I found it interesting to hear a specialist that is unhappy with the hospitalist trend. Around here, the specialist were the driving force to set up a hospitalist service as they didn’t like waiting for the primary physician to come to the hospital before or after office hours and the hospitalists are more agreeable to doing scut work on patients who’s sole reason for admission is under the specialist’s care.

A family doc

THE DOCTOR IS NOT IN

Many of you, particularly those of you who are primary care physicians who admit patients, ER doctors, hospitalists, and those of you involved in hospital administration, have noted how difficult it has been of late to obtain emergency room or inpatient specialist consultation. Particularly, some specialty consultations, such as Otolaryngology (Ear, Nose and Throat), are extremely tough to procure. Why?

There are many reasons, and as an Otolaryngologist practicing in Las Vegas, I’d like to elucidate what I perceive are the most important among them. I do this because I believe that although this is but one of many critical health care issues facing Nevadans today, it is hopefully a relatively solvable one. To solve a problem though, you really need to define what the root causes of the problem are, and address them. Doing anything less is just a “band-aid”, and such action is doomed to fail. Just throwing more cash at docs to cover ER call at a particular hospital or group of hospitals to compensate for those patients that are uninsured is one example.

I won’t lie and say it doesn’t help. The factors involved in the reluctance of specialists to see hospital and ER patients are both economic and non-economic, however. Let’s address the non-economic issues first, although they really are intertwined with the economic ones. (I will do this at the risk of sounding like I’m whining, but that risk is present anytime somebody lists problems that concern them.)

I remember, not too long ago (I like to think of myself as not that old) that hospital floors had separate, private, well-stocked examination rooms. A doctor attending to a hospitalized patient had the luxury of bringing that patient from his or her room into this dedicated exam room, with a proper examination table, working otoscope, working ophthalmoscope, and tongue blades, etc. There was privacy, cleanliness, a sense of professionalism, and hospital floors had enough nurses to even allow one to be present to assist the consultant in any minor procedure that had to be undertaken in that room. This scenario appears to have been relegated to the days of Marcus Welby.

Now, when a specialist gets a consultation request to see a patient, it is invariably at the patient’s bedside, and I, personally, would feel better equipped if I had seen the patient in his own bed at home.

This is a problem that is especially acute for ENT’s, as we are a very equipment-oriented specialty. To do the patient justice, to render an adequate consultation, the otolaryngologist has to essentially carry his office with him to the patient’s bed. Otoscopes may or may not be available at the nurses’ station. When they are, they often have dead batteries, or lack the proper disposable specula. To obtain the simple, ubiquitous wooden tongue blade requires the finding of a nurse (with interruption of her or his duties) to enter a secret code to access a clean utility room. Ditto for sterile gauze, or even band-aids. I usually hope I get everything I need from that sacred utility room the first time, lest I have to find the nurse again to repeat the process for an item I had forgotten.

Often, specialists have to perform minor (or even not so minor) procedures at bedside on a patient for whom they are consulting. This can be quite an onerous undertaking, as very little support with regard to equipment, supplies and nursing assistance is available right away. Hence, if an otolaryngologist is called to see a patient with a nosebleed, he may have to carry his own nasal endoscopy gear (including fiberoptic light source), and cautery supplies, nasal suctions (the large Yankauer suctions in the clean utility room just don’t fit very well up somebody’s nose) and nasal packing supplies, and even topical and local anesthetics. Lugging this stuff into the hospital isn’t fun (I once remember doing so, crossing the hospital parking lot while wearing a suit at noon in July and arriving at the patient soaked in sweat. Thankfully, my light source is not so heavy now). Any specialist bringing expendable supplies to the hospital costs the practice money that will not be reimbursed. Finally, bringing in fragile equipment from the office also subjects it to breakage or loss, and nasal endoscopes run into the thousands of dollars to replace.

An alternative to this is to call ahead to the nurses’ station and ask that all of the proper supplies be brought up from the OR. This, too, is problematic, as many of these supplies are obtained for me by folks that don’t regularly use them, and often the wrong supplies are present at the bedside (if they had even arrived there by the time the specialist does.)

This is in contradistinction to when a patient is seen in the office. An otolaryngologist usually has most of the equipment necessary to do evaluations and procedures quickly and efficiently, including some things that just can’t be obtained at the hospital, such as a hearing test.

Now, other than being inconvenient to the doctor, why is this scenario an issue? Remember I said that the non-economic issues were tied with the economic ones; a typical patient with a nosebleed might be quickly cared for in the office within 15 minutes. To perform a consultation on a patient in the hospital can take well over an hour, if not hours, especially when travel time to and from the hospital is taken into account. When Medicare is involved, inpatient consultations are often non-reimbursable when done on the same day as an inpatient procedure; an hour of work can be thus relegated by the government as being performed by the specialist gratis.

Actually, that hour of work is not for free-it may cost the consultant money. If the inpatient consultation is done during regular working hours, the specialist may have to forgo seeing patients in the office for the time that it takes to do the consultation. All the while, the office continues to accrue overhead that is not being offset by the relatively low level of income generated from the consultation.

There are many other non-economic factors that have led to the avoidance of hospital work by specialists. The rise of specialty surgical hospitals or same-day surgery centers has taken away some of the sense of affiliation that specialists may once have had with inpatient medical facilities. Hospitals have burdensome rules and piles of paperwork that needs to be fulfilled in order for a specialist to perform the exact same procedure that could be performed with less hassle in an outpatient surgery center. This isn’t the hospital’s fault; blame the federal government, and its heavy-handed implement, JCAHO. Unlike hospitals, same-day surgery centers don’t send out biweekly letters threatening damnation by HIM (no not a deity, but Health Information Management). They are the folks that track unsigned charts, and because of JCAHO pressure and threat of liability, records need to be completed within a certain period of time, and in order to do that, hospitals end up having to be coercive. Coercion does not a good relationship with consultants make.

The federal government also inadvertently took actions to sever ties between specialists and hospitals when the Stark laws were passed. I’m no expert, and I defer to our esteemed Clark County Medical Society President, Dr. Don Havins, for more detailed analysis, but my take on these laws was that they were passed with the intention of curbing self-referrals for the purpose of doctor enrichment; but they also prevented hospitals from giving perks or special treatment to affiliated consultants. Such perks included breaks on rent for hospital-associated medical office space. When hospitals were prevented from giving its consultants special treatment, the consultants in turn began to feel no obligation to render special treatment to hospitals.

Another trend that tended to alienate specialists from hospitals is the rise of the use of hospitalists. There is nothing inherently wrong with hospitalists, and I praise them for practicing medicine on tough, complicated patients in the ideal manner I learned in medical school. The problem with the relationship between hospitalists and specialists is purely economic. For a specialty such as otolaryngology, the most income generation due to patient encounters is from outpatient referrals. That is, insurers pay the most for those patients who are seen in the office as a result of a primary care doctor asking the specialist for them to be seen. Let’s say a specialist sees a large number of patients per week from a certain family practitioner; if that family practitioner also admits patients and wants an inpatient consultation on one of them, you can be sure that the specialist will honor the request-even for an uninsured patient. This is just business. Specialists will be unwilling to alienate a good referral source by not seeing that doctor’s inpatient (unless the specialist is otherwise uncomfortable with the particular problem). When a hospitalist admits a patient, he has no leverage with the specialist: in essence, no pool of outpatient referrals to promise to him in the future. As was mentioned before, inpatient consultations often cost a specialist rather than profit him.

This may appear to be a harsh, brutal truth, but one that needed to be said. I know plenty of hospitalists, and in part I write this article to apologize to them, and to explain to them why it’s been tough to get an ENT (or some other specialist) in Las Vegas to see their hospitalized patients. The same is true for emergency room physicians that I know who are my good friends.

We seem to have progressed more into the economic issues that stand between a hospital and access to specialty consultation. Let’s continue then.

Much has been made about the dwindling number of primary care physicians out there, and the fact that they get paid too little for what they do, especially by Medicare, and especially in relation to specialists. The perception is that procedure-oriented specialists are overpaid; nothing is further from the truth. Otolaryngologists are reimbursed more for seeing an hour’s worth of patients in the office (essentially acting as an ENT-primary care) than performing an hour’s worth of surgery, particularly when “global periods” of non-reimbursable post-op care are considered. High overhead costs mean that private practice ENT’s operate with a fairly narrow margin. Substitute the words “inpatient consultation” for “surgery” and you can see why few otolaryngologists really want to see hospitalized patients. The prevailing insurer in Southern Nevada has for a long time strongly depressed reimbursement for ENT services, including inpatient consultation. In a normal marketplace, if there is increased demand for a service that is scarce, the price paid for that service goes up; in Nevada, under the prevailing insurance paradigm, the service simply goes unrendered. One wonders what will happen when an even more dominant insurer takes over the market.

Another economic factor is the increased liability inherent with seeing emergency room patients or very sick inpatients. In the ER, there can be little or no time for development of patient rapport; in the event of a negative outcome, the patient or the patient’s family may not have even met the consultant, and may have no compunction against lawsuit. Another factor is the tendency for malpractice attorneys to take a “shotgun” approach to filing lawsuits. As an example: an inpatient has an adverse event such as an MI, and subsequently sues; if a consultant’s name is on the chart (even if all he did was clean earwax from the patient), he will be named in the suit, not as an act of extortion, but to remove from the defending attorneys a so-called “empty chair” defense. (Well, it can be an act of extortion too). Recent tort reform measures may have ameliorated this factor, but it’s too soon to tell what effect this will have on the willingness of specialists to see inpatients.

There are probably multiple other factors that play a role in the way physicians practice nationally, not just in Las Vegas, and these are too numerous and complex to go into great detail. Loss of physician prestige and autonomy means that physicians in general are not willing to sacrifice (i.e., come into the ER in the middle of the night) for a public less and less inclined to appreciate the value of their sacrifice; insurers continue to ratchet down reimbursements such that doctors are emphasizing having a good lifestyle rather than working harder for diminishing returns. Of course, there is always the debate about who is responsible to care for uninsured patients.

I’m sure there are personal reasons inherent to each and every one of the specialists who have made the personal (and believe it or not, agonizing) decision not to honor the request for some inpatient consultations or take ER call. We are healers after all, and do what we do for reasons that are not altogether economic. The forces that have changed medicine are, however, economic, and since we physicians are denied certain avenues of redress, such as collective bargaining, we often have no choice but to vote with our feet.

I don’t pretend to have an answer to this issue. Improved Medicare and insurance reimbursement rates may help, but who really sees that happening? Anyone proposing a mandate that specialists (who are private contractors) see ER patients and inpatients or else be penalized by the government needs to read Atlas Shrugged to see just where that will lead. Attempts by hospitals to simply deny privileges to specialists who don’t take call will just have an emptier roster of physicians on staff.

As one final note: this work represents my own opinion, and is the product of my own observations. It is in no way produced by a collective discussion among specialists, lest a hospital administrator or insurer accuse someone of collusion in deciding not to take ER call (as has been done before). Conditions are bad enough and getting worse such that independent practitioners have come to this in and of their own accord.