Map of life expectancy at birth from Global Education Project.

Wednesday, April 22, 2009

Anecdotal Evidence

Gulshan Sharma and colleagues, writing in the new JAMA, tell us that the likelihood that Medicare beneficiaries -- which means approximately all people over 65 -- will see their primary care physician while they are hospitalized declined from about 44% in 1996 to 32% in 2006. The likelihood is even lower in New England -- in 2006, only 16.2% of patients were seen by any physician they had seen on an outpatient basis in the past year. (Abstract here, but you don't belong to the private club that lets you read the article.)

Tell me about it. My mother recently fell and injured her back, and was hospitalized in an academic medical center in the nearest big city. Not only did her primary care physician not see her while she was hospitalized, he did not see her while she was subsequently in a rehabilitation facility -- even though I called his office and was personally assured that he was scheduled to visit her in two days. I guess he had better things to do after all.

There were consequences. The nursing home did not get complete information about her medications and she did not receive her glaucoma drops for three days. She had a nosocomial* bladder infection, which turned out to be antibiotic resistant, but she did not receive an effective regimen until after she had been discharged and finally saw her PCP in his office. (Try seeing a doctor, let alone one who gives a shit in one of those Intermediate Care Facilities. It's an M.D.-free zone, believe me. Actually, on evenings and weekends, it's often difficult to locate an employee anywhere on the premises.) Finally, of course, there is the sense of abandonment that people in that situation inevitably feel.

This trend is associated with the rise of the "hospitalist" model. It used to be that doctors had "admitting privileges" at a hospital, which meant they sent their patients there and then followed them while they were hospitalized. Now, a hospital employee who does nothing but see hospitalized patients is in charge of most people's care while they are hospitalized. This doctor has never seen you before and will probably never see you again. My mother liked the guy at Prestigious University Hospital, but he wasn't around once she left and we basically had nobody to talk to about her prognosis or aftercare. This model is supposedly more "efficient" but I am starting to question it. We had a similar problem when my father was hospitalized a few years back and the hospitalist inaccurately conveyed the family's wishes to his PCP, resulting in a great deal of confusion and anxiety. Had the PCP showed up while my father was in the hospital (which was in the same town as his office, by the way) all of this would have been avoided.

So, no specific recommendation here except that this ought to be revisited.

*Nosocomial means "of the house." Hospitals are very dangerous places because they are full of very nasty, antibiotic resistant drugs and you probably have tubes going into your body through which they can enter, which is exactly what happened to my mother. Urinary catheter infections are as common as doughnuts at the nursing station. Stay out of hospitals if at all possible.


kathy a. said...

you know i am with you on continuity of care issues, and on nursing/rehab being physician-free zones.

after my mother's devastating stroke and hip fracture [+ hip surgery], she was released from the hospital after only 5 days and never once visited in the nursing home by her attending physician. when she had complications and needed to be hospitalized again, not only was dr. wonderful the attending on vacation, but his backup didn't show.

the only physician my mother saw in those 30 days was her orthopedic surgeon -- who was also the only doctor who took a real medical history from us in the hospital, and the only one who told us what really went on when she came to the hospital. as in, she was in a coma and the whole ER thought she wouldn't make it through the night.

you know how i can ramble on. but i think that the impossibly low medicare reimbursement is at least part of the problem, maybe even for patients who have backup insurance, as mom did.

this is only anecdotal, too, but an old and good friend who is a geriatric psychiatrist had to leave his practice because he could not afford to stay afloat with the cuts in medicare. he'd gotten to be nearly 50, and had never been able to afford a house; nor even a piano, and that was something he loved nearly as much as helping our elder folks -- in medical school, he used to play ragtime and show tunes at nursing homes just for fun. he had practiced in the very town where my mother died, was very involved with elder care issues generally. when psychiatric issues came up with my mom shortly before her final decline, he could find nobody in the area still doing the work, even on a private basis, and he blamed medicare.

robin andrea said...

I guess my mom is pretty lucky because her PCP's practice is located right next door to the hospital. When she broke her ankle, he visited with her everyday, and when she was transferred to the horrific nursing home, he saw her there as well. Quality of care is huge issue, though. Are there just too few doctors? What is the underlying factors for such disappointing care?

Here in Santa Cruz, doctors receive reduced medicare reimbursements because we have been designated a small-town, rural area. Our congressman, Sam Farr has been arguing to get the designation changed. Roger had to change PCP physicians when we returned to Santa Cruz and found that our former medical clinic in town no longer accepts Medicare patients.

Cervantes said...

Yes, there are too few primary care doctors, they're all much too busy and that's definitely part of the problem.

Docs do complain about Medicare reimbursement rates, but I very much doubt that any physician working full time would be unable to afford a house and a piano! Shrinks are not among the best paid specialists, but they shouldn't have any trouble making 120k a year, which most people probably think is pretty good. How he does better by not working at all I really don't get. So that story isn't making a lot of sense to me.

Medicare doesn't actually pay docs all that badly, it pays 80% of what is called "usual and customary" rates, which are a bit inflated. So you can certainly make a living off of Medicare although it's not like being a Park Avenue plastic surgeon. Hospitals claim Medicare squeezes them, but that's a very complicated story.

kathy a. said...

it's not that my friend isn't working; he is working for a pharm company now, on developing meds for dementia patients. i think he feels really bad about leaving patient care, and is at least hoping to help seniors in the long term.

i really can see how he couldn't make enough to manage well in an urban CA metropolis, in solo practice, in a specialty that isn't mainstream. the costs of everything are very high where he was -- office space and minimal shared support by itself are huge. etc. [i cannot possibly afford an office outside my home for my practice in a different low-paying profession.]

maybe my friend isn't a great example, because he is not a PCP; anything psych is subject to drastic limitations in any health insurance plan, and frequent denials of coverage as well. there is a huge tension in how much to give to seniors anyway.

but it seems to me that working out the physical and psych and medication angles all together makes a lot of sense. sorry for the tangent, but i'm really arguing for more integrated and effective care.

Cervantes said...

Ah, okay. Your friend was trying to make it in individual practice. Maybe he just wasn't a very good businessman. It's not that psychiatrists' these days can't make a living! (Some of them get filthy rich, actually.)

C. Corax said...

So is there a turf thing going on: "PCPs not really welcome here" kind of thing? Or docs' office visits scheduled too tight and they don't want to/can't take the time to go to the hospital? Or they won't get paid for their time by the #$^@! insurance companies? All of the above? None of the above?

cknits said...

Yep. My mother just died of pneumonia. In the week my mother was there I managed to talk to a total of ONE nurse-practitioner and none of the doctors after the admitting hospitalist interviewed me. The nurse practitioner promised that they'd have mom sitting up in a chair the next day to take the pressure off her lungs, but of course, they had been too busy and made excuses. Mom died two days later.

If the family wants to have any input at all, you have to be there, in the room, any time the hospital will physically allow you to be there and hope you corner someone who didn't manage to do their rounds in the wee hours of the morning.

But in the end, what I consider to be the worst offense of the whole new system is that when a patient goes from one system to another, their records don't automatically go with them. So when Mom had delirium, congestive heart failure, kidney failure and a change of blood pressure all as a result of knee surgery two years ago, her PCP received *NO* records of any of her care upon discharge from the rehab facility, despite his being unwelcome in the place because they had "house" doctors - who used the emergency room as their office, I might add.

From what I just experienced of the lack of care and attention to detail, I now think they should get 1/10th the reimbursement if the patient dies. Not because they're always at fault - but because they seriously seem to be thinking of how to get the most money out of the dying person and not about the person's well-being.

Stay healthy, that's all I can suggest.

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