AS DIVISION CHIEF of general medicine at The University of Texas Medical Branch (UTMB) in Galveston, Sunil Sahai, MD, says that he and his colleagues try to hew to “what is recognized as a safe teaching hospital census: 12 to 15 patients per team.”
Yet he is increasingly aware that hospitalists in community facilities are seeing many more patients than that a day, sometimes up to 25 when working alone—or up to 40 paired with an advanced practice provider (APP).
“For me, seeing up to 25 patients is two doctors,” says Dr. Sahai. “I’m always surprised to hear that other groups can take care of twice as many patients.” Research is also delivering conflicting messages, he points out. While studies have historically found strong associations between higher hospitalist workload and longer length of stay, a study this summer in the Journal of Hospital Medicine found, the authors wrote, no “meaningful or consistent associations between high workload and clinical outcomes.”
“We need sister hospitals with better payer mixes.”
Sunil Sahai, MD
The University of Texas Medical Branch
Such findings give Dr. Sahai pause. “When RVUs are our only currency,” he asks, “how do you account for quality of care?”
The push toward greater productivity is nothing new. But groups now say that hospitals are pressuring them to do more with less—and for many, that means seeing their individual census climb. What used to be a doable load of daily encounters keeps rising to 20 or beyond, with no help from locums or backup physicians. Hospitalists worry that isn’t safe, efficient or sustainable.
At the same time, covid relief funds, which kept hospitals afloat, are a thing of the past. Both commercial and public insurers are keeping reimbursements down, while supply and labor costs have shot up.
Those financial realities are squeezing the long touted hospital medicine business model in which seeing 15 patients a day is the sweet spot and hospitalist subsidies can rise indefinitely.
“Hospitals right now are under significant financial pressure due to high costs and declining revenue,” says Rohit Uppal, MD, chief clinical officer of TeamHealth Hospital Medicine. “They have less ability to subsidize their hospitalist program, and the recruiting marketplace is tight with hospitalists demanding higher salaries. In the short term, it’s a very difficult equation to work through.”
Relying on consultants
Calls for greater productivity were already on before covid. “The pandemic dollars helped soften that blow,” Dr. Sahai says. “But now it’s actually worse because there are fewer dollars than there were before.”
“The one thing that matters that groups can control for their members is census.”
Thomas Pineo, DO
UPMC Community Osteopathic
As to how hospitalists in other hospitals can see up to 25 patients a day, he and his colleagues have some insights. After all, he explains, UTMB has “historically been the hospital of last resort for the state of Texas,” and patients from community hospitals throughout that state and Louisiana are transferred there.
“When a patient comes in with heart failure, liver cirrhosis and kidney disease, the internal medicine attending and the residents manage all those—and residents can’t call consults without an attending’s OK,” says Dr. Sahai. “But patients transferred from private hospitals have already seen three consultants there before they get here.” Relying on consultants, he points out, allows community hospitalists to spend less time with each patient and to move on more quickly. It also, “in my mind, raises the cost of care.”
At the same time, Dr. Sahai admits that 40% of the patients treated at the UTMB main campus on Galveston, a Gulf Coast island, are either uninsured or covered by Medicaid. The academic center maintains a hub-and-spoke model with several affiliated hospitals that have many more patients covered by Medicare or private insurance, with better reimbursement.
“Like many academic health systems in underserved areas, the ‘mothership’ hospital can’t survive on its own,” he says. “We need sister hospitals with better payer mixes to provide the revenue that supports the mission: taking care of underserved and at-risk patients.”
A sustainable model
Nationally, as hospital executives increasingly make bottom-line decisions that “patients equal dollars,” Dr. Sahai finds it becomes difficult to define quality of care. “Is it better quality to see only 12 patients a day where you can spend time with every patient, or have 24 a day with numerous consultants? I don’t know how to answer that.”
“We set a unique productivity target for each practice.”
Rohit Uppal, MD
TeamHealth Hospital Medicine
That uncertainty, he adds, makes it tough for hospitalists to figure out the best way to adapt their service lines and choose a care model to use. Should physicians see patients alone or supervise one or more APPs and/or residents? And what are reasonable census levels—and quality metrics—for each model?
Thomas Pineo, DO, hospitalist site director at UPMC Community Osteopathic in Harrisburg, Pa., believes his group members have a good handle on what census level and care model works, at least for them. The hospitalists each see 15 patients a day, and they are each paired with an APP who sees 10.
“There is a lot more to hospital medicine than how many patients did you see at the end of the day,” says Dr. Pineo. “This is the model that I have found to be sustainable over years.”
Maintaining that level of census, he adds, gives physicians time to discuss end-of-life goals with patients and families and get a good sense of the social health determinants that help land patients in the hospital in the first place. And it gives teams time to coordinate care across disciplines and to make peer-to-peer calls to insurers to make sure the hospital gets paid.
Size helps manage census
Maintaining that census also produces happy hospitalists. “The one thing that matters that groups can control for their members is census,” Dr. Pineo says. As site director, when he sees that a day hospitalist is starting with 18 patients, he cancels meetings or cuts back on administrative time to take care of some of those patients that day.
“I want that team member back at 15 patients,” he says. “I live by the 80/20 rule: You should have good days 80% of the time and struggle a bit the other 20%. We aim to have physicians 80% of the time able to eat lunch, leave on time and get their notes done.”
But if you flip that rule so hospitalists struggle 80% of the time to get through a high census, “they will cut corners and minimize phone calls and interactions,” Dr. Pineo says. With a high census, doctors become transactional, working to solve their own problems to reach a hectic finish line by the end of the day, rather than the problems patients need addressed.
He admits, however, that the sheer size of his group—150 providers across seven local hospitals— “makes it much easier to manage census.” In a small program in a small hospital, “when the census goes through the roof, you can share that burden with only three or four providers. We have 60 on a daily basis.”
While Dr. Pineo is not being pressured to boost productivity, his group is tasked to better manage length of stay—which, of course, affects census. To do so, they are using what he calls “nontraditional” patient care models including hospital at home and telemedicine.
In terms of telemedicine, some group members pick up extra shifts and do follow-up phone calls with high-risk patients one to three days post-discharge. “A good example is a patient admitted with a urinary tract infection and we’re waiting for sensitivities,” he says. “We can send them home, which lowers their costs of care and length of stay. Then we can review culture results and adjust antibiotics accordingly.”
Any care model that can lower costs is on the table, says TeamHealth’s Dr. Uppal. In almost every hospital and health system he interacts with, “executives are tasked with cutting costs and operating with lower revenue. One way to continue to pay high hospitalist salaries and not increase subsidies is to improve productivity.” His team has been working to figure out how each hospitalist program can improve productivity without negatively affecting quality, throughput or hospitalist burnout.
TeamHealth measures each group’s productivity daily; their patient experience, length of stay and readmission rates monthly; and hospitalist engagement every year. Since 2018, Dr. Uppal and his fellow hospital medicine leaders have been using those data in what they call the “productivity redesign committee,” pulling together clinical and administrative leaders from across the country.
A key component of the program has been the use of productivity coaches. “The committee identified hospitalist leaders of teams that achieved high levels of quality, physician engagement and retention—and productivity,” says Dr. Uppal. “We leverage their skill by having them partner with leaders at other facilities.” The committee has also developed a toolkit with a “how to” manual that has best practices, processes and support to operate more efficiently.
No right census
So what is the secret sauce for greater productivity? There is, Dr. Uppal says, no one right answer. “Each practice is so unique that you have to look at what kind of support is available,” he says. What’s the patient acuity level and specialty support? Do hospital bylaws or state restrictions limit APPs’ practice? Do hospitalists round in the ICU or do procedures? And are workflow opportunities like geographic assignments and effective multidisciplinary rounds in place?
“We have a calculation we use to set a unique productivity target for each practice,” he says. “We rolled this project out to 58 practices, and 52 of them improved their productivity.” Importantly, measures such as patient experience scores, readmission rates and case mix index-adjusted length of stay weren’t significantly affected.
That helps in the short term, Dr. Uppal notes. But in the long term, the stability of the hospitalist business model “is really going to be determined by where reimbursement goes. Hopefully, the public and politicians will realize that hospitals and physicians need more support.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.
Published in the November/December 2022 issue of Today’s Hospitalist