Rx for Health Care Reform

20. Let “Hospitalists” Take Charge

249 20 Let “Hospitalists” Take Charge On a balmy spring morning, internist Charles Meidt is making his rounds at Bryn Mawr Hospital in Bryn Mawr, Pennsylvania. One of his patients, Roger Johnson, a very pale, eighty-three-year-old man who came here from a nursing home the day before, has blood clots in his legs. He also has a history of gastrointestinal bleeding. Normally, his internist at the nursing home would have given him a blood thinner (also known as an anticoagulant) to dissolve the clots, but she was concerned about a recurrence of the gastrointestinal bleeding. When Johnson was admitted yesterday, Meidt consulted a gastroenterologist , and they considered the options together: try an anticoagulant and carefully monitor the patient for signs of recurrent internal bleeding, or put in an IVC filter to prevent the clots from entering the pulmonary arteries. Johnson doesn’t want invasive care, which rules out the IVC filter. So he’s now on injectable heparin, a blood thinner, and Meidt is starting to phase in Coumadin, an oral anticoagulant. Meidt takes a look at Johnson’s legs and comments that the swelling has gone down. Having seen in the patient’s chart that the gastroenterologist has checked the patient’s test results, Meidt calls Johnson’s daughter. He tells her that the blood thinners are working without causing internal bleeding . Her father will be here two or three more days while the Coumadin in his blood rises to a therapeutic level. When he’s discharged, Meidt will call his nursing home doctor. A New Breed of Physician One of the new breed of “hospitalists ,” Meidt coordinates the hospital care of patients referred to him by office-based primary-care physicians and specialists. The soft-spoken, forty-seven-year-old internist also takes “unassigned” patients who don’t have any regular physician. Meidt is chief of the hospitalist service of Main Line Health, which 250 Rx for Health Care Reform includes three acute-care hospitals—Bryn Mawr, Paoli, and Lankenau— and a rehabilitation facility. Besides caring for patients, he supervises thirty-two hospitalist physicians at Bryn Mawr and Paoli Hospitals. (Lankenau Hospital has internal-medicine residents who serve as hospitalists .) Each full-time hospitalist works seven twelve-hour shifts in a row and then gets a week off. As a group, the inpatient physicians are on the medical floors twenty-four hours a day, seven days a week. According to Meidt, who helped Bryn Mawr Hospital found its hospitalist service in 1996, nearly every hospital in his area now has one. As a result, he says, patients now expect to have a hospitalist manage their care when they’re admitted. So do doctors. Three-quarters of the primary-care physicians on Bryn Mawr’s staff refer to him and his colleagues. A “Bargain” for Bryn Mawr Because they do “evaluationand -management” work, most hospitalists don’t bring in enough feefor -service income from insurers and Medicare to justify their salaries. Yet Main Line Health prizes Meidt and his fellow hospitalists enough to make up the difference. “They’re very cost-effective because of the differences we see in length of stay, and the fact that there’s availability and responsiveness of physicians on a regular basis,” explains Claire Baldwin, Bryn Mawr Hospital’s vice president of nursing administration. “There’s someone there who’s coordinating care. And they can give feedback on the patient to the nursing staff and the regular hospital staff. They can get orders done. They’re just great.” Before the hospitalist program started, Baldwin notes, “We were having problems with excessive length of stay, basically because physicians weren’t able to get in here from the office. Physicians were covering for each other, and if someone started covering on Friday, they wouldn’t discharge a patient over the weekend.” While Bryn Mawr’s overall length of stay has dropped since then, the community physicians are still keeping patients in the hospital longer than the hospitalists are. The average length of stay for Meidt and his colleagues is 3.9 days, compared with 5.3 days for office-based physicians. Meidt emphasizes that he and his colleagues receive salaries and have no incentive to discharge patients any sooner than they should. One of the other hospitalists, Matthew Cahill, concedes that the hospital does Let “Hospitalists” Take Charge 251 put a “big emphasis” on expeditious discharges. But he adds, “I don...