Hospital Practice Attributes

Contract Negotiation

Stipend

Understanding the Jargon of Hospital Administration - FMV/etc

Access Issues - Dedicated OR Time, Radiology Support for Urgent and Elective Cases

Trauma Service Support Care of the Trauma Patient

Hospital - Supported Post-Discharge Trauma Clinic

Medical Directorship - Salaried

PA for Hospital Coverage

OR Nurse Liaison

Concessions to the Hospital


Contract Negotiation

Own the whole contract to provide all orthopaedic trauma care if possible, not just individual contracting (negotiate as a corporate entity).

Expect multiple long meetings with administration. Process may take 6-12 months for contracts lasting only 2-3 years. Longer contracts (i.e. 5 years) are more common. Consider adding provision for extensions to existing negotiated contract so entire process does not need repeating in two years. The physician is at a disadvantage, as they are negotiating not with other physicians but with professional negotiators (administrators), who continuously negotiate with multiple groups/departments/specialties.

Provisions for unfunded patients: hospital to pay at a negotiated rate (e.g. Medicare). Some contracts require a yearly cap (e.g. $100 - 200K).


Stipend

Stipend versus other models to generate 'salary'

Hospitalist/Sugicalist model=hospital employee=salary

Occurrence or Contact fees (can effectively increase stipend without being visible to FMV surveyors)

Each trip to the ED for a consult generates a fee

Stipends are part of the hospital Fair Market Value (FMV)

Hospitals legally need to use FMV as a guideline


Understanding the Jargon of Hospital Administration - FMV/etc

Doing your own research, not just relying on their FMV

The trauma service brings revenue to the hospital (1).

  • California Orthopaedic Association (COA), and likely other states, has surveys regarding range of stipends, call coverage and unrecognized costs associated with taking call.
  • MGMA has surveys of average income for orthopaedic specialists in each region (pay for this). Sharing this with the hospital at the right time can be advantageous (2).
  • Individual groups adjacent cities may be contractually bound not to reveal their negotatied rates or contract details to you. Hospitals often perform surveys as part of FMV analysis and obtain this information themselves, though not always accurate.

Access Issues - Dedicated OR Time, Radiology Support for Urgent and Elective Cases

Does your case load justify demand? Obtain this information from hospital billing to determine the number of operative and nonoperative cases/admissions.

OR time daily, either preferred access (shared but with priority access) or protected access, needed for long-term sustainability. If hospital not willing, negotiate a trial period where, if used less than an agreed percentage (i.e. 60-70%), this time can be reduced. If used more, time can be added.

Access C-arm/other technologies with available tech.


Trauma Service Support Care of the Trauma Patient

Trauma Service to provide inpatient care.

  • Direct patient care
  • logistical support for patient
  • Coordination of complicated¬† discharge plan
  • Trauma database managed by trauma service - can help for clinical or negotiations

CME Education Stipend

  • ACS requires panel to be current with CME
  • Physician can get support for this from hospital

Hospital - Supported Post-Discharge Trauma Clinic

This is an alternative to bringing the patients to the physician's private clinic.

All patients are seen, not just unfunded/underfunded.

This gives the hospital a reason to keep the trauma clinic. Significant fees generated for the hospital in diagnostic radiology (XR/CT/MRI) and returns to the OR for follow-up procedures. Revenue is positive for the hospital (2).


Medical Directorship - Salaried

Justified based upon hours required to manage the service, create protocols for improved trauma care, and perform community outreach (presentations to community non-trauma hospitals).


PA for Hospital Coverage

Options for employment, through hospital, where hospital bills/collects, or a 'stipend/budget' given for individual/group to employ PA, assuming risk but potential benefit of charges/efficiency.


OR Nurse Liaison

OR nurse liaison to mesh with OR, Ortho MD, Ortho PA, and trauma general surgeons/hospitalists to improve efficiency of case flow through the OR, workup/studies on patients, implants for cases, etc. This nurse is ideally one who has been an experienced OR nurse. Nurse starts earlier in the day than the traditional OR nurse, monitors progress of surgical patients for that day, and organizes the progress for the day based upon who is ready for surgery. Being an OR nurse, they understand what cancels surgery and keeps patients from getting to the OR.


Concessions to the Hospital

Do not be greedy. Be realistic in expectations for pay.

Implants (negotiate savings to be at least in part returned to trauma service through education and capital equipment purchases).

Hip Fracture Service (for those with combined ER/trauma coverage): Work with hospitalist service to explore reduction in length of stay, other financial benefits to an integrated service line.

  • Requires a geriatric internist or dedicated hospitalist to mesh directly with the orthopaedic service.
  • Commercial services exist through at least one major trauma vendor to support this concept.

References

(1) Orthopaedic Traumatology: The Hospital Side of the Ledger, Defining the Financial Relationship Between Physicians and Hospitals. April 2008 - Volume 22 - Issue 4 - pp 221-226.

(2) Getting Paid for Taking ER Calls: Who Pays, and How Much is Fair? MGMA Connexion, Vol. 6, Issue 7, August 2006.