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Agzarian and Agzarian Two Votes for the Hospitalist Model

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CLINICAL COMMENTARY

Two Votes for the Hospitalist Model

Alice E. Agzarian, M.D.

and Anita Y. Agzarian, M.D.

We have been practicing Internal Medicine for almost a quarter of a century and have seen a great transfor- mation in what we actually do during the day and the manner in which we take care of patients. American society has undergone dramatic changes, and medicine has reflected these changes and sometimes even has led the way - impacted by scientific break- throughs, technologic discoveries, economic pres- sures, expanding and aging population, and increased expectations. We too have changed in our approach to the practice of medicine; one of the ways in which we have changed is by the incorporation of the hospitalist model into our routine daily practice.

stays became more costly; new, more expensive diag- nostic tests, procedures and equipment became the standard of care.1 Since 1960 the overall cost of health care has increased from 6% of the gross national product to 15%, and it is projected to reach 20% by the year 2010.2,3

The costs of running a practice increased. As with all businesses, costs of overhead, particularly payroll, have risen steadily. Americans are more litigious, and the price for malpractice insurance has skyrocketed. In addition, there are "extra" hidden costs incurred just to stay in compliance with an ever-increasing number of government rules and regulations.

While in medical school and residency training as internists we were expected to categorize, evaluate and make a treatment plan for ALL of a patient's problems while he was in the hospital. Hospital stays on the average were much longer than now, and we never heard the term "length of stay", nor did we field phone calls from utilization review coordinators.

An internist, particularly in private practice in the community, was expected to oversee in person every aspect of a patient's care. This included outpatient visits, hospital visits, management in intensive care units, visits to convalescent hospitals, and occasionally even an old-fashioned house call. Often, whole families would be loyal and stay with the same doctor for years; they usually only left the practice if they happened to move away or if the doctor retired or died.

When we entered private practice in the early 1980's, we followed the "traditional role". As time went on, medical expenses began to increase; hospital

However, although costs of running an office were escalating, reimbursement for services was starting to decline. Payments were first "ratcheted- down" by the insurance companies, including Medicare, and then came the "capitated rate" as people gravitated to the HMO model. As time went by the HMOs even mulcted their puny payments and tried to shift more costs of administration (such as utilization review, physician credentialing, and refer- rals) and sometimes even the pharmaceutical costs to the physicians.4,5 These stringent financial difficulties have infiltrated all aspects of medical care - private, nonprofit and university medical facilities and, in particular, the primary care practitioner who is reim- bursed only for office visits.

Primary care physicians who really want to provide direct, hands-on patient healing have found it difficult to remain independent; many have joined large groups. We suspect that few patients actually

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