Sep 2002 Table of Contents

A Job-Share Model for the New Millennium



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This approach to family practice assures continuity of care for your patients as well as a healthy life balance and a decent paycheck for you.

Fam Pract Manag. 2002 Sep;9(8):29-32.

This content conforms to AAFP CME criteria. See FPM CME Quiz.

In theory, the broad scope of family practice ensures comprehensive and continuous patient care, but in reality, many family physicians are now limiting their hours and restricting their practices to the office setting. They’ve relinquished hospital, nursing home and home care services for valid and complex reasons, including the need to protect their personal lives. In some cases, the result has fragmented care, stressed the doctor-patient relationship and placed heavy productivity demands on physicians, who must provide a high number of office visits to meet the high overhead costs typically associated with family practice.

Family physicians who want to provide comprehensive patient care without having to sacrifice their personal lives would do well to consider job sharing as an alternative to the traditional practice model. Our experience sharing positions with others in academic and private practice settings helped us to develop a job-share model that provides patients with an unbroken “circle of care,” encompassing the office, hospital, nursing home and patient’s home. The model also contributes to the practice’s bottom line by generating up to 50 percent of practice income from services provided away from the office, which reduces costs. Here’s how it works.

KEY POINTS

  • Because the authors’ job-share model uses fewer office-based resources and generates up to 50 percent of the practice income away from the office, it increases revenue and decreases overhead costs.

  • The model enables family physicians to limit the number of hours they practice while maintaining continuity of care and a broad scope of practice.

Reinventing the circle

Our job-share model requires two or more physicians to link their skills, energy and time to provide comprehensive care to patients. Ideally, the physicians should share more than just patient care responsibilities. For the arrangement to work best, the physicians should also share similar competencies and a common patient care philosophy. These characteristics will help to facilitate the careful communication that cross-coverage requires and may also help patients accept the job sharing physicians as interchangeable.

The original concept for job sharing is two part-time physicians splitting the workload of one full-time physician. Expanding that concept to include more physicians isn’t difficult and may increase the likelihood of success. "Job-share models" provides multiple examples of job-share arrangements that cover the circle of care.

JOB-SHARE MODELS

The dedication and time commitment required for one physician to provide the entire “circle of care” and continuous coverage for a practice is considerable. In order to have a more balanced lifestyle, many physicians are opting to work fewer hours or job share. In these job-share arrangements, physicians practice the full scope of family medicine in varying capacities ranging from .5 FTE to 1 FTE.

KEY

AH = After-hours coverage

HC = Home care visits

HR = Hospital rounds

NH = Nursing home rounds

OB = Obstetrics

S = Surgery assistant

Model 1: Two part-time physicians

In this model, one physician provides out-of-office services such as hospital rounds and nursing home visits while the other physician covers the office. Each works five half-days a week, trading responsibilities on alternate weeks. No support staff is in the office unless a physician is present. The downside to this model is that it reverts to the solo model if one physician is sick or on vacation.

WEEK 1

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Physician A

Office

Office

Office

Office

Office

Part time (.5 FTE)

Physician B

HR, NH, HC,

HR, NH, HC,

HR, NH, HC,

HR, NH, HC,

HR, NH, HC,

HR, AH

HR, AH

Part time (.7 FTE)

S, OB, AH

S, OB, AH

S, OB, AH

S, OB, AH

S, OB, AH

WEEK 1

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Physician A

Office

Office

Office

Office

Office

Part time (.5 FTE)

Physician B

HR, NH, HC,

HR, NH, HC,

HR, NH, HC,

HR, NH, HC,

HR, NH, HC,

HR, AH

HR, AH

Part time (.7 FTE)

S, OB, AH

S, OB, AH

S, OB, AH

S, OB, AH

S, OB, AH

Week 2 and beyond: Rotate the physicians’ schedules.

Model 2: Three part-time physicians

Each week, two physicians work in the office while the other physician provides out-of-office services. All three work part time. If one physician becomes ill or is on vacation, the remaining physicians switch to the two-physician model (Model 1, above) and the practice continues to function at full capacity. Or one physician runs the office practice full time while the other physician maintains a normal schedule performing outside services.

WEEK 1

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Physician A

Office

Office

Office

Office

Office

Part time (.5 FTE)

Physician B

Office

Office

Office

Office

Office

Part time (.5 FTE)

Physician C

HR, NH, HC,

HR, NH, HC,

HR, NH, HC,

HR, NH, HC,

HR, NH, HC,

HR, AH

HR, AH

Part time (.7 FTE)

S, OB, AH

S, OB, AH

S, OB, AH

S, OB, AH

S, OB, AH

WEEK 1

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Physician A

Office

Office

Office

Office

Office

Part time (.5 FTE)

Physician B

Office

Office

Office

Office

Office

Part time (.5 FTE)

Physician C

HR, NH, HC,

HR, NH, HC,

HR, NH, HC,

HR, NH, HC,

HR, NH, HC,

HR, AH

HR, AH

Part time (.7 FTE)

S, OB, AH

S, OB, AH

S, OB, AH

S, OB, AH

S, OB, AH

Week 2 and beyond: Rotate the physicians’ schedules.

Model 3: Two part-time physicians and two full-time physicians

This model would be the most effective at ensuring protected time for the physicians in the practice. Each week, two physicians work full time in the office while one physician works five half-days in the office and another physician works seven half-days performing outside services. It is conceivable that in a practice this size or larger, another part-time physician will need to rotate out to do rounds and perform other services.

WEEK 1

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Physician A

Office

Office

Office

Office

Office

Full time

Physician B

Office

Office

Office

Office

Office

Full time

Physician C

Office

Office

Office

Office

Office

Part time (.5 FTE)

Physician D

HR, NH, HC,

HR, NH, HC,

HR, NH, HC,

HR, NH, HC,

HR, NH, HC,

HR, AH

HR, AH

Part time (.7 FTE)

S, OB, AH

S, OB, AH

S, OB, AH

S, OB, AH

S, OB, AH

WEEK 1

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Physician A

Office

Office

Office

Office

Office

Full time

Physician B

Office

Office

Office

Office

Office

Full time

Physician C

Office

Office

Office

Office

Office

Part time (.5 FTE)

Physician D

HR, NH, HC,

HR, NH, HC,

HR, NH, HC,

HR, NH, HC,

HR, NH, HC,

HR, AH

HR, AH

Part time (.7 FTE)

S, OB, AH

S, OB, AH

S, OB, AH

S, OB, AH

S, OB, AH

Week 2 and beyond: Alternate schedules. During the weeks when the full-time physicians are responsible for performing outside services, one half-day will be spent doing rounds and the other half-day will be spent in the office. The part-time physicians will continue to work half-days whether they’re in the office or doing rounds.

Benefits

Professional. The benefits of a job-share arrangement like ours include continued professional growth and increased patient satisfaction. For example, most physicians who want a more manageable work schedule opt to limit their hours or scope, or both. But because our job-share model incorporates the full circle of care, part-time physicians continue to use the full range of their clinical skills (including obstetrics) and maintain their hospital privileges. Physicians who have let their hospital privileges lapse know too well how difficult they are to obtain again.

Patients benefit from increased access and continuity of care. In our model, physicians who job share don’t have to block out time on the office schedule to do rounds. Instead their job-share partner is delivering the baby or seeing the patient in the hospital and the office is kept open, giving patients greater access. Patient satisfaction increases because the wait for an office visit isn’t as long. And, should the patient be hospitalized or placed in a nursing home, they’ll still be seen by their physician or someone else in the practice, not a hospitalist or another physician they don’t know.

Personal. Another benefit of our model is the opportunity to structure a work schedule that balances one’s professional commitment to providing quality, comprehensive patient care with one’s personal priorities. Physicians who job share have more flexibility and better control over their schedules. For example, part-time physicians in a three-physician model could opt to compress their workweek into 2.5 days instead of spreading the hours over five days, except of course during weeks when they are scheduled for rounds and after-hours call. To that end, physicians entering into job-share arrangements should be up front with the others involved about the number of hours they are willing to work.

Drawbacks

Cross-coverage and communication can be particularly challenging in a job-share arrangement. Using a pager to keep in touch with the physician providing off-site care may simplify communication. Faxing standard forms with brief admission/discharge/transfer/procedure/change-of-status information between alternate care settings and the physician’s home or office may also enhance continuity. E-mail and personal digital assistants also facilitate communication about patient care.

Cross-coverage and communication also become more complex as more physicians are involved. When too many physicians are part of a job-share arrangement, it may actually inhibit continuity of care. The benefits of job sharing are greatest when three or four physicians are involved. When more than six physicians are in the mix, managing the job share becomes unwieldy and patients begin to get confused.

Another potential drawback is that some physicians are concerned about their skill levels diminishing if they work less than full time. This isn’t an issue with the job-share model presented here. Because physicians alternate between working in the office and in other care settings, they have ample opportunity to use a full range of clinical skills.

Finally, it’s very likely that physicians who job share will encounter patients who are reluctant to see anyone but their personal physicians. Some of these patients may eventually leave the practice. However, it’s more than likely this loss will by offset by other patients who want the convenience of increased access.

The bottom line

The fixed overhead costs for a typical family practice are enormous. According to the MGMA Cost Survey: 2001 Report Based on 2000 Data, the median overhead costs for a family practice equal approximately 56 percent of total medical revenue. Our job-share model can reduce these costs from 10 percent to as much as 40 percent depending on the number of physicians involved and the volume of outside services they deliver. Although services rendered by physicians working outside the office do involve some costs to the practice (e.g., billing support, transportation costs and malpractice insurance coverage), they are generally much lower than the direct overhead costs associated with an office-only practice.

Midlevel office visits generate relatively low reimbursement and may be among the most costly and labor-intensive service family physicians provide. At a minimum, such visits require office space and equipment, staff and a provider. In our model, since physicians are never in the office simultaneously, less office space and staff are needed. For example, in a two-physician job share arrangement (see Model 1 in "Job-share models"), support staff are needed only during the mornings when a physician is in the office. And even in larger job-share arrangements where the office is open all day, physicians who work in the office during the morning can share staff with physicians who work in the office during the afternoon.

In our experience, the job-share model generates more than 50 percent of the practice’s revenue away from the office, further enhancing the bottom line. For an example of how income in a job-share practice compares with that of an office-only practice, see the table below.

Coming full circle

Family physicians today are struggling to retain their identity, core values and financial viability. To a certain degree, providing a broad scope of services to patients of all ages still ensures us a bright future, but at what personal cost? For some physicians, providing the full circle of care independently has become too difficult. Job sharing is one way to provide comprehensive care while maintaining life balance. Physician benefits are numerous, including a competitive salary and the opportunity to maintain a wide range of clinical skills without working long hours. And patients still receive the continuity of care they’ve come to expect from our specialty. Through job sharing, family physicians can shape their careers without compromising themselves or their patients.

OFFICE-ONLY PRACTICE VS. JOB-SHARE MODEL

Low-productivity example

Office-only practice (w/ 1 FTE physician)

Job-share (w/ two part-time physicians)

Office visits

Hospital services

Deliveries

Surgery or surgery assists

Home care

Nursing home care

Weekly encounters

120

86.5

60

14

.5

1

1

10

Average reimbursement per visit*

$50

$77.46

$50

$100

$2,000

$200

$100

$100

Total revenue (based on 48-week year)

$288,000

$321,600

$144,000

$67,200

$48,000

$9,600

$4,800

$48,000

Fixed office overhead (%)*

60% or $172,800

47% or $151,200

Physician income (total revenue minus overhead)

$115,200

$170,400 ($85,200 per physician)

High-productivity example

Office-only practice (w/ 1 FTE physician)

Job-share (w/ two part-time physicians)

Office visits

Hospital services

Deliveries

Surgery or surgery assists

Home care

Nursing home care

Weekly encounters

160

131

90

21

1

2

2

15

Average reimbursement per visit*

$50

$81.68

$50

$100

$2,000

$200

$100

$100

Total revenue (based on 48-week year)

$384,000

$513,600

$216,000

$100,800

$96,000

$19,200

$9,600

$72,000

Fixed office overhead (%)*

60% or $230,400

40% or $205,400

Physician income (total revenue minus overhead)

$153,600

$308,200 ($154,100 per physician)

*Baed on authors' experience in private and academic practice.

NOTE: The difference between the low and high productivity numbers can be attributed to such factors as number of years in practice, individual practice styles and patient mix. Revenue and overhead numbers have been rounded to the nearest hundred.

Low-productivity example

Office-only practice (w/ 1 FTE physician)

Job-share (w/ two part-time physicians)

Office visits

Hospital services

Deliveries

Surgery or surgery assists

Home care

Nursing home care

Weekly encounters

120

86.5

60

14

.5

1

1

10

Average reimbursement per visit*

$50

$77.46

$50

$100

$2,000

$200

$100

$100

Total revenue (based on 48-week year)

$288,000

$321,600

$144,000

$67,200

$48,000

$9,600

$4,800

$48,000

Fixed office overhead (%)*

60% or $172,800

47% or $151,200

Physician income (total revenue minus overhead)

$115,200

$170,400 ($85,200 per physician)

High-productivity example

Office-only practice (w/ 1 FTE physician)

Job-share (w/ two part-time physicians)

Office visits

Hospital services

Deliveries

Surgery or surgery assists

Home care

Nursing home care

Weekly encounters

160

131

90

21

1

2

2

15

Average reimbursement per visit*

$50

$81.68

$50

$100

$2,000

$200

$100

$100

Total revenue (based on 48-week year)

$384,000

$513,600

$216,000

$100,800

$96,000

$19,200

$9,600

$72,000

Fixed office overhead (%)*

60% or $230,400

40% or $205,400

Physician income (total revenue minus overhead)

$153,600

$308,200 ($154,100 per physician)

*Baed on authors' experience in private and academic practice.

NOTE: The difference between the low and high productivity numbers can be attributed to such factors as number of years in practice, individual practice styles and patient mix. Revenue and overhead numbers have been rounded to the nearest hundred.

According to the first column in the tables above, a physician in a conventional solo practice might expect to make between $115,000 and $154,000 depending on his or her productivity. But as the other columns suggest, two part-time physicians (totaling one FTE physician) in a “circle-of-care” job-share practice might each make as much as $154,000 if productivity is high. The differences come from 1) the increased average income per encounter for services performed outside the office, and 2) decreased overhead. Note that the actual reduction in overhead costs is proportional to the volume of care provided outside the office. Larger job-share groups will generate an even higher volume of services outside the office, which will allow them to realize a better bottom line.

Dr. Worzniak is assistant clinical professor at the University of Michigan School of Medicine in Ann Arbor and program director of the family practice residency at Oakwood Hospital in Dearborn, Mich. Dr. Chadwell is assistant clinical professor at the Wayne State University School of Medicine in Detroit and associate director of the family practice residency at Oakwood Hospital.

Conflicts of interest: none reported.

Send comments to fpmedit@aafp.org.

 

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