To the Editor:

I’m intrigued by “Seven Ways to Help Your Hospital Stay in Business” [May 2003, page 27] because of my concern that as physicians do less and less hospital work they will see these issues as irrelevant to everyday practice. As a family physician and full-time hospitalist, I’d like to offer the following comments:

• I disagree that physicians have an incentive to prolong hospital stays. They simply have no direct incentive to do the extra work, such as follow-up rounding in the afternoon, that would facilitate an earlier discharge. Unless the patient needs critical care, physicians usually get one charge per day.

• Hospitals do bear the burden of a denial. But because days are denied less frequently than stays, it’s in a hospital’s financial interest to prolong a “per diem” so that it may charge for more “in-between” days, which have lower costs and better net revenue.

• We do need to change the prevailing mind-set about what acute-care hospitals are for, but it will take quite a while for everyone to accept decisions such as directly admitting a frail, elderly patient to a skilled nursing facility. Right now, Medicare won’t pay for it, patients and family resist it and physicians are concerned that it’s poor medical care.

• In principle, not “including the kitchen sink” is a good philosophy, but our present system resists an elective admission or the rapid approval of an intensive service. The quick alternative is to perform certain tests and procedures while patients are in the hospital.

• I believe it’s still not mainstream to attribute the same level of importance to cost that is attributed to patient care.

• I see patients admitted from the office who don’t need inpatient care. I fear this problem will worsen as more primary care physicians stop doing hospital work and become less familiar with what can and cannot be done in the hospital.

• A patient-centered approach often will reduce unnecessary physician intervention. However, it forces physicians to make some difficult decisions about patient care.