How to build community trust with hospital-based specialty programs: 5 Qs with 2 physician leaders

Emergency rooms in communities where surgeon availability is limited can be forced into a game of patient hot potato when an individual presents with a condition the hospital is unable to treat. When the hospital has to send a patient to another facility as quickly as possible, quality patient care is put at risk, community trust in the hospital erodes and revenue opportunities are lost.

An orthopedic surgeon generates an average of $3,286,764 in annual revenue for hospitals, according to Merritt Hawkins' 2019 Physician Inpatient/Outpatient Revenue Survey. Physician shortages and hospitals’ overreliance on community-based orthopedic surgeons to come in and treat ER patients can result in reduced surgical revenue. These circumstances are driving many organizations to take advantage of physician specialty services to close gaps in staffing and ensure patients have access to the care they deserve.

Similar to surgery, hospitals’ obstetrics and gynecology programs are critical yet inherently fragile. Many patients first interact with a hospital through labor and delivery, meaning the OB/GYN program and experience is an important opportunity for the hospital to nurture longtime loyalty with patients. At the same time, stagnating birth rates, tightening margins and difficulty in recruiting providers make OB/GYN programs difficult for hospitals to operate.

TeamHealth provides both hospital-based surgical services and OB/GYN hospitalists to health systems around the nation. Neil Vining, MD, the company's national medical director for surgical services, and Khadeja Haye, MD, the company’s national medical director, obstetrics and gynecology, recently spoke with Becker's about opportunities in hospital-based physician specialty services.

Note: Responses have been edited for length and clarity.

Question: What value can hospitals and patients expect to realize from implementing a hospital-based specialty surgical or OB program?

Dr. Neil Vining: I think the value for hospitals comes in two fairly distinct forms. One is value from a strictly financial perspective and the other is value in the sense that you’re providing a better product to the consumer. Sometimes this value can be financially remunerative, but other times it is more mission driven.

On the financial side, if an ER is losing surgical cases because the hospital doesn’t have enough staff to deliver general and orthopedic surgical services promptly enough, every one of those cases they lose is a pretty significant financial hit to the hospital.

On the mission side, the difficulty many hospitals are having in a lot of markets is simply the provision of basic on-call surgical services. When they are able to provide those services reliably, hospitals provide value to the community by allowing patients and families to get the care they need locally. The ultimate patient dissatisfier is showing up to the ER with a problem and the hospital tells you, "We don’t have a doctor who treats that here, so we're going to take you back in the ambulance and send you to a different hospital." If you can stop that from happening, you've made a huge impact not just on that patient's satisfaction, but on the entire community's satisfaction.

Community-based surgeons have work to do in their clinics, so they simply can't be as responsive as we can. Our time is not divided. When a time slot becomes available in the operating room, we can take advantage of it and get the patient in as soon as possible. The sooner a patient sees a surgeon, the sooner they're discharged from the hospital, which is a major patient satisfier.

Dr. Khadeja Haye: As with surgery, a hospital-based OB/GYN program yields a number of benefits for the hospital, patients, private physicians and nursing staff. Having a physician in-house 24/7 to attend to obstetric emergencies is hugely important from a patient safety and quality care perspective. For example, if you have a patient that shows up with a post-partum hemorrhage, having a physician immediately available can often mean saving a life.

From a nursing perspective, I find that in traditional settings, where doctors are on call, nurses do not feel as supported when they have a question or concern. The doctor may be tired, it might be 3:00 a.m., so nurses might be hesitant to call and wake them up. But if a physician is on site, nurses won’t feel that they’re extending themselves outside the scope of their practice by being the only eyes and ears that can assess the patient.

For patients, hospital-based OBs have the time when rounding to counsel patients. They have the time to evaluate all the patients who come in through triage, both of which are huge contributors not only to quality care but to a positive patient experience.

Q: What is the scope of TeamHealth's specialty programs?

KH: We often provide obstetric and gynecologic care for unassigned patients. Those are patients who show up to the hospital and don't have a provider on staff there. They may have a provider somewhere else or, in many cases, they may not have an OB/GYN at all. When those cases present, either through labor and delivery or the ER, if they require a consultation or admission to the ER, we cover those patients.

We also provide assistant services to the private physicians, for both scheduled and nonscheduled cesarean sections. If there's an anticipated difficult delivery, if the private physicians want another physician's hands available, we're there for them. We also provide other services, such as educational support to all providers on staff at the hospital.

NV: Both on the orthopedic side and the general surgery side, our scope of practice is acute care surgery. We very specifically don't do elective and semi-elective surgeries for two reasons: one, so we maximize our responsiveness to the hospital for more urgent procedures; two, to ensure that we maintain good relationships with community surgical groups and don’t get into a competitive environment.

Something else we do that's particularly valuable to the hospital is that our surgical service lines run an outpatient clinic. That outpatient clinic is a landing pad for all those cases that present at the ER that need somebody to follow up. ERs hate it when somebody comes in with an ankle fracture and they're calling around town trying to find somebody who can see this patient and they don't have insurance and the ER has to find somewhere for them to go. Once our program is in place, they never have to make that call again.

Q: What is the financial impact of transitioning to a hospital-based model? 

NV: There's a cost — the hospital has to be willing to say, "Okay, we're going to put this line item on our budget and we're going to pay for it."

The bigger financial picture, though, includes all the other ways in which our services impact revenues and costs. The return on investment analysis is much greater than what the doctors collect and what share the hospital takes. There are hospitals where we don't make good financial sense, and I think it's important to be clear about that. If a hospital has a very robust call panel and it's got lots of doctors in the community who are willing to take call, provide good services, and do it for no stipend or a low stipend, they probably don't need our service. But for hospitals losing patients, the overall financial impact makes sense. If you look at the whole financial picture, the stipend a hospital pays us no longer looks like redline — it looks like a black line.

And, part of what we're saying to the hospital is "Look, a lot of these people are uninsured, they are self-pay or they are under-insured. We're probably not going to collect a ton of money from them, but we're going to see them and take care of them, regardless." And that matters. That has value in and of itself.

KH: As a result of the way we practice and the patient population we care for, many patients are uninsured and a lot of what we do we're never reimbursed for. Our programs don’t generate a lot of money based off professional fees. One of the benefits, however, is once you have an OB/GYN hospital program, it allows you to profitably convert the triage area into an obstetric emergency department, which then tends to provide some additional facility revenue for the hospital. This revenue can be significant and does help offset the cost of the program.

Q: What is the impact of hospital-based programs on community-based physicians?

NV: In most of our markets there’s some local surgical presence. In these instances, we are often viewed with skepticism. However, we've found we enhance these surgeons’ ability to do the cases that serve them best. Once upon a time, surgeons built their practice on the backs of ER calls. They sat around and waited for patients to come into the ER. That’s not how practices are built anymore; they're built on community referrals.

So, if you’re a total joint surgeon, hand surgeon, foot surgeon or geriatrics surgeon who really looks at the numbers, the last thing you want to be doing is taking call and filling your operating room with uncompensated or under-compensated trauma cases. You're much better off taking that time and adding on another total hip or another ACL reconstruction. What we've seen is that the community surgeons actually improve their own productivity by being able to take the whole burden of calls off their plate.

Q: What is the future for hospital-based specialty programs? How are these programs evolving to meet changes in reimbursement and rising consumerism in healthcare?

KH: I think these programs will eventually become the standard of care. I think more and more hospitals are recognizing the need for an in-house OB/GYN presence and that traditional staffing models are not necessarily sustainable long-term. I think OB/GYN hospital programs will ultimately become the standard of care, especially for larger hospitals that deliver more than 1,000 babies per year.

For hospitals, this service is an investment in the community and in taking better care of your patient population. It's also about getting ahead of the value-based reimbursement curve, especially for hospitals that are poor performers. Whether it's measures on C-section rates, epidemiology rates or even maternal hemorrhage rates, systems with these programs will be better positioned to withstand some of those changes to reimbursement.

'Our docs love this job' — The future of physician staffing models

At the end of the conversation, both Drs. Vining and Haye made a point to emphasize another group of individuals who benefit from these staffing models — the TeamHealth specialists.

"Our doctors love this job," Dr. Vining said, adding that the novel staffing models mitigate many of the circumstances that contribute to physician burnout, such as unrealistic and inflexible schedules. "We give surgeons an opportunity to actually get back to doing what they enjoy doing and to do it in a way that provides them with work-life balance you cannot find anywhere else in the surgical world ... I have a number of surgeons in my programs who would have left medicine if they hadn't ended up working for us."

Dr. Haye echoed this sentiment, stating that the TeamHealth model makes physicians' clinical load more manageable, which means they are more likely to stay in practice longer. "Not only are our doctors happy with the improved work-life balance, but this model is extending the life of their careers," she said.

As the nation's physician shortage worsens and recruitment becomes even more competitive, physician practices like TeamHealth are poised to become a destination for physicians looking to achieve work-life balance without abandoning their calling.

Learn more about the value TeamHealth is bringing to Hospital and ED partnerships at TeamHealth.com.

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