Another potential point of contention is the practice of admitting patients to the hospitalist service once the resident teaching service is capped. This is institution-specific. In cases where the entire resident overflow is admitted to the hospitalist service, patients seldom go back to the teaching service because ED doctors label them as belonging to the hospitalist service. Many of these patients either have no insurance (or have Medicaid); in addition, they often have multiple health problems, and noncompliance runs rife. Because unscheduled readmissions are viewed negatively under current guidelines, patients who are handed off in this manner can cause resulting penalties for the hospitalists who end up serving them.
Extended Care Readmissions
Patients with established primary care physicians often go to extended-care facilities where there is another physician of record. At readmission, the new attending is recorded as the patient’s physician. The prior primary attending might have wanted to follow the patient during the readmission. Unfortunately, the ED physician will typically call the newly assigned attending because that is the name that appears on the transfer note. If, at this time, the new attending decides to admit the patient to the hospitalist service, a misunderstanding may ensue. The original primary care attending may view this as an attempt on the part of the hospitalist service to appropriate patients, though the decision to admit to the hospitalist service is seldom made by the hospitalist.
The pitfalls of these practices are accentuated when the readmission occurs within a relatively short time frame. Another downside may arise if the new attending, who knows little of the patient’s history, orders another extensive inpatient workup. This example highlights a potential, and avoidable, cause of spiraling healthcare costs.
The Hospitalist’s Role
We practice in a milieu of increasing scrutiny. Pay for performance is gaining momentum and acceptance. Two years from now, non-compliance with specific indicators, such as readmission rates, will be met with financial penalties. Hospitals complain of decreasing reimbursements. Unscheduled readmissions to the hospital continue to be a source of lost revenue and patient dissatisfaction.
The hospitalist plays a central role in the management of the patient from a medical standpoint. Rules of admission to the hospitalist service vary widely amongst different institutions. Often, depending on patient load and available staffing, these rules are in flux even within institutions. Procedures run the gamut from the so-called “closed system,” in which only specific physicians can admit patients to the hospitalist service, to the “open system,” in which everyone is welcome, on a voluntary basis, to admit to the hospitalist service. The potential pitfalls of the open system will become more and more apparent in the years to come, and many of us will be forced to rethink our models of healthcare delivery. TH
Dr. Chabria is a hospitalist at Waterbury Hospital, Conn., and a clinical instructor at Yale University School of Medicine, New Haven, Conn.