It took my hospital medicine group (HMG) 20 years to implement a formal backup system. Of all the reasons we resisted creating a backup system, foremost was that we did not want to mandate additional work. Because our compensation model did not have a mechanism to financially reward hospitalists for unexpectedly having to come in on unscheduled work days (other than the work relative value units generated by seeing patients), there was not enough motivational energy to get a system started.
It turns out our group is not unlike many other HMGs across the nation. According to the 2016 State of Hospital Medicine report (SoHM), 58.3% of adult-only HMGs, 72.2% of pediatric-only HMGs, and 52.6% of HMGs serving both adults and children did not have staffing backup systems. Interestingly, the report also showed that for groups serving adults only, academic HMGs were more likely to have formal backup systems in place (62.6%, compared with 37.3% in nonacademic HMGs).
The reason most HMGs create backup systems is to have a consistent and fair approach for dealing with unanticipated absences and/or high-volume census. In addition to creating a safety net, implementing a backup system addresses the common problem of the same hospitalists disproportionately filling in during times of crisis.
Although our group created a formal backup system starting January 2015, it is not comprehensive and deals only with high patient volumes occurring during the late evening and night hours. Hospitalists rotate through a schedule, taking a week of backup call for which no additional compensation is offered. Then, if they are actually called to come in, an hourly stipend is paid in addition to work RVUs generated. Implementing a backup system was not necessarily a popular idea. Nevertheless, the system has successfully remained in place. Triggering the system infrequently, having a clear set of criteria for when to activate backup, and providing additional compensation for the additional work are key factors in our system’s success.
When data from the 2016 SoHM report are compared with the 2014 SoHM report, the proportion of groups with formal backup systems actually decreases for both adults-only HMGs and HMGs serving both adults and children. For adult-only HMGs, there was a decline to 41.8% from 57.6%. For adult/pediatric HMGs, there was a decline to 47.4% from 58.8%. It also is notable that pediatric HMGs in particular are much less likely to have formal backup systems, only 27.8%, which has changed little since the last survey (28.8 % in 2014).
All in all, the reasons for the decline in backup systems are unclear. Possibly, the decrease is because of issues surrounding compensation, as approximately one-third of survey respondents with backup systems received no additional compensation. But in my view, it’s more likely that the reason for the decreased percentage of groups with backup systems has to do with differences in the particular set of HMGs that responded to the survey this year.
Dr. Stephan is a hospitalist at Abbott Northwestern Hospital in Minneapolis and a member of SHM’s Practice Analysis Committee.