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The High Costs of Hospitalists

October 9, 2017

Hospitalists, doctors who only see patients in the hospital, almost always in a shift work model, are the fastest growing “specialty” in medicine, from nothing about 15 years ago to about 50,000 today. There were some studies that I won’t review much here that showed some benefits from hospitalists compared to “usual care” in highly controlled environments, outcomes such as a 0.4 day decrease in length of stay with no reported increase in the readmission rate. Of course, these studies were all conducted within the environment of a screwed up payment system.

I think most family physicians would agree that the reality on the front lines falls well short of the results of the controlled experiments. There is rarely continuity in the hospital, with patients often seeing 3+ different hospitalists on the same admission. Communication by the hospitalists with the patients’ personal family physician is almost non-existent. But because of the screwed up primary care payment system, many family physicians have given up hospital work for economic and many other reasons, so hospitalists have filled the void, often with the explicit support of hospital administrators.

A report in The Hospitalist shows how much hospital administrators are spending to maintain some level of control over the hospitalist groups, and also how screwed up the AMA’s CPT coding system is, and how screwed up the CMS Evaluation and Management rules and fee schedules are. I leave it to each reader to determine the contributing ratios for each agency. The report estimates that the average hospitalist income must be subsidized by $157,500 per doctor per year more than what they bill and collect using the current CPT/CMS codes and fee structure. Median total compensation was reported to be $278,746, which for the non-physicians reading this is more than family physicians make, but less than most of the ologists.

I still believe that patients would really like to see their personal family physicians when they are scared, vulnerable, and hospitalized. Because of the payment system that is biased towards procedures over thinking work, private family physicians have largely abandoned seeing their own patients in the hospital. This leads to poorer care that is more fragmented and more expensive. There is evidence that the most comprehensive family physicians deliver the lowest care per patient per year, and seeing patients in the hospital and doing hospital procedures are a big reason for this outcome. It’s time the payment system respected and rewarded this work.

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3 Responses to The High Costs of Hospitalists

  1. David Hanson on October 9, 2017 at 11:01 pm

    I think that hospitalists may increase the cost of care due to the hospital benefiting. I was in intensive care in November 2013 and then again a month later in December 2013. Both were because of a chronic subdural hematoma caused by a blow to my head during a fall. The first time I was admitted through the emergency room and I had short visits by several doctors all 3 days I was in the ICU – hospitalist, pulmonologist, and cardiologist each day – the hospitalist came more often. My insurance was billed for each of these visits. The second time I was admitted by a neuro-surgeon (same who did surgery the first time). He was the only doctor who visited me each day during the 3 days I was in the ICU this second time. And there were no more multiple charges for hospital ordered doctor visits like the first time.

  2. Michael Wu, MD on October 29, 2017 at 8:27 am

    Thank you Dr. Young for attacking your primary care colleagues working in the hospital setting. Similar to economy tenet stated “self-sufficiency leads to road of poverty”, hospitalists is much needed to share to overall health care burden. Imagining this Dr. Young, where will you be when your patient is much needed to be admitted to the hospital for acute stroke 3am or the middle of the night? where will you be when urgent dialysis is needed and to be coordinated when you have a full busy patient clinic during the day? when is your last time running a code blue and will be available right away when your patient is crashing in the hospital? When is your last time inserting a central line for your septic shock patient going into ARDS? when is your last time managing a ventilator? If your clinic network is linked to hospital network, maybe you will see the discharge summary and hospital performed tests results. I do agree with you our payment system is skewed toward procedures rather than thinking process. Hope your book will sell well…. I think I just waste my time here. It seems you are trying to sell your book here….

    • Richard Young MD on October 29, 2017 at 8:03 pm

      Dr. Wu,

      Thank you for your comments. I’ll answer many of your questions briefly this way. At this moment, I’m covering both the ER and already admitted patients in a U.S. hospital. I also am the attending physician for a hospital inpatient teaching service 4 to 8 weeks a year.

      I’m sorry you took the primary message of the post as an attack on the doctors. I thought it was very clear that the attack was on the screwed up payment system for primary care. If you would like to see the real family medicine heroes in action, those putting in central lines, managing vents, etc., I invite you to spend a weekend in any remote rural town in America. The family physicians provide all these services 24/7, because there is no one else to do it. They do it simply because they are dedicated to their communities. I just want them to be fairly paid for their dedication.

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