We work best when we remember who hired us and why. As hospital medicine matures, the goals of those who write the paychecks will continue to shape programs, even when this basic economic truth may be obscured by a program’s fast growth. That is why the 10 hospitalists at Nashua-based Southern New Hampshire Medical Center (SNHMC) work differently than their peers in other systems. They are employed by a unique joint venture of New Hampshire’s two largest multispecialty medical groups: Foundation Medical Partners of Nashua and Lebanon-based Dartmouth-Hitchcock.
The SNHMC hospital medicine group filled a definite need. As Tom Wilhelmson, SNHMC’s CEO and president explains it, Nashua’s population has grown tremendously—25% in the 1980s and an additional 14% in the 1990s—thanks to an influx of young families and industries relocating to business-friendly New Hampshire. During the growth spurt the area needed doctors—particularly primary care physicians. To attract physicians, in 1992 the hospital helped form Foundation Medical Partners (FMP), a large multispecialty group. Based on a private practice model, FMP physicians now cover 22 suburbs in the primary and nine in secondary service areas that serve 225,000 people. SNHMC is FMP’s safety net, negotiating malpractice rates, giving physicians access to capital, and helping with cash flow when a big payer is slow.
The hospital and FMP grew steadily, boosting hospital market share from 40% in the 1980s to 62% today. Michael Marshall, MD, medical director of the 134-physician FMP, saw it thrive.
“We were opening offices farther and farther from the hospital,” he recalls. “In 2002, when doctors’ drive times exceeded 30 minutes, we realized that hospitalists could relieve primary care doctors from hospital work.”
Issues, Options, and Resolutions
SNHMC and FMP considered these options for starting a hospitalist program:
Issue: Starting a hospitalist program from scratch.
- Hire them as hospital employees;
- Contract with a regional or national hospitalist company;
- Encourage formation of a hospital medicine group;
- Worry about Dartmouth-Hitchcock starting a program; or
- Make hospitalists FMP partners.
Resolution: Hospitalists would be FMP partners; therefore, approach Dartmouth-Hitchcock about a joint venture hospitalist program.
At the time, Dartmouth-Hitchcock, New Hampshire’s only academic medical center and FMP’s chief competition had made significant inroads in Nashua. Dartmouth-Hitchcock embraced the joint venture along with an even split of any necessary subsidies. In 2003 Wilhelmson and Dr. Marshall hired Stewart Fulton, DO, and a second career physician straight from residency, as their hospitalist medical director.
Dr. Fulton was the solo hospitalist and had a goal of assuming hospital duties for 20+ family care physicians in his first year:
Issue: Freeing a large number of primary care physicians from hospital rounds.
- Dr. Fulton’s pager went off incessantly;
- He was inundated with work;
- He routinely worked 12-hour days and longer; and
- Many FMP physicians still made hospital rounds and covered call to handle patient volume.