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One size does not fit all

Which hospitalist model is right for you?

By Maureen Glabman

From the September ACP Hospitalist, copyright © 2008 by the American College of Physicians

Four months before finishing his residency in Knoxville, Tenn., Ulises Perez, ACP Member, was offered a position with an independent, five-person hospitalist practice in Miami that served two prestigious sister hospitals.

Dr. Perez liked the eventual partnership and profit sharing that the practice offered and, as an added bonus, he and his wife had extended family in the area.

But although the job sounded perfect, “A few months into it, I knew it was a mistake,” Dr. Perez recalled. His only training consisted of shadowing one of the partners for a day. “Essentially, I was given a list of 20 to 25 patients daily and told to go,” Dr. Perez said.

One size does not fit allHe ended up leaving after 10 months to join a hospital-based, six-person group practice in a nearby county. The group meets weekly to discuss core measures and utilization and provides other information sharing Dr. Perez felt was missing from the first practice.

Dr. Perez’ experience illustrates the importance of finding the right fit. While there’s no way to guarantee satisfaction, the major models of hospitalist practice have distinct tradeoffs. Depending on personal preferences, a physician may be able to determine well in advance of accepting an offer which model best suits his or her personality.

The three most important job characteristics are schedule, pay and location, according to Polly Johnson, a recruiter for the national search firm Kendall & Davis in St. Louis who places about 100 hospitalists annually. But experienced candidates also mention stress-related exigencies, such as average patient loads, level of subspecialty backup, and amount of intensivist responsibilities. All of these variables help to predict job satisfaction.

Pros and cons

If getting a slice of the financial pie is desirable, a hospitalist might favor solo practice, a local hospitalists-only group or a multispecialty practice with partnership possibilities. But along with pride of ownership, be prepared for lack of mentorship, nonstandard benefits, irregular hours and the responsibilities of running a business.

In addition to hiring, firing, billing and other practice management responsibilities, independent hospitalists must routinely market themselves to local physicians in order to ensure a steady stream of referrals. Kenneth Weisiger, ACP Member, one of four hospitalists in Clear Creek Medical Group, a private practice group in Denver, has a Web site, circulates brochures to primary care physicians and regularly visits their offices with lunches in hand.

Multistate or hospital-based hospitalists are not as dependent on local referrals. In addition, hospital-based hospitalist jobs generally involve less administrative and practice management work, making them a good fit for those who just want to take care of patients, according to John Nelson, FACP, program director at Overlake Hospital Medical Center in Bellevue, Wash. Hospitalists based at academic medical centers also have the opportunity to teach and do research.

However, multistate and hospital-based hospitalists’ contracts or responsibilities often include treatment of non-assigned patients. Dr. Weisiger can refuse cases, especially if patients are indigent, which could limit liability. Moreover, he makes his own hours—he doesn’t adhere to a shift schedule—and he can work as many or as few hours as he desires. Private practice hospitalists can also earn additional revenue, an option that’s not available to their hospital-based colleagues.

“A private physician can read an EKG, run a central line, intubate or perform a lumbar tap, bill and get paid for it and earn a bigger salary. I still get the same base salary and team bonus, so I can’t add to my own revenue by doing extra work,” said Iris Mangulabnan, ACP Member, one of 17 hospital-based hospitalists at Covenant HealthCare in Saginaw, Mich.

Multistate groups have the advantage of offering built-in mobility. Employees of companies such as IPC, Apogee Physicians and HMG can transfer to a contracted facility in a new state without losing seniority, salary or benefits.

“If you work in a local group, there is no geographic flexibility. If your wife decides she doesn’t like the weather in Buffalo, you can certainly leave, but you have to start over,” said Stephen Houff, MD, chief executive officer of HMG in Canton, Ohio. Moreover, multistate practices often offer uniform salary, benefit and incentive packages as a competitive edge to attract physicians.

And unlike private practice hospitalists, those who work for a large group don’t have to worry as much about market forces. “There’s a comfort in knowing that even if you have a down month, you’ll still get paid,” said Dennis Deruelle, MD. Dr. Deruelle, once a solo hospitalist, is now a group leader with IPC The Hospitalist Company, which employs 800 hospital medicine physicians in 17 states.

An additional benefit of multistate practices is that they typically invest heavily in training, infrastructure and information systems. New hires at IPC, Apogee and HMG spend their first few days on the job at corporate headquarters in intensive courses on coding, documentation, and compliance. “There is just so much that should not be left to trial and error,” Dr. Houff said.

HMG also has certified coders who review physician bills to assure compliance and employs a full-time attorney whom physicians can call to discuss risk management issues, while Apogee employs support staff seven days a week for data entry so physicians can spend every working moment practicing medicine.

However, Kendall & Davis’s Ms. Johnson said physicians for multistate companies are often hired from out of town right out of residency and don’t always have a vested interest in their communities; turnover can also be high. “There could be more stability in a hospital-based practice because there is a commitment to the community, not just the contract,” she said.

In addition, multistate hospitalists may face other drawbacks, experts said. Like physicians in some other hospitalist models, they may have to travel to more than one facility in a day. Their duties are defined by hospital contract with little wiggle room, and they must adhere to written schedules. Turnover issues can create havoc with colleagues’ schedules, increasing patient loads.

Trying on models for size

A new hospitalist may need to try out different models. HMG’s Dr. Houff, for instance, was an accidental hospitalist who began with a hospital-based practice, then decided it was not his best option. In 1993, when he finished his residency, officers of Cleveland’s Park Medical Center asked him to stay on for 90 days to take care of indigent patients admitted through the emergency department, run code blues and direct three hospitalists.

He received a paycheck regardless of patient’s insurance status. Those 90 days stretched to six years, until the hospital was sold to Ohio State University. Although a consultant advised OSU to renew Dr. Houff’s contact for a year, he decided that associating with one hospital that could dismiss him was “unwise.” In 2000, he started HMG, which now employs 300 physicians in 14 states.

Steven Cervi-Skinner, MD, joined a private group of hospitalists in Phoenix backed by non-MD investors. Compensation was tied to volume, not outcomes.

“I was taking orders from people who had never taken call, never taken care of a patient, and never dealt with the family of a dying patient. I felt they just didn’t get it,” he said. Dr. Cervi- Skinner later moved to Apogee, where the company’s leaders are all physicians, and is now the chief medical officer.

Covenant’s Dr. Mangulabnan said that although she has not experienced it, the same discontent can surface in hospital-based practices if nonphysician administrators supervise the hospitalist program and set its policies and priorities. What’s more, typically the goals of the hospital and hospital-based hospitalists are aligned. For Dr. Mangulabnan, that means, among other things, that she must get more deeply involved in Joint Commission reviews than independent hospitalists.

Ultimately, “physicians are happiest when they have a culture of ownership and significant autonomy, even if they are employees, as long as they are connected to economic consequences of their decisions,” said Overlake Hospital Medical Center’s Dr. Nelson. “That means they have the ability to create their own schedules, compensation system, internal governance and role in the hospital’s medical staff.”

Maureen Glabman is a freelance writer in Miami.

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Benefits and drawbacks of major hospitalist models

Model Pros   Cons
Hospital-
based or
hospital corporation
  • No worries about patient payer status or billing issues
  • Hospital is responsible for practice management and liability
  • Good working relationships with hospital staff
  • Limited, or no, running between hospitals
  • Hospital-based jobs at academic medical centers offer research and teaching opportunities
  •  
  • May report to non-MD administrator who may not understand clinical issues
  • Entrepreneurship is not rewarded
  • Can't decline patients
  • Heavy involvement with Joint Commission reviews
  • Single-
    specialty or multispecialty group
  • Unless specifically contracted, group can refuse indigent, nonassigned patients.
  • Unless contracted, hospitals cannot dictate quality or performance measures
  • Ownership mentality
  • SHM reports hospitalists who work for multispecialty/primary care groups have the highest median salary of all models
  •  
  • Practice management and liability concerns
  • Lack of geographic flexibility
  • Possible lack of mentoring/training
  • Possible nonstandard benefits
  • Local,
    hospitalist-
    only group
  • Respect from community physicians and hospital administrators
  • Pride of ownership
  • Can decline patients
  • Rewards entrepreneurship
  • Can set own hours
  • Potential to work as much or as little as desired
  • No worries about loss of hospital contracts because allegiance is to primary care physicians
  •  
  • Responsibility for running a business
  • Market forces could affect pay
  • Hours could be irregular
  • Possible daily running between hospitals
  • Possible lack of mentorship
  • Potential lack of infrastructure
  • Lack of geographic flexibility to move and retain salary/benefits
  • Multistate hospitalist
    group or hospitalist management company
  • Standardized benefits, incentives
  • Ability to relocate without loss of seniority
  • More sophisticated information systems, established infrastructure
  • No responsibility for collections
  •  
  • Possible daily running between hospitals
  • Duties defined by hospital contract
  • Must adhere to written schedule; cannot make own hours
  • Turnover can affect schedules and add to workloads

  • Some material in this chart was adapted from "Hospitalists: A Guide to Building and Sustaining a Successful Program," by Joseph A. Miller, John Nelson, MD, and Winthrop F. Whitcomb, MD. Health Administration Press, 2007.

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