The managed care industry's latest cost-saving innovation, the hospitalist, is catching on in a big way at Los Angeles-area hospitals and for patient advocates, that's not necessarily good news.
Hospitalists are medical doctors stationed full-time at a hospital. Rather than having primary care physicians monitoring their patients' progress, managed care companies (and hospitals that contract with them) are hiring hospitalists to assume those duties.
The idea is for these doctors to keep closer tabs on hospital patients, which improves efficiency and thereby saves money. Meanwhile, primary care physicians are freed to focus on their growing volume of office patients.
Some 100 hospitalists are at work in the L.A. area, and that number is expected to double in the next five years, according to industry sources.
"This system makes health care more efficient," said Dr. Adam Singer, president and CEO of Hospitalist Co., a company with 30 hospitalists who work with several managed care companies and hospitals in the Los Angeles area. "It gives the patient someone who is there all of the time to take of their needs and reduces costs at the same time. The primary care doctor becomes more effective."
Some patient advocates, however, see the shift to hospitalists as the latest evidence that the managed care industry cares more about profits than care.
"It seems to be a way of pushing patients out of the hospital sooner," said Jamie Court, director of Consumers For Quality Care. "It is very easy for a patient to get lost if a generalist manages the care. Hospitalists are judged on how quickly they move patients out. It seems like a very dangerous trend."
Hospitals have been criticized for discharging patients too early a trend that gained attention in recent years over efforts to reduce the two-day hospital stay for new mothers. Critics have charged that cost-cutting measures have put patients' care at risk by releasing sick patients too early.
But defenders of the hospitalist system say the intent is not to push patients out.
"There is no benefit and only risk to discharging people prematurely," said Dr. Alan R. Zwerner, senior vice president and chief medical officer for Woodland Hills-based Health Net, an HMO. "If we were to do that, people would get sicker and that would cost more money."
Another potential problem with the hospitalist system, some industry sources say, is that patients can lose continuity of care when their case is shifted away from their primary care doctor.
"Patients establish relationships with their doctor, and if something goes wrong, they want to see a familiar face," said Dr. Pejman Salimpour, clinical chief of pediatrics at Cedars-Sinai Medical Center. "There is nothing wrong with being a hospitalist, but the quality of care has to be the same or superior."
The rise of managed care has swung the focus of U.S. health care from inpatient to outpatient. Ten years ago, a patient with pneumonia would be admitted to the hospital. Today he might go to his primary care doctor, get antibiotics and rest at home.
That transformation has turned primary care doctors' workload on its ear. On any given day in 1985, the typical primary care doctor had about 10 patients in the hospital and would see 15 patients in the office. By 1995, that doctor had just two patients in the hospital and saw 20 in the office, according to a study done by the Hospitalist Co.
A study by the University of San Francisco found that instituting the hospitalist system can reduce hospital costs by 10 percent to 25 percent without compromising quality of care. The study team was headed by Dr. Robert Wachter, a hospitalist himself and associate chairman of the university's department of medicine. He also was the one who coined the term "hospitalist" two years ago.
"An effective hospitalist system is very efficient and improves the quality of care for the patient," said Wachter. "It is better to have a specialist taking care of you that sees 30 to 50 cases of the same problem a year, rather than a doctor that sees it two to three times a year. Hospitalists become much more expert in common hospital diagnosis than the average primary care physician."
Hospitalists can manage up to 30 patients at one time and are either employed by the hospital, by groups of doctors, or by health maintenance organizations.
"Seeing all of the patients takes time way from their offices," said Dr. Gainer Pillsbury, medical director of Long Beach Memorial Medical Center. "The hospitalists that are in the hospital can more efficiently follow up with the patient. Hospitalists can expedite the discharge sooner and that is better for the patient."
Besides Long Beach Memorial, other local hospitals that have instituted the hospitalist system include Cedars-Sinai Medical Center, Glendale Adventist Hospital and numerous Kaiser Permanente medical centers.
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