Director’s Corner: Coping with cut hours

Preserving income through the pandemic.

Dear Director,

With the decline in patient volume because of the pandemic, we’ve cut our hours and now we’re all taking a pay cut compared to previous years. How can my group preserve our income while we’re overstaffed due to staffing changes that reduced our clinical hours?

ADVERTISEMENT

Necessity is the mother of invention

There is no doubt that COVID-19 has changed the way we do business in the emergency department. Nearly every colleague I’ve talked to in all parts of the country have had changes to their staffing or income (or both).

I wrote about staffing reductions early on in the pandemic and most docs I spoke to didn’t mind having a little extra time off during the summer. Certainly, all of us hoped that ED volume would have returned by now, but with volumes continuing to be down nationally and recent residency graduates being added to the staffing mix, most departments are feeling the income squeeze.

ADVERTISEMENT

A good friend of mine practices in a 100-percent productivity-based model. He was making a fortune before the pandemic. He took a pretty substantial hourly hit with the decline in volume, but his hourly rate would still make most of us jealous, so his group decided not to reduce staffing. They were happy with their rates as they were still above market. Some groups took hourly pay reductions. Many others were able to maintain their hourly rate, but reduced scheduled hours, which ultimately leads to less annual income.

Furloughing docs (or laying them off), was yet another option when hours became tight. This kept the full-timers busy, but at a cost of losing team members. This may also impact that group’s ability to recruit in the future or ramp up quickly if patient volume returns.

Furloughing docs who are putting their lives on the line and potentially getting family members sick just doesn’t seem like much of a thank you nor vote of confidence in the group’s leadership.

ADVERTISEMENT

Additionally, if you reduce your staff, that leaves less capacity to absorb temporary loss of staff for illness or exposure. Also, losing staff ultimately means that each of the remaining staff needs to increase their ratio of total patients per doc per month and that is ultimately exhausting.

As we look to preserve our incomes, we would like to do it without losing docs from our team, so we need to look outside the ED to see where our skill set can fill a void in the hospital. This requires exploring opportunities with your hospital administration, cooperating with the hospital and other departments, and being a bit of a visionary.

There are a few things to consider as you start to brainstorm potential revenue generating opportunities. First, we must consider our skill set. We’re very good at rapid assessment of how sick a patient is and what level of care they require, airway management and other procedures, and communicating with patients and families. Next is considering the opportunities. More on that in a minute.

Finally, since the C-suite lives in a business world, you need to consider each opportunity from the return on investment (ROI) mindset. I find it’s relatively easy to justify additional docs for quality or efficiency purposes, but harder to make it profitable and show the ROI.

ADVERTISEMENT

Used strategically, ED docs in the hospital could help get more patients home safely with telemedicine follow up…it is far less expensive being out of the hospital than in the hospital. Reducing hospital LOS is an easy way to show ROI.

Let’s look at potential opportunities.

• When the pandemic started and we thought the ED would get overrun with patients, I had docs from all specialties letting me know they were available to see patients in the ED if it helped us. That didn’t turn out to be the case for most of us while our hospitalist and ICU services have been overwhelmed in many places. As I surveyed my docs pretty early on to see who could help in the ICU, I was actually surprised by some of the responses. A few docs told me absolutely not, and a few said they had so many critical care rotations during residency, they would be completely comfortable lending a hand in the ICU. It’s been 25 years since I rotated in the ICU, so I figured I would need at least a week of rounding and learning before I would perform at a functional resident level. However, depending on your ICU model, your ICU attendings may be spending a tremendous amount of their time not on critical decision making, but on procedures. Many EDs added APPs for routine procedures decades ago which allows emergency physicians to manage the more complex patients. In talking to a variety of intensivists, this hasn’t really been their model as it wasn’t necessary prior to the pandemic. As everyone looks to increase the capacity of the ICU, adding a proceduralist to their team can be very cost effective. This can potentially help improve patient care by allowing intensivists to focus on individualized vent management, medications, treatment options, etc…
• Rounding on a transitional unit can be another way to use our skill set. These are typically patients on nasal cannula up to high flow nasal cannula who require regular assessments to maintain, upgrade or downgrade their care. There may be additional end of life discussions that are required that take advantage of our ability to communicate effectively with family members. The ROI can be seen in working with case managers/social workers to get home O2 and pulse oximeters for many of these patients, thus facilitating an earlier, safe discharge and reducing LOS.
• The amount of rapid responses and in-house cardiac arrests has increased considerably in most hospitals. These patient events typically require the intensivist or the hospitalist, who are already stretched thin. It may be in the hospital’s interest to hire an emergency physician to be the rapid response and code doctor. Although this may not pay as much as working an ER shift, a job that pays some income is better than no job and no income.
• While there may not be enough work as the ICU proceduralist, around the hospital, there may be a need for an additional proceduralist. The list could include intubations throughout the hospital, central lines, arterial lines and chest tubes. This would probably work hand in hand as the rapid response doc.
• There may be a way to expand our hours for what we do best. I have friends and colleagues whose hospitals have opened or taken over free standing EDs and urgent cares during the pandemic, creating the need for new contracted staffing responsibilities. I have another friend whose hospital is opening a freestanding ER this summer. While that doesn’t add hours in the immediate future, it does allow their chair to schedule more hours for the group when it opens. Talking to your CEO about opening another venue typically isn’t in our regular talking points. But making sure they know that you have the staff and expertise to get it up and running, certainly is part of our job.
• The CARES Act opened the door for telemedicine expansion. Many practices associated with the hospital got on board quickly. Your hospital likely possesses the necessary infrastructure to expand telemedicine for COVID follow-up patients. As hospital bed capacity remains stretched, getting patients home while providing follow-up to make sure they’re safe, remains a viable business option. There’s a large HMO in my region that has done a phenomenal job of doing telemedicine visits on all of their COVID patients after ER discharge. Many require returns to the ER and these telemedicine visits have likely saved lives and reduced the overall number of admissions.
• As of press time, monoclonal antibody infusions remain a viable treatment option for the high-risk outpatient. However, many hospitals are having trouble properly screening patients and funneling patients to an infusion clinic. If the telemedicine infrastructure exists, having a triage point that funnels patients to the hospital’s infusion clinic while keeping patients out of the ED is a win-win. If your hospital doesn’t have the space, this may be the time to create a monoclonal antibody infusion center (and consider other infusions like blood transfusion), that can be staffed by an emergency physician. Doing these infusions at urgent cares or freestanding EDs may be a way to drive visits to sites that likely have capacity. Free-standing EDs may have lower patient volumes and are well set up to handle these infusions as well as bring in more income for the hospital system while decompressing the main ED.

The pay model on any of these proposals could be a flat rate to the emergency physician or a baseline rate with a productivity component. We’d likely need to turn billing and revenue over to the hospital. Many of the potential sources could drive a lot of revenue based on procedures and critical care billing.

While some or perhaps all of the above suggestions may not pay as much as working in a busy ED, this is a means to an end. The end goal is to not have to furlough docs (keeping our team intact for when volume returns and maintaining staffing flexibility), and to create more opportunities for income outside the ED based on our skill set.

At the end of the day, we’re looking to increase the number of options to funnel money into the pot that our practice generates to pay our salaries. We need to take responsibility for developing the proposal to present the quality initiative and ROI to our hospital executive team. It will require a progressive c-suite and visionary thinking on our part. On a practical side, it may take some “emergency credentialing,” which is quite easy during a pandemic and of course a check on the implications to our malpractice insurance.