The critical role of hospitalists in controlling healthcare costs

As the most prominent providers of inpatient care, hospitalists should be aware that, of the total annual expenditures on US healthcare ($2.3 trillion in 2007), approximately onethird goes to hospital-based medical care, over one-half of which ( 57%) is covered by public funds through Medicare and Medicaid; this high cost of healthcare is increasingly being blamed for unnecessarily burdening our economy and preventing our industries from being globally competitive. I believe that the high proportion of spending on inpatient care places hospitalists firmly in the center of the debate on how to reduce healthcare costs. It is well known that the United States spends about twice as much per capita as other industrialized countries on healthcare, without evidence of superior health outcomes. However, it is also known that remarkable local and regional variations in healthcare spending also exist within the US, again, without evidence of superior health outcomes in the higher-spending regions. Both of these observations suggest that we are spending many healthcare dollars on things that evidently do not improve the health of our patients. How much of this waste is administrative, operational, or clinical is debatable and remains the focus of growing national healthcare reform efforts. However, from the hospitalist perspective, we should be especially wary of providing so-called ‘‘flat-ofthe-curve’’ medicine, that is, a level of intensity of care that provides no incremental health benefit. The purpose of this editorial is to challenge hospitalists to collectively examine how much of our inpatient spending is potentially unnecessary, and how we, as specialists in inpatient medicine, can assume a critical role in controlling healthcare costs. To illustrate the issue, consider the following clinical scenario, managed in different ways by different hospitalists, with approximate costs itemized in Table 1. The patient is an elderly woman who presents to the emergency room with syncope occurring at church. The first hospitalist takes time to gather history from the patient, family, eyewitnesses, and the primary care physician, and requests a medication list and outside medical records, which reveal several recent and relevant cardiac and imaging studies. He performs a careful examination, discovers orthostatic hypotension, and his final diagnosis is syncope related to volume depletion from a recently added diuretic as well as a mild gastroenteritis. The patient is rehydrated and discharged home from the emergency room in the care of her family, and asked to hold her diuretic until seen by her family physician in 1 or 2 days. The second hospitalist receives the call from the emergency room and tells the staff to get the patient a telemetry bed. He sees the patient 2 hours later when she gets to the floor. The family has gone home and the mildly demented patient does not recall much of the event or her past medical history. The busy hospitalist constructs a broad differential diagnosis and writes some quick orders to evaluate the patient for possible stroke, seizure, pulmonary embolism, and cardiac ischemia or arrhythmia. He also asks cardiology and neurology to give an opinion. The testing is normal, and the patient is discharged with a cardiac event monitor and an outpatient tilt-table test scheduled. Although the above scenarios purposely demonstrate 2 extremes of care, I suspect most readers would agree that each hospitalist has his or her own style of practice, and that these differences in style inevitably result in significant differences in the total cost of healthcare delivered. This variation in spending among individual physicians is perhaps more easily understood than the striking variations in healthcare spending seen when different states, regions, and hospitals are compared. For example, annual Medicare spending per beneficiary has varied widely from state to state, from $5436 in Iowa to $7995 in New York (in 2004), a 47% difference. Specific analysis of inpatient spending variations is presented in the Dartmouth Atlas of Health Care 2008, which reports healthcare spending in the last 2 years of life for patients with at least 1 chronic illness. While the average Medicare inpatient spending per capita for these patients was about $25,000, the state-specific spending varied widely from $37,040 in New Jersey to $17,135 in Idaho. There was also significant variation in spending within individual states (ie, New York: Binghamton, $18,339; Manhattan, $57,000) and between similar types of hospitals (UCLA Medical Center, $63,900; Massachusetts General Hospital, $43,058). Yet there is no evidence that higher-spending regions produce better health outcomes. Interestingly, the observed differences in spending within the US were primarily due to the volume and intensity of care, not the price of care, as has been seen in some comparisons of the US with other industrialized countries. In overall Medicare expenditures, higher-spending locations tended to have a more inpatient-based and