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Trends in Physician Employment Recruitment and Hospitalists in North East Ohio. January 17, 2008 A. Gus Kious, M.D. President Huron Hospital. Physician Recruitment. Magic Bullet? New vs. Established End State vs. Present State Population Based vs. Individual Case Work

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Trends in Physician Employment Recruitment and Hospitalists in North East Ohio


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    1. Trends in Physician Employment Recruitment and Hospitalists in North East Ohio January 17, 2008 A. Gus Kious, M.D. President Huron Hospital Hospitalist Presentation

    2. Physician Recruitment • Magic Bullet? • New vs. Established • End State vs. Present State • Population Based vs. Individual Case Work • Networked vs. Independent Hospitalist Presentation

    3. Physician Recruitment • Community Need • Strategic Need • Understanding Customers – The Doctors • Newer Models of Care • Mechanics Hospitalist Presentation

    4. Community Need – “The Ecology of Health Care” 1000 People 800 Report Symptoms 327 Consider Seeking Care 217 Visit Physician (113 PCP) 65 Complementary/Alternative Medicine 21 Visit Hospital OPD 14 Home Health 13 Visit ED 8 Hospitalized <1 Academic Medical Center NEJM 2001: 344:2022 Hospitalist Presentation

    5. CCHS Medical Staff Resource Model Define CCHS service area, collect age/sex cohort pop. (2006 – 2011) Estimate disease burden baseline (2006 – 2011) by major organ system prevalence/incidence models. Using NCHS – NAMCS survey data establish encounter frequency rates and estimate likelihood the patient will seek care. • Organic Growth • OHA share • Prevalence • Disease trends • Weighted average Adjust gross encounter estimates to current market specific share, project 5 year growth rates. Establish current physician supply, estimate future (> 5 yrs) based on three tiers of retirements Hospitalist Presentation

    6. CCHS Medical Staff Resource Model Correlate current physician supply with observed encounter activity (acute – ambulatory care) Correlate core program/Dx trends with estimated physician supply 5 yr projections Quantify impact on core product lines and clinical specialties based on retirement tiers Quantify net revenue impact on core service lines by retirement tier. Establish comparison baseline using net revenue per unit of service for core product lines. Quantify net revenue/retirement tier physician by service line. ID resource needs by net rev baselines and retirement tiers: Near term: < 18 months Medium term: 18 – 36 months Long term: > 36 months Hospitalist Presentation

    7. CCHS – Eastern Market Population Cohorts Net change 2006 - 2011 n = - 39,277 n =+ 29,328 Source: CCHS – CCF Marketing/Planning Total East Market population change: - 15,000 Hospitalist Presentation

    8. Disease Prevalence Findings • Peer reviewed research based prevalence and incidence rates for core disease groups (case types) were applied to 2012 service area population age/sex cohorts. Major disease categories considered in the analysis included: • Behavioral health • Neurological conditions • Cardiovascular disease • Digestive disease • Endocrine and metabolic disease • Female GU • Pulmonary • Infectious disease (primarily STDs) • Cancers • Chronic conditions specific to several of the disease categories were considered separately due to their increasing impact on resource utilization and have been considered by many as epidemic in proportion. • Metabolic syndrome (obesity, hypertension, diabetes, lipid disease) • Peripheral arterial disease (PAD) • Depression as a secondary diagnosis Hospitalist Presentation

    9. CCHS –Eastern Market Physician Staff Sorted by Specialty Pct of Net Revenue – 2006 (specialties represent 80% of total program revenue) Total net revenue 2006 = $ 451,278,000 Hospitalist Presentation

    10. CCHS –Eastern Market Specialty Impact By Core Service Line, > 62 years only Top specialties included in this case type Net Revenue per physician > 62 yrs. Hospitalist Presentation

    11. CCHS –Eastern Market Net Revenue Comparisons By Core Service Line Hospitalist Presentation

    12. Program Growth Rates Eastern Market Hospitalist Presentation

    13. CCHS –Eastern Market Anticipated Physician Need 2010 By Core Service Line, adjusted by net revenue units Hospitalist Presentation

    14. Strategic Needs • Orthopedic Surgery • Neurosurgery • Neurology • Interventional Radiology Hospitalist Presentation

    15. Understanding Customers - Practice Setting Practice Setting1996-19972004-2005 Solo or two-physician practices 40.7% 32.5% Groups of three to five physicians 12.2% 9.8% Groups of six to 50 physicians 13.1% 17.6% Groups of > 50 physicians 2.9% 4.2% Medical Schools 7.3% 9.3% HMOs 5.0% 4.5% Hospitals 10.7% 12.0% Other 8.3% 10.1% Family Practice Management / October 2007 Hospitalist Presentation

    16. Understanding Customers – Reasons for Resignation 51% - Poor cultural fit 42% - Move close to family 32% - Higher compensation 22% - Spouse’s job requirements 20% - Better community fit 17% - Incompatible work schedule 17% - Excessive call requirements 46% - Leave in first 3 years Family Practice Management / October 2007 Hospitalist Presentation

    17. Newer Models of Care – Chronic Care – Summa + Huron Nurse PractitionerClinical ExpertPatientInterdisciplinary Care Team Manage Planned Visit Team Lead Set Goals Pharmacist Manage Data Base Intensify Care Develop Skills Nutritionist Care Coordination Train Docs Self Care Social Work Accountable Psychologist Podiatrist Ophthalmologist Hospitalist Presentation

    18. Mechanics of Recruitment • Devoted Resources • Contracted Services – Contingent Firms Hospitalist Presentation

    19. Experience of Huron • 1 Vice President Physician Contracting • 10-15 Recruitment Firms – All Contingent • CCF Recruitment – Strategic Recruitment • 7 New Physicians in next 8 months • Fair Market Value • Work as a unit with CCF and CCHS • Consistent Message, Competitive Salary, Benefits, Strong Physician Leadership, Purpose • Success – Strong Commitment to Quality, Safety, Patient Care, Education, Physician Involvement. Hospitalist Presentation

    20. Physician Recruitment CCF Ratio Institution Recruiting Dept.Recruiters/Staff Duke 4.5 FTE Recruiters + 2 FTE 1/127 Mayo 8.0 FTE Recruiters + 1 FTE 1/78 Geisinger 5.0 FTE Recruiters + 2 FTE 1/75 + 1 FTE Marketing Lehigh Valley Hospital 5.0 FTE + 5 FTE 1/90 CCF 4.0 FTE + 0 FTE 1/292 2 FTE for Rad/Anesthesiology Hospitalist Presentation

    21. Physician Recruitment at CCF Physician Hires 12/27/07 20.2 Physicians per Recruiter 1.94 Site Visits per Week 91.4 Candidates/Recruiter Pipeline Hospitalist Presentation

    22. Physician Recruitment at CCF Best, Brightest, Most Diverse Talent Site Visits/Tours Individual Needs Salary, Benefits, Proximity to Family, Fit Hospitalist Presentation

    23. After the Recruitment – Retention (6-10% Turnover) • Lack of physician fit with partners and practice environment • Lack of clear communication of expectations to physicians during recruitment • Absence of two-way communication between physicians and practice management • Failure to include physicians in the decision making process • Lack of appreciation/recognition of physicians Merritt, Hawkins & Associates – “Guide to Physician Recruiting” (April 2007) Hospitalist Presentation

    24. Most Important Retention Factors For Patients Quality Work Environment Accessibility Efficiency Benefits Hospitalist Presentation

    25. What is a Hospitalist? • Physicians who specialize in caring for patients typically only in acute care setting. • Physicians are available 24 hours a day and 7 days a week to provide excellent quality of care to patients. • Physicians under the Hospitalist program are employed/contracted through the individual hospital. Hospitalist Presentation

    26. HOSPITALISTS • Barriers: • Tradition • Training • Expectations/Image • Commodity/Corporate Practice • Mandatory/Forced • House Officers/Staff Hospitalist Presentation

    27. HOSPITALISTS • Needs • Optimum Inpatient Management • Care Based Cost Management • Quality Outcomes • Efficiency Outcomes • Standardized Care • Reduced Undesirable Variation • Continuous Presence Hospitalist Presentation

    28. HOSPITALISTS • Needs 2. Hospital Aligned, Physician-Centric • Operational Expertise • Clinical Resources • 24 Hour Back-up • Clinical Excellence • Shared Performance Goals • Organizational Integration Hospitalist Presentation

    29. HOSPITALISTS • Needs • Turnkey Operations • Physician Management • Physician Recruiting • Physician Support • Information • Technology • Call Center • Physician Feedback, Training and Oversight Hospitalist Presentation

    30. Hospitalist Presentation

    31. HOSPITALISTS ALOS YEAR END ALOS Hosp. Non-Hosp. Δ • 4.05 3.70 4.15 -0.45 2004 4.09 4.07 4.09 -0.02 2005 3.98 4.18 3.88 +0.30 Hospitalist Presentation

    32. HOSPITALISTFISCAL VALUE TO ACMC 2003 2004 2005 2006 YTD Day Savings758 994 665 127 Potential Admissions181 243 167 32 Potential Bed 2.1 2.7 1.8 Construction Avoided $387K $486K $324K Quality Improvements Hospitalist Presentation

    33. HOSPITALISTS ACMC SUMMARY • Hospitalists satisfied needs of PCP - better lifestyle - efficient office 2. Patient Satisfaction – good 3. Hospitalist Operated at Breakeven in early years 4. Hospitalist Service created - more capacity = growth - more efficiency = lower costs, less need for capital, and volume growth Hospitalist Presentation

    34. Huron The Hospitalist Experience A.) Evaluation of Potential Benefits B.) Implementation & Support C.) Results Hospitalist Presentation

    35. Assumptions Uninsured/Unassigned Patients Voluntary For General Medicine Cases Oversight of Observation Process Management of LTACH Care Breakdowns Hospitalist Presentation

    36. HOSPITALIST WORK PRODUCT GOALS • Throughput Initiatives – Improve Flow (Reduced ALOS, Improved Management of Observation Patients, Preventing Bounce Back from LTACH) • Cost Reduction/Income Recovery/Credit for Work Performed • Growth/Improve Access/Reduce Ambulance Diversion • Improve Patient and Physician Satisfaction • Create a Competitive Environment Around Outcomes • Fulfill Commitment of Hospital to the Community Uninsured/Unassigned Patients Hospitalist Presentation

    37. Financial and Political Analysis Likelihood of Utilization Financial Proforma Worst and Best Case Scenario Payor Mix Analysis Professional Billing Projection Improvements for Patients/Hospital/Doctors Needs Hospitalist Presentation

    38. Proforma Hospitalist Presentation

    39. Best/Worst Case Scenario • Profitability According to the Initial Proforma Including: • All Profits (Incremental Margin for OBV Cases, Grace Hospital Stipend, Physician Billing, Teaching Savings, Utilization Reduction) and • All Expenses (Fee for Hospitalist Staffing Firm and Cost of Hospitalists) • Was $147,282 in the Best Case Scenario and Was -$171,859 in the Worst Case Scenario Hospitalist Presentation

    40. Benefits to the Hospital • ALOS Reduction/Competition • OBV > 24 Hours • Decrease Cost Per Case • Decrease Process and Outcome Variation • Creates Sustainable Environment for Private Practice (Growth and Profitability) Hospitalist Presentation

    41. Hospitalist Presentation

    42. Hospitalist Presentation

    43. 48% Improvement 14% Improvement Hospitalist Presentation

    44. Volume Hospitalist Presentation

    45. Huron HospitalAverage Number of Consultants Used Per Acute Inpatient Case Hospitalist Presentation

    46. Huron Hospital30-Day Readmission RatesHospitalists vs. All Other PhysiciansJanuary-December 2005 Hospitalist Presentation

    47. Huron HospitalHospitalist vs. InternistsCases and Average Direct Cost for INP PatientsCMI and ALOS Represents Only INP Patients Hospitalist Presentation

    48. Additional Calculations Hospitalist Presentation

    49. Summary of the January-December Data2004 vs. 2005 • Consultations obtained by Internists and General Surgeons have decreased by 17.4% or by 3173. • Total cases for Internist increased by 6.0% or by 350 patients. • Acute Inpatient Cases for the General Surgeons increased 17.4% or by 108. Hospitalist Presentation

    50. Summary of the January-December Data2004 vs. 2005 • Case Mix Index for Hospitalist (1.243) is higher than the Non Hospitalist (1.126) in 2005. • Severity (Case Mix) Adjusted LOS is lower for the Hospitalist than for the Non Hospitalist by 0.707 per discharge. • OBV/Total Discharge = 18.1% for the Hospitalist and 12.4% for the Non Hospitalist. • Hospitalist Self Pay was equal to 42.8% and all other internist decreased to 15.0%. This improved the payor mix to referring internist. Hospitalist Presentation