January 2015

The professor squinted through cigarillo smoke rings. She listened as fourth-year nursing students discussed ways to help Cambodian refugee families be more independent in their new American home.

“This independence drivel is bull s**t. People come for care. Dammit, care for them”, she snapped.

The nursing professor was persona non grata in a Central American country. She cared for—and politicized—indigenous women in the country’s highlands to the displeasure of ruling elite. But her command to care for those who come for care is unforgettable four decades later.

To care for another person means many things. Among them is a willingness to take responsibility for another human being’s welfare. Parents accept responsibility when they care for children; partners accept it when they care for each other. Grown children care for frail parents, assuming responsibility for their well-being.

Nurses and doctors used to accept responsibility when they cared for their patients. No longer. Now care is fractured. Responsibility ricochets around in the ether, never settling on an identifiable person.

Care is splintered among teams, electronic health records, data banks.

And hospitalists.

It’s Academic. The Birth of Hospitalists.

Hospitalists are not new. Robert Wachter and Lee Goldman, writing for the New England Journal of Medicine in 1996, invented the term “hospitalist”. The Society for Hospital Medicine now claims to represent 13,000 of the 44,000 practicing American hospitalists.

Twenty years later, patients are still dismayed to find their trusted physicians will not shepherd them through hospital stays. The substitution of hospitalists for personal physicians is met by confusion and blank stares. Most Americans are unacquainted with the hospitalist idea. People familiar with hospitalist care are rarely enthusiastic about it.

Not surprising. The Wachter and Goldman article didn’t mention patient welfare until a throw-away line at the end. They focused on the prospect of cheaper care first, then physician convenience. Finally, the two authors discussed the advantages of hospitalists for medical education. The authors brushed aside the most damaging effect of the hospitalist scheme with “…any possible discontinuity in care [emphasis mine] is outweighed by improved clinical outcomes, lower costs, better education for physicians…”.

Oh yeah “…and greater satisfaction on the part of patients.”

Perhaps only physicians marinated in academia could be so oblivious of the essential roles trust, understanding and familiarity play in patient satisfaction, much less healing.

Hospitalists: A New Breed of Physicians

Dr. Richard Gunderman posted an update on hospitalists last year in The Health Care Blog. Gunderman lists the benefits of hospitalists for each affected group. He talks about patients, hospitalists themselves, community physicians and hospitals. He hints at the advantages for the most powerful players —insurance companies, including Medicare—but doesn’t explicitly talk about them.

• Benefits for Patients. Patients may get better care because clinicians are always available. Hospitalists are well-versed in hospital management and part of hospital teams, according to Gunderman. And they are skilled in the latest hospital medicine theories. Dubious advantages.

• Benefits For Hospitalists. Hospitalists enjoy regular hours, predictable lives and no patient responsibilities off duty. These docs can avoid the messy work of caring for patients with chronic illnesses. Hospitalists need not waste time forming long-term bonds with patients. The hospitalist-patient relationship is a commercial transaction, not a healing relationship. No trust required because the patient has no choice. Patients are captives in hospital beds.

• Benefits for Community Physicians. Community physicians no longer need to make rounds, a time-consuming and revenue-gobbling activity. Doctors only make money when they do something to or with patients. Driving to several hospitals or writing progress notes on inscrutable electronic records isn’t billable time. Further, they don’t need to stay current on acute care medicine and hospital procedures. Community based doctors can devote their efforts to chronic disease and preventive care. They have no responsibilities to their hospitalized patients.

• Benefits to Hospitals. Hospitals have much to gain. Gunderman runs down a list of dividends that pile up for hospitals using dedicated inpatients physicians. All are some version of: It saves money. Hospitals can swell their revenue by controlling the hospitalists’ practice of medicine; demanding they deny admissions, force earlier discharges and withhold care. Then the hospitalists and their employers can dodge responsibility for the consequences. Patients turfed out of the hospital disappear. Vanished, like Brigadoon.

• Benefits to Insurance Companies. Insurance companies and Medicare profit when costs are lower. Drs. Wachter and Goldman promoted hospitalists as a lower-cost way to give inpatient care. Their article promotes cheaper hospitalist care as the leading reason to hire hospitalists: “First, because of cost pressures, managed-care organizations will reward professionals who can provide efficient care.” Managed care was in its heyday in the mid-nineties when ways to control costs began. Managed care organizations fell off radar screens because of bitter patient blowback. Cost control pressure is even more intense now, however.

Commercial insurance companies and Medicare seemed to gain the most by the wave of hospitalists washing over unsuspecting American patients.

That is until the hospitalist management companies popped up.

Rent-a-Doc: Hospital Temp Services

Hospitals aren’t the only players feeding revenue streams. Enter hospitalist management companies, essentially rent-a-doc operations. Large health care systems and academic medical centers often use their own flocks of hospitalists. But many other hospitals are contracting with management companies that deploy platoons of hospitalists from coast to coast.

Where there’s money to be made, there are investors. Where there are investors, there are mergers and acquisitions. Sound Physicians is a hospitalist management company based in Tacoma, Washington. Sound Physicians’s tagline is “Hospital Medicine—the way it should be”.

Apparently Fresenius thought so. It’s a giant German health care conglomerate with a market capitalization of $23.31 billion. The folks in Bad Homburg, Germany parted with a small chunk of that change. Fresenius pumped $600 million into Sound Physicians’ bank account in July 2014, becoming the company’s majority shareholder.

Sound Physicians, with an invigorated balance sheet, did some shopping of its own. The company bought Cogent Healthcare in November. Cogent Healthcare, another hospitalist outfit, based in Tennessee. The combined company employs more than 2250 providers in 35 states.

The hospitalist management company, IPC Healthcare is self-described as “the nation’s leading national physician group…focused on hospital medicine”. It employs about 2500 “hospitalist providers” (includes nurse practitioners and physician’s assistants). Its closest competitor is Fresenius, according to Morningstar.

IPC beats Fresenius in another category, too—the unenviable federal lawsuit category. The company is alleged to have pressured its hospitalists to “upcode” or bill for more expensive services than they provided. This is a civil fraud case, no criminal conduct is charged. Yet if IPC hospitalists are shown to cave in to company pressure to submit fraudulent billings, what other pressures sway them?

Wachter’s World: One-Man Hospitalist Industry

Bob Wachter has done well for himself, too, since he and Lee Goldman published the NEJM piece almost twenty years ago. Many of his accomplishments are listed on his (modestly named) blog Wachter’s World. He heads the Department of Hospital Medicine at University of California San Francisco. He’s published many articles and several textbooks. Peer-reviewed journal articles and texts represent great effort, so some accolades Wachter’s received are earned.

Wachter has spun those accolades into gold. He sits on many boards, advises private companies and government agencies. He was named to the board of IPC Healthcare in 2013. His position is sweetened with various stock and stock option offerings. Wachter is transparent about his financial interests in companies tied to the hospitalist industry.

Wachter is a popular motivational speaker on the lecture circuit. Hard to say who’s more motivated though, the audience or the speaker. He reportedly rakes in more than $25K per speech and gives forty or so talks per year. A cool million would motivate lots of folks to jet around the country and yammer at friendly audiences.

Transparency and objectivity are different things. It’s commendable that Wachter is forthright about his commercial entanglements. But a long trail of studies in health care has shown doctors are influenced by treats like lunches and pens. Stock options and lucrative speaking dates are a new order of magnitude. Wachter has robust vested interests in ensuring hospitalists remain a flourishing breed.

Robert Wachter benefits mightily from the hospitalist crusade he birthed. He cheerfully takes credit for its purported successes. He seems less eager to take responsibility for the failures. Or the federal lawsuit.

Hospitalists: Hype, Hubris and Hypocrisy

Dr. Gunderman also identifies drawbacks to hospitalist care. Many physicians miss long-term ties with patients just as much as their patients miss them. Despite Wachter’s and Goldman’s dismissive attitude, discontinuity in care is an immense problem that’s not solved by technology. Gunderman points out the information in electronic records and “true knowledge of the patient” are distinct notions. Expert, safe care demands knowledge of the patient, not electronic data.

Hospitalists: Who’s the Boss?

Healers have served humankind for millennia. For centuries, trust in the medical practitioner has been the bedrock of care. Hospitalist arrangements erode that foundation.

Companies like IPC and Sound Physicians have a simple formula: The more patients their rent-a-docs see, the more money is made. So an ugly pattern of overworked hospitalists has emerged around the country. Hospitalists themselves have reported understaffing that leads to mistakes, poor communication and even patient deaths.

The hospitalist holy grail of cheaper care is undermined by short-staffing. The bigger the physician workload, the longer the patients’ hospital stays.  And the longer the stays, the higher the bills.

The Buck Stops Nowhere

When doctors hospitalized their own patients, the line of responsibility was clear.  The doctor worked for the patient and no one else. He or she owed a duty to the patient. Full stop. Now the lines have blurred or sometimes, disappeared.

Hospitalist management companies can be controlled from abroad. Hospitals contract with these companies. Physicians employed by the companies see patients in hospitals that want a return on their investment in these contracts. The hospitalists must answer to the hospitals, their employers, insurers and Medicare, perhaps the hospital medical staff.

The only people not owed any answers are patients.

Globalization at the Bedside

Professional practice is built on trust, responsibility and accountability.  It’s difficult enough for patients and families to trust strange hospitalists who dash through on shifts, perhaps three or four docs in a brief hospitalization.  It’s almost impossible, in the best of circumstances, to decipher which hospitalist handles what. Or who should be held responsible when things go sideways.

How much tougher will it be to trust the doctor at your bedside when she has foreign bosses peering over her shoulder, directing your care?  If this is the way hospital medicine should be, heaven help us all.

About the author: Chris Kapsa, NP, DNP has been in nursing for forty-five years, thirty years as a women’s health nurse practitioner. She pioneered private practice for nurse practitioners in Utah and now owns a patient advocate business, Kapsa Care Resources. She researches and writes about America’s chaotic health care system, especially problems of health care economics and distribution.

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