Chances are, if you're admitted to the hospital, the doctor in charge of your care won't be your own. He or she will be a hospitalist, a relatively new type of specialist whose sole job is to oversee the care of hospitalized patients.
Hospitalists have spread rapidly since they were first officially recognized in the 1990s, because they are supposed to improve care and save money. The idea is that because hospitalists are around the hospital all the time, and familiar with the way the place works, they'd get patients taken care of better and more efficiently.
But a study in the current issue of Annals of Internal Medicine suggests that might not be the whole story.
Using more than 60,000 records from Medicare patients, researchers from the University of Texas Medical Branch in Galveston looked at what happened after patients cared for by hospitalists left the hospital, compared to patients who were cared for as inpatients by their regular primary care doctors.
What they found was that while the hospitalists' patients indeed had shorter hospital stays, they were more likely to be readmitted to the hospital within 30 days, or to visit an emergency room within that first month. They also found hospitalists were more likely to discharge patients to nursing homes or rehabilitation facilities, and less likely to send them straight home than the patients' regular doctors.
As a result, Dr. James Goodwin, a geriatrician and one of the study's authors, said hospitalists actually cost Medicare more than they save on those shorter hospital stays. "When you expand it to all hospitalizations nationally that hospitalists are caring for, Medicare is spending about a billion extra dollars in post-hospital costs," he said.
Goodwin wasn't particularly surprised by the findings. Hospitalists, he noted, are under pressure to get patients discharged as quickly as possible, even if they may not be ready to go straight home. Because Medicare pays hospitals according to each diagnosis, the hospital loses money the longer a patient stays, "and so when they reduce their costs by getting someone out sooner, that's a profit for them."
But Dr. Joseph Li, president of the Society of Hospital Medicine, which represents hospitalists, says the results may in fact show not that patients treated by hospitalists are getting too much care, but that patients being sent straight home are getting too little.
Li, who runs the hospitalist program at Boston's Beth Israel Deaconess Medical Center, says that he's not surprised that patients treated by hospitalists are more likely to be readmitted to the hospital or seen in the ER. "These patients are being monitored 24/7 by healthcare providers," he said. "You know, contrast that to patients who are sent home who are not monitored by healthcare providers."
Goodwin and Li agree that hospitalists could do a better job coordinating with patients' primary care doctors.
Said Li, "I'll be the first to tell you that we have a lot of work to do in terms of helping our hospitalists in our hospitals in this country work together to provide better care for our hospitalized patients."
For his part, Goodwin said, "Money drives lots of improvements." Medicare is already starting to experiment with bundling payments to include the cost of hospital readmissions in what it pays for a single episode of hospital care, he said. That would mean the hospital would have to eat the cost if the patient returned. "It's all about getting economic incentives aligned correctly," he said.