Building Physician Support for Trauma Care Best Practices in Community Hospitals

1. Building Physician Support for TraumaCareBest Practices in Community Hospitals Greg Bishop, President Bishop+ Associates June 2004

2. Building Physician Support for Trauma CareBest Practices in Community Hospitals • Problems, Factors & Principles • Improving Trauma Medical Staff Value • Cost-Effective Trauma Physician Support • Arriving At Fair Trauma Physician Compensation • Specialty Issues & Market Norms

3. Problems, Factors & Principles • Problematic Physician Structures • Multiple Contributing Factors • Principles For Proceeding

4. Problematic Physician Structures • Fragile, Complex Structures • Serious Shortages, Few In Pipeline • Costs, Closures, Weak & Unstable Structures • Balkans of Hospital/Physician Relations

5. 16 Trauma Center Specialists24/7 Availability

6. Multiple Contributing Factors • Increasing Burden of Uninsured Patients • Incompatibility with Private Practice • Undesirable Lifestyle Due to Trauma Call; • Reductions in Resident Support • Outpatient Surgery/Specialty Hospital Trends • Increasing Physician Sub-Specialization

7. Multiple Contributing Factors • Malpractice Market Turmoil • Physician Payment Penalizes Trauma • Managed Care Escapes Paying its Share • Demise of Community ED Call Panels • EMTALA Changes Encourage Dumping

8. Principles For Proceeding • Value, Not Cost Is Key Issue • Strengthen Structure For Decades • Pursue Opportunities For Ideal Solutions • Leadership Is Essential • Patient Care Is A Core Physician Value • Impact On Hospital Physician Relations

9. Improving Value In Trauma CareStrengthening Trauma Program • Quality of Care; Responsiveness • Maintaining Verification Status • QA, CME, Protocols • Cost effectiveness; Reduced LOS • Community Outreach & Injury Prevention • Public Advocate for Optimal Trauma Care

10. Improving Value In Trauma CareStrengthening Hospital • Surgical Critical Care Program • Ortho & Neuro Centers of Excellence • Orthopedic Hospitalist Model • Hospital/Physician Relations • ED/OR/ICU Issues • Trauma Center Halo Effect

11. Framework For Cost Effective Trauma Physician Support • Effective Structure • Hospital Support • Optimal Franchise • Trauma Physician Compensation • Dealing With Leverage

12. Effective Structure • Strong Trauma Medical Leadership • Strong Trauma Service • Make Trauma Call Less Burdensome • Only Call in Specialty When Needed • Have Patient Ready When Specialist Arrives • Don’t Make Specialists Wait for Diagnostic Results • Implement Tiered Call System; Facial Fracture Panels

13. Hospital Support • OR Block Time • ED Throughput • Physician Assistants • Nurse Practitioners • Other

14. Optimize Franchise • Trauma/SICU/Surgery • Hospital Based Orthopedic Program • Establishment of Centers of Excellence • Halo Effect for both Physicians and Hospital

15. Trauma Physician Compensation • Trauma Medical Director Compensation • Payment on Uninsured Patients • Call Stipends; In-house call versus on-call • Response Fees/Complex Schemes • Consolidated Trauma Physician Billing Support • Net Annual Hospital Cost (NAHC)

16. Dealing With Leverage • Balkans Revisited • Stark Provides Constraint • Do Not Form A Cartel • Compliance Is A Serious Issue

17. Arriving At Fair Compensation • Key Payment Factors • Employment vs. Contracting • Data and Market Norms • Process is Key

18. Key Payment Factors • Lack of Residency • Volume of Uninsured • Role versus Value Provided • In-House Call versus On-Call • Trauma Volume +/-

19. Employment vs. Contracting • Contract With Group For Service/Employment Of Trauma Specialist • Hospital Employment of Surgeons • Contract with Individual Surgeons

20. Data & Market Norms • Data Sources • Comparison to Salary Data • Specialty Outliers • Payment on Uninsured

21. Dealing With Leverage • Balkans Revisited • Stark Provides Constraint • Do Not Form A Cartel • Compliance Is A Serious Issue

22. Process Is Key • Do Not Ignore Requests • Effective Hospital Leadership • Benchmark Trauma Financial Performance • Solicit Specialty Input • Address Non-Financial Issues • Define Fair Level of Compensation

23. Specialty Issues & Market Norms • Trauma Surgery • Neurosurgery • Orthopedic Surgery • Plastic Surgery • Low Volume Specialties • Hospital Based Specialties

24. Trauma Surgery • Key Issues: • Core of Trauma Center • Highest impact specialty • Frontline and patient care manager roles • Franchise Value • Market Norms • Most Trauma Surgeons within Community Hospitals Receive Hospital Support • In-House Call $1000-$2500 per day • On-Call $500-$1500 per day

25. Neurosurgery • Key Issues: • High impact specialty due to shortage • Quick response time to surgery required • Relatively small professional fee franchise • Relatively poor payer mix • Market Norms • About 40% of Neurosurgeons In Community Hospitals Receive Support • $500-$2,500 per day

26. Orthopedic Surgery • Key Issues: • High volume trauma specialty • Sub-specialization making surgeons uncomfortable with trauma • Need To Reduce Number of Surgeons Taking Trauma Call • Large professional fee franchise • Market Norms • 30% Orthopedic Surgeons In Community Hospitals Receive Hospital Support • $500-$2,000 per day

27. Plastic Surgery • Key Issues: • Small volume specialty; ED call issues • Call structure is critical for this specialty • Declining number of surgeons taking call • High paying, busy private practices (Cosmetic Surgery) • Market Norms • 10-15% Plastic Surgeons In Community Hospitals Receive Hospital Support • $250-$1,000 per day

28. Low Volume Specialists • Key Issues: • Focus on Trauma Service making their life easier • Can be most difficult issue • Combined with ED call issues • Market Norms • Few are Compensated in Community Hospital Setting • No Real Market Norms • Payment on Uninsured Patients

29. Hospital Based Specialists • Trauma is Part of Their Hospital Franchise • Few Payment Examples • In house Anesthesia is exception

30. Trauma Center Of The Future • The emerging Hospitalist Model • Carved out Trauma Physician Billing • Trauma Specific CPT Codes and RVU’s • Unfallkrankenhaus Lorenz Bohler