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A surgeon dumps post-op patients to hospitalists

Kevin | Physician | June 5, 2009

Is it ever ok for a hospitalist to be the primary physician in post-op cases?

The answer is no, but as The Happy Hospitalist reports, it’s happening in some cases.

He details an instance where a hospitalist program is being asked by an orthopedic surgeon to provide care for his post-op cases, with the surgeon only coming in for a visit on the day of discharge.

As Dr. Happy correctly states, it’s “one of the worst examples of patient abandonment I can imagine.”

The reasons are purely financial. Surgeons are paid a bundled fee to provide care for a 90-day period. By dumping post-op care to the internal medicine team, they can spend more time in the OR doing cases, thus increasing revenue.

Medicare would certainly be interested in what’s going on in that particular hospital.

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Tagged as: Hospital, Hospitalist, Medicare, Patients, Primary care

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  • Matthew Bowdish

    I am not sure why this is a big surprise. Upon reading this, the only shocker in my thoughts were, “why only post-op care?” Orthopods at our Ivy League academic medical center quickly off-loaded any patients they deemed ‘medically complicated’ to the medicine housestaff and/or hospitalists. Instead, they wanted to act as an orthopedic consult to fix the fractured hips of normally well-controlled diabetic patients while medicine was stuck with all of the paperwork. From an economic sense, I can almost see their side of the deal with reimbursement cutbacks. But I always marveled how the smartest guys in med school couldn’t be bother with following finger sticks.

  • http://vendorMD.com VendorMD

    This scenario is the direct result of bundling the payments. First Insurances bundled the payments of surgery and subsequent visits together to cut costs. Then it slowly started cutting this bundled rate down so much that it disincentivised the surgeons to follow their patients after surgery. It is socialism creeping into a capitalist system. Reward and punishment still holds true in all walks of life. If you take away the reward, you will see a change of behavior. And this is what we are seeing.

  • HospiceDoc

    This is not shocking to me either. This was rampant in the academic setting. The orthopod would “consult” at their convenience and demand the Pt be admitted to medicine. And the only reason they were coming in was the hip fracture. The internist was a scut monkey pure and simple. This part of why I bailed on primary care/internal medicine.

  • ErnieG

    From the standpoint of patient care, it would not be a bad idea to have internists manage non-surgical issues post-op. I (an internal medicine specialist) have seen too many screw-ups that could have easily averted such as medications under/over dosed, missed, etc. This is especially the case with orthopedic surgeons, for reasons I don’t want to go into. Appropriate compensation for post op care for internists is another issue.

  • A surgeon

    This is not dumping-this is good patient care. Most of these hip fracture patients are from the nursing home and have multiple chronic medical problems that need to be managed by internal medicine.

    • http://www.kevinmd.com Kevin

      There is no reason why the surgeon shouldn’t remain the primary physician in post-op cases, with a hospitalist in a consultation role.

      Kevin

  • jenga

    http://www.ncbi.nlm.nih.gov/pubmed/15824300?ordinalpos=19&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

    Hospitalists are a victim of their own success their is no reason that they shouldn’t be consulted on every elderly hip fracture. It is after all about what’s best for the patient.

    That may be the only arrangement in which they will still take call. The hospital I trained at Orthopedics was a consult only service.

  • Matthew Bowdish

    I would beg to differ with A Surgeon. Where I attended medical school, the surgeons took great pride in being able to fully treat almost all of their patients from admit to discharge. I learned more about the parathyroid & calcium metabolism from surgeons than I ever did from internists. And some of my best intensivist training came from surgeons. I don’t know what’s worse; the fact that surgeons don’t want to assume this role, or that they are hindered from doing so by bad govt insurance mandates. Either way, patients lose when talented professionals like my surgical mentors go the way of the dinosaur.

  • Anonymous

    If surgeons do not want the extra work, then medicine doctors should welcome it. They should just be compensated at the same level as surgeons are for preforming the procedure, because the surgeons need the medicine docs to cure the patient.

  • Doc Stone

    This is basically a form of soft billing fraud. The surgeons get so much more for a 1 hour surgery than an internist gets for a 1 hour consultation in part because the fee is to pay for the post-op care. I am not a surgeon but the ones I trained with many years ago I think would have been ashamed of this and considered taking ownership of the responsibility core to their ethic as surgeons. Certainly they need the consultation of the hospitalist but I agree that this is, by traditional standards, a mild form of abandonment.

    It is not unique however and just another example of the ongoing process of deprofessionalisation of medicine predicted by the opponents of medicare and the economist/social philosopher Frederick Hayek as the eventual inevitable consequence of government control.

  • Doc Stone

    Another point: Why don’t the hospitalists just refuse to participate in this if they don’t think it is adequate? “No” is a powerful and often necessary word in medical practice. If they participate then they are agreeing that it is in fact adequate and appropriate and have no complaint.

  • Dr. Kranky

    a) You must keep the distinction clear between orthopods and surgeons.
    b) I assume Dr. Hospitalist is NOT griping about having to take care of a patient’s MEDICAL problems.
    C) An orthopod who sees a post surgical patient on the day of discharge only is a malpractice lawyer’s wet dream

  • http://orthologbook.blogspot.com BoneDoc

    I certainly do not “dump” my post op patients to any hospitalist/specialist other than myself. If patients do have other medical conditions to be taken care upon by specialist other than me, he/she is simply being co-managed and not dumped to some hospitalist. I take pride in seeing my patients pre and post op and after they are well into a functional member of a community even if they are being treated for other chronic medical conditions.

  • peter oconnor md

    our pediatric practice no longer rounds on newborns, they are seen by NNP’s (who are contracted by us). Are we obligated to see healthy newborns for followup whose insurance plans we don’t accept. Is it an EMTALA violation to tell them when they call to schedule a followup that they should seek another provider in plan or they will get billed by us?

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