Is your group calling in backup too often?

WHEN SHE LOOKS BACK ON 2021, Stephanie Leung, MD, a hospitalist with UK HealthCare at the University of Kentucky in Lexington, remembers the trouble her group had filling shifts.

“We had one shift a day available for moonlighting,” Dr. Leung says, “but it was difficult to get that picked up. We had to use our jeopardy system”—which was supposed to be used only for physician illnesses or emergencies—”just to get that shift filled.”

Fast forward to this year, and the program no longer has problems finding moonlighters. In fact, says Dr. Leung, “we’ve opened two moonlighting shifts a day, and we haven’t had any problem filling them.” Her group can now preserve its jeopardy system for physician emergencies in part because many of its new physicians are eager to work extra shifts—and because relatively few of the hospitalists cut back to part time after the pandemic.

But not all hospitalist groups are so fortunate. As the country heads into what could be a brutal flu season or another crushing wave of covid, some programs say they still don’t have hospitalists interested in working extra shifts. That puts more pressure on the backup plans those groups have in place. Other groups that have mandatory backup are now having to modify those plans to handle changes in post-pandemic staffing—and cover what feels like an unending surge in patient volume.

Backup incentives
Backup plans have different names including jeopardy or risk systems, or surge plans when they’re used for volume spikes and not just physician absences. While hospitalists certainly appreciate having backup in place when they fall ill or have a family emergency, calling in doctors on their days off can be a big dissatisfier, with reactions ranging from “some grumbling” to “deeply unpopular.”

“We don’t have any census cap that we use jeopardy for.”

Stephanie Leung, MD
UK HealthCare

Hospitalist programs recognize this, and many offer a range of incentives to make taking backup more palatable. In Dr. Leung’s group, for instance, as described by two of her colleagues in an article in The Hospitalist in 2019, physicians are credited one week of clinical service a year for every two weeks they serve on backup. In addition, she says, “when we activate jeopardy, the person coming in receives either extra compensation or a similar shift off.”

Her group, which has 85 physicians and up to a dozen advanced practice providers (APPs), schedules two doctors in two jeopardy slots every day in advance. During the pandemic, they also maintained a third position, designated as jeopardy 3, that physicians could sign up for.

“We actually paid jeopardy 3 people extra moonlighter money if they were called in” she says. “Because they were volunteers, they were often the first one called rather than the people scheduled for jeopardy.” That jeopardy 3 position, which is now “on the back burner” in case it’s needed, was used a lot during the omicron surge in January and February 2022.

Another reason why group members may not mind mandatory backup, says Dr. Leung, is that scheduled jeopardy is preserved for only physician absences or emergencies. “We don’t have any census cap that we use jeopardy for,” she points out. “If we have an unusual spike in volume, we just divide those patients among the daily teams that are already onsite.”

Built-in flexibility
At Spartanburg Medical Center in Spartanburg, S.C., hospitalist medical director Samuel Gacha, MD, MBA, says that his group similarly doesn’t want to use backup to cover census. And Dr. Gacha calls backup physicians in only reluctantly, relying on other options first to cover shifts.

“Backup physicians can take a census of 14 instead of 18 if they want to work fewer hours.”

Samuel Gacha, MD, MBA
Spartanburg Medical Center

“I know who likes to work extra, so I call them and give them the opportunity to pick up a shift,” says Dr. Gacha, who also steps in occasionally himself to take shifts and avoid using backup. “But if I’m not getting any traction after three or four calls, I pull the trigger on the backup schedule.” He estimates that he calls in a backup physician two or three times a month, which represents about 50% of the time a shift needs to be covered.

When backup physicians do have to come in, Dr. Gacha tries to make doing backup as flexible as possible. “They have some leeway on when they can come in and leave that day, in case they have to drop off or pick up children,” he says. “And backup physicians can take a census of 14 instead of 18 if they want to work fewer hours.” When brought in on backup, doctors are paid by the hour.

In his group, which has about 100 physicians, each FTE is scheduled for one week of backup a year. (The group’s dedicated nocturnists have their own backup plan.) Typically, doctors schedule four days of backup in the first half of the year and three in the second half, and the group doesn’t schedule any backup during weeks with holidays. Doctors tend to bunch their several scheduled backup days into one of their weeks off to limit the number of weeks they have to commit to not leaving town.

Even those scheduled days are flexible. “They can swap their backup days with anyone else if they want to,” Dr. Gacha says.

Doubling scheduled backup
Some hospitalist groups try to ease the sting of scheduled backup by paying physicians. EvergreenHealth in Kirkland, Wash., for example, pays a nominal fee every day hospitalists are scheduled on backup and not called in. That’s been a perennial feature of what Nancy Marshall, MD, chair of hospital medicine, calls the group’s “risk system” since it was put in place more than 15 years ago.

But this year, that risk system has undergone changes. For one, instead of having only one backup doctor scheduled a day, the group now schedules two. That’s due to covid. “Just this September, we had six or seven doctors out with covid, ” Dr. Marshall says. “They weren’t particularly ill but they were considered infectious.”

“This year, our RVUs in June were the same or higher than in January.”

Nancy Marshall, MD
EvergreenHealth

Another change: Instead of every FTE taking two weeks of backup a year, they are now scheduled for two and a half weeks. That’s due in part to having to fill that second risk slot on the schedule. It’s also due to the fact that while the group includes about 50 physicians, several cut back from working full time over the course of the pandemic. The physicians working less than one FTE are scheduled to a prorated amount of risk coverage.

“The team agrees that taking risk has gotten harder,” says Dr. Marshall. The nominal fee they receive when they’re on the schedule helps make it less painful. And when physicians are called in, “they’re paid premium per-diem rates, so they’re fairly paid.”

Higher acuity
According to Dr. Marshall, her group has seen a sharp drop in the number of doctors volunteering for open shifts, even among the part-time physicians who covered many extra shifts during the pandemic. That puts pressure on the group to activate its risk system more often.

And while the risk system before the pandemic was only rarely used to manage census, a physician may now be called in when the census reaches more than 17 patients per rounding physician. Both patient volume and acuity at the medical center are on the rise.

“The 17 patients we’re treating post-2020 are very different from the 17 patients you’d see in 2020,” Dr. Marshall says. “They are definitely sicker.” Now, “everybody has 10 medical problems and poor social support, and it takes them months to access outpatient primary or specialty care in our region.” She chalks up her group’s current surge of patients to a growing local population as well as to delayed care during the pandemic.

“People are coming to the hospital with a heart attack instead of having angina and seeing an outpatient cardiologist,” she says. “That’s at least my perception.”

“The strategy of solely relying on internal moonlighting is no longer viable.”

Kendall Rogers, MD
University of New Mexico in Albuquerque

Also putting more pressure on the risk system: Census stays high now all year, and scheduling more staff onsite only during winter months is a thing of the past. “We now have to schedule for census year-round, and we no longer see seasonal spikes,” Dr. Marshall says. “This year, our RVUs in June were the same or higher than in January.”

Rising census
Kendall Rogers, MD, division chief for hospital medicine at the University of New Mexico in Albuquerque, says his group used to schedule only one backup physician to be used for both illness and census needs—except during flu season. Now, however, the group schedules two backup physicians all year. Backups 1 and 2 are assigned evenly across the group of 45 physicians. If both those doctors are called in and a third is needed, “we send out requests for a volunteer ’emergency’ backup.”

All backup shifts that are called in are paid as extra shifts. There is a small stipend—about 10% of the extra shift payment—to be on backup on weekends and holidays, whether or not physicians are called, Dr. Rogers points out.

To reduce their potential need to call backup, his group also offers rounding physicians what it calls “patient stretch incentives” to voluntarily take on additional patients over their usual individual census for a stipend per patient. The program also encourages its doctors to moonlight, although Dr. Rogers notes that his group now has fewer takers than in previous years. “Most programs are reporting less interest by hospitalists to work extra shifts,” he says. “The strategy of solely relying on internal moonlighting is no longer viable.”

That’s a real problem, given that, “our census is still much higher than pre-covid,” he explains. Instead of the 100 patients his group used to treat a day, census now routinely goes as high as 160. “That’s our new normal, and we realize we’re not likely to go back to prepandemic levels.” To manage that high census while cutting down on scheduled backup and patient stretch initiatives, the group has to depend on external locums every day.

An “overhire strategy”
Before the pandemic, Dr. Rogers says his program hired FTEs for its anticipated average census, then developed surge plans to deal with peaks. But given the time it takes to recruit and onboard physicians, “it is impossible to ever attain your ‘approved FTE,’ and programs are perpetually short-staffed,” he notes. That short-staffing and the lack of internal moonlighting “leave no room to flex up for surges.”

Those flaws became more apparent during the pandemic with systems stretched beyond capacity—and hospitalists struggling to fill the gaps. Given the toll that took on hospitalists, Dr. Rogers says his thinking on staffing has evolved.

He now believes that hospital medicine should follow the lead of nursing and adopt what is referred to as an “overhire strategy,” hiring above approved FTEs. Such a strategy, he explains, would take into account anticipated attrition, the long lead time for recruitment and hiring and expected absences like parental leave.

“Making offers to between 5% and 10% more FTE than you anticipate needing will allow you to more consistently maintain the FTE levels you need,” Dr. Rogers says. “And being properly staffed will allow programs to better weather surges and retain their hospitalists.” In the event that programs truly overhire, attrition would correct that fairly quickly.

But such a strategy, he adds, “needs to be coupled with strict guidelines to quickly approve FTE increases due to higher census or productivity.” A quick process is needed, says Dr. Rogers, in part because “backup remains a very unpopular aspect of our program,” especially when it’s used so often.

At EvergreenHealth, Dr. Marshall notes that scheduling two risk physicians a day is an experiment that, she hopes, won’t be needed often for rising census.

“We always felt that using backup for volume was a reflection of poor planning,” she says. “A risk system shouldn’t be a surrogate for understaffing.” In the past, her administration has been willing to green light any hiring the group felt it needed. She expects the administration to continue to do so.

“If we show them our RVU needs on paper, we would definitely be able to hire more FTE —but it takes longer now to get approval for more docs,” Dr. Marshall says. “Because of the financial struggle that everyone is seeing, it’s now a harder argument.”

Phyllis Maguire is Executive Editor of Today’s Hospitalist.

Published in the November/December 2022 issue of Today’s Hospitalist