In his best-selling book Outliers, Malcolm Gladwell posits that great successes happen when highly talented people collide with favorable circumstances. For example, hobbyist teen programmer Bill Gates might never have founded Microsoft if he'd come of age a few years before (or after) the personal computer revolution. And the fortuitous timing of the industrial revolution made millionaires out of rising young businessmen like Andrew Carnegie and John D. Rockefeller.
Could a similar collision of ideas, readiness, and history explain the current boom in hospital medicine?
As a long-time hospitalist who attended one of the field's first leadership academies, it's been exciting to witness our specialty's growth. The number of practicing hospitalists has swelled from 100 in 1996 to 44,000 in 2014. Today, 72 percent of hospitals use hospitalists — up from just 29 percent in 2003.
So what accounts for this boom? And will it continue? To answer these questions, I believe it's important to examine recent history.
Pivotal Event #1: Managed CareThe first hospitalists appeared in the 1990s during the rise of HMOs. It was a time of huge upheaval for our industry. Greater scrutiny around utilization meant that primary care physicians (PCPs) were less willing to take calls in the emergency department (ED) to care for uninsured and unassigned patients. Around the same time, the number of specialists willing to provide on-call coverage began to decline as more specialty services shifted to outpatient settings. To solve the problem, hospitals started hiring physicians to cover night call and admit and treat unassigned patients.
As it turned out, these early hospitalists provided excellent value. Unlike PCPs, they knew the hospital's key players and unspoken rules. They knew how to hunt down lost test results and get the quickest turnaround on a CT scan. Their proficiency within the hospital ecosystem created efficiencies that reduced inpatient length of stay (LOS).
Hospitals began subsidizing hospitalists, and savvy managed care companies followed suit by adding hospital-based physicians to their networks.
Pivotal Event #2: The Accountability MovementWhen John Nelson, MD, FHM, and Winthrop Whitcomb, MD, FHM, founded the National Association of Inpatient Physicians (now Society of Hospital Medicine, or SHM) in the late 1990s, they sensed yet another upheaval on the horizon: The Joint Commission (TJC) and Centers for Medicare and Medicaid Services (CMS) were preparing to release their first core measure sets.
Hospitalists saw an opportunity to help their organizations succeed in these new accountability programs. From the start, SHM actively trained hospitalists to lead change within their facilities. It also conducted quality initiatives around key topics like transitions of care, co-management and meeting the initial core measures (e.g., aspirin for myocardial infarction).
By 2003, hospitalist numbers had swelled to 11,000 physicians practicing in 23 percent of America's hospitals. Their growth continued even as managed care declined in many areas. They now provided hospital coverage for a growing number of primary care practices and networks.
Pivotal Event #3: Healthcare ReformAs the cost of healthcare continued to soar through the 2000s, the pendulum began to swing back toward managed care. This movement culminated in the passage of the Affordable Care Act (ACA), which created a flurry of aggressive new quality programs. Ideas from the 1990s reappeared in new packaging — this time as ACOs, HCAHPS, value-based purchasing and bundled payments.
CMS leveraged these utilization and quality optimization efforts to shift the financial risk of care toward hospitals (and to a growing degree, individual physicians). The new programs created a tremendous squeeze for hospitals, which were charged with cutting costs while simultaneously boosting quality.
Once again, providers turned to hospitalists to meet these challenges. Now in addition to their burgeoning numbers, the role of hospitalists also began to expand as they took on new responsibilities:
- New directions in quality improvement. In addition to managing LOS and meeting core measures, hospitalists now play important rolls in reducing readmissions and improving patient flow and throughput across their hospitals.
- Population health. A recent Becker's Hospital Review webinar identified hospitalists as key players capable of helping providers align care efforts across settings. To this end, health systems, healthcare companies, business groups and multispecialty physician groups have all begun to hire hospitalists, often with an eye toward transitioning to an accountable care organization (ACO).
- EHR implementation. In my experience, hospitalists are perhaps the most prolific users of EHRs, entering the bulk of all documentation, health management plans and discharge summaries. During implementation, they often serve as the system's primary champions, teachers and super-users. Hospitalists can also help their hospitals achieve meaningful use. For example, an SHM subcommittee just released recommendations on how EHR can be leveraged to combat readmissions.
- Documentation optimization. Hospitalists are often charged with maximizing their organizations' CMI through accurate, specific documentation. By honing their skills in this area, hospitalists can help to limit reporting errors, prevent overpayments and boost reimbursement and quality metrics.
- Observation status. Hospitalists help their hospitals navigate CMS' thorny utilization rules around observation care. Through appropriate, accurate documentation of these patients, they can help guard against audits and resulting financial losses.
- Post-acute care. Hospitalists commonly staff post-discharge clinics to provide follow up to patients who lack a PCP or may not be able to get a follow-up appointment. Hospitalists also staff skilled nursing facilities (SNFs) to cover acute patients needing post-hospitalization rehab or skilled nursing care while completing a treatment such as IV antibiotics.
The Future: Integration, Integration, IntegrationHealthcare reform ushered in a new era in which hospitals that can deliver seamless care within integrated systems will have an enormous advantage. Once again, hospitalists are being called upon to lend their expertise in care coordination and transition planning. Some examples that have already emerged:
- Integration with emergency departments. By working together, hospitalists and emergency physicians can enhance throughput while keeping quality high. This model has been so successful that many hospitals are looking toward multispecialty groups to staff both departments.
- Expansion of post-acute roles. Hospitalists have staffed SNFs and long-term acute care facilities for years and are now expanding into acute care clinics, home health and palliative care. Some "transitionalist" hospitalists work in both acute and post-acute settings to foster continuity of care.
- Antimicrobial stewardship. Increasing rates of antibiotic resistance and antibiotic-associated diarrhea with Clostridium difficile underscores the need for hospitals to monitor and analyze antibiotics overuse. A growing number of hospitalists are joining multidisciplinary teams aimed at promoting best clinical practices and reducing unnecessary antibiotic usage to prevent adverse events and the development of resistant pathogens.
- Integration with primary care. Results from pilot projects suggest that alignment between PCPs and hospitalists will be crucial to the success of population health management — especially when it comes to managing patients with multiple chronic conditions.
Looking AheadThe need for coordinated care to contain rising costs has been a boon for the hospitalist profession. In many ways, hospitalists are ahead of the curve when it comes to re-envisioning acute care as a continuum. It is the nature of the specialty to care for the sickest patients, facilitate transitions and enhance the overall continuity of care.
Could the hospitalist profession have emerged at any other time? Perhaps. But without the pressures of managed care, accountability, healthcare reform and integration, it's doubtful that hospitalists would have become the fastest growing specialty in history.
The journey certainly isn't over. In future posts, we’ll examine the challenges and opportunities facing this evolving field.