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PROLOGUEHospitals & DoctorsThe past two decades have seen the slow decline of a model of health care in which U.S. primary care doctors also have overseen their patients’ needs if and when they entered the hospital. Back then, write Lawrence Casalino and colleagues in the paper that follows, hospitals were the "physician’s workshop"—providing office-based doctors with the equipment and staff they needed to deliver higher levels of care. But now newer arrangements are thoroughly transforming this long-standing doctor-hospital relationship. The story is told in data from the Community Tracking Study, sponsored by the Center for Studying Health System Change. One transforming force, write the center’s Hoangmai Pham and colleagues, has been the burgeoning hospitalist movement, in which specially trained physicians assume the lion’s share of responsibility for inpatient care. Hospitals are also hiring other specialists in growing numbers and employing them outright—in part because of the increasing difficulty and expense of recruiting doctors who’ll consult with patients in emergencies. And a third, well-documented trend is for community doctors to simply set up shop in direct competition with the hospital—for example, through direct ownership and operation of imaging facilities. What do these shifts portend for patient care? Focusing on hospitalists, Pham and colleagues see benefits and risks. Research suggests that the use of hospitalists may improve quality and reduce costs. On the other hand, higher pay for hospital-based specialists may continue to draw providers from primary care. That could yield an ironic contrast: patients could get excellent care as inpatients, but there would be fewer skilled providers to help them once they’re out of the hospital. Patient "handoffs" from hospital back to community could be more perilous than ever. Public policy could provide an antidote—for example, if Medicare’s pay-for-performance programs held hospitals responsible for improving care transitions. Measures like these could help close the "black hole of accountability" in health care—the gap, Pham and colleagues write, "between discharge and outpatient follow-up" that effectively sends too many patients now leaving the hospital into deep outer space.
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