Putting process over patients continues to hurt healthcare

Editor’s Note: Welcome to Medical Economics' blog section which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The series continues with this blog by Anish Koka, a cardiologist in private practice in Philadelphia. The views expressed in these blogs are those of their respective contributors and do not represent the views of Medical Economics or UBM Medica.

I had the special pleasure of going to a cardiology grand rounds being given by a new breed of physician: the cardiac hospitalist.

The problem with healthcare, you see, is that we don't have enough specialists. What began as a nascent movement spurred by an influential New England Journal of Medicine editorial in 1996 discussing the need for a new breed of doctors who specialized in taking care of medical inpatients is now spawning subspecialization within the field. 

Like most stories, this one requires context.

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The nation has perpetually been on the verge of being bankrupt ever since we became civilized enough to ensure senior citizens would have healthcare. Unbeknownst to most Americans, the moment President Lyndon B. Johnson signed the law affirming the nation's commitment to healthcare in 1965, an all-out assault on the nation's wallet began. It was a gold rush. The richest house in the neighborhood on Halloween was giving out an unlimited number of candy bars. You just had to go ask.

Dr. Koka

Hospitals asked a lot, and the cost of taking care of medical inpatients rose from $3 billion in 1967 to $37 billion in 1983, according to the U.S. Department of Health and Human Services (HHS).

Alarmed by the massive inflation in costs, Congress in 1983 mandated a change to how hospitals were paid. Whereas hospitals used to be paid based on the costs hospitals said they incurred after the fact, they were now to be paid a flat prospective rate based on the patients’ admitting diagnosis. Bundling payments by diagnosis codes put intense pressure on hospitals to be more efficient in care delivery. Reducing the length of stay of hospitalizations became paramount to ending the year in the black. 

The prior model that used to consist of primary care physicians splitting time in the hospital and the outpatient setting was deemed inefficient. Keep a pool of physicians in the hospital focused on getting patients out of the hospital rapidly, and allow primary care physicians to stay in the office full-time to see more outpatients, unburdened by demands to run over to the hospital to see patients.

Next: The bigger picture...and a problem

Add duty hour restriction on residents that put limits on the amount of work hospitals could eke out of the cheap labor force doctors in training are, and the stage was set for the avalanche that followed. In 1996 when the term was first coined by Wachter & Goldman there were a few hundred hospitalists. In 2016, there were 50,000 hospitalists, making this the largest “specialty” of internal medicine.  It is an attractive field. Even traditionally parsimonious academic centers will pay $225,000 for a hospitalists in contrast to paying a primary care physician in the low $100,000s. The hospitalist typically does clinical work for 14 days of the month and it is shift work; which means you are truly off the clock when the shift ends. On the other hand, primary care physicians take on responsibilities that never really end. That chest X-ray ordered for shortness of breath needs to be followed up the next day. It matters little that the next day has 20 more patients with problems to add to the list.

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It isn't surprising then that we now have cardiac hospitalists lecturing the cardiology department on improving the care of inpatients. I'm all ears.

The bigger picture … and problem

I find out that inpatients are upset about many things. A major source of frustration is the lack of continuity of care. Shockingly, patients would like their outpatient physicians to be participating in their hospital care, and if they're not, they would like their outpatient physician to know what happened in the hospital. Patients are also not sleeping enough in hospitals and become confused. I learn that this all is very bad, but can be rectified by communicating more, avoiding unnecessary disturbances to patients by establishing protocols to avoid doing MRIs in the middle of the night and blue lights.

Yes. Blue lights.

You see blue lights emitting at a certain wavelength in patient rooms may have beneficial effects on melatonin levels that may help with the disruption in circadian rhythms that may be making patients delirious. Grandma could have a urinary tract infection and be confused waking up in a strange room, but the blue light will fix her. I half expected healing magnets to be discussed next.

Next: "Another blow to the focus on process over patient"

The inspiration for this talk turns out be another giant in the field of health policy who ushered in this new era: Don Berwick. The former HHS chief gained prominence after co-authoring the Institute of Medicine report in 1999 titled “To err is human.” In order to effect a coup, the populace must first be convinced that the status quo is unacceptable. “To err is human” stated that as many as 98,000 people every year were dying in hospitals of preventable medical errors. Clearly, something had to be done.

“Something” consisted of many things.  A head spinning number of people fill hospitals now. Instead of a skeleton team of house staff with attendings that reminded me of camp counselors, there are now full-time hospitalists, intensivists, nurse practitioners, quality improvement teams, wound care teams, physician assistants and clinical documentation experts all busily checking boxes.

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To be fair,  8% fewer hospital deaths were seen between 2000 and 2016. But it is far from clear that the army of people focused on improving process to make inpatient care delivery more efficient is responsible. To the contrary, when outpatient primary care physicians were involved in patient care, length of stay was higher, but mortality was lower compared to care by hospitalists.

Another blow to the focus on process over patient is the observation that reducing 30-day heart failure readmissions has been associated with increased mortality. The cherry on top is that the army of people waiting in hospitals to discharge patients as fast as possible help make American hospitals the most expensive in the world.

American ingenuity in healthcare over the last two decades has fractured the continuity of care, helped bankrupt the nation and now leads to earnest cardiac hospitalists trying to fix what has been broken. Something tells me we're going to need a lot of blue lights.