Efficiency Rules
While nationwide demand for hospitalists outstrips supply, hospitals across the country are looking at how their hospitalists and their hospital medicine groups weigh in on efficiency.
The notion of efficiency at a time of rapid growth may seem counterintuitive, but healthcare dollars are always hotly contested, and an efficient hospitalist program has a better chance of capturing them than a less-efficient one.
Even the definition of efficiency is being refined. Stakeholders scrutinizing compensation packages, key clinical indicators, productivity and quality metrics, scheduling, average daily census, and patient handoffs to gauge whether or not their group has a competitive edge over others. And hospital medicine group (HMG) leaders are scrutinizing themselves because they know hospitals increasingly are inviting more than one HMG to work under their roofs—the better to serve different populations and compare one with another.
How to Measure Efficiency
An evolving medical discipline that aspires to specialize in internal medicine, hospital medicine is in the process of developing a consensus definition of efficiency for itself. Major variables included in the calculation are obvious: average daily census, length of stay (LOS), case mix-adjusted costs, severity, and readmission rates. Other, harder-to-quantify dimensions include how a hospitalist group practice affects mortality, and how scheduling, variable costs, hospitalist group type, subsidies, and level of expertise play out.
click for large version
click for large version
The foundation on which hospitalist groups build their efficiencies is the group type. In itself, how a hospitalist group chooses to organize itself reflects a maturing marketplace. SHM’s 2005-2006 productivity survey shows an increase in multistate hospitalist groups, up from 9% in ’03-’04 to 19% in the latest survey. Local private hospitalist groups fell from 20% in ’03-’04 to 12% in ’05-’06. The percentage of academic hospitalist groups rose from 16% to 20% in the same period.
It’s unclear how to interpret the shift from local to multistate hospitalist groups and the increase in academic medical center programs, but these trends bear watching. Comparison of the two most recent SHM surveys shows compensation models are also growing up, reflecting the need to balance base salary with productivity.
A major indicator of hospital group efficiency is the performance of groups with hospitalists on duty 24 hours a day, seven days a week. Although hospital administrators and hospitalist leaders struggle with the economics of providing night coverage when admissions are slow, such coverage pays off in quality and efficiency.
Stacy Goldsholl, MD, president of TeamHealth Hospital Medicine, a healthcare outsourcing firm based in Knoxville, Tenn., has long advocated 24/7 coverage as a crucial element in HMG efficiency. Even though she estimates that night coverage adds approximately $10,000 in subsidies to an average compensation package for a full-time hospitalist, such coverage improves efficiency in length of stay adjusted for severity and in readmissions. Full coverage allows hospitalists to be better integrated into the hospital in a way that fewer hours don’t.
“How hospitalists who cover 24/7 are used varies,” says Dr. Goldsholl. “Doing night admissions for community doctors, [working] as intensivist extenders, helping with ED [emergency department] throughput, being on rapid response teams—all are important contributors to improved efficiency,” says Dr. Goldsholl.
For Dr. Goldsholl, who has at least one academic medical center—Good Samaritan in Los Angeles at the University of Southern California Keck School of Medicine—on her roster, hospitalist group efficiency and productivity are major concerns for academic and community hospital administrators footing the bill for such services.
click for large version
click for large version
“Usually, TeamHealth is the exclusive hospitalist medicine provider contracting with a community hospital,” she explains. “Once we have been in a hospital for a while, we tend to see a progression in our responsibilities. Mostly we start with unassigned patients, then we expand to cover private primary care physicians’ patients. Then we co-manage complex cases with sub-specialists.”
