Collaboration, Not Calculation: A Qualitative Study of How Hospital Executives Value Hospital Medicine Groups
BACKGROUND: Hospital medicine groups (HMGs) typically receive financial support from hospitals. Determining a fair amount of financial support requires negotiation between HMG and hospital leaders. As the hospital medicine care model evolves, hospital leaders may regularly challenge HMGs to demonstrate the financial value of activities that do not directly generate revenue.
OBJECTIVE: To describe current attitudes and beliefs of hospital executives regarding the value of contributions made by HMGs. DESIGN: Thematic content analysis of key informant interviews.
PARTICIPANTS: Twenty-four healthcare institutional leaders, including hospital presidents, chief medical officers, chief executive officers, and chief financial officers. Participants comprised a diverse sample from all regions in the United States, including rural, suburban, and urban locations, and academic and nonacademic institutions.
RESULTS: Executives highly valued hospitalist groups that demonstrate alignment with hospital priorities, and often used this concept to summarize the HMG’s success across several value domains. Most executives evaluated only a few key HMG metrics, but almost no executives reported calculating the HMG return on investment by summing pertinent quantitative contributions. Respondents described an evolving concept of hospitalist value and believed that HMGs generate substantial value that is difficult to measure financially.
CONCLUSIONS: Hospital executives appear to make financial support decisions based on a small number of basic financial or care quality metrics combined with a subjective assessment of the HMG’s broader alignment with hospital priorities. HMG leaders should focus on building relationships that facilitate dialog about alignment with hospital needs.
© 2019 Society of Hospital Medicine
Alignment and Collaboration
The related concepts of “collaboration” and “alignment” emerged as prominent themes during all interviews. Executives highly valued hospitalist groups that could demonstrate alignment with hospital priorities and often used this concept to summarize the HMG’s success or failure across a group of value domains.
“If you’re just coming in to fill a shift and see 10 patients, you have much less value than somebody who’s going to play that active partnership role… hospitalist services need to partner with hospitals and be intimately involved with the success of the hospital.” (CMO, #20)
Alignment sometimes manifested in a quantified, explicit way, through incentive plans or shared savings plans. However, it most often manifested as a broader sense that the hospitalists’ work targeted the same priorities as the executive leaders and that hospitalists genuinely cared about those priorities. A “shift-work mentality” was expressed by some as the antithesis of alignment. Incorporating hospitalist leaders in hospital leadership and frequent communication arose as mechanisms to increase alignment.
Ways HMGs Fail to Meet Expectations
Respondents described unresolved disadvantages to the hospitalist care model.
“I mean, OPPE, how do you do that for a hospitalist? How can you do it? It’s hard to attribute a patient to someone….it is a weakness and I think we all know it.” (CMO, #21)
Executives also worried about inconsistent handoffs with primary care providers and the field’s demographics, finding it disproportionately comprised of junior or transient physicians. They also hoped that hospitalist innovators would solve clinician burnout and the high cost of inpatient care. Disappointments specific to the local HMG revolved around difficulty developing shared models of value and mechanisms to achieve them.
“I would like to have more dialog between the hospital leadership team and the hospitalist group…I would like to see a little bit more collaboration.” (President, #13)
These challenges emerged not as a deficiency with hospital medicine as a specialty, but a failure at their specific facility to achieve the goal of alignment through joint strategic planning.
Calculating Value
When asked if their hospital had a formal process to evaluate ROI for their HMG, two dominant answers emerged: (1) the executive lacked a formal process for determining ROI and was unaware of one used at their facility or (2) the executive evaluated HMG performance based on multiple measures, including cost, but did not attempt to calculate ROI or a summary value. Several described the financial evaluation process as too difficult or unnecessary.
“No. It’s too difficult to extract that data. I would say the best proxy that we could do it is our case mix index on our medicine service line.” (CMO, #20)
“No, not a formal process, no… I question the value of some of the other things we do with the medical group…but not the value of the hospitalists… I don’t think we’ve done a formal assessment. I appreciate the flexibility, especially in a small hospital.” (President, #10)
Rarely, executives described specific financial calculations that served as a proxy for ROI. These included calculating a contribution margin to compare against the cost of salary support or the application of external survey benchmarking comparisons for productivity and salary to evaluate the appropriateness of a limited set of financial indicators. Twice respondents alluded to more sophisticated measurements conducted by the finance department but lacked familiarity with the process. Several executives described ROI calculations for specific projects and discrete business decisions involving hospitalists, particularly considering hiring an additional hospitalist.
