Evidence-based medicine vs. the rising tide of hospitalists

Allocation of scarce resources in the health care economy drives investment in areas that yield the most bang for the buck.  That’s the theory, anyway. 

This week’s New England Journal of Medicine includes an article calling into question the value of the use of hospitalists (in terms of system savings).  Savings, whether measured in dollars or inpatient days, were insignificant (statistically significant, but not significant in the real world).  This observational study looked at Premier data from 45 hospitals nationwide over a 2 1/2 year period.

The authors (Lindenauer, et al.) acknowledge that hospitalists as a group and as a specialty are here to stay (more than 12,000 practicing in the U.S. today), and emphasize that the question they are left with is how to make the best use of hospitalists so as to improve outcomes and quality of care.

This whole new specialty has come into being over the last ten years or so, buoyed by early claims in the literature that hospitalist care is both effective and effective and economical.  And now the latest study turns earlier learning on its head.  Of course, the conclusion includes the time-honored caveat: more study is needed.   

This issue comes to the fore at the same time as a related resource question — how should physicians be paid for their services?  Part of the premise, all along, has been that hospitalists will save hospitals money; therefore, hospitalists’ salaries are often subsidized in part by their institutions. These salaries are seen as being in need of supplementation, or subsidization, thanks to the proceduralist-skewed Medicare physician fee schedule (see, e.g., Roy Poses’ RUC rant at Health Care Renewal) which  arguably undercompensates internal medicine.  The fee schedule is up for a 10% rollback January 1, though yet another Congressional waiver of the sustainable growth rate (SGR) rules is virtually guaranteed.

Perhaps some real change to the SGR will come next year, in which case hospitals may be able to let up on the subsidies to hospitalists.  The challenge will continue to be: how do we put hospitalists to work in a way that benefits patients and the system?

— David Harlow