The Evolution of Hospital Medicine

The HM specialty grew out of a few simultaneous points of origin.

Community-based physicians needed to maximize office time

As primary care physicians felt financial pressure to increase productivity and expand their reach into the patient population, they had dwindling time available to round on their hospitalized patients.

“Closed-panel” HMOs were employing their own physicians

To improve efficiency and effectiveness, companies like Kaiser, Permanente, Humana, and others worked to reduce length of stay and improve outcomes by hiring dedicated physicians to monitor patients.

Health crises augmented the need for a care “quarterback”

In the late 1990s, the AIDS epidemic severely burdened inpatient wards. In the midst of that crisis, the idea of a centralized, informed physician to run point on a person’s inpatient stay started to take real shape.

The Current State of Hospital Medicine

If its impact wasn’t significant, HM wouldn’t have grown as rapidly as it has. Recent studies and surveys have found that there are around 50,000 hospitalists in the United States2 , hospitalists work in over 80% of hospitals with 200+ beds3 , and 80% of hospitalists would choose the HM specialty over again4 . Why has it become so prevalent? What are the benefits? How does HM fit into the healthcare landscape? The answers are found within three perspectives: provider, hospital, and patient.

Benefits of a Dedicated Hospital Medicine Program

Provider Perspective

For community private practice clinicians, the benefits still reflect what we saw in the origin story: efficiency for their practice time and more attentive hospital care for their patients.

For dedicated HM providers, there is protected time off (work-life balance) and patient volumes are driven by the hospital. Additionally, they don’t need to build their own private practice and can specialize in inpatient internal medicine. The experience of caring for a high-acuity patient over a short period of time and being able to safely send them home is deeply gratifying.

Hospital Perspective

For systems and facilities, the benefits of a well-run HM program span three categories: growth and reputation, quality and clinical outcomes, and financial performance.

Growth and Reputation

One of the most important priorities to anyone who works in healthcare, anyone who has ever needed care, and anyone who has walked through medical scenarios with loved ones (so, nearly all of us) is patient experience. For hospitals, having a dedicated inpatient provider team is the key to many patient experience initiatives. It allows for continuity of care through a centralized and limited number of people—which creates stability and clarity for both the patients and their families. With this continuity comes improved operational throughput, rigorous patient safety, and timely discharges to the next appropriate site of care (ideally, home)—again enhancing the patient’s experience by providing the best care in the most efficient manner. Better patient flow throughout the hospital allows quick turnover to beds and growth in inpatient capacity. Ultimately, this positions the hospital to be the preferred facility in its community and to gain a larger share of patients.

Quality and Clinical Outcomes

Along with improved patient experience, optimized length of stay and improved throughput are beneficial for the hospital’s clinical and quality performance. The longer patients stay in the hospital, the higher their complication rates. A dedicated HM team has a solid grip on the right length and rigor of care that each type of patient needs and can develop best practices for healing their communities. In fact, research shows that higher numbers of hospitalists are associated with lower hospital readmission rates.

This team can also collaborate closely with other clinicians. HM providers can work with other departments to drive quality and safety initiatives (sepsis protocols, for example). They can build solid relationships and rhythms with the nurses on their floors. As a result, workflows become smoother, process compliance is enhanced, and resources are utilized more wisely.

Financial Performance

In financial terms, reduced length of stay as a result of dedicated HM programs emerges as an important factor again. Keeping patients for only the appropriate amount of days translates to fewer unnecessary costs on the hospital. And, as mentioned earlier, readmission rates have also declined with the growth of hospitalists— improving hospital ratings and reimbursement. Having a consistent team of hospitalists also enables hospitals to invest wisely in clinical documentation improvement programs. Return on that investment is realized when more accurate coding and billing improves case mix index—again driving higher hospital ratings and reimbursement.

Patient Perspective

The expected benefits of a dedicated HM program to the patient were explored within the provider and hospital sections, but to summarize:

  • Regular and consistent visits from providers (rather than waiting on a community provider or on-call specialists to find available rounding time)
  • Efficient movement through the admission, care, and discharge processes, enabling them to get home (or to the next site of care) at the right time
  • Proven, best-practice treatments from providers who specialize in the care they need
  • Lighter financial burden due to less unnecessary testing, fewer medications, and only staying the right number of days in the hospital

Now that we’ve illuminated the beneficial role HM plays in healthcare, let’s take a look at the other side of the coin. There are still some important financial implications to be aware of when looking at HM programs.

Economic Realities of Hospital Medicine

First, the nature of the inpatient population tends to be primarily Medicare and Medicaid—with a much smaller portion of commercial patients. Unfortunately, due to the way CMS reimburses, hospitals usually find that:

Patient Collections + Reimbursement < Cost of Dedicated HM Program

It might sound initially discouraging that HM requires subsidization, but there is a compelling, quantifiable ROI associated with that investment. Let’s run the scenario:

  1. We take the average, 150-bed community hospital with around 60% occupancy and find average number of discharges per year
  2. We juxtapose that against the industry average hospital medicine subsidies per provider FTE to see what it costs to cover those discharges
  3. We use those numbers to find the average cost per day of the average inpatient stay
  4. To see the effect of a dedicated HM program on costs, we reduce the number of average inpatient days by just half a day—12 hours
  5. We find that ROI is about four to one on the subsidy investment (typically millions of dollars in improvements for an average-sized hospital).

The ROI calculation above only accounts for cost improvement opportunities. To take it a step further, length of stay reduction adds more effective inpatient bed capacity to the hospital which can also lead to significant volume and revenue growth. Now knowing the benefits of a dedicated HM program, the clear question is: can those advantages truly be realized? In other words, is this qualitative and quantitative success really achievable? The answer is a resounding yes, but hospitals need the right framework, tools, and partnerships to get them there. We’ve boiled our experiences and outcomes down into a clear hierarchy of needs for HM success. Each tier of the hierarchy includes its own set of building blocks that help hospitals evaluate where they stand—and blaze a path forward.

Hierarchy of Needs: Tier One Foundational

Staffing to Volume/Acuity
Documentation Best Practices
Seamless Handoffs
Care Team Leadership

Hierarchy of Needs: Tier Two Intermediate

Optimized Length of Stay
Multidisciplinary Rounds and Geographic Rounding
Leadership in Hospital Initiatives

Hierarchy of Needs: Tier Three Advanced

Top-of-License NP/PA Practice
Use of Technology to Expand the Care Team
Post Discharge Care Coordination
Case Study

Building A Reputation of Quality Performance

A 138-bed facility was struggling with length of stay and quality metrics in both their HM and Critical Care programs. After being chosen to partner with this facility, SCP ensured that the staffing was appropriate for the volume and acuity of patients and began educating the teams on documentation strategies to capture all the work that was being done (both Tier One capabilities).

SCP also initiated leadership meetings (a JOC, as discussed in Tier One) that brought EM, HM, and ICU leadership together with the hospital’s executive team and frontline providers to work toward quality improvement. Finally, SCP implemented geographic rounding for the HM team and started a mega-huddle (type of multidisciplinary round, as discussed in Tier Two) to address specific patients with discharge barriers.

Read the Full Case Study
Case Study

HM Transformation Yields Significant Results

A 200-bed facility was faced with high length of stay and ineffective admission and consulting practices. SCP Health stepped in to help this facility optimize staffing, including hiring and integrating NPs and PAs (as discussed in Tier Three), to manage the actual number of patients on the census and empower the HM providers to take on their role as quarterback (as discussed in Tier One). This quickly freed up the beds necessary to release ED holds and keep patients from leaving without treatment or transferring to another hospital.

SCP also delivered provider education on appropriate admission and consulting processes, and documentation improvement (as discussed in Tier One). Finally, SCP empowered the HM providers and managers to lead initiatives focused on optimizing length of stay and throughput (as discussed in Tier Two).

Navigating the Road Ahead

Patient Experience

Evolve the focus from episodic patient satisfaction scores to longitudinal patient loyalty. This involves thinking about all the bumps and barriers that patients encounter when interacting with the hospital—before, during, and after admission.

Consider the following:

  • how patients are interacting with hospital services and representatives in the community
  • where they are located and how they transport themselves
  • what they know about how to navigate the revenue cycle process
  • how they access their health information
  • what their jobs demand physically and emotionally (or how they cope if they lack jobs)
  • who comprises (or is missing from) their support systems
  • what they might be struggling with that could affect their health journey

All of these questions (and more) are important to answer because they have a distinct impact on patient outcomes, population health, and the success of hospital initiatives. Prioritizing patients to this extent can require a widespread culture change, new or revised positions within the hospital, and working with external partners to help structure and deploy these efforts.

Scheduling Models

The HM model has evolved to primarily use 12-hour shifts with seven days on and seven days off for providers. While this model has it benefits, it also has some unfavorable side effects—and may need to be revised.

From a capacity perspective, the traditional scheduling model is too static. It is not responsive to unexpected daily or monthly changes and cannot flex to fit typical hospital volume patterns. With margins as tight as they are, hospitals cannot afford to bring on extra providers who may only be needed for the relatively brief increments where it is too busy for the normally scheduled providers to safely manage. On the flip side, hospitals cannot afford to find themselves regularly understaffed, as this builds up inefficiencies that result in patients leaving without treatment, transferring out, or staying too many days.

Changes to this model could happen in a number of ways, but two technology-enabled examples are:

  • using supplemental telemedicine coverage to augment onsite HM providers during surge periods
  • allowing hospitalists to re-deploy excess time during slow periods by taking virtual visits Be innovative here and think outside the box.

For example, consider offering virtual sports physicals at schools during the day—this creates ease for the patient and family, while also using your providers’ time wisely.

Value Based Care

HM teams must be focused on how to get patients on the best track for successful recovery. Set your organization up to be successful over the course of 90-day bundles, or other value-based care arrangements as they continue to grow in our market. These programs are—and will increasingly become—critical to helping sustainably fund a dedicated HM program

Technological Innovation

In order to be an innovative organization, be willing to think differently. This does not mean thoughtlessly investing in any new gadget or trick that emerges in the market. It does mean evaluating the hospital’s goals, soliciting input from various employees within the organization, and looking at the greater community’s needs when evaluating and choosing what technology to implement.

Consumers of all ages adjusted to and became comfortable with a virtual life as a result of the COVID-19 pandemic. Though virtual health was already on the rise, it is now an imperative for hospitals and health systems as they adjust to their patients’ new priorities. Offering accessible, affordable, and socially-distanced care options will significantly help hospitals rebuild consumers’ trust and loyalty, provide care when and where patients need it, and promote improved health throughout their communities.

While we believe that telemedicine capabilities are essential, hospitals should also consider the possible benefits of artificial intelligence, big data, natural language processing, blockchain, and more

Role of Hospitalist

As the specialty of HM continues to mature, there must be a discussion about how the increasing responsibilities of the department changes the role of the physician as well.

Given the existing role of quarterback, hospitalists have a good view into the processes of and interactions between other specialties within the hospital. As more care starts to take place outside the hospital, the provider has to be able to flex those QB muscles with external contacts. The hospitalist is critical to forming positive and sustainable partnerships with other members of the medical staff, primary care physicians in the community, local post-acute care providers, and community organizations; creating loyalty among the patient population; and bolstering the reputation of the hospital with patients and other providers along the care continuum.

While we’ve discussed the importance of hospitalists leading the charge on quality, safety, and experience initiatives, they should also be on the front lines of technological advancement in decision-making and implementation. To again quote the Society of Hospital Medicine, “they need to continue to master technology, clinical care, and the evergrowing importance of where those two intersect.” This includes being proactive in pursuing the training and developing the skills needed to understand the industry’s innovation landscape and provide care in new, technology-enabled ways.

Finally, hospitalists must be active participants in the industry-wide drive to reduce and avoid provider burnout. This means personally adopting self-care and stress-relieving habits, mentoring the next generation of hospitalists in healthy practices, and being leaders in the organization to call out and change any patterns or pressures that place unnecessary burden on the care team.