Orthopedic and obstetric surgeons are vital assets to any hospital, delivering essential patient care and serving as significant drivers of revenue.
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Yet hospitals facing thinner margins and a competitive recruiting environment find it increasingly difficult to maintain adequate ED coverage for specialty services. As a result, hospital leaders are challenged to provide the same high standard of care with fewer available physicians. Due to limited availability from local orthopedics and obstetricians, organizations often rely on physicians for on-call coverage, rather than keeping an orthopedic or obstetric specialist in-house 24/7.
Under this model, hospital staff page on-call physicians if a patient visits the ED and requires specialty care. Unfortunately, time spent waiting for a physician to arrive can present clinical and operational setbacks, particularly in obstetric medicine, when seconds can make the difference between a good and bad outcome. To compound patient safety concerns, relying on on-call coverage can influence the patient experience through longer wait times in the ED and inefficient throughput.
Moreover, inadequate ED coverage has financial consequences. Facilities that cannot fulfill patients' orthopedic or obstetric needs are forced to transfer cases to other facilities for care — essentially sending revenue to competitors.
"And not only ED revenue — additional consult services, radiographic workup, inpatient pharmacy charges. All of that is lost when a case must be transferred," Neil Vining, MD, MBA, national director for surgical services at TeamHealth, told Becker's.
Hospitals nationwide are seeing value in implementing specialty hospitalist programs to elevate the standard and accessibility of emergency care to pregnant and orthopedic patients.
This article examines industry trends contributing to difficulties in orthopedic and obstetric coverage. It unpacks the benefits of third-party hospitalist service models and identifies the advantages of partnering with experts for long-term hospitalist needs.
Trends affecting specialty coverage
Several factors, from economic realties to logistical considerations, are driving the trend toward on-site surgical specialists.
The changing orthopedic-hospital relationship
About 30 percent of ED visits are orthopedic in nature, making coverage for this specialty critical to a well-functioning ED. Traditionally, hospitals formed partnerships with local orthopedic surgeons to cover emergency cases on an on-call basis. The partnership benefited both parties: hospitals gained physicians to cover ED needs and surgeons established relationships with patients to strengthen case volume and build their outpatient practices.
However, value-based reimbursement models and the projected physician shortage are upending the long-held business relationship between surgeons and hospitals. "In a one-two punch, there are both fewer orthopedic surgeons available to cover ED and inpatient services, and the available surgeons are less likely to enter into an on-call relationship with their local hospital," Dr. Vining says.
The physician shortage is particularly acute in orthopedics. Only 670 orthopedic physicians enter the workforce each year. Of new recruits, about 90 percent seek subspecialty training, steering them away from general and trauma-related services. As a result, many hospitals are challenged to maintain enough orthopedists on staff who are qualified to cover ED cases.
Simultaneously, due to lifestyle and reimbursement issues, hospitals are finding fewer local surgeons willing to accept on-call duty. Surgeons' relationship with hospitals has become less obligatory as patient demand increases for high-reimbursement outpatient procedures, like total joint replacement. Private practice physicians no longer depend on hospitals for patient volume or revenue.
Moreover, orthopedic subspecialties allow physicians to have better work-life balance than general or acute orthopedics. Subspecialists can schedule outpatient surgeries according to their preference, and do not have to respond to pages when they leave work. This matters, as lifestyle bears increasing importance in physicians' professional decisions. Lifestyle considerations accounted for 55 percent of a physician's choice of specialty in 2002, compared to 9 percent based on income, according to a Journal of the American Medical Association study.
To guarantee patients have access to emergency orthopedic services, hospitals are implementing care models that use 24/7 specialty hospitalists to either replace or enhance on-call coverage.
Inadequacies in obstetrics triage programs
Current treatment protocol for pregnant women seeking emergency services often results in long wait times, lower quality care and poor patient satisfaction.
Women more than 20-weeks pregnant who visit the ED with an obstetric complaint — like abdominal pain or bleeding — are typically sent to an obstetrical triage area in the labor and delivery unit, where they are monitored for several hours by nurse while awaiting the patient's physician.
When the patient presents to triage, a nurse will assess the patient and call the on-call obstetrician for orders. The obstetrician will often not come in to the hospital to see the patient if they determine the patient does not need to be admitted or have an emergent issue.
This protocol can negatively affect patient care in several ways. Consider that quality of care administered through phone triage depends upon the observations and information a nurse relays to the provider, who is unable to directly interact with the patient. This limited, remote evaluation increases opportunities for miscommunication and process inefficiencies, and puts unnecessary stress on the nurse being asked to practice beyond his or her clinical scope.
Phone triage also negatively affects patient satisfaction rates. Patients often report long wait times and discontent due to the inability to see a physician. Moreover, return triage visits are higher for patients who are not treated by a physician before discharge.
"The obstetric triage area is the only place in the hospital where you can present with an urgent or emergent need and not see a physician before discharge," Khadeja Haye, MD, MBA, an OB hospitalist and national medical director for acute hospital medicine at TeamHealth, told Becker's. "Fortunately, hospital care for high-risk pregnant patients is changing, leading organizations to dedicate emergency resources just to these patients. OB hospitalists are a great way to meet that staffing need."
Hospitalist care models enable 24/7 specialty coverage
For hospitals facing a decline in reliable physician coverage, third-party, hospital-based surgical services are an effective way to guarantee emergency and inpatient orthopedic and OB care to patients.
Orthopedic hospitalist model
Under this model, a third-party partner, like TeamHealth, provides hospitals with a small team of acute orthopedic specialists who share emergency and inpatient hospital coverage on a rotating basis, ensuring a board-certified physician is available 24/7.
Because orthopedic hospitalists' primary concern is the ED, they are experts in acute orthopedic needs common in emergency situations, including community trauma and urgent care orthopedics. They also provide additional support by treating unassigned orthopedic inpatients as needed.
Unlike locums tenens coverage — that provided by a physician who temporarily fulfills the duties of an absent employee — TeamHealth orthopedic hospitalists work with hospitals on a long-term basis. An ongoing relationship has several advantages, including allowing physicians to provide follow up treatment to ED and unassigned patients and build strong, collegial relationships with employed physicians.
Besides improved patient safety and physician satisfaction, an orthopedic hospitalist model allows hospitals to capitalize on a substantial source of revenue. An orthopedic surgeon brings in estimated revenue of $2.7 million annually, according to a 2016 Merritt Hawkins report. That's more than any other specialty, including general surgery ($2.2 million), internal medicine ($1.8 million) and neurosurgery ($2.4 million).
Hospitalist-staffed OB-ED model
An OB-ED is an emergency department dedicated solely to treating women at least 20-weeks pregnant who present with obstetrical complaints. It's open 24/7 and is staffed by board-certified obstetricians. "The OB-ED really redefines the standard of women's care in the hospital setting," Dr. Haye says.
Because an OB-ED requires around-the-clock physician coverage, physician staffing is a critical component to establishing a program. With an OB hospitalist service, a hospital gains 24/7 staffing from a dedicated, on-site OB physician who can also provide coverage for unassigned OB inpatients.
The importance of quick physician response time in emergency obstetrics cases cannot be understated, as perinatal care is prone to rapid, unforeseen changes. A delivery can quickly change from routine to high risk without warning. Another advantage is that all obstetric patients receive an evaluation by a physician or advanced practice clinician prior to being discharged home. This additional benefit can only occur in a setting that ensures 24/7 presence of an Ob/Gyn hospitalist.
"The difference between a good outcome and a bad outcome is a matter of minutes in obstetrics cases," Dr. Haye says. "The patient does not have to wait for a physician to be called into the hospital — the physician is already there to ensure expedient and safe handling of any emergent situation."
Not only is an OB-ED much safer and more satisfying for patients, this model allows hospitals to capture greater reimbursement. An OB-ED staffed by dedicated hospitalists allows the hospital to bill ER facility charges for obstetric patients greater than 20 weeks, which is much higher than the outpatient charges they capture in a triage setting and which are often not reimbursable. This model also reduces the number of patients who might otherwise be transferred to another facility for treatment of a high-risk condition, thereby allowing the hospital to capture greater revenue.
Benefits of using third-party hospitalist models
Orthopedic and obstetric hospitalist programs benefit hospitals in three key ways, according to Dr. Vining and Dr. Haye.
Support for ED physicians and nurses. Having clinicians on-site to help with specialty care helps relieve ED staff of excess stress and responsibility, which is a common problem in hospitals. The specialty group that reported the greatest degree of burnout is emergency medicine at 59 percent, compared to 51 percent of physicians overall, according a 2017 Medscape survey.
Additional support provided on a long-term basis is invaluable, as it can both improve quality of care and physician satisfaction. In fact, hospitals with OB-EDs tend to have higher levels of job satisfaction among nurses and lower turnover rates, according to TeamHealth research.
"Specialty hospitalist programs can also be a huge selling point for hospitals recruiting prospective ED physicians," Dr. Vining says. "Knowing they have that level of additional support is incredibly comforting."
Improved patient safety and quality. Capacity constraints in EDs can adversely affect clinical quality, safety and the patient experience. Patients treated at crowded EDs had a 5 percent greater mortality rate and were twice as likely to experience a preventable medical error compared to patients at less-crowded departments, according to a 2012 study in Annals of Emergency Medicine.
Not only do OB hospitalist and orthopedic hospitalist models reduce ED wait times, they also elevate the standard of patient care. An Ob/Gyn hospitalist program can help ensure that each pregnant patient is quickly evaluated by a physician who is comfortable managing obstetric patients in an emergency setting. As a result, hospitals see higher satisfaction rates, better throughput, improved outcomes and decreased ED readmissions.
Enhanced community access. Specialty hospitalists enable hospitals to provide their communities with the greatest possible access to healthcare services at a local level. In some cases, these programs make the difference between treating a patient locally or transferring him or her 2 hours to the nearest facility offering treatment, which could affect his or her ability to receive long-term or follow up care.
As call coverage becomes a significant issue for specialists, a handful of companies — including TeamHealth — have emerged to help hospitals build long-term orthopedic and obstetric hospitalist programs.
"Because hospitalists work with hospitals on a long-term basis, our physicians develop a collaborative, collegial relationship with hospital staff, who truly appreciate the additional support," Dr. Haye says. "An experienced, full-service hospitalist provider has value across an enterprise, from the ED to the finance department."