Efforts in the name of efficiency and cost reduction have unintended consequences.

When I was in practice, I admitted, or at least followed, all my patients in the hospital. There were no issues of aftercare, because I discharged them with appointments to see me within a day or two (rarely more).

I knew what medications they were admitted on, and what they were discharged on, because I was involved in every change. There were few agonizing family discussions about end-of-life care, because, usually, we had discussed this before they ended up in the hospital.

There were no issues of referrals not being followed up on, because specialists who did not see my patients in a timely manner never got referrals from me again. If a patient didn’t show up to see a specialist, the specialist called to inform me. If a patient didn’t show up to an appointment with me, I called the patient to ask why.

Now we have hospitalists, a whole breed of specialists created to facilitate short length of stays because of their presence in the hospital 23/7.

Length of stays down, readmissions up

An intended consequence of hospitalists was length of stays went down (driven by DRG payment) but unintended were readmissions went up. There are dozens of articles on reducing readmissions, suddenly important to hospitals (but a source of income before ACA).

I considered a readmission a personal failure, or an inevitable spiral downward. The former was rare, the latter often interrupted by Hospice. I read about “normal” readmission rates of 20 percent.

I cannot recall many of my patients needing readmission, but I guess it wasn’t lucrative for me. Inpatient care was not a money-making proposition. The time away from the office, and the constant nocturnal interruptions both contributed to my departure from primary care practice.

The unreimbursed costs and flat payment rates of insurance, accompanied by spiraling upwards costs of insurance for me and my staff (both health and malpractice) and salaries for my staff drove me to close rather than continue reducing my meager take-home from the practice.

I was paid for quantity, not quality. I guess I didn’t see enough patients. No one reimbursed me better for having low readmissions, being the coordinator of care in and out of the hospital. Nor did they give me more, for that matter, for seeing a patient in my office after hours. Was it less expensive to the payer to send them to the ER than to pay me an after-hours fee?

A solution

What if we paid primary care doctors to go back to the hospital and take care of their own patients? Workarounds, like nurse managers, medication reconciliation, end of life and ethics teams would not be needed. Hospitalists could go away. For the primary care docs too far from the hospital to admit their own patients, they could admit to internists, pediatricians or even fellow family docs (like the old days).

These were docs who also had outpatient practices, and understood a phone call to the primary care solves tons of problems. Reducing reimbursement to the primary care docs, and to inpatient care charges results in that continuity being interrupted, and to the need for more efficient hospitalists care.

But was there an unintended consequence – higher readmissions, less coordination or care, more confusion and thus more costs to the system. Did the system create its own problem?