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The new busy

December 2012

Published in the December 2012 issue of Today’s Hospitalist

PRODUCTIVITY FIGURES FROM the 2012 Today’s Hospitalist Compensation & Career Survey don’t contain many surprises. Hospitalists nationwide see about 16 patients per daytime shift, a number that has hardly budged in five years, and they work about 16 shifts per month.

While our survey results paint a relatively stable picture of patient volumes, hospitalists say that those numbers don’t tell the whole story. Many physicians say they’re busier than ever seeing more patients, working more hours, and making sure patients aren’t admitted unnecessarily or readmitted. That doesn’t include the time they spend on committee work, IT design and quality improvement.

A good example can be found at St. Tammany Parish Hospital in Covington, La., where hospitalists find themselves now spending much more time on the phone with insurers appealing denials. "It used to be once or twice a month," says Patrick J. Torcson, MD, hospitalist medical director there. "It’s an everyday occurrence now." As payers struggle to meet provisions of the Affordable Care Act, he explains, many are scrutinizing every billed bed day.

"We’re lucky to be in a system where administrators appreciate that we spend 45 minutes on the phone appealing two denied bed days," says Dr. Torcson. "This is counted as a kind of productivity."

Not all hospitalists, however, work at hospitals that take such a progressive view of productivity. While hospitals everywhere are expanding hospitalist productivity to include more than just patient care, many want hospitalists to see just as many “or even more “patients.

The shifting definition of productivity has hospitalists scrambling for ways to squeeze new duties into already packed schedules of rounding, admitting and discharging patients. It also has many groups looking for ways to work smarter, even as the definition of productivity in the looming era of the medical home may be about to change.

More encounters and complexity
Despite national data, many hospitalists say that they are in fact seeing more patients. The 12-member hospitalist group at Florida’s St. Lucie Medical Center offers an example of how patient volumes are creeping up for some hospitalists. The group, which is run by EmCare Inpatient Services, currently has each daytime physician handling between 22 and 25 patients a shift, according to medical director Fernando Petry, DO, MBA.

Patient volume has spiked as the last holdouts among community doctors decided to turn their patients over to hospitalists, in part because of concerns about their ability to meet provisions of health care reform. But as Dr. Petry explains, surging volume makes it difficult to control length of stay and prevent unnecessary readmissions.

"Patients are coming back because we are not having the difficult discussions with them regarding palliative care, possible futility of treatments and hospice as an option," he explains. And some patients discharged with home health services bounce back in two or three weeks. "They failed home health because we hadn’t spent the extra time figuring out that home health wasn’t going to work," Dr. Petry says.

Martin Buser, MPH, a founding partner of Hospitalist Management Resources LLC, a national hospitalist consulting firm in Del Mar, Calif., and Colorado Springs, Colo., says that hospitalists can expect to feel busier as they see a greater level of acuity in inpatients.

Mr. Buser notes that the latest study of hospitalist compensation and production from the Medical Group Management Association found that the median adult hospitalist ratio of physician work RVUs to total encounters rose slightly to 1.91, up from 1.90 the year before. He attributes that to the "increasing complexity of hospitalized patients" that results from the drive to admit only those patients who have no other alternative to hospitalization.

"I would expect that to go up in the next five years," Mr. Buser notes, "because there will be more effort with medical homes to keep people out of hospitals."

A new definition
Hospitalists in Southern California may be able to provide some insights into what the future of hospitalist productivity looks like. HealthCare Partners Medical Group (HCP) in Torrance, Calif., is one of 32 accountable care organizations (ACOs) around the country chosen for CMS’s pioneer ACO model. A productive hospitalist is considered one who sees between 13 and 16 patients, with the emphasis on trying to stay closer to 13, which is well below the national average.

"We interpret productivity a different way," explains Tyler Jung, MD, the group’s hospitalist medical director. "We do not look at RVU productivity with a singular focus on how busy are you. Instead, are you making interventions for patients? Are you moving them through the system efficiently and safely? Are you getting them home with a low readmit rate?"

Under an accountable care system, the HCP hospitalist group has reduced patients’ length of stay to about three and a half days, lower than the national average. Readmission rates for seniors range between 12% and 15%, which is also well under CMS’ national average of around 19%.

In an ACO world, Dr. Jung points out, the hospital is viewed not as a revenue generator but a cost center. As a result, he explains, "You really want to have a proper census. You are willing to spend time in an emergency room with patients to be able to admit them or safely discharge them home."

Making the personal calls
In the fee-for-service world, on the other hand, "I hear, ‘Just send him upstairs. I’ll see him later.’" While Dr. Jung or his colleagues could each see several patients upstairs in the time they spend in the ED, "for us and our patients, that trade is worth it, even though RVUs don’t fully capture that work."

Here’s another tradeoff: Instead of seeing more patients, "our hospitalists call patients’ families to say, ‘I haven’t seen you in a couple of days. I need to update you on what’s going on.’ " Hospitalists also personally get primary care physicians on the phone to discuss individual cases.

"In the fee-for-service world," Dr. Jung says, "you often say, ‘The primary care physician has my discharge summary. I don’t need to call him too.’ Or, ‘I’ll text him later.’ In an ACO environment where you don’t want anything to happen to patients that can be prevented, you call the PCP."

That’s not to say that the hospitalists aren’t pressured to see more patients. "I would love to stretch out our average daily census to 16 a day," Dr. Jung says. "But will doctors have to stop having those important discussions with patients and families, which could lead to nonadherence or confusion and unhappy families? Productivity is in the eye of the beholder."

Changing the value equation
There are signs that the new definition of productivity is beginning to show up in other groups around the country. "I agree that 15 to 18 patients per shift is the average," says Alan Wang, MD, director of the Emory division of hospital medicine in Atlanta. "But more than ever, I’m seeing a discrepancy, with some groups seeing a lot more patients and some seeing less."

According to Dr. Wang, some hospitalists at both the large academic Emory University Hospital and a small community hospital, Emory Johns Creek Hospital, now work on floors reorganized into new "accountable care units." They see around 12 patients per shift, have nursing ratios of four or five to one, and run structured interdisciplinary bedside rounds. But at another of the eight hospitals where Emory’s 115 hospitalists work, administrators are urging doctors to see more than 20 patients a shift and work more shifts a month.

That hospital "wants to move away from subsidies," Dr. Wang explains. Given that hospitalist value is often depicted as an equation of quality divided by cost, Dr. Wang notes that those administrators "want to lower the denominator on cost" to increase hospitalist value. Discussions with that administration are just beginning, he says, and how things will play out in terms of productivity expectations are up in the air.

Models like the accountable care units, on the other hand, "are born out of the idea of maximizing the quality numerator," Dr. Wang says. And according to Louisiana’s Dr. Torcson, who also chairs the Society of Hospital Medicine’s performance measurement and reporting committee, evolving payment systems like bundled payments mean that "productivity is not going to be strictly about the number of encounters" for hospitalists nationwide.

In 2017, Dr. Torcson explains, the Affordable Care Act says all physicians will have a variable adjustment in their Medicare reimbursement based on quality. "We will all be transitioning from payment for volume to payment for value."

Working smarter
For now, however, most programs are struggling to manage growing patient loads, not reduce their daily number of encounters.

"People say we have to become more productive. We’ve known that for quite some time," says Anil Goud, MD, a founding hospitalist and president of Independent Hospitalists, whose 15 hospitalists work at John C. Lincoln Deer Valley Hospital in North Phoenix. "But right now we don’t have the tools to allow us to see 25 patients a day as opposed to 15."

Unfortunately, he says, he and his colleagues now average more than 20 patients a day, much higher than the 15 to 16 he considers ideal. (The cause is supply and demand ” too many patients, and not enough doctors; the group is recruiting.) Due to some efficiencies the group has put in place recently, however, Dr. Goud is rethinking his idea of ideal: "I think we could do 17 to 18, and our hospitalists would feel comfortable that they had a productive day and are making money."

To boost their productivity, Dr. Goud says, the group focused first on discharges. "We tried to improved the discharge process so it’s not the most difficult part of our job ” and to do it early in the day," he notes, saying the group has increased its number of discharges before 10 a.m. "The earlier patients leave, the fewer calls we get asking when they’ll be discharged."

The doctors also focused on reducing waste and redundancy, particularly wasted time spent on hold, waiting for callbacks or playing phone tag with nurses and other clinicians.

"I am a very impatient person," Dr. Goud admits, "and a 30-second wait seems like five minutes." Because there were no systems on the market to solve that problem, the group hired its own programmer and developed its own software solution called EHRX. The group is now marketing it to other local hospitals.

The program, which interfaces with the hospital’s EMR, has cut down significantly on the communication time-suck. It lets all providers using the system see summary statements about each patient’s daily care, ask and answer questions, and avoid the redundant work of rewriting information for discharges, handoffs and billing.

"If we didn’t have these efficiencies right now when we are shorthanded, we would pretty much be dead or lowering our level of quality," Dr. Goud says. "One change can sometimes fix a lot."

Making time for more
Like Dr. Goud’s group in Arizona, the Carolinas Hospitalist Group, which is based in Charlotte, N.C., may be moving toward a new normal in terms of productivity.

Right now, the group’s "sweet spot" is between 14 and 16 patients per day with two or three admissions, says the group’s finance director, John M. Scherr, MD. Even though the hospitalists, whose compensation is based on productivity, could earn more if they saw more patients, they are determined to keep 16 as a good ceiling.

To maintain that level, the group calls in additional doctors from its backup schedule when the census edges up to 18. If the creep persists, Dr. Scherr adds, "people bring up hiring. We have a group-wide standard of where we think people can perform and be professionally satisfied because we don’t want turnover."

Because he walks between six and seven miles a day around the hospital, Dr. Scherr wants to save time by figuring out how to move to unit-based staffing. In the meantime, probably the most important efficiency innovation the doctors have undertaken, Dr. Scherr says, was learning to use their new EMR.

"It was a painful transition, but it has been a pretty big timesaver," he says. "Of everything I did during the day, writing my progress note was the task I hated the most. I’m happy to see an extra couple of patients if someone says I don’t have to write my progress notes, and now I don’t have to write them."

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