Shifting from Inpatient to Outpatient Care

Outpatient health care environments have seen remarkable growth over the past decade. A major driving factor of this change has been the emergence of value-based care, which seeks to reward hospitals for delivering the highest-quality care at the lowest price. While the number of inpatient admissions has stayed relatively flat over the past fifty years, outpatient visits have increased exponentially. In 1975, there were around 250,000 outpatient admissions—in 2015, there were more than 800,000. [1]

These patterns have led many hospitals to shift their revenue structure toward outpatient care, according to a recent study by Deloitte. In 1994, outpatient care accounted for just 28% of hospitals’ overall revenue. In 2020, outpatient care and inpatient care each account for nearly half of hospitals’ overall revenue.

The transition from inpatient to outpatient care can be jarring for physicians. The intense nature of inpatient care is satisfying for many physicians but also makes it difficult to develop long-term relationships with patients. When transitioning from inpatient to outpatient settings, physicians should consider the differences in these environments, as well as the impacts on their practice. 

One of the reasons that the shift between settings can catch physicians off guard is that inpatient and outpatient practitioners work in relatively distinct arenas. The separation between these two healthcare settings can make it difficult for medical practices and healthcare systems to communicate with each other about a patient’s health. Consequentially, physicians working in inpatient settings may have little experience interacting with outpatient physicians and vice-versa. A study by the Community Tracking Project found that this trend is not going away, either—in fact, inpatient and outpatient practitioners are drifting farther apart. [2]

The lifestyle of inpatient physicians is typically associated with long hours and a high-intensity workload. As a result, there is a common perception that hospitalists are at an increased risk of burnout as compared to their outpatient peers. However, there has been very little research to confirm the veracity of this statement. In fact, one study by Roberts et al. found that outpatient physicians frequently reported more emotional exhaustion from their work than their inpatient peers. [3] Additional research into the topic will help clarify what physicians can expect from a shift between practice settings.

There are some areas where physicians can expect little change, including the realm of malpractice claims. A study by Bishop et al. found that patients filed malpractice claims at the same levels for both inpatient and outpatient environments. [4] In outpatient environments, the most common claim was for diagnostic issues, while surgical issues were the primary reason for inpatient claims. In both cases, major injury or death were the most common outcomes.

The rise in telemedicine and advances in technology that allow more procedures to be done in outpatient environments have led more and more physicians to consider transitioning to outpatient work. The growth in telehealth was also accelerated by the COVID-19 pandemic, which pushed many providers to offer online services. [5]. These services allow for more flexible hours and the ability to work from home, which many physicians find appealing.

References 

[1] “2019 Physician Inpatient/Outpatient Revenue Survey.” Merritt Hawkins, 2019, www.merritthawkins.com/uploadedFiles/MerrittHawkins_RevenueSurvey_2019.pdf.

[2] Pham, Hoangmai H., et al. “Hospitalists And Care Transitions: The Divorce Of Inpatient And Outpatient Care: Health Affairs Journal.” Health Affairs, vol. 27, no. 5, Sept. 2008. doi:10.1377/hlthaff.27.5.1315.

[3] Roberts, Daniel L., et al. “Burnout in Inpatient-Based versus Outpatient-Based Physicians: A Systematic Review and Meta-Analysis.” Journal of Hospital Medicine, vol. 8, no. 11, Oct. 2013, pp. 653–664. doi:10.1002/jhm.2093.

[4] Bishop, Tara F. “Paid Malpractice Claims for Adverse Events in Inpatient and Outpatient Settings.” JAMA, vol. 305, no. 23, June 2011, p. 2427. doi:10.1001/jama.2011.813.

[5] Koonin, Lisa M. “Trends in the Use of Telehealth During the Emergence of the COVID-19 Pandemic – United States, January–March 2020.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 30 Oct. 2020, www.cdc.gov/mmwr/volumes/69/wr/mm6943a3.htm.