Start Me Up

The Hospitalist. 2006 April;2006(04):

April 1, 2006 | The Hospitalist

In 1999 the program hit a speed bump when the hospital threatened to reduce the group’s rates. The group, in turn, threatened to leave. “We resolved it by demonstrating that every dollar they paid us earned seven dollars for the hospital, not to mention the growing scope of our activities,” says Dr. Fitzgerald. “In the beginning we were forbidden to do consults, particularly for surgeons. Two years later, we were doing it all.”

He says that the hospital loves the group because it serves the medical staff’s goals and helps grow market share, as hospitalists continue to market to physician practices in outlying suburbs.

Rundsarah Tahboub, MD, medical director of the Hospital Medicine Service at Grant Medical Center in Columbus, Ohio, also succeeded the second time around. With a passion for inpatient medicine, she helped launched a hospitalist program in response to restrictions on residents’ hours at Ohio State University. Having just completed a residency herself, Dr. Tahboub struggled with her lack of experience and, she felt, credibility to lead the program.

“I felt I wasn’t being heard, that I had no autonomy or support,” she says. “When my mentor, the program director of family practice residency at Grant, contacted me to establish a hospitalist program there, I took the challenge.”

The Hospital Executive’s Vantage Point

A hospital’s executives decide when to implement a hospitalist program and how much they’re willing to pay for it. Understanding what they’re thinking as they fashion an inpatient service is important. Here’s what drifts across their radar screens as they decide how to proceed:

Why do we need hospitalists? Common reasons include cost pressures, demands from community doctors unwilling to provide 24/7 coverage for their hospitalized patients, the need to cover unassigned patients, managing patient flows in the ED, and problems with efficient handling of admissions and discharges.
How can hospitalists improve our bottom line and care quality ratings? The answers vary but common goals include better use of resources leading to reduced costs per case and length of stay, high patient satisfaction ratings because physicians are readily available, better compliance with core measures and evidence-based guidelines, and opportunities to gain market share.
What model will work for us? Choices include hiring their own hospitalists or contracting with one or more local hospital medicine groups, a regional/national hospitalist only or multi-specialty physician group, or outsourcing to medical recruiters.
Should we build in-house or outsource? That depends on whom they know and trust. Academic medical centers with stellar graduating residents/chief residents may approach those physicians and let them build the program. Administrators with out-of-control patient volumes, attendings who won’t cover calls, or a large number of unassigned cases may need to contract with outsiders for fast relief.
How will we pay for this? Administrators know their local norms and that they have to pay competitive salaries to attract hospitalists. The hospital setting (academic medical versus community hospital), local competition, and community quality of life/workload factor in. The rule of thumb is $75,000 per full-time hospitalist beyond the offset of fees, and a minimum of six hospitalists to provide 24/7 coverage.—MP

Dr. Tahboub evaluated her management style, realizing that she values communication and congeniality with colleagues, getting input and analysis before moving ahead, and flexibility in dealing with obstacles. Citing the example of night call, she explains that hospitalists started with day hours only, leaving residents swamped at night and needing an attending physician.

“We [hospitalists] all talked about it,” says Dr. Tahboub. “While we weren’t thrilled to take night call, we each agreed to cover every fourth night because it was necessary for us to do so.”