“When we started in this business 15 years ago, the average hospital might have three to five hospitalists, maybe a subsidy of $300,000 to $500,000,” says Martin Buser, a partner in Hospitalist Management Resources of Del Mar, Calif. “That same program today is probably running 15 to 20 hospitalists, a subsidy of $3 million-plus. It’s really strongly on the radar screen for administrators to look at, ‘Can I keep affording this, or do I need to find less expensive ways to get the same result?’”
Viewpoints Vary
The origins of the seven-on/seven-off schedule are a bit murky. Some believe it was borrowed from the shift-work model in the ED. Others think it has roots in the nursing ranks. Still others think that in the nascent days of HM, two- and three-physician groups developed the schedule by simply splitting monthly schedules by weeks. Regardless of pedigree, the model has grown to be just about the most common schedule for HMGs serving adults only. The State of Hospital Medicine report reported that 41.9% of adult groups use the seven-on/seven-off schedule, with 41.6% reporting their schedule as “variable” and “other.”
SHM has never queried hospitalists specifically about their schedules before, so no comparative data are available for information. Interestingly, the State of Hospital Medicine report found that hospitalist management companies and private HM groups were less likely to use the seven-on/seven-off schedule than hospital-owned or academic groups.
Jeff Taylor, president and chief operating officer of IPC: The Hospitalist Co., a national physician group practice based in North Hollywood, Calif., says just 10% of his 1,400 providers nationwide uses the seven-on/seven-off construct. He argues the model “is economically inefficient.” For example, he says, take a hospital with a census of around 60 inpatients per day. An HM group that wants to limit daily censuses to about 15 patients would need four doctors to staff that patient load. Using the seven-on/seven-off schedule, the group would need eight dayside hospitalists (not counting nocturnists). In a more traditional staffing model of a five-day workweek and call coverage, a group likely could handle the same workload with five FTE hospitalists, Taylor says.
“We have been doing some education with hospitals over the last three or four years of just doing the math,” he adds. “How many doctors would you need to staff this census? … We often give a dual proposal. This is how much it will cost for seven-on/seven-off; this is how much it will cost with the Monday-through-Friday model. Obviously, the Monday-through-Friday model is a lower cost, but it may take a little bit longer to get it staffed.”
Staffing difficulties—particularly recruitment and retention—are a major driver of the popularity of the seven-on/seven-off schedule, says Gregory Martinek, DO, FHM, medical director of Lexington Hospitalists in Altoona, Pa. He says it’s tough to recruit hospitalists to work in a small town in central Pennsylvania, so offering a schedule those physicians want to work is helpful.
In fact, Dr. Martinek offers his hospitalists an extra week of vacation in addition to the 26 weeks they don’t work. That allows some of his foreign-born physicians to take a three-week break from work, which many use as a chance to return to their birth countries.
“We had trouble recruiting when we had a different model,” Dr. Martinek says. “This has really worked for us. It’s allowed us to recruit.”
Cost Concerns
How do HM group leaders answer C-suite questions about whether the expenses associated with the seven-on/seven-off model are worth it? The short answer is data. Know basic metrics on length of stay, cost of care, etc., before having that conversation. For example, a traditional 40-hour workweek is 2,080 hours per annum (and probably less with vacation time). And while some might think that 26 weeks off a year equates to fewer hours, 26 weeks of 12-hour shifts totals 2,184 hours.