Many hospitals are establishing hospitalist programs to provide more focused care to hospitalized patients and to help reduce length of stay and readmissions. In late August, for instance, St. John's Mercy Heart and Vascular Hospital in St. Louis began a cardiology hospitalist program to standardize care practices and improve the quality of care. However, hospitalists can be costly for hospitals, which often must pay subsidies to hospitalists when the services to patients do not generate sufficient revenue. R. Jeffrey Taylor, president and COO of IPC The Hospitalist Company, explains how a change in the hospitalist staffing model may reduce the need for subsidies.
Staffing
Hospitalists may need subsidies for several reasons, including an unfavorable payor mix and nocturnist program. The biggest driver of cost, however, according to Mr. Taylor, is the hospitalist staffing pattern. In the current pattern, hospitalists work for seven days and are off the subsequent seven. While popular among hospitalists, this model gives them only 14 days a month to see patients, which is usually an inadequate amount of time to generate enough revenue for the hospital to avoid subsidies. Mr. Taylor suggests using a traditional staffing model for hospitalists, in which they work five days a week, take four weeks for vacation and cover weekend work on rotation.
Productivity
A traditional staffing model may lead to increased hospitalist productivity. Hospitalists working five days a week and occasional weekend shifts would have about 21-22 days to see patients, allowing hospitalists to see enough patients a month to cover their salary and benefits and thus reduce or eliminate the need for subsidies from the hospital, Mr. Taylor says. While both staffing models require the hospitalists to work a similar number of hours, hospitalists are able to see more patients under the traditional model because of the increased number of days they work. Some hospitals cap patient volumes for hospitalists working in the seven-on/seven-off pattern, according to Mr. Taylor. "That just further exacerbates the need for the hospital to subsidize the program because they are working fewer days and seeing fewer patients," he says.
Mr. Taylor says recently, hospitals have been subsidizing hospitalists at more than 50 percent of their total compensation, a figure that has been rising in recent years, according to the Society of Hospital Medicine. In the traditional call schedule model, however, hospitals need to subsidize only 10 or 15 percent of pay and often less, according to Mr. Taylor. Typically this yields a subsidy-to-compensation ratio of roughly a third of the block-schedule model, he says. "A program staffed [the traditional] way can require a smaller subsidy from the hospital because it would only be looking at [the costs from an unfavorable payor mix and nocturnist program] and not the extra burden from staffing."
Mr. Taylor predicts that the high cost of subsidizing hospitalists in the more popular seven-on/seven-off staffing model coupled with increasing economic pressure will eventually spur hospital leaders to consider staffing hospitalists in the standard pattern, as they do for other physicians, nurses and employees at the facility. "If the high cost of the hospitalist program is being driven by essentially a lifestyle choice of the doctors in the program, [hospital CEOs] may rethink that and try to migrate to a different staffing model," Mr. Taylor says.
Hospital alignment
Hospitalists who work a five-day-a-week schedule will also be able to closer align with the hospital because they would be at the hospital more often than the hospitalists in the seven-on/seven-off model. "Doctors who are choosing to come to work every week are invested in their career and their hospital," Mr. Taylor says. "They are available as things are developing in the hospital." In contrast, hospitalists who work every other week may not be able to participate in committees or initiatives if they occur on the hospitalists' "off" week. Furthermore, this work pattern does not provide continuity in staffing for the nurses and other employees because two groups of hospitalists are switching each week. The seven-on/seven-off model also requires twice as many hospitalists as the traditional staffing model, which could exacerbate the current hospitalist shortage, Mr. Taylor says.
Challenges
Although the traditional employment pattern offers several benefits, including a reduced need for hospitals to pay subsidies, challenges remain. For one, the seven-on/seven-off model is "immensely popular with doctors choosing this career," according to Mr. Taylor. Its popularity may affect how quickly a hospitalist program using the traditional staffing model can recruit hospitalists. "There is a bit of an advantage in staffing the program quickly using seven-on/seven-off because it's an attractive work model, particularly for younger doctors coming out of training," Mr. Taylor says. "It might take slightly longer to do in [the traditional] model." In addition, hospitals would face the high expense of a nocturnist program in both models because of the difficulty in recruiting hospitalists to work this shift. A traditional model is not feasible for a hospitalist nocturnist program, Mr. Taylor says, because no one would want to work the night shift five days a week every month. Instead, the seven-on/seven-off model would be more appropriate.
Learn more about IPC The Hospitalist Company.
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Staffing
Hospitalists may need subsidies for several reasons, including an unfavorable payor mix and nocturnist program. The biggest driver of cost, however, according to Mr. Taylor, is the hospitalist staffing pattern. In the current pattern, hospitalists work for seven days and are off the subsequent seven. While popular among hospitalists, this model gives them only 14 days a month to see patients, which is usually an inadequate amount of time to generate enough revenue for the hospital to avoid subsidies. Mr. Taylor suggests using a traditional staffing model for hospitalists, in which they work five days a week, take four weeks for vacation and cover weekend work on rotation.
Productivity
A traditional staffing model may lead to increased hospitalist productivity. Hospitalists working five days a week and occasional weekend shifts would have about 21-22 days to see patients, allowing hospitalists to see enough patients a month to cover their salary and benefits and thus reduce or eliminate the need for subsidies from the hospital, Mr. Taylor says. While both staffing models require the hospitalists to work a similar number of hours, hospitalists are able to see more patients under the traditional model because of the increased number of days they work. Some hospitals cap patient volumes for hospitalists working in the seven-on/seven-off pattern, according to Mr. Taylor. "That just further exacerbates the need for the hospital to subsidize the program because they are working fewer days and seeing fewer patients," he says.
Mr. Taylor says recently, hospitals have been subsidizing hospitalists at more than 50 percent of their total compensation, a figure that has been rising in recent years, according to the Society of Hospital Medicine. In the traditional call schedule model, however, hospitals need to subsidize only 10 or 15 percent of pay and often less, according to Mr. Taylor. Typically this yields a subsidy-to-compensation ratio of roughly a third of the block-schedule model, he says. "A program staffed [the traditional] way can require a smaller subsidy from the hospital because it would only be looking at [the costs from an unfavorable payor mix and nocturnist program] and not the extra burden from staffing."
Mr. Taylor predicts that the high cost of subsidizing hospitalists in the more popular seven-on/seven-off staffing model coupled with increasing economic pressure will eventually spur hospital leaders to consider staffing hospitalists in the standard pattern, as they do for other physicians, nurses and employees at the facility. "If the high cost of the hospitalist program is being driven by essentially a lifestyle choice of the doctors in the program, [hospital CEOs] may rethink that and try to migrate to a different staffing model," Mr. Taylor says.
Hospital alignment
Hospitalists who work a five-day-a-week schedule will also be able to closer align with the hospital because they would be at the hospital more often than the hospitalists in the seven-on/seven-off model. "Doctors who are choosing to come to work every week are invested in their career and their hospital," Mr. Taylor says. "They are available as things are developing in the hospital." In contrast, hospitalists who work every other week may not be able to participate in committees or initiatives if they occur on the hospitalists' "off" week. Furthermore, this work pattern does not provide continuity in staffing for the nurses and other employees because two groups of hospitalists are switching each week. The seven-on/seven-off model also requires twice as many hospitalists as the traditional staffing model, which could exacerbate the current hospitalist shortage, Mr. Taylor says.
Challenges
Although the traditional employment pattern offers several benefits, including a reduced need for hospitals to pay subsidies, challenges remain. For one, the seven-on/seven-off model is "immensely popular with doctors choosing this career," according to Mr. Taylor. Its popularity may affect how quickly a hospitalist program using the traditional staffing model can recruit hospitalists. "There is a bit of an advantage in staffing the program quickly using seven-on/seven-off because it's an attractive work model, particularly for younger doctors coming out of training," Mr. Taylor says. "It might take slightly longer to do in [the traditional] model." In addition, hospitals would face the high expense of a nocturnist program in both models because of the difficulty in recruiting hospitalists to work this shift. A traditional model is not feasible for a hospitalist nocturnist program, Mr. Taylor says, because no one would want to work the night shift five days a week every month. Instead, the seven-on/seven-off model would be more appropriate.
Learn more about IPC The Hospitalist Company.
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