I am enthused about the quality of healthcare that can be delivered by multidisciplinary teams (MDTs) such as the ones that staff the U.K. one-stop breast clinics and, more broadly, most cancer centers (see: The Value of "One-Stop" Breast Cancer Clinics Confirmed in the U.K.). The Wall Street Journal, in a recent article covering the Barack Obama visit to the Cleveland Clinic, had this to say about the healthcare delivery model utilized by this hospital (see: Replicating Cleveland Clinic's Success Poses Major Challenges):
The key to the Cleveland Clinic's success, many policy makers say, is its integrated approach. Like other so-called multispecialty clinics, the Cleveland Clinic employs its own physicians, creating teams of specialists that collaborate in treating each patient. By contrast, at most traditional community hospitals, doctors remain independent, private practitioners. The clinic model makes it easier to coordinate care, implement evidence-based treatments and reduce the red tape of referrals, proponents say. The clinics say their doctors also have less incentive to order unnecessary tests or procedures because they are paid fixed salaries, not on a fee-for-service basis like the majority of U.S. doctors. Despite the favorable attention from the White House, however, the multispecialty clinic model isn't easy to replicate widely. One issue is cultural: Most doctors tend to be fiercely independent. Working at multispecialty clinics requires that professionals buy into the teamwork ethos and tight hierarchy that have dominated these institutions since their inception decades ago.....The other problem is economics: the predominant fee-for-service payment system, driven largely by Medicare's payment policies, reimburses hospitals and doctors largely by how much they do to patients, not necessarily for making them healthier.
Although I agree with most of the points in this article, I think that the author is missing a very significant shift in the way that many community hospitals are organizing physician staffing. Although the most common model is for community physicians to admit and care for their patients in the hospital, the movement toward hospitalists is significant gaining steam. The majority (85%) of hospitalists are trained in internal medicine; some (5%) have completed subspecialty fellowships with pulmonary/critical care being the most common (see: Definition of a Hospitalist). In a previous note about residency programs (see: Impact of the Hospitalist Movement on Residency Training Programs) I made the following point about hospital billings for Medicare patients treated by hospitalists:
MedPage Today reports on a NEJM study, not surprisingly concluding that "hospitalists now account for nearly 40% of inpatient Medicare claims for general internist services, up from less than 10% in 1995."
The New York Times ran another article in which it discussed a hospital in up-state New York in which all of the hospital physicians were salaried (see: Savings for Hospitals: Salaries for Doctors, Not Fees). As I understand it, the major difference between this model and the hospitalist model is that, in the latter, the hospitalists are salaried and take charge of inpatients admitted by primary care physicians (PCPs) from the community. Community-based surgeons admitting patients to the hospital also use hospitalists as consultants for problems that they can't manage (YouTube video link: The Role of a Hospitalist - Alan Wang, MD - Chief Medical Officer). Dr. Wang reports in this video that the hospitalist service embedded in Emory Healthcare, Department of Medicine employs 80 intensivists across seven hospital sites. He says that over 50% of inpatients within the Emory system are being managed at some point by hospitalists.
The take-home lesson of all of this is that an alternative model is emerging in addition to a salaried physician staff -- the hospitalist model. Salaried physicians, mainly internists but also surgeons (surgicalists) and obstetricians (laborists), collaborate and interoperate with private physicians in the same hospital environment. It seems to me that that this model is far easier to deploy than the pure salaried physician approach. It is probably easier to recruit general internists on a salaried basis than subspecialists with higher earning power. The broad use of hospitalists can also be a means of controlling inappropriate referrals for inpatients.
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