The Appropriate Role of the Hospital

The Appropriate Role of the Hospital
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Hospitals are often the most convenient setting for patients to receive care. Unfortunately, hospitals also are by far the highest cost setting. Current health care spending is already almost $3 trillion and greater than 17 percent of GDP per 2012 figures. With many patients living longer with chronic illness, the Baby Boomer generation entering Medicare age, and the latest Centers for Medicare and Medicaid Services (CMS) projections forecasting an increase in growth of health care expenditures, reining in costs is at the forefront of any health care discussion. One major factor in containing costs is a paradigm shift in how we view hospital-based (i.e. inpatient) care.

Through my experience first as a resident and now as an attending internal medicine physician, I've noticed a persistent disconnect between patient and provider expectations for inpatient care. When patients are admitted to the hospital, especially those with multiple co-morbidities and preexisting conditions, many want all of their medical issues to be resolved before discharge -- including those unrelated to their presenting problem. This week alone, I had a patient who had been in the hospital for several days with an exacerbation of his emphysema (a condition of diminished lung function usually related to chronic smoking); when his respiratory status had improved sufficiently and he was medically stable for discharge, the patient did not want to leave because he still had occasional nausea. He also pointed out that he had a colonic polyp five years ago and was due to see his gastroenterologist for a repeat colonoscopy, so it only made sense for him to stay and get that test as he was already in the hospital. In a world of infinite resources, there would be no issue.

However, the hospital is not always the most appropriate setting to treat every illness, and ultimately health care resources are limited. Hospitals and insurers, including the government, have increased pressure on providers to reduce lengths of stay and shift care towards lower cost (yet high value) settings. In turn, the role of the hospital has evolved -- and continues to do so.

With increasing frequency, the goal of inpatient care has become to address and stabilize a patient's active medical issues so that any remaining care can be conducted in the outpatient setting. This evolution does not mean we should discharge hospital patients before they are clinically ready or when appropriate outpatient services are not available. Providers and hospitals should always ensure patients receive high quality, responsive care for acute medical issues. But in the course of treating patients, especially those with complicated and/or multiple medical issues, there often does come a point when additional care can be safely administered outside of the hospital -- even if the patient is not quite back to his/her baseline health.

In 2012, almost one-third (32 percent) of all health care spending was in hospital-based care, which represented the largest single category of spending and approximately $900 billion. Hospital and physician services together accounted for more than 50 percent of total health care spending [1]. Thus, when looking at areas to increase efficiency and lower expenditures, those two categories stand out. Furthermore, the disparity between the costs of inpatient and outpatient care is striking. According to the Kaiser Family Foundation, the average 2011 hospital expense per inpatient day was almost $2,000 nationally [2]. But according to the Agency for Healthcare Research and Quality, the average national cost per outpatient visit was roughly $200. That means for every extra day in the hospital, a patient could see a physician in the clinic 10 times for the same aggregate cost.

Many patients experience access issues in obtaining outpatient care, including problems with transportation, lack of appointment availability, and poorly communicated discharge plans -- amongst many other reasons. This predicament needs to be continually addressed in order for the health care community to shift more care safely to the outpatient setting. The Affordable Care Act (ACA) only represents a potential starting point in that endeavor. Nonetheless, if we as a society want to help curb health expenditures, I believe we need to recalibrate our view of and expectations for hospital-based care. The hospital needs to be a deliberate acute care factory, not the primary location for medical care

With this paradigm shift, providers and hospitals must help patients understand the services that require hospitalization and continued inpatient care -- ideally before (when possible) or early in the course of a patient's hospital stay. Such action necessitates improved communication, streamlined processes, and cohesive outpatient strategies that address bottlenecks and empower/educate patients. I was once taught that in an efficient, optimally functioning system, work should be conducted in environments that provide an appropriate level of resources -- not too much, not too little. When applied to health care, that axiom means patients should be treated in the inpatient setting when their level of illness requires hospital-based care. Once a patient is stable enough to require a lower level of resources, it's both acceptable and preferable that care should be transitioned out of the hospital and into an alternate setting.

Studies have shown that more expensive care does not equal better care[3]. Prolonged hospitalizations can be unexpectedly harmful to patients due to the risk of infection, hospital error, deconditioning, and disruption of normal life routines. Society and the health care community are slowly moving in a direction that acknowledges these facts. The challenge moving forward is continuing to inform, augment, and redefine traditional views on health care delivery. Not only should we strive to improve the tools by which we treat patients, but we also must commit more attention and research into improving the manner in which we treat illness. Ultimately, such commitment will enhance both the quality and economics of care for patients in a substantive and sustainable fashion.

[1] California Healthcare Foundation, California Healthcare Almanac.

[2] This cost figure does not include expenditures for imaging or procedures.