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February 26, 2010

"Known to you"

I was recently talking to a New York medical director charged with examining the consulting patterns in her community hospital. The hospital’s cost per case was high even for the Northeast, which is known to spend nearly twice as much on health care as more rural regions. What she found was that a full one-third of the consults in her hospital were generated because the patient was "known to you." The hospitalist group had requested the vast majority of these while serving as the attending on most of the hospital’s patients.

I suspect this won't surprise any hospitalist working in a community hospital, as many of the consults we call for are based on patients' previous relationships. So what drives "Known to you" consults, what's their fallout, and what will happen to them in the future? What follows is my take on the "known to you" Good, Bad and Ugly.

The Good: Presumably, a "known to you" patient receives some continuity of care. An example: a patient in the hospital for pneumonia with an extensive cardiac history, generating a "known to you" consult to our friend, the cardiologist. Assuming that the cardiologist you get is the one with an ongoing outpatient relationship with the patient, this consult may be, at least on the surface, have some benefit.

The patient, who largely remains oblivious to the consult's added expense, will be happy to see a familiar face. Let's assume the consultant confirms that the patient is taking the correct dosing of their heart medications. (Yes, given our fragmented health care system, the cardiologist may be the only doctor with easy access to an accurate list.) Perhaps there is even a yet-to-be recognized cardiac issue that calls for the cardiologist's expertise.

The Bad: If the patient has multiple chronic conditions—and who doesn’t anymore?—the patient may be "known to" many doctors. Given the fact that specialists tend to view patients within their slice of expertise, what ends up being provided is "organ-centric" care. The cardiologist believes the problem is the heart, the nephrologist the kidneys, and so on … with each specialist tailoring treatment accordingly. The converse can also occur, with each specialist signing off on his or her organ as "not the problem," leaving the hospitalist with a patient whose parts are all "well" while, astonishingly, the sum of those parts adds up to a crashing patient in the unit. It is our job as hospitalists to coordinate care, but this can become exponentially more complicated as each new consultant tries to navigate the ship.

A second problem: Doctors are not passive people. You may be here for pylonephritis, but this still may be a great time to get that colonoscopy or stress test. Tests only beget more tests; when was the last time you saw a CT of the abdomen that did not suggest a follow-up MRI for the nonspecific liver findings? These can become scenarios of learned helplessness for hospitalists who are charged with controlling hospital costs, meeting patients' expectations for one-stop shopping, and satisfying consultants' desires to do what they do well: procedures.

The Ugly: Politics, pure and simple. Plenty of "known to you" consults bring no appreciable value. Instead, they are nourished by a perverse reimbursement model and generated primarily for political reasons we know only too well. While the business and the practice of medicine will always be intertwined, when consults are generated as part of a quid pro quo relationship—well, you get what we have now, an expensive, redundant health care system that continues to consume more of our GDP each year. Dr. Atul Gawande covers this topic masterfully but disturbingly here.

The future: Simply put, consults drive cost, particularly when there is little if any disincentive to consult anyone and everyone. Any effective system of health care cost containment will have to change that paradigm. I have to believe that bundling payments is a very attractive idea to those who plan to reform the system. If adding more doctors to the pot means everyone receives a smaller piece of the pie, unnecessary consults will undoubtedly wane.

If so, the "known to you" consults may soon become unknown to us all. I suspect that none of us, patients and hospitalists alike, will miss them.
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2 Comment(s)

Dr. M Alar wrote:
How about just normal unnecessary consults? How many times do we get cardiology consults when they call us over night, just to get them. We don't even see the patients, but as soon as we hear "ACS," we consult cardiology. The cardiologist is surprised in the morning when he comes in to find a 20 year old male who was doing bench press the day before.

How about we take our time, interview the patients, maybe even stress them, and call cardiology only if we actually get a positive stress.

This is actually a bigger problem than social consults (known to you).
Chicago, IL | Sat, Mar 6 2010 17:16 PM

Erik DeLue wrote:
Dr. Alar,
Thanks for the comments. A simple equation is at play here. Hospital politics X hospitalist autonomy = Number of consults.

Politics is local as the saying goes, ranging from one environment in which the cardiologist expects to be consulted even if his office patient is admitted with cellulitis to another in which the cardiologists doesn't want to be involved unless there is a chance of a procedure. Autonomy is largely determined by the quality of the hospitalists' training and their respective personality. I suspect hospitalists will continue to struggle with what defines our collective standard of practice, given how profound these variables can be.

Mt. Holly, N.J. | Mon, Mar 8 2010 08:40 AM


About Erik DeLue, MD
Erik DeLue, MD, examines the challenges of running and reinventing a hospitalist program. He is medical director of the hospitalist program at Virtua Memorial, a hospital in Mt. Holly, N.J.

This is the third community hospital program that Dr. DeLue has worked for in his nine years as a hospitalist. Join in the dialogue on issues that range from compensation and 24/7 scheduling to how to work with competing hospitalist groups.

The opinions expressed by Dr. DeLue are his own and do not necessary reflect the opinions of his employer or Today's Hospitalist.
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