Are Hospitalists Killing Primary Care, Redux

The comments to my original post on this topic are so striking and passionate that I wanted to answer them in a new post rather than as another comment.

First, “LPrieto” wrote, “I think the death of outpatient general Internal Medicine is inevitable.”  Then “C33333″ wrote that 16/17 of his or her (hard to sort out the gender of people named C33333) residents this year chose to go into hospital medicine.

All I can say is, Wowza! That’ll cheer all the hospitals and staffing companies who are in perpetual hospitalist recruit mode. But it is a remarkable statement re: the future of primary care.

Won’t that be ironic – if docs who chose hospital medicine over primary care are forced back into the office because there is no one else who wants to do the job. For hospitalists who are now in a cold sweat, having left their office practice vowing never to return, I think you can calm down: my guess is that there will be some hospitalist mission-creep in the form of post-discharge clinics staffed by hospitalists, to which patients can return within a few days or weeks for a single check to be sure they’re improving. But hospitalists can no more solve the PCP shortage than they can solve the malpractice crisis or the nursing shortage. This’ll have to be solved on the merits, with payers and others deciding that primary care is valuable, that it needs to be adequately supported with money, staff, IT, and respect, and that the consequences of not providing that support are unacceptable. You might say, “well, it is unacceptable now!” and I’d reply, “obviously, it is acceptable to somebody, since it is being accepted.”

One new twist to throw into this particular martini: look for the Next Big Thing in quality measurement and reporting to be 30-day readmission rates. Then look for the next mega-trend in hospital payments to be “episode-of-care” payments: bundled payments that include the initial hospitalization and some reasonable (1 month, 3 months?) post-hospital period. When both of these things happen (I’m guessing 1-3 years), hospitals will change their worldview from a DRG-induced myopia that says, “how do we provide high quality care with the shortest LOS and lowest hospital costs” to one that says, “how do we provide high quality care with the lowest costs during the entire period of the bundle, while avoiding readmissions like the plague.”  Why? Because a readmission will become a two-fer from hell: an exceptionally expensive complication for which they will not be paid, and a big-time ding on the public report card.

When that happens, you’ll see hospitals becoming very creative about one piece of the PCP shortage: how to at least be sure the patients are well cared for in the period after a hospitalization. Obviously, this would solve only one sliver of a much larger problem, but put enough slivers together and you have… well, come to think of it, not much. But something.

Anyway, thanks for the thoughtful comments. Keep ‘em coming. 

9 Responses to “Are Hospitalists Killing Primary Care, Redux”

  1. andrewmc October 26, 2007 at 2:39 pm #

    I think that the UK maybe somewhat further ahead on some of these issues than the US.

    I am currently working on the development of some Vascular pathways. These are to prevent inappropriate admissions to hospital from primary care and inappropriate attendance at outpatient clinics.

    To do this we have developed three escalating pathways. The first is through the use of PCP’s, district nurses, podiatry services etc who we are providing training to so that they can develop patient treatment and management plans.

    When a patient is identified as being more complex the patients will be looked after by a community team, the second level of care, who will carry out advanced vascular assessment and post angio follow up as well as a number of functions.

    The final level is a one stop day of admission secondary care investigation / intervention clinic.

    By removing inappropriate attendences in out patient clinics we are going to be able to offer same day investigation and intervention.

    The way that these are being dealt with from a finance point of view is that we are unbundling the HRG (similar to your DRG I would think) and moving the components that will completed in the community out to the provider who will receive support from the Acute Hospital.

  2. Brian Clay October 26, 2007 at 8:51 pm #

    I always enjoy thinking about what Medicare will do next regarding payments, because I get to play the game of “how will doctors and hospitals get around it?”

    Two obvious methods (one subtle, one rather overt):

    1. Length-of-stay creep. We often currently discharge patients as soon as possible once they “meet discharge criteria” or they can be cared for at a lower level-of-care facility. Part of the drive to employ hospitalists has been to tighten LOS as much as possible. Bundled episode-of-care payments would probably reverse this phenomenon quickly. Assuming a 30-day readmission rate of 15% (not uncommon for our medicine service at what is essentially a county hospital), increasing the average LOS by a day or so looks pretty good compared to one-sixth of the medicine admissions suddenly going unreimbursed.

    2. Change in the threshold for admission. Often ED physicians are driven toward admission as the “safe” option for those patients on the borderline with regard to the need for inpatient care. I suspect that, along with post-discharge hospitalist clinics, we will start seeing “interim” clinics for patients sent home from the ED rather than being admitted.

    Because of patient safety concerns and a desire to do the right thing on the part of physicians, these changes will likely be pushed by hospital administrators in order to maintain revenue.

    Your point about the current status being “acceptable” comes with a caveat — many active physicians now may deem the situation unacceptable, but are willing to stick it out until retirement or a shift to different employment. Supply in the medical world is relatively inelastic; however, the critical drop in supply in the primary care realm is surely coming soon.

  3. riechmar October 26, 2007 at 10:09 pm #

    The death of primary care seems to be primarily driven by economics. IF primary care is something that is valuable to third party payers, the solution is simply to remove office based primary care from the CPT driven coding and reimbursement and move them more toward a unit based billing, similar to the one anasthesia uses; such that primary care would be paid for their time, including administrative time that the law frequently mandates for physicians. Ideally telephone or email time would also be ‘billable’ (it certainly is litigatable) in a manner similar to the practice the attorneys use.

    In the zero sum game, it would be a relatively simple task to move all physicians to such a system, so that coronary angiography or colonoscopy or cholecystectomy, could be remunerated based on time spent, rather than a procedural code. I know that if I was on the operating table I would like the surgeon to take his time to do it properly…

    This may encourage some physicians to dawdle in patient care, however if the payment for units 1-5 is higher than 6-10, the incentive is definitely for more units 1-5 to be billed.

  4. Medicaster40 October 28, 2007 at 2:09 am #

    Sorry for returning back to the subject of the “death of primary care”…

    I have been a hospitalist for 15 years (based on the squishy definition) and it is no surprise to me that so many residents would choose this career. After all, we all really trained to be hospitalists, with a wink and a nod to our 1/2 day outpatient clinic every Thursday AM, except when we were post-call or presenting at rounds or doing Geriatrics/Dementia clinic (where most indigent patients forget to come in anyway). Let’s get right to the crux: traditional internal medicine is essentially training to become a hospitalist (or a stepping stone to subspecialty care). We all chose an internal medicine residency because there was some intrigue, excitement and intellectual stimulation during our 3rd year rotation IN THE HOSPITAL.

    Those of us that were immediately “placed” into an outpatient practice, as I was after leaving residency in 1992, felt terribly out of place. I was fortunate enough to find partners that were overjoyed when I volunteered to take over their inpatient loads. As my inpatient practice grew to 50% in 1994, I knew my calling – or was reminded of why I originally became an internist – I love the hospital.

    The death of primary care is a misnomer: it is the death of primary care internal medicine which is imminent. We all know why… $45 reimbursements (at least in Washington State) for complicated office visits that take an hour, extremely high overhead, insurers shorting payments by $20 because because it’s not worth having your billing company chase that small amount, etc. Contrast that scenario with an efficient Family Practice office doing far more procedures, quick urgent care visits, pediatric care, and referring complex patients to internists or subspecialists. The future of primary care appears to rest with midlevels and Family Doc’s.

  5. tholt October 30, 2007 at 3:39 am #

    I am a 14 year family physician turned hospitalist. Primary care is suffering for all the reasons listed above and many more. Hospitalists help primary care physicians in caring for their patients. Yet hospital medicine competes with primary care in the job market. One third of my office partners want nothing to do with inpatients and the other 2/3 are still doing some hospital rounding but generally happy with my full time hospitalist role. When I left the clinic there was no net loss of primary care clinic FTE. Those physicians who once spent time in the hospital now had more time in the clinic, equivalent to the time lost when I left the clinic.

    While the distribution of physicans in the workforce is important, I think we should first decide what is the best way to care for patients. Readers of this blog will likely agree that hospitalists improve patient care. That is more important than the unfortunate decline of primary care internal medicine.

  6. Rick Miller November 3, 2007 at 4:24 am #

    Hospitalists are not killing Primary Care. The specialty is not dying, but rather evolving. Certainly, Internal Medicine Primary Care is in crisis, facing intense and diverse economic, professional and social pressures. It may be that Internal Medicine, as a function of the residency training process, is just not cut out for primary care. My own outpatient training, as is the case of most internists with whom I have worked, focused on performing in-depth, comprehensive patient oriented evaluations, creating plans of action, and even offering a few minutes of counseling, with each office encounter. We were trained to provide an outpatient service that may be theortically advantageous for patient care in many ways, but simply impractical to deliver in terms of the economic realities of the reimbursement system and business overhead. Even as a resident I recognized that this model might be great for patients but would be a disaster for a small private practice business. Nevertheless, I tried anyway. I eventually left primary care, after 8 years, because I felt I could no longer in good conscience pretend I was doing my best to care for patients as I struggled to keep to a 10-15 minute appointment schedule, 22-25 patients per day, in order to keep the clinic financially viable. I am now a hospitalist. I am so much happier, because I finally feel that I am doing the job I was trained to do, and that I am doing it well.

    I think that primary care will evolve into a soecialty field consisting mainly of nurse practitioners and physician assistants as first-line providers, managed and supervised by family practice physicians and internists. This model will evolve as a result of the financial pressurs that now drive Internists into hospitalist careers, not because of the growth of the hospitalist specialty itself. Will this be a good thing for patient care? Who knows.

  7. Eric Siegal November 14, 2007 at 8:00 pm #

    It’s interesting that internal medicine points the finger at everyone but itself when it bemoans the death of primary care. In my last position at a major academic medical center, the prevailing attitude was that primary care was the refuge for residents who were neither bright nor motivated enough to subspecialize. Based upon my entirely unscientific observations, there reputation of a medicine training program is inversely correlated to the percentage of its housestaff who choose generalist careers.

    The ranks of primary care (and by extension, hospital medicine) are now being primarily filled with graduates of community programs (which are, of course, disproportionately populated wiith international medical graduates). All of which further widens the prestige gap.

    Until the academic big guns stop treating GIM as their ugly stepchildren and actually (gasp) promote generalists to positions of prominence, housestaff will rightly assume that generalist careers are for losers.

  8. Rick Miller November 15, 2007 at 2:41 am #

    “prevailing attitude was that primary care was the refuge for residents who were neither bright nor motivated enough to subspecialize”.

    This is an attitude that I frequently encountered as a private practice primary care internist when working with subspecialists. The lack of respect, sometimes outright disrespect, for primary care docs is insulting and disheartening, and combined with the reimbursement inequities, is a major reason why the specialty of primary care is in such trouble.

  9. Doc Sacks January 20, 2008 at 2:41 am #

    I agree with some of the above, but fundamentally disagree wholeheartedly that Primary Care of the sickest most complex, elderly patients complex can or should be turned over to frequently undertrained, unsupervised P.A.’s, F.N.P.’s or poorly trained Foreign Medical Graduates. They cannot care for these folks – and at their core, they will admit as much, and so should you. They NEED Internists to care for them.

    I absolutely agree we have ourselves (Medicine) to blame for much of the current mess we’re in, only I would refer part of that blame to our forebears. It was their laissez-faire attitude toward internal policing, avarice and abuses of the system that forced (unfortunately over-zealous) reform. It is impossible to rectify the Hippocratic Ideal of representing the patient’s best interest, while simultaneously being forced to represent a profit driven organization. It is this conflict that will tear us apart. I think we physicians will eventually have to drop out of this unfair and immoral system en-mass. I think that we will be replaced in the Managed Cost organizations by the P.A.’s, F.N.P.’s or F.M.G.’s. However, I believe the public will eventually catch on and demand reform, but I don’t think any of us can make house payments for 10 years on our current savings. Further, it is immoral to “brain-drain” the rest of the world, particularly the 3rd world countries where many of these Doctors are from, just because you WON’T pay Primary Care Doctors a real wage.

    I am an Internist for over 20 years, and I was the founder of our local Hospitalist group in November 2000. I recently closed my Primary Care Practice as I cannot make a living at it. I made $28K in the last 11 months. And, my departure from practice is only the beginning of a Tsunami of closures of Primary Care practices due to: defections by Doctors to the likes of Kaiser (as is already happening here in Northern California); or to “Boutique” practices serving just a few wealthier patients across hi-rent areas like California, New York/East Coast, Florida etc.; and early retirements of an aging Internist work-force. For a population of >250,000, Santa Rosa, CA now has 15 practicing Internists (outside of Kaiser) of which only 3 are under 55 years old. More choose early retirement each day and will not be replaced in the current regulatory and economic climate. Medical students are not going into Primary Care specialties as they are not idiots. Given the unhappiness of current Primary care Docs, the huge debt accrued by Medical students and the paltry return on investment in Internal Medicine/Family Practice and Pediatrics, the collapse is inevitable and will be truly frightening in its scope and degree.

    ER Docs, rightfully disturbed at the overcrowding of their E.D.’s complain that if a patient calls their PMD with an urgent problem, they will tell you to “go to the ER.” Why is that? In the past, we left “holes” in the schedule to accommodate “urgent calls”, but because of declining reimbursement and ever-increasing bureaucratic demands and costs, we are already double-booked JUST TO PAY THE BILLS.

    Our medical leadership, is still not getting it. They say they want to address Primary Care’s survival; but I’ve seen no real action in all the years I’ve been practicing. They couch the crisis in Primary care with terms like “may” or “will be” as if the crisis were not already upon us and worsening by the day. They offer “pie in the sky” solutions like the “Medical home” while oblivious of the up-front costs of these programs and the EMR’s (Electronic Medical Record) that would be necessary to implement them. Just where is the hapless Primary Care doc who is struggling merely to pay the bills gonna find $100,000 to 1 million dollars to PAY FOR THIS STUFF????

    And to the policy wonks that say; “oh, universal single payor will fix everything”, let me remind you all that IT IS THE SINGLE PAYOR, government run, entitlement driven system for all Americans over the age of 65 that has put me out of the business of seeing my patients and keeping them OUT OF HOSPITALS.

    I am apparently supposed to shuffle elderly and/or complex/complicated patients in & out of my office every 10 to 15 minutes, or I cannot make a living. Alternatively, I can bring them back every WEEK to address one more of their multitude of problems…Frankly, this is NOT a solution that I, or these debilitated patients can live with.

    I had scheduled new patients in a 1 hour slot – allowing us both time to talk and get the whole history and do a detailed exam – usually for the 1st time in years (if ever); and then plot a course on their way to wellness. I did follow-ups in 1/2 hour – again to allow these patients to express what my medicines/interventions did for them, further problems/concerns, and do a good follow-up exam.

    I believe – strongly – that this time should & must be allowed for patients…yet, Medicare/MediCal and the Insurance monopoly will not pay me enough to meet expenses, much less a decent living. Frankly, if Medicare were to do an actuarial analysis of my patients and predict how often they would likely be admitted to the hospital – then look at how infrequently that actually occurred and reimburse me only ¼ of that, I would be a rich man and would have been able to continue to KEEP THOSE PATIENTS OUT OF THE E.D. & HOSPITAL – and save Medicare $$$$. This model would prevent cherry picking and encourage Primary Care docs to be available in order to address problems early BEFOPRE they require a hospitalization.

    You cannot piecemeal fix a completely (fiscally, ethically and morally) broken system. It must end. As for me, I have been offered a position as Hospitalist that is too good to turn down. Thus another Primary Care practice closes not due to preference, but due to the economics of survival.

    Should our governments decide to remedy this situation, it would be easy enough for them to do so, but we would need visionary leadership, not reactionary puppets.

    Once again this discussion skirts the issue but doesn’t really hit the most important point. Primary care is unravelling around us. Indeed, all of the articles about the inordinate strain & crowding of Emergency Departments across the U.S., overlook the obvious – the impending failure of Primary Care is going to completely OVERWHELM Emergency Rooms. There is no way to prepare for this other than to save Primary Care…

    The whole house of cards has begun to collapse, and all the articles and discussions fail to put it in terms with sufficient emphasis. All of the “universal” systems that actually work are built on a very strong and well-funded foundations of Primary Care. Everything else in Healthcare is built upon that foundation, and THAT is precisely what is failing across the country. Why are emergency rooms overcrowded, why are the wait times increasing even for the seriously ill? BECAUSE PRIMARY CARE IS FAILING! DUH!

    Just remember, I told you so…Good luck to all of us – we’re ALL gonna need it. So I look forward with a certain morbid glee to the day SOON when the house of cards falls in the hope that something better can be built from the rubble and chaos.

    As for me, personally: Good news! At least for me…

    I am doing well for the 1st time in a VERY long time. I feel I am wanted, needed and appreciated AND PAID! Heck there are multiple entities fighting over who’s gonna get me!

    In late November, I got an (unsolicited) call from the VA in Ukiah when they apparently heard I’d given up my Primary Care practice – where I made $28,000 (yes, after taxes…) for the first 11 months of this year – to try to entice me to work for them. I talked to their “Human Resources” folks in San Francisco (though my initial calls were answered both times by an answering machine at 14:20. Must be nice to have that job…) and they’re offering 5-days a week w/o call at all, paid-time-off, CME allowances and lots of other perks of being a government employee for 160K/yr (+ bene’s) – certainly sounds good, though the pay is unlikely to be sufficient to tear me away from Hospitalist work and I’m pretty sure it won’t be enough to convince me to drive that long a distance daily – or stay away from my wife 20 days a month. (They have two unfilled Primary Care slots and that’s just the beginning of THAT shortage…) I’m going to do a site visit, then maybe 5 days as a trial.

    Sutter Santa Rosa through IPC (the largest Hospitalist employer in the country) has offered me a more than triple what I made this year based on a 12 hour day and 10 days of Hospitalist duty/month (plus 1 or 2 nights of “call”) with a FULL year contract for and will match $7,000 in a 401K (which I obviously will do), and will pay 1/4 toward my health, dental, eye insurance. The only reason I’m not full time with them is my choice to stay up here and do Hospitalist work here, locally where I started the Hospitalist program in November 2000. They would be THRILLED to have me full time and then would pay double (including 1/2 of my health insurance costs)! Plus, if I stay with Sutter for a year, they will give me a $10,000 bonus! Once again showing how much I’m needed there as opposed to my Primary Care Practice. I will continue Hospitalist here 10 days a month (in 5-day aliquots) for which I’m paid; and down there 10 days a month for which I’m paid.

    2 months ago I went to a Syneron Cosmetic Laser demonstration/lecture in Walnut Creek; I find it truly ironic and yet emblematic of our society today that I would be paid handsomely for doing “Foto-Facials” and laser skin tightening, hair removal etc. etc., yet my lifesaving interventions in my office are worth so little I could make more as a Manager in a McDonald’s.

    I plan to set up my Laser clinic in my wife, the general surgeon’s (another vanishing breed) extra space as her costs are way up and her income way down

    Sincerely,

    Richard E. Sacks-Wilner, MD

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