Inadequate Communication Between Hospitalist and PCP is Detrimental To Patient Care

The American health care delivery system is reaching a point of crisis.  Its costs are escalating as outcomes and quality of care are diminishing.  It focuses on crisis management and treating problems aggressively with medicines and interventions of uncertain benefit, while neglecting true health and wellness.  It is estimated that 1 trillion dollars annually is being spent on unnecessary care, much of which occurs in the hospital, and some of which leads to harm. Medicare, although concerned about rising health care costs, does little to address the real issues and actually but subtly encourages aggressive management when less could indeed be more.  Hospital acquired infections and death from medical errors are far too numerous, often occurring in patients who did not have to be hospitalized in the first place.  Patients and physicians are frustrated, while private insurers and both Medicare and Medicaid are becoming unable to fund this excessively costly care without raising premiums or exhausting trust funds.  Something certainly must be done.

We wish to focus on one glaring problem occurring in hospitals that is relatively easy to fix and whose resolution could improve outcomes.  Currently, as many hospitals close their doors to primary care physicians (PCPs) and instead rely on hospitalists, there often is a lack of communication between these doctors that can lead directly to costly mistreatment.  A true and common story will set the stage.

Mrs. P suffers from dementia and lives in a nursing home.   One day she became unresponsive.  The nurse on duty could find no obvious reason and so immediately called 911 and sent her to the hospital.  While she quickly woke up, the emergency medicine physician admitted her for further evaluation.  Her assigned hospitalist found bacteria in the urine and treated her for a urinary tract infection, calling in an infectious disease consultation and starting her on a potent intravenous antibiotic.  He also requested consultations from a cardiologist and a neurologist to determine the cause of her unresponsiveness, and they ordered further tests including an MRI and an echocardiogram.  Mrs. P became more confused, was exposed to aggressive evaluation and treatment, and was losing her strength as a result of bed confinement.  She was ultimately sent back to her facility after tens of thousands of dollars of medical care, worse off than when she arrived.  She was fortunate to have not suffered further harm from her hospital-induced delirium and the potent medicines she received.

Let’s dissect what happened, and why.

The emergency medicine physician was faced with a lethargic person who could not give a coherent history, hence she was subjected to an extensive work-up and then admitted to the hospital. The hospitalist, likewise, was faced with a patient he had never met before, with only the emergency room records as guidance. He detected neurologic, infectious, and cardiac problems and so called for specialist consultations and extensive testing. 

It is unfortunate that the nursing home nurse did not call the patient’s primary care physician (PCP) upon transfer, but it was even more unfortunate that her PCP was not contacted at any time during her emergency room stay or subsequent hospitalization by any of the doctors who saw her.  Had they called Mrs. P’s PCP they would have learned that she had a long history of progressive dementia and similar unresponsive episodes in the past that had been fully evaluated. Further, they would have learned that she always carried bacteria in her urine without tissue invasion and that she could have received any of her treatments in the nursing home where she would have been safer and more comfortable, at a far lower cost.  A recent study showed that 20% of hospitalized patients who receive antibiotics develop an adverse event so avoiding unnecessary antibiotics must be a top priority.

The growth of the hospitalist movement over the past twenty years has been truly phenomenal – at 50,000 physicians it is the largest medical sub specialty, surpassed as a specialty only by general internal medicine at 109,000 and family medicine at 107,000. Studies suggested that quality was improved and costs reduced with hospitalist care. This was especially true for complicated patients who required multiple physician visits and interactions each day, something increasingly difficult for the community based PCP to achieve.

The hospitalist is experienced in managing the types of medical issues that lead to hospitalization and works full time in the hospital. As a result they come to know how to “get things done” and potentially can give more efficient care. But they are far too often burdened with large numbers of patients, and often know very little about the patients they are treating. With too many patients to care for and too little information they tend to request consultations for problems that, given adequate time, they could have managed. This is especially problematic if the patient has multiple medical issues and is elderly. Other reasonable concerns are the diminishment of the patient-physician relationship and miscommunication and discoordination at both admission and discharge.  Communication with the patient’s PCP however could alleviate many of these issues.

PCPs have been – generally – content to allow the hospitalist to manage their patients, indeed it has been a major advantage for many. PCPs have seen their overhead costs rise dramatically, necessitating seeing more and more patients per day for less and less time each in order to cover those overhead costs. The multitude of rules, regulations and requirements foisted upon them by the insurers has further consumed extensive time, time that previously could be used to care for their hospitalized patients. Today, many PCPs do not have time to see patients in the hospital, while others are barred from doing so by hospital rules. 

In this situation, both PCPs and hospitalists could have improved Mrs. P’s care substantially, and reduced the cost of unnecessary care, simply by communicating.  A call or text by the hospitalist to the PCP upon admission and at various decision points might have enabled Mrs. P to leave the hospital before any consults were called, before extraneous tests were ordered, before antibiotics were initiated, and before she became more confused and weaker.  More than half of elderly patients leave the hospital worse off than when they came in, and involvement of a PCP in a patient’s care could potentially facilitate more rapid discharge and less aggressive treatment. 

A recent survey indicated that 95% of hospital leaders are concerned that discharge communication is “inefficient” and 80% have concerns about communication among care team members.  PCPs complain that they are never called. Hospitalists often state that they just don’t have time to call the PCP but when they do, the PCP is not available. Each is culpable. Each must remember that the issue at hand is the patient’s care and welfare, not their convenience or preferences. It is a matter of professional responsibility. What could help? The electronic medical record was supposed to solve these sorts of problems but it has not and probably will not in the foreseeable future. There are some HIPPA compliant texting systems which could be utilized and there are HIPPA compliant smart phone apps that can coordinate among all involved physicians, nurses, hospitals, other facilities and even the patient him or herself. One of these types of systems could potentially negate the issue of non-availability although it will not top the value of nuanced conversation among physicians. 

In the end, there is nothing that trumps good physician to physician communication. It must be incumbent on hospitalists to involve PCPs during in-patient stays and it must be incumbent on PCPs to respond to hospitalists and provide crucial insight and information when asked to do so.   Not only can outcomes be improved, but costs can drop and patients and their families can feel more comfortable knowing that their own doctor is involved in their care.  If necessary, hospitals should set policy that makes hospitalist to PCP communication mandatory; everyone will benefit.  Very basic solutions can frequently lead to profound improvement. 

 

This post was co-authored by 

Andy Lazris, MD, CMD  a primary care physician whose private practice focuses on geriatric patients especially those residing in long term care and assisted living facilities. He is the author of Curing Medicare and co-author of Interpreting Health Risks and Benefits and was first published on Medical Economics on July 29, 2017

Primary care has lost its quarterback position in patient care

There is a crisis in primary care and that crisis is now flowing over into the hospital when a primary care physician’s (PCP) patient is admitted. No longer cared for by the PCP, the role has largely fallen to the hospitalist. There has been a loss of the long time primary care physician- patient relationship, the trust that comes with time. There has been a frequent loss of satisfactory communication when the patient is admitted and again when discharged.  At a time when the patient most wants and needs the comfort of a long time trusted professional friend, the patient instead is confronted with a stranger at the helm. What has happened to this create state of affairs?

PCPs have seen their overhead costs rise dramatically along with insurer mandated paperwork and government mandated electronic medical record (EMR) time requirements. This means the PCP must see more and more patients for shorter and shorter periods to cover overheads and reserve time for the nonclinical requirements. The average visit time is now 15 minutes with only 8 to 10 minutes of "face time". It also means that most – but definitely not all – PCPs no longer attend their patients in the hospital, leaving that function to the hospitalist

Hospitalists are trained in caring for patients in the hospital. Since that is all that they do, they become very experienced in dealing with the types of medical issues that require hospitalization. Working full-time in the hospital means that they know how to get things done in that setting and do so fairly efficiently. The growth of the hospitalist movement over the past twenty years has been truly phenomenal – at 50,000 physicians it is the largest medical sub specialty (cardiology is next at 22,000), surpassed as a specialty only by general internal medicine at 109,000 and family medicine at 107,000.

Early studies suggested that quality was improved and costs reduced with the advent of hospitalist care. This was especially true for complicated patients who required multiple physician visits and interactions each day, something difficult for the community based physician to achieve. And with the need to see multiple patients each day in the office to cover overheads, many PCPs willingly ceded hospital care to the hospitalist. 

In our experience hospitalists are a heterogeneous group, many are just out of an internal medicine residency; some are working part-time because of childcare obligations. Many are contemplating a fellowship but want to catch up on loan obligations. Some hospitalists anticipate at a future point to become PCP’s. Still others intend to make a career as a fulltime hospitalist.

Frequently employed by the hospital, they still must meet productivity standards in order to earn their salary.  Often this means caring for a large number of patients, most of them quite ill. Although they are expert in what they do, they do not have the years of interaction with the patient that the PCP has. And so they did not know the patient before the hospital event and are not likely to know him or her after.  Each patient is an individual with his or her unique family, social, economic and of course medical background. The patient today may well have multiple chronic illnesses such as diabetes, congestive heart failure or chronic lung disease and now enters the hospital with a new problem or an exacerbation of an old one. The hospitalist can deal well with the reason for admission. Nevertheless they will not be cognizant of the fine balance of personality and medication that has otherwise maintained the patient as independently living in the community.  It also unlikely that they know what studies have been done prior to the admission. 

In recent back to back articles in the New England Journal of Medicine, Wachter and Goldman along with Gunderman present rather different perspectives on the rise of the hospitalist subspecialty yet the decline of comprehensive care. 

 

Our observations of routine hospitalist care is that a given patient may have multiple hospitalists over the course of the admission rather than one doctor who knows the patients well. In a four-day stay a patient may easily be cared for by three different hospitalists. Test redundancy and unneeded consultations are all too common.

There is also a tendency to ask for consultations from subspecialists when more time with the patients might have been sufficient to establish the issue at hand. Fever-infectious disease, pneumonia-pulmonologist, chest pain – cardiologist.  Relatively easy procedures are also handed off to a specialist, e.g., joint effusion - call the orthopedist to do the arthrocentesis.  Mildly demented patients all too often get a repeat head scan because of an inadequate handoff that the patient has already had a more than adequate evaluation for reversible causes of dementia. Typically a hospitalist service is made up of many physicians that have a minimum of three years of internal medicine training. We are not sure if the statistic exists but in many community hospitals the average number of years of experience after residency is likely less than five years.  So if an unusual problem arises, call for a consult. There typically are multidisciplinary rounds but the admitting hospitalist may not be the rounding physician. 

More discouraging is the finding that hospitalists tend to place the primary care doctor’s patients often on the wrong medication, very often there is inadequate communication between the hospitalist and the primary care physician to review details at the time of admission. This of course can lead to a more extensive hospital stay. To compound the problem, the handoff back to the PCP at discharge is often problematic with inadequate communication between them. The PCP may not even know that the patient was admitted or discharged until the patient calls for a new appointment. Meanwhile, the fine balance of those chronic illnesses may be out of kilter so that, not surprisingly, about 20% of older individuals end up back in the hospital with an unplanned admission within the following month.

The PCP was always the backbone of American medicine. He or she not only cared for patients in the office but also collaborated with the emergency room physician and attended to hospitalized patients, seeking specialist consultation as needed. Today, only a few PCPs even visit their hospitalized patients, relying entirely on the hospitalist and the emergency medicine physician.

Hospitals are scary places. You never really want to be admitted but sometimes it is necessary and indeed even lifesaving. This is the time when you most want a knowledgeable professional friend of long standing, one you with whom you have deep seated trust.

Although most PCPs do not visit their patients in the hospital today, some do and they are committed to give the patient the expert care that the patient requires. But for these physicians some community hospitals for various reasons have determined that only the hospitalist may have privileges to care for the patient. That’s right; hospital managements are discouraging primary care doctors from coming to the hospital and in many cases have prohibited them from having active admitting privileges.  Somehow, they discount the possibility that the primary care doctor knows the patient best and can work effectively and collaboratively with the hospitalist for the patient’s benefit. Erroneously, hospitals in many cases believe that primary care doctors diminish quality and increase the length of stay. We have discussed this very issue with a retired board member from a large Maryland insurer and confirmed that a huge  uncontrollable expense to the hospital bill is over consulting with specialists and redundancy of procedures and testing ordered by hospitalists.

The PCP is being marginalized. This is distinctly to the patient’s disadvantage.

Interestingly insurers are having an impact on control of costs but not in the hospital. Primary care physicians are now rewarded for guiding patients to the less costly specialist and using visiting nurses to manage co-morbidities that have saved hundreds of millions of dollars. We believe now the insurers need to understand the value of comprehensive primary care that extends into the hospital; this would translate into even more savings. PCPs need to earn enough with a smaller panel of patients that they can afford to care for fewer patients but with greater time spent with each as appropriate including visiting their hospitalized patients, working collaboratively with the hospitalist and interacting with the emergency medicine physician. Insurers (including Medicare) need to dramatically reduce the unnecessary paperwork and requirements so that the PCP can actually spend time with the patient.

We are not intending to disparage hospitalists. They are well trained, committed and productive and overall have added quality to the hospital environment. We are advocating however for a collaborative process of hospitalist and PCP working together. Returning the PCP to his or her positon as the quarterback of patient care is good medicine; it means greater quality, a more satisfied patient, less frustrated physicians yet much lower total costs of care. A win-win-win.

Harry A Oken MD, who coauthored this post with Dr Schimpff, is a primary care physician in private practice who still cares for his patients when hospitalized and is a clinical professor of medicine at the University of Maryland School of Medicine.

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United Airlines Fiasco Should Be a Healthcare Wakeup Call

The forcible removal of a passenger from the United Airlines flight has reminded flyers of their general dissatisfaction with the airline industry. Perhaps surprisingly, it should also be a stern warning to physicians. The brunt of dissatisfaction in healthcare delivery will fall on the providers although the real culprits are the insurers; they too should take notice.

The airlines do not appreciate the real basis for the outburst by the traveling public. The forcible eviction, despicable as it was, was really just the “straw that broke the camel’s back.” Airline travel was once a special, adventurous part of the journey. Today it is an undesirable but necessary means to an end. Why? Because the airlines treat their customers with disrespect at every part of the process. It is not just United; it is all of the airlines. The uproar is not about the rules, “the contract of carriage,” but about the manner in which airlines think about their passengers – definitely not customers who deserve respect. Respect and dignity are the key words.

The public’s general consensus – it's not fun anymore; there has been complete loss of autonomy and dignity; flyers often feel they are herded like cattle with total loss of all control and definitely not treated as valued customers. The sense is that the corporate view is "stockholder value "as the priority, not customer satisfaction, preference and loyalty as a means to generate that value.  "The friendly skies" are no longer, if they ever were. There is no sense that the airline executives who set the employee standards and culture remember that a customer pays the employees’ salaries, their bonuses and ultimately the stockholders’ dividends. In this environment, the employee from captain to gate agent to luggage handler is captive. They may – and I suspect to a large degree do – want to treat their passengers as real people, real customers deserving of real respect but it is clearly not the corporate ethos.

In any business, for profit or not for profit, it is true that "no money, no mission" but money has become the mission.

Such is the case with much of healthcare. Patients are frustrated feeling that they are not respected, not afforded autonomy or control and not valued. As a retired physician and academic hospital CEO I have witnessed and felt the transformation within medicine over the past 50 years. As with the airlines, most physicians, nurses, pharmacists and other staff are all well-meaning and caring. But patients are at the breaking point. In short, the patient is not treated like a valued customer but more like a commodity.

 It takes about three weeks to gain an appointment, there are long waits in the “waiting room” and then just a few minutes with the doctor.  You may personally like your physician but you are not pleased with the situation and feel helpless to rectify it because you are not the customer, the doctor’s customer is the insurer.  The insurer will determine if and how much the doctor is paid; the patient is a bystander to the transaction yet saddled with copays and deductibles. The patient cannot even request more time for more pay – the insurer prevents direct payments to the doctor. 

From the doctor’s perspective, he or she is undervalued by the insurer who acts capriciously, produces extensive rules, regulations and requirements that do not add to patient care but require extra work – time not spent with the patient. And since insurance payments for primary care especially are notoriously low yet with ever rising overheads, the physician is obliged to shorten visits often to about 8-12 minutes of actual face time.

It is a situation right for an outburst – from both patient and doctor although for different reasons. An event – not malpractice but just something totally unacceptable like being dragged off the plane – could dramatically upset the status quo. Patients will cry out that they “will not take it anymore.” They will demand accommodation for privacy, courtesy, autonomy and especially respect and dignity. They will expect to be treated as valued customers. 

Physicians are in a bind as well. If the time per patient is short and the PCP only deals with “simple” problems, referring all of the rest to specialists, then the patient comes to feel that the PCP (e.g., internist, family medicine doctor or pediatrician) is irrelevant, often unavailable and yet expensive. The patient is increasingly likely to go to CVS, Walmart or Walgreens and get seen promptly for minimal cost. Here is an example from a friend: “For Boy Scout camp it is necessary to have a health form filled out by the pediatrician. In our son’s case, our insurance covers one physical a year, and we usually go around his birthday in June. But the form is due April 17th so I found myself in a Catch 22 situation. The insurance company won't pay for a physical until June, the pediatrician won't fill out the form without doing a physical. So I ended up taking him to CVS WellCare and paid them $69 to fill out the form, much less than what the pediatrician would have billed.”

There is a clear difference between the airline industry and the healthcare industry, even above and beyond the obvious that one is an option much of the time and the other is frequently not an option. The issue with the airlines is not price which is generally reasonable; it is the lack of being treated as a customer. In healthcare, the prime issue is also about not being treated as a valued customer – with respect and dignity. But now, where price never mattered in the past, it has become very important. Previously, I have suggested some “fixes.”

Healthcare needs to open its eyes and realize that its bread-and-butter is highly vulnerable. Yes, the insurers make life difficult if not near impossible. But the object of healthcare delivery is, or at least should be, for the patient. The hospital and the physician may be vulnerable to the whims of government and insurers but – more importantly yet unrecognized– may be exceedingly vulnerable to the very patients who have entrusted their care to them. Let this be a wakeup call and let it begin a careful look in the mirror rather than looking for external demons. When the uprising occurs, the blame will be heaped on the providers – hospitals and physicians alike. If it is a hospital issue, the doctor can’t escape – the patient looks to the doctor as the face of the hospital.

Insurers should take a close look as well. In their effort to reduce costs, they – beginning with Medicare - have systematically held primary care reimbursements low yet added excessive nonclinical work requirements. The result is the morass of today with frustrated, burned out physicians, angry patients and increased costs.

The initial response of United Airlines completely missed the depth of societal outrage and later did not appreciate how deeply the traveling public feels devalued. More recently, the board chair stated that this was a “defining moment in the history of United Airlines pivoting to customer service and customer delivery.” If he means it, it will mean a momentous change in corporate ethos and business practice. Let’s hope.

Perhaps healthcare – including Medicare and commercial insurers – will come to recognize that it too must change or ultimately feel the wrath of dissatisfied patients – their customers. Meanwhile physicians need to take the offensive to direct change. Unified they can force the changes needed for the benefit of their patients, themselves and the total costs of care.

The forcible removal of a passenger from the United Airlines flight has reminded flyers of their general dissatisfaction with the airline industry. Perhaps surprisingly, it should also be a stern warning to physicians. The brunt of dissatisfaction in healthcare delivery will fall on the providers although the real culprits are the insurers; they too should take notice.

The airlines do not appreciate the real basis for the outburst by the traveling public. The forcible eviction, despicable as it was, was really just the “straw that broke the camel’s back.” Airline travel was once a special, adventurous part of the journey. Today it is an undesirable but necessary means to an end. Why? Because the airlines treat their customers with disrespect at every part of the process. It is not just United; it is all of the airlines. The uproar is not about the rules, “the contract of carriage,” but about the manner in which airlines think about their passengers – definitely not customers who deserve respect. Respect and dignity are the key words.

The public’s general consensus – it's not fun anymore; there has been complete loss of autonomy and dignity; flyers often feel they are herded like cattle with total loss of all control and definitely not treated as valued customers. The sense is that the corporate view is "stockholder value "as the priority, not customer satisfaction, preference and loyalty as a means to generate that value.  "The friendly skies" are no longer, if they ever were. There is no sense that the airline executives who set the employee standards and culture remember that a customer pays the employees’ salaries, their bonuses and ultimately the stockholders’ dividends. In this environment, the employee from captain to gate agent to luggage handler is captive. They may – and I suspect to a large degree do – want to treat their passengers as real people, real customers deserving of real respect but it is clearly not the corporate ethos.

In any business, for profit or not for profit, it is true that "no money, no mission" but money has become the mission.

Such is the case with much of healthcare. Patients are frustrated feeling that they are not respected, not afforded autonomy or control and not valued. As a retired physician and academic hospital CEO I have witnessed and felt the transformation within medicine over the past 50 years. As with the airlines, most physicians, nurses, pharmacists and other staff are all well-meaning and caring. But patients are at the breaking point. In short, the patient is not treated like a valued customer but more like a commodity.

 It takes about three weeks to gain an appointment, there are long waits in the “waiting room” and then just a few minutes with the doctor.  You may personally like your physician but you are not pleased with the situation and feel helpless to rectify it because you are not the customer, the doctor’s customer is the insurer.  The insurer will determine if and how much the doctor is paid; the patient is a bystander to the transaction yet saddled with copays and deductibles. The patient cannot even request more time for more pay – the insurer prevents direct payments to the doctor. 

From the doctor’s perspective, he or she is undervalued by the insurer who acts capriciously, produces extensive rules, regulations and requirements that do not add to patient care but require extra work – time not spent with the patient. And since insurance payments for primary care especially are notoriously low yet with ever rising overheads, the physician is obliged to shorten visits often to about 8-12 minutes of actual face time.

It is a situation right for an outburst – from both patient and doctor although for different reasons. An event – not malpractice but just something totally unacceptable like being dragged off the plane – could dramatically upset the status quo. Patients will cry out that they “will not take it anymore.” They will demand accommodation for privacy, courtesy, autonomy and especially respect and dignity. They will expect to be treated as valued customers. 

There is a clear difference between the airline industry and the healthcare industry, even above and beyond the obvious that one is an option much of the time and the other is frequently not an option. The issue with the airlines is not price which is generally reasonable; it is the lack of being treated as a customer. In healthcare, the prime issue is also about not being treated as a valued customer – with respect and dignity. But now, where price never mattered in the past, it has become very important. Previously, I have suggested some “fixes.”

Healthcare needs to open its eyes and realize that its bread-and-butter is highly vulnerable. Yes, the insurers make life difficult if not near impossible. But the object of healthcare delivery is, or at least should be, for the patient. The hospital and the physician may be vulnerable to the whims of government and insurers but – more importantly yet unrecognized– may be exceedingly vulnerable to the very patients who have entrusted their care to them. Let this be a wakeup call and let it begin a careful look in the mirror rather than looking for external demons. When the uprising occurs, the blame will be heaped on the providers – hospitals and physicians alike. If it is a hospital issue, the doctor can’t escape – the patient looks to the doctor as the face of the hospital.

Insurers should take a close look as well. In their effort to reduce costs, they – beginning with Medicare - have systematically held primary care reimbursements low yet added excessive nonclinical work requirements. The result is the morass of today with frustrated, burned out physicians, angry patients and increased costs.

The initial response of United Airlines completely missed the depth of societal outrage and later did not appreciate how deeply the traveling public feels devalued. More recently, the board chair stated that this was a “defining moment in the history of United Airlines pivoting to customer service and customer delivery.” If he means it, it will mean a momentous change in corporate ethos and business practice. Let’s hope.

Perhaps healthcare – including Medicare and commercial insurers – will come to recognize that it too must change or ultimately feel the wrath of dissatisfied patients – their customers. Meanwhile physicians need to take the offensive to direct change. Unified they can force the changes needed for the benefit of their patients, themselves and the total costs of care.
20,2017

Originally appeared in Medical Economics, May