It's time to rethink old sterotypes about different practice models Supply and demand realities are now blurring the lines between in-house and outsourced programs
Published in the February 2007 issue of Today's Hospitalist.
When it comes to different types of hospitalist programs, you've heard all the stereotypes, from the long hours that for-profit practices can demand to the cushy shifts offered by some hospital-employed groups. But physicians and recruiters alike say that because hospital medicine is evolving so rapidly, these clichés are not only incorrect but misleading to physicians who are thinking of entering the job market.
To cope with the brutal laws of supply and demand-and a shortage of experienced physicians-hospitalist groups are doing whatever they can to interest qualified candidates. That includes changing the
Hospitalists looking for a new position are asking "better questions" about local politics, turnover rates and long-term stability.
number of shifts they ask their physicians to work and redesigning their benefit package and raising salaries.
One result is that many of the lines that have traditionally separated different practice models in hospital medicine-number of shifts is a good example-are beginning to blur. While that's ultimately to the benefit of physicians looking for a new position, it can make choosing opportunities based on different practice models difficult.
But while the models are transforming and stealing from each other, certain differences remain. Here's what several hospitalists-and a few recruiters-had to say about those issues, which range from physician autonomy and the availability of subspecialists to program stability.
The prevalent practice model
According to industry data, one out of three (34%) practicing hospitalists now works in-house as a hospital employee. The other two-thirds fall into one of several different outsourcing models: multistate hospitalist-only groups; local hospitalist-only groups; multispecialty/primary care groups; or emergency or critical care physician medical groups.
In addition, one out of five hospitalists works in an academic practice, where physicians may be employed by the institution or members of a contracted, outsourced group.
Geography also comes into play in determining employment models. Many states-including some of the biggest, such as California and New York-have "corporate practice of medicine" doctrines that prohibit physicians from entering into employment relationships with non-physicians. In those states, physicians can't be employees of hospitals, which are defined as "non-physicians," so they must work for a third party.
As a result, according to Society of Hospital Medicine data from 2005-06, more hospitalist programs in the East are affiliated with either multistate management groups or local hospitalist-only groups. And in the Western part of the country, which has a longer history of physician group consolidation in the face of managed care, more hospitalist programs tend to be affiliated with multispecialty or primary care medical groups.
The academic setting
Apart from geography, there are other important differences among the models. Kathleen Mimnagh, MD, for example, medical director for the hospitalist service at Charleston Area Medical Center (CAMC) in Charleston, W.Va., says that academic practices offer distinct benefits.
For one, working at an academic center ensures a high level of patient acuity. In fact, the hospitalists can choose to focus on either cardiac hospital medicine or orthopedic or neurosurgical co-management.
Another advantage? The hospitalists in her group have a full complement of subspecialists they can turn to. "They can call in a nephrologist for someone with renal failure," says Dr. Mimnagh, "or a pulmonologist or intensivist for a patient who's crashing."
Hospitalists can also keep their skills current by taking advantage of CAMC's continuing medical education or its clinical research infrastructure. And all the hospitalists enjoy the benefit of working within a larger program. The CAMC hospitalist service now numbers 14, which Dr. Mimnagh intends to grow to 16 by this spring and 20 by this summer. (In addition, the practice employs eight midlevel extenders.)
"If they want to take a vacation or even if they're sick or exhausted, they can call in and let me know," she says. "That's an enormous psychological benefit that helps them feel more in control and not as overwhelmed."
Keeping local control
Business control is one of the big reasons why John Krisa, MD, a full-time clinician and administrative site director, likes working for a large multistate hospitalist management company. His group, HMP of Albany County in Albany, N.Y., is part of Hospitalists Management Group (HMG), which is based in Canton, Ohio, and manages 20 practices in seven states.
Dr. Krisa says that he and his HMG colleagues have the best of both worlds. While they're incorporated as a small business and have local control over staffing and scheduling, they are also backed by a multistate management services company that has business expertise and can take advantage of economies of scale.
"They know how to process claims and deal with hospital administration," says Dr. Krisa. The management company also provides all back-office services like recruitment, legal representation and marketing.
Dr. Krisa points to another plus of working for HMG: The parent company-like many multistate companies and local hospitalist-only groups-offers physicians equity in the local practice, as well as equity in the parent company after three years.
"That gives you a piece of the big pie," says Dr. Krisa, who has been with the group since July 2003, "and a stake in what you're doing."
Potential for partnership
The potential for equity or partnership also draws physicians to another outsourced model: multispecialty or primary care private practices.
The hospitalists employed by the San Diego-based Sharp Rees-Stealy Medical Group, a multispecialty group with 330 physicians, for instance, become group shareholders after two years. (For more, see the Sharp Rees-Stealy Medical Group Practice CloseUp on page 45.)
According to William Contreras, MD, lead physician for one of two Sharp Rees-Stealy hospitalist teams, another big advantage of working for a large multispecialty group is the built-in referral network of specialists and subspecialists who work for the group.
"You are using the same four or five GI people, pulmonary people and oncologists," Dr. Contreras says. "It's not like you have to build relations with different subspecialists. That is already set up and ready to go."
Another big plus: career stability. "When you work for a hospital, that hospital can do anything with the program it chooses, including shutting it down or firing everyone and contracting the program out," says Dr. Contreras. "As a shareholder, the group can't just get rid of you unless there is some reason like disciplinary action."
In search of stability
In fact, program stability is considered a big plus, for different reasons, for large multistate hospitalist management companies as well.
Stacy Goldsholl, MD, the president of the hospital medicine division for TeamHealth, which has 400 hospitalists working in 100 different facilities across 17 states, points to the effectiveness of the company's recruiting muscle in promoting the stability of local practices.
"With 60+ recruiters nationwide, we can recruit hospitalists in a very tight market-and can supplement coverage in the short-term with our internal locums company," Dr. Goldsholl says. That ability to respond quickly to staffing issues is one big factor in TeamHealth's 97% client retention rate, which is "almost unheard of in this market," she says. (For more, see the TeamHealth Practice CloseUp.)
And Dr. Krisa from HMG adds that working for a multistate group offers a different kind of stability for individual physicians. In the worst case scenario, he says, if he wants to relocate or if there is instability in the local contract, he as a physician will be protected.
"You're not all on your own," he explains. "The company is successful on a national basis and expanding rapidly. If I go to work at another HMG program, all my equity will carry over."
How employers are responding
Because physicians are in the driver's seat as far as recruitment, the key concerns of hospitalists are beginning to shape the job market.
According to Regina Levison, president of Levison Search Associates, whose Northern California search firm is part of an 11-firm national recruitment partnership called First Choice, programs that want to compete-whether they're in-house or contract companies-are realizing that a major concern of physicians is the number of hours they have to work as hospitalists.
That puts programs needing physicians to fill more hours at a disadvantage. "One client right now requires 144 hours a month, which is a lot," Ms. Levison says. "Those opportunities are more challenging to recruit."
Many of today's recruits are also looking for a full complement of benefits, she says, which can be a stumbling block for smaller local hospitalist groups or small multispecialty practices. Ms. Levison notes that many of these groups, in an effort to keep expenses down, have offered barebone benefits, something they may no longer be able to do and be competitive.
Security above pay
Ms. Levison says she sees another trend among hospitalists: Many say they want the security of a paycheck with a productivity bonus, but none of the headaches associated with running a business. "They want to come to work, work their shifts and that's it," she explains.
As today's job-seekers become increasingly savvy about issues like staffing and retention, recruiters predict that other changes may be on the horizon. Sean Crosswhite, vice president of hospital-based recruiting for Merritt, Hawkins & Associates, a national recruiting firm, says that when it comes to hospital-employee groups, for instance, hospitalists are asking better questions.
Across the board, says Mr. Crosswhite, physicians are very well versed in both the internal and external challenges that programs face. And those physicians who are motivated enough to change jobs are scrutinizing potential positions closely.
"They want to know about a hospital's plans for recruitment, the local politics and if the group has had a 'revolving door,' " Mr. Crosswhite says. "Are physicians leaving and if so, why?"
And when interviewing for positions offered by a group with an outsourced model, physicians have the same targeted concerns. They want to know how long the company has had the contract, he says, when is it up for renewal and if the hospital administration is shopping that contract around.
A ripple effect?
Ms. Levison wonders whether hospitalists, who are a relatively young group of physicians, will begin to demand more positions that offer partnership or an equity stake in the program as they mature into mid-careers. But she is certain that faced with such a tight recruiting market, hospitals will have to devote even more funds to hospitalist programs in the form of higher salaries.
Some experts wonder whether that trend will have a ripple effect on the specialty. If hospitals have to pay more for hospitalist salaries, the thinking goes, will hospitals that now outsource the management of their program try to bring those programs in-house?
Or will rising physician salaries mean that hospitals will want to make sure programs are well-managed-so will turn in growing numbers to either local or multistate groups?
"Hospitals with hospitalist programs will graduate to focusing on quality," Ms. Levison says. "They will be particularly interested in companies that have systems to track quality issues."