I have long thought that a future economist will look back and conclude that one of the principal drivers of the explosion in US health care expenditures was the misguided decision to dramatically cut provider reimbursements for office visits. The result was greater remuneration for physicians who performed procedures and operations. This shift really impacted primary care providers who use a combination of their medical knowledge, their experience, and their relationship with the patient to guide treatments. Sadly, these difficult to quantify attributes are neither well understood nor valued by US health care payors.
The unintended consequence of this payment cut, lead providers to squeeze more patients into daily office-hours, which meant less time spent with each patient. And contrary to popular myth that tries to lay the blame for ballooning health care costs at the feet of provider earnings, this was done not to allow providers to maintain highly lucrative practices. It was to allow them to stay afloat.
this change also lead to the creation and rise of hospitalist medicine
I hadn’t realized how hospital medicine had shifted during my time as a practicing plastic surgeon. My last full-time experience on the hospital wards was during my chief year of residency (mid 1990’s). One of our hospitals had one of the first ‘hospitalists’ in town. She was trained in family medicine, but unlike most family medicine doctors she disliked outpatient care. Taking care of patients in the hospital was her passion.
She convinced a primary care group to hire her to take over much of their inpatient duties. This arrangement allowed these physicians to spend more time with patients in their office since they didn’t have to worry about running over to the hospital to make patient rounds. And she, their ‘hospitalist’, had easy access to the patient’s primary care physician as well as office records, ensuring continuity of care. Truly win-win.
But hospital-based medical practice has morphed into a completely different beast. And although hospitalists have a special skill, that of treating patients acutely ill, there are considerable challenges and drawbacks to this model. For one, even with the rise of the electronic medical record, many hospitalists do not have access to the patient’s outpatient medical records, so continuity of care is challenging. And the hospitalists have no baseline relationship with the patient/their family- which can present a significant impediment, especially when treating patients who are seriously ill.
Today, patients have less time and less of a relationship with their providers across the spectrum of care. My belief is that more prescriptions and more tests are ordered to compensate for this. The patients may not mind less time with their provider if they get something tangible- a test, a prescription. But on both the inpatient and outpatient side of medicine, more “things” do not necessarily improve patient outcomes.
To change the arc of the healthcare expenditure curve and improve outcomes for our patients, we need to revisit and reset the worlds of primary care and hospitalist medicine. Allow primary care providers more time with patients in the office, and reimburse them in a way that shows the importance/value of their skillset. And either afford them the time to follow their patients into the hospital, or at least have an arrangement as I described earlier.
some exciting ongoing research
There is great work being done by Dr David Meltzer in Chicago, described in a NYT magazine article, and it’s the post for this week. I hope you will check it out https://www.nytimes.com/interactive/2018/05/16/magazine/health-issue-reinvention-of-primary-care-delivery.html
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