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Show us the Money

From: The Hospitalist, June 2006

“The Authoritative Source on the State of the Hospital Medicine Movement”— SHM’s almanac for our profession’s productivity and compensation benchmarks

by Gretchen Henkel

At a hefty 291 pages, SHM’s 2005-2006 survey, “The Authoritative Source on the State of the Hospital Medicine Movement,” contains a wealth of detail about hospitalists and their working conditions. Most readers will probably first refer to the compensation and benefits package statistics. But take a closer look: The survey’s chapters and tables yield a depth of even more helpful information.

After reviewing the survey’s “Executive Summary” (available online at the SHM Web site, www.hospitalmedicine.org), Charlene Carroll Clark, MD, a hospitalist at Inpatient Care Service at Good Samaritan Regional Medical Center in Corvallis, Ore., says “I think knowledge is always a good thing. Just knowing what is going on in other locations helps us. We can see that we fit right in with the median compensation, and that we are competitive as we recruit.”

It is reassuring, other sources concurred, to see that their hospitalist groups compare favorably with national median salaries and benefits packages. However, some group leaders caution that hospitalists should not benchmark their groups’ professional viability using only compensation and benefits medians. The real worth of the survey’s statistics, they say, will be realized when hospitalists utilize the document as a tool for improving management and care processes at their own institutions.

Indeed, in conversations with SHM leaders and with hospitalists across the country, it becomes clear that the survey has multiple uses, depending on its readers’ specific characteristics. And that’s just what SHM intends, says Joe Miller, SHM senior vice president, who was in charge of the survey project. “Our role was to create more of an almanac and a reference, rather than furnish an interpretation,” says Miller. “I think the real value for people will be in finding the metrics that are descriptive of their particular program.”

Survey Participation Increases

Miller is gratified by the increase in participation since the 2003-2004 SHM survey. Two years ago approximately 300 hospital medicine group (HMG) leaders participated in the survey. This time 396 HMG leaders participated—a 32% increase. Individual hospitalists completing the survey increased by more than 500 over the previous survey to a total of 2,550 individual hospitalist respondents.

“Given the magnitude of this survey, I think we’ve got very impressive representation of the industry,” says Miller. For instance, the regional representation of respondents was almost equally divided: 24% from the East, 26% from the South, 27% from the Midwest, and 22% from the West.

Miller attributes the greater participation to a variety of factors: conducting a multifaceted communication campaign, targeting every SHM board member and committee member, and extending the survey deadline.

An Eclectic and Thriving Group

According to Miller, the survey reveals many characteristics about hospitalists and the profession in general. While some of the results may not be surprising, they serve to corroborate (with real numbers) what many have perceived anecdotally about the hospital medicine movement. For instance:

  • The hospital medicine movement is diverse. The survey documents six different models for hospital medicine programs. Currently, 34% of hospitalists are employed by hospitals or hospital corporations, and 12% are employed by local hospitalist-only groups. Multistate hospitalist-only groups or management companies employ 19%, while multi-specialty groups employ 14% of hospitalists. Academic hospital medicine programs employ 20%, and another 2% are employed by emergency or critical care physician groups.
  • Hospitalists provide documented value for their hospitals, including around-the-clock patient care (51% of HMGs have on-site providers at night, and 41% of programs provide hospitalists on call), and participation in quality improvement (86%), hospital committees (92%), and other value-added activities, such as implementing information technology (54%).
  • Other trends emerge when comparing 2003-2004 survey results with the current survey, including an increase in HMGs that now use a hybrid coverage schedule (a combination of shift and call schedules; an increase to 35% from 27%); more groups being paid using a mixed compensation model (a combination of salary and productive/performance-based compensation; up to 67% from 47% in 2003-2004); and a slight increase in hospitalists employed by academic institutions—up to 20% from a prior 16%.

Value Added

Dr. Bolinger
Dr. Bolinger
Dr. Bossard
Dr. Bossard

The survey also underscores hospitalists’ roles as change leaders in their institutions. In the “non-clinical activities” section of Chapter 3, “The Work of Hospital Medicine Groups,” results reveal high participation in hospital committees (92%), in quality improvement initiatives (86%); and other activities, such as generating practice guidelines, teaching, planning, and research.

John A. Bolinger, DO, FACP, medical director of the hospitalist program at Terre Haute (Ind.) Regional Hospital, serves on multiple committees at his hospital: critical care, pharmacy therapeutics, patient safety, credentials (as chair), and the executive committee. He and his hospital’s clinical pharmacist have developed standardized order sets, a new IV insulin protocol, and a new DVT prophylaxis protocol.

“I think participation in non-clinical activities is a plus for the hospitalist profession,” he says. In addition, “every hospital with a hospitalist involved in practice sees a tremendous benefit from that very thing.”

The Devil’s in the Details

John Nelson, MD, medical director of the Hospitalist Practice at Overlake Hospital in Bellevue, Wash., a consultant for hospitalist practices with Nelson/Flores Associates, and cofounder and past president of SHM, was one of three panelists at the recent annual meeting where survey results were presented. Dr. Nelson believes that the statistics “can be a kind of starting point for thinking about whether your workload and compensation are typical. However,” he cautions, “the mistake I see so often is that people tend to think the average compensation, the average workload, are right for a given practice. Well, there are very few practices that are average. The variation is dramatic, and there’s no reason you should be average.”

Dr. Nelson advises hospitalists and group leaders not to interpret the compensation medians in the survey as a “final authority” for what hospitalists should be earning. Rather, he says, “what you could do is look at the big picture of an average practice—in terms of compensation, productivity, and other factors, such as location, whether your practice is primary adult or pediatric—and then compare your practice to see how you differ.

“Do you work harder and make less? In that case, you might want to fix it. If you work less and make more, you might want to be quiet!” he quips.

Brian Bossard, MD, medical director of Inpatient Physician Associates, a group of 15 hospitalists and two nurse coordinators that contracts with Bryan LGH hospital in Lincoln, Neb., to provide hospitalist services, agrees with Dr. Nelson’s characterization of the survey results as “a starting point.” While Dr. Bossard declined to state specifics about his group’s compensation figures, he did say that the median total compensation for non-leader physician hospitalists ($168,000 per year) was “about what I would expect it to be if you combine all hospitalists.”

He says that the numbers listed for HMG leaders was more reliable because leader roles are not quite as variable as non-leader roles. The survey shows that HMG leaders typically make $12,000 more annually than non-leader hospitalists, and that they tend to do less clinical work.

“It is also important to caution everyone in this area, too: This survey has not established the correct salary for a group leader—it varies tremendously,” reiterates Dr. Nelson.

In his role as HMG director, Dr. Bossard finds the survey’s work hours and work productivity data more valuable than compensation medians. “The number of hours per shift [median, 10.8] is very useful as a guide, I think, for someone who is starting a program or for someone like me, who knows what my numbers are,” he explains. “That—the median of 187 shifts per year; 10.8 hours per shift—provides an excellent target for new or established groups.”

Dr. Clark says that, in terms of pertinent data, the average number of encounters per hour was high on her list. Although that information is not highlighted in the survey’s “Executive Summary,” it is contained in Chapter 8, “Hospitalist Productivity.” Dr. Clark says this issue engenders an ongoing discussion with hospital administration.

“There are only so many patients you can see and provide excellent care, but there is a pull [from the administrative side] that they would like that number to be more,” she explains. “It’s nice to know what the average number of encounters is and what the society considers reasonable. I think it’s one of those things that we’re going to have to emphasize since the trade-off for seeing increased numbers of patients is to sacrifice quality patient care.”

Walter Bohnenblust, MD, is medical director of a hospitalist group at The Reading Hospital and Medical Center in West Reading, Pa. “What I like most about the survey is that productivity is represented not just with total billing, but with encounters and RVUs [relative value units]. We are in a low reimbursement area here, so if the survey included only gross charges and gross collections and not encounters plus RVUs, it would be more difficult in our market to justify to administration how hard we’re working. It’s uncanny how our group fits right in with the median in terms of productivity,” he says. “This gives me a baseline and more leverage with the administration, when they say we should be doing twice as many encounters as I think is reasonable.

“Like it or not, when someone is paying a subsidy for your service, they will try to get more out of you,” continues Dr. Bohnenblust. “It’s their job to try and get more out of the nurses and more out of the doctors. It’s not just us they’re picking on—the ER docs at our hospital have the same pressure. It’s good to have these numbers to go back and say, ‘Look, we are right where we should be [in terms of work productivity]. If you try and work us harder, you may lose some people and also not get out of the program what you wish.’”

Work productivity data provides an additional tool for recruitment, adds Dr. Bohnenblust, although he has not had much problem attracting new staff: “People are smart enough now to not only look at what [the prospective hospitalist group] income is, but how many patients they will have to see and what the work hours are.”

Uses of the Survey

Chapter 3, “The Work of Hospital Medicine Groups,” devotes attention to the types of non-clinical activities in which hospitalists participate. The section, say several sources, can also be a valuable negotiating tool with hospital administrators because it quantifies the amount of time hospitalists spend in such endeavors.

“One of the things that hospitalists add to inpatient care is that they have a greater presence all throughout the day in that facility,” says Timothy Bode, MD, medical director of Hospital Physician Services of Central Alabama. “And they’re a lot more involved with the medical staff, serving on committees, and involved in new processes and changes.

“To be able to see what kind of numbers are represented nationally, with hospitalists’ involvement in non-clinical activities, helps me with the hospitalists in my group,” he continues. “I can use these numbers to say, ‘This is a national trend. We need to be involved and we need to be leaders here as well, because that’s really the core of what we do.’ ”

Dr. Clark sees another important aspect of the hospitalist role: “ … participating on committees and QI initiatives and developing order sets, [which] can be additional and/or non-paid time. I think this needs to be recognized by hospitals in general, and physicians have to advocate for their value in this regard.”

The section on participation in non-clinical activities also drew praise from Dr. Bossard. “I don’t think this [percentage of time in non-clinical activities] would be necessary in terms of negotiating with the hospital, but it would be a very useful gauge for assessing where an individual program is relative to the rest of the programs, to see whether you are overdoing or under-representing yourself on committees.

“These surveys are just fabulous,” he says. “I’ve used the prior surveys to present information to the hospitals and identify how hard we’re working relative to our own region, and I present results to my hospitalist group in terms of pay and benefits. The survey is a wonderful tool.”

Academic Hospitalists Weigh In

Robert Wachter, MD, FACP, professor and associate chairman of the department of medicine at the University of California, San Francisco, and past president of SHM, also participated in the survey panel discussion and addresses issues specific to academic hospitalists. The growth in academic hospitalists shown in the current survey—while not surprising—confirms his impression that the field has grown in the last couple of years. The evidence of growth furnishes useful information for him as a hospitalist group leader in an academic institution.

“Unlike seven or eight years ago when I would be competing against only a handful of other academic programs for good people, I am now going to be competing against dozens and dozens of different groups,” he explains. “That changes the dynamic of my recruiting strategy.”

In addition, Dr. Wachter says he will make use of specific tables addressing concerns of academic hospitalists. “There are certain issues that are very different in an academic program, as compared to a community-based program,” he notes. “For instance, in my environment, burnout issues—or ‘dissatisfiers’—may relate to income or schedules or the abilities of support staff, but they may also relate to the teaching role or the research infrastructure—things that may be irrelevant to other people [in community programs] answering the surveys.”

Healthy Signs, Troubling Signs

Dr. Nelson summarizes his main points from the panel discussion about the survey: “It seems to show that incomes are rising faster than could be explained by inflation. There is also a rise in productivity, so incomes are up in part due to that.”

Another healthy trend, he says, is that in the last several surveys there has been a significant decline in hospitalists paid a fixed salary and an increase in those paid a combination of a base salary with a variable component, such as productivity. “I think getting away from fixed salaries is a good idea,” he notes.

Mary Jo Gorman, MD, MBA, SHM president and chief medical officer of IPC—The Hospitalist Company, was also a presenter during the survey’s debut in panel discussion. “Sustainability,” she says, is “very important for the field of hospital medicine. What this [survey] shows is that physicians are making a living, doing better than the average internist, and apparently getting career longevity out of this. Each year, the percentage of people who are staying in hospital medicine is increasing. New people are coming to the field, but other people are also staying. It’s not all about money and hours worked, but it’s some magical mixture of that.”

Dr. Bolinger agrees: “I definitely think that hospital medicine will sustain itself because we’re constantly setting the standard, and we’re showing the way it should be, the way it can be. As a profession, and as physicians, we are constantly striving to improve our quality of care. I think we are setting the mark for evidence-based medicine, and trying to encourage more evidence-based research.”

Dr. Bossard, who is based in Lincoln, Neb., found the 9% program turnover rate to be a relatively healthy sign, as did Dr. Wachter. “The turnover rates do not strike me as being incredibly high, given the portability of the field,” says Dr. Wachter. “We know very well that it is easier for hospitalists to pick up and leave their institutions for another one. In a primary care practice, changing practices involves a fair amount of work and a moderate amount of angst: You’re saying goodbye to all your patients and changing practice structure and style.”

One statistic did strike Dr. Bossard as potentially troubling, however: the increase in the percentage of hospitalists employed by multi-state hospitalist-only group or management companies from 9% in the 2003-2004 survey to 19% in the current survey.

“I think we’re seeing larger entities infiltrating markets and I’m not sure it’s a healthy trend for the hospitalist movement,” he says. “If you bring in physicians who do things a certain way, who may not have a commitment to a certain community, then I think you potentially lose some of the benefit of hospitalist programs. I think the finances will change. There will be a profit issue: Neither the hospital systems nor the hospitalist will see [that profit], and that’s a concerning trend to me.”

A Service to Members

Dr. Bohnenblust believes SHM truly serves its members by conducting the survey. The particular work environments and conditions of hospitalists can only be appreciated by a survey this specific, he says: “I applaud them for this [survey]. This is exactly what SHM needs to do to keep us viable as a profession.”

Dr. Wachter also believes the surveys are an invaluable tool.

“ … [Because we work in a] still-new field, we [hospitalists] are operating in a complex marketplace,” he says. “We are trying to figure out the best practices across all dimensions: schedules, organization structure, reporting relationships, funding. These kinds of surveys do not necessarily tell you the best practices, but they tell you about the prevalent practices. And I think that often is helpful in examining your own system and seeing whether it’s organized in the way you want to organize it. Having the society be the source of such information is a useful thing to do. It also helps the society design programs.”

The survey highlights many of the strengths of the growing hospital medicine movement. “I think in medicine in general there has been a frustration with having so much to do in so little time that it brings on stress,” says Dr. Bode. “When you can have a practice that devotes itself to one area, like the hospital, when you’re not running back and forth from the office to the hospital, you feel that you can really do a good job.

“I think most of the general population has no idea how the [healthcare] system works,” he continues. “To have a few minutes to spend telling patients how it works and how their care is flowing along is neat. You don’t feel that you have got to rush in and rush out all the time. The system can be so complex and frustrating for patients. When you can dive into the middle of it and try to streamline and demystify it, it’s really exciting.”

Conclusion

All survey participants received a free CD of the survey results. Copies of the CD as well as a booklet are available for purchase.

For more information on ordering “The Authoritative Source on the State of the Hospital Medicine Movement,” contact SHM at (800) 843-3360. TH

Gretchen Henkel writes regularly for The Hospitalist.


This copy is for your personal, noncommercial use only. No part of this article can be reproduced without the written permission of the publisher. Order presentation-ready copies for distribution to your colleagues, clients, or customers by contacting our reprints department at reprints@wiley.com. Copyright © 2009 Society of Hospital Medicine, administered by John Wiley & Sons Inc.

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