Hospitalists: Riding the Wave of Changes in Healthcare

Leigh Page

Disclosures

April 26, 2016

In This Article

Moving Into Postacute Care

When hospitals started to be penalized for readmissions and had to worry about what happened to patients after discharge, a whole new line of work for hospitalists opened up in postacute care. Some hospitals have opened up postdischarge clinics in which hospitalists, called "subacutists," see patients two or three times after discharge. Hospitalists also see discharged patients in skilled nursing facilities (SNFs), inpatient rehabilitation facilities, and long-term acute-care hospitals.

These hospitalists, called "transitionalists" or "SNFists," are "the fastest-growing part of hospitalist medicine," Dr Wellikson says. The SHM reports that up to 30% of its members work at least part of the time in postacute settings. "Their work is truly team care," he says, because it involves collaborating with nurses and other nonphysicians. Transitionalists either follow their hospital patients to the outpatient facility, or stay in the outpatient facility and only deal with them there.

Hospitalists are split about working outside of the hospital. A 2016 survey[9] found that whereas 57.8% of hospitalists think they should work in postacute settings, 42.2% think they shouldn't.

In addition, outcomes from this approach are mixed. A 2011 study[10] of one nursing home linked hospitalists working there to a significant increase in laboratory costs, but no improvement in fall rates and an insignificant reduction in medication errors and pharmacy costs. However, the study didn't examine the impact of hospitalists on readmission rates.

But What About Compensation?

Hospitalists are generally better paid than their PCP counterparts. The Medscape Hospitalist Compensation Report found that 54% of hospitalist internists thought they were fairly compensated, compared with 45% of nonhospitalist internists. The median salary for hospitalists is $210,420, compared with $188,583 for generalists, according to Salary.com.[11,12] Median compensation for hospitalists rose 8% from 2012 to 2014, compared with 5.5% for PCPs, according to the SOHM report.

However, hospitalists' income is not set in stone, because much of it is subsidized by the hospitals and could be taken away. More than 89% of hospital medicine groups relied on their host hospitals for financial support, and the median amount was $156,063 per hospitalist, according to the 2012 SOHM report.

Dr Wellikson says the subsidy is needed because hospitalists have to be available around the clock, even during off-hours, when reimbursements alone would not be sufficient. He also says that many of the patients whom hospitalists treat are uninsured.

The danger with subsidies is that hospitals might lower them if their bottom lines were threatened. R. Jeffrey Taylor, CEO of IPC, a hospitalist outsourcing company bought by TeamHealth last year, made this argument in a 2014 interview.[13] To get value for their payments, he said, hospitals would have to tie a larger share of reimbursements to productivity.

IPC was already taking this path. Whereas the SOHM reported that 6.6% of hospitalists' compensation was tied to performance, Taylor said the IPC rate was 30%-40%. He said this made it possible for IPC to pay its hospitalists 15% more than the nationwide median for hospitalists.

Another way to control costs is to shift more of the hospitalist's work to nurse practitioners (NPs) and physician assistants (PAs). Use of NPs and PAs in hospitalist programs serving adults rose from 53.9% in 2012 to 65.9% in 2014, according to the SOHM report. With the help of these professionals, "hospitalists can see 50 patients a day if they focus on making the diagnosis and setting up a treatment plan and have others manage the patients," Dr Wellikson says. "The role of the physician is changing."

Consolidation

Hospitalists are working in larger institutions. Employment with private multispecialty or primary care groups fell from 14% in 2007 to 5.6% in 2015, according to a report[14] by the SHM. Meanwhile, almost one half of hospitalists were employed by hospitals in 2015, up from one third in 2007. Large hospitalist companies, which employ or manage hospitalists on behalf of hospitals, account for more than one quarter of all hospitalists, up from 19% in 2007.

The big hospitalist companies are also consolidating, Dr Wachter observes. Sound Physicians, based in Washington State, bought Cogent Health in late 2014, and TeamHealth's acquisition of IPC in late 2015 was the largest of all—worth $1.6 billion.

The reason for this consolidation? One explanation[15] is that hospitals are pushing the companies to provide sophisticated data processing, compliance education and oversight, and professional development for their physicians. Also, in the future, these companies may have to share financial risks in such arrangements as ACOs and bundled payments.

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