Study of Hospitalists Raises Questions

In the 1990s, a new medical specialty emerged whose purpose was to help control the cost of hospital care and improve the outcome for hospital patients. “Hospitalists” are physicians who care only for inpatients; generally, they do not have a private patient practice. As noted in a recent report on NPR, the growing popularity of hospitalists does not appear to be reaping either the hoped for financial or health benefits.

The notion that hospitalist care is superior to that of a personal physician derives from the expertise a hospitalist develops because he or she practices solely within that setting. Dr. James Goodwin of the University of Texas, who studied the impact of hospitalist care among a large cohort of Medicare recipients, said these patients tended to be released sooner than those under the care of their personal physicians. He pegged the population of inpatients under hospitalist care at 30%-40%.

The sooner you leave the hospital, of course, the lower the cost of care. But the complication arises after release. The objective of Goodwin’s study, published in the Annals of Internal Medicine, was “to assess the relationship of hospitalist care with hospital length of stay, hospital charges, and medical utilization and Medicare costs after discharge.” It concluded that patients under hospitalist care were more likely either to be readmitted within 30 days, or to visit an emergency room than patients cared for by their regular doctor.

That represents, Goodwin concluded, additional costs for Medicare of more than $1 billion every year.

Hospitalists, it seems, are more likely to discharge their patients to a convalescent or rehabilitation facility than they are to their homes. And that’s expensive.

Dr. Joseph Li of the Society of Hospital Medicine, an organization that represents hospitalists, raised the possibility that patients who go home directly from the hospital might not be receiving adequate follow-up care, an issue we addressed last week in our discussion of care transition from hospital to home. Li also suggested that hospital patients who transition into a secondary care facility might be receiving the more appropriate treatment than if they had been discharged to their homes.

“These patients are being monitored 24/seven by health-care providers,” he told NPR. “Many of these patients being sent back are being appropriately sent back to the hospital for evaluation.”

Of course, it’s in his organization’s interest to draw that conclusion. That doesn’t mean it’s wrong, but clearly, the study indicates a need for hospitalists and the doctors of individual patients to coordinate care better to meet the needs of both budgets and health.