CMS just released its newest star ratings for U.S. hospitals. The ratings were supposed to come out last summer but there was a delay because of problems with the methodology...
It is that time of the year when department chairs and division directors come to the hospital administration asking for financial support for the upcoming year. Few specialties can be self-sufficient in an academic medical center so the hospital has to provide some amount of money to ensure that there is adequate physician staffing. Inherent in being an academic physician is the premise that you are not going to be seeing as many patients or doing as many surgeries as your colleagues in private practice because you are going to be spending part of your time doing academic activities: teaching, writing papers, developing a focused area of clinical expertise, and doing research. You also commit to directing part of your income to the college of medicine (“dean’s tax”) and the department/division (“academic expense”). For this, you are willing to make a little less than your private practice counterpart, but not too much less. Thus, the need for the subsidies from the hospital.
But the hospital wants to know that there is some value in the these subsidies. By and large, the funds are ultimately used for “academic release time”, that is the time that the physician spends doing those activities that are important to the academic mission of the medical center but are otherwise unfunded. Back in the 1980’s, unfunded academic release time was typically about 40% for a newly hired physician: the physician would do 6 months of inpatient service and see patients for a half-day in the clinic. By the 2000’s, that had dropped to about 20% and now 10-15% is more common for new physicians.
The problem with academic release time, is that if everyone gets it, it can become an entitlement and then it becomes next to impossible to take away without organizational disruption. So, our challenge is to find a way to ensure that physicians are accountable for that otherwise unfunded academic time that they have. In order to figure out how we can do that, lets start with a look at how several specialties in our medical center deal with unfunded academic time. For the purposes of simplicity, I am going to use “department” to mean either department or division.
Department #1. All physicians start at 100% clinical full time and then after they are practicing for months or years, they come up with specific proposals to acquire academic release time. These could include doing a hospital quality project, chairing a hospital/college committee, doing a clinical research study, taking on an administrative position, etc. The physician continues to get that academic release time as long as he/she continues to perform that particular non-clinical activity.
- The problem: many of these physicians never have the initial time investment to get any kind of academic activities off the ground and so after several years, they often move to private practice jobs since there is nothing tethering them to the university.
Department #2. All physicians get some percentage of academic release time that is negotiated individually at the time of their initial appointment. The percentage varies from 10% to 20%. The purpose is to teach and obtain research funding. At this time, however, none of the physicians except the chair have research grants.
- The problem: there is a lot of “release time envy” by those physicians who only negotiated 10% release time versus those with 15% or 20% release time since those with more release time are seen as having to work less but getting paid the same as those who have less release time.
Department #3. All physicians get 20% academic release time and that is maintained in perpetuity, regardless of what they do during that time. There is an annual review process with the chair and those physicians who lack any academic productivity are directed by the chair to do more.
- The problem: in theory, this academic productivity would be tied to physician bonuses but the department has not had any money to give bonuses for 15 years. Therefore, there is little incentive for the physicians to do anything productive for 20% of their time.
Department #4. All physicians get 10% academic release time at the time of their initial appointment. If they don’t have any academic output to show for after 3-4 years, then their release time is eliminated and they become 100% clinical.
- The problem: once you go 100% clinical, you can never go back. Eventually, a private practice job across town that will pay you more for the same amount of work looks pretty inviting.
Department #5. All physicians get 20% academic release time but they are expected to produce work RVUs at the 75th percentile of national benchmark during the 80% of their time that they are doing clinical activities. In this way, the physicians self-fund their own 20% academic release time.
- The problem: you are really deceiving yourself by making yourself be way more productive than the average physician 4 days of the week so that you can have the 5th day to do academic stuff. The reality is that most physicians work at a pace of average productivity so inevitably, they end up doing clinical work on that 5th day to catch up. In other words, the physicians coast for 1 day to make up for sprinting the other 4 days. What you are in reality doing is asking the physicians to have average productivity 100% of the time; you are just wrapping it up differently.
Department #6. All physicians get 20% academic time. If a physician gets a paid administrative or teaching position, that 20% of time is eliminated.
- The problem: you reward those physicians who do not take on administrative or teaching roles. Those physicians who do take on a paid administrative role have to do more work than everyone else and get paid the same. You discourage anyone from volunteering to take on paid teaching and administrative roles and you encourage your doctors to not do anything that might ultimately improve care within the hospital or bring academic notoriety to the college of medicine.
So what is the answer? Ultimately, what the academic medical center wants are those activities that bring research grant dollars, result in journal articles with the institution’s name on them, create teachers who attract the best medical students & residents, generate clinical expertise that attracts patient referrals, create an environment of high-quality clinical care, and result in efficient clinical care with a positive financial margin. What the doctors want is enough time to do academically creative things that will help them achieve whatever they define as an academically success for themselves. Here are two proposals:
This is essentially what department #1 does above. Namely, all new physicians start out at 100% clinical and then submit specific proposals to “buy down” academic release time. The goal would be for most physicians to buy down 15% academic release time by their 4th year of practice. Because there is not enough money in the system to pay for every single physician to have 15% non-clinical time, there would have to be some way of adjudicating the proposals to cull out those that do not provide institutional value or that have a low chance of success. This model works best for physicians who do shift work where it is relatively easy for them to flex up or down in the number of shifts that they do since they are relatively interchangeable with one another. Examples include hospitalists, anesthesiologists, and emergency medicine physicians.
This is a variation on the “ramp up” period that many surgeons have in their initial contract with the assumption that as they build experience and a build a referral base in their first 5 years of practice, they are more able to support their own salary so that they need a lot of hospital support their first year in practice but need progressively less each subsequent year. So, in model #2, a typical clinical-track physician faculty member would get 20% unfunded academic time in their first 2 years, 15% unfunded academic time in their third and fourth years, and then 10% unfunded academic time in their fifth and sixth year. The physician could maintain their 20% unfunded academic time after their second year by demonstrating that they have been good steward of that time by producing publications, obtaining grants, doing a lot of unpaid teaching activities, etc. After year six, a physician who has no academic output would be moved to a 100% clinical role. This model works best for physicians who are office-based or who rely on an individual referral base since increasing non-clinical release time after they have become established can be disruptive to patients by transferring his/her patients to other physicians in order to reduce the physician’s outpatient patient panel or by refusing some patients referred specifically to that physician. Examples include primary care physicians, surgical sub-specialists, and outpatient consultative specialists.
Ultimately, unfunded academic time should be used as an investment in junior physicians with the potential to become academically productive and to support those physicians who are doing academic or clinically unique activities that are vital to the success of the institution but that are otherwise unfunded. It is up to us to ensure that this unfunded time does not simply become an entitlement that allows the physicians to leave work at 2:00 on Friday afternoons or do fewer surgeries per week, just because they have an academic title in front of their name.
April 9, 2017