A reader writes:
I agree with you completely on the importance of having a physician functioning as the coordinator of care for a patient (I have always assumed that a primary care physician would do that) my experience has been that they resist that role. I have become my own and my wife’s primary care person because of that.
There are hospitals that discourage primary care doctor participation. If you are admitted to the hospital, then primary care is not permitted to participate in treatment even if they on the staff. Rather you are under the care of the “attending physician” or the “hospitalist”. If you are discharged and readmitted a few days or weeks later you have a completely different set of physicians. Your primary care is not permitted to intervene (and doesn’t feel like endangering their position by forcing intervention).
In these situations a third party (in this example it was me) forced coordination by hand caring documents and reports, and running down staff members and having adhoc meetings. Primary care physicians don’t do that.
Welcome to the today’s hospitalist model, a trend entirely dictated by the physician payment system. Primary care physicians are now able to stay in the office, where they can see patients more efficiently, instead of dividing their time between the hospital and clinic.
The downside is the lack of continuity, as this reader has experienced. Indeed, if an inpatient is discharged and readmitted, an entirely new set of doctors may assume care. In many cases, the primary care physician does not have say in this matter.
That is why the implications of allowing hospitalists to care for inpatients need to be clearly communicated to patients.
Regarding the coordination of care, this often is done inadequately. Again, the payment system does not offer any economic incentive to do so. Time spent away from the patient coordinating care is done pro-bono, and the already strained generalist can ill-afford to do so in these trying financial times.
Good news is on the horizon. The so-called “medical home” model is being piloted on select Medicare populations, where money is alloted for coordination of care between hospitals and specialists. Initial results are promising, and can help reduce overall health costs.
Until this model is widely adopted, the current patchwork of providers providing the majority of the care in this country will continue to be the norm.
