General Internists at the Hospital: Cost Saving or Big Spenders?

Abstract

Evolution of medicine has brought with it changes within the hospital organization. One of them is the balance within the hospital of general internist and the subspecialty internist. The general internist is a specialist in multiple organ systems, while subspecialty internist has his/her practice limited to selected diseases (for example, cardiologists). The rise of hospital specialties careers has created the need for a redefinition of the role of the internist. In addition, as, over time, clinical practice in the hospital has come under economic and accounting scrutiny, pressure on the internists has increased. Since they take care of multiple organ failure cases (and co-morbidity patients) more often than in the specialized services, a mere comparison of resources used per patient is quite misleading in assessing their contribution to the hospital. We examine here whether, or not, general internists have been cost saving (given the more difficult patients they treat, they do it in a less expensive way than a specialty physician). The data used comes from Portuguese hospitals.

Our approach relies on looking at several sources of data, each allowing for a different type of analysis. They complement each other and provide a more global picture. The first set of results is based on cross-hospitals comparisons. Using a cost function approach we investigate whether having a higher proportion of general internists is positively or negatively associated with costs. The second set of results is based on DRG data for one large Portuguese hospital. For that hospital, we identify episodes classified in the same DRG but treated in different services (internal medicine, cardiology, pneumology and neurology). We then use matching estimators, controlling to the possible extent for the initial severity condition of each patient, to see whether, or not, general internists consume more resources. The same information, from the DRGs, is used to discuss how the probability of alive discharge varies between services. Finally, we collect data on patients from several hospital services, internal medicine and specialties, and construct measures for initial health status, consumption of resources and health status after treatment. With these, we compare the relative efficiency, in terms of health production, of internal medicine versus specialties that treat comparable patients.

The first preliminary results reveal that general internists are associated with lower costs, and more so in the larger hospitals. This holds true irrespective of the particular empirical formulation used (regression or stochastic frontier analysis, recognizing or not, the panel data nature of the data). In a complementary way, the DRG data shows that general internists use fewer resources, for the complexity of cases, and do not have worse outcomes. Overall, these results point out that the trend in hospital organization away from general internists and towards specialists may be one possible driver of higher hospital costs.

Keywords: internists, efficiency