Head to Head: Hospitalists and PCPs

Dino seems to think that Hospitalists are equivalent to Subprime Mortgage lending... not sustainable and the bubble will pop eventually.

His reasoning?

My point is that if [Happy Hospitalist] cannot produce enough income to cover his salary, benefits, etc. and the hospital cannot find other monies with which to pay him, then eventually the same situation will occur at every hospital. It may take a very long time for this basic fact of economics to percolate through to the critical point -- perhaps longer than Happy's professional career, at which point he'll just retire and laugh at the rest of us struggling to take care of patients, who will always be there. But the situation is not financially stable. Eventually it will break down. It has to. It's just basic economics.

Look at the housing market. It took decades, but because of the fundamentals of subprime lending, it had to happen. You cannot go on indefinitely spending more money than you make.

http://dinosaurmusings.blogspot.com/2008/11/what-happy-hospitalist-and-subprime.html

Happy Hospitalist responds with his opinion.

Simply put, because the market says so. Hospitals are willing to pay for the services hospitalists bring to the table. I blog continuously about how hospitalist medicine has left the fixed pot of the failed economics of RVU/SGR engrained in the Medicare Part B. If hospitals did not value our service, they would not be subsidizing it, and they would not be paying an average subsidy of $100,000 per hospitalist.
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DRG. Known as diagnosis related group, this is how most hospitals get paid by Medicare. If you get discharged with a diagnosis of chronic obstructive pulmonary disease (COPD), the hospital gets paid a fixed dollar amount for that diagnosis.
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You see Dino, my value on the front end, doesn't even come close to the value I bring on the back end. Not even close. The millions upon millions of dollars in DIRECT money being paid to hospitals in terms of increased admissions/DRG's more than makes up for the several hundred thousand they pay out for the right to have me at their hospital.

What if the hospital isn't always at capacity? The decreased length of stay could potentially decrease their staffing/labor needs without any decrease in reimbursement.

So the DRG argument is a huge one. It brings in more money for the same labor. It allows much higher paying procedural admissions to have a bed and not get diverted to another hospital. It discharges the often money LOSING internal medicine admissions sooner and decreasing labor resource consumption on your money losing granny with COPD.

He goes on to cite Physician Satisfaction, Happy Staff, Happy Patients, Efficiency, Documentation, Unassigned/Uninsured, CPR response, Out of State Referrals as other reasons. I'm less inclined to talk about them because ... well, a good PCP has these same traits also.
http://thehappyhospitalist.blogspot.com/2008/11/hospitalist-medicine.html

Then, DB chimes in as well.

The Dinosaur, like many generalists, seems to write this rant with some anger. The rapid growth of hospital medicine has actually had a negative impact on family medicine and outpatient internal medicine. I understand Dino’s anger, but I really do believe that hospitalists are here to stay. Hospitalists are here for the same reason that ER physicians are here - because they are filling a role that no one else wants. Many generalists have ceded inpatient care to hospitalists. Many surgeons cede inpatient care of surgical patients to hospitalists. Many subspecialists would rather have the hospitalists provide the daily care and then they can just provide consultation.

http://www.medrants.com/index.php/archives/3908

I am just a mere bystander to this new up and coming Hospitalist field. I'm also at the cusp of deciding which path in medicine I will take, so their arguments mean a lot to me. My own worries about these fields diverge slightly from their concerns about economic sustainability though. I am witnessing a lot of graduates of my medical school in the IM program going on to become Hospitalists. It certainly is nice to run into them in the hospital, but I wonder what will happen to the outpatient internists and other PCPs.

I respect Hospitalists. They bring a lot to health care by providing care to patients IN the hospital. However, I've never heard anyone say "Ooohh... I love my Hospitalist at Queens. You should go to her!" Hospitalists do not have the same relationship with their patients as a primary care doctor. When they DO have continuity of care, it is almost a failing of sorts -- given their block schedule, a patient they've discharged (yay for DRG cost-savings with earlier Hospitalist discharges!) has likely returned with some sort of complication. Not necessarily by any fault of their own; patients like this are really sick. I was totally bummed out when some of my patients came back to the hospital.

I respect Primary Care Physicians. They have the ability to be the most cost effective doctors by providing early education, screening and intervention for preventable diseases. They have relationships with patients that are sustainable over time and are not based solely on the tragedy of illness. They have the tremendously difficult job of being the sentry on watch for ALL disease, filtering out which cases deserve specialist attention... and they take a brunt of the blame if something shows up inside the city. I've heard a professional bemoan "primary-care-ville" whereupon amidst the sniffly noses, hypertension and diabetes, someone missed the diagnoses of hemochromatosis and pheochromocytoma even though they had very benign presentations.


Hospitalists and PCPs follow different philosophies in their practice. I enjoy the academic side of inpatient hospital care. I enjoy the personal side of outpatient family medicine. Hospitalists take the thick slice of comprehensive care, seeing all sorts of patients in an acute setting. PCPs take a long slice of comprehensive care mainly seeing all sorts of patients in an outpatient, non-acute setting. Can they handle seeing their patients in the hospital as well, given the rise of the hospitalist specialty?

Probably not. I think Hospitalists are here to stay and trends in inpatient care management show it. The big question for me is... what do I want to become?

I'd like to think that it's easy to remain vigilant and spot that one zebra in a neverending horse show. I'd like to think that choosing a specialty is about more than the amount of money I'd make, or the money I'd save the hospital or the healthcare system. I'd like to think that I'll have a decent schedule and I'll get respect for my work no matter what I end up in.

I'm quite certain that these are all merely delusions of a third-year medical student and someday soon I'll be ranting as much as Dino and Happy.