How much is enough? Issues related to what defines full-time work for a hospitalist

John Nelson writes…

In my work with practices around the country, I’m struck by the wide variation in how each practice defines what constitutes full-time work.  This is a pretty big deal for reasons that are obvious and not so obvious.

Say you’re in a practice that defines full-time as 181 shifts annually.  The practice across town provides higher compensation and also requires 181 shifts annually.  The other practice gets a better deal, right? 

Of course, things aren’t that simple.  You need to know how much work is typically done on each shift.  You might measure the work in hours; that is the duration of each shift.  But then you’d have to investigate whether the doctors in each practice always stay to the end of the shift, and how often they end up having to work past the end of the scheduled shift.  Leaving before a day shift is over is really common in my experience (maybe one doc is designated to stay until the end of the shift, but others leave early).  Because it can be tough to get this information reliably, it turns out that it is difficult to know exactly what is meant by a practice that says any specified number of shifts (181 in this example) defines full-time.

So when comparing practices, it often makes more sense to compare the average doctor’s workload over a long period such as a year.  The number of work RVU’s or billable encounters, despite their weaknesses, are usually a much better way to compare workloads.  But they very few, if any, practices use them to define full-time work (Please contact me if your practice does.)

Another thing to think about is that a practice that uses an annual number of shifts or hours to define full-time work is using a somewhat arbitrary definition of full-time.  In some practices the hospitalists are happy to work much more than the definition of full-time, and they may work extra shifts in their own practice.  This is so common that based on the hours or shifts that define full-time a practice might require 12 FTEs, but because all the hospitalists want to work lots of extra shifts it employs only 9 individuals.  It is OK to do this, and lots of practices do, but it has always seemed to me that if the average doctor wants to work more than 181 shifts it might be reasonable to increase the definition of full-time work and compensation accordingly.  This wouldn’t disadvantage the hospitalist, and might provide a more accurate description of the typical work and pay for the practice.

SHM did a survey asking practices how they define full-time, which my colleague Leslie Flores, summarized as follows:

SHM recently did a Focused Survey which, among other things, asked about contractual definitions of a hospitalist FTE.  There was little consensus about how an FTE is defined: with an n of 116, 12% of respondent specify a minimum number of shifts per year (median 181); 17% specify a minimum number of hours worked per year (median 2,000); 17% specify an average number of shifts per month (median 15); 10% specify an average number of hours per month (160); 17% specify “works about the same as others”; 15% specify “devotes full time and attention” and 12% were “other”.  (Focused Survey available for purchase through the SHM website store.)

2 Comments

  1. Robert Bessler on August 5, 2009 at 12:20 pm

    John
    I think this is a very good point that we ended up creating a education docuemnt on for new grads. My problem with your comment about RVU’s is that is then brings in the variation in coding practices. You assume that everyone is coding accurately using the same approach. There are clear rules on what meets the cpt code requirements but as we spend more of our time helping improve programs that were once hospital employed models and now Sound we find great variation. Some under code for the severity of illness and documentation based on fear or lack of knowledge and some have coding practices that dont fit in the other direction. We correct that through training and education. Matters are made worse by how docs are compensated. There is no question at programs we have taken over that were compensated partially on RVu’s or charges directly they had more robust coding until we came in.
    Nothing is simple but perhaps a combination of days/nights worked and average encounters per year would be best assuming an even distribution of ICU volume and admissions/discharges which of course would be best reflected in the rvu approach if there was consistentcy in use of cpt codes. I am curious what percent of groups don’t do their own cpt coding?
    Rob

  2. Robert Bessler on August 5, 2009 at 12:21 pm

    John
    I think this is a very good point that we ended up creating a education document on for new grads. My problem with your comment about RVU’s is that it then brings in the variation in coding practices. You assume that everyone is coding accurately using the same approach. There are clear rules on what meets the cpt code requirements but as we spend more of our time helping improve programs that were once hospital employed models and now Sound we find great variation. Some under code for the severity of illness and documentation based on fear or lack of knowledge and some have coding practices that dont fit in the other direction. We correct that through training and education. Matters are made worse by how docs are compensated. There is no question at programs we have taken over that were compensated partially on RVu’s or charges directly they had more robust coding until we came in.
    Nothing is simple but perhaps a combination of days/nights worked and average encounters per year would be best assuming an even distribution of ICU volume and admissions/discharges which of course would be best reflected in the rvu approach if there was consistentcy in use of cpt codes. I am curious what percent of groups don’t do their own cpt coding?
    Rob

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