Arbitrary Definitions
SHM’s “2007-2008 Bi-Annual Survey on the State of the Hospital Medicine Movement” shows full-time hospitalists work an average of 2,172 hours annually. This might not be a reliable figure. Even so, many practices define full-time work based on annual hours (or shifts), but the doctors regularly adjust actual number of hours worked depending on that day’s workload, and few practices rigorously track actual hours worked. So I think data on hours worked annually (from SHM or other sources) should not be used as reliable or valid target for a practice.
Annual number of shifts worked can be reported by a practice more reliably but usually isn’t included in surveys because shift lengths can vary significantly from one place to the next. Ultimately, the number of hours or shifts that define full-time work for a given practice is arbitrary. And it has an impact on the budget.
Many—maybe most—practices arrive at a definition of full-time work based on annual hours, and any provider who works more than that number is paid for “extra” hours or shifts. If the number of hours or shifts that define full-time work is set low, the practice will end up paying for a lot of extra hours or shifts. Payment beyond the projected salary allowance can cause the practice budget to balloon.
One test to see if this might be an issue in your practice is to total the compensation and productivity (e.g., work relative value units, or wRVUs, or billable encounters) for each doctor in the practice. Analyze how the compensation per wRVU or encounter compares with survey data. If your group is higher than survey data, then the definition of full-time work might be unreasonably low, and vice versa.
Night-Shift Costs
Hospitalist night shifts tend to result in low productivity until the practice has grown enough that there are six to eight daytime hospitalists (rounder/admitter) for every night-shift doctor. Still, most small practices find that it is worthwhile to schedule a separate in-house night shift. The cost of the additional FTEs required to staff a separate night shift can be significant, and is a reason many very small practices require more financial support per FTE hospitalist from the hospital than larger practices.
In most cases, I think it is in the hospital’s best interest to provide support for a separate night shift (see “Finding and Keeping Dedicated Noctornists,” February 2008, p. 61). If the practice budget, or amount of support required of the hospital, is seen as excessive, it is worth estimating how much of the excess is attributable to the expensive night shift.
One simple way to do this is to think about the amount of hospital support that goes to each doctor during each shift. For example, if a hospitalist works 182 shifts a year and is compensated $230,000 (salary and bonus at $200,000, and benefits at $30,000 annually), then the doctor costs the practice $1,264 per shift. You might conduct an analysis and learn that the doctor averages $900 in collected professional fees during a day shift and $500 during a night shift. That means more hospital support goes to cover a night shift ($764) than a day shift ($364). Put another way, in this example, each night shift worked by a doctor requires $400 more hospital support per shift than the day-shift hospitalist ($764 vs. $364). In most cases, the hospital realizes a significant return on spending the extra money on the night shifts.
Hospitalist Productivity
Some hospitals have systems of care that interfere with hospitalist productivity. These could be such things as a poorly organized medical record, an IT system that requires logging into multiple programs to retrieve data on a single patient, or hospitalists being required to do clerical work. Productivity also is influenced by time spent on nonclinical activities, which leads to decreasing professional fee revenue. Every practice should think carefully about the systems and activities that might be getting in the way of efficiency. TH