A Rough Patch

I was the medical director of a hospitalist group in the Southeast that had been hospital-owned for eight years and grew to more than 20 full-time providers. New hospital administrators took over and, faced with staffing and compensation issues, outsourced the program. Within a year, all but one of the HMG employees (physicians, nurse practitioners, and physician assistants) resigned. As expected, the exodus put a strain on the program, patient care, and community. After a shakeup in administration, the management company pulled out. The hospital now runs the HM program. Is this occurrence just an outlier or are thes kind of situations becoming common to our field?

—Dr. Nore-grets

Dr. Hospitalist responds:

While I’m saddened at the disruption of so many lives (hospital executives, physicians, advanced practice providers, other clinical staff, and patients), I must say I’m not surprised by the outcome. Hospital medicine continues to be a rapidly growing specialty; approximately 70% of all hospitals in the U.S. have a hospitalist program. It’s only 17 years old, and as with all adolescents still finding their way, disputes are common.

Like most good stories, there are usually two sides. Hospitals have a board to satisfy, large numbers of employees (professional and non-professional), varying revenue streams to contend with, and an annual budget. There are many different groups vying for a larger slice of the pie—and the pie is only so big. No matter how we see it, some administrators believe physicians are overpaid and are not hard workers. There may not be much empathy for the docs, who work “only 182 days a year,” asking for more time off, paid vacations, smaller patient loads, and more money.

Physicians see their student loans stretched out for 30 years, hospitals on building sprees, heavy patient loads, complex administrative tasks, and a lack of appreciation for the myriad intangible and non-billable services they render every day. Not being able to take a paid vacation like most workers in this country seems unfair to many. Even though most hospitalists still work 12-hour shifts, we resist being labeled “shift workers” because of the negative and non-professional inference.

It appears your hospitalist group had concerns about staffing and pay, and instead of effectively dealing with their concerns, the hospital’s administrators decided to outsource the program. While most national firms that hire hospitalists are well intentioned, they (like most hospitals) are driven by profit and sometimes bring in transient and inexperienced physicians. The eight-year-old group, while still relatively young, likely had members who had established both personal and professional relationships with many of the physicians and other clinical staff. These relationships, when built on trust, mutual respect, and competence, are the foundation of good clinical care. It is no surprise they were not able to adequately replace the clinicians who resigned.

The issues of pay and staffing are common points of contention among hospitalist and hospital administrators. The mode of compensation most often used is based on hospitalist productivity and is heavily subsidized by the hospital. While this model has served us well, the passage of the Affordable Care Act will change how healthcare systems are reimbursed. There will likely be many instances of bundled payments tied to inpatient care, but also an opportunity for hospitalists to further expand their roles into improving the quality of care and efficiency of delivery. The formation of accountable care organizations will offer even more opportunities for physician leadership and organizational assistance. The more hospitalists become imbedded in and invaluable to the hospital, the less likely we are placed on the chopping block when budget cuts happen or leadership changes (as in your case).