Primary Care Physicians: Get paid for hospital visits

Hospitalists are here to stay. The forces driving this include increased profits for health insurers and hospitals, the complexity of technology and information systems, the need for 24/7 availability of health professionals in hospitals, and increasing office productivity for primary care physicians.

But the hospitalist movement brings some negatives. When full-time hospital-based physicians assume care of patients, PCPs become much less involved. This creates a discontinuity in patient care.

In examining the unintended consequences of the hospitalist movement, I feel that we should measure the results not through financial data, but through an ethical code. Principled medical ethics speaks of a fiduciary relationship-one of trust, confidence, and obligation between health professionals and patients. A doctor is ethically bound to consider whether or not the patient and family receive care that respects their core values, and whether decisions about treatment are proportional to the patient's quality of life.

Consider whether a hospital-based physician who has just met a patient has sufficient knowledge of her social, cultural, and spiritual beliefs to help patient and family choose between aggressive and palliative treatment. Or, as another example, think about the importance of input from the PCP of a woman who has just given birth to a baby with profound disabilities-and faces decisions that will affect not only her future but that of her child.

Pay for continuity visits

The only way that hospitalists are likely to get the full gamut of patient information is if PCPs visit patients in the hospital and interact with the hospitalists. But if insurance plans won't reimburse for these visits, few doctors will make them.

One potential solution is to require insurance companies to reimburse primary care doctors for such continuity visits. Insurers would likely take the position that the cost for primary care hospital visits would be prohibitive. I disagree. In my view, such shared and coordinated continuity of care would serve to address the difficult medical and personal issues that often arise in a timely and cost-effective manner.

In order to encourage insurers to reimburse for continuity of care, hospital representatives and physicians need to bring pressure for change. I encourage you to write to your legislators, or contact them through your national, state, or local medical society. Let them know that continuity of care is in the best interests of patients and society. You can also promote change by speaking out to insurance commissioners, employers, and the media.

We must continue to focus on continuity of care and guard against short-term economic solutions that benefit insurers or hospitals-but not patients. The absence of the primary care physician's compassionate but authoritative input in the acute care setting does a disservice to patients, physicians, and-perhaps most importantly-the sacred art of medicine.