Fragmented Care Can Drive up Medical Costs

By Amit Vashist, MD, MBA


“Dr. Vashist, I’m sorry to bother but you really need to look at this medication being taken by our patient.”  My hospital pharmacist gently prodded me as he handed over the patient’s medication list along with cost information and side-effects of the offending medication. The issue with the list was a subcutaneous injectable form of calcitonin, Miacalcin costing approximately $11,300 per day of treatment. The patient had been admitted about 11 days back for respiratory distress and also had primary hyperparathyroidism, which we prescribed   Miacalcin for early in her treatment. Multiple consultants, including the pulmonologist, cardiologist, nephrologist, and myself were involved in the patient’s care.  I had “inherited” the patient from another hospitalist on day 5 of her hospital stay and the exorbitantly priced medication. However, suffice it to say that in trying to take care of my patient, unsurprisingly the cost of her medications totally escaped my attention. At that time, I felt it was “sufficient” that we had provided the right medication and that the patient was being well managed.  By the time the pharmacist informed me that the patient had been on the medication for 10 days, there were already more than $110,000 in charges! For those of us who deal with hypercalcemia, especially when non-life threatening, there are several cheaper and equally efficacious alternatives.

As a practicing hospitalist and a medical director, I could not help but step back and ponder over the whole patient experience after I overcame the initial sticker shock. Ever since Bob Wachter coined the term “hospitalist” in an article in New England Journal of Medicine in 1996, hospital medicine has become the fastest growing specialty in the United States. Hospitalists have generally come to be regarded as the “quarterbacks” of hospitals and are now responsible for being a gate keeper of value.  These are physicians who are ideally supposed to tie all the pieces of a patient’s care together and instill order in a somewhat chaotic and fragmented episode of medical care. However, as we experience a significant increase in inpatient volumes and combined with short-staffing, hospitalists including myself are seeing a significantly higher number of patients each day.  It has become more of a struggle to be the peace keepers throughout the hospital and ensure all decisions are indeed cost conscious.

I realize that these scenarios are playing out across many hospitals in the country.  As we see a much sicker population in a value driven health care environment and struggle to manage costs, hospitalists will be increasingly called upon to lead and integrate all aspects of patient care with a laser eye.  There will be an increased focus on controlling costs and minimizing waste, a challenge that hospitalists must stand ready to address as the leader of patients’ hospital care.


Dr. Amit Vashist is the Regional Medical Director of the Hospitalist Division for Mountain States Health Alliance’s hospitals in Virginia. He is a dual board-certified internist and psychiatrist, and an avid proponent of implementing initiatives aimed at promoting quality, reducing cost and minimizing variation in the delivery of care imparted by hospitalists.

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