Are Hospitalists Necessary "To Follow" Post Op?

I suggested lightheartedly that hospitalists would be required to consult for pain management on surgical patients who's doctors have never learned to prescribe anything but Percocet and Vicoden, two drugs which may have seen their last days. The conversation got off track with this anonymous subspecialist comment, but I thought it raised some important issues to discuss.

Anonymous said...

I'm curious Happy.

Don't you make a living by seeing the "Specialist's" patients?

I don't mock the internists when they send me common things that they could treat....I figure they are happy to see my general medicine patients post op.

Am I wrong?

I responded with the following:

We are all specialists. Some are more subspecialized than others. So yes, I make my living almost entirely from the referrals of out patient family medicine and internal medicine specialists.

As far as being happy to see "general medicine" patients, I don't have any idea what that means. If there is an acute issue that needs to be addressed, elevated blood pressure, abnormal blood sugar, chest pain, fever I am more than happy the evaluate patients who need a physician specialist as my self to evaluate an acute issue. This is not general medicine. This is internal medicine.

If you are asking me if I am happy to see post op surgical patients to write discharge orders, address home meds and field nuisance pages, then you must be mistaking me for someone you should be hiring to do your work for you.

No specialist as myself needs to address stable medical issues. It's one reason why 99.999999999999999999% of the world's population does not have a live in physician outside the hospital. You do not need an internist "to follow for medical management", any more than I need an orthopaedic "to follow for orthopaedic management" on a patient admitted with pneumonia but has a history of a hip fracture

I am happy to consult on medical or surgical patients when I am being asked to evaluate an acute issue. I am not needed to see a patient "to follow". If that's what you need, you should hire your own PA or NP to assist your needs. The patient certainly doesn't need me in these situations.

Oh yeah, the comment about consulting a hospitalist to write for pain management was not meant to be taken seriously.

What do you think America? Not a day goes by where I am not called for "hospitalist to follow post op". Should I be happy to see stable general medical patients post op or medical patients admitted to medical subspecialist services with no acute internal medicine issues to address? I view these types of billable encounters as bordering on insurance fraud. I am being asked to create medical necessity when medical necessity doesn't exist. It is not difficult to generate a level two or level three follow up note (2 ROS, document the status of three chronic medical conditions, review pre op lab, personally review pre op EKG, review IV PCA plan, and discuss the care plan with the nurse). Viola, a level three follow up note that meets every criteria as required by the E/M Guidelines of 1995 or 1997.

Now was it medically necessary? You tell me. I am being asked to provide a service by the physicians asking for me "to follow". A service that should fall under the subspecialist's duties and responsibilities (if they don't want to do it, they should use the profit from their bundled payments to pay someone to do it (RN, PA or NP).

Does consulting me make it medically necessary? Well, Medicare and their carriers seem to think so. No claim is ever rejected. So what am I to do? Do I say no to the physician's request? Or do I do it and submit a claim. Thus is the life of fee for service. Should I be grateful for this easy money while the Medicare National Bank goes bankrupt? I find great personal internal conflict from this type of practice that never ends. I believe I have no role in these patient's care plan. I believe medical necessity is generated by physician request where none should exist.

This is a huge area of co-management controversy in hospitalist medicine. What exactly is the role of hospitalists in patients with stable internal medicine conditions, if any?

Like I said above, patients with stable medical issues do not require a daily internists for evaluation and management any more than they require an orthopaedist to follow my pneumonia and afib patients who have a history of a hip fracture.