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.


Latest Skirmish in California’s Scope of Practice Wars

SB 491, expanding scope of practice for California's advance practice nurses to limited tasks done without direct supervision, was not passed out of committee yesterday.  You can read about it here: http://blogs.sacbee.com/capitolalertlatest/2013/08/nurse-practitioner-bill-fails-in-california-assembly-committee.html.  Interestingly, SB 491 was not voted down so much as allowed to die — several members on the committee simply did not vote. Silence, of course, speaks volumes.

Public rhetoric runs high, including fears of lower quality and increased medical negligence, as illustrated in the article I have linked above. It is interesting to think that this may also be about power.  The expanded scope of practice bill for California's  pharmacists has survived the same committee after all. So, what's the difference?

Actually, before yesterday, California had three interesting scope of practice bills pending:

  • SB491: Would allow nurse practitioners to establish independent practices and deliver the level of care their training permits without a physician's oversight, including being able to see Medi-Cal patients.

  • SB492: Would permit optometrists to examine, prevent, diagnose and treat conditions and disorders of the visual system and human eye. It would permit an optometrist to diagnose, treat
    and manage additional conditions, and also to give vaccinations and perform primary care procedures requiring no more than topical or local anesthetic.

  • SB493: Would establish "advanced practice pharmacist" recognition status with specific training requirements, allowing such pharmacists to perform physical assessments, order and interpret medication-related tests, and refer patients to other providers.

One difference is the way SB493 has been amended to retain much of the power and authority of the work to be done by specialty pharmacists under the control of physicians.  You can see an analysis of SB 493's different iterations here: >http://www.leginfo.ca.gov/pub/13-14/bill/sen/sb_0451-0500/sb_493_bill_20130528_amended_sen_v96.html>.

Sure, it is about compensation.  But it is also about power and control.

Missouri’s Scope of Practice Wars

Missouri is one of the most restrictive states in the U.S. for scope of practice for APRNs (advance practice nurses). Yet, parts of Missouri are greatly underserved by primary care practitioners (PCPs). Although we have what might be best described as a nationwide shortage of PCPs, the Center for Studying Health System Change has documented that that the shortage is particularly acute in southern and western states. 

So, it could be worse here in Missouri.  But, it could be better.  And it might get much worse with the addition of a further 17 million Americans moving into insured status under the Affordable Care Act.

If we are stressed to provide PCP services in rural Missouri under the status quo (where an estimated 13 counties have only a CRNA — Certified Registered Nurse Anesthetist– to provide anesthesia services) what will happen if we expand Medicaid?  Is this a reason not to expand Medicaid? 

I sometimes hear this advanced as what I call the "we can't do it, so we shouldn't even try" argument, as if provider supply were immutable, immune from market forces.  PCP supply is so tight — the argument goes —  the whole system might collapse of its own weight if we further expand the pool of those seeking services.

This argument in favor of a rationing system based on grandfathering in the previously insured leaves me non-plussed.  Yet, it is a argument with considerable purchase in some health care reform debate circles.  It is, after all, the thinking behind widely discussed proposals to repeal the ACA but retain the provisions extending family health insurance coverage to children of insured families until the age of 26. 

The rationale — accident of birth, consanguinity or affinitity as a preference for insured status – seems to me to be close to arbitrary. The rationale for favoring employer based health insurance is in rewarding valued employees, not their 25 year old married, independent tax status, employed elsewhere offspring.

Similarly, the argument that Missouri not confront head on its primary care provider shortage as a form of health care rationing also seems arbitrary.

Scope of practice regimens — including Missouri's restrictive collaborative practice requirements restricting phsycians-CRNA collaboration to a 3:1 ration– are not accidents of nature or, even, next best systems thrown together in a world of limited resources.  They are programmatically designed to restrict the provision of  PCP services by APRNs in Missouri.  This they do very well.

Whether the solution to the PCP shortage is to loosen scope of practice constraints on APRNs or to increase PCP phsyician supply, we might best start by owning the problem and owning our own role in creating the problem.