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Tag-team medicine



It's time to learn a new word for your medical vocabulary, especially if you're covered by United HealthCare of Florida: hospitalist. The term, coined just three years ago, signals a palpable shift doctor/patient relations.

A hospitalist works exclusively with inpatient care, replacing a person's primary-care physician during the duration of a hospital stay. Proponents of this new tier of doctors say that, with a hospitalist on site, patients receive more attention. HMOs and hospitals like the arrangement because decisions get made quicker, reducing the length of stays and thereby cutting costs. Critics are wary, though, that hospitalists intrude on the patient/doctor bond. Many also worry that those who jump on this new money-saving bandwagon are letting the balance sheets rule health-care judgments ... and that never bodes well.

United HealthCare, which lost almost $21 million in 1998, is currently implementing a voluntary hospitalist program in several Central Florida hospitals through a contract with California-based Hospitalist Inc. That means if a UHC member ends up in the hospital for either an emergency or a planned procedure, his or her physician can agree to hand off care to a hospitalist, who will order tests, confer with specialists and make evaluations. The hospitalist regularly updates the primary-care physician, who can visit the patient as a courtesy but doesn't have a say in treatment.

"If you break down health-care costs, half are spent on inpatient care," says Michael Brouthers, president and CEO of Hospitalists Inc., which contracts with more than 90 hospitals and medical groups that cover 3 million people. He sees hospitalists as a way to "save money and at the same time enhance inpatient care."

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For the primary-care physician, hospitalists can be a big help by eliminating the daily trip to the hospital to see perhaps one or two patients. Without the distraction, "They can do a better job in the office," says W. Dennis Young, senior medical director for United HealthCare of Florida. Additionally, hospitalists are accustomed to dealing with acute problems and can check progress more often: "They're comfortable with a critically ill person," says Young.

The word "hospitalist" might be new, but for years now doctors have had set-ups that let them juggle their hospital duties; for example, the members in a group practice might rotate the inpatient rounds. "The hospital is a complication, an aggravation," admits family practitioner Richard Hays, president of the Florida Academy of Family Physicians. But he points out that hospitals give physicians a way to meet colleagues and keep up on new procedures. "The bottom line is that a hospitalist in a suburban setting is a cost-saving measure. It's not that they're physicians who are specially trained or with some unique expertise."

"It's not making the patient less sick quicker," says United HealthCare's Young. Rather, it simply chops out the down time between one phase of a hospital stay and the next.

But not everyone sees a smooth-running system. "A couple members have told me they didn't know their patient had been admitted or didn't know their patient had been discharged," says Martha Moores, executive vice president of the Florida Academy of Family Physicians. Moores is also concerned with how these programs are evaluated. Generally a patient's stay is shortened by about a day, but researchers "are only looking at one thing, not the 30-day experience afterward," she says. Was the patient re-admitted? Was additional care from the regular physician needed?

Unable to stop the hospitalist movement's surge, the medical establishment is focusing on making sure physicians and patients have a choice in the matter. "This really needs to be a physician and patient decision," says Moores, "not a decision based on control and money." The Florida Medical Association has been working on an amendment in the Florida Legislature that would prohibit HMOs from requiring physicians to hand over care. Such a requirement is already the case in South Florida and Tampa, where a program started last month by Prudential HealthCare mandates the use of hospitalists.

Hospitalist CEO Brouthers believes the next step will be a formal specialization, which is what happened 20 years ago with the establishment of emergency-room specialists. As for his company, does he guarantee in the contracts that efficiency will increase and costs will decrease? "I could. I don't," he says. Although he notes that all his contracts (which include clients in California, Colorado and Florida) have produced those results, "We don't believe that physicians should be put financially at risk" for the health-care decisions they make.

Brouthers sees hospitalists as part of the trend toward more and more specialization. "It's less friendly, less emotionally appealing," he admits, than one doctor caring for all your needs. "But we cannot afford inefficient care anymore."

In his West Palm Beach practice, Hays doesn't use hospitalists, and he sees the movement as a sign that patients, often bounced from one health plan to another, have grown accustomed to health-care disruptions and tag-team doctors. "It's really unfortunate that people accept it," he says. "It's another means of breaking up their health care into little bits."


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