Center Voices
Why Should You Develop A Medical Staff Plan?
By Nathan Kaufman
A hospital is only as good as its medical staff. Yet in recent years, the physician "supply" (to put it in the language of economics) of several clinical specialties--such as obstetricians, orthopedic surgeons, neurosurgeons, cardiologists--has not matched community "demand" (i.e., need), and hospitals have even been forced to divert patients from their emergency departments as a result. It is therefore critical that hospitals ensure they do not leave the supply of their most important resource to chance.
As hospitals' need for physicians increases and physicians' need for hospitals decreases, the relationship between the institution and its medical staff becomes more complex. For example:
- As a result of technological advances in imaging and surgery, many specialists who used to depend on hospital resources do not need to practice in a hospital to generate a decent living.
- In many cases, members of the medical staff have become major competitors to their hospital by developing freestanding centers and/or other types of specialty hospitals.
- Although hospitals are ultimately accountable for the quality of care provided in their facilities, many quality standards are directly related to physicians' decisions and performance.
- Although reimbursement for most inpatient services is now fixed by insurers, including Medicare and Medicaid, using case rates or per diems, the cost of care and, ultimately, the financial solvency of the health care institution are directly related to the practice patterns of its medical staff.
Hospitals generally do a good job planning for their future "hardware," such as facilities, diagnostic, clinical and information technology. However, most do not plan ahead for their "software"--e.g., the number and mix of physicians on staff--to meet their patients' future needs.
Traditionally, administrators and the board have relied on the medical staff to recruit the physicians they think they need. That's why a medical staff development plan is so important, and why the board should insist that such a plan be in place and updated regularly. Medical staff development plans should focus on addressing the two key areas of leadership and supply.
Leadership. The chief medical officer (CMO) should have the ultimate responsibility for developing and monitoring compliance with clinical policies. However, CMOs cannot do this alone; they need a solid "bench," or backup in the form of other physician leaders.
At a minimum, the hospital needs physician directors of critical care, cardiology, surgery, radiology, laboratory, emergency medicine and other major departments. These should be paid positions as these directors are responsible for managing clinical care in their departments. The goal of physician leaders should be to ensure that the best medical science is being applied consistently and cost-effectively in each of their oversight areas.
Supply. The supply of physicians in a market cannot be left solely to the discretion of physicians practicing in a given specialty. The need to minimize competition, for example, may motivate some members of the medical staff to sway recruitment decisions for certain specialists more than meeting the community's needs.
Patients with unmet needs for care will ultimately leave the market to get it. That's why it is essential that physicians on staff be convinced of the need for the right mix of additional physicians.
In addition, the more physicians there are on staff, the less often any one doctor will have to be on call and the more opportunities there will be for physicians to share other responsibilities, such as committee assignments.
The issue of supply is further complicated by the fact that there is no standard methodology for determining the right number of physicians for a population. However, obtaining the following information may serve as guidelines:
- Assessment of the current supply of full-time equivalents (FTEs)--not all physicians on the current medical staff wish to have full practices. Keeping an accurate count of physicians in a given specialty should be based on estimating those who are FTEs, not just "bodies."
- Opinions from referring physicians (primary care doctors, for the most part, but could include almost all practicing physicians)--the subjective opinion of referring physicians is an important criterion for determining the need for more specialists.
- Tenure and capacity--the need for more physicians in a given specialty is indicated when there have not been any new physicians joining the staff for several years and current specialists are not accepting new patients.
- Age--Anecdotal evidence suggests that physicians begin to wind down their practices after age 60. A succession plan needs to be developed for all physicians age 60 and older.
- Loss of market share--in many states, it is possible to measure market share by service line.
With that information, the hospital can tell if a disproportionate share of patients has left the market in search of a specific specialty. If that's the case, more specialists in that area may be needed.
Given the national shortage in many specialties and the many threats to physicians' incomes, such as declining Medicare reimbursement, hospitals that offer a range of options for recruiting and retaining physicians may have an advantage over those that don't.
Many hospitals offer physicians employment within a tightly structured, productivity-based, hospital-affiliated medical "division."
Alternatively, the hospital can offer an existing "host practice," providing incremental overhead support combined with an income guarantee for a new physician recruit.
Working with their current physicians, hospitals and health systems should use both quantitative and subjective assessment tools to determine community need. Then they must develop plans to meet that need.
Governing boards that understand the need for, and key components of a medical staff development plan can help ensure their hospitals have the physicians required in place to help meet their communities' medical care needs today and into the future.
Nathan Kaufman is senior vice president, health care strategy, ACS Healthcare Solutions, San Diego. He can be reached at (800) 535-1366.
Physician-To-Population Ratios*
|
Physician
Need Per 100,000 |
|
| Primary Care | |
| Family Practice | 35.0 |
| Internal Medicine | 27.0 |
| Obstetrics/Gynecology | 13.0 |
| Pediatrics | 13.0 |
| Subtotal Primary Care | 88.0 |
| Medical Specialties | |
| Allergy/Immunology | 1.0 |
| Cardiology | 6.0 |
| Dermatology | 2.3 |
| Endocrinology | 0.9 |
| Gastroenterology | 1.7 |
| Hematology/Oncology | 2.5 |
| Infectious Disease | 2.5 |
| Nephrology | 0.9 |
| Neurology | 2.2 |
| Physical/Occup. Medicine | 1.3 |
| Pulmonary Medicine | 1.5 |
| Rheumatology | 0.8 |
| Subtotal Medical Specialties | 23.5 |
| Surgical Specialties | |
| Cardiothoracic Surgery | 1.1 |
| General Surgery | 7.0 |
| Neurosurgery | 1.3 |
| Ophthalmology | 3.3 |
| Orthopedics | 7.0 |
| Otorhinolaryngology | 3.2 |
| Plastic Surgery | 1.2 |
| Urology | 3.1 |
| Vascular Surgery | 0.7 |
| Subtotal Surgical Specialties | 27.9 |
| Other Specialties | |
| Anesthesiology | 5.5 |
| Pathology | 4.5 |
| Psychiatry | 10.0 |
| Radiology | 8.0 |
| Radiation Oncology | 0.9 |
| Subtotal Other Specialties | 18.9 |
| Total All Specialties | 158.3 |
| *In 1990, the Graduate Medical Education National Advisory Committee published physician-to-population ratios by specialty. | |
have also published ratios.But many other recommended ratios
have not been published. The ratios presented here have
been culled from all of these sources.--N.K.
This article 1st appeared in the December 2099 issue of Trustee Magazine.
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