Published in the November 2006 issue of Today’s Hospitalist
Is hospital medicine in danger of becoming a victim of its own success? That may seem like an odd question given the specialty’s booming growth, but industry experts worry that the pace of growth at some practices may spell trouble in the near future.
Part of the problem is hospitalists’ seeming inability to say “no” to new opportunities. Whether they’re hungry for more revenue or eager to
prove the value of hospital medicine, there are signs that some groups around the country are biting off more than they can chew.
Hospitalist practice consultant Martin Buser, MPH, says the number of hospitalist groups he sees falling into this trap is on the rise. Just a few years ago, he explains, nearly all the calls he received were from new programs starting up and looking for feasibility studies.
Not anymore, explains Mr. Buser, a partner with Hospitalist Management Resources LLC in Del Mar, Calif. “About half of our consults are mature programs that have run into trouble because they’ve grown too fast,” he says. “At that point, you have to get in there fast before the group goes over the edge.”
Once a group slips over that edge, Mr. Buser notes, it can be a long road back. That was the lesson learned at Salem Hospital in Salem, Ore., where one hospitalist service imploded under the weight of too much work and too little planning.
Several years later, a new program is now thriving in its place, thanks to extensive support and carefully controlled growth. But the resuscitated program had to weather skittish recruits and skeptical local physicians who had troubled memories of the first program’s demise.
Here’s a look at what went wrong with the hospitalist program at Salem Hospital, and how the program was reborn “after lots of hard work and perseverance.
A downward spiral
It all started in 2000, when a local independent physician association (IPA) with health plan funding set up three physicians to serve as hospitalists at Salem Hospital, a regional medical center located one hour south of Portland.
The IPA, which had about 35,000 full-risk Medicaid patients, hired the hospitalists to control utilization for those patients as well as to provide emergency department (ED) call coverage to its primary care physicians. But the program quickly grew to include surgical co-management and inpatient coverage for primary care and subspecialty consults.
With no caps on daily census or on the number of primary care contracts, the service snowballed to one with “too many patients, too few physicians and no infrastructure to support it,” says Mr. Buser, whose consulting group was called in after the program had dissolved. As an example of how far the group was in over its head, he says that during the Christmas holidays, all of the primary care physicians signed out their patients to the hospitalists, leaving them responsible for every patient in the hospital.
Burned out and feeling unappreciated by their poor reception and lack of financial support, physicians began leaving the group. By the time the IPA pulled the plug on program funding two years later, only one of the three full-time hospitalists was still on staff.
Kaiser Permanente, which has local HMO members but no hospital, continued its hospitalist service at Salem for Kaiser patients. And when the IPA’s hospitalist program failed, Salem Clinic, a local multispecialty group with more than 50 doctors, hired a hospitalist of its own to follow patients when they were admitted.
But for most of the community physicians who had grown to depend on Salem’s hospitalists, they had to once again round on their own inpatients. They also had to shoulder care for the unassigned patients who make up a major portion of the hospital’s more than 100,000 emergency and urgent care visits every year.
Laying the groundwork
Fast forward one year when Norman F. Gruber, MHA, was named Salem’s new president and chief executive officer.
One of his first priorities was to hammer out a long-range strategic plan for the hospital, which would include reviving a hospitalist service. But he soon learned that the medical staff would talk about long-term strategies only after a hospitalist program was restored.
“The physicians said, ‘We don’t want to talk about the future until we deal with some immediate issues’ “and having hospitalists was at the top of that list,” Mr. Gruber says. From the outset, he decided to correct what he saw as a major flaw of the first program: The hospital had had, in his words, “no skin in the game.” With the new hospitalist program, the hospital, not an IPA or health plan, would financially support the program.
When the hospital issued a request for proposals, it heard from one local physician group and two outside companies. Mr. Gruber says that the fact that the first program had imploded was a big factor in the hospital’s decision to go with an outside group.
“The group that made the local proposal didn’t have a structure or hospitalist experience,” he says. “We didn’t want to replicate what had happened the first time with local physicians.”
Mr. Buser, whose company guided the revival of Salem’s hospitalist group, says that the goal was to create a state-of-the-art program that had sufficient staffing, financial support and systems. Also key, he says, was to make sure that growth in the new program would be controlled and follow a well-defined plan.
The proposal Salem eventually accepted was from Sound Inpatient Physicians, a hospitalist management company that now has 18 hospitalist services throughout the Pacific Northwest. Sound’s chief executive officer, Robert Bessler, MD, made it clear from the beginning that unlike the defunct hospitalist program, the new service could not “at least in its early stages “be all things to all people.
“While it may be good for revenue, fast growth is always on the backs of the docs,” says Dr. Bessler. To avoid the mistakes of the first group, the service wouldn’t begin until three physicians had been hired. “And we stressed that the group would spend the first six months just managing the ED unassigned before we would start signing up any primary care physicians.”
Salem gave Sound a timeline to have the program staffed and up and running. But that deadline came and went, with no physicians yet on board.
“We underestimated going in how much damage the demise of the first program did in the surrounding communities,” Dr. Bessler admits. He recalls that at the same time that his group was recruiting hospitalists for Salem, it was also getting a program off the ground in Portland, Ore.
“In Portland, we were able to recruit all the physicians within five or six weeks,” Dr. Bessler says. While several of the applicants who were not hired in Portland were looking for other opportunities, “All of them knew what had happened with Salem’s first program,” he adds, “and none were interested.”
While Sound was eventually able to hire one physician, a hospitalist from Oregon, it also had to go far afield in its search for candidates “and offer a premium in terms of salary and incentives.
The physicians who originally signed on to the new group came from all over the country. The chief hospitalist, Claire E. Norton, MD, was formerly an office-based internist in Texas. The revived three-physician hospitalist program was finally launched in August 2005.
During the long recruitment process, Dr. Bessler says that several members of Salem’s medical staff championed the proposed program, going out of their way to meet with prospective recruits.
But once the program was up and running, according to Dr. Norton, she and her colleagues ran into some resistance. For one, there were some initial hard feelings from the local physicians who’d proposed organizing the new service. Even more pronounced was “a lot of skepticism that the program would fail like the first one had,” she says. “We got bombarded with that attitude for a while.”
Along with sharing coverage and call with her two original colleagues, Dr. Norton says she made plenty of time in her first few months to try to bring skeptical physicians around.
“When it became obvious that this was going to work, that attitude just dissolved,” she says. At the same time, she points out that before medical school, she spent several years as an elementary school teacher. “That perhaps gave me some interpersonal skills,” she says, “that may have been particularly good for this situation.”
Keeping some services on hold
Once the program was up and running, both Sound Inpatient Physicians and the hospital’s administration held to the principle of tightly controlled program growth. (See “Keeping the reins on growth,” below) According to Dr. Norton, the program’s ability to cap its daily patient census at 15 during the first few months was also a big help.
At the same time, the hospital initiated several other programs to make sure the hospitalists wouldn’t be overwhelmed. It launched a program, for instance, to pay subspecialists for taking ED call. Mr. Buser says this change was critical because it provided specialists willing to accept referrals.
The hospital also implemented both an orthopedics hospitalist and an obstetrics hospitalist service, as well as an intensivist program. All of those groups, Mr. Gruber says, “complement each other. If we didn’t have these programs, the hospitalist program might not work as well.”
Within three months, the hospitalist group had grown to five physicians, and then two more came on board in April 2006. (As a sign that the group had shed some of its old reputation, it was able to recruit many of these physicians from the region.) But what was originally scheduled to be a six-month moratorium on primary care coverage stretched to eight months, until the program had grown to seven physicians.
Since April, the hospitalists have been providing inpatient coverage for a total of 48 office-based clients, in addition to all the ED unassigned.
But there are still several primary care physicians on the program’s waiting list, Dr. Norton says, as well as other services that are being kept on hold. The Kaiser hospitalists have asked Dr. Norton’s group for coverage help, which will have to wait.
“The surgical service could use a lot more help and the orthopedic group would like us to do their admissions and medically screen their patients prior to surgery,” she adds. “But we don’t have the manpower.”
Her group has likewise said “no” for the time being to the psychiatrists who want the hospitalists to admit and screen all their patients, and to Salem’s regional rehabilitation center, which is three miles away and wants the hospitalists to round on its patients.
And while the hospitalists have taken on post-surgical blood sugar control in certain areas, like cardiothoracic surgery, “We could do those glucose rounds for all of surgery, which might be as many as 100 patients daily,” Dr. Norton says. “But we’re not up to that yet.” According to Dr. Bessler, Sound Inpatient Physicians plans to grow the program again to 10 doctors this winter “when it will carefully consider which services to add.
Since the Salem group was launched in 2005, Dr. Bessler’s company has taken over the management of three other existing hospitalist groups that, like the first program at Salem, lacked clear direction and discipline.
“There’s no lack of demand, which is the reason why hospital medicine is the fastest growing specialty,” Dr. Bessler says. “If you don’t know how to say no appropriately, the person who suffers is the physician.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist
Telltale signs that your program is in trouble
How can you tell if your hospitalist program is growing too fast or stretched too thin? Practice consultant Steven Nahm, vice president of physician services for The Camden Group in El Segundo, Calif., lists the leading indicators that a hospitalist group needs help fast:
- Too many shifts. Are you continuously working 10 shifts in a row? Or instead of working 18 shifts a month, are you working 30? Mr. Nahm says both are clear signs that your group isn’t at the right level of staffing and has taken on too many services. While you can handle the volume in the short term, it spells trouble.
- Too high daily census. You’ll find seasonal peaks when you have more admitted patients than at other times of the year. But Mr. Nahm says he is leery of average census figures that continuously hover above 19 or 20 patients per daytime hospitalist.
- Creeping resource use. Another leading indicator that a group needs help: Are monthly trends, including length of stay and the use of consultants and other resources, inching up rather than staying flat or declining? Overworked physicians are often major contributors to performance problems.
- Poor communication within the group. The lack of informal and formal communications among a group’s members is generally a sign of dysfunction. Do you have monthly meetings to review the group’s performance on core measures and quality outcomes? Do you hold journal clubs to help each other stay abreast of advances in evidence? If you’re not clearly communicating and working well with each other, Mr. Nahm says, “you’re going to have problems.”
- Complaints from patients and colleagues. Another leading indicator of trouble: Mounting complaints from other physicians, as well as from nurses and patients, about hospitalist response time and signs of stress. Are physicians hard to reach or don’t respond quickly?
- Tantrums and blow-ups. These are classic signs of stress and burnout. “When they finally just blow up at the nursing staff,” Mr. Nahm says, “you have a problem.”
- Lack of participation in medical staff and hospital activities. “The hospitalists are supposed to be the change agents and leaders of the hospital,” says Mr. Nahm. When they’re not serving on medical staff committees and socially engaged, he adds, “it’s a sign that they see this as just a job or they are just too busy, and neither is good.”
- Capping services. When mature programs still need to rely on caps “cutting off their service when patient volume hits a certain threshold “they haven’t right-sized their staffing or schedules.
What to do? Practice consultants suggest that groups in trouble immediately go back to basics and concentrate on core services until help is recruited.
But what hospitalist groups tend to do instead is “internalize it and just work harder,” says Martin Buser, MPH, a partner with Hospitalist Management Resources LLC in Del Mar, Calif.
“Everybody sucks it up, which works for about six months,” he says. Then something catastrophic happens “a hospitalist will get sick, two others will leave, recruiting efforts will stall “”and the program gets into real trouble very fast.”
Mr. Buser also points to another symptom that your program needs an overhaul: Salaries are no longer competitive.
“Usually, program leaders are so busy trying to rescue the program that they don’t realize their compensation now trails the market by $20,000 or $30,000,” he says. “Hospitalists figure out very quickly that they can go across town and make more money.”