One in five hospitalists say they work too many hours for too little pay
Published in the 2013 Today's Hospitalist Compensation & Career Guide
WHEN HOSPITALIST SOWMYA KANIKKANNAN, MD, was looking for a new job earlier this year, she could have chosen a practice near her parents that paid $80,000 more a year than the position she ultimately chose. But she realized that money isn’t everything—especially when the trade-off is a community where she preferred to live, a job that promised a bearable workload, a “privademic” model with a mix of academic, clinical, and administrative work, and leadership and growth opportunities.
"Money is not the only way to compensate a physician.”
–Greta Boynton, MD Sound Physicians Baystate Medical Center
how you compare with other hospitalists nationwide.
It also didn’t hurt that the job she ultimately opted for in southern New Jersey still delivers what Dr. Kanikkannan considers fair and reasonable compensation. Like everyone else, she thinks her salary could be a bit higher, but she has no regrets. “But if I thought I was significantly underpaid, I would not be happy in my field,” says Dr. Kanikkannan. She is the hospitalist medical director at the new Rowan University School of Osteopathic Medicine and provides hospitalist services at Lourdes Medical Center in Willingboro, N.J.
According to data from this year’s Today’s Hospitalist Career & Compensation Survey, Dr. Kanikkannan’s earnings place her near the mean for full-time adult hospitalists: $251,360. That figure represents a 7% jump over last year’s reported mean of $234,900, showing that pay for adult hospitalists continues to grow at a very healthy clip.
Full-time pediatric hospitalists reported an even bigger increase—10%—for a mean of $184,380. The survey’s self-reported compensation figures include bonuses and incentives, but not benefits.
While this year’s data reveal that nearly two-thirds of hospitalists, like Dr. Kanikkannan, are happy with their choice of career, there are some red flags. For one, more full-time adult hospitalists say they’re “not satisfied” with their current compensation than those who are satisfied, 54% vs. 47%.
Why? About one in five (19%) hospitalists say they “work too many hours for too little pay,” and a similar number (18%) think they’re underpaid compared to “other comparable specialties.” And one-third (34%) note that responsibilities have been added to their job for which they are not compensated.
Plus, a slim majority of hospitalists (53%) believe that compensation is going to either stay the same over the next five years or that they will have to increase their workload or hours to earn the same amount.
The need to be competitive
Analysts, however, don’t take such a glum view of hospitalist pay. Most predict that hospitalists will continue to see their pay grow into the foreseeable future. Despite everything else happening in health care, the supply and demand imbalance in hospital medicine persists in most parts of the country.
Many other specialties aren’t getting the same level of recognition—or hikes in compensation. This year’s data from the Medical Group Management Association, for instance, show that physician pay in general is largely flat, with some increases in primary care and decreases for specialists. And data from a 2012 Medscape survey found that physician income had declined overall, with specialties like general surgery, orthopedics and radiology taking annual hits of more than 10%.
“It is market-driven. There is a huge demand for hospitalists, and employers are very competitive,” says Ron Greeno, MD, founder and chief medical officer of Cogent Healthcare Inc., the Nashville-based national hospitalist company that staffs hospitalist programs in more than 100 hospitals. “Hospitalists are in a tremendous place compared to the rest of the physician community in terms of how they are being compensated.”
The position that hospitalists find themselves in, says Dr. Greeno, is due to both an aging population that needs medical care and payment changes brought about by health care reform. “Compensation for primary care physicians is going up,” he adds, “and hospitalists are the primary care physicians in the hospital. The system is rewarding those who are seen as part of the solution.”
New roles, or uncompensated work?
Faced with continuing compensation growth, you might think that many hospitalists would feel like they’re on top of the world. But a troubling number of physicians in the specialty say that burnout is a big concern, and there are signs that it’s linked, at least in part, to compensation.
In this year’s survey, 68% of hospitalists say that burnout is a “significant” or “very significant” concern for them personally. But among hospitalists dissatisfied with their current compensation, that percentage shot up to 79%.
For physicians like John D. Morris, MD, medical director of the hospitalist program at Northern Alabama’s Cullman Regional Medical Center, “burnout is a very real thing.” A big part of burnout, he says, is “the added responsibilities with no added compensation” that many hospitalists are complaining about.
“Administrations are happy to lump extra on you when they know you are highly motivated and you will do it,” Dr. Morris points out. His “intimate relationship” with burnout was spurred by six months of work without a day off while trying to get his start-up hospitalist program off the ground.
According to Dr. Greeno, there are hospitals “where some physicians are dissatisfied because they are being asked to do things” that don’t add value, “like putting in IVs.” But he strongly believes that at least some of the dissatisfaction hospitalists express about compensation and unreimbursed work may have to do with hospital medicine’s “young workforce,” which has “less perspective on why hospitalists exist.”
“It is fundamental to our specialty that we are doing things that bring value to the health care system by providing new solutions, like championing performance improvement,” Dr. Greeno says.
In her seven years in hospital medicine, Dr. Kanikkannan has definitely experienced “scope creep.” While not all of that is bad, she notes, it definitely changes the job.
“Take patient satisfaction or readmissions,” says Dr. Kanikkannan. “As physicians, we would always talk to patients about discharge planning, but it takes more time to do it in a structured way and make sure outpatient appointments are made before discharge. That is what people are talking about with uncompensated responsibilities.”
Pay that’s under par
But uncompensated care isn’t the only thing that has hospitalists grumbling about pay. While their compensation is going up, it’s still not on a par with comparable specialties.
As Jasen W. Gundersen, MD, MBA, president of the Tennessee-based national staffing company TeamHealth Hospital Medicine, points out, “$250,000 is a good salary. But compared to what a specialist makes per hour or to an ER doctor making $200-plus an hour, $110 an hour for a hospitalist is a big disparity.”
That’s particularly the case when hospitalists are being asked to provide an increasing amount of care for general surgeons and orthopedists. “Pay is good,” Dr. Gundersen says, “but nowhere as good as that of other folks in the industry.”
Because of that discrepancy, Dr. Gundersen has long thought that hospitalist salaries eventually will equal those of emergency physicians.
“I think productivity is going to have to go up, but I don’t see how we are going to have a huge disparity between doctors working alongside each other 24 hours a day 365 days a year with a 30% pay gap,” he notes.
Productivity and revenue
That doesn’t mean that hospitalists should count on $350,000 salaries, particularly when hospitals and health systems are facing potential reimbursement cuts.
Instead, Dr. Gundersen says, hospitalists may eventually be earning $250,000 working 12 shifts, not 16 or 17 a month like they do now. While that equation has the potential to increase program costs, Dr. Gundersen explains that hospitals now understand that investing in better work-life balance for doctors pays off in terms of less burnout and turnover and better efficiency on the job.
“That’s where productivity needs to increase: through better efficiency, not more shifts worked,” Dr. Gundersen says. “As programs improve how well they function, physician efficiency will rise—and so should physician compensation.”
When hospitalist Stephen Giordano, DO, looks at the survey data, he sees pay and workload figures on par with his group’s in the Charlotte, N.C., area. Group members have about 16 patient encounters each shift and work about 182 shifts a year. (Our survey found hospitalists reporting a slightly greater number of shifts.) When Dr. Giordano multiplies that by the average amount his hospitalists earn per encounter, he figures that hospitalist salaries are actually lagging behind where they should be.
“In the Today’s Hospitalist survey, the average hospitalist only got a $16,000 increase in salary,” notes Dr. Giordano, CEO of the four-year-old physician-owned Optimed Hospitalists that staffs programs at North Carolina’s Iredell Memorial Hospital and CaroMont Regional Medical Center. (The Today’s Hospitalist survey found a mean increase of $16,460 from last year.) “But doctors probably earned much more than that in revenue, so I think hospitals are still taking advantage of doctors’ productivity. Hospitalists are doing more for more patients, but they are not being comparably compensated for that additional work.” As Dr. Giordano sees it, “Hospitalist compensation still has room to grow.”
But the way in which hospitalist pay grows may be a sticking point with many in the specialty. According to this year’s survey, 44% of hospitalists say they don’t think the salary increases in their group are given fairly.
One-quarter don’t anticipate ever receiving a salary increase, and only one in six say they receive increased pay based on merit, performance, longevity or seniority. And one-third report that pay increases result only during periodic market adjustments.
In the six years that Today’s Hospitalist has conducted its survey, the specialty has seen consistent increases. So how can so many hospitalists be unhappy with rising compensation? Consultant Leslie Flores of Nelson Flores Hospital Medicine Consultants, based in La Quinta, Calif., says that many groups give raises irregularly, which may give physicians the impression that pay raises are arbitrary—and scarce.
Ms. Flores explains that the norm in hospital medicine is to “set comp at X dollars for everyone and then not look at it for some years, until they need a new hospitalist and can’t recruit for X dollars.” It’s only then, she adds, that groups analyze survey data “and say, ‘we need to adjust our hospitalist salaries.’ If they adjust them for new candidates, they go back and do it for existing people as well.”
That’s if they want to keep the physicians they already have on board. “Nothing is worse for satisfaction,” says TeamHealth’s Dr. Gundersen, “than finding out that a doctor is making more than you, even though you have been there longer.”
Fatter bonuses, slim base
There’s another factor in hospitalist pay that may affect the specialty’s view of compensation: Analysts say that at many groups, physician compensation has been rising through larger bonuses, not increases in base pay.
Ms. Flores says that many practices she consults for are now less likely to boost base salaries and more likely to increase opportunities for hospitalists to earn more in bonuses. That may explain, she says, some hospitalists’ pessimism about their prospects for rising income in the near future.
“They are probably saying, ‘I expect my base salary to stay the same,’ in the next five years,” she explains. “The bonus opportunity may be larger, but because doctors are not guaranteed that money, they don’t think of that as a pay increase.”
While bonuses may be giving some hospitalists a skewed view of their earning potential, the reality is that the more bonus pay physicians receive, the higher their overall compensation.
Our data indicate that hospitalists paid a combination of salary and incentives reported considerably higher income ($256,520) than those paid a straight salary ($234,720). Among those reporting bonuses, respondents received more than $45,000 on average, which was 19% of their total compensation. Most said bonuses were paid for productivity (number of admissions, shifts worked and RVUs), quality measures (satisfaction scores, guideline compliance and documentation), and clinical measures (core measures).
Building in flexibility
While bonuses may cloud the specialty’s true rise in compensation, about half of hospitalists understand the positive impact bonuses have on pay. Our data show that 45% of hospitalists would like “more opportunities” to earn bonuses and incentives. Only 29% say they wouldn’t want to change their current compensation structure.
According to Thomas McIlraith, MD, chair of hospital medicine for California’s Mercy Medical Group in Sacramento, his group’s compensation model breaks down into two-thirds base and one-third bonus, with about 20% of the bonus amount pegged to quality and the rest to productivity and shareholder earnings. Having a substantial productivity bonus has allowed him to convince group members to take on service lines—like comanaging elective orthopedic patients—that they initially were reluctant to do.
“They said, ‘We don’t take care of healthy patients,’ ” says Dr. McIlraith, whose group of 60 hospitalists works in four hospitals. But when physicians realized that taking on ortho comanagement would help boost their productivity bonus, they came on board.
The same is true, Dr. McIlraith explains, for other goals that hospitalists are being asked to achieve, such as 9 a.m. discharges and faster responsiveness to the ED.
“How do you get buy-in from doctors on those if you have a rigid compensation plan?” Dr. McIlraith asks. “Without a bonus, that’s just more work that people won’t think they’re being compensated for.”
Leaving dollars on the table?
Bonus payments may lead to more compensation, but some see a significant downside to them as well. In our survey, 14% of hospitalists said the concern that “bonus targets are not attainable” was a reason they weren’t satisfied with their compensation.
In New Jersey, Dr. Kanikkannan’s group worries that it may leave some bonus money on the table because the physicians don’t have the support or infrastructure they need to achieve some goals, particularly those related to patient satisfaction. She is working with administration to beef up clerical and nursing staff.
“Unless we create structures for our practices, it is going to be difficult to achieve our incentives,” Dr. Kanikkannan says. “Docs will get burned out, and it will become harder to recruit new ones into the field.”
As a result, some believe the next trend in hospital medicine may be less of a focus on boosting compensation and more on convincing hospitals and health systems to invest in the infrastructure hospitalists need, from more support staff to better IT resources.
A longer view
Despite the issues that many hospitalists seem to have with their compensation, program directors say that compensation has reached a fair enough level that salary is no longer a deal-breaker. When Greta Boynton, MD, interviews candidates for the hospitalist program she directs for Sound Physicians, a national hospitalist organization, at Baystate Medical Center in Springfield, Mass., she is less likely than ever to gain or lose a hire over salary.
“As hospitalists mature in the profession, they realize that compensation is constantly evolving—and they are no longer hyper-focused on small differences in salary or bonus structures,” says Dr. Boynton. For doctors chasing the big dollars, she adds, “they find a place willing to pay a bit more for the moment, or they work multiple jobs simultaneously.”
“The doctors who are making hospital medicine their long-term career are asking pointed questions beyond compensation,” Dr. Boynton explains. “The discussion is not over a $10,000 salary difference but the longevity and sustainability of their career. Will the employer value me? Is this a place where I am going to have career development? Are they going to invest in me long-term? That’s where the conversation has gone for me with my applicants and employees. Money is not the only way to compensate a physician.”
Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto.
Pediatric hospital medicine and pay
PEDIATRIC HOSPITALISTS have always earned less than physicians who treat adult patients, and this year is no different. The mean pay for full-time pediatric hospitalists continues to lag behind by nearly $67,000. Their national mean compensation reported by respondents to the 2013 Today’s Hospitalist Compensation & Career Survey was $184,380.
Pediatric hospitalists, meanwhile, express the same dissatisfaction with their pay as their adult hospitalist colleagues: Only 46% of respondents said they are satisfied with their compensation vs. 54% who were not.
Nearly one in three reported being specifically unhappy that “responsibilities have been added for which I am not compensated,” while one in five think they are underpaid compared to other comparable specialties in their group or hospital.
Jeff Gill, MD, MBA, president of Inpatient Specialists Medical Group of Brea, Calif., a pediatric hospitalist group of three full-timers and several part-timers working at Antelope Valley Hospital, attributes pediatric hospitalists’ discontent to the fact that they work in “a shakier market.” He points out that community hospitals located near children’s hospitals are cutting back on or even closing their pediatric wards. That means that in many communities, there is less competition to help drive up salaries.
“In general, pediatricians have not been strong negotiators, but also if they push too hard, there is a fear that they might push themselves out of a job,” Dr. Gill says. “Many community hospitals here are closing pediatrics because they can. A hospital can’t say it is closing med-surg.”
Despite these market pressures to regionalize pediatric hospital care, Dr. Gill suspects compensation will continue to rise, at least for the foreseeable future.
But he also expects it will top out once more “midlevel practitioners start replacing some hospitalists. Then we’ll see compensation go down.” That development is more likely in pediatrics, he adds, “because we already have a well-established model for nurse practitioners. It’s just a matter of time before they really become the workhorse.”
Location and payment models
ACCORDING TO the 2013 Today's Hospitalist Compensation & Career survey, significant geographic pay differences persist. In the Northeast where there are more bodies available to fill jobs and a greater proportion of traditionally lower-paying academic positions, hospitalists earn on average $41,540 less than hospitalists in Texas and other states in the Southwest.
But demographics don’t explain all of that discrepancy. Hospitalists in the Northeast also report working less: 40 fewer hours a month on average. And considerably more hospitalists in the Southwest report being paid entirely on productivity than those in the Northeast: 13% vs. 1%. Traditionally, some of the highest paid hospitalists are those whose income is based solely on productivity.
What the survey also showed, however, is that the proportion of hospitalists whose compensation comes via straight salary is shrinking. Going up, however—to 64% from 60% in 2012—are hospitalists paid a combination of base salary and bonuses or incentives, usually for both productivity and for meeting various quality targets.
In the meantime, the number of full-time adult hospitalists reporting being paid 100% salary dropped to 30% this year from 34% last year. And only 5.4% of hospitalists in this year’s survey reported being paid 100% productivity—essentially the same percentage as last year (5.7%)
Who likes what they earn?
NEARLY HALF OF THE HOSPITALISTS who responded to the 2013 Today’s Hospitalist Compensation & Career Survey described themselves as “satisfied with my current compensation.” But certain groups of hospitalists voiced much more satisfaction than others:
The most content were older hospitalists, including those over age 50 (56% of whom were satisfied with their compensation) and those who have worked more than 20 years as a hospitalist. Within that group, 80% were happy with what they earned.
The type of shift that doctors work seems to matter. Those who work only as a nocturnist expressed higher than average satisfaction (53%). The happiest nocturnists, moreover, were those who see fewer than 10 patients per shift. Within that group, 72% said they were satisfied with their compensation.
Not surprisingly, hospitalists whose shifts are shorter than the mean of 11.68 hours were also more content with what they earn. Among hospitalists working shifts that are less than 10 hours, 54% were satisfied with their compensation.
And control seems to matter. Among the happiest hospitalists were those whose compensation is based entirely on their productivity, with no base salary. In this group, 55% reported being satisfied with their pay.
But some subsets of hospitalists are less satisfied than the average:
Nocturnists, again, occupy this slot. But this time, it’s nocturnists who work busy shifts. Nearly 70% of hospitalists who see more than 11 patients per night said they were dissatisfied with their current compensation.
Hospitalists who work at a university or medical school are also more likely to feel underpaid. Within this group, 60% voiced discontent.
Also dissatisfied are those who work in small groups (1-4 FTEs) and those who rotate day and night shifts. About two-thirds (62%) of these hospitalists were unhappy
with their pay.
Demographically, the hospitalists least satisfied with their pay are those between the ages of 41 and 50 (60% dissatisfied), those who have worked in the field for only three or four years (59% dissatisfied), and those who work in the Northeast (64% dissatisfied with compensation).
View the 2013 Career & Compensation Survey Results
Are you a physician who wants to know more about the schedules and work hours of hospitalists? Or are you a compensation manager or group administrator who wants to drill down into the details of hospitalist pay? Nearly 800 hospitalists responded to the 2013 Today’s Hospitalist Compensation & Career Survey, providing information about everything from pay and productivity to their attitudes about their jobs and the specialty. You can view the results of this survey for free on our Web site following a brief registration process.
And for those users who want to drill down and get more details about compensation and work load in specific work environments, a complete Excel spreadsheet of the data is available for purchase.
The 2013 Compensation & Career Report provides both information about pay, work hours, and patient load in your region or at your type of employer, and also insights into what hospitalists are thinking about their jobs, the specialty and more. Could be useful in identifying what hospitalists would like to see in their jobs…good for recruiters… click here to learn more.