Do hospitalists boost costs? - a reality or fiction?

The Hospitalists community is shocked. Or at least I am.

Yesterday Drs. Kuo and Goodwin published a very well written study in Annals of Internal Medicine. It is in fact, an impressive study despite all its limitations. They evaluated a 5% sample of Medicare patients in 454 hospitals, comparing 36,871 patients treated by their Primary care physicians (PCP) with 21,254 patients treated by Hospitalists during a period of 2001 through 2006.

They found that although the length of stay was lower (0.64 days less) among patients treated by hospitalists, and that the inpatient charges were S282.00 lower, the Medicare costs in the 30 days after patients were discharged were in fact $332.00 higher. This translates in an additional 1.1 billion in Medicare costs per year based on the approximate 25% Medicare admission managed by hospitalists. (This is very dramatic if we take into account that the government almost shut down yesterday).

In addition, the authors found that patients cared for by hospitalists may have a decreased lenght of stay hypothesizing that this may be at expense of increased rate of discharge to skilled nursing facilities or nursing homes by almost 20% compared with primary care physicians.

As well, they found that patients cared for by hospitalist had an 18% increase in subsequent emergency department visits and 8% increased risk of readmissions.

The findings were confirmed with an impressive statistical analysis in the entire cohort study of 205,190 admissions in 4657 hospitals.

However, this study had multiple limitations including: only included patients with an identified PCP; patients admitted with medical (non-surgical) diagnoses; did not include patients cared by subspecialists who may as well be hospitalists; only studied patients with fee-for-servide Medicare coverage; it included a period of 2001-2006 which may not be representative of the current practices; they extrapolated the costs, based on total Medicare charges, but did not actually directly assessed the costs.

Their last conclusion was very interesting - given that hospitalists may have incentives based on a fixed prospective payment based on the severity of the admission (medical diagnosis-related group or DRG) shifting costs to the outpatient in a post-discharge fee-for-service model, this drive overall to increased Medicare costs. The authors proposed the increase in bundling of payments based on the episode of care to minimize these incentives. The latter translates to the current proposed model of Patient-centered Medical home in which bundled payments will cover both inpatient and outpatient care.

I'm appalled. I am a strong believer that hospitalists in fact decrease overall costs of healthcare - why - because we provide evidence based quality care. We focus on quality improvement, increased patient safety, improved patient outcomes; we are very critical of our performance and advocates of increased accountability and transparency. We advocate the model of increased quality and decreased costs.

However this incredibly large national database is in fact, proving otherwise. In addition it proves some quality metrics to be in the red numbers area - for instance, shows an increased number of ED visits and readmissions.

If we take the heart failure model, it has been shown that early outpatient follow-up decreases readmission rates; but this requires a proactive behavior from all the healthcare system (including the patients). This is a current national priority and at least in this population we most likely will be seeing soon data of current practices.

I can argue that in the period of 2001 to 2006 a flawed system with limited access to outpatient medical care may have contributed to these results, and that this has been changing with time, and at least from my personal experience, we ensure that our patients receive a soon follow up with a PCP to facilitate transitions of care.

Now, it may be true that hospitalists may discharge patients more to skilled nursing facilities - but this may be due to the increased attention to detail to the patient's ability to perform activities of daily life and provide self-care; we may have increased Physical Therapy evaluations to ensure safer transitions of care. For instance, in this cohort of patients, they averaged 77.5 years old - any patient that age who is acutely admitted to the hospital may in fact suffer from substantial deconditioning that may not facilitate a safe discharge to home.

In addition, this analysis focus on economic impact and do not include all inpatient quality metrics, such as core measures, current national patient safety goals practices, use of VTE prophylaxis, documentation practices, etc.

An additional thing that is very important to take into account is the famous cost-to-charge ratios analysis in the Medicare population as well as differences in reimbursement in both inpatient and outpatient settings. In this study, the authors state that they calculated the Medicare spending 30 days after discharge based on total charges; as well they state that charges reflect price setting rather than resource consumption and therefore may overestimate costs.

So, this is a very statistically impressive study, but that focus on economic outcomes and may not be in fact evaluating the quality of care provided by hospitalists. In addition, Hospital Medicine has gone a long road since 2006 to 2011. We are very well embarked in the journey of patient safety and quality. We are advocates of the formula improved quality/decreased costs.

I believe further analysis based on newer populations, other payors systems (private insurances, Kaiser system, etc.), including more recent data, as well as more inpatient quality metrics, as well as adjusted severity and mortality should be done.

We need to be critical of our own practices and look in detail what can we do to improve. As the healthcare system in the United States moves toward the Patient-centered Medical home with bundled payments, most likely this presumable differences in healthcare expenditure between the PCP and the hospitalists model may in fact narrow to a non-significant level.

For the time being, the hospitalists will need to take this as an opportunity for reflection, and as a source of energy to fuel new research endeavors to improve patient outcomes and decrease healthcare costs.

For us as hospitalists our principle will always be....primum non nocere.

An Academic Hospitalist

Well.  A lot of things have happened since my last post. I'm not precisely very happy with my scant productivity in this blog, and as frequent as I have ideas that I want to share, it is the same frequency I have other things to do.

I was busy in May, attending the ACP Leadership Day, advocating for Internal Medicine, attempting to minimize the Medicare cuts based on the obsolete Sustainable Growth Rate (SGR) formula; as well tried hard in advocating to ensure the perpetuation of a constant supply of Primary Care providers to ensure the future medical coverage of americans. It was exciting as well as intense and inspiring.

Then in June, I had a fantastic trip to the Far East, especifically, South Korea, where in addition to climbing the Halla-San in Jeju, we enjoyed the temples and cold water of the Sea of China in Busan, the jovial nature of the University in Gwanju, and the energetic life of Seoul. We appreciated the Korean food and hospitality, attempted to understand the Hangool symbols, and to learn some of their salutations and greetings ..."ani-aseei-yoh!, kansamnida!, etc...."as well as got inspired by their incredible and fast evolution within half a century. Understood a lot of their sentiments toward the japanese, whom essentially attempted to destroy their culture and heritage in a savage and brutal way. I'm impressed on the power of forgiveness and the intelligence of dialogue that both countries have nowadays; an example to follow in the rest of the world.

Then in July, the excitement of the new academic year brought winds of energy and passion; I attended in the Pediatric wards the first week of the month, and was happy with the new interns' performance.
Subsequently, got a sequential series of academic and curricular updates - got an accepted workshop at the 2011 Society of Hospital Medicine meeting, about Perioperative Management of the Pediatric Patient; got promoted to Full Staff; started my activity as a core faculty at the Internal Medicine residency; started a 4 weeks slam in the Internal Medicine teaching service (briefly interrupted by a family emergency that required switching my role from a physician to become a patient's relative).

Looking at the vertiginous last month, I realized how passionate I am about academic medicine, most importantly, Hospital Medicine. My accepted SHM workshop is in Pediatric Hospital Medicine and I'm giving tomorrow the Children's Hospital Grand Rounds on Pediatric Perioperative Medicine which will be a nice catalizer to find out which topics will be the best ones to present at the national meeting.

I was very fortunate, given my interest in academics, that there is an fantastic available course for thriving academic hospitalists, called the Academic Hospitalist Academy. It is sponsored by 2 of my favorite institutions, the Society of Hospital Medicine and the Society of General Internal Medicine. We flew last September 21 to Atlanta, GA. Then took a cab to the hotel in Peachtree, GA, 45 min away from downtown Atlanta, located in a picturesque town where people trasnport themselves in.....golf carts! (they have more than 9000 golf carts in this town).

This course was given over three days, covering the most important aspects that will enhance any academic physician's career. I appreciated the innovative approach to teaching medicine, such as the Clinical Coaching, where rather than filling the students and residents with a bunch of facts, we teach them how to do clinical reasoning and think in a structured way. We had a fantastic approach to the Bayesian method for problem solving, and the use of a Socratic non-threatiening questionning technique for bedside teaching, as well as classroom teaching. In this very tenure, time management is a very important element, and the way to better administrate the time was taught in a masterful way.

We rediscovered the magic of the white board and color markers, with the idea of making didactic points clear and outstanding. We gave all mini-lectures, 6 minutes each in break groups, providing afterwards a feedback based upon the content and outline, as well as delivery of the talk. We used specific feedback with the idea of strongly improving  flaws such as "talking to the board", talking pace, shyness, etc. We discussed as well ways to give feedback to our students and residents, both on the fly and in a formal separate setting, with the notion that feedback is non-judgementa, targeting areas for improvement.

We discovered a new way of setting goals and expectations in a SMART way - Goals should be specific (but also systematic, synergistic and significant); measurable (and also meaningful and motivating); achievable; relevant (but also realistic, reasonable, rewarding, responsible, reliable, and remarkable); timely, tangible and thoughtful.

Fantastic lectures and workshops on career building and paths for Promotion with specific 1- and 5-Year Planning were held, and this apparently threatening activity showed how important it is to efficiently organize the academic activities; some activities can occur simultaneously; some will occur at different stages; but the most important thing is not to lose track of  at what level of progress is each activity standing. The long term goal is the continuous career development and academic advancement. For instance, one of my goals is to be promoted to Associate Professor within the next 3 to 5 years.

The peer networking was fantastic, and I loved to meet so many young people from all the US, especially from the most important academic medical centers, all motivated with a single interest - become better academicians to improve medical education and patient care.

Other important skills were the Applied Principles of Quality Improvement (QI) and Change Management, as well as Patient safety and error analysis - hospitalists have a niche in QI. Most of the subspecialists will be busy enough to even attempt to stare at this. The hospitalists have become stewards of QI and patient safety, mainly through the use of IT, improved communication skills and efficient transitions of care. The systematic and critical analysis of errors, along with the proposal of corrective strategies to overcome these errors, are paramount in the establishement of QI initiatives to promote patient safety. We felt good about the importance hospitalists can achieve for their healthcare system.

Other fun activites included the teaching on how to develop a great Clinical Vignette - we had one on one teaching on pre-written Clinical Vignettes, and in a very rapid way were able to find significant flaws in the initial vignettes and correct them immediately. It was nice to see the before and after.

The creation and mainteinance of a teaching portfolio was one of the most important skills practiced, which will help find success in the academic career advancement. It was very clarifying to see the organization of the CV's according to each academic institution, which although seemed like a very though task, once accomplished, is a great stress reliever, as it is the tool required to apply for academic positions, awards, grants, etc.

Finally, the discussion of what the relationship among a mentor and a mentee should be was clarifying. I have changed my CV to my institution's characteristics and am now in search for an experienced but motivating and empowering mentor.

I found a lot of substance in this course - actually, I found that there is a lot of substance in our academic practice; a lot of raw energy and talent that appears as a brute diamond that needs to be polished. The energy needs to carefully be  focused and shifted toward constructive and highly achieving goals and profiles. I think the elements we obtained from this fantastic resource will be rewarding in the near future.

Clinical vignettes - an incredible trip toward an infinite learning paradise

Fourth day of seven in the Pediatrics wards. I was awake last night finishing writing and reviewing abstracts to submit to the Society of Hospital Medicine. I went to bed finally at 2:30am; I submitted 4 clinical vignettes: a case of Mycoplasma Pneumoniae induced Stevens Johnson's Syndrome; a case of innapropriately diagnosed Diabetes insipidus in a patient with SSRI/SNRI-induced polydypsia; a case of catastrophic antiphospholipid syndrome; and finally, a case of edema blisters that appeared after an acute attack of hereditary angioedema.

We all see interesting cases every single day. All patients can be as fascinating and interesting as you want them to be. The residents at the Cleveland Clinic, present fantastic morning reports with all the imaging and labwork included, excellent bibliographic search, etc. This is in both Medicine and Pediatrics. As an academic hospitalist, I am invited to the morning reports to help catalize the case's presentation and emphasize high yield teaching points.

What surprises me, is the extemely poor academic outcome that yields from those morning reports in terms of productivity - the residents have already extensively summarized the case, and put it all together - the only thing is to put all the information in an abstract, as the slides can just be copied and pasted in a poster template. Or even the slides can be used to present in a National meeting as case conference. But, most of the residents leave those fantastic cases in the academic oblivion; they met their function - teach whomever was present in the morning report, but these cases deserve more than that; the educational value is superlative, and a lot of physicians can benefit from them; you share knowledge by means of presenting the cases in a national meeting. The work is already done; it is just means of finding submission deadlines for the different meetings and take the advantage of your own effort.

As a hospitalist, I work in teaching services with fantastic residents in both Internal Medicine and Pediatrics, and sometimes in non-teaching services, where I enjoy my loneliness to attempt to master the floors in the most cost-effective and evidence-based way as possible; I look for original references in the literature, and in many occasions, share the publications with my patients, to expand their knowledge and horizons. I don't hide things from my patients; the savvier they become, the more they develop their health literacy, the better outcomes they'll have. But, in addition, I learn an impressive amount of new things on a daily basis; and I find cases that are incredible for teaching purposes; more patients will benefit from the acquired knowledge and experience.

I have two choices; just "do my job", and try to be ready at 5 pm for sign out and prepare for the next day, and enhance the turnover. The other choice is "enjoy my job", learn as much as I can, make a list of all the interesting academic cases, read as much as possible, put them together, and when the time comes, present them in my own Department of Hospital Medicine Grand Rounds or in national meetings such as the Society of Hospital Medicine. Once you are in the meeting, it is pleasurable to see how you enhance other colleagues knowledge, but as well it is fascinating to learn a lot of different new things and overall, appreciate the different perspective and approach to Medicine in other institutions around the country.

Once in the meeting it is very interesting the peculiar questions you get asked which enrich and expands further the insight about the case. It makes you better; you learn from your colleagues experience and return home with novel ideas. These ideas work very well at the time of putting together the case for submission to a medical journal and then enhance the teaching in a global way.

Despite working late, I woke up with a lot of energy and enthusiasm, with the happiness of achievement; I hope that the abstracts will get accepted; it may happen otherwise, and then may think of improving them and perhaps submit to a different meeting or just have them for further teaching purposes, as our own experience and learning make us better every day to help is provide the best medical care and as always...primum non nocere.....