Are telehospitalist services right for my hospital?

Written by Andrew McWilliams

Intro

Is your hospital having trouble recruiting and/or retaining hospitalists? Are you having trouble getting doctors to cover certain shifts, like nights or weekends? Are some or all of your current onsite hospitalists overburdened?

If so, you are not alone. According to theSociety of Hospital Medicine’s 2020 State of Hospital Medicine Report, a median of 11% of all hospitalist jobs remain unfilled. Half of HMGs serving children only, half of HMGs serving both adults and children and close to three-quarters of HMGs serving adults only reported having unfilled positions in their HMGs during at least a portion of the year.

Impact of the hospitalist shortage

Higher costs

What does the shortage of hospitalists mean for your hospital? Even if you are one of the fortunate hospitals able to hire enough hospitalists to meet their requirements, you will probably be paying more for them. In 2020, the average US hospitalist salary was over $272,000, compared with $215,000 in 2010.

In order to cover some of the added costs, you may be pressing your hospitalists to increase their productivity, e.g., by making more billable visits faster. However, this strategy can be self-defeating; the pressure to increase billings can lead to physician burnout and more turnover, with the high costs that come with recruiting replacements.

On the plus side, despite the addedsalary costs, the use of hospitalists does bring significant benefits, such as shorter average hospital stays. On average, patients cared for by hospitalists stay in the hospital nearly half a day less than those cared for by general internists. Treatment costs are correspondingly lower, whilemortality and readmission rates are similar.

Even though the difference in the length of hospital stay is relatively small, the overall impact can be quite large when multiplied by the thousands of admissions that hospitalists oversee each year. An0.4 day shorter length-of-stay per case multiplied by 5,000 cases annually can save 2,000 bed days and enable 500 more patients to be cared for each year without increasing the number of hospital beds.

Empty positions

Other, less fortunate hospitals are unable to hire the hospitalists they need, either because they cannot afford the cost, or because candidates are not applying for the available hospitalist jobs. Rural hospitals are particularly affected by the hospitalist shortage. Many hospitalists are not interested in rural practice and there are other issues preventing them from applying, such as limited job availability for spouses/partners, and community acceptance of hospitalists.

The ramifications of empty hospitalist positions can be far-reaching, including heavier workloads and longer hours for other care providers, which may cause them to burn out and/or quit, compounding the hospital’s staffing problems. The hospitalist shortage is likely to lead to longer wait times for patients who then become frustrated, complicating the healthcare process and even adversely impacting overall outcomes.

HCAHPS(patient satisfaction) scores can be impacted dramatically if patients do not get the attention they need from care providers. HCAHPS is a core component of value-based purchasing’s pay-for-performance and has a significant impact on hospital reimbursement.

Low patient confidence in health outcomes and satisfaction with the entire rural hospital experience are also among the root causes of rural hospital bypass, i.e., rural residents starting out by seeking care directly from urban hospitals rather than their nearby local hospital. Rural hospital bypass is one of the major causes of rural hospitals’ declining inpatient census, which places further downward pressure on their revenues.

The telehospitalist solution

Telehospitalist services are a potential way to extend the services of a hospitalist to rural and other hospitals that otherwise might be unable to obtain or afford them. This can improve outcomes and bring the benefits of hospital medicine, including decreased hospital spending, to smaller communities.For telehospitalist programs that cover multiple sites, the cost is significantly less that employing individual on-site hospitalists to do low-volume work

Pain points

For an initial indication whether you should be considering telehospitalist services, ask yourself whether your hospital is experiencing any of these signs of strain:

  • Trouble recruiting and/or retaining hospitalists
  • Losing admissions to big city hospitals. Are local physicians telling patients to check into big urban hospitals?
  • Low/declining inpatient census
  • ICU turning away patients for lack of beds
  • Unnecessary transfers and readmissions
  • Underrepresented specialties
  • Underserved population
  • Nurses/physician’s assistants are main on-site care provider
  • Imbalances among hospitals in a system, e.g., ratio of nocturnists to admissions
  • Volume surges
  • Long distance to central hospital
  • Hard-to-cover shifts,e.g,, doctors resisting night shifts
  • Overburdened onsite nocturnists
  • Hospitalists with low work load
  • Low volume of night-time admissions

The more of these signs you are experiencing, the stronger the business case for your utilizing telehospitalist services is likely to be.

Financing the telehospitalist service

Before a accepting a telehospitalist services provider’s proposal, ask yourself whether yourhospital has enough business to support thew service? You could argue, of course, that there is no way to place a value on improved clinical outcomes or patient satisfaction.

However, you will need to convince your CFO that a telehospitalist service is going to generate sufficient revenues to pay for itselfThis can be a complex question, with no one-size-fits-all answer. Although this is a rapidly changing landscape, telehospitalistshistorically have not been able to generate much revenue from professional billing. Unlike in-person visits, Medicare has been unwilling to reimburse professional fees for telehospitalist visits. Although each payer is unique, most other (nonMedicare) payers have also been unwilling to reimburse for televisits.

This situation has changed, at least temporarily, under the COVID-19 pandemic. To help relieve the pandemic’s strain on scarce hospital resources, Medicare has started reimbursing hospital televisits that involve real-time audio and video telecommunications between clinician and patient at the same rate as in-person interactions.

Any long-term changes in the reimbursement of most telehospitalist services are not certain. For one thing, no one knows how long the pandemic will continue, which services will continue to be reimbursed by Medicare after the pandemic ends, and at what level. On the other hand,Medicare does pay for virtual specialty services such as telestroke, possibly paving the way for a new policy of reimbursing for telehospitalistservices. In addition, many states have enacted telemedicine parity laws, which require private payers to pay for all health care services equally, regardless of modality (audio, video, or in person).

Amid this uncertainty, you should require prospective telehospitalist services provides to submit a detailed financial impact analysis as part of their proposal. Examine their assumptions and analysis critically, with the help of a consultant if you prefer. Discuss the financial impact analysis with the provider, and ask enough questions to be sure their proposal is financially realistic.

Adequacy of the IT infrastructure

Working with the potential telehospitalist services provider, ensure thatyou have adequate IT infrastructure, particularly broadband internet access, to support data-rich, real-time two-way communications with a high level of reliability between the hospital and the telehospitalist. If you have inadequate broadband, you should determine the availability of potential remedies before proceeding.

As a short-term solution, some telecommunications providers are working with local hospitals to provide Wi-Fi hotspots where cellular services are available. Longer-term solutions are also in progress, such as the USDA’s Rural Utilities Service and The Federal Communications Commission’s Universal Service Fund (USF). These programs fund infrastructure deployment of broadband and telecommunications throughout rural areas.

Tags: Telehospitalist ,Services ,Hospital ,Impact ,Recruiting

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