Hospitalists Play Critical Role in Primary Care

January 25, 2012

Hospitalists provide essential primary care in the hospital for the extremely sick, chronically ill patient population responsible for the majority of Medicare spending.

We need to face a basic fact; it’s a fact so basic, yet difficult to fully comprehend, that it is virtually ignored throughout the country in boardrooms addressing healthcare reform. The fact is this: Internal medicine and family practice hospitalists provide essential primary care in the hospital for the extremely sick, chronically ill patient population that is responsible for the majority of Medicare spending in America today. These patients are routinely dealing with life-threatening decompensated organ failures - heart, brain, lung, liver, kidney - and of course we must mention gastrointestinal bleeding and septic shock.

These ill people suffer through acute life-threatening illnesses in the larger context of debilitating chronic illness. Their chronic illnesses are either too complicated for outpatient providers to manage, or never get to be managed by outpatient providers because the patients simply bounce in and out of hospitals, nursing homes, assisted living facilities, etc.

These patients consume the majority of healthcare services billable to Medicare and major insurance companies; they put the bread on the table for cardiologists, pulmonologists, and other hospital-based providers. These patients are routinely admitted under the primary inpatient service of an internist, hospitalist, or family practitioner with inpatient skills. In one day, the physician can do what outpatient providers do in 6 months: check LDL, A1C, blood pressure, check for occult cancers, check heart function, maximize cardioprotective medication dosages (beta blockers, ACE inhibitors, etc). In one six-hour period, the patient gets more attention paid to each organ system and their inter-connectedness, thanks to the attending internist, compared to the years of care they’ve received by outpatient practitioners.

Why? Simply because if you are admitted to the hospital, that means your life is in danger. The doctor caring for you is vigilant against any possible threat to your life. Tests are ordered, perhaps in excess, in anticipation of the pulmonary embolus about to kill you. We inpatient practitioners work very hard in a 12-hour period to make sure you don’t die on our watch.

Consequently, we provide extremely good care. Good enough to prevent readmissions because the underlying issue has been solved? No; absolutely not. Let me state it here in case you haven’t heard it elsewhere: Medical readmissions are not attributable to poor quality care; they are for the most part due to extreme burden of illness. We have an epidemic of chronic illness. We have more human beings living with minimally functioning organs than ever before in the history of mankind.

I routinely deal with demented (brain not working) patients with heart failure (heart not working) which leads to kidney failure (kidney not getting blood flow from aforementioned heart) and lung failure (lungs filled with fluid from sad heart), which leads to complications such as pneumonia (septic burden compromises multiple organ systems)…etc etc.

The regular frequent flyer patients that come in and out of hospitals receive their primary care in the hospital from vigilant internists. The moment we accept this fact, and we change pay structures and priorities according to the consequences of this fact, we will be more likely to meet the enormous challenge of chronic illness in 2012.

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