Dude, where's my doc?

In October of 2018, an article appeared in the Naples Daily News describing a new policy that proposed elimination of admission privileges by Naples Community Hospital for unaffiliated primary care physicians, sparking outcry from the community. In fact, so poorly was the policy received, that the CEO and his chief of staff were forced to resign in the beginning of 2019 after a vote of no confidence as reported by the Naples Daily News. But was the error in idea or implementation? This predictable public response presented several teachable moments for hospital leadership as well as an opportunity to make meaningful improvements to the proposed policy which could actually be patients' best interests. It is imperative to examine the issue in perspective from both sides. I will attempt to do so here as objectively as possible.

First, some context. What are admissions privileges? What role to primary care providers (PCP’s) and hospitalists play in the healthcare delivery value chain? And why would a hospital system move to control who has admission privileges?

Admission privileges allow a physician to admit a patient into an inpatient facility, design the care plan for the patient while the patient is in the hospital and determine when a patient has sufficiently recovered to be released. The admitting physician is the ultimate authority on the key decisions involved in the patient’s care. The actual care delivered to the patient is carried out by the hospital staff of nurses, technicians, and other medical professionals with support and consultation from specialist physicians as needed. The admitting physician, be they a hospitalist or an external PCP is responsible for checking in on the progress of care usually once or twice per day.

In understanding the difference between PCP’s and hospitalists, the fundamental question is ‘what is the mindset, skillset and competencies required in acute vs long term care?’ In the healthcare delivery system, the PCP has the responsibility for helping a patient maintain their health through a combination of medical interventions, lifestyle and behavioral changes. The PCP has a long term view of the patient’s history and future. This vital activity is usually carried out in an outpatient setting and does not require advanced equipment and support services. Due to the power of preventative care and its positive impact not only on the quality of life of the patient, but also in its affect to lower the overall cost of care, primary care is the cornerstone of good care delivery.

In the process of care, there arise occasions when the patient becomes sick enough to need more intensive resources to get better. In these acute events, patients are admitted to the hospital for (hopefully) short durations of intensive care to recover from the acute event. It cannot be emphasized enough that it is in every patients’ best interest to spend as little time in the hospital as safely possible. The single greatest factor in many serious hospital acquired conditions is the length of time the patient spends in the hospital. The longer the stay, the more dangerous for the patient. Hospitalists spend their time and are trained specifically to operate in this acute, short term environment to heal the patient as quickly and safely as possible.

Healthcare is often compared to the airline industry as there are a surprising number of parallels that do a good job of illustrating concepts. Using this analogy, your PCP is your pilot, guiding you from where you are to where you want to go. The hospitalist is the chief mechanic when your plane needs repair or maintenance. Both are invaluable in getting you safely to where you want to go, but you would not necessarily want your pilot in charge when the plane is in for maintenance or repairs.

Why would a hospital move to restrict the ability for non-affiliated PCP’s to admit patients? NCH claims this is done for patient safety, but what does that mean? First, let’s introduce the elephant in the room. PCPs are the financial funnel for hospitals, providing referrals for high cost procedures that make up most of a hospitals revenue. By controlling the primary care physicians, the hospital controls its access to patients. It is worth noting that this strategy does not come without financial downside. Physicians no longer able to refer to NCH will refer their patients to other hospitals along with the revenue that those patients represent. One approach used by many health systems in the US is to acquire and affiliate as many PCP’s in their operating area as possible to mitigate that effect. It would not be surprising if after restricting admitting privileges, NCH moves to aggressively affiliate and acquire primary care physicians. This scene is playing out across the country as hospitals and health systems struggle to survive and adapt to an increasingly challenging operating environment and is by no means unique to Southwest Florida. While this looks like, and is, an economic power grab, there are real patient care quality impacts that deserve an honest look.

The modern health system is a complicated and interdependent machine that spans care settings from outside the hospital, primary care, acute care, rehab and skilled nursing depending on the disease status and progression of the patient. This complexity has led to significant specialization and sub specialization in which the distinction between the PCP and hospitalist are just a small taste. In the modern healthcare delivery setting, it is no longer possible for any single primary care physician to be knowledgeable enough to manage the complete spectrum of care.

When a patient is admitted to the hospital, regardless of who does the admission, the hospital assumes responsibility for the patient’s outcome. Hospitals are financially measured and penalized on performance such as the 30 day readmission rate which forces them to create and improve quality practices, based on collective experience and data which improves the patient outcomes, reduces the time that it takes them to recover, reduces the cost required to treat them, and prevents them from needing to be readmitted to the hospital soon after being released. Hospitalists are measured, tracked and held accountable adhering to these best practices. Unaffiliated PCP’s with admitting privileges have no such accountability. They are free to select whichever course of treatment they feel most appropriate regardless of the demonstrated efficacy. Therein lies the predicament of a hospital. It is held responsible for performance yet has no means by which to compel unaffiliated PCP’s to change their behavior if that behavior is adversely affecting patient care, safety or outcomes and thus hospital performance. This is what is meant by “improving patient safety and outcomes” the hospital is moving to be able to control care variation in care, which leads to more predicable and improved patient outcomes.

While hopefully the previous writing has explained why this trend or limiting independent PCP admissions is happening nationally and why it is actually good for patients, there have been several excellent points raised by the community which offer suggestions for meaningfully improving this initiative. The biggest and most important issue that when independent PCPs do not have admitting privileges, the intimate familiarity with the patient’s history, and the associated record is lost. We are all individual with unique history that significantly impacts the efficacy of the care we receive. The same care given to two patients that seem to equally need it may result in drastically different outcomes. The sharing of medical information between caregivers is one of the biggest weaknesses and challenges for the US healthcare system. This need for sharing of information has led to billions of dollars spent on everything from combining and consolidating entire healthcare systems, to buying different players such as PCP’s into a single entity, to massive technology projects to get everyone on a unified healthcare record.

I would suggest a much simpler suggestion. When NCH revokes admitting privileges to independent PCP’s, grant them the privelage (and appropriate vehicle for compensation) to do consults on their admitted patients, just as one may consult a cardiology or pulmonology specialist. The hospitalist overseeing the patients’ acute treatment will still have the final care authority on the medical team so the patient can benefit from hospital quality initiatives and accumulated insight into care best practices, while the PCP has an official, compensated and valuable role on the care team. The patient (and care team) benefits from the history and familiarity that the PCP has with the patient. The PCP serves as a common link to help the patient transition from outpatient to inpatient and then back to outpatient settings smoothly, advocating for the patient while they undergo acute care. Under such an arrangement, patients would likely see their PCP as often as they do now when admitted to the hospital. For those concerned about hospital-imposed care measures, or hospitalists ignoring PCP’s remember, the hospitalist’s objective (as well should be the patient’s) is to get the patient treated as safely, quickly, and effectively as possible. No good physician will choose to ignore the information provided by the PCP if it leads to this outcome. There will undoubtedly arise differences of opinion on the best course of treatment. However, if we cannot trust our doctors to come to consensus in a professional and mutually agreeable manner means we have much more serious issues in our health system then who can and cannot admit whom to the hospital.

#communityhospitals #primarycare #admissions #healthcare