Health care reform is a locomotive barreling down America's tracks. In two years, the Affordable Care Act will cover some 30 million out of the 50 million of us who currently lack health insurance, provided neither the Supreme Court nor a new president overturns the law. Political beliefs aside, it would seem that supplying insurance to protect the health of more people is a societal good. Though the costs of reform will be debated for years to come, one major question remains that has not been adequately addressed:
Who will see all the new patients?
It's no secret that there's a looming crisis in primary care. Estimates place the shortfall of doctors at 30,000 in the next couple of years. Yet medical schools are flush with applicants. Residency slots are filling at higher rates than ever before as new medical schools have been chartered and class sizes have expanded. So where are all the new doctors?
For the most part, in hospitals.
"Hospital medicine is the fastest-growing specialty in American medical history," said Dr. Robert Wachter, chief of the division of hospital medicine at the University of California (San Francisco), and the man credited with coining the term "hospitalist" in 1996. According to statistics compiled by the Society of Hospital Medicine, the number of doctors practicing as hospitalists has increased 172 percent from 2003 to 2010. There are now more than 30,000 doctors nationwide that are classified as hospitalists: physicians who take care of hospitalized patients but no longer have office-based practices or do primary care.
To understand how difficult it will be to find a primary care doctor in two years, look no further than Massachusetts. In 2006, the state passed a health care law mandating that everyone obtain insurance (sound familiar?). For those unable to afford the cost, subsidies were made available. Within weeks, the "uninsurance" rate in Massachusetts dropped precipitously. Commensurate with that was a rise in both the number of "closed" office practices and the length of time it took to get a new-patient appointment. Nearly six years after the law passed, more than half of the family practice and internal-medicine offices in the state are closed to new patients. According to the Massachusetts Medical Society, the average wait for a new patient to be seen by an internist is 48 days. Turns out insurance doesn't guarantee access after all.
For young doctors just finishing residency, practicing as a hospitalist has many attractions. The most enticing aspects are financial and lifestyle considerations. A starting hospitalist (depending on what region of the country they practice in) can earn around $200,000 per year (a starting office-based internist will make in the neighborhood of $150,000). Perhaps more importantly, many hospitalist groups operate with "seven-on/seven-off" schedules. This means that a hospitalist earns that salary working seven consecutive days followed by seven days off. This option is extremely popular with doctors who are parents, as well as those that want to earn extra income or volunteer during their off time.
During the three-year internal-medicine residency (like the kind I administer), doctors-in-training will spend about two-thirds of their time on hospital-based rotations. If familiarity breeds comfort, then it's not a surprise that recent residency graduates choose to stay in an environment to which they're well-adapted. And since hospital work is shift work, there is no on-call or after-hour responsibilities to handle. When a hospitalist leaves the hospital, they're done -- unlike office-based internists who still carry pagers and get phone calls in the middle of the night.
Couple the lifestyle and the training experience with the huge debt burden that U.S. medical students accrue, and deciding on a hospitalist career becomes a rational choice. Wachter compares hospital medicine to site-based specialties that came before it: emergency medicine and critical care. All of these specialties represent a convergence of high-complexity and high-cost care in a single location, where it makes sense to have well-trained specialists who handle the specific set of problems encountered there.
Since the severity of illness seen by hospitalists tends to be high, specialization improves safety and quality, which are key metrics for hospitals as insurers now tie payment to such indices. Hospitals have almost all transitioned to hospitalist models to at least some degree. According to Society of Hospital Medicine data, the larger the hospital, the more likely it is to have hospitalists. Management likes the efficiency and improved patient satisfaction that comes with having doctors on the premises at all times. Earlier discharges and shorter lengths of stay for patients keep the hospital beds turning over and consequently the reimbursement dollars flowing in.
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