Hospitalists 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.
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.