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.

 

Medicare Does Not Provide Long-Term Care in Nursing Homes

Let me say it again: Medicare does not provide long-term care in nursing homes. The idea that Medicare does provide long-term care in nursing homes is one of the greatest enduring myths about Medicare. And, here's the scary part: I encounter this myth in discussion groups at all income and educational levels. I have seen the individual look of astonishment on the faces of clients and their families when I have had to debunk this myth and I have surveyed the faces of  groups where, only gradually, did audience members come to accept the truth.

In its September-October issue, Harvard's alumni magazine published  "Coping With Alzheimer's" repeating the canard only to have to  correct itself in the next issue. Medicare only covers rehabilitation care up to 90 days following a three day hospitalization.

Harvard Magazine should not be burying the correction on page 6 of the Letters section, it should be broadcast as a cover story because, although it is not news, it is new information for many Americans.

12/10/13: As Buzzell points out in the comments, I overstate. I stand corrected and thank Buzzell for the comment. Here’s what I should have said:

http://longtermcare.gov/medicare-medicaid-more/medicare/

Finding the Uninsured

We all know people who lack health insurance. We just may not know that they lack health insurance. They know.

Of course, some people's need is obvious — they put it forward in disease groups or through pharmaceutical assistance programs. But the quietly uninsured, they have been in a kind of "don't ask, don't tell" place for some time. If we had asked regularly and recorded their responses and then thought about aggregating the data, we might have had to do something programmatic with what we knew.

Our deeply unprogrammatic safety net patch work for the uninsured comes back to haunt us now. How to find the uninsured, now that we (more so in some states, less so in others) want to do something programmatic?  Here's a fascinating article about how the state of Maryland is looking for tracings of uninsurance in things like emergency department overuse: http://www.baltimoresun.com/health/health-care/bs-hs-health-care-uninsured-20130907,0,2157047.story.    Of course, those tracings are also somewhat  consistent with under-insurance. It ought to be interesting to see — now that we officially care to know — how we sort the two out.

Missouri’s Stealth Health Insurance Exchange

Glad the NY Times has spotted it.  That Missouri federally facilitated health insurance exchange is a tricky one. You can rarely spot it.  But you can read about it here: http://www.nytimes.com/2013/08/03/us/missouri-citizens-face-obstacles-to-coverage.html?

Based, anecdotally, on the number of questions I receive via email as well as the number of speaking engagement requests I receive, I imagine that  most of Missouri's citizens are not only woefully underinformed about the ACA but also woefully underinformed about the choices the state has made that will shape the Missouri ACA experience.

In June, I suggested in remarks at a conference of health law professors, that we were in the midst of the largest health insurance counseling challenge of our lifetimes.  Missouri's stealth exchange may make ours particularly acute.

Bodegas Clinicas: Diagnosing an Outbreak of Competition

The New York Times today has an interesting article about the
ambivalence of the Los Angeles medical establishment over the
proliferation of what are known as  "bodegas clinicas" –small
storefront licensed physicians' offices that operate on a cash economy
without the intermediation of health insurance.  These bodegas clinicas 
specialize in offering primary care services to some of California's
uninsured including some of California's estimated 2.5 million
undocumented residents.

What's not said in the article is as telling as what is.  Bodegas
clinicas have been thriving in California for some  years. Their growth
is of a piece with the growing number of medical clinics found in
Mexican border cities — clinics that cater to undocumented California
residents who may re-cross the border for care as well as uninsured or
underinsured American residents who cross the border for care in Mexico.

Why the hue and cry now about quality concerns in Los Angeles' bodegas clinicas?

One reason is surely that some of the documented now using these cash-based programs have (under California's early Medicaid expansion) or will
become eligible for Medicaid.  And whatever can be said about Medicaid
reimbursement rates in California, they are certainly higher than zero. 
The newly or about-to-be low income insured, as a result, are in the
genuinely odd position of being sought after as customers. 

Competition appears to be breaking out on the low end of the health
insurance scale between bodegas clinicas and safety net providers for
newly or about-to-be Medicaid eligible and soon-to-be subsidized health
insurance exchange purchasers. Students of competition policy will note
that one way to drive competition from the marketplace is to attempt to
raise rivals' costs, say — for example — by activating expensive
licensing investigations into the business models of thinly margined
competitors.

California has some of the lowest Medicaid reimbursement rates in the
entire country.  They are on a downward trajectory. This does not and
will not make Medicaid beneficiaries particularly sought after in
facilities with a better payor mix.  But California's Federally
Qualified Health Care Centers (FQHCs) and FQHC look-alikes are fighting
for their financial lives.  And Medicaid reimbursement may look good to
them.

In fact, if California's 100 plus FQHCs cannot make the case for
their own newly insured to stay with them as well as to solicit the
business of newly insured from others, they will be in trouble.  This is
because they serve the undocumented — the outsiders to the Affordable
Care Act. An FQHC will be hard pressed to make the successful business
case for a patient panel consisting entirely of the undocumented
uninsured. The problem is that some FQHCs have behaved exactly like
providers of last resort — impersonal and inflexible.

What I do like about the New York Times article is how it offers
insight into why some consumers with options might prefer bodegas
clinicas for primary care over an FQHC.  The article points out the good
neighborhood access of these facilities, the extended hours designed to
accomodate the many service worker patients who work the night shift, 
and the linguistic competence of all levels of the staff. I have written
elsewhere on what patients at all income levels seek from the clinical
encounter. (You can read more here:
http://papers.ssrn.com/sol3/papers.cfm?abstract_id=2078684.)

Is it possible that, in one of the more modest corners of our
country's health care delivery system we can learn lessons about health
care delivery success that is neighborhood based, culturally competent,
and forgiving of those without the foresight to fall ill only inside of
bankers' hours?

 

X posted at http://prawfsblawg.blogs.com/