Published in the November 2009 issue of Today’s Hospitalist
Most hospitalist practices around the country rely on two key strategies to deal with winter spikes in inpatient census: “Work harder” and “Don’t get sick.”
Many years, those tactics work well enough and even earn hospitalists some extra income. But this year, fears about a surge in census due to H1N1 have hospitalist programs calling for better planning and more action. Even hospitalist groups in areas long accustomed to dramatic seasonal variations due to migrating “snowbirds” are scrambling to be better prepared.
Programs, for instance, are busy assembling a larger-than-usual stable of potential part-timers and moonlighters. They’re also “some for the first time “developing formal sick-leave policies and “jeopardy” back-up schedules for their physicians, trying to figure out ahead of time how to “flex up” staffing for what may be a hellacious winter season.
But putting these strategies in place is often easier said than done. Some hospitalist programs trying to pump up staffing levels, for example, are finding resistance from the primary care physicians they’re turning to for help. Others are finding that there may simply not be enough healthy physicians in their town or region if H1N1 strikes.
A big if: community physicians
In September, Charles M. Hodges, MD, director of the 13-physician inpatient medical service at Duke Raleigh Hospital in Raleigh, N.C., sent an e-mail to all primary care doctors on the hospital staff, asking who was interested in some potentially lucrative hospitalist moonlighting shifts in the event of a winter surge.
The response, says Dr. Hodges, was “not enthusiastic. Everybody is busy, and I don’t think the primary care physicians in our area are looking to work harder.”
That’s certainly not a universal experience throughout the country, especially not in areas that depend on winter tourists to keep the local economy afloat. In Harlingen, Texas, near the Mexican border, for instance, a busy winter season is a godsend. The medical population nearly doubles with “winter Texans” who drive down in RVs from the frigid Midwest, explains James Castillo, MD, hospitalist program director at Valley Baptist Medical Center-Harlingen. As in any winter resort town, doctors “both inpatient and outpatient “depend on winter income to cover their lean summer.
According to Dr. Castillo, help from community physicians is the only reason that his hospitalists aren’t overwhelmed by the winter surge. Primary care physicians are happy to take the ample hospitalist moonlighting shifts available in the winter, he says. It helps that winter business can be lucrative.
That’s because winter Texans, Dr. Castillo explains, tend to be insured. (Gas prices are low enough this year, he adds, that he doesn’t think the winter population will be appreciably lower.) “It works out well because community doctors need that work in the winter, and in fact they depend on it,” Dr. Castillo says. “If we didn’t have these community doctors, I don’t know how we would be able to handle it.”
In Phoenix, which likewise sees a winter population surge, Obinna Egbo, MD, practice group leader for the IPC The Hospitalist Company program at St. Joseph’s Hospital, has some new ammunition this winter in the form of an additional full-time physician.
While the group also has two regular moonlighters, Dr. Egbo says his group relies primarily on several flex-up strategies that have worked in the past. Those include tweaking the schedule so hospitalists work every other weekend during the winter vs. every third weekend in the summer; forbidding doctors to take extended vacations during the winter or any time off longer than five days, except for emergency situations; and adding a fourth physician on weekends vs. only three per weekend in the summer.
In Tucson, Doug Bischoff, MD, the practice leader for the IPC hospitalist group at Carondelet St. Mary’s Hospital, says that the 17-member group traditionally sees between 40 and 50 additional patients per day during winter months. Last year, Dr. Bischoff says, the group got over that hump by hiring locum tenens physicians to work 3 p.m.-3 a.m. doing admissions. The group is now debating whether or not to go the locum route again.
The hospitalists have also worked hard to build up a stable of regular moonlighters they can hire to work those swing shifts. According to Dr. Bischoff, he primarily draws on a pool of physicians finishing fellowships. Tucson also has, he says, a large group of IMG physicians who, for visa advantages, agree to work for low-paying primary care clinics and are always interested in earning more money. The idea is to free up full-time hospitalists for extra rounding in the busy season.
But this year, “I am concerned,” Dr. Bischoff says. “Tucson has enough flu right now that what if three of my partners got sick? The only answer really is to buck up and make the needed adjustments.”
An early surge in illness
Indicators in other parts of the country point to an early winter surge in illness, and hospitalists are similarly wondering if their best laid staffing plans will hold up to a spike in patient volumes due to the H1N1 virus. As of October, the CDC reported that hospitalizations for confirmed flu were higher than expected for this time of year.
Ginna Cavender is a staffing specialist for the Alpharetta, Ga.-based IN Compass Health Inc., which runs about 30 hospitalist programs in 10 states. According to Ms. Cavender, the spike in volumes that IN Compass groups usually see starting in January was already upon them in October.
While IN Compass physicians typically see between 14 and 17 patients a shift at this time of year, she says, “we’re already consistently seeing between 17 and 20. It’s making us re-evaluate things and ask: If it’s like this in October, what are we going to do about January, February and March, when we know it’s going to spike?”
That re-evaluation is taking the form of a concerted effort to “recruit a lot of part-timers to come in and fill the gap,” Ms. Cavender says. The silver lining in a gloomy economy, she adds, is that IN Compass is having no trouble finding hospitalists willing to work as part-timers at other practices on their days off from their full-time jobs.
“We’re finding doctors who need to earn extra money,” she explains. “A good chunk of the doctors who moonlight for us are hospitalists on block schedules who moonlight on their days off.”
Fallout from hospital medicine’s success
But being able to rely on moonlighting hospitalists isn’t a luxury that Dr. Hodges in Raleigh, N.C., has. He’s not finding many prospective moonlighters among local community physicians, in part because many have turned their inpatients over to hospitalists.
That’s because he can draw on only those community physicians who still have hospital privileges “a dwindling pool. It takes so long for hospitals to credential new physicians that if they’re not already in the pipeline, they’ll probably be credentialed too late to be of any help this season.
“The difficulty for us,” Dr. Hodges says, “is getting available people with a relatively small lead time to be able to help us out. It’s hard to do it quickly.” With so few community physicians interested in picking up hospitalist shifts this winter, Dr. Hodges moved to plan B.
That was putting the issue of how to handle a potential surge on the agenda for his October hospitalist staff meeting. In response, the group decided to “pitch in where they need to,” says Dr. Hodges. Six of the 13 physicians volunteered to take on additional shifts if necessary.
“We decided that if our census was overwhelming this winter because of the virus, we would temporarily form an extra team and pay physicians for that,” he explains. “It gives us a measure of comfort that we can handle it up to a certain point at least. Beyond that, who knows?”
Formulating sick-leave policies
In New York, Dahlia Rizk, DO, director of the 20-physician hospitalist program at Beth Israel Medical Center, says a major concern of hers is what to do if the doctors themselves get sick. New York hospitals got a taste of how busy they might become last spring when H1N1 influenza struck the city hard, exposing perhaps as many as 20% to 40% of the population to the virus.
“In the past, if someone was sick, we just cross-covered their patients,” Dr. Rizk says. “But as our volume continues to grow in the winter months, it’s not as easy to cross-cover.” When hospitalists were each responsible for only 15 patients, she explains, it wasn’t hard to pick up an additional four. “But if we begin to see volume increases and the census grows,” she adds, “then adding four or five more becomes extremely difficult.”
Complicating matters, Dr. Rizk says, each of the hospitalists at Beth Israel is now working toward covering only one unit in a ward-based coverage model. That makes it much harder for any one doctor to care for patients on different floors.
The result is a new, first-ever sick-leave policy for the group, she says. Starting this month, a “sick-call” person “like a “jeopardy” backup “will be designated on the schedule from the pool of off-duty hospitalists.
That physician will have to stay local on a day off because he or she will have to come in if someone calls in sick. “The sick-call person could be a simple way to flex up too,” Dr. Rizk says. “The sick-call person could easily be the person to come in and increase capacity.”
Because hospitalists earn their billings, Dr. Rizk points out that they have a financial incentive to work extra shifts. “But at a certain point,” she admits, “you don’t care about that anymore. When you are working hard, you just value your free time.”
H1N1 planning at Miami’s Baptist Hospital also prompted a review of sick-call policies. Tomas Villanueva, DO, MBA, program director for Baptist Hospital Medicine Group, convened a staff meeting of his 25 hospitalists this summer. Rather than requiring already scheduled hospitalists to shoulder any additional census, the group decided to call in off-duty hospitalists.
“Our average ratios are 18-to-1,” Dr. Villanueva says. “The group decided that if the ratios come to more than 23-to-1 because we are getting slammed or a group member is sick, we are going to choose people from the ‘off team’ to come in.”
That person will have to work only two days in a row, the group decided, so he or she can still have five days off, as opposed to seven. After two days, the plan goes, another person from the off team will have to come in.
“We don’t want to be burning people out,” Dr. Villanueva says.
And as part of its flu planning, the hospital agreed that in the case of a surge, it will reassign nurse practitioners who generally work on quality-related issues to work as hospitalist extenders instead.
“We think our plan will work,” Dr. Villanueva explains, “because we have the extender help.”
Deborah Gesensway is a freelance health care writer who covers U.S. health care from Toronto.
Planning may take you only so far
COUNTING ON MOONLIGHTERS who work at other community practices to help you through a surge fueled by H1N1 “or any other virus “isn’t foolproof. That’s because many of those physicians will likely be pulled in by their own facilities when the workforce thins out.
“We have a pool of providers we can call in to help in an emergency, but how helpful it will be in a big surge, I’m not entirely sure,” explains Kimberly A. Bell, MD, regional medical director for the Pacific Northwest Region of EmCare Inpatient Services and a hospitalist at Auburn Regional Hospital in suburban Seattle. “If flu wipes out the region, doctors are not going to be able to work here because they are going to be called by their own practices.”
Right now, “we have more physicians wanting to work for us than we have shifts for them to work,” she says. “But if there was a major outbreak in the community, would we still have the depth and breadth that we have now? Probably not. We would have some, but not as many.”
In addition, Dr. Bell says, figuring out how to flex up staffing to cover the busiest census periods makes it even harder to figure out how to “right-size” a hospitalist program. At her hospital, for instance, the patient census this August and September “dropped to about half of what it normally is.” Discussions started about the need to “flex down,” by maybe dropping one physician.
“Our practice volume is back up so that wasn’t necessary,” says Dr. Bell. “But we always need to be fiscally responsive in terms of do we have enough providers to match the volume or are we overstaffed.” Although the conversation on how to right-size the practice was aborted this fall, she says, it may return.