WITH ED VISITS evaporating and elective procedures suspended in the first months of the pandemic, the University of Virginia School of Medicine in Charlottesville, Va., decided on a 20% across-the-board faculty pay cut.
For the hospitalists, “that was a bit of a bitter pill because we had plenty of work to do,” says George Hoke, MD, hospitalist director. “While some faculty were home not getting full pay, we were working and not getting full pay.” True, the hospitalists didn’t have their typical census. But “we had to learn covid, and we created a separate unit with dedicated staff. Our work was basically unchanged and just shifted to covid.”
But the pay cut was in effect only three months—and University of Virginia, like many other hospitals and health systems, gave its hospitalists and other front-line covid providers a one-time bonus to help mitigate the earlier cuts. Now, hospitalist volumes have not only rebounded to their pre-covid levels but surpassed them.
~ George Hoke, MD
University of Virginia Medical Center
“Our volumes are about 115% of what they used to be,” says Dr. Hoke. While everyone at first insisted “it’s just catch-up” with people who’d delayed surgeries or medical care, “it’s months later, we’re even higher still, and I don’t know how to explain being in a market where the demand for inpatient services continues to rise.”
And how are the hospitalists handling that rising demand? “We’re hiring.”
But Dr. Hoke’s experience and his rosy local market outlook for hospitalists are far from universal. During the pandemic, hospitals have been either slammed, decimated or both at different times, with some inpatient physicians experiencing unprecedented pay cuts or even furloughs.
Many of those doctors—and their salaries—have come back, but sometimes not completely. And while Dr. Hoke wants to hire four new recruits, others say their local markets have tightened, with fewer opportunities available.
Hospitalists’ experiences with compensation and raises also vary. Some programs plan to give raises, although perhaps not as robust as usual. But others say they’re lucky to maintain the status quo as far as pay. They need to see what the fall and winter bring in terms of resurging covid before they plan any raises.
A seller’s market?
This summer, the staffing search and consulting firm Merritt Hawkins released its 2020 review of physician and advanced practitioner recruiting incentives, the firm’s 27th annual compensation report.
While the report data were collected before March, the review included a write-up of the impact of the pandemic on recruiting. Its conclusion: For the first time, the physician recruitment market “has flipped—from a buyer’s market in which physicians had multiple practice opportunities … to a seller’s market in which physicians may have to compete for job openings.”
“The new grads who are out there are probably not in the position to negotiate as they have been in the past.”
~ Kimberly Bell, MD, MMM
Michael Belkin, JD, a divisional vice president with Merritt Hawkins, says he knew the pandemic was having a major impact when a client had to withdraw a contract it had previously extended—to a nocturnist.
But that was during the shutdown, and Mr. Belkin says that recruitment is bouncing back. While not all his former clients have returned, new ones have stepped forward. Hot specialties being recruited include pulmonology/critical care, neurology, psychiatry, anesthesiology, radiology and “tele” anything.
As for job markets on the rebound, “it is geographical,” he explains. “The Northeast and the West Coast have been slow, but most other areas of the country have very similar recruiting needs.” In Texas, for instance, where he is based, “they started opening up months ago in terms of recruiting volume. Right now, it’s not that different from what it was pre-covid.”
But on the West Coast, Kimberly Bell, MD, MMM, regional medical director at TeamHealth West in Seattle, is still seeing more of a seller’s market. According to Dr. Bell, many doctors during the pandemic experienced either reduced hours or lower compensation—or both. “In some cases, it’s come back,” she says, speaking of hours and pay. “In some cases, it’s come back, but not all the way.”
One implication: “The amount of recruiting has gone down significantly.” Inpatient volumes are still about 20% off from where they were last year, while ED visits in some hospitals are down 50%. “We’re trying to adjust staffing based on volume and to optimize productivity for our groups,” she says.
“Recruits now don’t need to be sitting in Fort Dodge, Iowa, to be a part of our team.”
~ Stephanie Johnson, MSSW
That also means much less locums use, removing a career option many young doctors have found appealing. “New providers just starting out used to work locum for several years before taking a permanent job,” says Dr. Bell. “But the locums market has dried up, and those doctors need to find work.”
Physicians right out of residency in her market are also finding that the big-city jobs they want aren’t available, at least not this year. While that helps with recruiting in secondary markets, it means that “the new grads who are out there are probably not in the position to negotiate as they have been in the past.” Instead of negotiating hard on compensation, with multiple job offers as leverage, “they’re looking for a stable environment. They’re not applying as much pressure on compensation.”
Other fallout of lower volumes: When both ED and hospital medicine groups shrink, advanced practice clinicians (APCs) are bearing the brunt.
“Groups have been much more ready to let APCs go or to cut their hours than physicians,” Dr. Bell says. “The expectation is that, given different hospital bylaws, groups can get more productivity out of a physician.”
Recruiting as usual
But in other parts of the country, hospitalist recruiting this year is on par with years past. In west Florida, hospitalist Syed Irfan Ali, MD, president and CEO of the multispecialty Pioneer Medical Group, says his group is in fact recruiting even more than usual, with 37 new doctors and APCs now in the process of being credentialed. Group members, who number about 140, work across nearly a dozen AdventHealth hospitals.
“Not only are we seeing medical patients come back to the hospital, but they’re high-risk patients.”
~ Syed Irfan Ali, MD
Pioneer Medical Group
Some new hires will cover new beds added in at least one hospital. But Dr. Ali anticipates this winter’s volumes—usually triple the number of patients seen the rest of the year—will be even higher as more snowbirds want to be able to stay outdoors during the pandemic and come south.
Then there’s this factor: “Not only are we seeing medical patients come back to the hospital, but they’re high-risk patients and we expect to see more of them who are more acute,” he points out. “I would rather be prepared.”
In the Midwest, Stephanie Johnson, MSSW, operations director of the inpatient medical service for UnityPoint Health, notes that hospital census went from being cut in half during the spring to “just soaring volumes now, and it’s not just covid. Our physicians are seeing a variety of diagnoses.”
Further, the hospitalist service—which has around 150 providers across 18 hospitals—plans to recruit about 15 more, which Ms. Johnson says is typical. Some of that new staffing is to meet program changes put in place last year to right-size provider utilization.
But the program is also recruiting for another key staffing transformation: telemedicine. The UnityPoint hospitalists launched their telemedicine program in 2019, using telenocturnists to cover several hospitals at night. But they kicked telemedicine into much higher gear when covid surged this year, expanding into all 18 hospitals.
“It’s still unclear how covid has affected compensation.”
~ Ryan A. Brown, MD
“We provided a comprehensive manual for 200 providers—hospitalists and critical care physicians, as well as nurses—so they could self-train,” she says. During the pandemic, the hospitalists began doing tele-rounds in hospitals where colleagues had tested positive. Going forward, Ms. Johnson adds, expanding telemedicine will not only get the hospitalist service past geographic coverage barriers, but broaden its pool of potential applicants.
“Recruits now don’t need to be sitting in Fort Dodge, Iowa,” she says, “to be a part of our team.”
Ryan A. Brown, MD, specialty medical director, hospital medicine at Atrium Health and the Carolinas Hospitalist Group, says his group’s volumes “have rebounded quite heavily.” As for recruiting, a typical year means hiring about 15 or 20 new clinicians.
“This year,” he says, “we’ve recruited probably around the same number.” But Dr. Brown, who is based in Charlotte, N.C., says his health system is likewise now more in the market for hospitalists to work virtually instead of onsite. Atrium Health has a long history with telemedicine, launching a division in 2013, he explains. But the pandemic jumpstarted that division’s expansion.
The health system had planned, for instance, to build out an existing post-discharge program into a full-blown hospital at home service. But covid “sped up that timeline from between 12 and 18 months to three,” says Dr. Brown. “We created a virtual hospital solely for covid patients,” one that continues to see around 25 covid patients across the system. (Also see “Going virtual with covid hospital at home.”) Hospitalists use telemedicine for cross coverage, night-time surges and admissions.
“I think more people are going to stay put in their jobs for security reasons and not really leave the area that much.”
~ Linda Kurian, MD
Both the virtual covid hospital and the telemedicine service have some dedicated hospitalists, Dr. Brown points out. At the same time, “we have providers who flex back and forth and go where they are needed. If one hospital has a low census, we can flex physicians there to virtual care and see patients in hospitals that are more busy.” The group has about 250 hospitalists in 18 of Atrium’s 40 acute care facilities.
As for recruiting virtualists, “they carry a bit of a different skill set,” he notes. “They have to have very strong patient-experience skills and be flexible enough to switch work among different sites, and those skills are a little harder to come by.” At the same time, “we’ve found that more and more of our existing hospitalists, this year in particular, were willing to experiment and try the new platform. And they’ve loved it.”
While he doesn’t see the hospitalist job market tightening, he does believe hospitalists will need to broaden their skills. “We used to just do acute care,” says Dr. Brown. “Now, we’re doing acute care, rehab, telemedicine into patients’ homes or post-discharge work.” To hone new skills, he believes hospitalists will need to “build on what they’re good at—patient experience and connecting with patients in only a few encounters.”
Raises aren’t a sure thing
As for compensation and possible raises this year, Dr. Ali with Pioneer Medical Group says it’s business as usual. “We sometimes either increase the base salary or the bonus potential. We don’t plan to stop that.”
In Iowa, Ms. Johnson says the hospitalists with UnityPoint have historically enjoyed a 4% yearly raise, with other physicians in the system given 3%. This year, leaders have proposed dropping each by one point so the hospitalists would get a 3% raise, the others 2%.
But the pandemic has played a big role in her health system’s financial performance, just like elsewhere. “This is the first time we’ve sent the proposed rate changes to the board,” she says. “There are questions about whether they will be approved.”
In Charlotte, Dr. Brown says the shutdown didn’t result in any furloughs or salary cuts, and group members’ quality and bonus incentives have stayed the same.
As for raises, “we don’t necessarily make a change every year,” Dr. Brown says. “This year, we have decided not to change our compensation, so everybody is staying at the same level for next year.” Why? “It’s still unclear how covid has affected compensation. We’ll re-evaluate next year and have a better idea of what the landscape looks like.”
In New York, Linda Kurian, MD, division chief of hospital medicine at Northwell Health’s two flagship hospitals, says her system will likewise wait and see before making any decision to boost compensation.
“Right now, we’re just trying to take stock of how the year plays out,” says Dr. Kurian. “We’re really thankful that we didn’t face pay cuts and, given what’s happened around the country with physician pay, we think that being able to maintain our salaries is just incredible.”
A more competitive market
Dr. Kurian also says that she and her colleagues believe patient volumes will stay about the same for the coming year. She is actively preparing for a covid resurgence this fall, and she wants to “broaden the bench of moonlighters” she can call on if her groups’ census starts to rise. But her hospitals aren’t recruiting doctors the way they usually do.
“We doubled our group in the past five years, and we usually hire between 10 and 20 FTEs every year,” says Dr. Kurian. But when it comes to recruitment, this year—as in so many other areas—is an outlier.
“I think more people are going to stay put in their jobs for security reasons and not really leave the area that much,” she says. The result, at least for the coming year: a much more competitive job market with fewer positions. As for hospital medicine’s longer-term prospects, however, she’s optimistic.
“I think the field will continue to grow,” says Dr. Kurian. “Beyond just the volume of patients, we’re seeing that hospitalists are natural leaders, and they’re constantly being sought after for leadership roles.
“ Mr. Belkin from Merritt Hawkins is also bullish long term. “My personal opinion is that it’s hard for this space to not be a buyer’s market,” he says. “It’s still challenging to find candidates right now.”
But for the time being, at least in her market, Dr. Bell in Seattle sees lower patient volumes as the new normal. “The pressure to expand hospital medicine is decreasing and we won’t maintain the pace of growth we’ve seen previously,” she points out. “The days when everything was wide open and each hospitalist had five or 10 job offers—I think those days are behind us.”
IN CHARLOTTESVILLE, VA., George Hoke, MD, hospitalist director for the University of Virginia Medical Center, is ramping up to hire four hospitalists for next year. So far, all the interviews—including with physicians who live locally—have been via Zoom.
“Offers are being made and contracts are being signed without the candidate ever going to the site.”
~ Michael Belkin, JD
“I try to imagine myself wanting to move 1,000 miles to a city I’m unfamiliar with, and I’d be reluctant to do that,” Dr. Hoke says. “I think not being able to travel this year will affect how people recruit and who they recruit.” He suspects his group will end up hiring more candidates from among its own pool of residents or doctors from Virginia who can at least drive for an onsite interview.
Michael Belkin, JD, divisional vice president with staffing firm Merritt Hawkins, says he has seen the entire recruitment process flip this year from having fewer than 10% of client meetings and candidate interviews done virtually to more than 95%. He finds some advantages to going virtual.
“You can speak to multiple stakeholders in different sites, which was hard to do in person,” he says. And candidates and clients are taking the opportunity to get comfortable with one another over Zoom.
“Offers are being made and contracts are being signed without the candidate ever going to the site.” While that’s not common, “it never happened before.”
In Charlotte, N.C., Ryan A. Brown, MD, specialty medical director, hospital medicine at Atrium Health and the Carolinas Hospitalist Group, says he was shocked to have new recruits actually sign on this year “without coming to see the place.
“We didn’t bring them on campus and take them out to dinner and have them meet the whole team,” says Dr. Brown. “If you build a good program, people have more comfort in being able to do that.”
He believes the size of his hospitalist group—with about 250 providers—represents stability for candidates. Still, “it was a surprise,” Dr. Brown says. “We were able to recruit during a pandemic much better than I thought we would.”
Cutting pay, hours—or neither
As their census doubled from 500 to 1,000 in April, the hospitalists in Northwell Health’s two flagship hospitals—North Shore University Hospital in Manhasset, N.Y., and Long Island Jewish Medical Center in Queens—never heard a word about furloughs or pay cuts. Instead, says Linda Kurian, MD, division chief of hospital medicine at both hospitals, the health system redeployed many of its surgeons and internal medicine subspecialists to work in the hospital.
“It was all available hands on deck,” Dr. Kurian says. The health system ended up acknowledging all of its front-line providers—from doctors and nurses to environmental services employees and housekeepers, as well as administrators—with a $2,500 bonus and a week of paid time off that they can take at any point while employed.
“I’m particularly proud of the fact,” she says, “that the bonus was across the board.”
In west Florida, hospitalist Syed Irfan Ali, MD, president and CEO of the multispecialty Pioneer Medical Group, says his group’s volumes plummeted during the shutdown this spring.
“We didn’t have to let go of a single physician or cut anyone’s salary or benefits,” Dr. Ali says. The group did, however, let its physicians know that they were in a tough financial spot. The decision: Hold physicians’ monthly quality and productivity bonus for a couple of months. That bonus, he explains, amounts to about 20% of doctors’ total monthly income.
“We ended up being able to pay out about 50% of those bonuses within 45 days and all of them in 60 days,” says Dr. Ali. “That strategy helped us, and it kept everyone together.” During this summer’s covid surge, instead of hiring locums, the group paid what it called “critical shift pay” to doctors who worked more than their standard 15 shifts per month.
And within UnityPoint Health, which has 18 acute care hospitals in Iowa, Wisconsin and Illinois, all physicians across the system took a 10% pay cut at the height of the shutdown—except for intensivists and hospitalists.
That’s according to Stephanie Johnson, MSSW, operations director of the inpatient medical service across the system. The group did, however, put a tracking mechanism in place to track hospitalist encounters per provider hours in all its programs, looking for a 1:1 ratio. “We wanted to see providers working a 12-hour shift having at least an average of 12 patient encounters.”
When the average number of encounters dipped below, “we’d reduce the number of rounders in that program the following day,” says Ms. Johnson. Because hospitalists receive a shift rate, fewer rounding days did translate into less pay—something the hospitalists didn’t complain about.
“They understand the financial reality,” she adds. Ironically, the hospitalist programs in April and May also implemented a paid jeopardy system in case a hospital was overwhelmed with covid patients or clinicians became infected and had to quarantine.
“When our volumes tanked, we were actually sending people home while also paying jeopardy as a precaution,” Ms. Johnson says. “We deployed two conflicting plans at the same time to try to manage the unknown.” Jeopardy pay was in place for only eight weeks, and the program stopped tracking patient encounters at the end of September.
As for the hospitalists and other front-line providers, the health system is considering recognizing them by paying out the full citizenship component of their performance incentive plan. “That’s $7,500,” Ms. Johnson points out. “It’s not an insignificant amount of money.”
Published in the October/November 2020 issue of Today’s Hospitalist