The American health care delivery system is reaching a point of crisis. Its costs are escalating as outcomes and quality of care are diminishing. It focuses on crisis management and treating problems aggressively with medicines and interventions of uncertain benefit, while neglecting true health and wellness. It is estimated that 1 trillion dollars annually is being spent on unnecessary care, much of which occurs in the hospital, and some of which leads to harm. Medicare, although concerned about rising health care costs, does little to address the real issues and actually but subtly encourages aggressive management when less could indeed be more. Hospital acquired infections and death from medical errors are far too numerous, often occurring in patients who did not have to be hospitalized in the first place. Patients and physicians are frustrated, while private insurers and both Medicare and Medicaid are becoming unable to fund this excessively costly care without raising premiums or exhausting trust funds. Something certainly must be done.
We wish to focus on one glaring problem occurring in hospitals that is relatively easy to fix and whose resolution could improve outcomes. Currently, as many hospitals close their doors to primary care physicians (PCPs) and instead rely on hospitalists, there often is a lack of communication between these doctors that can lead directly to costly mistreatment. A true and common story will set the stage.
Mrs. P suffers from dementia and lives in a nursing home. One day she became unresponsive. The nurse on duty could find no obvious reason and so immediately called 911 and sent her to the hospital. While she quickly woke up, the emergency medicine physician admitted her for further evaluation. Her assigned hospitalist found bacteria in the urine and treated her for a urinary tract infection, calling in an infectious disease consultation and starting her on a potent intravenous antibiotic. He also requested consultations from a cardiologist and a neurologist to determine the cause of her unresponsiveness, and they ordered further tests including an MRI and an echocardiogram. Mrs. P became more confused, was exposed to aggressive evaluation and treatment, and was losing her strength as a result of bed confinement. She was ultimately sent back to her facility after tens of thousands of dollars of medical care, worse off than when she arrived. She was fortunate to have not suffered further harm from her hospital-induced delirium and the potent medicines she received.
Let’s dissect what happened, and why.
The emergency medicine physician was faced with a lethargic person who could not give a coherent history, hence she was subjected to an extensive work-up and then admitted to the hospital. The hospitalist, likewise, was faced with a patient he had never met before, with only the emergency room records as guidance. He detected neurologic, infectious, and cardiac problems and so called for specialist consultations and extensive testing.
It is unfortunate that the nursing home nurse did not call the patient’s primary care physician (PCP) upon transfer, but it was even more unfortunate that her PCP was not contacted at any time during her emergency room stay or subsequent hospitalization by any of the doctors who saw her. Had they called Mrs. P’s PCP they would have learned that she had a long history of progressive dementia and similar unresponsive episodes in the past that had been fully evaluated. Further, they would have learned that she always carried bacteria in her urine without tissue invasion and that she could have received any of her treatments in the nursing home where she would have been safer and more comfortable, at a far lower cost. A recent study showed that 20% of hospitalized patients who receive antibiotics develop an adverse event so avoiding unnecessary antibiotics must be a top priority.
The growth of the hospitalist movement over the past twenty years has been truly phenomenal – at 50,000 physicians it is the largest medical sub specialty, surpassed as a specialty only by general internal medicine at 109,000 and family medicine at 107,000. Studies suggested that quality was improved and costs reduced with hospitalist care. This was especially true for complicated patients who required multiple physician visits and interactions each day, something increasingly difficult for the community based PCP to achieve.
The hospitalist is experienced in managing the types of medical issues that lead to hospitalization and works full time in the hospital. As a result they come to know how to “get things done” and potentially can give more efficient care. But they are far too often burdened with large numbers of patients, and often know very little about the patients they are treating. With too many patients to care for and too little information they tend to request consultations for problems that, given adequate time, they could have managed. This is especially problematic if the patient has multiple medical issues and is elderly. Other reasonable concerns are the diminishment of the patient-physician relationship and miscommunication and discoordination at both admission and discharge. Communication with the patient’s PCP however could alleviate many of these issues.
PCPs have been – generally – content to allow the hospitalist to manage their patients, indeed it has been a major advantage for many. PCPs have seen their overhead costs rise dramatically, necessitating seeing more and more patients per day for less and less time each in order to cover those overhead costs. The multitude of rules, regulations and requirements foisted upon them by the insurers has further consumed extensive time, time that previously could be used to care for their hospitalized patients. Today, many PCPs do not have time to see patients in the hospital, while others are barredfrom doing so by hospital rules.
In this situation, both PCPs and hospitalists could have improved Mrs. P’s care substantially, and reduced the cost of unnecessary care, simply by communicating. A call or text by the hospitalist to the PCP upon admission and at various decision points might have enabled Mrs. P to leave the hospital before any consults were called, before extraneous tests were ordered, before antibiotics were initiated, and before she became more confused and weaker. More than half of elderly patients leave the hospital worse offthan when they came in, and involvement of a PCP in a patient’s care could potentially facilitate more rapid discharge and less aggressive treatment.
A recent surveyindicated that 95% of hospital leaders are concerned that discharge communication is “inefficient” and 80% have concerns about communication among care team members. PCPs complain that they are never called. Hospitalists often state that they just don’t have time to call the PCP but when they do, the PCP is not available. Each is culpable. Each must remember that the issue at hand is the patient’s care and welfare, not their convenience or preferences. It is a matter of professional responsibility. What could help? The electronic medical record was supposed to solve these sorts of problems but it has not and probably will not in the foreseeable future. There are some HIPPA compliant texting systems which could be utilized and there are HIPPA compliant smart phone apps that can coordinate among all involved physicians, nurses, hospitals, other facilities and even the patient him or herself. One of these types of systems could potentially negate the issue of non-availability although it will not top the value of nuanced conversation among physicians.
In the end, there is nothing that trumps good physician to physician communication. It must be incumbent on hospitalists to involve PCPs during in-patient stays and it must be incumbent on PCPs to respond to hospitalists and provide crucial insight and information when asked to do so. Not only can outcomes be improved, but costs can drop and patients and their families can feel more comfortable knowing that their own doctor is involved in their care. If necessary, hospitals should set policy that makes hospitalist to PCP communication mandatory; everyone will benefit. Very basic solutions can frequently lead to profound improvement.
This post was co-authored by
Andy Lazris, MD, CMD a primary care physician whose private practice focuses on geriatric patients especially those residing in long term care and assisted living facilities. He is the author of Curing Medicare and co-author of Interpreting Health Risks and Benefitsand was first published on Medical Economics on July 29, 2017