Healthcare reform and the new role of hospitalists

by John Gever

With growing pressures on hospitals from the new healthcare reform law and from the stakeholder community to become more efficient and effective, administrators may find they already have the necessary expertise under their own roofs, a prominent hospitalist said.

“Some organizations with hospitalist programs need look no further than these programs to chart a course toward more effective physician-hospital integration,” wrote Robert M. Wachter, MD, of the University of California San Francisco.

“Hospitalists recognize that part of their ‘value equation’ (which justifies the hospital support dollars) is that they help the hospital deliver higher quality care more efficiently,” Wachter said in an editorial appearing in the April issue of the Journal of Hospital Medicine.

The editorial was adapted from a speech Wachter planned to give April 11 at the Society for Hospital Medicine’s annual meeting in Washington.

Wachter argued that “a well-functioning hospitalist program” already has many of the features of so-called accountable care organizations, an emerging model that policy experts have touted as the best way to cut healthcare costs without reducing quality.

With the Mayo Clinic and the Geisinger Health System sometimes cited as models, accountable care organizations are intended to forge teamwork among different types of providers, rewarding high-quality care while discouraging unnecessary tests and treatments.

“It may be that hospitals and doctors need not look to Rochester, Minn., or Danville, Pa., for positive examples of physician-hospital integration, but simply to their own local hospitalist groups,” according to Wachter.

Wachter also addressed some of the other goals of healthcare reform and how hospitals might change to meet them.

He noted that comparative effectiveness research has been suggested as a way to identify high-cost therapies for which cheaper treatments that are just as effective, or nearly so, could be substituted.

Great Britain has made comparative effectiveness a linchpin of its health system through the National Institute for Health and Clinical Excellence (NICE), which determines what treatments will be available in the National Health Service.

“While NICE appears to be working well, all signs indicate that the U.S. political system is not ready for such an approach,” Wachter wrote. He observed that the Medicare system “generally supports comparative effectiveness research,” but the recent Congressional debate on healthcare reform showed that it remains a political hot potato.

But if broad use of comparative effectiveness research is out of bounds, Wachter suggested, “how about focusing on one small segment of healthcare: expensive care at the end of life?”

He cited studies by Dartmouth researchers demonstrating large variations among hospitals in intensiveness of end-of-life care that were unrelated to outcomes or care quality.

But when an early reform bill proposed allowing Medicare to reimburse physicians for advance care planning with terminally ill patients, it “was caricaturized into the now famous Death Panels,” Wachter lamented. “American political discourse is not yet mature enough to support realistic discussions about difficult subjects.”

In the end, he contended, the final reform package “does little to tackle the fundamental problems of the payment and delivery systems,” with tough questions “mostly kicked down the road.”

Wachter suggested that it remains largely up to individual healthcare organizations to figure out how to bend the cost curve, through such approaches as accountable-care structures and service bundling.

John Gever is a MedPage Today Senior Editor.

Originally published in MedPage Today. Visit for more hospitalist news.

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