With an average of 185 billable patient encounters per day, Dr. Gundersen attributes his successes to a management style based on a financial business model and a revision of the compensation plan. By increasing effectiveness, they reward their doctors with more free time and subsequently improved physician retention.
As the group, the budget, and the financial impact all expand, formal training becomes more important for leaders. While few HMG leaders have a background in the strategic processes of running a company, Dr. Gundersen earned his MBA and believes his training made it easier to talk to administrators, meet clients, track data, effect change, and better handle the politics inherent to the job. “The role is a lot more political than people are aware of because you are such a big presence to the hospital,” he says. “Everybody wants something from you.”
Part of that phenomenon, coined “medical creep” by one hospitalist, can best be defined as the gradual increase in workload shifted to HMGs without a proportional shift in resources to do the work. Work previously done by either surgical specialists or medical subspecialists must be shifted as they more narrowly define their workload; what is left over (more general medical care, phone calls, after-hours work, and paperwork) goes to “co-managing” hospitalists.
Asked about this phenomenon, Tom Lorence, MD, chief of hospitalist medicine for the Northwest Kaiser Permanente region, Portland, Ore., says: “The larger the hospitalist groups become, the bigger a target we are for this shifting. Most try to justify it by saying, ‘It is only a little more work.’ ”
Dr. Lorence and two colleagues began his HMG in 1990; he now manages 55 hospitalists at three facilities. “Administrators have to be convinced that it is worth the money to reshift their priorities and give more resources to the hospital medicine groups,” he says.
Mark V. Williams, MD, FACP, professor and chief, division of hospital medicine, Northwestern University Feinberg School of Medicine, Chicago, moved to his current post last September. Northwestern Memorial Hospital almost doubled its hospitalists to 42 in one year. The initial challenges at Northwestern primarily include assimilating new faculty and establishing a culture of thriving on change, says Dr. Williams, who is also editor in chief of the Journal of Hospital Medicine.
The distinction between academic and non-academic programs is an important one says Michael B. Heisler, MD, MPH, who became the interim medical director of Emory Healthcare, Atlanta, in March 2007 when Dr. Williams moved to Northwestern. Generally, the Emory group has increased in size by 20% each of the past five years. Beginning with nine hospitalists in 1999, it now exceeds 80 (see Figure 2, p. 28).
Academic hospitals have additional stakeholders and deliverables expected by those to whom the medical director reports. Whereas community hospital medicine programs are driven by patient encounters/RVUs, quality improvement, and the bottom line, academic groups also must engage in scholarly activities.
Dr. Heisler and his group have just completed a three-year strategic plan that emphasizes medical education and research and a plateau to the group’s growth.
“We can’t be the premier academic program with growth going through the roof,” Dr. Heisler says. “With some limits we are not going to increase services within our institutions and will not entertain requests to grow into any other facilities through 2010. You can’t develop faculty, define protected time, and invest in scholarly work when you are constantly in growth mode.”