Hospitals run by private practice hospitalists, increases Length of Stay?

[DrMetal]

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Riddle me this.

If a hospital is run by private hospitalists (or a few groups, in which each hospitalist acts as a private hospitalist, billing themselves for every HNP, Progress note, discharge, etc) . . . does this increase the average patient Length of Stay (LOS)?

For instance: Say I'm a private hospitalist, today is Thursday, I have 10 patients on my list. I could probably discharge them before the weekend. But if I know I'm going to be here this weekend anyways, because I'm admitting from the ER on Saturday/Sunday, why not keep those 10 patients and just discharge them on Monday? If I'm billing for those patients, that could easily be an extra $1K/day. If I keep those 10 (and if they're sick enough, you can always find a reason to keep), round on them Fri/Sat/Sun, that equals $3K.

 

[sloh]

This logic only works if the ER is "dead" and there are zero new patients to admit. In a "busy system," the math almost always favors the physician who clears the bed for a new, higher-complexity admission

 

[DrMetal]

This logic only works if the ER is "dead" and there are zero new patients to admit. In a "busy system," the math almost always favors the physician who clears the bed for a new, higher-complexity admission

lets assume a very busy ER.

But if you clear the bed, you may not get the next complex admission (it may go to your colleague), unless you're admitting. And there's no cap to your list. So even if you keep the 'easy' 10 patients, you can still admit the next complex one. If I know I have to be here this weekend, I'd rather just round on 15 than 5 patients, why not keep the easy 10 ?!

And quite honestly, unless the hospital goes on divert, clear beds or not, people are still getting admitted (may hoard up in the ER . . .but the ER will certainly still admit, regardless of your DC rate).

 

[sloh]

Yeah in theory this could work. Is this scenario usually just playing out over the weekend? RAC audits could specifically look for "Friday-to-Monday" LOS spikes. If a private group is consistently camping on patients over the weekend, they are essentially begging for a federal audit.

 

[DrMetal]

Yeah in theory this could work. Is this scenario usually just playing out over the weekend? RAC audits could specifically look for "Friday-to-Monday" LOS spikes. If a private group is consistently camping on patients over the weekend, they are essentially begging for a federal audit.

Sometimes they're even discharged (so we've done our part). We just don't pressure casemanagement as much to place them right away . . .let em take their sweet time.

it seems like this model would always increase LOS. That's probably why most hospitals shifted to single group, hospitalists paid by shift (w2 or 1099), paid the same whether they saw 10 or 20, maybe with some bonus structure for increased census, and cash incentives for early DC, right ?

 

[MD46]

Lets assume the private group is doing this and making more money due to this. How is this any different from unrealistic metrics the admin pushes on doctors to meet so they can make their own bonuses? In my previous practice, the so called Director of Operations (an RN with masters) was paid bonuses based on physician encounters for the month. She would make sure all our slots were filled and always pushing for double bookings and addons

 

[DrMetal]

Lets assume the private group is doing this and making more money due to this. How is this any different from unrealistic metrics the admin pushes on doctors to meet so they can make their own bonuses? In my previous practice, the so called Director of Operations (an RN with masters) was paid bonuses based on physician encounters for the month. She would make sure all our slots were filled and always pushing for double bookings and addons

I don't think its different.

I was just wondering about how different hospitalist models affect LOS. Say Model A is private practice, eat what you bill on a daily basis . . . Model B is the employed, pay constant rate per shift, with some bonuses for higher census, early discharges.

I think in Model A, the LOS is higher, no incentive to discharge. Keep longer so you can bill more. (again, not hard to do with sick patients . . . you could even place a DC order, just don't push CM to do their jobss).

Model B (and it seems most hospitals have shifted to this) seems more likely to reduce LOS.

True?

 

[MD46]

I don't think its different.

I was just wondering about how different hospitalist models affect LOS. Say Model A is private practice, eat what you bill on a daily basis . . . Model B is the employed, pay constant rate per shift, with some bonuses for higher census, early discharges.

I think in Model A, the LOS is higher, no incentive to discharge. Keep longer so you can bill more. (again, not hard to do with sick patients . . . you could even place a DC order, just don't push CM to do their jobss).

Model B (and it seems most hospitals have shifted to this) seems more likely to reduce LOS.

True?

Agreed, in an ideal world our duty to Patient is > than Money. Does that happen in reality , not really and unfortunately. Another experience Ill share, as part of a private heme onc group, our managing partner wanted us to give Ferrlecit 125mg weekly x 8 weeks instead of Injectafer 750mg weekly x2 so we can charge chair time and administration time for iron 8 times vs 2 times. They didn't care about patient convenience etc.

 

[anonperson]

Riddle me this.

If a hospital is run by private hospitalists (or a few groups, in which each hospitalist acts as a private hospitalist, billing themselves for every HNP, Progress note, discharge, etc) . . . does this increase the average patient Length of Stay (LOS)?

For instance: Say I'm a private hospitalist, today is Thursday, I have 10 patients on my list. I could probably discharge them before the weekend. But if I know I'm going to be here this weekend anyways, because I'm admitting from the ER on Saturday/Sunday, why not keep those 10 patients and just discharge them on Monday? If I'm billing for those patients, that could easily be an extra $1K/day. If I keep those 10 (and if they're sick enough, you can always find a reason to keep), round on them Fri/Sat/Sun, that equals $3K.

This is something that gets monitored by any decent CMO.

My community hospital actually just talked about this length of stay issue at the med exec meeting. He pulled some data showing length of stay differences between the solo docs who rounded on their own patients vs the hospitalist group (hospital paid). It was by different primary diagnosis etc ( pneumonia etc)

Also provided data on 30 day re admit rates etc.

The numbers all tilted toward the hospitalist group as having lower length of stay and less re admits etc. I know not totally analogous.

These things typically do get noticed. Just depends on what administration wants to do about it. If it costs them enough money, they will start making it an issue.

----------------------------------
You have some similar stuff in surgery.

I actually get paid less (less wrvu) for a typical laparoscopic/robotic hysterectomy than an open abdominal hysterectomy. I've only done a handful of abdominal hysterectomies in the last few years because it was indicated. Majority are robotic.

 

[collegestud2013]

I think that is part of why true private hospitalist groups are much less common now. For most hospitalist programs, professional fee billing from E/M alone usually does not cover the full cost of the service, so the group often needs a hospital subsidy or other institutional support to stay afloat. The exceptions are usually favorable payer mix (ie lots of private insurance and very low Medicaid or uninsured percentage
) or seeing very high volume.

In that setup, yes, an individual hospitalist can sometimes increase personal revenue a bit by discharging less aggressively and collecting a few extra low-effort follow-up notes/RVUs. But that only helps the physician side. For the hospital, longer LOS is usually a net negative because the facility is generally being paid under DRGs, so extra hospital days do not translate into proportional extra payment and instead just increase cost and reduce throughput.

That is why administration usually notices this pretty quickly. Whether the group is private or hospital-employed, if LOS starts creeping up and throughput worsens, the hospital system takes the loss. Once that happens, leadership will put pressure on the hospitalist group, either informally or through contracts, metrics, subsidy negotiations, or replacement threats.

 

[Splenda88]

I don't think its different.

I was just wondering about how different hospitalist models affect LOS. Say Model A is private practice, eat what you bill on a daily basis . . . Model B is the employed, pay constant rate per shift, with some bonuses for higher census, early discharges.

I think in Model A, the LOS is higher, no incentive to discharge. Keep longer so you can bill more. (again, not hard to do with sick patients . . . you could even place a DC order, just don't push CM to do their jobss).

Model B (and it seems most hospitals have shifted to this) seems more likely to reduce LOS.

True?

The incentive for discharge at my shop is that the new admits get distributed equally.

For instance, if both hospitalists A & B start with 16 patients and hospitalist A discharges 6 and B discharge 1, if there is 6 admits total for the day.... A will end up with 13 patients and B will have 18 the following day. There is cap that is 22.

We all get paid a daily rate so it does not matter how many encounters we have. There are times that a couple of us might have a 9-11 patients in our census.

 

[DrMetal]

The incentive for discharge at my shop is that the new admits get distributed equally.

For instance, if both hospitalists A & B start with 16 patients and hospitalist A discharges 6 and B discharge 1, if there is 6 admits total for the day.... A will end up with 13 patients and B will have 18 the following day. There is cap that is 22.

We all get paid a daily rate so it does not matter how many encounters we have. There are times that a couple of us might have a 9-11 patients in our census.

Yeah. Not the case at my place. I work this one hospital where you keep all your admits, daily pay for each charge. So if you want to make more money, it actually makes sense to keep the patients longer than needed (or at least, you don't fight with case management so much to place).

Somehow, the LOS has supposedly decreased under this model. But I don't get it. Seems a little shady.

 

[Splenda88]

Is 30-40 minutes commute each way acceptable for an ok-to-good hospitalist job.

Let me preface by saying I like my current job right now except it's not close to a major city. I would give my job a ~7/10 ( on a scale 1 to 10 with 10 being a dream job)

Someone just approached me about a hospital medicine job that is about 1h15m from a major city with one of the busiest airports in the US. I know two people who worked there (1 nocturnist and 1 EM) and both told me it's a good place to work at. I don't see why they would lie to me because they both used to work where I am now and they both left 2 yrs ago.

I don't know everything about the job yet as far as compensation. I know it will be ~320k/yr plus another 35k incentive. Some type of 401k match (I don't have that now in my current job). CME 3-5k (only 1k now at my job). I will be working for the hospital system (not a hospitalist group)

Job will be 7 days on/off from 7am to 5pm (available by phone until 7 pm).

I plan to live in the suburb... halfway between the job site and that major city/airport.

My commute right now is 12-15 minutes (~30 minutes total)

What do you guys/gals think?

Sorry. I don't want to create another thread

 

[gutonc]

Is 30-40 minutes commute each way acceptable for an ok-to-good hospitalist job.

Let me preface by saying I like my current job right now except it's not close to a major city. I would give my job a ~7/10 ( on a scale 1 to 10 with 10 being a dream job)

Someone just approached me about a hospital medicine job that is about 1h15m from a major city with one of the busiest airports in the US. I know two people who worked there (1 nocturnist and 1 EM) and both told me it's a good place to work at. I don't see why they would lie to me because they both used to work where I am now and they both left 2 yrs ago.

I don't know everything about the job yet as far as compensation. I know it will be ~320k/yr plus another 35k incentive. Some type of 401k match (I don't have that now in my current job). CME 3-5k (only 1k now at my job). I will be working for the hospital system (not a hospitalist group)

Job will be 7 days on/off from 7am to 5pm (available by phone until 7 pm).

I plan to live in the suburb... halfway between the job site and that major city/airport.

My commute right now is 12-15 minutes (~30 minutes total)

What do you guys/gals think?

Sorry. I don't want to create another thread

I wouldn't think about the "is it worth it" from the perspective of the job. Think about it from the perspective of the rest of your life and how it would affect your life outside of the hospital. Lots of people commute 30-45min every day and think nothing of it. If the job is good enough, and the outside the job lifestyle is better for you, that seems like a pretty good reason to move.

 

[DrMetal]

My commute right now is 12-15 minutes (~30 minutes total)

Is this the only thing positive about your current job? If so, then bail on it. Take the offer for the new one.

If there are more positive things about your current job, sometimes it's best to stay with the beast that you know. (in the end, all of these hospitalist gigs are starting to look like each other. pay is equalizing, benefits, etc . . . logistics differ from one place to another, but you may be trading one set of problems for another).

 

[Splenda88]

I wouldn't think about the "is it worth it" from the perspective of the job. Think about it from the perspective of the rest of your life and how it would affect your life outside of the hospital. Lots of people commute 30-45min every day and think nothing of it. If the job is good enough, and the outside the job lifestyle is better for you, that seems like a pretty good reason to move.

Like most, I don't like changes. I feel like we are settled where we are now, but quality of life could be a bit better.

We like to take short frequent trips and that job would make it easier to do that even more given that we would be 35-45 minutes away from a major airport.

I am also apprehensive about leaving my ok gig for something unknown. To put this in one sentence. "I like to play it safe."

 

[Splenda88]

Is this the only thing positive about your current job? If so, then bail on it. Take the offer for the new one.

If there are more positive things about your current job, sometimes it's best to stay with the beast that you know.

I get along well with colleagues, and other staffs. No micro managing. I spend only ~64 hrs in the hospital on my 7 days on. LCOL area etc...

 

[DrMetal]

I get along well with colleagues, and other staffs. No micro managing. I spend only ~64 hrs in the hospital on my 7 days on. LOL area etc...

So this is really important. I feel the same way about my current situ. Have good colleagues, good staff, short commute, no micromanagin. Pay is a little crappy, schedule a little hectic.

But I'm staying.

 

[Splenda88]

So this is really important. I feel the same way about my current situ. Have good colleagues, good staff, short commute, no micromanagin. Pay is a little crappy, schedule a little hectic.

But I'm staying.

Maybe I should:

Keep my privilege (do 1099) and also my house, and go back if I don't like the new job. I am going to apply then and see what happens.