Intended as a temporary solution, hospitals engage locum tenens for general surgery call coverage when their current call model cannot meet hospital’s demands. The cause? Time needed to recruit a full-time surgeon, or perhaps filling a gap in coverage, an illness, extended leave, vacation, or another unexpected absence. Regardless of the reason, locum tenens is a costly fix, not just financially, but also creating a trickle-down effect to quality and outcome metrics, as well – begging the question, are you really getting a return on your investment?
Let’s first explore how utilizing locum tenens is a costly fix, financially. On average, locum tenens make $33 per hour more than a full-time, permanent surgeon, which can add up quickly for a full day’s coverage. They can also limit a hospital’s capabilities to properly provide a full service acute care surgery program (more on this later), so the hospital is essentially paying top dollar for a subpar program. In a short matter of time, the cost to provide temporary general surgery coverage can have a ripple effect where lack of follow up, multiple hand offs between surgeons, dissatisfied patients and referring physicians can lead to patient leak and re-routed referral patterns.
What’s Age Got to Do with It?
When it comes to age, the majority of locum tenens tend to be at the ends of the spectrum – either young and inexperienced surgeons or senior-level staff at the end of their careers, often looking for an easy gig before retirement. For the younger surgeons, hospitals may be overpaying for inexperience, a costly fix considering the potential for additional time needed in the OR, poor surgical judgement and outcomes, excessive transfers, high rates of readmissions, and worst of all – malpractice issues. On the opposite end of the spectrum, senior-level surgeons often come with great surgical experience. If they are burnt out, they may not have the desire to put 100% effort into seeing patients in a timely fashion (especially at night) or the patience to deal with all the nuances that goes with 24/7 patient care. This can lead to tension, lack of professional respect, decreased patient retention, and poor intra-hospital coordination, ultimately decreasing efficiencies.
Geography Matters
Often traveling for their temporary assignments, locum tenens only intend to be stationed at a particular host hospital for a short period of time. It comes as no surprise that they often lack the desired presence. Standard hospital operations, ranging from OR operating procedures to familiarity with electronic health records, are usually foreign to locums. Unfamiliarity leads to poor communication, missed protocols, subpar documentation – and ultimately – lost revenue. Given their temporary status, it may be difficult for local providers to refer their own patients to a facility where they are unfamiliar with integrity of the surgeon on call. A lack of local presence also impacts continuity of care – there is none – unless the hospital sets those measures in place with another provider. Once a locums surgeon leaves their assignment it is often difficult to get them to complete their charting or follow up on documentation queries. As we all know, documentation is the key factor in reimbursement. Non-committed surgeons tend to minimally document clinical details in the depth needed to capture all appropriate DRG’s. This ultimately leads to a decrease in case mix index (CMI) and falling revenue – again impacting the hospital’s bottom line.
Outcomes are Key
The transient and inconsistent nature of locum tenens directly impacts the hospital’s quality and outcome metrics. Already mentioned, poor surgeon judgement can, and often does, lead to unsafe practices and poor surgical outcomes. Without a specific continuity , patients do not receive the proper post-operative care, follow-up on labs and pathology results, and rehabilitative care needed to recover. Oftentimes rounding and discharges fall to a secondary priority or are handed off to hospitalists, increasing length of stay and potential complications. Some patients will even get readmitted due to complications from poor surgical techniques. To the hospital, poor outcomes and quality metrics have a direct impact on reimbursements, impacting their bottom line. An increase in 7 day or 30-day readmission rates will mean lower reimbursement from Medicare and Medicaid.
Backed Into a Corner
So, if the cost, quality, and outcome metrics are at stake, why do hospitals continue to use locums? The perception is that they have no other choice – they need a warm body. The length of time it takes recruiting a new surgeon can be detrimental with lost volumes and revenue from extended gaps in call coverage. If locums are used to fill that gap, the hospital pays for locums in addition to recruiting fees and a surgeon salary line. Perhaps locums are used to cover call when adding a full-time surgeon doesn’t align with the supply and demand for elective case volumes. In this situation, locums can potentially serve as a longer-term solution. While the service may be long-term, there is no guarantee the same surgeon(s) will serve the hospital each shift, several different surgeons could rotate in and out over the duration of the locums assignment – you never know what you are getting.
The Right Fix: Surgicalists
There is a better alternative for call coverage: Surgicalists. A novel call model for acute care surgery coverage that is gaining popularity. Similar to hospitalists in the 90’s – with surgeons solely dedicated to in-patient care, it continues to be the coverage model of choice by more and more hospitals nationwide. Surgicalists, or surgical hospitalists, offer a permanent staffing solution with minimal upfront cost and, unlike locums, with huge return on investment. While they aren’t always the answer for the immediate unexpected vacancy in call coverage, once in place, coverage gaps are no longer an issue for the hospital, it is a long-term permanent solution.
Our Surgicalists are dedicated to providing call coverage to the hospital 24/7/365 with no distraction of an elective practice. By having a permanent, local presence and integrating themselves in the community, symbiotic connections are made with area practitioners. Additionally, our Surgicalists form relationships with elective practice general surgeons, helping to bolster their practices by sending elective surgical patients to their office for a consultation and operations.
In and out of the OR, our Surgicalists influence key quality and outcome metrics that positively affect the hospital’s revenue. They actively collaborate with hospital leadership, developing best practices and protocols to enhance ED and hospital throughput and efficiencies. Around-the-clock availability means less time for patients waiting in the ED. In the traditional model, the wait time for proper care is much longer and the more hospital resources are used, the greater the patient leakage from the ED, the less patients are satisfied with their care, and the more frustrated the ED providers become. With Surgicalists on hand, patients are consulted upon quickly in the ED and moved to the OR as soon as it becomes available, improving OR utilization. Without the distraction of an elective practice, Surgicalists round early in the day so discharges can occur in a timelier fashion, opening much needed available beds, decreasing the length of stay and opening the hospital to take on additional volume. That additional surgical and patient volume is also a proven benefit of the Surgicalist model. Being available 24/7, solely to the hospital, Surgicalists capture more index cases and perform more operations than can be done under the traditional model. The leads to a direct increase in the hospital top line.
OR efficiency and utilization improve once the team realizes the Surgicalist is always available, if there is an unexpected cancelation in the schedule, our surgicalist can fill that spot, not needing to wait until the end of the day potentially keeping staff after hours. Our Surgicalists follow detailed documentation protocols, are all trained in clinical documentation improvement techniques and have a positive impact on case capture, documentation, accurate CMI, as well as additional opportunities for revenue generation.
More and more, hospitals are adopting the Surgicalist model and seeing huge benefits. No longer do they struggle to find last-minute coverage for general surgery call or find the need to manage disengaged, temporary surgeons. Instead of paying top price for little more than a warm body, hospitals are able to enhance their ED throughput, surgical outcomes, quality metrics, and revenue.
To explore bringing Surgicalists to your hospital, contact our hospital advisor: (813) 940-SURG (7874) or visit TheSurgicalist.com.
Editorial written in collaboration by Mit Desai, MD, FACS and Dave Terry, DO
