Over the past decade, the number of non-physician providers (NPPs) practicing within hospitals has increased dramatically, especially in hospitalist programs. This is largely due to the increased demand for streamlined inpatient medical care and an inadequate supply of physicians. Additionally, the fact that the cost of hiring NPPs is just a fraction of the cost of hiring physicians certainly adds incentive for programs nationwide to embrace the practice.

The lack of consensus regarding the proper use of NPPs, however, is widespread and concerning.  Hospitals—and hospitalist programs in particular— must strive toward a more structured collaboration between physicians and NPPs.

While each hospital is unique and therefore requires specific staffing and scheduling solutions, there are some common characteristics of programs that have successfully integrated NPPs.

Here are the “Top 10 Keys to Success”:

1.    Avoid assigning NPPs to clerical tasks that absolutely do not match their skill sets
2.    Focus on great patient care and involve the NPPs as partners in the process
3.    Insist on CME maintenance and participation in didactics
4.    Recognize the NPP as a provider and, as such, insist on a mutually respectful work environment
5.    Provide a thorough orientation process to build strong relationships and trust among all providers
6.    Limit the daily availability of each NPP to just one or, at most, two physicians
7.    Avoid the temptation to task the NPPs with scut work
8.    Make it a priority to educate physicians  about the work and role NPPs contribute to the team
9.    Clearly define the duties and responsibilities of NPPs  
10.  Consider identifying a “Lead NPP,” especially in larger programs

For more information on how Medicus Consulting Services can help you incorporate NPPs into your program, please call 603-816-9038, email us at This email address is being protected from spambots. You need JavaScript enabled to view it. , or complete this short form to request a call from one of our consulting physicians.

Executive summary
Over the past decade, the field of hospital medicine (HM) has grown tremendously and continues to accelerate the demand for hospitalists. With this growth come issues surrounding the supply of an adequate number of qualified providers. This article provides a snapshot of the industry and suggests two steps that hospitals should take to evaluate their HM programs and best position themselves to attract and retain providers.

Present and future HM demand and supply
Most industry experts agree that the actual number of hospitalists needed nationwide hovers between 45,000 and 55,000. With approximately 805,000 staffed beds spread across 5,700 acute care community hospitals, the number of hospitalists needed to cover all these beds (at least in the near future) certainly balloons beyond expert suggestions. And the implications and potential result of adding over 30 million insured patients due to the Affordable Care Act and other healthcare changes would increase the demand for hospitalists even more. At present, best estimates indicate a total of 35,000 practicing hospitalists in the U.S. today; some of whom are not FTEs, but rather part-time providers. 

Steps for building a sustainable—and scalable—HM program
With the limited number of current HM providers and a supply-demand scenario that promises to remain heavily weighted on the demand side, it is imperative that hospitals migrate toward a system of provider retention, shunning the notion that the next hospitalist is just around the corner. Here are two steps hospitals should take:

Step 1: Identify the symptoms of a fractured HM program
Hospital medicine (HM) programs must learn how to identify the early signs and symptoms of a fractured program. The question is: What are the symptoms of a fractured HM program? Many would argue (correctly) that the symptoms are numerous and program dependent. While I agree with this position, identifying provider turnover (for established programs) and difficulty recruiting (for new programs) is a solid place to start. Identifying either of these symptoms provides one of the most reliable ways to diagnose a troubled program—or, at the other end of the spectrum, confirm a healthy HM program when neither symptom is present.

I place the following in the category of “secondary symptoms,” as they fall more in the realm of inadequate administrative and hospitalist leadership:

• Suboptimal patient satisfaction scores
• Poor core measure performance
• Suboptimal readmission rates
• Poor ED throughput
• Higher-than-expected resource utilization
• Poor colleague satisfaction

Step 2: Move in earnest to employ sustainable solutions that will not simply steady the ship but will strategically position you for the future
In this HM landscape with limited supply of and high demand for hospitalist services, providers have a very low threshold for discomfort. This is not to imply that hospital leaders must bend to the whims of providers, but consistent and deliberate attention to provider needs and concerns is an absolute must. Hospital leaders must insist on a sustainable HM model that is built on the foundation of trust, ownership, professionalism, and respect. This means:

Most hospital leaders will quickly identify with at least some of the symptoms of a fractured HM program mentioned above. The next steps beyond recognition can be complicated and difficult to achieve. Some institutions will have the infrastructure and personnel who can identify and focus on these issues and dedicate themselves to foster the dialogue and changes necessary to achieve a healthy HM program, maybe eventually even yielding the elusive Shared Institutional Vision. Others will quickly realize their institutional limitations. For the latter, seek help from a qualified hospitalist consultant. A proper assessment of your program and/or situation can yield rapid yet sustained improvement, especially when failure is just not an option.

Contact us
Medicus Consulting Services, LLC (MCS) partners with clients to launch, transition, or restructure hospital medicine programs. We specialize in helping organizations not only assess their current performance against both organizational goals and industry best practices, but implement the changes necessary to improve efficiency and performance. Contact us at (603) 816-9038 or e-mail This email address is being protected from spambots. You need JavaScript enabled to view it. to discuss your needs and how MCS can help you.

7 Industrial Way, Unit 5
Salem, NH 03079
(603) 816-9038

Implementing hospital medicine a challenge for critical access hospitals

Only a decade ago, some questioned the benefits and sustainability of hospital medicine (HM). Today, over 80 percent of hospitals with 200 or more beds have an HM program, and most hospitals with fewer than 200 beds either have an organized HM program or are seeking to develop one.

For critical access hospitals (CAHs), the progression toward organized HM services has been a bit more deliberate. Indeed, the executive teams at most CAHs struggle with the issue of HM implementation on a daily basis. Community size, difficulty in provider recruitment, slower PCP acceptance, and more challenging ROI achievement are some of the more common reasons for less HM use in CAHs.

There are, however, strong drivers for CAHs to implement the HM model, such as:

• the loss of patients to larger regional institutions, resulting in a steady, sustained decline in CAH patient volume,
• local PCPs’ displeasure in caring for marginal cases that could be managed locally if there were a dedicated physician with the requisite skill set present and available, and
• patients’ desire to be treated at their community hospital to receive care from trusted and familiar healthcare providers—and to be closer to family and loved ones.

Promising HM models for the CAH
An emerging HM model that appears to be a promising option for many CAHs: the emergency department-hospital medicine (ED-HM) hybrid model, which relieves PCPs of the burden of unassigned—and some assigned—patient referrals.
ED-HM hybrid programs share some common themes. And, in most circumstances, the system requires two FTEs per day for sustained success. But each CAH builds its ED-HM program to satisfy its unique needs and circumstances. And the ED-HM collaboration has been framed in a number of ways; usually with the actual provider staffing and schedule depending on both the ED and in-house patient activity.  As a result, there are slight variations among hybrid models. The models below highlight two of the more common arrangements.

Model #1: Two FTEs, an ED physician plus a hospitalist

Both physicians are in-house from 8 a.m. to 5 p.m. Both can be off-campus from 5 p.m. to 8 a.m., but one must remain on call at all times for admissions and cross-coverage of inpatients—responding to all patient-related issues and functioning as the house physician—with one covering 5 p.m. to 12 a.m. and the other 12 a.m. to 8 a.m.

Essentially, the two providers collaborate and function as a single unit, managing the patients within the institution. As expected, the key to success is proper communication. Throughout the day, both providers engage in a structured dialogue about the patients. At all transition points, they discuss patient status, making certain that all members of the care team (e.g., nurses, social workers, and case managers) are up to date on the plan of care.

Model #2: One house physician who functions primarily as an ED provider, but also continues care by rounding on inpatients.

This model can be accomplished only in an environment with very low patient volume that hovers at around five patients or fewer on the service at any given time. In most instances, there is a non-physician provider (NPP) available at targeted times of increased patient activity.

Both models above also will usually engage a few of the local PCPs for the rare case of disasters or an overwhelmed service. As the inpatient service gains acceptance within the community, the overall service volume will inevitably increase, requiring adjustments to meet the needs of the patients, PCPs, and institution.

On June 28th, the US Supreme Court voted to uphold the Patient Protection and Affordable Care Act (PPACA). The 5-4 decision likely satisfied a few eager constituents, but many people (including physicians) are still unaware of the actual provisions in this law. The ruling created more points for discussion since it was based on Congress’ authority to impose a tax penalty on some people who choose not to purchase health insurance. All this controversy notwithstanding, the ACA was ruled constitutional. Healthcare providers need to therefore make every effort to understand its implications as we strive to be better patient advocates.

The expansion of Medicaid was also a noteworthy point in the Supreme Court ruling. The court affirmed the constitutionality of this ACA provision for people with incomes up to 133 percent of the federal poverty level – with a caveat that limits the federal governments ability to terminate existing Medicaid funding to states that choose to opt out.

Since most of us providers have difficulty simply keeping up with our journal reading, I doubt our schedules will permit a page-by-page review of the PPACA law – it is over 900 pages. Fortunately, the Henry J. Kaiser Family Foundation released a very thoughtful and objective summary of the new Health Reform Law. It focuses on the key provisions and more importantly is devoid of any political spin. Another very useful resource for physicians is a list of inclusions and time of implementation. These documents are comprehensive and will help to educate providers about the new changes in US healthcare, now and for the next few years.

The implications of healthcare reform are here. As providers, it is our imperative to educate ourselves about this (not so) new law and become active participants, not mere observers.

I found the websites below very informative. These should provide a great start to a better understanding of the new healthcare provisions.

http://healthreform.kff.org/timeline.aspx
http://www.kff.org/healthreform/8061.cfm

Many surveys indicate that hospitalists whose compensation is mostly based on productivity have a higher total compensation and, for that matter, higher productivity. Hospitalists, especially those who are employed, are unwilling to accept compensation that is mostly based on productivity, in spite of survey evidence indicating their potential for greater financial rewards.

Try to strike a happy medium that satisfies physicians' need for a base salary while allowing some compensation to remain at risk. That will help to drive desired behaviors, such as increased productivity, increased patient satisfaction survey scores and improved performance on other various hospital initiatives.

One place to start would be setting the base salary between 75% and 80% of the total estimated compensation. The remainder should be based on incentives that are aligned with organizational goals.

For information on how Medicus Consulting Services can help you design a competitive compensation package for your market, please fill out this short form to Request a Call from one of our consulting physicians.

 

Over the past decade, organizations such as SHM, MGMA and Today’s Hospitalist Magazine have conducted surveys that give both prospective employers and hospitalists a glimpse of the national hospitalist marketplace. These reports indicate national and regional data including hospitalist activity, work type, workload and productivity. The data is very important for establishing general trends and ranges, but the question remains: What can an employer do to attract and retain qualified hospitalists?

One very important and impactful element is the compensation package, but the decision-makers in hospitalist programs should do their due diligence in seeking out comparables. Each program has so many unique aspects that even after a careful review of the local market and regional data, programs must exercise caution when interpreting those figures.

How to compare? First, what is the key clinical and non-clinical hospitalist duties required in a new (or reorganized) service? What will each hospitalist's job look like in year 1, 2, 5 and beyond? Next, review the available surveys that give details of hospitalist activities, and try to pinpoint the most pertinent categories and survey results that apply to your institution. Then, make every attempt to investigate the local market. This is easier said than done because most local competitors can be very tight-lipped about their program details. At the very least, try to find out: What services are other regional, similar sized hospitalists programs providing? How many patient encounters do they have and how long are their shifts? Are hospitalists in-house 24/7? Do they participate in pre-code or code blue situations? Do they perform procedures and, if they do, what procedures?

The goal is to make certain that you can legitimately compare the programs. During most investigations, administrators will likely discover that the hospital next door is quite different than their own. From one region to the next, employers can gain a general idea of what packages are being offered. However, if you are comparing a critical access hospital to a 100-bed facility just a few blocks apart, you might as well be comparing apples and oranges.

For information on how Medicus Consulting Services can help you design a competitive compensation package for your market, please fill out this short form to Request a Call from one of our consulting physicians.