Hospitalist's role needs to be defined

A column examining the ins and outs of contract issues

By — Posted Jan. 12, 2009.

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Hospital medicine is a relatively new medical field, and with any new field in medicine come new legal issues and concerns.

Many physicians and nonphysicians alike are unclear as to what a hospitalist is and what the hospitalist's role is in patient care. In short, a hospitalist is a physician trained in internal medicine who monitors and treats other physicians' hospitalized patients. Typical responsibilities include coordinating patient admissions and follow-up visits, providing bedside care throughout a patient's hospital stay, managing consultations and communications with specialists, ordering labs and procedures, and managing the discharge of patients.

There are two ways to employ a hospitalist. First, a hospitalist may be employed directly by the hospital.

Alternatively, a hospitalist may be employed by an individual medical practice, which in turn contracts with a hospital to provide the hospitalist's services. In the latter employment arrangement, it is the medical practice that is the hospitalist's employer, not the hospital.

In that situation, the employment agreement should explain the three-party relationship.

Regardless of whether the physician's employer is a medical practice or a hospital, the following key provisions should be addressed in the hospitalist's employment agreement:

Duties and responsibilities. Typically, a hospitalist is given a form agreement that reads: "Physician is employed to provide medical services customarily performed by hospitalists." This sentence alone is too broad. It does not define the scope of the hospitalist's responsibilities and leaves room for interpretation.

The employer might believe that a specific duty is one "customarily performed by hospitalists," whereas the hospitalist may think otherwise.

Depending on the leverage and negotiating power of the physician, I suggest that the employer and hospitalist mutually agree upon specific job responsibilities, which are then described in the employment agreement. Moreover, the hospitalist might suggest that the contract indicate tasks that are not within the scope of employment.

Scheduling. Because shifts are scheduled 24 hours a day, the employment agreement should indicate the hospitalist's share of the night shifts. If a hospitalist is expected to work more night shifts than others, then the hospitalist might wish to seek additional compensation.

The following schedule is becoming increasingly popular because it allows for a smooth, four-physician rotation, with two hospitalists responsible for in-patient care each week: Four hospitalists are employed by or contracted for by the hospital, with each physician working seven consecutive 12-hour shifts every other week. For example, a hospitalist will work Sunday through Saturday 7 a.m. to 7 p.m., but will have the following Sunday through Saturday off from work. Regardless of the schedule offered or negotiated, the arrangement should be described in detail to avoid the unexpected.

Compensation and benefits. Hospitalists typically are compensated based on a set salary, productivity or a combination of the two. However, geography and the size of the medical practice employer and/or the hospital will influence compensation. Additionally, how the hospitalist's labor is billed to third-party payers and how those payers handle reimbursements may also dictate how the hospitalist is ultimately paid.

Depending on the desirability of the individual hospitalist and the needs of the employer, deal sweeteners are often added to the compensation package. In my experience, the employer will not offer these add-ons upfront. Rather, they are made available for the "select" physician. Such add-ons include a signing bonus, relocation package, student loan payback, home mortgage assistance, or other compensation. However, please be aware of how these add-ons are structured so as not to violate a federal or state law.

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