Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

Why hospital culture influences medical costs

Jason H. Wasfy, MD
Physician
May 8, 2013
Share
Tweet
Share

“You have to be affable, available, and able,” a senior general internal medicine physician taught me during my final year of residency. “Trust me,” he added, “when you’re in practice, you will love easy consults.”

A consult – short for “inpatient consultation” – occurs when physician caring for a hospitalized patient requests another physician to evaluate the patient and provide recommendations.  Typically, both physicians are paid – one for providing overall care and the other for providing consultation.

A neurosurgical resident had just asked one of my internal medicine classmates for a consult.  The patient didn’t have any acute internal medicine problems. He had one new serious neurosurgical problem – a recently resected brain tumor. The neurosurgical resident admitted to my fellow medical resident that he wanted her “to see the patient so we can sort out his home medications.”

Any physician can determine a patient’s home medications. Sometimes that involves calling the patient’s pharmacy or nursing home – tedious work, but easily doable without a consult.

Trainees do not receive payment for consults.  They tend to “push back” against these requests more than their supervising physicians, who generally receive money for each consult.

Most physicians find discussing money unseemly. We should be caring for patients and providing consults because patients need care, not because of money. And I really do believe that the overwhelming majority – trainees or supervising physicians – have no ambivalence when called to provide consultation for a patient who needs consultation. Cardiologists-in-training do not bicker when called to see patients with heart attacks. Those few who bicker should find a different job.

That said, incentives differ for trainees and supervising physicians.  All physicians have professional satisfaction from helping patients.  For supervising physicians, an additional benefit is the financial reward – more pay for more consults. Most consults are legitimate, because often the needs of hospitalized patients require multiple specialists.

Even when a consultation is not really necessary – a “bogus consult,” in hospital jargon – the attending still may embrace the request cheerily. Both trainee and supervisor know the consult is not really necessary. But for the supervisor, the added work may be worth the added pay.

Those incentives will be familiar to any physician at a teaching hospital, immersed in the quirks of academic medicine. But more important for all Americans, incentives for doctors provide insight into how medicine may change — for better or for worse — with emerging models of physician payment. Instead of specific payments for consults, procedures, and office visits, my generation of physicians will encounter lump salaries for the care of patients over time without incremental payments for additional tasks.  Without additional payments per consultation, senior physicians may scrutinize requests for their services more.

This change may reduce health care costs and improve value for patients. But while incremental payments encourage unneeded services, taking those payments away may encourage not providing enough services. The majority of consults enhance patient care.  Even the consults that do not appear necessary at first sometimes generate important insights, because a fresh perspective can create a breakthrough.  Doctors’ professionalism will be essential to minimizing the risk that a response to overutilization could engender underutilization.

On that morning in 2009, the senior physician was stressing a lesson we all knew. Senior physicians, both in private practice and teaching hospitals, sometimes agree to accept unneeded consult requests because of their payment incentive structure.

Just like any other unnecessary medical expense, excessive consultation can raise costs without improving care. As American medicine moves away from rewarding physicians for consuming health care resources, and focuses on value for patients, perhaps the perspective and behavior of senior physicians will evolve to resemble the perspective and behavior of trainees. The behavior should not be hard to change – because after all, all senior physicians were trainees once.

Jason H. Wasfy is a cardiologist.

ADVERTISEMENT

Prev

The big impact of small changes for DSM-5 ADHD diagnosis

May 8, 2013 Kevin 1
…
Next

Fixing healthcare requires the essence of excellence

May 8, 2013 Kevin 0
…

Tagged as: Cardiology, Hospital-Based Medicine

Post navigation

< Previous Post
The big impact of small changes for DSM-5 ADHD diagnosis
Next Post >
Fixing healthcare requires the essence of excellence

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

More in Physician

  • Why some doctors age gracefully—and others grow bitter

    Patrick Hudson, MD
  • The hidden incentives driving frivolous malpractice lawsuits

    Howard Smith, MD
  • Mastering medical presentations: Elevating your impact

    Harvey Castro, MD, MBA
  • Marketing as a clinician isn’t about selling. It’s about trust.

    Kara Pepper, MD
  • How doctors took back control from hospital executives

    Gene Uzawa Dorio, MD
  • How art and science fueled one woman’s path to medicine

    Amy Avakian, MD
  • Most Popular

  • Past Week

    • Why flashy AI tools won’t fix health care without real infrastructure

      David Carmouche, MD | Tech
    • Key strategies for smooth EHR transitions in health care

      Sandra Johnson | Tech
    • 2 hours to decide my future: How the SOAP residency match traps future doctors

      Nicolette V. S. Sewall, MD, MPH | Education
    • Reassessing the impact of CDC’s opioid guidelines on chronic pain care [PODCAST]

      The Podcast by KevinMD | Podcast
    • When the diagnosis is personal: What my mother’s Alzheimer’s taught me about healing

      Pearl Jones, MD | Conditions
    • Why Medicaid cuts should alarm every doctor

      Ilan Shapiro, MD | Policy
  • Past 6 Months

    • Why tracking cognitive load could save doctors and patients

      Hiba Fatima Hamid | Education
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • How scales of justice saved a doctor-patient relationship

      Neil Baum, MD | Physician
    • The silent toll of ICE raids on U.S. patient care

      Carlin Lockwood | Policy
    • My journey from misdiagnosis to living fully with APBD

      Jeff Cooper | Conditions
    • “Think twice, heal once”: Why medical decision-making needs a second opinion from your slower brain (and AI)

      Harvey Castro, MD, MBA | Tech
  • Recent Posts

    • Why some doctors age gracefully—and others grow bitter

      Patrick Hudson, MD | Physician
    • Why removing fluoride from water is a public health disaster

      Steven J. Katz, DDS | Conditions
    • What the research really says about infrared saunas

      Khushali Jhaveri, MD | Conditions
    • How the cycle of rage is affecting physicians—and how to break free

      Alexandra M.P. Brito, MD and Jennifer L. Hartwell, MD | Conditions
    • Why ADHD in adults is often missed—and why it matters [PODCAST]

      The Podcast by KevinMD | Podcast
    • Dedicated hypermobility clinics can transform patient care

      Katharina Schwan, MPH | Conditions

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

Leave a Comment

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

  • Most Popular

  • Past Week

    • Why flashy AI tools won’t fix health care without real infrastructure

      David Carmouche, MD | Tech
    • Key strategies for smooth EHR transitions in health care

      Sandra Johnson | Tech
    • 2 hours to decide my future: How the SOAP residency match traps future doctors

      Nicolette V. S. Sewall, MD, MPH | Education
    • Reassessing the impact of CDC’s opioid guidelines on chronic pain care [PODCAST]

      The Podcast by KevinMD | Podcast
    • When the diagnosis is personal: What my mother’s Alzheimer’s taught me about healing

      Pearl Jones, MD | Conditions
    • Why Medicaid cuts should alarm every doctor

      Ilan Shapiro, MD | Policy
  • Past 6 Months

    • Why tracking cognitive load could save doctors and patients

      Hiba Fatima Hamid | Education
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • How scales of justice saved a doctor-patient relationship

      Neil Baum, MD | Physician
    • The silent toll of ICE raids on U.S. patient care

      Carlin Lockwood | Policy
    • My journey from misdiagnosis to living fully with APBD

      Jeff Cooper | Conditions
    • “Think twice, heal once”: Why medical decision-making needs a second opinion from your slower brain (and AI)

      Harvey Castro, MD, MBA | Tech
  • Recent Posts

    • Why some doctors age gracefully—and others grow bitter

      Patrick Hudson, MD | Physician
    • Why removing fluoride from water is a public health disaster

      Steven J. Katz, DDS | Conditions
    • What the research really says about infrared saunas

      Khushali Jhaveri, MD | Conditions
    • How the cycle of rage is affecting physicians—and how to break free

      Alexandra M.P. Brito, MD and Jennifer L. Hartwell, MD | Conditions
    • Why ADHD in adults is often missed—and why it matters [PODCAST]

      The Podcast by KevinMD | Podcast
    • Dedicated hypermobility clinics can transform patient care

      Katharina Schwan, MPH | Conditions

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Leave a Comment

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...