Unfortunately, this situation can create a culture in which a hospitalist feels that the only job that is important is to see the next patient. These hospitalists may be reluctant to participate in efforts to ensure the financial health of the practice. Examples: 1) They may not be attentive to optimal documentation and coding, and the practice may lose significant billing revenue; 2) They may not want to accept new referrals or encourage growth in the practice; or 3) They may be too quick to add doctors to the group, with the aim of working fewer hours.
Even if the doctors are employees of a hospital or other large entity, make every effort to encourage them to think of themselves as owners of their practice. One way to create this environment is to have a tight connection between the economic health of the practice and the hospitalists’ income (e.g., production-based incentive compensation). This should lead to greater autonomy in decision-making, as well as hospitalist satisfaction.
3) Poor leadership: Many hospitalist practices start with doctors who have no prior hospitalist experience. This may result in physician leaders poorly suited for their roles. For a practice that is uncertain whether it has an appropriate medical director among the initial doctors it has hired, it might be a good idea to wait a year or two to select the leader. An interim leadership model can be implemented, taking advantage of physician leaders in the hospital, perhaps including the vice president for medical affairs, respected primary care physicians, or emergency physicians. Establishing a hospitalist oversight committee that is made up of leaders among the medical staff can also provide guidance for the new program until there is an effective hospitalist leader in place.
4) Excessive or inappropriate hospitalist overhead: This can take two forms. First, excessive overhead results from securing too much office space and/or staff support. Because the majority of a hospitalist’s work is done on the hospital wards, it is usually sufficient for a hospitalist group to share a single office with enough seating and workstations, including computers, for one-third to one-half of the total number of doctors in the group. For example, a 12-hospitalist group might share an office with four to six workstations. A small group—six or fewer doctors—might function effectively with a single clerical assistant supporting the hospitalists and some other department at the same time.
Second, inappropriate overhead may occur in multispecialty groups that charge hospitalists the same overhead paid by office physicians. This high overhead rate—more than 50%—may leave insufficient funds to pay the hospitalists a competitive salary. Thus, it is important for the group to assess hospitalists’ overhead based on what they actually consume. In general, this should include the cost of billing and collections, malpractice insurance, and modest clerical support. The hospitalist collections should not ordinarily go to support office-based expenses such as support staff and building/equipment expenses.
5) Initial tolerance of inappropriate expectations of hospitalists: To gain support from the medical staff in the early stages of a program, hospitalists sometimes overcommit, assuming responsibility for the scut work that no one wants to perform. This is not a sustainable model. Eventually, it will be hard to tell physicians that they must take back responsibility for something the hospitalists have been doing. This is likely to lead to unhappiness for everyone involved.
One common example of this problem is when hospitalists assume responsibility for tuck-in admissions—those in which the hospitalist admits a physician’s patient overnight and then transfers the patient back to that physician the next day. Another example involves hospitalists who assist with paperwork on patients they did not care for; for example, the hospitalist is expected to do a discharge summary for a heart surgeon, even though the hospitalist wasn’t involved in that particular patient’s care.