Where: Munson Medical Center, a 391-bed acute care facility where hospitalist care is provided by Hospitalists of Northern Michigan (HNM).
The issue: Allowing hospitalists to set their own pace and schedule.
As in many hospitalist practices, the physicians of HNM had very individual visions of an ideal schedule. “We have doctors who want to work 120 days. We have physicians who want to work 270 days. We have people who want 12 patients [per day]—a whole variety of different things that folks want for the way they feel comfortable practicing,” said Troy W. Ahlstrom, ACP Member, chief financial officer of HNM. Dr. Ahlstrom spoke about his hospitalist program during a session on workload at the Society of Hospital Medicine's annual meeting in April.
Under typical hospitalist compensation models, patients are distributed about equally among physicians. “Equal pay structures are going to necessitate that you distribute patients in a roughly equal way, because otherwise people might think it's unfair,” said Dr. Ahlstrom. But, at first with complicated calculations on a white board, and now using an electronic system, this hospitalist program found a way to allocate patients based on physician preferences rather than equality, and also pay hospitalists in a way that seemed fair.
How it works
“Let's pretend that Dr. O wants only 12 patients per day and is going to work a standard 180 days, roughly half the year. Whereas Dr. A has kids in college so she's going to work 240 days with an average load of 16 patients. Dr. U is a monster who can see 20 patients per day and can do only 180 days and have all that other time off,” described Dr. Ahlstrom.
In the HNM system, the number of patients a physician wants to see is converted to a full-time equivalent (FTE) statistic. For example, on any given day, Dr. O would be a 0.75 FTE, Dr. A would be 1.0 and Dr. U would be 1.25. Then the practice scheduler (who has a full-time position in this practice) calculates how many hospitalist FTEs are required for a specific shift, based on the number of patients expected (both already admitted and new arrivals). Hospitalists are added to the schedule until the shift's FTE requirement—for example, 10 FTE physicians if the practice will see 160 patients—is met. So, in addition to Drs. O, A, and U, 7 FTE physicians would be needed for the example day.
The physicians' salaries (which make up 50% of their compensation, with the other 50% coming from productivity) are based on their chosen workload. “When people see more patients, they make more money,” said Dr. Ahlstrom.
“There are disadvantages,” acknowledged Dr. Ahlstrom. “You absolutely have to have a productivity-based compensation of some sort. You can do all productivity, or the most common method, salary plus productivity incentives.”
The schedule is also more complicated to organize than most. In addition to the employee who keeps track of the schedule, the practice bought a software system, which cost them $20,000 to start up and incurs continued costs for maintenance and modification.
The concept can also be intimidating to potential hires. “It's a foreign concept,” said Dr. Ahlstrom. “Recruiting does take more time.”
Once physicians have joined the practice and gotten used to the system, they appear to like it. “We think this retains hospitalists,” said Dr. Ahlstrom. “It lets physicians work at their optimal pattern and they can change it as desired—not day by day, but every six to 12 months or so.”
The system can increase income both for hospitalists, if they choose to work more, and for the program, since some physicians will choose to work a lot, and even those who don't may be more efficient when they're working a schedule of their choosing.
Dr. Ahlstrom listed one more benefit that any hospitalist program leader would appreciate: “It minimizes whining.”
How patients benefit
The system can provide some surge capacity that other scheduling systems may not have, because the doctors who typically see fewer patients in a day can pick up the pace if necessary.
“The half and three-quarter people, on a day where you have a lot of people coming through the ER, they're the ones who have to pick up a little bit of extra work. That gives you a surge capacity, and a surge capacity is very difficult to schedule in a traditional hospitalist model,” said Dr. Ahlstrom.