Hospitals & Doctors

The past two decades have seen the slow decline of a model ofhealth care in which U.S. primary care doctors also have overseentheir patients’ needs if and when they entered the hospital.Back then, write Lawrence Casalino and colleagues in the paperthat follows, hospitals were the "physician’s workshop"—providingoffice-based doctors with the equipment and staff they neededto deliver higher levels of care. But now newer arrangementsare thoroughly transforming this long-standing doctor-hospitalrelationship.

The story is told in data from the Community Tracking Study,sponsored by the Center for Studying Health System Change. Onetransforming force, write the center’s Hoangmai Pham andcolleagues, has been the burgeoning hospitalist movement, inwhich specially trained physicians assume the lion’s shareof responsibility for inpatient care. Hospitals are also hiringother specialists in growing numbers and employing them outright—inpart because of the increasing difficulty and expense of recruitingdoctors who’ll consult with patients in emergencies. Anda third, well-documented trend is for community doctors to simplyset up shop in direct competition with the hospital—forexample, 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 suggeststhat the use of hospitalists may improve quality and reducecosts. On the other hand, higher pay for hospital-based specialistsmay continue to draw providers from primary care. That couldyield an ironic contrast: patients could get excellent careas inpatients, but there would be fewer skilled providers tohelp them once they’re out of the hospital. Patient "handoffs"from hospital back to community could be more perilous thanever.

Public policy could provide an antidote—for example, ifMedicare’s pay-for-performance programs held hospitalsresponsible for improving care transitions. Measures like thesecould help close the "black hole of accountability" in healthcare—the gap, Pham and colleagues write, "between dischargeand outpatient follow-up" that effectively sends too many patientsnow leaving the hospital into deep outer space.

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