Published in the September 2005 issue of Today’s Hospitalist
Patients assume that doctors are camped out in the wards overnight caring for sick patients, and consultants say that a growing number of hospital administrators are demanding “real” hospitalists who can provide 24/7 coverage. In the hospitalist community, however, not everyone thinks that around-the-clock coverage should be the dominant practice model.
That view confounds Stacy Goldsholl, MD, a national medical director for Cogent Healthcare, who has a strong view of the importance of 24/7 coverage by hospitalist programs.
“I know I’m a little bit controversial here,” says Dr. Goldsholl, but there are some who feel that hospitalists who don’t work in a 24/7 model function merely as “inpatient rounders,” not “real hospitalists.” In her mind, hospitalists who work under other scheduling systems can’t possibly have the same impact on length of stay, quality of care and patient satisfaction as physicians in a program with 24/7 coverage.
As Dr. Goldsholl sees it, hospitalists need to be intimately connected to their hospital, not just internists who happen to practice in the hospital setting under the private practice reimbursement model. In an ideal world, she argues, hospitalists see patients more than once per day, are involved with quality improvement initiatives, sit on hospital committees and share incentives with their institutions for achieving the lowest possible length of stay and highest quality for their patients.
“If your name is hospital-ist, there is a definite connection to the hospital,” she says, and 24/7 coverage goes a long way to helping achieve those ends. “Hospitals want it,” she says. “Consumers want it. The only question “and it’s a big one “is how we are going to pay for it.”
Before joining Cogent last year, Dr. Goldsholl worked as a hospitalist for 10 years in hospitals from Georgia to Michigan. Witnessing the different staffing models used by hospitalists across the country helped cement her opinions about the importance of 24/7 staffing.
During her keynote presentation at the Fall 2005 Hospitalist CME Series in Atlanta on Oct. 17, Dr. Goldsholl says she hopes to challenge her fellow hospitalists to think differently about how they organize their practices and how they should be compensated. The meeting is being presented in cooperation with Today’s Hospitalist magazine. For instance, she thinks hospital medicine is evolving toward the model used by emergency medicine, at least in terms of how connected its practitioners need to be to the hospital.
“I’ve always been vocal in my feelings about our specialty’s evolution paralleling emergency medicine,” Dr. Goldsholl explains. “Reimbursement needs to be restructured to truly value hospitalists for what they are doing as inpatient physicians, as opposed to the private-practice model of reimbursement.”
The problem with the private-practice model, she says, is simple. Because professional fees alone can’t pay hospitalists an adequate salary, Dr. Goldsholl explains, average hospitalists are being subsidized to the tune of about $60,000 a year by their hospital. Look at 24/7 programs, she adds, and that support rises to about $70,000 per physician.
The wrong incentives?
Talk about concepts like length of stay, and the picture gets even more complicated. Because hospitalists and other attendings on the floors are paid per patient visit, Dr. Goldsholl says, they have few financial incentives to reduce length of stay. This runs contrary to the goals of hospitals and their administrators.
“Right now,” Dr. Goldsholl explains, “there is an economic disincentive to truly be efficient with length of stay and at the same time take home a marketable, competitive salary. If I cut my length of stay by 30 percent, I am cutting my salary by 30 percent because I get paid per visit.” With some payers now refusing to pay physicians for services provided on the day of discharge, she says, the situation will only get worse.
“To me,” Dr. Goldsholl says, “a hospitalist is there to manage length of stay as a vehicle for the hospital in providing cost-effective and high quality care. I should have no financial incentive to keep a patient an extra day.”
In emergency medicine, by contrast, many physicians are paid by the hour. Even when they are paid professional fees, the patients they see are considered “emergency.” As a result, payers tend to categorize them as more acute and reimburse them at a higher rate.
“It’s kind of an oxymoron,” Dr. Goldsholl says. “A patient is seen as acute and emergent in the emergency room. Then when the patient meets acuity and necessity for inpatient admission, the reimbursement for the subsequent physician care does not always keep pace.”
This is why Dr. Goldsholl concludes that hospitalists “need a different definition of productivity” that doesn’t revolve around patient encounters. She acknowledges that a hospitalist who stays in a hospital overnight may not be as productive, based on patient encounters, as someone in the hospital rounding and admitting during the day. But she says that doesn’t mean there is no value.
“What is the value added by a 24/7 program?” she asks. “Is it a code blue team? Is it a rapid response team? Is it a night admitting service for the medical staff? Is it patient satisfaction? Is it functioning as intensivist extenders? Is it throughput?”
Dr. Goldsholl notes that the market clearly values hospitalists, but the question now is how the market will value 24/7? “I really think that is the break point we are at now,” she explains.
In the decade she has worked as a hospitalist, Dr. Goldsholl says she has had a chance to experience firsthand most of the employment models hospitalists work under, from hospital employee to private practitioner and now to hospitalist management company.
She says that no matter what model they work under, hospitalists must be paid an appropriate income and given a reasonable patient census. In addition, the hospital needs to recognize the value that hospitalists bring to the institution and has to agree to share gains with them.
Making the switch
Hospital-sponsored hospitalist programs are leading the charge for 24/7. The Society of Hospital Medicine’s 2003 benchmark survey, Dr. Goldsholl says, found that 39 percent of the responding hospital medicine programs reported that they provide 24/7 coverage. She notes that nearly 50 percent of hospital-employed programs, by contrast, said they provide around-the-clock coverage.
“There is a true benefit to having a night physician see a patient in the emergency room at 3 in the morning and admit you then, as opposed to being called at home, giving orders over the phone and seeing the patient at 10 the next morning,” Dr. Goldsholl says. “That’s a half a day of savings right there. And the rest comes when staffing ratios are such that doctors are not overloaded with their patient census and are able to make second visits during the day to maintain efficiency.”
Dr. Goldsholl acknowledges that her view of what constitutes a “real hospitalist” may be controversial within the specialty, but she says her intent is to get hospitalists thinking about what makes them so valuable to the profession, so they can be compensated and treated fairly. “This is a win-win situation,” she says.
Deborah Gesensway is a freelance writer who reports on U.S. health care from Toronto, Canada.