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Health Market Changes Spur Use of Hospitalists Across the U.S.

Journal Study Examines Market Trends Driving Use and Roles of Hospital Medicine Specialists

News Release
Feb. 1, 2005

Alwyn Cassil, HSC: (202) 264-3484

ASHINGTON, D.C.—Mounting financial pressures, increasing problems with patient flow in hospitals, a growing focus on patient safety, and rising malpractice costs have spurred the use of a new breed of physicians who specialize in caring for hospitalized patients, according to a study by Center for Studying Health System Change (HSC) researchers in the February edition of the Journal of General Internal Medicine.

Known as hospitalists, the number of physicians specializing in hospital medicine has increased from a few hundred in the mid-1990s to more than 8,000 in 2003, according to information in the HSC study provided by the Society for Hospital Medicine, the professional society of hospitalists.

Hospitalists most commonly care for patients whose physicians prefer not to provide inpatient care or who lack admitting privileges. However, hospitalists’ clinical roles are expanding, for example, as they increasingly substitute for intensivists in intensive care units (ICUs), team with subspecialists to care for complicated patients, function as primary attending physicians in skilled-nursing facilities and care for nursing home patients hospitalized at night.

"The market trends spurring increased use of hospitalists and their expanding clinical roles will likely continue as hospitals and health plans seek to reduce costs, streamline patient flow and improve patient safety," said Hoangmai H. Pham, M.D., M.P.H., lead study author and a senior health researcher at HSC, a nonpartisan policy research organization funded principally by The Robert Wood Johnson Foundation.

The study--Health Care Market Trends and the Evolution of Hospitalist Use and Roles--examined the emerging hospitalist trend during HSC 2002-03 site visits to 12 nationally representative communities. The communities are Boston; Cleveland; Greenville, S.C.; Indianapolis; Lansing, Mich.; Little Rock, Ark.; Miami; northern New Jersey; Orange County, Calif.; Phoenix; Seattle; and Syracuse, N.Y.

In all 12 markets, hospitalists were present in at least one of the largest hospital systems, and in some markets, such as Boston, most medical groups used hospitalists for the majority of their admitted patients. In other communities, such as Syracuse, hospital medicine programs were newer to hospitals and medical groups and expanding slowly.

Between 2001 and 2003, new hospitalist programs were started in at least six of the communities--Indianapolis, Little Rock, northern New Jersey, Orange County, Seattle and Syracuse. Common market trends--financial pressures on primary care physicians and hospitals, problems with patient flow in hospitals, patient-safety initiatives and malpractice cost concerns--in varying degrees contributed to increased use of hospitalists across the 12 communities.

The study found that the intensity and scope of hospitalist use varied significantly across the communities. Estimates of the proportion of inpatients cared for by hospitalists ranged from 5 percent at one Miami hospital to 50-75 percent of patients in an Orange County health plan to 100 percent of non-ICU patients at a Phoenix hospital.

Hospitals, health plans and medical groups had diverse reasons for initiating hospitalist programs, and local market pressures contributed to the initiation or expansion of hospitalist programs:

  • In Orange County, for example, health plans and medical groups cited strong interest in cost control, while hospitals wanted to accommodate their medical staffs’ desire to avoid inpatient care in favor of increasing outpatient visit volume because they could bill for more outpatient visits in equivalent amounts of time.
  • In Phoenix, respondents cited a deepening physician shortage and physicians’ growing interest in revenue sources other than inpatient care or emergency department consultations, resulting in both primary care physicians and specialists growing less dependent on hospital privileges and necessitating the use of hospitalists to provide inpatient care.
  • In Miami, respondents cited physicians’ focus on increasing outpatient visit volume as in other markets, but also a malpractice insurance crisis that prompted physicians to avoid inpatient care and to send more acutely ill patients to emergency departments, where they added to demand for hospitalist care.

The growing and varied role of hospitalists has implications for the quality of care, medical education, hospital management, and hospitalists’ relationships with other physicians and health care organizations, according to the study. For example, hospitalists charged with increasing caseloads and patient flow may find that at odds with providing more focused care for complicated patients.

The growing demand for hospitalists and the new conditions under which they work suggest that new hospitalists may not be properly prepared and may need more diverse training than in the past, according to the study. Most hospitalists are trained as internists, and medical schools may want to consider elective training for graduates interested in hospitalist careers.

Moreover, the growing number of hospitalists could change hospitalists’ relationships with other physicians and physicians’ relationships with hospitals.

"If current trends continue, hospitals may be populated with hospitalists with different employers, goals and incentive structures, raising important questions about how hospitals and other physicians will adapt to the changes," Pham said.

Along with Pham, co-authors of the study were HSC consulting researchers Kelly J. Devers, Ph.D., Virginia Commonwealth University; Sylvia Kuo, Ph.D., Mathematica Policy Research; and Robert Berenson, M.D., The Urban Institute.

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The Center for Studying Health System Change is a nonpartisan policy research organization committed to providing objective and timely research on the nation’s changing health system to help inform policy makers and contribute to better health care policy. HSC, based in Washington, D.C., is funded primarily by The Robert Wood Johnson Foundation and is affiliated with Mathematica Policy Research, Inc.


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The Center for Studying Health System Change Ceased operation on Dec. 31, 2013.