CHICAGO-Is care rendered to inpatients by hospitalists good or substandard? And if it is good, how good is that for pulmonary specialists? Those were merely two of the provocative questions posed, and in some measure answered, during the 65th Annual Meeting of the American College of Chest Physicians. At issue was the impact of hospitalist programs on inpatient care in the evolving managed care marketplace, and what that impact might bode for pulmonary intensivists.

WHAT IS A HOSPITALIST?

Susan Murin, MD, FCCP, assistant professor of clinical internal medicine at the University of California, Davis, presented a working definition of a hospitalist developed by Winthrop F. Whitcomb, MD, co-president of the National Association of Inpatient Physicians: "A hospitalist is a general internist, medical subspecialist, or family practitioner who is predominantly engaged in the care of inpatients on acute care medical wards and intensive care units and who acts as a consultant on surgical patients through a dedicated on-site approach." A hospitalist has limited outpatient responsibilities, she added.

According to Dr. Murin, hospitalists are growing in numbers, especially in "very managed-care-predominant marketplaces," such as northern California and Minneapolis. She explained that profound changes in medicine in the last half decade are largely responsible for this movement. "There are fewer and sicker patients in the hospital and growing numbers of patients seen by physicians in offices, making it increasingly hard for physicians to accommodate the sicker hospital patients during the day," she noted. In addition, the presence of hospitalists extends the concept of organizing care around the site where care is given. "Perhaps most importantly, hospitalists have been rapidly embraced because of cost improvements," Dr. Murin stated.

MULTIPLE MODELS

She predicted that a variety of hospitalist models (rather than a single über-model) will be adopted nationwide. At least three such models currently exist. In some instances, hospitalist services are being provided (formally or informally) by groups of physicians who agree to alternate performing in-service rounds to promote efficiency. In other cases, hospitals are hiring new doctors to work specifically as hospitalists. Finally, several for-profit corporations have approached hospitals with the offer of taking over inpatient care at an alleged savings for both parties. A variety of payment plans for hospitalists also can be found (ie, fee for service, salary paid by hospitals or physician group, incentives, and various combinations of those and other methods).

BENEFITS AND DRAWBACKS

Dr. Murin pointed out that hospitalist models of care "are neither entirely good nor entirely bad." At their best, hospitalists have the potential to be good for both patients and physicians. The rationale is much the same as that given for full-time intensivists: a practitioner who does something every day is likely to do it better and more efficiently than is someone who does it only occasionally.

The danger when hospitalists are used is the possibility of mandatory "handoffs" of patients-something already occurring in some areas of California. Other potential negatives include decreased subspecialty consultation, disappearance of intensivists from the intensive care unit, and a disconnection between inpatient and outpatient care as a result of the hospitalists' emphasis on rapid patient discharges and shifting of patient care to outpatient providers.

ACCESS TO CARE

Jonathan C. Weissler, MD, FCCP, who is chief of pulmonary and critical care medicine at the University of Texas Southwestern Medical Center, Dallas, seconded Dr. Murin's concerns about mandatory patient handoffs. If such handoffs become widespread, he noted, "the hospitalist would control access to care-not only what care is provided in the hospital but also who gets admitted." This "will allow hospitals and insurers immense leverage over the practicing habits and reimbursements of hospitalists," Dr. Weissler added.

If hospitalists believe that their primary responsibility is to their employer and not to their patients, insurers will have the opportunity "to truly manage care and control physicians' activities," he stressed. Dr. Weissler explained that the presence of a hospitalist is often attractive to insurers and hospitals because of the potential for cost cutting and improved efficiency. When cost is a high priority, for example, the potential benefits of controlling physician behavior are likely to be exploited. However, this is unlikely to occur before hospitalists are certified, he noted.

CREDENTIALING ISSUES

"A major thrust in recent years has been to get professional internal medicine organizations to provide certification for hospitalists," he stated. "This would establish the validity of the field and defuse the criticism of the lack of specialty care. I believe that hospitals and insurers are waiting for certification of hospitalists as expert caregivers before they fully support the hospitalist movement." Indeed, the lack of specialty training is a common concern about many hospitalists. Dr. Weissler noted that there is a decade's worth of research showing that care delivered by trained specialists results in better patient outcomes than does care delivered by other physicians.

Dr. Weissler pointed out the potential dangers for internal medicine in the certification process: an imbalance in the number of residents desiring to be hospitalists, undertrained ambulatory care doctors, and fewer primary care practitioners. Internists are not guaranteed to be the hospitalists of the future; nonphysician providers, emergency medicine physicians, and anesthesiologists are other likely candidates.

"I think it is very unclear at the moment what will happen regarding the formal certification of hospitalists. On the one hand, there has been no evidence that there is a defined body of knowledge or area of expertise that would merit board certification. On the other hand, there are very powerful financial forces that are pushing toward certifying hospitalists. I think that there is going to be a battle between the managed care companies and some of their allies, who are very interested in hospitalists being certified, and those who do not view hospitalists as a distinct area of medical specialization. I think right now the outcome is very difficult to predict," he noted.

"Finally," Dr. Weissler said, "I believe that it is an error for the field of internal medicine to certify an individual as an expert when there is no evidence of expertise. It would dilute the value of subspecialty training, not only in pulmonary and critical care, but also in cardiology and infectious disease, and would foster an impression among the public, Congress, and insurers that specialized knowledge exists where in fact it probably does not."

Dr. Murin shares these concerns, noting, "many pulmonary intensivists currently fill an informal hospitalist's role, a role that could be lost. There is also the potential for fewer consultations for pulmonary/critical care trainees and loss of fellows."

Dr. Murin advised pulmonologists and critical care specialists to become actively involved in shaping policy, if the movement toward use of hospitalists becomes apparent in a given institution.

-Lynda Charters

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