Recent Report on Hospitalists Misses the Mark on Care, Cost

A recent report published in both the peer-reviewed and the press concerned the inflated costs in the care of patients post-discharge who were treated by hospitalists during their inpatient stay. The discussions occurring as a consequence of this report especially highlight the contrast between shorter and less expensive inpatient stays with complicated and more expensive outpatient care supposedly as a result of hospitalist care. The question that essentially rises is: How significant are the costs saved by hospitalists if more spending must occur later on?

The first point I would like to make in response to this entire discussion is that before hospitalist care had launched in the mid-1990s, a severely low number of Medicare beneficiaries were even getting primary-care physician appointments post-discharge. The largest meta-analysis quantifying the number of billings for primary-care physician appointments for more than 11 million Medicare beneficiaries post-discharge revealed that about 50 percent did not see the physician. No appointment means no follow up, which means no care and no costs.

The hospitalist movement is concerned with not only tight, efficient, common sense-based inpatient care, but also coherent and effective post-discharge care. Hospitalists have pioneered efforts to improve coordinated care post-discharge to reduce the 30-, 60-, and 90-day readmission rate. Project BOOST is one example of such an effective effort. The hospitalist movement is a response to the very American crisis in primary care that leads to an alarming amount of inpatient care for issues that could be addressed by primary-care physicians. The essential lack of primary care necessitated expensive inpatient care. Hospitalists focus on minimizing unnecessary inpatient costs while maximizing outpatient follow up.

So post-discharge, every patient gets a primary-care appointment, a specialty consultation if necessary, physical therapy if necessary, a week at a rehab center if necessary, temporary care at an assisted living facility if necessary, a home care physician or home nursing if necessary, or hospice if necessary. During the inpatient stay, necessity is determined by coordinated inputs from different clinical professionals, all of which is tethered together by the hospitalists’ eye on the big picture, which is to address the acute issues, and create an effective post-discharge environment to address the subacute and chronic issues.

Post-discharge care for Medicare beneficiaries is expensive. Compared to the relative dearth of care they received before the advent of the hospitalist movement, it seems downright exorbitant. But it’s the reality. Hospitalists are responsible for cost-effective inpatient care and shorter length of stays. But primary-care physicians and the burgeoning nurse practitioner population are going to be responsible for effective, sensible outpatient care to minimize outpatient costs. But we cannot be so short-sighted as to suggest that hospitalist care is to blame for the fact that medical care is expensive and complicated in the outpatient setting.

My solution to the problem of exorbitant outpatient costs is the doctor making house calls. I hope a generation of home care physicians carrying black leather bags and Blackberrys can emerge to meet this crisis. Home medical care was the law of the land for hundreds of years, and it is the only solution to the problems of the future. Doctors need to make house calls once again.

Home care has been shown to reduce the adverse effects of hospital and nursing home stays, such as nutritional problems, mentation problems, depression, and nosocomial infections. We need compassionate young people entering medical school to fill this need. Maybe physicians just don’t have it in them to be primary care physicians and maybe nurse practitioners, (who are better doctors than most nurses, and better nurses than most doctors), are the key to a successful future.

Who knows. Time will tell.

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