Hospital Medicine initiates in early 1990’s

August 06, 2014

In 1992 an innovative Internal Medicine Doctor in Fresno contacted The Doctors’ Insurance Agency to ask a simple question:

“Just make my policy extend to cover more hours and possibly more doctors” Can you endorse my current TDC policy to include evenings and weekends in the hospital. Since he was already paying full time for his conventional Primary Care policy, and since the work that he was going to be doing in the hospital was consistent with his regular field of training and education, there was nothing to be done to his policy. We just noted the file, continued his policy and he increased his workload.

Eventually, the work in the hospital, the contractual commitment that he made began to grow, to eclipse the work in his primary care practice.
Creating a policy that can accommodate a changing roster. Still his policy was unchanged. As the hours and patients and referrals and expectations from the hospital grew, all he had to do to staff his 7 day per week hospital commitment was to work long hours and report locum tenens workers on his policy. his annual premium for a 1 Million / 3 Million claims made policy with The Doctors’ Company was just over $ 6,500.

Because he was ‘loading up’ on LT dates, we added a 10 % surcharge to his policy. His usual 10 hour per day, five day per week policy was now covering 12 hours and seven days. And he did not add any employees.

The Insurance Company had to be compensated for covering the additional physicians helping him meet the demand.
Eventually, we sat down and decided that it was time to add two more full time equivalents to his policy (both claims made slots that matured (increased in cost) over the years) and one ‘auxiliary physician’ header (which allows the all-important hourly flexibility to his policy.

Over the years, The Doctors’ Insurance Agency has worked with similar hospital groups in the same primary care specialty and in specialty surgical categories.

The Doctors Company underwriters are creative and they work hard to understand the unique staffing requirements of hospital medicine. The key to allowing a medical group like this to grow is to make two accommodations:

Tail and pricing

1. tail has to be included when the physicians cancel for any reason

2. the premium should be developed by measuring the number of patients seen or RVU’s attributed to the service.

Sophisticated pricing models, which match the nature of the hospital medicine staffing and schedule, combined with patient safety / risk management strategies designed to reduce premiums going in to the policy and reduce the number of claims reported once the policy is initiated.
Discussing the patient safety work in an article submitted by Dr. Burke Kealey of the Society for Hospital Medicine (
He says that Early hospitalists are well positioned to improve inpatient care and expand the specialty by Burke Kealey, MD, SFHM

Dr. Kealey reports that Society for Hospital Medicine President Rusty Holman, MD (MHM) in 2006 introduced new methods and processes in hospitals across the country. 100,000 Lives Campaign Improving Hospitalist Medicine Patient Safety

Following the 2004 proclamation of Dr. Don Berwick to save or prevent the deaths of 100,000 lives through changing culture and implementing safety,

Dr. Holman worked with leadership at national hospitals to develop rapid response teams, medicine cross references, use of prescription protocol and reporting, reformations and surgical site infection prevention, That program estimated that it saved 122,000 lives. Earlier in the new millennium, the Hospitalists were busy perfecting and understanding the role of effective handoffs, communications and to improve the diagnostic medicine in the hospitalist setting.

The Society of Hospitalist medicine and the Institute for healthcare improvement combined to expand the success of the 100,000 lives campaign to extend it significantly. The new broad based, wide sweeping effort was to reduce the incidence of increased illness, prolonged illness in hospitals, the by 5 Million. To succeed, Dr. Holman needed to initiate a deep belief that hospital medicine needed to improve.

In the article in The Hospitalists (the publication of The Society of Hospital Medicine,): Burke Kealty tells us about the history of hospital medicine:

In 1984, Libby Zion, an 18-year-old college student, died from serotonin syndrome. A contributing factor was felt to be overworked residents not getting enough sleep. …In 1994, Betsy Lehman, a health reporter for the Boston Globe, died from a massive chemotherapy overdose. That same year Lucian Leape, MD, a Harvard pediatric surgeon, published his influential article in JAMA, “Errors in Medicine,” which called for a systems approach to improving patient safety. Awareness of improving safety and saving lives in the hospital setting

These key moments in safety and quality, all of which occurred in the years leading up to hospitalists gaining their identity, were a prelude to the widespread patient safety and quality movement.These were also precursors to a wider social, medical movement: brought about by the 1999 report by the institute of Medicine: To Err is Human’ In this report, The institute reported that up to 98,000 U.S. patients per year were dying from medical errors.

Dr. Leape’s earlier work calling for system changes was referenced in this report. The six points to emphasize to improve and overhaul systems: safe, timely, effective, efficient, equitable, and patient-centered.5

Before 1999, hospitalists were just getting their feet on the ground. There were and continue to be different iterations of hospitalist medicine, different practice models that aim to increase rest, flexibility and ultimately efficiency and safety.

The Doctors’ Company and The Doctors’ Insurance Agency is working along with industry to understand what schedules work and how we can best design premiums and policy limits to support the expanding field and the need to employ and contract with part time and quarter time physicians who also have another passion in their lives.