Hospitalist Employment Models: Which Fits You Best?

Surinder Yadav

Surinder Yadav , MD

Vice President of Operations, Hospital Medicine

Published September 12, 2016

Hospitalists are enjoying an incredibly favorable employment market. As a job seeker, you might be tempted to snag the best-paying opportunity in your target area. But there's another factor you should consider: fit.
There are currently a handful of hospitalist employment models in use — each with benefits and limitations. Many physicians underestimate how much these models can impact day-to-day practice. That's because each model fosters a culture that fits some physicians better than others.
There are myriad ways to classify hospitalist employment models. But for simplicity's sake, I recommend getting familiar with these four.

Hospital Employment

Working directly for a hospital is a common employment scenario for hospitalists.
Many hospitals employ hospitalists (directly or through their foundations) in hopes of fostering physician alignment. This arrangement allows for more control of physician behavior, which can help to boost quality. Leaders also believe employment will spur greater clinical integration among service lines.
As a group, hospitalists also show a preference for hospital employment. For most of us, it's the most familiar model, the one we experienced during residency. Other attractions include clearly defined benefits with predictable schedules and workloads. Employed physicians have relatively little administrative burden, because the hospital assumes responsibility for billing, risk management and staffing.
While popular, this model has potential downsides. For one, hospital-employed physicians don't have much autonomy in their jobs. A lot of directives affecting their practice come from the top down. If they disagree, they're straightjacketed to some extent.
This lack of autonomy tends to squelch physician engagement and leadership. There are plenty of dedicated, highly motivated physicians working for hospitals. Unfortunately, they often find themselves alongside individuals who do just enough to meet their contractual productivity requirements.
Physicians themselves bear out this observation. A 2009 MGMA survey found that directly employed hospitalists see 19 percent fewer patients than their outsourced counterparts.
So at the end of the day, hospitalist employment has some benefits, but it doesn't automatically improve quality. The costs of managing a hospitalist practice can be high and unpredictable.
As a result, many hospitals choose to outsource the management of their hospital medicine practices to corporations, independent contractors and physician groups. Let's take a closer look at each of these.

Company Employment

Several companies are in the business of managing physician practices for hospitals. Some specialize in hospitalists, while others offer multiple service lines.
When it comes to designing hospital medicine programs, management companies often have a greater depth and breadth of experience than hospital leaders. They can bring expertise, fresh ideas and best practices to the table.
For hospitalists, employment by a management company has some of the same perks as hospital employment, including predictable schedules and benefits. Most companies also offer practice management services, though the level of support varies.
While many physicians build fulfilling careers with management companies, others find corporate culture at odds with practice. In a corporate environment, the first responsibility is to the shareholders. This creates a conflict of interest between profit on one hand and patient care on the other. And some companies do a better job of walking this line than others.
As in hospitals, physicians employed by corporations have very little voice in practice matters. In some large companies, the top clinical leaders oversee an enormous number of physicians and practice locations. Even if they're in touch with the needs of the front-line hospitalists, they may be spread too thin to offer meaningful support.

Independent Contracting

Another option for hospitalists is self-employment. Physicians following this model work as independent contractors for hospitals and practice management companies. This arrangement is more common in states that prohibit physician employment (including New York and California).
Self-employed hospitalists tend to be more mobile than their employed counterparts. They can choose long- or short-term jobs, take breaks between assignments and step up their workload to boost earnings. The downside: because contracting relationships tend to be shorter and more tenuous, these hospitalists have fewer opportunities to innovate, lead change or otherwise engage with their hospitals.

Physician Partner

Most hospitalists have had little exposure to physician partnerships (also known as independent groups).
Partnerships are physician practices in which all members have the opportunity to become owners. As such, they share both the group's profits and the responsibility for its success. This tends to incentivize engagement, with hospitalists going the extra mile to align with hospital goals, innovate new processes and lead initiatives.
The partnership model fosters cooperation among physicians, because everyone is motivated toward the same goal. This collaborative spirit can also cross service lines, improving clinical integration. For example, when a partnership staffs both the hospital and emergency department, colleagues work together to facilitate admissions. Patients see everyone working together as one team, which is a great satisfier.
Partnership is ideal for physicians who hunger for autonomy. Each hospital medicine department is basically it's own entity. The partnership provides administrative support, but the physicians on-site call the shots when it comes to patient care, workflows, productivity, schedules and so on. In addition, partnerships emphasize financial transparency. Every partner knows how profits are spent and has a voice in these decisions.
The partnership culture isn't ideal for everyone. For example, at CEP America, we expect our partners to put the patient first. This means that when difficulties arise, all team members make an extra effort — even if it means going above and beyond their routine duties.
I'll temper the above statement by pointing out that balance is important to our partners. We really value quality of life and try to provide that for one another. On the other hand, being a partner takes a lot of dedication, because we value the care that we provide for our patients. The partnership model is a good fit for physicians who want to be very engaged in their group and hospital.

Making the Right Decision

While I hope these practice model categorizations are helpful, they also shouldn't be taken too literally. Within each of these models, there's a lot of variation. There are also plenty of gray areas in between.
However, being familiar with the basics can inform hospitalists' career decisions. In the end, employment models tend to shape culture. And cultural fit is probably the best predictor of long-term physician satisfaction.

This post originally appeared at Perspectives on the Acute Care Continuum on Jan. 5, 2016.

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