Published in the 2009 Today’s Hospitalist Compensation & Career Guide
Is there a change underfoot in the number of patients that hospitalists are seeing “or are expected to see “per shift?
Data from the 2009 Today’s Hospitalist Compensation & Career Survey show a slight uptick in the number of hospitalists’ daily patient encounters. In 2008, the mean number of daily encounters was 15.36. For 2009, that number jumped to 16.26, a rise of 6%.
Because the increase is relatively modest, it’s hard to say whether it’s a real trend or a statistical blip. Hospitalists say that the increase reflects what they’re seeing on the ground “and that it may be a sign of things to come.
In some instances, patient loads are increasing because of factors like the refusal of other physicians to take ED call. But in many cases, hospitalists say patient volumes are rising because hospital administrators are trying to wring extra productivity out of their hospitalist programs.
More patients from the ED In any discussion of hospitalist productivity, an obvious starting point is to look at data on who physicians work for and the type of program they work in. Academic hospitalists, for instance, tend to see fewer patients than hospitalists in other practice settings, while entrepreneurial hospitalists working with locally owned companies often see significantly more.
Our data do show that hospitalists who work for university hospitals see fewer patients than their counterparts in other settings. But the data show no other obvious trends when it comes to increases in patient volumes by employer type.
So what may be behind rising volumes? When Gavin Warner, MD, was recently running a hospitalist program at a 100-bed hospital just outside of Atlanta, he saw patient encounters jump from about 15 per shift to 20 because of a surge in ED patients being sent to the wards.
Dr. Warner, who is now vice president of medical affairs and clinical operations for IN Compass Health, a hospitalist management company in Alpharetta, Ga., says that the ED was filling up largely due to the troubled economy. People were postponing or canceling visits to their primary care doctors and opting to use the ED for primary care instead.
To handle the surge in volume, the practice added additional shifts, and the hospitalists in the group worked additional hours. “We’ve ended up,” says Dr. Warner, “going from 15 shifts a month to 18 or 20.”
Still “manageable” volume
At another IN Compass hospitalist practice, climbing patient volumes reflect the attitude of physicians in the community.
“Two to three years ago,” explains Thomas Smith, MD, vice president of medical affairs and clinical quality for IN Compass, “we had a much more robust medical staff willing to work with the emergency room to do admissions.” Over the past 18 months or so, however, fewer physicians have been willing to take call. As a result, hospitalists have been the ones to pick up the slack.
Dr. Smith estimates that the physicians in his group probably see an additional five patients per shift for a total of about 18, without the need for any additional staffing. They do on occasion call in a moonlighter to help with admissions when the daily census becomes unmanageable.
Dr. Smith notes that because many patients who come through the hospital tend to receive regular primary care, their chronic conditions are pretty well-controlled. “They tend to be coming in for solitary conditions like pneumonia or chest pain,” he says. The fact that so many patients have a regular physician makes discharge go fairly smoothly. “Disposition is relatively easy,” he adds.
The upside of the rise in volume is that physicians are earning more through more robust team-based productivity bonuses, Dr. Smith says. But the group is still adjusting to its patient volumes going from 13 or 14 encounters per shift to 18 or more. “There are some days when it seems worse than others,” says Dr. Smith. “Overall, it’s still manageable.”
Recruiting problems for new groups
Brian J. Bossard, MD, hasn’t seen any spike in patient volume at his group, but he’s not surprised by the survey numbers. Dr. Bossard, who founded the hospitalist program at BryanLGH Medical Center in Lincoln, Neb., says that one trend driving the data is the number of new hospitalist practices being formed.
“You start out with a certain number of doctors,” Dr. Bossard explains, “and that’s fine for a very short period of time. But then those physicians become overworked, and it takes some cycles to hire enough staff to take care of the additional volume.”
Because his group is relatively mature ” it’s eight years old “Dr. Bossard doesn’t have those problems. His group’s average daily census runs from 13 to 15 encounters, numbers that have held firm for years.
Dan Fuller, co-founder and president of IN Compass, can attest to the ferocious growth that his programs are seeing. “In some programs where we have between eight and 12 physicians, the demand on them has been overwhelming,” he says. “The only way to keep up with demand is to either add shifts and/or have physicians see more patients per shift. There is a limited pool of resources.”
Mr. Fuller says that with the economic downturn and the uncertainty created by possible health care reform, many hospitals are taking a hard look at the financial support they provide, even though many hospitalist groups feel understaffed. “More and more, when we go to renegotiate the agreement,” he explains, “administrators are looking for ways to reduce their support fee. One of the ways is to increase the productivity of the program.”
According to Mr. Fuller, “Hospital CEOs and VPMAs have become very educated on the issue of hospitalist productivity because they know it directly impacts their subsidy.” And with so much competition in the market place right now, many groups are differentiating themselves by aggressively pricing their services.
“Productivity and cost are important,” Mr. Fuller adds, “but we need to focus on quality, service and ROI.”
Pressure from the C-suite
Christopher Frost, MD, vice president of hospital medicine for TeamHealth Hospital Medicine, a Knoxville, Tenn.-based hospitalist management company, agrees that hospital executives are putting new pressure on hospitalists to increase their productivity. It’s a trend that he doesn’t think is going to end soon. Administrators, he says, are paying particular attention to hospitalists’ scheduling and staffing models.
“Hospitals want to know what tools we bring to the table to ensure that our hospitalists are as efficient and productive as they can be,” Dr. Frost explains. “We’re seeing a greater focus on the quantitative value that hospitalists bring.”
According to Mr. Fuller, hospital administrators are increasingly asking if he can offer a shift-plus-call model, instead of 24/7 coverage. Some executives see shifts-plus call “as a less expensive model,” he says, while others think it offers better care.
Dr. Frost says he believes that data from the Today’s Hospitalist survey may point to exactly that trend. The number of hospitalists who report working shifts plus call jumped from 27.5% in 2008 to 34.9% in 2009, a 27% increase. The number of hospitalists working shifts only rose slightly, while the number of hospitalists working traditional daytime coverage (9 a.m.-5 p.m.) with beeper call at night dropped almost 10 percentage points.
Dr. Frost thinks that trend can be explained not only by physician preferences but by hospital executives trying to squeeze more value out of hospitalist programs.
“You’re seeing more hospitals look at what they’re really getting from 24/7 coverage in terms of return on investment,” Dr. Frost says. “Some are looking at the night shifts as less productive. If there’s a way to transition to a call based model at night where there are some savings, you’re going to see more hospitals migrate to that.”
A shift in physician expectations
Dr. Bossard says he understands that executives at some hospitals may be looking to contain costs, but he has yet to have a conversation about serving as a source of savings. While his group is independent and not employed by the hospital, administrators haven’t tried to wring extra value out of the group, in part because he’s worked to help them understand the value the group brings to the table.
“They understand value from the standpoint of our participation on committees, reductions in length of stay, improvements in the efficiency of care and the savings we’ve produced on medication costs,” Dr. Bossard says. “From day one, there has been enough education that everyone knew that seeing 20 to 25 patients a day wasn’t the busiÂ¬ness model for hospital medicine.”
But according to Dr. Frost, many of the hospitalists he talks to understand that expectations about patient volume may be on the rise.
“I have seen a northern migration in terms of the expectation of hospitalists themselves to titrate up their productivity,” Dr. Frost explains. “We’re seeing expectations among hospitalists to see around 18 to 20 encounters per shift.”
Interestingly, he adds, “Hospitalists don’t talk about 18 to 20 encounters a day with a sense of despair. They ask, ‘How did you get there?’ And they start to talk about how they changed their workflow and were able to increase their capacity without increasing the stress of the job.”
Working more efficiently
Dr. Frost says TeamHealth is using a variety of strategies to help hospitalists work more efficiently so physicians can achieve optimal productivity without burning out. Geographic rounding, documenÂ¬tation templates and the increased use of nonphysician providers are all on the table, he explains.
While groups are looking for ways to work smarter, not necessarily harder, everyone knows that there’s a big downside of asking hospitalists to see too many patients. The obvious boomerang effect would be an increase in length of stay and unnecessary utilization of resources.
“Instead of saving $250,000 on the subsidy you give to a hospitalist program,” Mr. Fuller says, “you lose $2.5 million by incurring excessive costs.” Some hospitals understand that by investing money upfront in a subsidy for hospitalists, they’ll see results on the back end like better patient care and patient satisfaction, improved length of stay and reduced utilization, he adds. “But some don’t get that and focus on the subsidy.”
Edward Doyle is Editor of Today’s Hospitalist.
Changing volumes and physician expectations
If you’re looking for an example of how tough economic times are taking their toll on hospitalists, look no farther than the hospitalist program at Temple University Hospital in Philadelphia.
The program recently had to let several hospitalists go when Temple closed one of its satellite facilities due to low volumes, says William T. Ford, MD, who manages Cogent’s hospitalist program at Temple and is hospital medicine section head.
At the same time, many patients who’d been treated at the satellite started coming to the main hospital, where Dr. Ford’s group still works. As a result, the group is seeing the same volume of patients that used to be spread over two facilities “with less manpower. In all, the group went from 28 hospitalists to 19 in a year.
Dr. Ford admits that the number of patients that the group at the main hospital used to treat “about 10 patients per shift “was low. Today, hospitalists in the group see about 18 patients a shift.
“It’s all about setting expectations,” Dr. Ford says. “If we had been used to seeing 28 patients a shift and we dropped down to 17, it would be like Christmas morning. But since we started at six or eight patients a day and are going to 17, we’ve had some turnover.”
Hospitalists’ days are getting longer
For Catherine Price, MD, the notion that some hospitalists are being asked to see more patients per shift is ill advised.
Dr. Price, associate director of the hospital medicine service at Emerson Hospital in Concord, Mass., says that as the specialty matures, hospitalists are being asked to spend more, not less time, on patient visits. The idea that somehow hospitalists can squeeze a few more encounters into their already packed day rubs her the wrong way.
“As time goes by, we have introduced more and more patient safety and QI initiatives that make each encounter longer,” Dr. Price explains, pointing to the discharge process as just one example.
Discharge medication reconciliation and discharge summaries, she says, take a considerable amount of time to do effectively. “No longer can we write, ‘Discharge home,’ and expect nurses to figure out the appropriate discharge medications and follow-up instructions,” says Dr. Price. Instead, “the responsibility is on the hospitalist to adequately communicate with and educate patients and families. Education has become an essential component in the patient-hospitalist interaction.”
Efforts to reduce readmission rates, which is a Medicare priority, is another factor at play in the discharge process, she points out. “The expectation is that a discharge summary will be completed on the day of discharge and forwarded to the primary care physician,” she says. “When I was a resident, it went on a list somewhere and maybe we’d get to it within the next 30 days.”
Then there’s the seemingly endless flow of committee meetings. “On any given day,” Dr. Price says, “I might have at least one committee meeting and leave that meeting with additional projects and time commitments. The number of hours hospitalists need for non-clinical work continues to expand as hospitalists fill the void formerly occupied by primary care physicians.”
While Emerson has some tools to help hospitalists streamline their work, it’s hospitalists who do most of the day-to-day tasks, whether it’s creating discharge summaries or reconciling medication regimens. Hospitalists are also in charge of patient education and talking to family members, both of which Dr. Price says have become more involved.
On average, the hospitalists in her group, which is employed by the hospital, see between 12 and 15 patients per shift, a figure she knows is the envy of other groups in her area. When the census goes up significantly and consistently, Dr. Price says, the group adds staffing.
She notes that her group is in that comfortable position in large part because of the program’s relationship with hospital administrators. “Our administration understands that if you want quality, which we very much do, you lose something when you go up in census,” she says.