Funding and Finances
For most institutions a non-resident service represents incremental faculty members without any significant incremental professional fee revenue. The billings on the new service really are just a shift in revenue from the resident services. In addition, given the high clinical workload and current market conditions, the salaries of hospitalists hired for such services tend to be on average $15,000 to $20,000 above that of hospitalists hired onto a traditional resident-based service. There is some opportunity for increased revenue capture because of 24-hour attending presence, but the incremental gain is unlikely to be enough to create financial self-sufficiency. In our program there has been an increase in department-wide consultative revenue as specialized patients are now placed on our general medical service where they were previously cared for by residents and a specialty attending. In addition, we have improved our charge capture by a small margin. This extra revenue will not, however, come close to offsetting our overall cost. Many programs therefore require hospital support to be viable. Given the strong incentives for hospitals to ensure compliance with ACGME rules and maintain maximal inpatient occupancy, many hospitals can be convinced to provide funding.
We argue strongly that the creation of programs developed primarily to deal with residency work hours should be viewed separately from the funding of existing or new resident-based hospitalist programs. Similar to how resident salaries are paid for by the hospital (via federal graduate medical education funding), the cost of a new hospitalist service that is created to replace residents should come from the hospital. Programs should exercise caution in using existing paradigms such as reduction in LOS or decrease in cost as a basis for funding. There is little data comparing resident-based care to non-resident-based hospital care in a tertiary center, and what little that exists does not necessarily suggest a cost benefit (5). In addition, there is a significant future risk if such proposed benefits do not become a reality
New Roles and Responsibilities
Once established, many programs will be asked to take on additional tasks that were previously performed by trainees or other faculty. This is especially true of nighttime tasks. Many programs are asked to run code-blue teams, supervise procedures at night, supervise sedation in radiology, triage patients in the ER, provide emergent patient coverage for other services: the list can go on and on. The challenge is accepting some and rejecting others without being seen as non-cooperative.
We strongly believe that taking on some of these tasks provides significant added value for non-resident programs, something that becomes vital in the long-run once the urgency of work-hours compliance has passed. Programs should pick wisely and move slowly when adding additional roles. Whatever roles are added, it is vital that ample consideration is given to the impact on workload and faculty satisfaction. Many of these roles may also present an opportunity to garner additional revenue, whether through billing or direct payment from the hospital.
The Challenges of Academia: Separate and Unequal
The greatest challenge that all major academic hospitalist programs will face will be how to create satisfying long-term faculty positions that involve providing direct inpatient care without the assistance of housestaff (6). There is already a growing problem of physician dissatisfaction among clinical-track faculty in many academic centers where the emphasis on clinical productivity has usurped the missions of teaching and research. The challenges faced by academic hospitalists working without residents are even greater than those faced by existing clinical faculty.
The first consideration for academic programs is whether to create two classes of hospitalists within the same program: those that work primarily with residents and those that do not. In our program we had an already established group of classic hospitalist-educators who worked only on resident-staffed services when we were asked to create a non-resident service. Our easiest option, therefore, was to hire new faculty whose sole responsibility is staffing a non-resident service. With this has come a significant struggle on how to ensure faculty satisfaction and avoid creating a split within the hospitalist program. We also struggle with how to administer such a program and whether leadership should have clinical roles on both services (we currently do not).