Sunday, February 13, 2011

Industrialization Comes to a Small Hospital

If the relationship I have with the University Medical Center where I work is like a spousal relationship (substantial, committed, long-term, serious), then the hospital where I moonlight is more like a friends-with-privileges arrangement. I 've been moonlighting at this small hospital (about 200 beds) for the past five years now, and my feelings for the place are unquestionably fond, but my emotional and spiritual investment in it is minor. I use her for a little extra sustenance, not merely financial, as I like the people there and they--shockingly and inscrutably--appear to like me back in turn. In short, I like her but I do not love her. I want her to thrive but my heart will not be broken if she doesn't.

That said, my heart did a little breaking this weekend when I strolled in for an evening shift, ready to enjoy the give and take with patients and staff alike, and emerged 10 hours later having bade farewell to five employees (four docs and one secretary) that I had come to respect. They are all headed out the door, and while each has some particular reasons for departing, they all share one common motivation: the hospital is "industrializing" its hospitalist work force (using it for lack of a better word, I am definitely open to suggestions), and about 40 percent of the current hospitalist group has decided nearly en banc to look for greener pastures. Amazingly, after these departures are complete and the new crop of docs comes in, I am going to end up being one of the graybeards of the group, either the second or third most senior of the hospitalists...perhaps apropos since my actual beard has been sprouting grays & whites more insistently these past few months. What I find somewhat sad and slightly disconcerting about this is that I am, among the medicine physicians at least, becoming the one with the longest institutional memory.

But let's backup a moment and explain how we got here.

This hospital used to operate on the old model: if a patient was admitted to the hospital under the medicine service (i.e. not for a surgical procedure), the patient was usually under the care of that patient's primary care physician. I'm oversimplifying things here, but since internal medicine had begun to get significantly more complicated in the '80s and '90s, that old model, where the outpatient doc doing rounds and writing orders at 7 a.m. on the way into office hours, became increasingly impractical. The "hospitalist" movement sprang up as a consequence, and a new specialty was created: full-time inpatient internal medicine doctors whose sole job was to take care of internal medicine patients during a hospitalization.

At my hospital, about 10 or so years ago a few physicians began hospitalist work, and they would contract with particular medical groups to take care of that group's patients when they were admitted. When I first came to moonlight there that first hospitalist group was small, covering perhaps a third of all the patients admitted to the hospital. If a patient was admitted, the ER doc would call us, and we were supposed to check to see whether the patient belonged to our contracting medical group, and if they didn't we were supposed to inform the ER that such a patient was the "responsibility" of some other group. Since I found spending 15-20 minutes figuring out who "owned" such-and-such a patient rather tedious, and since I was moonlighting at least in part to maintain my hard-earned internal medicine skills, I just admitted everyone they told me to without concern for the primary physician, and accepted the frequent lectures from some of the full-time hospitalists the following morning when I found out that 5 of the 8 patients I admitted didn't "belong" to the group. (Their group still made money off those admissions since they could bill for them, while then as now I was paid to work by the hour, so I don't feel so bad about the whole thing.)

Anyway, once the primary care physicians saw how much contracting with hospitalists relieved their work burdens, a clamor arose to expand the hospitalist group, and the hospital started placing direct pressure to achieve this, because if the PCPs could find hospitalists at the other nearby small community hospital, then my hospital's revenue stream would start to dry up. The problem was (and I say this from the perspective of an outsider who watched from afar, so take my observations both with a grain of salt and at your own risk) the group couldn't expand fast enough to keep up with the demand. This led directly to a major problem, which was that the hospitalists who had been recruited had to shoulder larger and larger amounts of work, and see more and more patients, in order to keep up with the demand. The hospital, feeling perilously close to losing its patient base, mandated that within 6-9 months the hospitalist group be prepared take on all of the patients previously seen by the PCPs. But there weren't enough boots on the ground: each individual hospitalist was seeing more than 20 patients a day, which is far too many to do good medicine on a daily basis, and so morale sank. A few people departed, making matters worse, since larger amounts of work had to be shouldered by even fewer hospitalists.

Long story short, the hospital became concerned enough to take the program over and administer it directly. They promised to recruit more physicians and resolve the morale problem by lowering the patient census for each doc. I was skeptical and on the verge of hanging up my spurs, wondering in particular how the hospital thought it was better situated to recruit nearly a dozen physicians where the private group had failed, but over the next several months I was pleasantly surprised to see the administration deliver on pretty much all of its promises. I stayed on and met several new colleagues with whom I was proud to work. I thought that this little community hospital had solved the riddle of creating a stable hospitalist group, with at least some of the docs serving for years to come, becoming part of the fabric of not only the hospital, but of the community as well. And what better way for a community hospital to achieve its mission than by effecting this change?

Alas--that happy arrangement lasted about 18 months. While the hospital managed to succeed in a stellar manner in creating and sustaining a decent group of physicians devoted solely to the hospital and its patients, it came at a high cost. Literally. I have no idea of the numbers involved but by the summer of last year the administration began discussions with various companies who would take over the hospitalist group and administer them. The one they chose to take to the prom is a for-profit company, listed on the NYSE I am told, who must have promised huge savings for the hospital. Whence my term "industrialization": I remain uncertain as to whether this is the optimal word. Either way, the affairs of a major chunk of how this hospital runs was going to be dictated by a company run from far away, with its primary concern for the economic welfare of its shareholders rather than the health of the community who live and sometimes die within the hospital walls.

The administration found the pitch so irresistible that within the span of a few months, they went from trying to "explore options" with the hospitalist group, to submitting a take-it-or-leave-it offer to each individual physician that they become employees of this "hospitalist corporation" or submit their resignations. (To digress briefly, from my own narrow standpoint their offer seemed quite handsome, as the corporation would cover my malpractice insurance, which costs me nearly $10 thousand per year--that covers several nice bottles of zinfandel, I can assure you--and I was not required to work a minimum number of shifts for coverage.)

So over the past 3-4 months I watched with dismay the hospital re-create the exact situation it was trying to solve when it first took over the group, and this weekend I saw off some colleagues that not only will I miss, but much more importantly my "girlfriend" the hospital will as well. And this was just a quirky night where my schedules intersected with theirs: there are several other physicians who also chose to call it quits whom I haven't seen.

What kind of financial alchemy does this company perform to both make a profit for itself and save money at this not-for-profit hospital? After all, they can't increase the revenue stream unless they have a plan to make everyone in Small New England Town sicker, or unless they plan to blow up Other Local Community Hospital. Cutting costs may be part of it but I haven't read anything in the documents I signed that rewarded physicians by limiting test utilization, an approach that's totally reasonable in concept and very difficult to execute in reality.

Again, because of my very part-time status, my answer is far from definitive, but my suspicion is that they're not giving us a new wheel so much as repackaging the old one. Which is to say that the way they will generate more revenue by increasing the individual doc's workload. Overhead for hospitalists is relatively small (depending on how a hospital would charge a practice for things like office space and computer access), but salary is huge. Cut the size of the group by a third and you've found a lot of previously missing money--I'm thinking something approaching $2 million based on my back-of-the-napkin calculation for this particular hospital. I have no experience with hospital budgets, but for a hospital of that size, I'm guessing that's a serious amount of cash. Some of that, of course, will go directly to the pockets of the shareholders of Hospitalist Corporation, but the hospital stands to benefit from this arrangement.

As to whether the whole venture will succeed, I have no idea. My nature is to be suspicious of anything tied to the term "for-profit," and doubly so when it applies to entities involved in healthcare. But that is--to appropriate a term from RW Donnell--a bias, and it may well prove to be a faulty one in this instance. At this particular moment in the life of this particular hospital, its influence cannot be described as anything other than destructive, but I remain open to the idea that this new, industrialized relationship might benefit everyone by the time we next sing Auld Lang Syne. To say that I am optimistic, however, may be saying too much. We will see, and barring an unforeseen event, I'll be around at least long enough to see the immediate effects of the transition, which takes place in less than a month.

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