What’s a Hospitalist?

Last week, I participated in a discussion of primary care provider supply on KCUR, Kansas City's local public radio affiliate.  I was pleased to participate and enjoyed the conversation with my fellow panelist, Dr. Michael Munger and with our host Gina Kaufman.  I suppose I was invited to participate because I just won't be quiet about primary care provider supply, medical school education, Kaiser Permanente's recent announcement of its decision to fix the broken pipeline of primary care providers representative of and responsive to communities with the greatest shortages by opening a proprietary medical school in southern California and on and on.

Today, I want to focus on a point made later in the radio program when listener call-in questions were fielded.  One self-described "older"  caller disparaged the rise of hospitalists and the use of hospitalists in places where they were previously unknown, including rural settings. Forgive me KCUR host Gina Kaufman, but the most interesting thing about the whole exchange with the call-in listener was that you did not seem to know who or what a hospitalist is until, apparently, you were guided to some understanding by someone in the studio.  I note this without dismay for two reasons.  First, unless and until you have experienced a hospitalization for something other than scheduled elective surgery or a planned normal birth, you may not have been introduced to the new normal: acute in-patient care delivered by a physician typically previously unknown to you, a provider often employed by the hospital itself, and a provider you are unlikely to ever encounter again outside of an acute care in-patient setting. Or, it could have been that the use of hospitalists in America's acute care in-patient facilities is so widespread that the term has become obsolete to lay people, though recognized inside baseball as the fastest growing medical specialty. Either way, the caller's point was that quality care should not be based on a system of strangers treating strangers. The easy answer to that is that electronic medical records will make us all strangers no more and that care by strangers is cost effective. 

Whatever you make of the alleged impersonalism of modern health care, the caller may have been on to something in noting that there is an ongoing problem with the hand off between hospitalist provided hospital based acute care and the ongoing treatment and monitoring of things like chronic disease required of community based medicine. Our hand offs are problematic. Less expensive care in the in-patient acute care setting under the hospitalist  combined  with the costs of poorly integrated transitions to community based care on discharge can lead to higher community care based expenses along with the cost of unnecessary human suffering pushed elsewhere.  So much of our health care system is financed and delivered under principles designed to push costs elsewhere in the system rather than acknowledge that poorly integrated care costs us all but costs some of us more than others.

So, whether you are in the "What's a hospitalist?" camp  or the  "You can see someone beside a hospitalist during an acute care admission?" camp, we all ought to be interested in valuing and prioritizing the hand off from acute in-patient care to community based care, where the real rubber meets the road

X-posted at Prawfsblawg.


Making Patients Happy and What About the Discouraged Patients?

This past week, the New York Times discussed the role of patient satisfaction scores in changing Medicare reimbursement.  The timing is linked to the October 1st introduction of the new Medicare payment rate partly  based on hospital survey patient experience  data collected beginning in July of 2011.  

Never mind that 70 percent of the payment rate differential is based on procedural metrics unrelated to the satisfaction surveys, most of the ink I have seen spilled has been over the satisfaction surveys. This is because the survey questions try to get at the subjective experience of and observation of the quality of care.

I have written about this elsewhere. You can read my "'How's My Doctoring?' Patient Feedback's Role in Physician Assessment" paper here: http://papers.ssrn.com/sol3/papers.cfm?abstract_id=2078684. I am heartened, as well,  to see this topic  discussed in the 2012 Health Care Reform Supplement to the Furrow, Greaney, et al Health Law casebook.  

Janet Adamy did a good job in her New York Times article of highlighting how survey questions like "How often did doctors treat you with courtesy and respect?" are about provider-patient communication and, ultimately, patient treatment plan adherence. But there were two topics that, though mentioned briefly, deserved far more attention.

First, when a patient notes and reports that an examination room is not completely clean it is not just an aesthetic observation, deeply relevant to "what we would want as a patient."  These same patient survey observations on hospital cleanliness standards should be deeply relevant to what we should  all want of our hospitals, objectively lower rates of hospital acquired infections.

Second, when urban hospitals note that patients who enter acute care stays through the emergency rooms, with their concommitmant lengthy waits, are significantly more displeased with their hospital experience, we should all take note.  Put aside important questions about why urban acute care hospitals tend to treat the sickest of the sick and the challenges this can pose for weighting patient satisfaction data against middle class commercially insured patients commenting on the amenities provided during suburban hospital  elective procedures. This matters. But we should also focus on the issue of patient wait times and discouraged patients abandoning the quest for care, something we don't track.  The latter are the wait times of failed encounters, after all.

But these failed encounters are tracked elsewhere, particularly in the U.K. The goal of tracking is to find out if the discouraged health care seekers enter the system later at  more expensive health care venues to seek services they could not obtain earlier. 

Thinking about discouraged patients is a little like thinking about discouraged job seekers in the labor and employment statistics.  In the latter, though we know the discouraged job seekers exist, we choose not to count them.

I wonder if something very similar isn't going on with emergency room data collection. What would we learn if we tracked everyone who arrived and not just those whose work and family commitments allowed them to wait hours to be seen? Do discouraged patients in the U.S. disproportionately abandon the quest for care or simply delay it or transfer it?