30TH ANNUAL AIM EDUCATION

CONFERENCE

HOSPITAL MEDICINE
GROWTH, RETENTION AND TRANSITION TO AN
ACADEMIC PROGRAM

Presenters:
Peter J. Ceriani
Beth Gentilesco, MD AAIM Meetings
October 21 – 25, 2009
Sajeev Handa, MD, FHM
Philadelphia, PA
Tammy L. Lederer
Version 3 – 9/28/09 1

AGENDA

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1. Welcome 3 RIH History off Hospitalist
3.
• Who We Are Program
• Who Are You • Activities
• Recruitment
• Orientation
2. Challenge # 1- Rapid Growth at
RIH
• Hospitalist Compensation Incentives 4. Challenge # 2 - Academic
• Crisis Staffing - Moonlighting Model Transition
• Basic Contracting (MD and Hospital) • Definition of Academic
• Core Issues:
– Becoming Significant Contributors
– Creating a Rewarding Position
– Nurturing Growth

5. Questions

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 Who We Are
Lifespan Includes 4 Hospitals
– Rhode Island Hospital (719)
– The Miriam Hospital (247)
– Newport Hospital (129)
– Bradley Hospital (60)

Statistics (2008) RIH TMH

– Employees – 6,863 – 2,475
– Licensed Beds – 719 – 247
– Affiliated MDs – 1 570
1,570 – 894
– Discharges – 34,102 – 15,661
– ED Visits – 144,343 – 50,199
– Outpatient Visits – 199,023 – 47,312
– Research Revenue – $49.3M – $22.7M
– Net Patient Revenue – $840 M – $313M
– Charity Care (costs) – $25.8M – $6.7M

The Rhode Island Hospital

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 The Miriam Hospital

Challenge # 1 – Rapid Growth at RIH

(July 2008 – June 2009)

Why The Large Demand

Demand…
• Cap on Resident Training Admissions Allowed
• Group of 75 Community-based MD’s No Longer Providing Own Hospitalists
• Marketplace Shifts

Active Recruitment Through…

• Word of Mouth
• Ads (NEJM, Local Papers, Website)
• Recruitment Firm

Provider Supply Could Not Keep Up With Increased Patient Census

• Developed Numerous Moonlighting Models
– Residents
– Fellows
– Contracted Outside
– UMF Faculty

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 Hospitalist Compensation & Incentives - MD
• 12 Hour Shifts - 15 Shifts / Month - Alternate Nights - 157 Shifts/Year

• For a Census of 105 – 126

– 7 MD’s Days (15 – 18 Patients/MD is Safety Margin)
– 2 MD’s Evenings
– 3 MD’s Nights

• Base Compensation = 80% of Total Market Driven Compensation

– 10% Volume – WRVU’s Capped at a $15,000 - $25,000 Range Pool
– 10% Quality – Chose Press Ganey Patient Satisfaction (In Year 1)

• Resources:
– MGMA and Local Market for Total Compensation
– Actual Median Achieved by Last Years Cohort of MD’s For WRVU’s
– Press Ganey Reports of 6 Months Prior at 95% Confidence Interval

All financial dollars are for illustration purposes only

FY 2010
Hospitalist Employment Model – Flexible Scheduling

Bonus Benefit # Shifts # Shifts Extra # Required On call

Category FTE Eligible Eligible per Month per Year shifts/stipend on Call/Yr stipend

1 Full time Model - Flex 1.0 Yes Yes 15 158 $1,000 none -

2 Part time Model - Flex 0.5 Yes Yes 8 84 $1,000 20 $150

3 Hybrid Model - Flex 0.4 No No 6 63 $1,100 16 $175

1. Base Salary at $ 145,000 - $185,000 Range

2. FT = 10.5 months of service (4 weeks vacation, 2 weeks holiday/CME) = 158 (12 hour) shift/year.
3. Ranges of flex time per model: 1 full time - 15, range 13 - 17 shifts/month
2 part time - 8, range 6 - 10 shifts/month
3 hybrid – 6, range, 4 - 8 shifts/month

All financial dollars are for illustration purposes only

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 Crisis Staffing / Moonlighting Options - 1

Subcontract with Outside Attending

Attending-Stipend
Stipend Per Shift

Offer Resident Moonlighting

• $700 + $50/Admission Week Night
• $800 + $50 / Admission Weekend, Holiday

Offer Fellow Moonlighting

Offer Faculty Moonlighting

• Existing Core of 120 Multi-specialists

All financial dollars are for illustration purposes only

Crisis Staffing / Moonlighting Options - 2

Faculty Models for Daily “Overflow” (Beyond Safety Census)
• $250/C
$250/Case (for
(f Morning
M i Calls
C ll Oft
Often 8:00
8 00 am))
• $15,000 + 10% Pension / Year for 1 Shift/Month (and Sign Annual Contract
Amendment)
• $8,000/Week (3 Admissions/Day, 21 Cases/Week, Primary Care)

Weekdays (Nights )
• $1,500/ Shift + 10% Pension if 2 MD’s on
• $1,750/ Shift + 10% Pension if Solo

Weekends
• $1,750 + 10% Pension (Days)
• $2,000 + 10% Pension (Nights)

Sign up for 1,2,3 Shifts/Month

All financial dollars are for illustration purposes only

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 Basic Hospitalist Contracting
• UMF Hires MD’s and Subcontracts their Services to the Hospitals

• Hospitals Cover Net MD and NP Support, Relocation and Legal Expenses

and Recruitment Firm Costs

• Contract Revenue has Multiple Components:

• UMF Bills FFS revenues
• UMF Receives Deficit Funding From Hospitals

• Annual Reconciliation Goal:

All R
Revenues (UMF)
– All Approved Expenses (UMF)
= Net $0

• MD’s and NP’s Treated Identical in the Contract Methodology

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How to Calculate Split Revenues - 1

Cost of Employment of MD’s, NP’s
• S l
Salary
• Bonus or Evening Stipends
• Fringe Benefits / Pension (28%)
• Malpractice Insurance Premiums
• Cell phone, CME, Licenses
• UMF General Administration Overhead
• Academic Enrichment Fund Contribution (AEF)

Revenues from Fee-for-Service Expected

• Less Billing Service fee 8%

Hospital provides – Space, Equipment, Office supplies

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 How to Calculate Split Revenues - 2
A. Revenues: Fee-for-Service Collections of Professional Charges
− Billing Services Fee (8%)
= Net Patient Revenues

B. Expenses: Employment Related and Agreed Upon with Hospital

(Includes MD’s, NP’s, Support Staff)

C. Net Subsidy from Hospital

Calculate Net Subsidy for MD $ ___________
NP $ ____________
− Related to FFS Ability of Each Type of Provider
− Allocates Administrative Support Staff to MD’s and NP’s

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RIH History

• First Inpatient Program In Rhode Island

• Service Begins August 7, 1996 with 3.0 FTE MDs

• Known as the Internal Medicine Inpatient Service (IMIS)

• Under the Division of General Internal Medicine

• Service Non-Teaching

• Role: Cultivate Relationships with Community Physicians and Provide

24/7 Coverage

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 RIH History - 2

Demand for Group Steadily Increases

• Outpatient Practitioners Realized that Hospital Practice Becoming a

More Complex Endeavor

• Reduction Of Workload Mandated by the Accreditation Council for

Graduate Medical Education’s Residency Review Committee

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RIH History - 3

• JJuly
l 2003 – Division
Di i i off Hospital
H it l Medicine
M di i Established
E t bli h d (RIH-
(RIH
DHM)

• Two Services:
– The Internal Medicine Inpatient Service (IMIS) – Hospitalist Program
– The Community Physician Alliance Service (CPAS) – Primarily
Staffed by Nurse Practitioners

Both services non-teaching

• 2003 Designated Hospital Medicine Units Established

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 Activities - 1

• Clinical Service

• Medical Student Teaching

• Elective Rotation for PGY II & III

• IT – CPOE

• Division Morbidity & Mortality Review

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Activities - 2

Hospital Committees
• Medical Reconciliation
• Heart Failure
• Vaccination Improvement
• Patient Flow
• Clinical Documentation Integrity
• Patient Satisfaction
• H1 N1
• Physician Communication
• Universal Protocol

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 Activities - 3

Foundation
• UMF Board of Directors

• Human Resources Committee

• Compliance Oversight Committee

• Investment Committee

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Recruitment - 1

• The Challenge of Recruitment

• Sources of New Hospitalists

• Residency or Fellowship: 50%
• Another Hospitalist Group: 28%
• Different Field of Medicine: 19%
• Other: 1%; Unknown 1%
SHM Biannual Survey 2007-2008

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 Recruitment - 2

2009 Sources of New Hospitalists

• Residency or Fellowship: 86%

• Another Hospitalist Group: 14% (RIH- DHM n=14)

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Recruitment - 3

Career Choice of Departing Hospitalist

• Another Hospitalist Program: 33%

• Fellowship/Other Training Program: 26%
• Different Field Of Medicine: 22%
• Family/Personal Reasons: 9%
• M di l Ad
Medical Administration/Consulting:
i i t ti /C lti 4%
• Retirement: 1%
• Other Choice: 2%
• Unknown Choice: 2% SHM Biannual Survey 2007-2008

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 Recruitment - 4

Staffing changes (DHM)

• 2007-2008 – 10 MDs – 1 Termination- Fellowship

• 2008-2009 – 15 MDs – 4 Terminations- 3 Fellowship;

1 Relocation - Hospitalist

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Recruitment - 5

How Does One Recruit 12

12.0
0 FTE MDs Within a Matter of
Five Months?

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 Recruitment - 6

• New Strategies – Head Hunter

• LOR’s then Invitation to Visit

• Coordinate Visit and Interview Schedule

• The “Red Carpet” Treatment

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Recruitment - 7
• Selling
g our Communities and Life Styles
y

• Housing and Community Tours

• Supporting Applicant with New Hire Process

• Important Relations
• Candidates
• Head Hunter
• Relocation Specialist
• Immigration Lawyer
• RI DOH

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 Recruitment - 8

Current Staffing 2009

2009-2010
2010 (RIH – DHM)
• 1.0 Medical Director
• 23.25 Clinical FTEs
• 4.0 FTE Nurse Practitioners

Shift Based Model

• 8a – 8p
• 2p – 11p
• 8p – 8a
• 11p – 8a
• 9a – 5p

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Orientation - 1

Schedule - Components
• Welcome Address – Chair/CMO

• Introduction – Review of Service Guidelines

• Compliance – Billing

• Risk Management – Lifespan System-wide

System wide Loss Prevention Specialist

• Physician Order Management – Training

• Overview – Nursing Clinical Managers (DHM Floors)

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 Orientation - 2

New Physicians
• Opportunity to Ask Questions

• Provide Support (Seasoned/Senior MD)

• Ramp Up Case-load Gradually

• Address Problems Early

• Provide Detailed Written Guidelines

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On the Path to an Academic Model

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Challenge #2 – Academic Model Transition

Who’s
Who s an Academic?
• A Community Hospitalist Takes Care of Patients

• An Academic Hospitalist Takes Care of Patients and Does

Something Else Too

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Putting the “Academic” in…

What are the Characteristics of an Academic

Hospitalist Program?

• In-patient Care Predominates

• Teaching

• Research

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 Core Issues for the MDs

• Making Substantial Contributions to the Hospital

Community

• Creating a Rewarding Job

• Nurturing
g the Other Half

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Become Part of the Fabric

• Committees
• Co-management
• Procedures
• Quality
• Education
• IT
• Research
• Safety

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 Creating a Rewarding Job
Preventing Burnout

• Teaching vs. Non-teaching Time

• Average Daily Patient Census (safety)

• Other Services (Procedures, Nights)

• Clinical vs. Non-clinical Time

• Scheduling/ Vacation/ Planning Ahead

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Nurturing the Growth

• Orientation
O i t ti
• Mentorship
• Faculty Development (Research, Teaching)
• Morale Building
• g
Meetings
• Opportunities

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 Questions

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Contact Information
Peter Ceriani, MBA Sajeev Handa, MD, FHM
Chief Executive Officer Division Director
Director, Hospital Medicine
University Medicine Foundation, Inc. University Medicine Foundation, Inc.
Rhode Island Hospital Rhode Island Hospital
593 Eddy Street 593 Eddy Street
Providence, RI 02903 Providence, RI 02903
401-444-5135 401-444-3985
401-444-5492 (fax) 401-444-3986(fax)
pceriani@lifespan.org shanda@lifespan.org

Beth Gentilesco
Gentilesco, MD Tammy L L. Lederer
Assistant Professor of Medicine Chief, Human Resources Officer
University Medicine Foundation, Inc. University Medicine Foundation, Inc.
The Miriam Hospital Rhode Island Hospital
164 Summit Avenue 593 Eddy Street
Providence, RI 02906 Providence, RI 02903
401-793-2104 401-444-7815
401-793-4047 (fax) 401-444-5492 (fax)
bgentilesco@lifespan.org tlederer@lifespan.org

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