Ka-ching!

Ka-ching!

Hospitalists now have an array of options to earn extra money

November 2016
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Published in the November 2016 issue of Today’s Hospitalist

FOR MOST HOSPITALISTS, the big takeaway from the 2016 Today’s Hospitalist Career & Compensation Survey may be a surprise, but not a shock: More than one-third of full-time hospitalists (and nearly 40% of those who are not academic hospitalists) now report a mean annual compensation of more than $300,000.

Even more of an eye-opener, 8% of full-time hospitalists who treat adults earn more than $400,000. Overall, full-time hospitalists who treat adults report an average compensation of $280,438. That represents a one-year increase of 7.1% and a 19% rise over the last five years.

As Amit Vashist, MD, MBA, system chair of Mountain States Health Alliance’s hospitalist division in Johnson City, Tenn., puts it, “that’s good news for us as a profession.”

“We get quite a few people volunteering to work extra for extra pay.”

comp-vashist~ Amit Vashist, MD, MBA, Mountain States Health Alliance

Even in his economically struggling region—Appalachia—hospitalist salaries are rising robustly, due to high demand and low supply. “In harder-to-recruit-to hospitals, you have to increase compensation or no one would even interview,” says Dr. Vashist, who oversees about 80 hospitalists in six hospitals.

But the key to growing compensation comes not just from healthier salaries. In most markets, says Dr. Vashist, perennial short-staffing leaves unfilled shifts always up for grabs, creating multiple opportunities for hospitalists to augment their high salaries.

Hospitalists can, for instance, supplement their income with shift differentials being offered for hard-to-fill slots at other facilities within the same system. They have their pick of external moonlighting possibilities at other hospitals, emergency departments and urgent care facilities. Are you willing to supervise advanced practice clinicians at night from home? There’s a stipend for that. Want to work on a rapid improvement activity at your hospital? You can expect to be paid.

Add up all the available extras, and it’s no secret who hospital medicine’s big-earners are: Those who go where they are needed and work more. “We get quite a few people volunteering,” says Dr. Vashist, “to work extra for extra pay.”

Constant opportunities
Leslie Flores, a partner with Nelson Flores Hospital Medicine Consultants who’s based in La Quinta, Calif., says she’s seeing the same trend across the country.

Hospitalists are “working extra shifts both internally and externally,” Ms. Flores notes. “They’re contracting with locum tenens companies, doing ED shifts, and working at skilled nursing facilities, urgent care clinics and wound care centers.” They also make extra money for leadership or administrative work not directly related to their hospitalist program, such as working as a physician advisor for utilization review or health IT. “All this is helping bump up the dollars,” she says.

According to our survey, 70% of full-time adult-only hospitalists say they supplement their income by working extra shifts, either internally or as moonlighters, and that working extra shifts boosted their income by an average of 13%. In addition, one-quarter of full-time non-academic hospitalists who treat adults report having no restrictions on moonlighting for other programs.

“There are always extra shifts,” says Kevin Sowti, MD, hospitalist group medical director at Penn Medicine’s Chester County Hospital in West Chester, Pa.

But Dr. Sowti says that rising income goes beyond picking up more shifts. “One main reason our pay has been going up is our involvement in governance and quality,” he explains. Hospitals are relying on hospitalists to “to do this nonclinical work, whether it is case management, contesting insurance company denials for second-level review or leading performance on quality metrics.”

In some places, he says, that money is showing up as a direct stipend or an increased bonus pool. In others, it is the rationale for increasing group subsidies. In Dr. Sowti’s program, where hospitalists are paid a straight salary, their expanding scope of clinical and nonclinical practice means both more demand and more remuneration.

A growing pool of bonuses
If hospitalists are finally being paid for their nonclinical eff orts, many in the specialty will breathe a sigh of relief. For years, too many hospital administrators have expected hospitalists to perform nonclinical work for free.

As Kimberly Bell, MD, associate vice president of hospital medicine for the CHI Franciscan Inpatient Team in Tacoma, Wash., points out, that attitude is becoming harder to maintain as the stakes for performance-based care grow. “Hospitals need clinicians to help them as value-based purchasing rolls out, and they expect physicians to show up at a meeting and do all this work. If they don’t pay for that, it’s just not going to happen.”

That’s particularly true, Dr. Bell adds, when hospitalists can instead choose to pick up extra paid shifts. The revamped compensation plan at her 100-plus person group now includes a pot of money—potentially $40,000—that hospitalists can collect if they are involved in nonproductivity-related projects. They can, for instance, receive $10,000 for doing a major quality improvement project, like one completed in the last year to improve throughput for patients with low-risk chest pain. (See “A personal solution for better compensation.”)

Around the country, signs indicate that bonuses and incentives for quality, performance, citizenship and productivity—on top of base salaries—account for another growing compensation component. According to Today’s Hospitalist data, full-time adult-only hospitalists earn nearly $80,000 from productivity and bonuses, an increase of $10,000 over the previous year.

If you exclude academic hospitalists from that cohort, the figure jumps to $84,000. Ryan Brown, MD, medical director of the 200-hospitalist Carolinas Hospitalist Group in Charlotte, N.C., says he sees a “general movement away from paying for years of service and more toward participation bonuses.” That includes paying hospitalists to supervise nurse practitioners and physician assistants or to chair committees.

As stable groups have a greater percentage of older hospitalists, Dr. Brown believes it is becoming more important to figure out how doctors can augment their base compensation without working extra clinical shifts. Instead, he says, “groups need to allow doctors, as they get more experienced, to do extra hospitalist initiatives.”

Working more than one FTE
In addition to taking on different types of work, top earners are most likely to be in local, private groups, which tend to have low administrative overhead.

They also tend to be based in Texas, Arizona and parts of the South. In fact, 57% of the hospitalists who report earning more than $300,000 are in the South and Southwest. Another 19% hail from the Midwest, with only 11% in the Pacific region and 10% in the Northeast, where the greater number of training programs means a more equal match between physician supply and demand.

The Midwest’s generally high compensation is due to the fact that many markets, which were slow to adopt the hospitalist model, are now “playing catch-up and finding it is really hard to recruit people to a lot of those places,” says consultant Ms. Flores.

Surveys by the Medical Group Management Association, she adds, find that hospitalists in the Midwest have the lowest productivity as measured by work RVUs, “but some of the highest pay.” In the South, on the other hand, “productivity is the main driver” of high compensation.

In the Today’s Hospitalist data, hospitalists in the Southwest report seeing 18 patients on average during a daytime shift, above the national mean of 16.7. They also work an average of more than 20 more hours a month than full-time, adult-only hospitalists in any other region—and they are more likely to say their primary shift is daytime with beeper call at night.

“They are really working as a 1-¼ or 1-½ FTE, and they need to get paid for that,” says Jasen Gundersen MD, MBA, the Fort Lauderdale-based president of TeamHealth’s Acute Care Services. TeamHealth now encompasses more than 3,300 physicians and 1,000 advanced practice clinicians in close to 2,700 facilities across 35 states. “I don’t think it’s unjustified for doctors to want to get paid more to work in these locations, given what they have to do there.”

In the rural South, Dr. Gundersen adds, hospitalist pay rates have “gone through the roof,” largely for two reasons: Towns tend to be small, with limited subspecialty support and without additional lifestyle opportunities. Plus, “Hospitals are pushing the acuity of what they want hospitalists to do, like critical care and ICU procedures,” he points out. “They need to pay more for the people they want to go there.”

Productivity per shift
Consolidations and mergers and acquisitions among national groups like his own likewise drive up compensation, says Dr. Gundersen.

“When there is instability in the market, doctors get nervous, and they start looking to leave,” he explains. “With a limited supply and everybody recruiting, rates start to creep up. The doctors know they are a limited commodity, and they have the ability to leverage that a bit.”

At Self Regional Healthcare in Greenwood, S.C., Chad Friel, DO, director of hospital medicine, says that “hospitalists can always have higher compensation if they choose to work more.” But what they aren’t doing for higher compensation, he notes, is becoming more productive during each shift.

The Today’s Hospitalist survey confirms Dr. Friel’s impression. It shows that the number of regular shifts that fulltime hospitalists work each month and the length of those shifts has remained steady or even shrunk a bit since last year, to an average of 15.4 shifts per month and 11.43 hours per shift. Other surveys have come to similar conclusions, says Ms. Flores: Productivity as measured by RVUs has been “hovering” around the same level for the last several years.

“Our physicians, especially the new grads, care much more about quality of life than compensation,” Dr. Friel says, particularly because “we already make decent money.” In his experience, hospitalists rarely opt to “stay late after they have already worked a 12-hour shift to see the patient who came in 15 minutes prior to the end of shift and make an extra $50.”

In fact, when he has asked his group if they would rather see additional patients a day and collect bonus money or hire locums, “I can’t think of a single person who wanted us to not get a locum physician.” That vote, he adds, reflects “our group culture. We want to be paid fairly and adequately and have quality of life.” Moreover, he now finds that group members are asking about how they could work less—and specifically asking for paid vacation time.

In Prescott, Ariz., Albert Caccavale, DO, is founder and director of Northern Arizona Hospitalists, which serves Yavapai Regional Medical Center. His is precisely the type of group that could include a lot of the big earners identified in the survey: those who practice in local private groups in the Southwest. In addition, many of the doctors in his group are shareholders.

But according to Dr. Caccavale, for every colleague who wants to work and earn a lot, more doctors these days are satisfied with their above-average $300,000-plus incomes and aren’t interested in more work for more money.

“I have one guy who said he wants to work as a 1-½ FTE,” he points out. “There were people in the room who were incredulous that someone wanted to work that much.”

Until they hire the six practitioners they plan to in the next year, Dr. Caccavale says he and his physician partners “are making more in their quarterly profit-sharing bonuses, but we are also working more. At some point, everybody says money isn’t everything.”

Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto.

compensation chart

How to be a big earner
BECAUSE THERE IS NO FREE LUNCH in hospitalist medicine, here are things that hospitalists who want to earn big bucks need to do:

Work more. Some of the highest earners report functioning more like a hospitalist-and-a-half, working more shifts per month and seeing more patients per shift.

Michael R. Reitz, DO, clinical chair of hospital medicine for the Phoenix, Ariz.-based Banner Medical Group and the interim CMO of Banner Casa Grande Medical Center, recalls several hospitalists he has known over his nearly 20-year career who earned more than $700,000 a year. They did so by working “about 28 days a month and seeing 30 patients a day every day, and billing high levels on everything.” Although he worked with those outliers years before coming to Banner Health, he still sees that mindset among some hospitalists.

Over the last few years, for instance, he helped overhaul the compensation structure for Banner’s hospitalists in Arizona, replacing a straight productivity plan with a hybrid model that combines a base salary with some productivity and performance incentives. That change began in July 2015—and represented “a pay cut for the very high producers who would work as many shifts as they could.”

How well was that change received? As Dr. Reitz explains, “All five of the very high producers left.”

In West Chester, Pa., Chester County Hospital hospitalist director Kevin Sowti, MD, calls doctors willing to see large panels of patients for high salaries the “gunslingers” of the profession.

“Sometimes, they are great docs who come in and clean up” when a practice is particularly short-staffed and needs help, Dr. Sowti says. “But six months later, someone offers them a little more money and they leave. Or they burn out.”

Even in the generally lower-paying Philadelphia area where he works, Dr. Sowti can name a few colleagues who earn in excess of $400,000. “But they are picking up shifts right and left,” not seeing lots of patients each shift.

Do more. According to the 2016 Today’s Hospitalist Compensation & Career survey, not only do big earners work more shifts (including moonlighting), but they take on different kinds of paid work: administrative or leadership slots, case management or billing review work, or other clinical work in outpatient clinics or skilled nursing facilities.

Amit Vashist, MD, MBA, system chair of Mountain States Health Alliance’s hospitalist division in Johnson City, Tenn., points out that paying hospitalists to take on quality improvement on top of their clinical work “helps our bottom line as well as theirs.” Moreover, he adds, “It doesn’t hurt their enthusiasm and involvement that we pay a stipend for that.”

Survey data show that those earning $300,000 and more are more involved in operations beyond direct patient care. For instance, 45% of top earners are engaged in leadership vs. 36% of hospitalists overall.

Go where you are needed. “The average doc working seven-on/seven-off in a non-rural, semi-metro, couple hundred bed hospital is not making $400,000 a year,” says TeamHealth Acute Care Services president Jasen W. Gundersen, MD, MBA. “They are making between $250,000 and $300,000.” However, “if you go to rural Texas or rural Virginia to a 30-bed hospital trying to keep its ICU open, nobody is willing to do it for less.”

And hospitals are open to paying that in those markets because “it is still cheaper than a locum,” he says.

Stick it out. The highest earners tend to be older, more experienced—and male. Hospitalist veterans who have been in their current job for more than 10 years reported a higher compensation increase than the national average: nearly 9%.

Full-time, non-academic, adult-only hospitalists in the same job more than 10 years reported a mean compensation of $305,312. Non-academic, full-time male hospitalists—no matter how long they’ve worked—reported a mean compensation of $290,850. That is $16,000 higher than for comparable women, who reported $274,621.

Comp finally rises for academic hospitalists
DATA FROM
the 2016 Today’s Hospitalist Compensation & Career Survey contained this interesting news: The hospitalists with the biggest recent jump in compensation are those working for medical schools and universities. This year, that group posted a 14% pay hike, earning a mean annual compensation of $235,417. Since 2014, average compensation for academic hospitalists has risen 20%.

Nonetheless, this group still ranks as the lowest paid of all full-time hospitalists who treat adults. Meanwhile, full-time pediatric hospitalists still earn less, reporting a mean compensation this year of $212,500. That’s a 2.3% increase over 2015 data.

That academic pay hike isn’t a surprise to leaders trying to recruit academic doctors to their programs. It’s particularly evident when groups are part of university health systems but don’t function or feel like academic programs.

In Chicago, for instance, Loyola University Health System started hiring hospitalists last year to staff Gottlieb Memorial Hospital, a community hospital it acquired in suburban Melrose Park, Ill. Leaders found that the only way to successfully recruit was to set starting salaries “about $50,000 higher” than what they pay at the main medical center, explains Loyola hospital medicine division director Elizabeth Schulwolf, MD.

“We have to be competitive with the community market” because the work is so different between the two sites, Dr. Schulwolf explains. “Community hospitalists are accustomed to higher salaries, and we need to be mindful of this when recruiting within a system with both academic and community sites.”

This year’s Today’s Hospitalist survey finds that her $50,000 figure is in line with what has been happening nationally. The disparity between the average compensation reported by hospital-employed hospitalists and university/medical school-employed doctors equals about $50,000—but that gap seems to be shrinking. A couple of years ago, it stood at about $60,000.

Dr. Schulwolf notes that the university also learned that a sole focus on base salaries may not be enough to attract community-oriented hospitalists to academically-owned programs. To successfully recruit hospitalists to Gottlieb, for instance, the university had to tailor some longstanding rules.

“Right now, we don’t have a lot of moonlighting at our community site,” she points out. “But when we said ‘no external moonlighting’ to the candidates we were trying to recruit, they were very frank.” Potential recruits weren’t interested in the job unless they could earn moonlighting dollars to “make up for the loss of income” they’d experience if they left their current community job for the new Loyola post.

At the same time, hospitalists in academic centers are realizing that many of their jobs look increasingly like community positions—and should be compensated as such. In many university hospitals, for instance, the non-teaching hospitalist services are far larger than the teaching ones.

“There is a huge dissatisfaction among academic hospitalists across the country because they went into the role thinking that they would be spending their clinical time working on teaching services,” says Leslie Flores, a partner with Nelson Flores Hospital Medicine Consultants. Ms. Flores chalks the big increase in academic compensation up to the fact that medical schools have had to rethink what they pay academic hospitalists because of the changing environment.

“They are losing too many people as academic hospitalists are spending much more time doing traditional clinical work,” she notes. “They have to come up with a compensation model that recognizes that.”

A personal solution for better compensation
FOR THE HOSPITALISTS at the CHI Franciscan Health system in and around Tacoma, Wash., the compensation wake-up call came two years ago. When they compared what they were offering to national and regional benchmarks, they feared it might be $30,000 or $40,000 too low.

“We had multiple open shifts and had gone through the process of interviewing and extending offers, and had more than one candidate say ‘no,’ ” recalls Kimberly Bell, MD, associate vice present of hospital medicine. “We knew we had to do something.”

What finally convinced administration, however, was much more personal than data: The daughter of one of the system’s senior vice presidents was finishing her residency and came in to talk about hospitalist careers. She was shocked at how poorly the compensation plan compared to others she’d encountered—and she told her father.

As Dr. Bell recalls, “He came into my office and said ‘You are not going to get anybody; you aren’t paying enough.’ I said, ‘Tell me something I don’t know!’ That’s when we got a new plan approved.”

But the bump-up didn’t come without strings. While their previous compensation was below market, so was hospitalists’ productivity. The restructured plan increased not only the proportion of pay linked to RVU-based productivity, but the length of daytime shifts, which are now 11 hours.

“We had a few people who left because of the uncertainty around the compensation change,” says Dr. Bell. “But the rest stayed, and we have no more talk now about how we are being underpaid.”

compensation chart 2

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