A recent article from the Tulsa World about “hospitalists,” doctors employed by hospitals to take care of patients in the hospital, points out very clearly the conflicts inherent in physicians working for someone other than their patient.  Many enter this line of work because they want no part of private practice.  Some of these folks want to raise a family or to volunteer at a charity.  The article also quoted “hospitalists” as going for better hours and better pay.  Residents in training also justified this path claiming that no one in medical school had taught them how to run a business, deal with the reams of paperwork of private practice or deal with insurance companies.  One Dr. Ziad Sous, president of the Tulsa Hospitalists said the hospitalist “movement” (italics mine) has “improved health care by making it more efficient and saving money.”  

He continues, “The traditional method became really time consuming and they weren’t providing good care in the hospital.”  Continuing from the article, “Hospitalists decrease the length of stay and costs of care partly because the doctors can order tests and look at the results throughout the day, instead of just visiting the hospital once every day, Sous said.”  Maybe he hasn’t heard of the telephone.  The article goes on to say that length of stay has been decreased by hospitalists, but that the effect on costs is mixed. This is generous.  More research points to an increase in costs with hospitalists involved than studies that show a decrease.  Less time in the hospital if your care is managed by of these folks is guaranteed, though.

That must mean the generation of hospital charges is pretty intense while you’re there!  Let me see.  You aren’t in the hospital as long and it costs just as much (or more, depending on what study you are referring to).  That translates into more available beds in the hospitals that in spite of not wanting to make a profit continue to do so, partly it seems by having their employed doctors kick people out early, but test and charge them aggressively while they are there.  Like a restaurant trying to quickly turn the tables over.  Maybe Dr. Sous (not The Cat in the Hat Dr. Seuss) meant that hospitalists can hang out at the hospital and order tests all day.  The notion that the care is somehow better from these “doctors” doesn’t deserve a response on this blog.

Another point.  These hospitalists are typically paid $200,000/year, more than the average primary care doctor out there.  Where are the hospitals getting this kind of dough?  Think the hospitals are going to pay them more than they’ll make for the hospital?  And you thought the greedy doctors were responsible for the high cost of health care?  You think the hospital is tracking whether or not these hospitalists are earning their keep?  Think there’s any performance pressure to order a little more of this test and a little more of that test?  To discharge patients a little earlier?  I’m sure there are some good people working as hospitalists.  But what do you think these folks will do when there is a conflict between what is right for the patient they are attending and what is right for their boss?  What if the administrator wants an unprofitable patient discharged and that is medically not the best thing for them?  What then?  What if the surgeons employed by the hospital aren’t any good and the hospitalist with a conscience sends the patient to someone “outside of the  family?”  Think they’ll get a visit from the “Don?”  

This “specialty” is actually a bubble, a market distortion, whereby extraordinarily wealthy and subsidized “not for profit” hospital systems throw a ton of dough to heavily indebted medical graduates, knowing that they will reap many times from the tests these kept doctors will order, all consistent with the latest practice guidelines, or meaningless use nonsense, of course.  This is the type of mal-investment that Mises wrote about, resulting in any number of unintended consequences.  One of the consequences is that faced with a cush, $200,000/yr job, with lots of time off for whatever, or pursuing the more difficult, but more honorable path where patients refer to you as “my doctor,” most graduating residents are going to act consistent with human nature and take the easy, although, short-sighted, road.  Can you say shortage of primary care physicians?  Many young physicians will never realize what working for their patients, instead of the vicious administrator, would have meant.  This “specialty” wouldn’t exist, of course, without the government’s intervention.  Provision of this no-tax status to giant hospitals has burdened these organizations with amounts of cash used now to distort the physician labor market.  Hospitals are also reimbursed disproportionately for what they provide compared to physicians and are thus inclined to pursue very intense billing practices.  Private practice physicians with a conscience are not as easily coerced into ordering countless and unnecessary tests and procedures as the hospitalist accomplice whose job depends on complying with this assault on the patients assigned to him…..hence the appearance of this “specialty.” 

A surgeon recently told me that the hospitalists at one of the large hospitals here in Oklahoma City have become “aware.”  Not aware that they are no longer patient advocates, but aware that they are going to be paid the same as long as they meet their “target production numbers.”  They will not see one single patient after that.  Regardless the circumstances. The hospital has had to hire more and more of these “doctors” as no motivation exists to entice these belligerent folks to work a little harder when there is work to be done.  Sounds like the old East Berlin, or current-day Canada to me.

G. Keith Smith, M.D.