I have been mulling over writing this blog piece for well over a month, never having it quite crystallize. I read a piece in one of my favorite blogs, The Incidental Economist today which served to prompt me to put fingers to keyboard...(http://theincidentaleconomist.com/wordpress/another-hospital-stay-and-whats-not-being-discussed-in-a-polarized-health-policy-debate/).
Sometimes a particularly assertive physician will assume this role but this is the exception rather than the rule. In the inpatient setting, the move toward hospitalists has created a very short term outlook when it comes to management of patients. They head a team of providers whose job is to get the patient discharged as soon as possible. Don't get me wrong. Many of my hospitalist colleagues are wonderful physicians and if placed within a system which gave them the tools and incentives to consistently do more and extend their impact beyond the hospital stay, they would do so.
Some efforts are being made to do just that in order to avoid readmissions. It is in this realm that these efforts are running into the fundamental problem. Even if the hospital coordination and team creation issue is addressed, when a patient is discharged there is no consistent hand off infrastructure present which leads to a soft landing. When sick patients leave the hospital, who is in charge, what resources do they have at their disposal to address the problems they face, and how well prepared are they to address the problems they will face?
In almost any other realm of the economy this niche would have been filled with resourceful individuals who see a need and create a service to fill that need. However, in health care the payment system created barriers to responding to this need. First, insurance created the impression that health care services were covered and patients assumed that when they became sick, these sort of services were available through their regular providers. Second, those in the best position to provide these sort of coordination services are ones who have undergone extensive medical training. They have had little incentive to take risks and provide services which are not covered by insurance. Finally, the issues with the present state are even more nuanced since patients assume that this sort of service is already built into the health care system and doctors are reticent to explicitly admit they do not consistently provide them. I suspect that many physicians are reticent to admit this to themselves.