Strike a Balance
One trap hospitalist groups fall into is hiring more support staff than they need, says John Nelson, MD, a principal in Nelson/Flores, a hospitalist management consulting firm, and the medical director of the hospitalist practice at Overlake Hospital Medical Center in Bellevue, Wash.
In his consulting work, Dr. Nelson has seen secretaries file huge volumes of reports and spend their time creating charts and spreadsheets no one will look at again. “It’s very unusual for a hospitalist group to need any sort of medical records kept separately from the hospital,” he says. “So support staff may be doing busy work that doesn’t benefit the practice.”
His advice? “Think critically about whether adding that person is really likely to make the practice better. Challenge yourself to justify any support person you’re considering adding. Make sure every element of the job description contributes to the practice.”
The need for support staff often depends on the hospitalist group’s working relationship to the hospital. Julia Wright, MD, is director of hospital medicine at the University of Wisconsin Hospitals and Clinics (UWHC) in Madison, an academic hospital medicine group of 11 physicians and one advanced practice nurse practitioner. She says the group is assisted by support staff working within the Department of Medicine.
Her part-time program assistant, who tends to secretarial duties such as setting up meetings and assisting with policy development and scheduling, is employed by the primary care department. “We have a benevolent arrangement with the hospital,” she says. “It allows us to do more research and teaching. When we want to put forward an initiative, we usually have the person power and interest and the support to do it.”
Another trend in hiring among hospitalist groups is employing midlevel practitioners, such as nurse practitioners and physician’s assistants. Dr. Ford worked with a physician’s assistant when he was a hospitalist at Union Hospital, a 120-bed community hospital in Elkton, Md. He called midlevel practitioners, who make $70,000 to $90,000 a year —about half the average pay for a hospitalist—a “windfall.”
“They see less-acute patients,” he says. “Patients with stable pneumonia still generate the same billing code as a sicker patient who takes more time and expertise, so midlevels can be more efficient providers from that aspect.”
But this strategy can backfire, according to Dr. Nelson. “On paper, giving nurse practitioners patients who are less sick is logical,” he says. “But in practice, it’s hard to divide up the responsibilities efficiently every day, and there is often a lot of inefficient or unnecessary overlap in work done by the MD and the NP.”
At UWHC, Dr. Wright has found it useful to create a specific definition of the advanced practice nurse practitioner’s role, using feedback from the nurse practitioner and the group’s hospitalists. “We came up with a document that looked at patient complexity, diagnoses, patient volume, and the nondirect patient care issues she is able to help with,” Dr. Wright says. “It’s posted so everyone can remember what kinds of things she can do.”
Sometimes, hospitalist groups can’t make full use of nurse practitioners and other midlevel providers because of hospital regulations. Matthew Szvetecz, MD, head of the hospitalist program at Kadlec Medical Center in Richland, Wash., says he would like to hire nurse practitioners, but hospital bylaws prevent nurse practitioners from writing orders. “If we have to give that kind of direct level of supervision, we might as well take care of them ourselves,” he says.
Dr. Szvetecz’s program has 13 adult hospitalists, four intensivists, and four pediatric physicians. Support staff members include a coordinator in charge of secretarial and administrative assistant duties, a coder who helps with billing, a nurse coordinator, and an executive director. He says the support staff helps contain costs and prevents physicians from spending too much time on administrative duties.