Human Exceptionalism

Do Hospitalists Lead to Discharge of Sicker Patients?

I understand the point of hospitalists. They are employees or contractors that manage the care and plan the discharge of hospitalized patients.  The point is to save money without compromising quality of care.

But the former may not be happening, and perhaps also, not the latter, at least according to an article in Current about the Texas experience.  The story primarily reports about purported malpractice cases arising from hospitalist care. But malpractice happens and that doesn’t prove one thing or another.  But, it gets into some details that, I think are more pertinent as to whether the hospitalist system is the best approach to caring for patients who are hospitalized.  From the story:

Hospitalists have been a specialty since the 1990s, but their ranks swelled to 30,000 from 7,000 in the past decade as administrators learned their service was ultimately cheaper than primary care physicians and more efficient at moving patients in and out of hospitals…The specialty has come under fire across the country for recurring problems with patient transitions. The University of Texas Medical Branch in Galveston (UTMB) began researching concerns with the hospitalist paradigm after geriatric specialists noticed hospitalists were not fully communicating with primary care physicians about patient histories and hospital stays.

A study published in the August 2 issue of Annals of Internal Medicine found that Medicare patients under hospitalist care checked out of hospitals sooner than those managed by primary care physicians. However, the hospitalist patients were more likely to be readmitted, costing $1.1 billion in added payments for 120,000 Medicare patients. Yong-Fang Kuo, a co-author of the study, told the Current that the hospitalist model encourages early discharge to cycle more patients through hospitals. “The shorter stay means more beds are open and, if beds open, that means you can admit more patients,” she said. “In some cases, they can bill for six days even if the patient is only at the hospital four days.”

That’s because of the Medicare DRG system.  But patients are better off getting out of the hospital earlier–what with acquired infection and the like–just not too early before they are ready.  And that can be a delicate matter.

The question is which side gets the benefit of the doubt, money or health. Now with Obamacare–and I can’t believe I am writing this–the benefit of the doubt regarding time of discharge may begin to swing the patient’s way:

Dr. Greg Maynard, senior vice president for innovation and improvement at the Society of Hospital Medicine, said hospitalists began working to remedy criticisms long before the UTMB study. The specialty is under added pressure to address concerns since the federal health care reform act includes Medicare penalties for high re-admission rates. “Hospitalist programs are obliged to make this one of their top priorities or else face appropriate criticism that they are part of the problem,” Dr. Maynard told the Current.

Of course, that is a blunt instrument that can unfairly punish hospitals, as I have written.  But it seems to me that the purported financial benefit of hospitalists may be eliminated by the Obamacare pressure.

The potential for errors increases when doctors manage high volumes of patients. Studies published in the Journal of Hospital Medicine in 2006 and 2008 show that hospitalists managing 14 patient encounters or more per shift are more likely to overlook documentation and communications with primary care physicians. Yet, health care administrators often expect hospitalists to see 18 to 25 patients per shift, up from 12 to 15 just five years ago, according to Today’s Hospitalist.

That’s called being squeezed between a rock and a very hard place.  Too few hospitalists and patient care suffers.  Too many, and you have a cost control problem.  Ditto if you keep patients in too long.  Moreover, hospital compensation is likely to take a big hit once the Independent Payment Advisory Board is up and running, and yet, if that leads to more readmissions because of the pressure that reduced compensation puts on discharge timing, they also pay the price if there are too many readmissions. There’s nowhere to run, nowhere to hide.

Perhaps we should not have gone down this road in the first place.  Primary care physicians tend to know patients better and don’t have to worry about being punished by an irate administrator under pressure from Washington bureaucrats.  And let’s not get into the futile care problem. This much seems clear, the more we try to tweak the system–the more complicated we make things–the more problems are created–and the increased number of bureaucratic solutions are invented to try and make things right.  It’s like an avalanche. What a mess.

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