Report: Demand for Hospitalists Continues to Outpace Supply

Larry Beresford

Disclosures

December 29, 2016

Demand for hospitalists continues to outpace supply, according to the Society of Hospital Medicine's (SHM's) recently released "State of Hospital Medicine" report. On the basis of on a survey of 595 hospital medicine groups, along with compensation data from the Medical Group Management Association's Physician Compensation Survey, SHM reports that salaries are up an average of 9% from 2014. Median hospitalist physician compensation is now $278,746, according to the biannual report, which was released in October.

Trends

One of the biggest findings is how this field continues to grow, says Andrew White, MD, MD, FACP, SFHM, associate professor of medicine at the University of Washington, Seattle, and a member of the State of Hospital Medicine task force. "If you look back 10 years ago, not many thought we'd reach 50,000 hospitalists, but we just blew past that threshold," he says. Salary figures reflect the continued demand for hospitalists, which speaks to their continued value to hospitals and health systems, Dr White says.

Martin Buser, MPH, FACHE, consultant with Hospitalist Management Resources, LLC, says that among his clients, the demand curve is flattening somewhat owing to reduced turnover, although there still is a strong need for hospitalists. But Roberta P. Himebaugh, MBA, SFHM, senior vice president with TeamHealth Acute Care Services, tells Medscape that recruiting hospitalists for TeamHealth's contract hospitals is, if anything, harder than it's ever been. "There just isn't a big enough pool of providers to draw upon," she says.

TeamHealth strives to recruit residents to choose a career in hospital medicine while they are still in training. According to the SHM report, 35% of new physicians joining hospital medicine groups are coming right out of residency, although this proportion is down from 48% in 2012.

Himebaugh also sees a growing role for family medicine physicians, who now represent almost one fifth of TeamHealth's hospitalist workforce. The company is using locum physicians to fill shifts more often than in the past. TeamHealth also has its own in-house locum company and special operations teams of hospitalists who can be mobilized to sites of greatest need.

Leslie Flores, MHA, SFHM, a consultant with Nelson Flores and a member of the SHM Task Force that developed the report, also sees a growing presence of family medicine in hospital medicine. The scope of practice for hospitalists continues to expand, with practices diversifying in various ways, she says. Two-thirds of hospitalist groups are now using physician assistants and nurse practitioners, and the majority of practices employ full-time nocturnists to fill after-hours shifts. Others have their members taking on a variety of other specialty roles, such as palliative care or cardiac code blue teams and managing patients in intensive care units or observation units.

At the same time, the postacute setting is growing in importance for hospitalist practice, whether with postacute specialists; hospitalists who divide their time between settings; or new services, such as postdischarge clinics where patients can come back to see a doctor on the hospital campus for one or more follow-up visits. "I'm not sure we accurately captured what's happening in the postacute space in our report, but if current trends continue, more hospitalists are going to be involved in postacute care," Flores says.

Staffing models seem to be evolving away from the once common 7 days on/7 days off approach. Five-day workweeks supplemented by rotating or moonlighting weekend coverage now represent 31% of group practice, with 38% of groups still doing 7 on/7 off—a modest drop-off from prior surveys, according to the SHM report. But this may just be a different group of survey respondents this year, Flores suggests. The trend may reflect evolving ideas about how best to preserve continuity of care, but also what an aging workforce is able to handle physically over the long run.

Pressures Accompanying Growth

Another way of viewing these pressures is what Himebaugh calls "mission creep... hospitals wanting, in fact needing, their hospitalists to do more," including quality improvement and committee work. In some hospitals, comanagement with such medical specialists as surgeons is becoming a thing of the past—replaced by the hospitalist as the attending and the surgeon as consultant. SHM's report says hospitalists are now serving as admitting and attending physicians for surgical patients 64% of the time.

Despite these increased demands on hospitalists, the report identifies a leveling off for total average subsidy paid by hospitals to full-time hospitalists. In the 2012 survey, average subsidy was $139,000; in 2014, $156,000; and in 2016, $157,500. If income has gone up and subsidy has not, that suggests hospitalists are generating on average more billing income, which also means providing more relative value units—and working harder, if not longer.

Dr White highlights the growing number of hospitalist groups that are using some sort of pay for performance or incentives, for example, based on patient satisfaction scores. "Groups are recognizing the growing alignment between hospitals and their hospitalist groups," he says. But the downside is that it can be tough to construct fair metrics that reflect the doctor's true performance, because this often depends on the group's performance and other factors.

Ongoing pressure for performance and generation of billing income by the hospitalist may also be seen in lower morale and increased risk for burnout that Flores' clients report to her. "Morale is not really covered by SHM's data, but we have seen a downturn in morale as people struggle with balancing these demands."

Job satisfaction is based on caseload and competitive salary, among other factors. "Hospitalists have gotten more sophisticated in their expectations of their employers. They expect infrastructure and administrative back-up. They expect good leadership and fair compensation. It's not the Wild West anymore," Buser says.

Long-term, hospitals will not want to see their financial subsidy of hospitalist programs increase faster than the consumer price index. As a result, hospitalists will need to maintain quality and increase productivity by delegating nonphysician tasks to others.

"Can nurses do medication reconciliation? Can a case manager be assigned to the hospitalist? Can scribes help with completing computer notes? It looks to us like the field is ripe for more industrial engineering expertise. Our best programs are innovating like crazy in order to stay ahead of this volatile environment," Buser says.

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