Why hospital culture influences medical costs

“You have to be affable, available, and able,” a senior general internal medicine physician taught me during my final year of residency. “Trust me,” he added, “when you’re in practice, you will love easy consults.”

A consult – short for “inpatient consultation” – occurs when physician caring for a hospitalized patient requests another physician to evaluate the patient and provide recommendations.  Typically, both physicians are paid – one for providing overall care and the other for providing consultation.

A neurosurgical resident had just asked one of my internal medicine classmates for a consult.  The patient didn’t have any acute internal medicine problems. He had one new serious neurosurgical problem – a recently resected brain tumor. The neurosurgical resident admitted to my fellow medical resident that he wanted her “to see the patient so we can sort out his home medications.”

Any physician can determine a patient’s home medications. Sometimes that involves calling the patient’s pharmacy or nursing home – tedious work, but easily doable without a consult.

Trainees do not receive payment for consults.  They tend to “push back” against these requests more than their supervising physicians, who generally receive money for each consult.

Most physicians find discussing money unseemly. We should be caring for patients and providing consults because patients need care, not because of money. And I really do believe that the overwhelming majority – trainees or supervising physicians – have no ambivalence when called to provide consultation for a patient who needs consultation. Cardiologists-in-training do not bicker when called to see patients with heart attacks. Those few who bicker should find a different job.

That said, incentives differ for trainees and supervising physicians.  All physicians have professional satisfaction from helping patients.  For supervising physicians, an additional benefit is the financial reward – more pay for more consults. Most consults are legitimate, because often the needs of hospitalized patients require multiple specialists.

Even when a consultation is not really necessary – a “bogus consult,” in hospital jargon – the attending still may embrace the request cheerily. Both trainee and supervisor know the consult is not really necessary. But for the supervisor, the added work may be worth the added pay.

Those incentives will be familiar to any physician at a teaching hospital, immersed in the quirks of academic medicine. But more important for all Americans, incentives for doctors provide insight into how medicine may change — for better or for worse — with emerging models of physician payment. Instead of specific payments for consults, procedures, and office visits, my generation of physicians will encounter lump salaries for the care of patients over time without incremental payments for additional tasks.  Without additional payments per consultation, senior physicians may scrutinize requests for their services more.

This change may reduce health care costs and improve value for patients. But while incremental payments encourage unneeded services, taking those payments away may encourage not providing enough services. The majority of consults enhance patient care.  Even the consults that do not appear necessary at first sometimes generate important insights, because a fresh perspective can create a breakthrough.  Doctors’ professionalism will be essential to minimizing the risk that a response to overutilization could engender underutilization.

On that morning in 2009, the senior physician was stressing a lesson we all knew. Senior physicians, both in private practice and teaching hospitals, sometimes agree to accept unneeded consult requests because of their payment incentive structure.

Just like any other unnecessary medical expense, excessive consultation can raise costs without improving care. As American medicine moves away from rewarding physicians for consuming health care resources, and focuses on value for patients, perhaps the perspective and behavior of senior physicians will evolve to resemble the perspective and behavior of trainees. The behavior should not be hard to change – because after all, all senior physicians were trainees once.

Jason H. Wasfy is a cardiologist.

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