Saturday, December 27, 2008

Hospitalists have destroyed "teaching hospitals"

I am learning so much about what has happened to our hospitals. I am concerned that we are losing the phenomenal resource of true, traditional teaching hospitals to medical corporations.

We, as the general public have not noticed that the delivery of medical care in our nation's hospitals has changed. It has happened under the proverbial radar.

Increasingly, hospitals are outsourcing their entire EDs and inpatient medical programs to national healthcare management companies. In the last few years, their have been acquisitions and mergers, the major players in the hospital changes:

Cogent Healthcare

HMG (Hospitalist Management Group)

IPC: The Hospitalist CompanyBold


The questions that concern me are:

1. Why did hospitals start hiring using these companies?

I understand that some primary care doctors do not want to follow their own patients who are in hospitals. These PCPs attribute their decision to the fact that Medicare reimbursements have lowered and they can make more money focusing on the clinical practice.

I frankly have never met a PCP or non-hospitalist admitting physician who really wanted to completely hand-off their patient's care. My experience has been that hospitalists fervently try to protect their "turf" by disregarding the PCPs.

2. Do some parts of the country utilize these management and outsourcing companies more than other states?

It is my impression that Arizona uses the companies more than most other states. Arizona has a problem with undocumented foreign nationals using the EDs. Do states such as Arizona outsource their EDs to management companies in order to push the patients quickly through the ED?

3. Who actually employs the physicians associated with companies?

The hospitalist management company or the hospital where they work? Where does the "buck stop"? Where is the accountability?

Who is legally responsible in a medical malpractice lawsuit?

4. Where is the company's physician licensed to practice medicine?

Is the physician associated with the company licensed to practice medicine (a) in the state where the company is located or (b) in the state where the hospital is located?

5. Why do teaching hospitals need hospitalists and outsourcing companies?

The original purpose of a hospitalists is to provide the hospital with access to a dedicated internists who would be available 24/7. But teaching hospitals (such as Duke University Hospital and Carle Foundation Hospital) have residents and fellows who are available 24/7.

One of the most significant benefits of the tradition teaching hospitals is that residents and fellows get actual, practical patient experience. And, their work was closely monitored by the supervising physician/professor.

How do young soon-to-be doctors get that experience now?

The traditional teaching hospitals are a dying breed. I have seen young residents at Duke University Hospital make recommendations for my dad just to have a hospitalist override the young resident without explanation. Those over-riding confuses the patient and robs the resident of the opportunity to treat patients with the supervision and oversight of the medical school.

Certainly the hospitalists are not the supervising physicians/professor for the resident or fellow. In fact, the hospitalist competes with the resident for "turf."

6. Is the advent of hospitalists and medical management companies responsible for the healthcare crisis (both access and financial)?

We need to think about when these corporations invaded the hospitals and compare that time with when the current healthcare crisis.

7. Why was the public upset at the thought of an HMO making medical decisions yet they seem indifferent to the new breed of medical management corporations making decision?

Remember that the hospitalist at Duke University Hospital ignored the attending (non-hospitalist)'s order for urinary cultures and merely performed a UA. That hospitalist told me that his job was to make sure the medical care was "cost effective." The UA was negative but my dad had a serious UTI.

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