What Will We Do When The Mother Ship Is Abandoned?

I had a long talk today with a colleague about the state of our nations health care. We talked about where things have been, where things are now and where things are going. We talked about the fee for service, the misplaced economic incentives built into the current fee for service model. We talked about practice style. We talked about what it would take to make a practice experience the most rewarding. With that said, I have come to the conclusion that hospital medicine is a pain in the ass for most physicians. If given the choice between doing hospital care and not doing hospital care, most physicians would abandon the hospital in a heart beat. Why? Because it's all built into the financial model and patient experience.

The job I love so much is a major pain in the ass for most. And it makes complete sense. Happy's Hospital has already experienced an exodus of some very important specialties. One of my biggest fears as a hospitalist is to have a patient in my care that needs urgent specialist care that I don't have access to. On January 1st, 2010, when the 15% across the board cuts resume because of the flawed sustainable growth rate that Medicare Part B is built around, my biggest fear is the withdrawal of specialists from hospitals all across this country. Withdrawal to the comfort of their clinics. And here's why. It was an eye opening discussion that raised my eyebrow to the vast difference between in patient and outpatient medicine.

The following are the reasons for the mass exodus coming shortly to hospital based medicine.

1. Difficulty. If given the choice between inpatient and outpatient medicine, hospitalized patients are generally much more difficult to manage. They are in the hospital for a reason. It takes effort to be sick enough to get admitted. While I occasionally get a patient with one medical condition, often, my patients have 10-15 chronic medical conditions and several chronic organ failures. Sick patients get sicker very quickly. They decompensate very quickly. They are unstable. They take lots of thought. They take lots of time. When put into the context of outpatient medical issues, inpatient care takes more time and more effort for no increased payment. In fact, because Medicare does not pay on time, the more time you spend in the hospital taking care of difficult complicated patients, the less time you have for the stable, generally healthier outpatient issues. In the time it takes to see one or two hospital patients, you could see 3 or 4 or 5 or 6 or more patients as a specialist, caring for one single issue and referring the patient back the the PCP for the "HA" or the "leg numbness." That's when the "Talk to your primary" comes in handy. Specialty offices can often see two or three times the number of patients a comprehensive care office can because they can focus on just a small part of the patients disease and exclude ownership of all the other baggage that comes with the patient. In terms of difficulty of the patient, outpatient medicine wins hands down. If Medicare cuts physician payment come January 1, 2010, look for a mass exodus of specialists from hospital medicine to the relative ease of clinic based care.
   
2. Liability. Hospitalized patients represent a higher liability for med mal. Sick patients get sicker. They have complications. They become unstable. They die. The emergent endoscopy or the emergent heart cath or the emergent paralytic ileus  with perforation represents a much higher risk of morbidity or mortality. A much higher risk of error and complication. Why would you want to spend your days doing three hour emergent bowel perforations at 2 am when you could go to your specialty hospital for 5 elective cholecystectomies in the same period of time. Hospitalized patients are uninsured patients. They are all comers. Nice people. Jerks. Punks. Antisocial. Entitled. Uninsured. Under insured. When you are on call for the emergency room, you are on call for everything that comes in. You can't pick or chose who you are going to see and who you aren't. If you don't want to take emergency room call, then you can't practice at the hospital. And for many specialties, that is becoming more and more of an option as their practice style moves toward outpatient and elective procedures and interventions. They don't need hospitals like they used to. They build their own surgery centers and expand their office hours. And they fill it with patients they can fire for any reason at all. They build a doctor patient relationship. And we all know that a patient is less likely to sue a doctor that they have a good working relationship with. So hospital patients are filled with difficult, complicated sick folks. And they represent a higher liability with no increased payment. If Medicare proceeds with their cuts come January 2010, look for a mass exodus of physicians from emergency room call to the decreased liability of their office based medicine.
   
3. Payment. Medicare makes no distinction in payment between easy patients and hard patients. Hospitalized patients generally require more time. A heart catheterization done urgently at 3 am on a patient with shock and hypotension causes pay no more than an elective heart catheterization done at 11 am for stable angina. An EGD done on a patient with massive hematemesis pays no more than an elective EGD done on a patient in the office with heart burn. There is no financial incentive to chose more complicated interventions in the hospital when you have an outpatient stable clinical practice filled with stable patients. The payment system is flawed in the sense that you do not get any financial incentive for doing complicated work in the hospital when the outpatient equivalent pays just as much, with far fewer complications and takes less time. It comes down to volume. You can do more outpatient interventions for far more money than you can on complicated, time consuming interventions on sick hospitalized patients. Why come into the emergency for that acute GI bleed or acute MI or perforated bowel when you can do the same stuff electively as an outpatient for the same amount of money and far less time consuming complications. Outpatient wins again. If Medicare cuts payment for all doctors come Jan 1st, 2010 look for a mass exodus of specialists from hospital call to the comfort of their outpatient referral base.
4. Efficiency. I touched on this earlier. Hospital medicine is chaos. Patients are unstable. They decompensate. They crash and burn. They end up on ventilators. They bleed out of every oriface. They code. They take time and energy. Lots of it. Often times, they have multiorgan failure in the setting of multiple chronic organ failure. It is very difficult to create order in a practice filled with chaos. My days are often chaotic. I can have 50- 100 pages a day while trying to see 15 or more complicated patients. It's the same as well for specialists. Many groups have hired extenders to increase their efficiency. To data gather. To write the majority of their notes. To dictate so they can see more patients. So they can bill more money. But the fact remains the unstable nature of hospitalized patients makes it far less efficient to care for them than an equivalent outpatient. And in today's environment of decreasing payment, if you can't be efficient, you can't survive. The more patients you see the more you make. And outpatient medicine is far more efficient and controlled than the chaos of hospital patients. If Medicare tries to cut physician payments 15% across the board come January 1, 2010, I see a mass exodus of specialists to the efficiency of their outpatient practice.
5. Volume. In the eat what you kill mentality of American health care, if you do more, you make more. I know some comprehensive care doctors who come to the hospital every day at 4:30 am. I know this because the occasional time I come in early for rounds, I see them. When you come in at 4:30 am and don't get home until 8pm, you can make a lot of money, no matter what field of medicine you are in. If you put in 15 hours a day and work your ass off, you will be financially rewarded for your effort. Because volume rules in American medicine, the more you can see and do, the more you can make. It is far easier for a specialist to see 50-60 clinic patients in a day managing one or two stable medical problems than it is to see 50 or 60 sick complicated, decompensating hospitalized patients. You can do more elective cholecystectomies in younger otherwise healthy patients than you can in nursing home grandma coming to the emergency room with cholecystitis and 15 medical problems. If given the choice between volume of inpatient medicine and volume of outpatient medicine, I fear than any cut in payment come January 1st, 2010 will result in a mass exodus of specialists from emergency room call to the comforts of their out patient experience.
6. Continuity. I see a lot of patients as frequent fliers. For me they represent continuity in the hospital. For many specialists, a hospital consult is a one time event. It does not lead to clinic referrals. It leads to time away from the clinic. Hospital medicine, for many specialties is a pain in the ass. Any cut in Medicare funding come January 1st, 2010 will most certainly lead to a mass exodus of specialists to the comforts of their clinical experience.
   

While not all specialties are alike, many have their bread and butter interventions that could be done on a mass volume scale quite easily outside of the community hospitals. The surgeons have their overnight procedures, their debridements. The elective tendon repairs and joint replacements. The aspirations. The angiograms. The stress tests. The endoscopies. The biopies.

I don't ever get to experience the controlled environment of outpatient medicine. Where volume can be scaled at a much higher success rate than the chaos of unstable inpatient medicine. You want to piss off an entire nation of specialists, cut their payment 15% across the board. They will retreat en mass to the comforts of their clinics. They will abandon hospital medicine in a heart beat. Why work harder in the hospital when you can do more with less complicated patients in your office.

This is the reason comprehensive care has abandoned hospital medicine. They had to. Their business model said they had to. And if we piss off an entire nation of specialists, they will retreat to their offices. It's already started in my community. It's only a matter of time before the collateral damage spreads. What will we all do when the hospital mother ship is abandoned?

As I see it, all six of these practice defining characteristics lean heavily toward the outpatient experience. There is no benefit to building a hospital based practice in the current payment model. We shall all suffer from the destruction RUC/RVU and SGR has brought to our front door.