities (SNFs), maximizes the effect of the patient's time in the hospital by focusing on efficient diagnosis and treatment.

She and the other hospitalists enhance continuity of care by using personal digital assistants (PDAs) to communicate with PCPs, LTC facilities, insurance companies, and case managers. The PDAs are also useful for downloading, storing, and rapidly accessing relevant clinical guidelines.

Chronic Illnesses

As a hospitalist, Dr. Jones deals extensively with conditions affecting the frail elderly, including pneumonia, congestive heart failure, chest pain, COPD, GI bleeding, syncope, stroke, and pancreatitis. Many of the elderly patients she sees have several chronic illnesses, and during the course of a hospital stay, Dr. Jones manages the acute illness, which often has an overlay of other, chronic, conditions. She deals extensively with LTC facilities and family members--for example, by sorting out medications and following up on home care referrals. In this context, hospitalists relieve local physicians of the need to travel to the hospital to see a single admitted patient.

Although committed to process improvement, Dr. Jones knows there are limits on how much hospital costs and lengths of stay can be cut. "One can only push a chest pain so fast, and beyond that you can't go." On the other hand, because she's at the hospital all day, she can avoid excess tests and costs because she has a certain "comfort level," she said. "I know when I do and when I don't need a neurology consult, CT scan or MRI. Being a hospital physician is just qualitatively different than seeing patients once a day on rounds, even if you are their PCP."

However, not all hospitalists and practices are alike. Cogent Healthcare, based in Laguna Hills, CA, provides outsourced physicians to hospitals. Approximately 300 physicians work in 15 markets nationally, relying heavily on disease-management protocols, and moving patients efficiently along a care continuum.

Ronald Greeno, MD, Cogent's Medical Director, said that hospitalists smooth out the gaps between acute and long-term care. There are even hospitalist sub-specialists working in SNFs. "We organize care around where physicians' practices and SNFs are different than LTC settings and hospitals."

In Los Angeles, where a five- or six-day SNF stay is average for an elderly patient, SNF hospitalists see patients every day. Post-operative orthopedic care, IV antibiotics, wound care, beginning of intensive rehabilitation for stroke victims, and recovery from abdominal surgery are some of the most common types of situations seen in SNFs. "It's a transition between hospital and home or LTC facility," says Dr. Greeno.

Dollars & Cents

At a time of burgeoning health care costs, the majority of hospitalist programs are cost effective. A UCSF study of national hospitalist programs reported recently in the Journal of the American Medical Association (2002;287:487-494), indicates that 15 of 19 programs studied decreased costs by 13.4% and LOS by 16.6%. In the aggregate, that amounted to a system-wide savings of $2.4 billion, approximately 10% on an average $8,000 inpatient stay.

Although hospitalist programs are effective, Dr. Greeno noted that there does come a point when hospitalists probably can't keep pushing costs and average LOS down. "We can't improve dramatically after we've been around several years, but we can keep maximizing efficiency. If we go away, the numbers will go back up. Length of stay will creep up from four to six days, and then people would be groping again to find what works."

Another caveat regarding hospitalists may be their reliance on subsidies. Even Dr. Wachter, originator of the term "hospitalist," admitted that the average hospitalist generates only between 50% and 90% of revenues needed to cover the compensation package through professional fees. Cash-starved hospitals think twice about subsidizing a hospitalist program, weighing the costs and benefits. Administrators allow for the "soft" benefits of a hospitalist--coverage of unassigned patients and 24-hour call, and suggestions about utilization management and process-improvement initiatives that come with being in the hospital all the time.

Despite the up-front costs, many hospitals are willing to invest in a hospitalist program. Mercy Medical Center, a community hospital in Springfield, MA, owns a group of eight hospitalists. Professional fees cover 75% of the program costs, with Mercy paying the rest.

Baptist Hospital of Pensacola, Florida, contracts with Cogent hospitalists, saving an average $3,514 per case after making a $200,000 investment in start-up costs. Reimbursement is by case rate, with 60% going to the hospitalist to manage an episode of care.

However, some hospitalist programs are not subsidized. Dr. Jones of IPC said that the firm's physicians see an average of 18 patients a day in a variety of settings--and earn a good living. "Because I'm at the hospital all day I can see patients, work with PCPs, and coordinate with care managers for discharge to SNFs, ALFs, and home care."

Nevertheless, not seeing their patients on a daily basis can be a sore spot rather than a benefit for some PCPs. Dr. Levenson points out that "many doctors have been squeezed from all directions in the past year or so. They may not want to give up their hospital practices." If a physician group is organized so that one doctor covers the group's hospitalized patients, the hospitalist may be a duplication of effort.

Dr. Jones has had mixed reactions from PCPs about giving up their hospital practices. "Eighty percent of PCPs love us. However, there is a pocket of internists, maybe 20%, who don't want to give up their skills and some revenue." This may be less of a problem when use of hospitalist services is voluntary.

On balance, though, it seems that the "can-do" attitudes of hospitalists create value. With their training in internal medicine added to a commitment to improve what happens to patients in the hospital, they can be important to long-term care residents needing hospitalization for an acute illness. Because the vast majority of hospitalist programs are indeed voluntary, lingering tension between hospitalists and PCPs has lessened, if not disappeared altogether.

Freeing the PCP or long-term care medical director to focus on maintaining the frail elderly person's health on an outpatient basis rather than having to divide time between the hospital and LTC setting can make the hospitalist a valuable ally.

Furthermore, it appears that hospitalists, with their emphasis on managing inpatient care of complicated cases efficiently and working with case managers for appropriate care after discharge, are slowly but steadily becoming a part of the continuum of care.

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