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Physician (provider) in triage

Discussion in 'Emergency Medicine' started by TrumpetDoc, May 17, 2014.

  1. TrumpetDoc

    TrumpetDoc 7+ Year Member

    Sep 17, 2009
    I wanted to get a general idea, how many of you currently utilize some variant of the title (PIT)?

    I started my new gig, which is a SDG with a large hospital system. One of their contracts is a CMG, and has been for a while. The hospital has repeatedly praised the SDG and wanted to keep them...for as little as that is worth;)
    I am new to the group relatively. Now a partner. I came from a region where PIT was the standard. And from what I read and hear from colleagues, I venture to hypothesize that it is the rule rather than the exception (likely adjusting for some volume and staffing level).
    I have been hinting this to the group for months now, literally since I came on, and nothing.
    We get BUSY for the staffing we employ. I have worked in a PIT system and if you can do it without increasing staffing (we could) then it only makes things easier, for the most part.
    Also, when it does get busy, the lwats and DTD times go way up and I seem like the only one who cares. Now, I only care because I want to hold onto what we have.

    Just wanted to get an idea as to if this is really a trend in community EDs or not.

    We are a Midwest, suburban Metro. We see 40k staff docs 27 hours (three MD shifts) with variable MLP coverage.
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  3. EctopicFetus

    EctopicFetus Keeping it funky enough 10+ Year Member

    May 3, 2004
    We have discussed this but have not employed it. I know some people like it. IMO if you run waits then it might make sense. you can quickly turn around your easy patients. if you dont run waits i think its a waste.
  4. Greenbbs

    Greenbbs 10+ Year Member

    Sep 21, 2007
    Glorious upstate NY
    We have a MLP in triage from 0700-0300 daily with an MD/DO from 10a-10p. It works well. We can filter sometimes 40% of the volume out in triage, which is huge considering we see 120 k a year! When I work, I'm busy there, sometimes seeing 50 dispos a day, but we are scribed so it helps.
  5. USCDiver

    USCDiver Percocet-R-US 10+ Year Member

    Aug 31, 2003
    It all depends on whether you are truly JUST screening and triaging patients, in which case, their full evaluation and dispo is done by someone else. If so, this is not a revenue generating position unless you can eliminate a HUGE number of LWOTs. Otherwise a vast majority of your patients are already getting seen and billed, even if there are wait times. You aren't adding anything to the coffers by seeing them sooner.

    Now if you're seeing and streeting a big number of really low acuity patients (hopefully with scribes) like Greenbbs says then you can make a big difference on the backside. But you're basically just running fast track out of triage at that point.
  6. The White Coat Investor

    The White Coat Investor AKA ActiveDutyMD Physician Partner Organization 10+ Year Member

    Nov 18, 2002
    SDN Partner
    Our volumes don't justify it, just like scribes. Patients don't wait in our waiting room, so why do we need a doc out there?
  7. Arcan57

    Arcan57 Junior Member 10+ Year Member

    Nov 21, 2003
    Why do patients back up in the lobby at your shop?

    1) Lack of space with sufficient doc and nurse staffing
    a) Typical number of ESI 4 and 5 patients - perfect scenario for PIT
    b) Low volume of ESI 4 and 5 patients - reduces LOWT and door-to-doc without effecting overall length of stay
    2) Lack of doc staffing with sufficient nurse and space resources
    a) Able to screen out significant number of low acuity patients - go for it
    b) Not able to screen out significant number of low acuity patients - won't help​

    3) Lack of nurse staffing
    a) Able to screen out significant number of low acuity patients - sure
    b) Otherwise - no
    All of these are strictly from an improved throughput standpoint. Figuring out if it's cost-effective is something that would involve very facility specific numbers as well as how likely you are to lose the contract if you don't.
    EM Junkie and WilcoWorld like this.
  8. TrumpetDoc

    TrumpetDoc 7+ Year Member

    Sep 17, 2009
    It's a mix of things. Out group under staffs the docs to three single physician shifts with added MLPs throughout the day (varies by day) for the vast majority of the time, we get them in and through. But as you might imagine, w do have days that are damn busy ( and cannot place them into a pattern) where the door-to-doc times are way up and lwbs rate is up. But this is NOT the norm.
    However, the "hospital" is inquiring as to how we can "fix" this?

    So, my intention was just to gauge what the actually prevalence of these are? Our volume is not that high. We handle things quite well, but I am getting the sense that the hospital admin knows about this (PIT) and wants us to do it.

    I thought that to save staffing we would just shuffle the MLP to the PIT for their first half and when new one comes one, the new one foes there, no increased staffing.
  9. Arcan57

    Arcan57 Junior Member 10+ Year Member

    Nov 21, 2003
    We have a midlevel in triage currently and it's a mixed bag. Our bed to provider time averages 1 minute, but our door-to-dispo and LWBS didn't significantly improve.
  10. MSmentor018

    MSmentor018 Hooah! Physician Faculty SDN Advisor 10+ Year Member

    Jul 9, 2007
    it's always hot!
    does your group/ED have a monthly bonus when meeting the door to doc, los, dispo, lwbs times?
  11. TrumpetDoc

    TrumpetDoc 7+ Year Member

    Sep 17, 2009
    No bonuses. Just old fashioned monthly pay with end year bonus...worked at a couple of EDs with payment structure affected by such metrics. Not impressed. Did little to change any of the metrics as a lot of things are systems issues and you feel your pay being harmed by things out of your control. No bueno.
  12. thorg12

    thorg12 Junior Member 10+ Year Member

    Nov 18, 2005
    Is 40k volume with 27 doc hours kind of low doc coverage? How much mid level coverage do u have? Does everyone else use that little doc coverage?
    My shop is 36k. 34hr doc coverage 12 mlp
  13. TrumpetDoc

    TrumpetDoc 7+ Year Member

    Sep 17, 2009
    It is...but this won't change any time soon. Most I have seen are heavier in doc coverage.
  14. GeneralVeers

    GeneralVeers Globus Hystericus Physician 10+ Year Member

    Mar 19, 2005
    Las Vegas
    I don't like having pay based on door-to-doc and LWBS, LOS, etc. Much of the factors involved in these things are beyond the control of the physician/physician group . About the only thing we can to significantly impact these things (if it's a provider issue) is to increase coverage of MLPs or docs. Unfortunately that means a usually means a pay cut as your reimbursement is spread out over more physician hours. It's always easy for hospitals to put the boot on doctors to fix these things, as increasing physician coverage doesn't affect the hospital bottom line.

    One of the few good things about the hospital employee model, is that if the hospital wants to improve those metrics by increasing coverage, your pay generally stays the same as the hospital is the one who has to pony up the money to pay for additional providers.
  15. n2b8me

    n2b8me 7+ Year Member

    May 27, 2008
    My shop is 30k. 81hr doc coverage without MLPs. That does include a 9 hour afternoon PIT shift. Of course we are on the higher end of staffing.
  16. MSmentor018

    MSmentor018 Hooah! Physician Faculty SDN Advisor 10+ Year Member

    Jul 9, 2007
    it's always hot!
    are you also running patients in the back? granted the PIT doc (supposedly) only does the esi 3ish-5 but at our shop besides the full service given in triage, those that need headache cocktails, LP, complicated lacs......etc. are in another area that we look after
  17. Hercules

    Hercules Son of Zeus 10+ Year Member

    Jul 25, 2000
    Mobile, AL
    81 hrs of physician coverage for 30k?!? Was that a typo?? That's 1 patient per hour. We are seeing ~45k with 31 hrs physician coverage and 18 hrs of midlevel coverage.
  18. Birdstrike

    Birdstrike 7+ Year Member

    Dec 19, 2010

    That's right. Here's what always drove me insane about that. For people that model hospital and EDs after a Walmart or fast food mentality, they sure don't ever seem to want to respond in the same way that such a business would to similar problems. As far as staffing goes, it drove me insane that every day I walked into the ED, I knew at some point there would be a patient surge, the wait room would fill up, and for a while the placed would be slammed. Almost every day. There was no surprise value there. Yet, every day, when this occurred admin would freak out, like it was a big shocker, as if someone had just spotted big foot or unexpectedly isolated a case of Ebola virus at the nursing station.

    Why can't I take 30 min (most shifts) to rest my brain with a meal break like the rest of humanity, while working one of the most stressful jobs there is?

    "We're slammed. This never happend before."

    Why do I have to work more shifts, more nights, and be more sleepy-groggy than I signed up for?

    "We're slammed. This never happend before."

    Rather than doing the obvious, expanding capacity, adding staff, nurses, doctor coverage, rooms, techs, etc, they would expect everyone to buy into the frenetic panic as if it was their first day shadowing in the ED. I know extra resources cost money, and there are certificate of need issues that slow down efforts to expand, and providers are hard to find, but the concept of EDs being "slammed" by non-emergencies is not new. Rather than taking real steps to meet the needs of the problem, they look for tokens and buzzwords such as "provider in triage" or "improve greet times" where resources are put one place, and just short another.

    If you're going to survive in EM, you have to decide either you're going to

    1-Ignore the manufactured sense of panic of "wow we're slammed, this never happened before. Run around like you're a chicken with your headul cut of for this and almost every shift the next 30 years," and block it out, which I think is next to impossible nowadays, with jobs and contracts being threatened over patient sat and throughput times, or

    2- Buy into the panic, that every level 2 work note needs to be treated with the urgency of a 3-yr-old impending cardiac arrest, and risk emotional exhaustion, or

    3-Opt out. Opt out could mean leave the ED setting in some form (without necessarily leaving the specialty or Medicine in general). Or more commonly you'll see people jump at something like a directorship, or something else that allows them to reduce shifts and throw other troops into the line of fire. Often times such people refuse to admit they just wanted out of the grinder, because doing so, would either undercut their message of wanted to get you to jump into combat or, they feel they'd be stigmatized with having the "Bigshot" stamp on the white coat replaced with a "Burn Out" stamp. Opting out coil also mean contractually refusing to work over a certain amount of hours/shifts, but could risk being replaced.

    Maybe not all EDs are this way, but I've worked in enough it seemed to be a common theme. Staff things bare bones and pray that everyone buys into the theme that a wait room full of (> 2/3) walking-well is a "crisis," never happened before and that there is no solution but for you to always run faster. Hope that there's more young bucks, PAs and new recruits to fill the revolving door of those who "burnout" or wise up. This is all done with ZERO focus on physician wellness, physician "satisfaction" (patient satisfaction is the only golden goose, because it lays golden eggs) and solving the actual problems with resources from the administrator year-end cash-bonus fund. The only solution are "keep turning the crankshaft boys" and keep that goose laying those eggs.

    The real crisis will occur if and when they just can't find anyone to buy into it anymore.

    Solution: Think for yourself, and don't drink the Kool Aid.

    "Medicine’s Top Earners Are Not the M.D.s

    THOUGH the recent release of Medicare’s physician payments cast a spotlight on the millions of dollarrs paid to some specialists, there is a startling secret behind America’s health care hierarchy: Physicians, the most highly trained members in the industry’s work force, are on average right in the middle of the compensation pack.

    That is because the biggest bucks are currently earned not through the delivery of care, but from overseeing the business of medicine.

    The base pay of insurance executives, hospital executives and even hospital administrators often far outstrips doctors’ salaries, according to an analysis performed for The New York Times by Compdata Surveys: $584,000 on average for an insurance chief executive officer, $386,000 for a hospital C.E.O. and $237,000 for a hospital administrator, compared with $306,000 for a surgeon and $185,000 for a general doctor.

    And those numbers almost certainly understate the payment gap, since top executives frequently earn the bulk of their income in nonsalary compensation. In a deal that is not unusual in the industry, Mark T. Bertolini, the chief executive of Aetna, earned a salary of about $977,000 in 2012 but a total compensation package of over $36 million, the bulk of it from stocks vested and options he exercised that year. Likewise, Ronald J. Del Mauro, a former president of Barnabas Health, a midsize health system in New Jersey, earned a salary of just $28,000 in 2012, the year he retired, but total compensation of $21.7 million.

    The proliferation of high earners in the medical business and administration ranks adds to the United States’ $2.7 trillion health care bill and stands in stark contrast with other developed countries, where top-ranked hospitals have only skeleton administrative staffs and where health care workers are generally paid less. And many experts say it’s bad value for health care dollars.

    “At large hospitals there are senior V.P.s, V.P.s of this, that and the other,” said Cathy Schoen, senior vice president for policy, research and evaluation at the Commonwealth Fund, a New York-based foundation that focuses on health care. “Each one of them is paid more than before, and more than in any other country.”

    She added, “The pay for the top five or 10 executives at insurers is pretty astounding — way more than a highly trained surgeon.”

    She said that executive salaries in health care “increased hugely in the ‘90s” and that the trend has continued. For example, in addition to Mr. Del Mauro’s $21.7 million package, Barnabas Health listed more than 20 vice presidents who earned over $350,000 on its latest available tax return; the new chief executive earned about $3 million. Data released by Medicare show that Barnabas Health’s hospitals bill more than twice the national average for many procedures. (In 2006, the hospital paid one of the largest Medicare fines ever to settle fraud charges brought by federal prosecutors.)

    Hospitals and insurers maintain that large pay packages are necessary to attract top executives who have the expertise needed to cope with the complex structure of American health care, where hospitals and insurers undertake hundreds of negotiations to set prices.

    Ellen Greene, a spokeswoman for Barnabas Health, said Mr. Del Mauro’s retirement package was “a function of over four decades of service and reflects his exceptional legacy.” Nearly $14 million was a cumulative payout from a deferred retirement plan, she said, and the remainder included base compensation, a bonus and an incentive plan

    Ms. Greene also said Barnabas’s compensation program follows I.R.S. rules and is established by an executive compensation committee with “guidance from a nationally recognized compensation consultant.”

    In many areas, the health care industry is home to the top earning executives in the nonprofit sector.

    And studies suggest that administrative costs make up 20 to 30 percent of the United States health care bill, far higher than in any other country. American insurers, meanwhile, spent $606 per person on administrative costs, more than twice as much as in any other developed country and more than three times as much as many, according to a study by the Commonwealth Fund.

    As a result of the system’s complexity, there are many jobs descriptions for positions that often don’t exist elsewhere: medical coders, claims adjusters, medical device brokers, drug purchasers — not to mention the “navigators” created by the Affordable Care Act.

    Among doctors, there is growing frustration over the army of businesspeople around them and the impact of administrative costs, which are reflected in inflated charges for medical services.

    “Most doctors want to do well by their patients,” said Dr. Abeel A. Mangi, a cardiothoracic surgeon at the Yale School of Medicine, who is teaming up with a group at the Yale School of Management to better evaluate cost and outcomes in his department. “Other constituents, such as device manufacturers, pharmaceutical companies and even hospital administrators, may not necessarily have that perspective.”

    Doctors are beginning to push back: Last month, 75 doctors in northern Wisconsin took out an advertisement in The Wisconsin State Journal demanding widespread health reforms to lower prices, including penalizing hospitals for overbuilding and requiring that 95 percent of insurance premiums be used on medical care. The movement was ignited when a surgeon, Dr. Hans Rechsteiner, discovered that a brief outpatient appendectomy he had performed for a fee of $1,700 generated over $12,000 in hospital bills, including $6,500 for operating room and recovery room charges.

    It’s worth noting that the health care industry is staffed by some of the lowest as well as highest paid professionals in any business. The average staff nurse is paid about $61,000 a year, and an emergency medical technician earns just about minimum wage, for a yearly income of $27,000, according to the Compdata analysis. Many medics work two or three jobs to make ends meet.

    “It’s stressful, dirty, hard work, and the burnout rate is high,” said Tom McNulty, a 19-year-old college student who volunteers for an ambulance corps outside Rochester. Though he finds it fulfilling, he said he would not make it a career: “Financially, it’s not feasible.”

    Elisabeth Rosenthal is a reporter for The New York Times who is writing a series about the cost of health care, “Paying Till It Hurts.”

    Correction: May 18, 2014

    An earlier version of the headline for this article was revised to more precisely capture the principal insight offered by the news analysis."
    Last edited: May 20, 2014
    Makati2008 and TrumpetDoc like this.
  19. Vandalia

    Vandalia 2+ Year Member

    Feb 21, 2014
    Sorry, I just had to chuckle over this:

    “At large hospitals there are senior V.P.s, V.P.s of this, that and the other,” said Cathy Schoen, senior vice president for policy, research and evaluation at the Commonwealth Fund, a New York-based foundation that focuses on health care."

    I agree with what she said, I just can't let that pass by.
  20. Birdstrike

    Birdstrike 7+ Year Member

    Dec 19, 2010
    Actually, if you read between the lines there's a tremendous amount of information implied in that clumsy statement. Her quote translates to this (if you would allow me to finish it for her) after passing it through my patented BS-detector machine, honed over many years in the ED:

    "At large hospitals there are senior V.P.s, V.P.s of this, that and the other. [I'm not sure what they do, really, if anything...pfft. But I am sure they make a crap-load of money, though!]"
    Last edited: May 20, 2014
  21. EM_Rebuilder

    EM_Rebuilder Member Physician 10+ Year Member

    Feb 27, 2006
    Our pay structure has recently changed with a portion 'at risk' based on Press Ganey Scores, LWOBS, and Patients Per Hour. My two favorite parts is that A.)I tend to have 1-5 'scores' on my Press Ganey which somehow is stastically significant enough to change up to 10/hr of my pay and B.)Our PPH top pay metric is higher than anyone ever meets at my shop, when I tried to exceed it by pushing nursing staff and going to triage and being creative at using rooms not used, I got HUGE push back from nursing staff and Midlevels who said I was stealing their patients. We do have a MLP in triage.

    Its a constant changing environment.
    Last edited: May 22, 2014
  22. Groove

    Groove Member Physician 10+ Year Member

    May 3, 2004
    I think PIT is beneficial in the right shop and environment. We utilized it at my last gig and although I was extremely skeptical, it actually did help our metrics. We had an appreciable # of LWBS and LOS 2/2 a host of factors, much of it outside our control. CMG group. For starters, I think you need incentives to make one of those shifts bearable to the point that all the docs are on board. Many of the docs just aren't going to give a rats ass about the metrics. We had RVU incentives and this is basically how it worked....

    1) We'd funnel the pt's in waiting to a "quasi fast track" with the ED doc and a nurse. Mostly 4's and 5's. If it was treat and street, those pt's were yours. If they were even mildly complicated, you threw in some orders, wrote a small MSE note about your thought process and dumped them in the main ED for another ED doc to pick up. By the time he got to them, work up was completed and he could get them dispositioned faster. If I had one or two tests and just needed to keep them a little longer, or say... a quick I&D, I'd dump them over in a lower acuity section where a MLP +/- ED doc was located and they sectioned off 4 rooms that were mine where I could obs/treat them a little longer. When I got time, I'd run over and disposition them. Those were mine too. At the end of the 9hr shift, I might see 30-40 pts. I didn't get to bill on all of them, but most.

    At the end of the month, I noticed that a hand full of these PIT shifts really amped up your PPH and RVUs and gave a measurable bump in pay. The docs that were up for the hustle volunteered to staff a few of these a month, and the ones that weren't...didn't. It all worked out. Metrics improved and those were hard numbers to hand to hospital administration that made us look like we were improving ED efficiency.

    At my current gig, we run much more efficiently and utilize MLPs for virtually all of the 4's and 5's with very low wait times, so no need for that type of shift. At the end of the day, if it's a SDG and you have any amount of metrics that would benefit from a PIT position, I'd say it would be worth it though I would provide incentives to the ED docs that work them because let's face it... they are not fun shifts. RVU vs differential, whatever... It would improve your numbers and make you look better in Hospital Administration's eyes when the mighty CMG comes in and throws numbers at them to show how they can run the ED more efficiently.

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