In a recent article in the New England Journal of Medicine, a rheumatologist at a teaching hospital lamented about “hospital problems,” a phenomenon where patients are not allowed to stay in the hospital when they no longer have a medical necessity for hospital care, even though the physician may want to keep the patient longer to wait for test results or get prepped for a test. He proceeds to blame this loss of physician autonomy on the development of hospitalists as a specialty, the increasing employment of physicians by health systems, and “business majors.” His patient with vasculitis required a kidney biopsy but was medically stable on her current medication regimen. The doctor was not allowed to keep her hospitalized the three days necessary to allow aspirin to clear to safely proceed with the biopsy.
What this physician may not realize is that in many, if not most, hospitals, patients requiring hospital care are being held in hallway beds in the emergency department for hours or days due to a lack of inpatient beds, and patients requiring non-emergent surgery are having their surgeries postponed due to a lack of inpatient beds for their post-operative care. This lack of inpatient bed capacity is multifactorial, with limited capacity in nursing homes meaning elderly patients are “stuck” in the hospital awaiting a SNF bed. For some patients, they have no skilled needs but are unable to afford the private pay rates at long-term care facilities, so their stay is prolonged as alternative arrangements are made. Other patients are unhoused and need continued medical care, such as IV antibiotics. Additionally, hospitals are often constrained in their ability to adequately staff ancillary departments such as physical therapy, extending patients’ hospital stay while awaiting necessary assessments.
And while it would be convenient for the patient to remain the three days waiting for the biopsy, hospital confinement also imposes risks to patients, including exposure to nosocomial infections, medication errors, effects of sleep deprivation, and other health care-acquired conditions. The financial aspects can also not be ignored. Most hospital admissions are paid as a single payment covering all care provided during the stay. A discussion of the profitability of nonprofit hospitals and their executive salaries is beyond the scope here, but adding three days of convenient hospital care, including the required nursing care and daily physician visits, without any additional reimbursement is not a sustainable model to expand services to all in need. The patient may also have added financial liability depending on her insurance.
This physician does express hope that “value-based payment models may break down the barriers between inpatient and outpatient medicine.” The term “value” itself has components of quality, safety, and experience divided by cost. Using principles of “since you are here” methodology not only adds to the cost; it also compromises quality and safety and thus decreases the value of care markedly. These would not be “value-added” services for the patient or the hospital. They would do more harm than good by creating increased competition for already scarce resources. This happens all too frequently, such as ordering services and consultations that could be deferred to the non-hospital setting.
There is no equity in using highly paid clinical staff to provide hospital care to a stable patient awaiting a procedure that can be safely done after discharge, while a patient with sepsis needs to be transferred to another facility because the ICU is filled, partially with patients awaiting transfer to a medical bed, but there are no medical beds available. Using precious hospital beds to carry out outpatient work would be antithetical to the very idea of the right patient, right service, and the right setting. What we are missing is seamless communication, shared ownership, and missed opportunities to remove psychosocial barriers for patients to meet goals for their health care.
We offer a simpler solution here. Develop a relationship with the hospital’s care management staff. They can provide that bridge between settings, helping to arrange outpatient follow-up and testing, communicating with the patient to ensure they do not miss their appointment, and ensuring that the results of testing are conveyed to the patient and the physician so they can get the best care in the most appropriate setting.
Deepak Goyal is an internal medicine physician. Ronald Hirsch is an internal medicine physician and can be reached on Twitter @signaturedoc.