Reinventing Hospital Care

Fifty years ago, doctors visited their patients in the hospital on a regular basis. But as primary care evolved, they found themselves traveling to the hospital just
to see one or two patients – an inefficient model. Thus emerged the hospitalist specialty, based on the conventional wisdom that having a primary care physician tend to all hospitalized patients is more cost-effective and leads to better results.

Recent studies have shown that the hospitalist model doesn’t have the outcomes that one might expect,either.“There is very strong evidence to show how valuable it is to have a doctor who knows you, in terms of trust and ability to communicate,” says Dr. David Meltzer, an associate professor at Chicago Harris and the Department of Medicine, who also serves as chief of Hospital Medicine and directs the Center for Health and the Social Sciences. “It’s particularly true when you’re sick.”

With a $6 million federal grant made possible by the Affordable Care Act, Meltzer is testing the impact of his Comprehensive Care Physician model, in which primary care physicians maintain their clinics but see only patients at high risk of hospitalization.

The study will capture data on 850 people over the next year. The control group will continue to be seen by hospitalists in addition to their primary care doctors. Meltzer intends to measure whether the patients who see a comprehensive care physician are better served and whether the approach is more cost-efficient for providers.

“The key things that will be examined are continuities in care, communication lapses between the inpatient and outpatient setting and less ideal decision-making because of the lack of a doctor-patient relationship,” Meltzer says. “It’s about knowledge, communication, interpersonal relationships and trust.”

The early results are promising, Meltzer says, adding that the model has the potential to be a game-changer. He expects to report comprehensive results in the second year of the study and hopes to secure more funding to measure longer-term outcomes.

One issue the study has already identified is that some patients don’t get adequate primary care because they can’t get to the clinic. Incorporating old-fashioned house calls, Meltzer says, will “make a big difference for those folks.” Another group of patients who might also receive better, more efficient care are those reaching the end of life, Meltzer says. A doctor who knows a patient with terminal lung cancer, for example, might be more responsive to the patient’s preferred approach to treatment.

The typical patient in Meltzer’s study has spent $50,000 to $100,000 in the past year on medical care. “If we can change things for a handful of them, the study will pay for itself,” he says. “Adequate attention to individuals by a doctor or a whole team is extraordinarily rare in health care, yet it’s critical to helping people make the best decisions.”

To Meltzer, that’s reflective of what public policy analysis can accomplish. “You systematically analyze the forces that cause problems, come up with solutions and test whether they work,” he says. “And then you disseminate them.” 

Ed Finkel


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