Debunking myths about the hospitalist movement.

The hospitalist movement, first described in 1996 (1), has grown from several hundred practitioners to more than 4,000 today. The movement’s 2-year-old professional association, the National Association of Inpatient Physicians, enjoys a membership of more than 1,500, and is probably the fastest growing medical society in the United States. A manpower analysis published in The Green Journal last year projected an ultimate workforce of 20,000 American hospitalists (2), comparable in size with the field of cardiology. In this issue of The Green Journal, Davis and colleagues (3) provide useful new data that enhance our understanding of the effects of hospitalists on health systems. In their study of a voluntary hospitalist system at a large rural nonteaching hospital in Mississippi, they found that patients cared for by hospitalists had adjusted hospital stays that were 25% shorter, and costs that were 12% less, than patients cared for by nonhospitalist internists. For patients in the highest severity group, these savings were even greater. Annualized, the authors extrapolate that the hospitalists would have saved $2.5 million had they cared for all of the internists’ patients. As with prior studies that found similar reductions in resource use (4 –7), these substantial savings were achieved without diminishing quality or patient satisfaction. Nor was there evidence of cost shifting: hospitalists’ patients were no less likely to be discharged to home (instead of another institution such as a skilled nursing facility) than were patients of primary care internists. We can now state with considerable confidence that hospitalists markedly decrease inpatient costs and lengths of stay with no compromise in quality or patient satisfaction. As important as these data are, the descriptive elements of the Davis study are as telling as its quantitative findings. The paper addresses, and helps to dispel, several widely held myths about the hospitalist movement: that hospitalists work only in urban or suburban settings; that hospitalists are an “invention” of managed care, and are always employed by either hospitals or managed care organizations desperate to slash inpatient costs; and that hospitalists must always overcome the resistance of primary care physicians reluctant to relinquish hospital care. It is important to recognize that hospitalists are not simply an urban phenomena. Although many hospitalist programs are located in urban and suburban areas, this distribution may simply reflect the location of most US hospitals. In fact, one of the key drivers of the hospitalist movement is the distance that primary care physicians have to travel to see their patients in the hospital, a major concern in rural areas. Rural hospitals tend to be smaller than their urban counterparts. Initial speculation was that a hospital of less than 100 beds would not be able to sustain a hospitalist program, as programs generally require a medical-surgical inpatient census of at least 50 to support three hospitalists (2). This theory has given way to experience, which has taught us that even hospitals of 40 to 70 beds can support a successful hospitalist program. Of course, many rural hospitals are not small, and the rural hospital described by Davis et al is a 647-bed referral center, large enough ultimately to support a 10to 25-person hospitalist program. The study also confirms that hospitalist programs are not the invention of managed care organizations. Most early programs were formed by medical groups or by individual physicians, often in regions with relatively little managed care. The first reports of hospitalists hired by health maintenance organizations (HMOs) did not reach the literature until about 1997, several years after the movement began to grow in earnest. In a survey of 372 hospitalist-members of the National Association of Inpatient Physicians, only 14% worked directly for managed care organizations and only 4% were paid on a per-member, per-month basis (8). During the past few years, most managed care organizations have become fans of the hospitalist model (9,10). Through a variety of arrangements, many now contract with hospitalists to care for inpatients whom primary care practitioners choose to hand off. In a few cases, HMOs have mandated this arrangement, leading to a substantial backlash and even some threatened legislation (11–13). Although HMO-mandated hospitalist programs are worrisome, they represent only a tiny fraction of the national hospitalist movement: one recent study of internists found that only 2% were mandated to hand their patients off to hospitalists (A. D. Auerbach, personal communication). As noted above, relatively few hospitalists are employed directly by managed care organizations. Although a larger proportion (23%) are employed by hospitals, this proportion is smaller than the percent who are employed by a medical group (35%) or are self-employed (12%) (8). Relatively few hospitalists support their salaries and expenses based on professional fees alone, and therefore even those who are not direct hospital employees often depend on some support from the hospital. Although Am J Med. 2000;108:672– 673. From the Department of Medicine, University of California, San Francisco, San Francisco, California. Correspondence should be addressed to Robert M. Wachter, MD, Box 0120, University of California, San Francisco, San Francisco, California 94143-0120