How to Verify Your Value as a Hospitalist

MIAMI BEACH – Although hospitalists are gaining more and more recognition for shrinking both costs and lengths of stay, one expert says it’s time to promote yourself and your services using with the V word: value.

"Hospitalists have been known over the last 10 to 15 years to be able to decrease the length of stay and decrease the cost of care within the hospital," said Dr. Joseph Ming Wah Li, director of the Hospital Medicine Program at Beth Israel Deaconess Medical Center in Boston. "But I’ve never been entirely comfortable with the notion that people view me as the money saver. I would much rather be perceived as a high-value or high-quality provider."

"Consumers in this country don’t want the cheapest care. They want the highest-value care," noted Dr. Li, who is also president of the Society of Hospital Medicine.

"When I meet with hospitalists around the country, I find a lot are confused about what value really means. But it’s pretty simple ... it’s health care quality divided by costs," he said at a meeting on perioperative medicine sponsored by the University of Miami.

It was value that Dr. Li emphasized when National Public Radio (NPR) news asked him to comment on a 2011 study about hospitalists and costs. Compared with inpatients who did not see a hospitalist, the group of Medicare Part A and B recipients cared for by hospitalists during their stay cost the hospitals less ($338 lower hospital charges per patient) and left the hospitals sooner (0.64 days earlier) (Ann. Intern. Med. 2011;155:152-9).

However, there was a catch. "For the 30 days post-hospital, they found that if you were cared for by a hospitalist, you were less likely to have a follow-up visit with your PCP [primary care physician] within 30 days; you were more likely to be discharged to a nursing home or other facility instead of home; you were more likely to be readmitted to the hospital within 30 days; and the cost of care was about $50 higher per admission, but higher than if you were cared for by a PCP," Dr. Li said. "They were essentially saying that hospitalists were just cost-shifting all these costs to the next 30 days."

Dr. Li decided not to criticize the observational design of the study or its use of a billing database, he said, when speaking with NPR. Instead, he explained that with health care reform, hospitalists and other physicians are trying to improve the value of health care in the United States. For example, the researchers found that a lower proportion of patients was discharged home after care from a hospitalist. The researchers pointed to higher costs, for example, of treating patients transferred to a nursing home setting. Dr. Li explained that it could be that patients not seen by hospitalists and discharged directly home did not receive enough care and therefore were more likely to be readmitted.

"This study could have been true, but we know nothing about the quality of care these patients received. Some may have needed to be readmitted," Dr. Li said.

One lesson Dr. Li learned from having been a hospitalist since 1998 is that it is difficult to improve if you do not know what you are doing. In other words, if you want to demonstrate health care value, start with assessment and tracking of performance measures.

As an example, in 2006 there was a question about whether or not the critical care unit at Beth Israel Deaconess had enough beds. Intensivists alerted hospitalists that they were transferring the least-sick patients out of the ICU earlier than they would have otherwise, because they did not have enough beds. Clinicians approached administration and asked them to construct another ICU.

"Property is not [inexpensive] in Boston. It would have cost tens of millions," Dr. Li said.

The administration asked if instead an appropriate way to shorten length of stay in the existing unit could be identified.

The hospitalists, critical care medicine specialists, and other clinicians targeted ventilator-associated pneumonia (VAP), which played a significant role in high utilization of the ICU. In April 2006, 90% or more of ICU patients received some of the VAP prevention measures recommended in the Institute for Healthcare Improvement Bundle.

"We thought we were doing pretty well," Dr. Li said. However, all of the bundle’s five measures are required for it to count. "Our bundle performance score was in the range of 74% to 83%," Dr. Li said. "We would like to think we were providing high-quality care, but at end of the day, one quarter of patients were not getting the very appropriate care that we were supposed to be providing."