Hospitalist care is more expensive but don’t blame hospitalists

Hospitalist care is more expensive but dont blame hospitalistsHospitalists save money.  Until the patient leaves the hospital, at least.

A recent study from the Annals of Internal Medicine ignited debate over the cost effectiveness of hospitalists. Looking at Medicare patients from 2001 to 2006, researchers found that “those who were followed by a primary care physician spent about half a day more at the hospital, costing Medicare $282 more on average than patients cared for by a hospitalist.”

But what about after patients were discharged? That’s where the cost savings evaporated: “But in the month following hospital discharge, the spending pattern was turned on its head. Patients who’d been under hospitalist care incurred the most expenses, averaging an extra $332.”

The reasons ranged from an increased number of re-admissions by hospitalist-cared patients, to more patients being sent to nursing homes, instead of back home.

I highly recommend you read the opinions of two internal medicine leaders on the study, Robert Centor and Bob Wachter.

Dr. Wachter, the father of the hospitalist movement, alludes to a multifactorial cause for the findings:

More likely, the findings represent the cumulative effects of influences on all the players. Hospitalists – highly motivated to cut hospital days – were more likely to send patients to skilled nursing facilities when they were ready to leave and less able to hook the patients back up with their primary care doctors at the time of discharge. Primary care docs who were uninvolved in the hospitalization may have been less comfortable that they understood the ins-and-outs of the hospital stay and more likely to favor readmission for the post-discharge patient who wasn’t doing well. Patients may have believed that, since their PCP didn’t see them in the hospital, the best thing for them to do if they were wobbly was to return to the ED or the hospital.

Personally, I think the health system incentives lead to this. Don’t blame the players, blame the game.  The push for primary care physicians to see more patients in the clinic contributed to the growth of the hospitalist movement, and the incentive for shorter hospital stays pushed hospitalists to discharge patients quicker.

Nowhere do I see any incentives for close post-discharge followup, or improved communication with primary care doctors.

Perhaps with the talk of bundling and global payments, this may change, but more resources are clearly needed to incentivize post-discharge care and facilitate hospitalist-primary care communication.

Otherwise, it’s entirely unsurprising that fragmenting care into hospital-outpatient silos balloons the cost of care.

 is an internal medicine physician and on the Board of Contributors at USA Today.  He is founder and editor of KevinMD.com, also on FacebookTwitterGoogle+, and LinkedIn.

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  • Anonymous

    So where is the patient in all this?  The incentives should be being a decent physician.  Hospitalists should be more than aware they have a limited role in caring for patients and should know that this arrangement is suppose to be a team effort.  Isn’t this what a “medical home” is all about?  The problem with the clinic is that physicians have become hired hands and seem to take less responsibility since their incentive is to to have 9 to 5  lives.  

    Also the comparison of the half day advantage is an illusion.  The real comparison, since hospitalists are to be considered the pinnacle of hospital care, they should be put next to the record of doctors who have shown efficiency, commitment and attention to their patients. A better system might improve a doctor’s ability to care for their patients in hospitals.  Perhaps this would be a better model.

    Finally it was not physicians who pushed hospitalists but the main push came from hospitals.  They wanted to maintain market share and enticed physicians into thinking they were putting their patients into better hands.  Now we know this is not so.  

  • Anonymous

    Read the abstract at least. Limitations: selection bias is possible. As a practicing Hospitalist who takes “” all comers” from the ED I can’t ” cherry pick” my patient population. A few years ago I remember a PCP who was still doing his own admits claiming his LOS, mortality and re admission rates were significantly better than our Hospitalist Group. Any patient without insurance, poor social support, substance abuse, mental illness, noncompliant or ” difficult” in any significant way was fired from his practice. They became automatic Hospitalist admits. You can always ” buff” your numbers if you are good at selecting your patient population. I call this paper ” Junk”.

  • http://drrjv.wordpress.com/ drrjv

    Hospitalists clearly have increased costs at our facility, with frequent unnecessary admissions, consults and diagnostic testing.

  • Anonymous

    Great piece, interesting observations!

    The issue, as you have clearly stated, is fragmentation and this goes directly to failure to communicate and the loss of skills that primary care physicians suffer over time as they no longer take care of hospitalized patients.

    One of the solutions may very well be the coordinated use of physician extenders, primary care physicians and hospitalists. Another area of resolution might go to e-mail communication, though, sadly, this is not likely to occur any time soon as only 15% of physician practices in the United States have this capability.

    Given the nature of the beast supported by this latter fact, it makes one wonder about the pie-in-the-sky expectations of the PPACA regarding doctor to doctor and doctor to hospital communication. Add to this the Baby Boomer onslaught that is coming, mix in a healthy dose of medical schools not graduating any increasing number of doctors and mix with the fact that fewer young doctors are selected primary care as a medical career path and you have a formula for real concern and a solid foundation to posit that the new healthcare law grossly understates the costs involved with care giving in the future. I would direct the reader to the current issue of Foreign Affairs and the article by Peter Orszag to support these statements.

    Mitchell Brooks, M.D.
    http://www.hotnationtalk.com

  • Kevin Yee

    Having been a hospitalist/consultant/medical director at an internet startup that is now is a PCP (probably the only one who has gone this direction in the state of CA) – all I have to say is that I all of the etiologies cited for these cost differences doesn’t exist where I practice – Kaiser Permanente. Not only that, I enjoy a more enjoyable practice and relationship with patients as a PCP than I’ve had in any other job. Pretty amazing. Can’t say enough.

  • http://twitter.com/DoctorPullen Edward Pullen

    If hospitalists would dictate their hospital discharge summary at the time of discharge, not days or weeks later, and if the summary were immediately available, not waiting to be reviewed and signed a good deal of time and probably money could be saved with hospitalist care.  

    • Anonymous

      I could not agree more.  One of my pet peeves is poor quality and/or delayed dc summaries.  I continually have to struggle to get my hospitalist colleagues to dictate summaries on time but also USEFUL summaries with appropriate information.  A lousy dc summary, even if dictated on time, is nearly useless to the pcp seeing the pt for the 1st post-hospital visit.  I’ve also “discovered” that dictating a good dc summary at the time of disch forces me to review the hospitalization and pick up on items/issues I may have missed.  And isn’t this part of a comprehensive discharge process, in the absence of which important results are missed, communication is spotty and preventable readmissions increase?   

  • Anonymous

    I think this is certainly a valid criticism, but just to put it into perspective we’re talking about a net increase in cost of $50 for patients disch’d by hospitalists.  This hardly can be described as “ballooning” the cost of care.   
    But let’s face it, the disch process is poor (inconsistent at best) in most hospitals, whether we’re talking about hospitalists or non-hospitalists.   Efforts to focus on and improve discharges (like Project RED from Boston U Med Ctr, and Project BOOST from the Society of Hospital Medicine) have tremendous potential, in my opinion, to really improve care, educate patients better and reduce readmissions.