Building Physician Support for Trauma Care Best Practices in Community Hospitals Greg Bishop, President Bishop+ Associates June 2004

Building Physician Support for Trauma Care Best Practices in Community Hospitals Problems, Factors & Principles Improving Trauma Medical Staff Value Cost-Effective Trauma Physician Support Arriving At Fair Trauma Physician Compensation Specialty Issues & Market Norms

Problems, Factors & Principles Problematic Physician Structures Multiple Contributing Factors Principles For Proceeding

Problematic Physician Structures Fragile, Complex Structures Serious Shortages, Few In Pipeline Costs, Closures, Weak & Unstable Structures Balkans of Hospital/Physician Relations

16 Trauma Center Specialists 24/7 Availability

Multiple Contributing Factors Increasing Burden of Uninsured Patients Incompatibility with Private Practice Undesirable Lifestyle Due to Trauma Call; Reductions in Resident Support Outpatient Surgery/Specialty Hospital Trends Increasing Physician Sub-Specialization

Multiple Contributing Factors Malpractice Market Turmoil Physician Payment Penalizes Trauma Managed Care Escapes Paying its Share Demise of Community ED Call Panels EMTALA Changes Encourage Dumping

Principles For Proceeding Value, Not Cost Is Key Issue Strengthen Structure For Decades Pursue Opportunities For Ideal Solutions Leadership Is Essential Patient Care Is A Core Physician Value Impact On Hospital Physician Relations

Improving Value In Trauma Care Strengthening Trauma Program Quality of Care; Responsiveness Maintaining Verification Status QA, CME, Protocols Cost effectiveness; Reduced LOS Community Outreach & Injury Prevention Public Advocate for Optimal Trauma Care

Improving Value In Trauma Care Strengthening Hospital Surgical Critical Care Program Ortho & Neuro Centers of Excellence Orthopedic Hospitalist Model Hospital/Physician Relations ED/OR/ICU Issues Trauma Center Halo Effect

Framework For Cost Effective Trauma Physician Support Effective Structure Hospital Support Optimal Franchise Trauma Physician Compensation Dealing With Leverage

Effective Structure Strong Trauma Medical Leadership Strong Trauma Service Make Trauma Call Less Burdensome  Only Call in Specialty When Needed  Have Patient Ready When Specialist Arrives  Don’t Make Specialists Wait for Diagnostic Results  Implement Tiered Call System; Facial Fracture Panels

Hospital Support OR Block Time ED Throughput Physician Assistants Nurse Practitioners Other

Optimize Franchise Trauma/SICU/Surgery Hospital Based Orthopedic Program Establishment of Centers of Excellence Halo Effect for both Physicians and Hospital

Trauma Physician Compensation Trauma Medical Director Compensation Payment on Uninsured Patients Call Stipends; In-house call versus on-call Response Fees/Complex Schemes Consolidated Trauma Physician Billing Support Net Annual Hospital Cost (NAHC)

Dealing With Leverage Balkans Revisited Stark Provides Constraint Do Not Form A Cartel Compliance Is A Serious Issue

Arriving At Fair Compensation Key Payment Factors Employment vs. Contracting Data and Market Norms Process is Key

Key Payment Factors Lack of Residency Volume of Uninsured Role versus Value Provided In-House Call versus On-Call Trauma Volume +/-

Employment vs. Contracting Contract With Group For Service/Employment Of Trauma Specialist Hospital Employment of Surgeons Contract with Individual Surgeons

Data & Market Norms Data Sources Comparison to Salary Data Specialty Outliers Payment on Uninsured

Dealing With Leverage Balkans Revisited Stark Provides Constraint Do Not Form A Cartel Compliance Is A Serious Issue

Process Is Key Do Not Ignore Requests Effective Hospital Leadership Benchmark Trauma Financial Performance Solicit Specialty Input Address Non-Financial Issues Define Fair Level of Compensation

Specialty Issues & Market Norms Trauma Surgery Neurosurgery Orthopedic Surgery Plastic Surgery Low Volume Specialties Hospital Based Specialties

Trauma Surgery Key Issues :  Core of Trauma Center  Highest impact specialty  Frontline and patient care manager roles  Franchise Value Market Norms  Most Trauma Surgeons within Community Hospitals Receive Hospital Support  In-House Call $1000-$2500 per day  On-Call $500-$1500 per day

Neurosurgery Key Issues :  High impact specialty due to shortage  Quick response time to surgery required  Relatively small professional fee franchise  Relatively poor payer mix Market Norms  About 40% of Neurosurgeons In Community Hospitals Receive Support  $500-$2,500 per day

Orthopedic Surgery Key Issues:  High volume trauma specialty  Sub-specialization making surgeons uncomfortable with trauma  Need To Reduce Number of Surgeons Taking Trauma Call  Large professional fee franchise Market Norms  30% Orthopedic Surgeons In Community Hospitals Receive Hospital Support  $500-$2,000 per day

Plastic Surgery Key Issues :  Small volume specialty; ED call issues  Call structure is critical for this specialty  Declining number of surgeons taking call  High paying, busy private practices (Cosmetic Surgery) Market Norms  10-15% Plastic Surgeons In Community Hospitals Receive Hospital Support  $250-$1,000 per day

Low Volume Specialists Key Issues :  Focus on Trauma Service making their life easier  Can be most difficult issue  Combined with ED call issues Market Norms  Few are Compensated in Community Hospital Setting  No Real Market Norms  Payment on Uninsured Patients

Hospital Based Specialists Trauma is Part of Their Hospital Franchise Few Payment Examples In house Anesthesia is exception

Trauma Center Of The Future The emerging Hospitalist Model Carved out Trauma Physician Billing Trauma Specific CPT Codes and RVU’s Unfallkrankenhaus Lorenz Bohler