Monday, August 08, 2011

Reactions to the Annals article on costs attributable to the hospitalist model

My recent post about the new Annals study showing hospitalist care to be associated with reductions in inpatient costs counterbalanced by increased costs 30 days post discharge was, due to time constraints this week, quite pithy. Now I have a little more time to reflect on the findings and comment on some of the other blog reactions. (Such is the life of a 7 on, 7 off hospitalist).

My short version: if you discharge patients quicker and sicker you'll have more bounce-backs and more utilization of post hospital services. Research comparing the pre- and post-DRG eras strongly suggests that financial incentives beginning with the advent of DRGs cause patient instability at discharge (quicker and sicker) which contributes to bad outcomes.

Now to briefly review the research findings, prior to the Annals paper, on utilization attributable to the model. As I said here and elsewhere, the data are mixed. Analysis of research findings was compromised because one of the largest and best quality studies ever done, presented at HM 2005, finding no improvement in efficiency attributable to the hospitalist model, was buried, the apparent victim of publication bias. Then a study last year, I thought, tipped the balance of evidence in favor of the hospitalist model. But none of this research looked at the cost of the entire 30 day episode of care as the Annals study did.

Happy Hospitalist wrote:

Let's just assume that hospitalist patients are equal in all ways to patients cared for by primary care physicians. It's also possible that primary care physicians shift cost into the hospital where DRG payments don't account for or fund for additional service. In an environment where hospital Medicare profit margins have been negative for almost a decade, doctors who try and get everything done in the hospital aren't doing their community hospital any service. A hospital that goes under will provide no care for anyone.

Correct. The findings of the Annals paper suggest that hospitalists shift utilization from single inpatient stays to other services. In some cases that might mean a shift from Medicare part A (non fee for service) to part B (generally fee for service). For the hospital bounce-back it means the hospital gets a whole new DRG payment for the same episode of care. Not good for the medical commons but hospital administrators love it under today's incentives (those incentives may change soon).

Happy adds this note of caution:

The data is from 2001-2006. A lot has happened, especially in IT, in the last 10 years. The discharge process has improved in many ways, and we know that a healthy discharge process helps prevent readmissions more than any other aspect of care. It is quite possible that the 2011 discharge process has eliminated or reduced many readmissions that would have otherwise occurred in 2001, when resume home meds was the most common acceptable discharge process.

But “med rec” as we now know it has been a failure. Sound in concept but inscrutably hard to implement in the real world and there's no convincing evidence that it improves outcomes over the old way. But I digress. Yes, things have changed in the last few years. There have been major efforts to improve the discharge process. It would be reasonable to assume this has helped improve outcomes but we don't know from research data. It's equally plausible that the collapse of primary care that has occurred over the same period has driven outcomes in the other direction.

Happy's post offers a lot of speculation that the patients cared for by hospitalists were more ill and complex. Be that as it may the conclusions of the Annals paper reflect the best evidence we have to date on overall costs.

Over at Med Rants DB cited lack of continuity, both at admission and discharge. I believe I recall Bob Wachter saying on more than one occasion that this discontinuity is deliberate. It's built into the model. There's been a lot of stewing about how to compensate for it. DB had this common sense advice:

We need to develop a better system for communication. We must (and I use that verb purposely) learn how to communicate better between primary care physicians and hospitalists. We must spend time on the phone – paper and email are insufficient, because we need questions and answers; we need to stress the important observations – on both sides of the communication.

A phone call at admission and again at discharge would be helpful but how does one find time? Say you admit 4 and discharge 4 complex patients on an average day. 8 phone calls. At 15 minutes per call (taking into account the time you spend on hold and playing phone-tag) that's 2 hours carved out of your day.

DB's point is backed up by evidence that just making the PCP aware the patient is being hospitalized reduces adverse events. There are guidelines which address this. They place much of the onus for communication on the ED physician and the PCP. That's as it should be. All involved should do their part. Hospitalists can't do it alone. They are not the grand integrators of health care.

DB made this interesting point:

I have written many times that the best care in a hospital comes from a physician who does both inpatient and outpatient care.

All other things being equal that would be true. The original notion of hospital medicine was that physicians who spent 100% of their clinical time caring for hospitalized patients developed exceptional skills in inpatient medicine which would exceed those of traditional doctors. That's where the educational emphasis was: the latest on sepsis, pneumonia, thromboembolism, cardiac emergencies, metabolic and toxic emergencies and the like. Research over the past decade has shown no difference in clinical outcomes between the hospitalist and the traditional model of care, suggesting that any harm attributable to the discontinuity was counterbalanced by the special expertise. That may not be true much longer, though, as the educational focus of hospital medicine shifts increasingly to the organizational and business issues (coding, clin doc, performance measures) while clinical skills are devalued.

Bob Wachter, generally a booster of the hospitalist model, made no attempt to spin the results:

Like the Annals editorialists, Lena Chen and Sanjay Saint of the University of Michigan, I find myself unable to dispute the main findings. The sample size is huge, the definitions and assumptions are reasonable, and the analysis is strong.

Although he disagrees with me on the “quicker and sicker” notion he correctly cites multiple factors that are inherent in the hospitalist model:

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.

Here's where I disagree with Bob (and a lot of other people):

Today’s study tells us that hospitalists have done their jobs well, but the job has been defined too narrowly...

As hospitals’ lenses widen..their willingness to help support their hospitalist programs will be predicated on the latter’s prove ability to improve quality, safety, patient experience, and efficiency over that entire period, not just the hospital stay.

Indeed the founding notion of hospital medicine was narrow, as reflected in the original name of our professional society, the National Association of Inpatient Physicians. So a fundamental question becomes is special clinical expertise in the acute care of inpatients really too narrow? Who do you want caring for your hospitalized patients? A clinician whose total focus is on their clinical problems or a part time clinician, part time business consultant whose skills are spread a mile wide and an inch deep?

More from and Kevin MD.

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