In order to develop properly the idea of either outpatient or inpatient recidivism, some background is necessary. In this case, it involves who is responsible for the patient and who is responsible for patient care transitions.
1 of the most important concepts in a healthcare system is what this author will term “patient ownership”. In other words, who is responsible for the overall care of a patient at all times and circumstances. While hospitalized, every patient must have an “attending of record”. This is, the physician who admits the patient into the hospital and is responsible for the patient’s care while there. Up until recent times, the patient’s primary physician usually admitted the patient to the hospital and cared for that patient. That was predominantly the protocol for the author of this article, caring for all hospitalized patients. When the same physician provides outpatient and inpatient care, information loss is reduced. As a rule, that physician will know the patient’s outpatient history, what circumstances led to the hospital admission, what happened during the hospital admission, and what needs to be done as an outpatient after discharge. For a variety of reasons, physicians who do both outpatient and inpatient care are waning. Ultimately, the reason for this is declining reimbursement. Over the last 20 years, reimbursement for a PCP administering hospital care has gone down (in constant dollars). Thus, even the drive back and forth to the hospital from the office and back has been sacrificed due to reduced financial incentive.
This leads to a discussion of a relatively new type of internist, the hospitalist. The term was generated almost 30 years ago, in 1996. In general, hospitalists are internists who narrows the focus of practice solely to hospitalized patients (inpatients). Hospitalists need not travel back and forth to see outpatients and inpatients both. They only deal with hospitalized patients. As would be expected, this manner of care has both positives and negatives. Hospitalists are present within the hospital if the patient suffers a change in status. Thus, in theory, they would be quicker to reevaluate at the bedside a patient who declines in status. In teaching hospitals, this may be less of an issue because the nurse would call an intern or resident to evaluate any patient on a so-called “covered” service. If the intern or resident thought the issue important enough, then the PCP, if outside the hospital, could be contacted. Although hospitalists limit their focus to inpatients, a given hospitalist would see an admitted patient for only 1-3 days in a row and then no longer see the patient whose care would transfer to the next hospitalist. With each transition between hospitalists, the loss of information accumulates. Indeed, if a patient has had a long, complicated hospital course, it would take each subsequent hospitalist a bit of time to master the patient’s history. At the time of discharge, the discharging hospitalist may not have full command of facts of the hospitalization (especially if the care interval was limited) and would be unable to convey care issues for the receiving outpatient physician (e.g., timing of 1st outpatient appointment, what laboratories need to be repeated, what imaging studies need to be done, the timing of subspecialty follow-up, etc.)
In the last few decades, increasing focus has been given to the issue of hospital recidivism otherwise referred to as readmission. The metric for this issue of returning to the hospital after discharge is usually measured as a readmission within 30 days of previous discharge. Common diagnoses associated with a high rate of readmission include congestive heart failure (CHF), pneumonia, chronic obstructive pulmonary disease (COPD), sepsis, and acute myocardial infarction. Because of the lack of coherent electronic medical records going back decades, an apples to apples analysis of this trend over time cannot be made. However, as 1 data point the issue reached a pinnacle sufficient that, in 2010 the Affordable Care Act made a special effort to reduce hospital readmissions. One has to speculate that a complex issue such as causes of hospital readmission is not easy to analyze. However, this author witnessed firsthand the difficulties when different physicians were responsible for outpatient and then inpatient care of complicated patients. The complicated transitions of admission to and discharge from the hospital of these patients were quite prone to error. In part, I believe that it’s due to different physicians caring for the patient inside and outside of the hospital. So, the question, once again, is raised how can we elevate the quality of care while improving costs?
To address this issue, Medicare initiated a new financial incentive. If a patient were readmitted within 30 days of discharge, Medicare would not pay for the second admission. With this 1 policy change, Medicare effected a partial alignment of incentives. Sloppy discharge transitions would lead to higher risk of recidivism/readmission. This in turn would cost the hospital more money. Thus, to prevent this loss of money, better discharge protocols were developed. This even led to coordinating with the receiving physician. In this author’s opinion, this should have been done from the outset of the hospitalist movement but a cultural barrier existed with some hospitalists who considered their responsibility only the patient care given within the walls of the hospital. The transition from the hospital to outpatient care was not a primary concern (a few of my hospitalist colleagues would chant the mantra “keep ’em alive ‘til 8:05 [a.m.]”). In other words, the scope of responsibility for the patient transitioned sharply when the hospitalist’s shift was over or when the patient exited the front door the hospital. Granted, the majority are professional in their conduct but for many, the attraction of hospital medicine is the narrowness of responsibility for the patient. However, with the 30 day recidivism/readmission policy in place, patient care improved leading to fewer readmissions and greater cost savings for the overall system. The transitions from outpatient to inpatient to outpatient again had to approach the effortlessness of when 1 physician was in charge of all.
So, if hospitals were not paid extra money for sloppy transitions from inpatient to outpatient, imagine what would happen if hospitals were only paid a fixed amount per patient per month! Sloppy discharge transitions which led to readmission would still be avoided. Borderline laboratory tests, radiographs, CAT scans, and MRIs would be avoided. Useless inpatient cardiac monitoring/telemetry would be avoided. Useless, unnecessary inpatient oxygenation with nasal cannula, facemask, etc. would be avoided. Daily blood draws would no longer be automatic but collected only if the patient’s care would be changed. Indeed, unnecessary admissions to the hospital would be avoided. This would lead to emergency physicians coordinating with primary care physicians for a higher percentage of discharges straight from the emergency room. This also would lead to hospitalists, once the patient was ready for discharge, communicating earlier and more directly with the receiving PCP also. As a reminder, “global capitation” which is mentioned in previous articles would compel hospitals to review all patient processes including admission, discharge, and everything in between. The concern about withholding payment leading to poorer care does not seem to be the case as evidenced by the above programs to penalize recidivism. Indeed, with better coordination of transition, the care improves. “Global capitation” not only compels the hospital to transition patients back to outpatient status more “cleanly” to avoid recidivism, it incentivizes hospitals not to admit patients inappropriately or for marginal indication. The whole concept of hospitalization would be reviewed.
Thus, cost-effective care walks hand-in-hand with better patient outcomes. Win-Win.