Retooling today's practices to accommodate part-time physicians.

The practice management challenge de jour is to successfully and profitably fold part-time docs into the caregiver mix, without sacrificing coordinated care or chiseling away at office harmony.

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Growing numbers of physicians--women as well as men--are pushing for part-time work. Many newly graduated physicians entering the medical world prefer part-time positions to better balance lifestyle demands.

Senior doctors, tired of the stress and strain of call and burgeoning paperwork, are increasingly negotiating part-time employment as a transition into retirement. Whatever the motivation, practice leaders are finding that employing physicians on a part-time basis can reap big rewards but requires creative care delivery and financing strategies.

Actually, dedicating part-time to clinical duties isn't an entirely new concept. In the world of academic medicine, physicians' time has always been divided among research, teaching and clinical care. Here, though, there is silent agreement in play, whereby the physician, in an emergency, could return to the practice to help out.

This fluidity to the allocation of time softens the impact to clinical care. But where is the cushion when part-time physicians stipulate that their time away from the office is sacrosanct? Practices must take steps to accommodate this protected time.

Motivation

Leaders at academic medical centers and private group practices are favorably disposed to hiring part-time physicians for a number of reasons:

* Practices want women physicians, who tend to fill their patient panels easily and draw to the practice. The growing numbers of women in medicine are fueling the part-time trend. A study conducted by the American Academy of Pediatrics found that 45 percent of pediatricians are women, of whom 28 percent worked part-time in 2000. Additional specialties with high concentrations of women, according to the American Medical Association, are obstetrics and gynecology at 35 percent, psychiatry at 29.5 percent, family practice at 28.5 percent and internal medicine at 27.6 percent.

* Practices want to attract physicians in specialties experiencing shortages, such as radiology. Offering part-time employment can be a real plus in recruiting. Flexible hours can make a less desirable location, in an especially rural or hard-core urban setting, more enticing.

* Part-time physicians can also help the practice increase capacity and offer patients options for extended office hours during weekends and/or evenings.

* Practices want to attract younger doctors and retain older, senior physicians. Both camps want lifestyle accommodations. Keep in mind that retiring doctors have the experience, drawing power, name and good-will--all paying big dividends in patient loyalty. The practice benefits in retaining these seasoned pros. Patients also flock to younger, and in many cases, female physicians. Part-time options are often appealing to doctors at either end of the career spectrum.

New approaches needed

Understanding how the part-time physician trend will affect practice finances and care delivery is complicated by the fact that those who work reduced hours will probably only do so for a portion of their careers.

But it is clear that practices must forge a new set of guidelines in a number of key areas to deal with this still developing trend:

* Compensation

* Partnership/tenure

* Opportunities

* Physician retention

* Scheduling

* Patient access

* Care coordination 

Additionally, it is essential that patient satisfaction and perception of quality of care delivery are not compromised, as health insurers increasingly tie success in these areas to compensation and reimbursement.

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Delivering care

Most physicians and administrators agree that part-timers work equally as hard as their full-time peers. A study of 2,700 patients conducted by The Health Institute at Boston's New England Medical Center reported no discernable difference between the two physician groups. The study queried communication, access, exam thoroughness, patient familiarity and preventive counseling. However, friction can arise around the following issues:

* Work schedule

Some part-timers commit to 20 hours a week, but because they end up putting in extra time, they feel like they are working 40 hours. This scenario is especially true if the physician agrees to work half days, which can quickly stretch to five or six hours during patient emergencies. Full-time physicians in the practice may resent that part-time colleagues have little or zero flexibility to cover unexpected volume and unanticipated patient demand. For this reason, many part-timers find three 10-hour days to be ideal.

* Call duties

Is call obligation in proportion to the percent of time working, with an associated reduction in pay? Call duties can spark disagreements and hard feelings. Most groups expect call to be divided evenly and full-timers can grouse about their part-time colleagues who don't take it. One creative solution is to pay extra to those who take call or offer less salary (in some cases, up to 30 percent) to physicians who bow out. Alternately, allocate call to part-timers who comprise a "patient care team" in proportion to their hourly commitment.

* Care coordination

If patients call with an emergency, how are they managed when their part-time doctor is not in the office? Who covers in the office and do patients mind seeing someone else? Consider grouping part-time physicians so that they manage a full-time patient panel together. This configuration gives patients access to someone on the team at all times to ensure coverage, continuity and coordination.

The patient care team can comprise as many people as necessary to make a full-time equivalent, but it needs to be overseen by a full-time team physician leader. Again, communication and set protocols can mitigate any bumps in the road. Patients should understand the situation from the get-go. Generally, they are willing to trade any slight inconveniences part-time raises for the opportunity to be in their preferred doctor's care.

* Patient connection

Are patients angry or disappointed when they call and learn their part-time physician is not there? Scheduling can help ensure that part-time physicians are no more than four days away from the office. In actuality, with staff following set protocols, 80 to 90 percent of phone calls and prescription refills can wait until the physician returns to the office. Complete communication disclosure is the key to keeping patients happy and satisfied. Staff should brief patients on their part-time doctor's schedule so they know what to expect. And, there must be a care plan in force that ensures that patients who cannot wait for care don't.

* Operational support

Practice cultures have to change to accommodate the demands of a growing part-time workforce. More than ever, practices need tools, such as electronic medical records, to diminish physicians' administrative burdens. Equally critical is the infrastructure support necessary to ensure that providers can successfully deliver care within part-time constraints. Patient flow needs to be smooth without hitches and glitches that can trip up the day, messages need to be taken correctly and delivered efficiently, and managed by support staff who ensure that patient need is met.

* Misunderstanding and mixed reaction from peers

Peers can resent reduced call and having to shoulder the burden of patient commitment on the days the part-timer is absent. The practice really needs part-time docs with full-time attitudes to disarm any critics. Part-timers who appear grateful for the option to work less and those who are willing to do more than their fair share mix better with full-time colleagues. Leadership should be vigilant about quickly addressing and resolving any issues that arise by communicating with all parties involved.

Financial impact

A healthy bottom line--for the practice and the part-time provider--is key. Seven common issues usually arise:

1. Pay

All parties, including full-time physicians, must view pay as equitable. Three compensation formula options are emerging: salary based on a percentage of full-time pay, generated revenue minus overhead, or pay hinging on a percentage of practice profits.

2. Benefits

Many practices make a lower contribution to health care insurance costs, based on the proportion of time the part-time physician works. Some prorate benefits in proportion to the time the doctor works. Still others offer no benefits at all. As for profit sharing, each practice organization has its own plan design. Part-time employees of any type may be ineligible.

3. Overhead

Because most practices allocate overhead equally, part-time doctors experience a proportional reduction in take-home pay to make up for fixed overhead expenses. Sure, it would be more equitable to have an arrangement where the part-timer's overhead results from hours worked, actual utilization of staff and space and revenue generated. But in truth, most groups don't usually track or calculate these figures.

Large groups or lucratively reimbursed specialties can more easily afford to absorb the overhead, which they might readily do to attract part-time physicians who can ease the patient care burden for very busy specialists or increase patient access.

Here's an alternative formula to allocating fixed overhead. Charge the part-time doctor's salary with:

* A full share of fixed expenses, such as rent and office manager salary

* A proportional share of variable expenses, such as support staff salaries, in accordance with the percentage of the group's patients seen

* Direct expenses, such as insurances

* A pre-determined dollar allocation to compensate full-timers for managing the part-timers' patients when they are not in the office

4. Malpractice insurance 

Malpractice insurance premiums often don't distinguish between full- and part-time hours. In most states, the cost is the same regardless. Moreover, the practice may not be able to discount malpractice insurance for part-time work. As malpractice premiums continue to skyrocket, a higher percentage of revenue generated by the physician must go toward this cost. Some practitioners are finding it prohibitive to reduce their workweek if they must shoulder premium costs themselves.

5. Continuing medical education 

CME money, time and travel may not be available to part-timers as it is becoming hard enough for full-timers to get. This reality can create issues, as all physicians must earn CME credits to retain their licenses. A practice's investment in technology could help all physicians more easily access CME courses online and in virtual meetings.

6. Partnership and tenure

Partnership and tenure are rarely available to part-time physicians. During hiring negotiations, some new part-time docs have successfully negotiated for their part-time work to be credited toward the years it takes to become partner/tenured, once they start working full-time.

A physician who works part-time for two years, for example, may get a half-year credit toward the time requirement for partnership. Additionally, practices that wish to retain retiring physicians as part-timers should buy back their stock, as these doctors no longer have the same financial commitment to the practice's future. It makes more sense for these retiring physicians to become employees because personal goals--scaling back--now supersede their long-term interest in the practice.

7. Performance standards

Hours shouldn't be the only measure of productivity. Doctors working half time should be half as productive as their full-time peers and measured against all other practice performance standards as well. Some practices tie benchmarked performance to the partner/tenure opportunity; for example, the part-timers must contribute 75 percent of the group's average productivity or they can't count their time toward partnership.

Breaking new ground

New ground rules and approaches are necessary as practices grapple with the challenges of hiring part-time physicians. It's well worth the effort, as both younger and seasoned physicians--the groups that tend to sign on for part-time duty--can draw patients into the practice.

Practice leaders must work hard to smooth patient flow and access, and to keep communication channels open, expectations clear and salary and duties fair and equitable. With guidelines in place and office efficiencies addressed, part-time efforts can bring full-time success.

Jayne Oliva is a principal with The Croes Oliva Group, a Massachusetts-based medical group management consulting firm, specializing in developing outpatient operational improvement plans for physician practices at major academic medical centers and integrated delivery systems throughout the U.S. She can be reached at [e-mail] or 781-272-5055.