After returning home from HM14, I reflected back on the talks delivered by Ian Morrison and (Sir) Bob Wachter. Without scratching below the surface, the takeaway message from both might accord with every industry prediction you read nowadays, mainly, tough times ahead, but “exciting” ones —because we need to transform how we deliver care. Moreover, the change agent will be you, Dr. Hospitalist. And we know you love change. Your DNA has change written all over it.
Both avoided fawning over accountable care and bundling as the saviors of our industry. Praise god. They had practical goals and dispensed a realistic prognosis for what might be in our future.
However, one thing did not hit home, and they both missed an opportunity to deliver an important point. While we are not frogs—and we will certainly do more than our share to improve hospital care—we are in hot water with the burners running.
We call the hospital home. Yet, every day the beast we slay—inpatient overutilization and excess—will ultimately lead to the deceleration and partial demise of our field.
Do you know the hospital occupancy rate in the United States? We have trended down over the last decade as the guaranteed revenue streams from commercial and government payers have diminished. Our average hovers in the mid-60s, and as you can see relative to other OECD nations from nearly a decade ago, we lagged considerably. We have fallen further behind today. Excess beds do not bode well for hospital expansion and job offers (nor should they).
We all hear from the docs retiring, “we use to admit colonoscopies for 2-3 days.” Yes, that tired trope. However, what do you think you will be telling PGY1s when your social security check arrives in the mail? More than likely, nurses use to hang antibiotics in the hospital; the dialysis department had its own wing; and folks got admitted for poor glycemic control. While I am not a dyed in the wool believer of ACOs as beacons of population health, I do reckon the home will serve as a perfectly good vessel to deliver subacute and chronic care. You many not know it, but the trend has started post haste. Outpatient care has eclipsed inpatient growth for years:
Perhaps you think the drift has not translated to hospital closures and consolidation. In fact, merged hospitals have become de rigueur. Currently, 60% of our nation’s facilities reside within a health system. The number of institutions involved in M&A activity has accelerated the last few years, and unless the FTC has something to say about it (they might), don’t expect a slowdown:
Finally, if you can sum up excess beds, decreases in inpatient admissions, and industry consolidation, the denouement unfolds without thought. What was a cash cow since the inception of Medicare fifty years ago, and what served as a job creating machine during frothy and rough economic times, has ceased to be. We can no longer feed the beast. You can see the long game below (h/t), and I don’t think you need translation: red equals more chuck, and a little less sirloin. I believe the trend will persist long-term:
Of course, you can interpret the above graphs in isolation or justify them away. You can attribute the findings to outdated information, overextrapolation, or statistical noise. Don’t! In aggregate, the trend will not be our friend.
Inpatient providers, good ones, will be change agents. However, when the change concludes, there will be less need for types like us—not because we don’t fulfil a greater good, alas we do, but because there will be fewer destinations for us to ply our craft.