The Foglight - Why the Face of Your Hospital Doctor Keeps Changing

September 2023

Issue # 3 September 2023
In This Issue: Hospital Physicians (Hospitalists) Part 1

Dear Reader,

When my client was first hospitalized, her family assumed that the doctors were making recommendations based on a full understanding of her multiple medical conditions. As her hospitalization dragged on and the doctors kept changing, they began to realize that the doctor of the day was simply skimming the surface. The family tried to provide information they thought would be helpful, but the doctors would hurriedly cut them off, leaving the family frustrated and angry.
 
Please read on to learn how our current system of hospital-based physician care came to be. 

Why the Face of Your Hospital Doctor Keeps Changing

We all have ideas about the way things used to be. It used to be safer. Cars used to stop for pedestrians. Schools used to teach the basics. Much of the time, these are just memories of the way things never really were. But sometimes things really were different in the olden days. To take one example, if you believe that 30 years ago, your family doctor helped take care of you in the hospital (and no longer does), you’re probably right.

But today, if you are admitted to the hospital—after a car accident, for a cardiac episode, for a serious infection, for whatever—you may never see your primary care physician (if you even have one). Instead, the doctors making decisions about you will be a rotating cast of specialists and “hospitalists” who have no idea who you are, have never treated you before, and have no relationship with your family. If you are lucky, your family doctor or primary care physician will get a message that you have been admitted. He or she is very unlikely to so much as pop in to check on you.
 
What changed? Why does your personal doctor have practically no role in your treatment, when you are admitted to the hospital?

There are a lot of factors at play, but the turning point was 1983 when Medicare changed the way it reimbursed hospital stays. Previously, Medicare had used the “cost-plus,” system: hospitals documented their costs, then got paid that amount plus a small margin. This system created an incentive for hospitals to keep people in the hospital and do more procedures, which then increased their costs and their profits.

So Medicare switched to the DRG, or “diagnostic-related group,” payment system, which pays a fixed amount depending on the diagnosis codes. Once Medicare switched, other insurers followed suit.
But hospitals now had a new incentive: to get patients out as soon as possible. If taking care of a heart attack only got reimbursed a fixed amount, then every day that the patient stayed, and took up resources—food, linens, nurses’ attention—cut into profit. Now the hospital gets the same payment whether a patient is there for 3 days or 13 days. So now the hospitals wanted to move patients out as quickly as possible.

One way to save money was to discharge a patient early in the day, freeing the bed up for another patient (with a new payment). But there was a catch. Your family doctor. The family doctor couldn’t necessarily get there early in the day. In fact, he or she often came late in the day, after seeing patients in the office. Plus a patient discharged at six o’clock in the evening cost the hospital another day of care.

Hospitals needed to churn their bed occupancy—“churnover,” as it came to be known.

So there was now an economic imperative for hospitals to hire doctors who could round first thing in the morning, discharging anyone who could possibly go home that day. These “hospitalists” did not have their own practices for life-long patients. They could still be terrific doctors, passionately devoted to patients, but they were constantly reminded by their employer—the hospital—of the bottom line.

To some, this seemed like a win-win. The advent of hospitalists released primary care physicians from the necessity to visit their patients in the hospital, a duty some of them were grateful to be released from. (There was a transitional time when some primary care physicians still rounded along with the hospitalists. But basically, everyone got with the program.) And there was a hope that the new system would yield better care. Hospitalists wouldn’t be distracted by what was going on in the office, because they had no office. And they could work more efficiently because they knew the hospital setting. If a patient needed a lab result, the doctor knew who to talk to and said, “Hey, could we move along the results for Mrs. Jones on the sixth floor?” That was something your family doctor couldn’t do.

And there was the clinical reality that if you treat 30 people a week with heart attacks, you are going to do the job better than if you treat 30 people a year with heart attacks. Hospitalists developed a knowledge base different from the one primary care doctors have.

But by excluding the doctors who knew the patient best, there was bound to be a trade-off. And that’s what I’ll discuss in my next newsletter.

Dr. Gerda Maissel, MD CPE, BCPA

Dr. Maissel is a Board-Certified Physical Medicine
and Rehabilitation physician
and a Board-Certified Patient Advocate
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