Home Blog What’s next?

What’s next?

August 2011

I have to say that the hot-off-the-presses observational study and editorial in the Aug. 2 Annals of Internal Medicine certainly caught my eye. The authors sampled Medicare inpatients in 2001-06 who were cared for by either a hospitalist or a primary care physician.

While the hospitalists in the study delivered shorter lengths of stay, patients treated by hospitalists were found to have higher rates of post-discharge ED visits and readmissions than those seen in the hospital by primary care physicians. Those higher associated post-discharge costs completely wiped out any savings that hospitalists achieved in the hospital.

As someone deeply entrenched in the world of hospital medicine, I’m a bit disappointed that hospitalist care was not a slam-dunk winner by any stretch of imagination. Like all studies looking at a very complex care system, the authors studied only a few–albeit important–parameters of inpatient and post-discharge care. The sample was large enough and the observational time frame was certainly adequate.

So even after more than a decade of hospital medicine, here is a study that’s asking whether hospital medicine is cost effective from the point of view of resource utilization. Are our tax dollars and Medicare dollars being well spent?

First the good news: I am glad the study looks at utilization not as an isolated hospital event but in terms of the continuum of care. If this study looked only at hospital utilization, the headlines would have been different and would have been the ones that we’re accustomed to: Hospitalists deliver more efficient inpatient care.

But as accountable care organizations become a reality, we will have to start taking a much broader view of care utilization, especially for Medicare and Medicaid populations, to encompass not only hospital care but post-discharge care as well.

So, the big question: Is this study an attempt to justify hospital medicine’s existence? The answer is “yes.”

What impact will this study have on hospital medicine’s continued expansion and, more specifically, on hospitalists and primary care providers? Will physician functions–both of hospitalists and outpatient providers–undergo another round of reorganization?

Here’s my nonscientific opinion: The existence of hospital medicine is predicated less on care utilization and more on market realities driven by a fee-for-service system. Right now, primary care remuneration is based upon a doctor’s number of patient contacts while specialist income is based on the number of procedures performed, not on the quality of post-procedure care. As long as hospitalization is divorced from the larger continuum of post-discharge care, hospital medicine is on a solid ground.

But what happens if we change the current dynamic and move to reimbursement based on outcomes and utilization management that includes post-discharge care? Then we are most certainly looking at revamping how we organize care.

Once upon a time, I did work in a traditional setting in which a single provider delivers all-encompassing care: office, ED, hospital, skilled nursing facility, even an occasional home visit. So I will have to swallow my hospital medicine pride and say that that the traditional model does have its advantages.

I can see many implications down the road as a result of this study. Smaller hospitals typically struggle to justify the costs of hospitalists, and they might see these results as a justification for plugging that red ink. They very well could start encouraging local PCPs to continue taking care of their hospitalized patients. Larger, tertiary care facilities, on the other hand, where specialists see patients with more complex medical conditions, will continue to see the value of hospitalists as captains of the ship who coordinate patient care–and continue to underwrite hospitalists’ costs.

One possibility to bridge the post-acute gap is post-discharge clinics run by hospitalists in partnership with PCPs. Another strategy could be hospitalists rotating through SNFs.

Still another approach could be developing cohorts of PCPs and hospitalists, especially for hospitals that have an open admission policy. In a cohort model, certain PCPs will always admit their patients to a finite number of hospitalists. Such an arrangement would mean that “frequent flyers” (patients with frequent admissions) would be more likely to see the same hospitalist(s) when admitted. Another option would be to harness telemedicine as a way to assess patients post-discharge. These are just a few possibilities.

There’s no doubt that PCPs are losing touch with hospital medicine, and there’s no doubt that outpatient care also needs to be improved. (In fact, if this study had looked at prehospitalization care as part of the continuum and at preventable admissions, it would have been an even more compelling narrative.) But there is also a substantial population of hospitalists who lack an in-depth understanding of outpatient care.

Maybe it is time we reeducate ourselves on both ends of the equation? Whatever the next step or the next tweak to the care system may be, evolution and adaptation is the name of the game! If studies conclude that the care we provide is more expensive and isn’t any better quality, then we may find ourselves on the receiving end of that evolutionary process if we don’t take charge of it ourselves.