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Enero 31, 2006
The Rise of Hospitalists (Parte 1), Richard Vernick y Mitchell Wilson
If you're considering developing a hospitalist program, first map out your needs and your resources, then create a plan for introducing the idea.
The field of hospital medicine, the general medical care of hospitalized patients, continues to grow. The number of hospitalists working nationwide expanded from a few hundred in the mid-1990s to more than 8,000 in 2003. By the end of this decade, their number is expected to more than triple--to 25,000.
Hospitalists are not only growing in number; they are permeating hospital care. In Massachusetts, for example, only four out of 75 acute care hospitals had hospitalist programs in 1996. Today, 210 hospitalists coordinate care for 42 percent of 1.8 million inpatient days annually.
But perhaps the most significant issue concerning hospital medicine is not its rapid growth but the impact it's having on the way health care is delivered. The Center for Studying Health System Change--which recently published the results of a hospitalist market trend study, Health Care Market Trends and the Evolution of Hospitalist Use and Roles, in the February 2005 issue of the Journal of General Internal Medicine--described it this way: "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 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."
As hospitals struggle with increasing financial pressures, a growing shortage of primary care physicians willing to cover the hospital, and problems with patient flow and safety issues, many are turning to hospitalist programs for solutions--often with great success.
If you're a CEO interested in starting a hospitalist program, consider the five issues below. They will help you determine what sort of program will best suit your organization, how it should be implemented and how your organization will pay for it.
What do you want out of a hospitalist program?
Generally speaking, two issues drive the development of most hospitalist programs: service and care management.
Some of the most common needs regarding service include:
* Managing admissions on behalf of the physicians, which improves their lifestyle and allows them to focus on outpatient volume.
* Providing prompt, attending physician services to patients without regular physicians and often without insurance or financial resources.
* Providing on-site, 24/7 physician coverage to hospitalized patients.
Some of the most common needs regarding care management include:
* Efficient use of resources, resulting in a decreased cost per case.
* Improved patient satisfaction due to increased physician presence.
* Improved quality of care due to the physician's increased familiarity with hospital procedures and processes.
* Improved compliance with order sets and standards of care.
* Improved throughput, better capacity management and decreased length of stay.
* Improved ED performance due to facilitated admission procedures.
What type of hospitalist program do you need?
There are at least four basic models or types of hospitalist programs. Each has its advantages and drawbacks, depending on your market and immediate needs. It is important to understand the pros and cons of each model before you begin--just as it is important to realize that hospitals often find themselves "mixing and matching" one or more types--especially when they're just getting started. The following information comes from a 2004 productivity and compensation survey by the Society of Hospital Medicine.
Hospitalist program by model/type and Percent of hospitalists employed by type:
* Hospital/hospital corporation
* Single specialty/multispecialty group
* Local hospitalist-only group
* Multistate hospitalist-only group/hospitalist management company
* Other (includes medical schools/academic programs, which may operate a mixed model)
Research the pros and cons of each type of hospitalist program to determine which model best fits your needs. Talk with someone who knows hospital medicine from the inside out. You may choose a consultant who can introduce you to the topic, evaluate the level of your needs and make recommendations. Or you might contact hospitals with established hospitalist programs to gain insights into the development and growth process of the program, as well as the problems encountered, the costs and other factors.
How will you gain acceptance from your medical staff?
Acceptance by the physician community is critical--as is selling the concept to your medical staff. Depending on the market and type of hospitalist model you choose, the medical staff may perceive a hospitalist program as a competitive venture. Physicians are concerned about patient retention and satisfaction, as well as discontinuity of care.
Typically, when they're developing a new clinical service, hospital administrators will form a committee of doctors from the medical staff and start inviting vendors to make presentations. The act of bringing in vendors--such as a hospitalist management company or local hospitalist-only group--can raise all kinds of red flags among various interest groups if it's done too soon or not handled properly. You could wind up solidifying opposition to the program before it ever gets off the ground.
It's a good idea to find a physician who can champion your cause--someone who can be an advocate for implementing a hospital medicine service. This physician should be someone who has the communication ability, business savvy and clinical care legitimacy within the community, so he or she can also represent the conscience of the physicians.
How will you pay for this program?
Costs will vary, depending on the type of hospitalist model you choose, the payer mix and service requirements. On average, hospitalists will cost approximately $75,000 or more per FTE than the pro fee offset. A full-blown program with 24/7 coverage requires a staff of six hospitalists to stay within the benchmark numbers of shifts or hours per year.
If you're in a market where you want the hospitalist to provide unassigned and unfunded coverage, then the hospital must pay for the program based on other metrics or soft targets such as optimizing resource utilization, length of stay and so forth.
Hospitalist programs prove their worth by decreasing unnecessary consumption of hospital resources and increasing efficient handling of patients. Any savings that accrue from more efficient care, shorter length of stay, reduced use of resources and quicker disposition go directly to the bottom line.
Make or buy?
After defining your short- and long-term goals for the program, and determining the costs involved, you must decide whether you want to build your own program or buy one. Again, that decision depends on your needs and goals. If, for example, your hospital is drowning because you're at 100 percent capacity, your ED's on bypass all the time or you have a lot of unsponsored care, you may need to jump-start your program by contracting with a multistate hospitalist-only management group. On the other hand, you may decide to start off slowly with a call-based system of hospitalists that can evolve into a 24/7 program--either comprised of hospital-employed doctors or contracted with a local hospitalist-only group.
A New Way to Deliver Health Care
The numbers suggest that hospital medicine is here to stay. Whether you decide to have a hospitalist program or not, remember that as the field of hospital medicine grows, it will impact the way you and the doctors in your community do business. Hospitalists have been called "a new breed of physician"--fueling a debate over whether hospital medicine will eventually become a new specialty. No matter how that is resolved, hospitalists are clearly creating a new breed of health care delivery.
Fuente: This article 1st appeared on 2005-08-23 in Hospitals&Health Networks Magazine online site