| When a Doctor Wants to Work Part TimePractice |
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| Medical Practice Management Articles | |
Consider the following scenarios: If your group hasn't yet bumped up against physicians petitioning to work part time, it will soon. With women now comprising nearly 50 percent of medical students, many young physicians are entering practice expecting that they'll work part time to raise families at some point in their careers. And Gen-Xers of both genders have made it clear that maintaining balance in life—coaching Little League and eating dinner with the family, for example—ranks far above achieving partnership. Doctors in their autumn years are also expressing the desire to work at a less frenzied pace. And some simply need to keep working at least part time past typical retirement age to recoup stock market losses or to put late-in-life children through college. The challenges of meeting such work schedules are not inconsiderable, however. Doctors working half time struggle to generate enough revenue to offset their portion of the group's fixed overhead expenses. And prorating call based on the number of hours a part-timer works usually leaves the rest of the doctors grumbling about taking more than their fair share. Yet part-timers can also be a valuable asset to a group. In one six-physician neurology practice, the doctor moving into semiretirement happily took all the patients requiring high management, spending over an hour with each one. "This doctor was beloved by the group, patients felt well taken care of, and he allowed the younger doctors to be much more productive and see a greater number of patients," says Jayne Oliva, principal of The Croes-Oliva Group in Burlington, MA. "The other physicians had no trouble sharing some of their revenue with him—he was paid quite nicely—and they wanted the arrangement to last as long as possible." Part-time doctors can also help groups increase their capacity and extend their office hours. And they might be the perfect answer for groups that don't have the patient volume to support a full-time physician, such as the dermatologists who gratefully recruited a part-time Mohs surgeon. What to do about call Perhaps the most difficult issue groups confront with part-time physicians is figuring out how to divide the call schedule. One equitable solution is for the group to place a monetary value on call and then either deduct that amount from the income of part-timers who don't take it or increase the compensation of those willing to accept more. "But," warns Geoffrey T. Anders, president of The Health Care Group in Plymouth Meeting, PA, "if you permit the buying and selling of call, you need a policy on how much an individual can take." Otherwise, physicians who want larger paychecks may take on too much call and become overworked, jeopardizing patient safety. Another approach, in lieu of the buy-and-sell strategy, is to excuse part-timers from a full call schedule but require them to take call on nights when no one else wants it. Doctors moving into semiretirement often receive special dispensation to drop call without financial penalty, however. "Older doctors have invested a considerable amount of themselves in the practice, so when it's time to pass the torch, younger doctors may have to assume some burdens, such as taking the senior doctor's share of call," says Lawrence Vernaglia, a partner with the law firm Foley & Lardner in Boston. "Relieving him of call responsibilities can be viewed as part of the transition." It's generally easier for a large, single-specialty group to exempt part-timers from call than it is for a multispecialty group that may have some departments with as few as two doctors. One large multispecialty group decided that no more than 5 percent of its shareholders at one time would be eligible for "shareholder emeritus" status—a part-time position reserved for doctors who were at least 60-years-old with 25 years of service, or 65 with at least 20 years with the group. The semiretired doctor was expected to take full call unless his department came to a unanimous agreement to exempt him. "Rather than have a clinic-wide policy, the decision was left to each department's physicians because they had to live with the arrangement," says Jon-David Deeson, senior manager of Pershing Yoakley & Associates, a consulting firm in Knoxville, TN. The other big problem: overhead When two part-time doctors evenly divide their time and space at work, it's a fairly simple matter to split the fixed overhead costs of one full-time physician between them. But in the absence of a true job-share, groups have little choice but to charge the part-time doctor with a full share of fixed expenses. "If a family practice group has an overhead of 65 percent, the practice may decide to pay the part-timer between 30 and 35 percent of his collections, depending on how much profit it wants to make on the physician," says Anders, who advocates paying a doctor moving into retirement more generously than a young part-time physician. Oliva recommends another formula to allocate overhead to salaried part-timers: Charge them a full share of fixed expenses; a proportional share of variable expenses based on productivity; direct expenses; and a predetermined dollar amount to compensate full-time doctors for managing the part-time doctor's patients when necessary. Part-time doctors should be employees Allowing a semiretired physician to continue making strategic decisions about the direction of the group understandably makes younger owners nervous. Will he be willing to take a long-term view and agree to invest the group's assets in new technology or another office building when he won't be around to reap the benefits? Yet for a group that depends on a senior doctor's insight and hard-earned business acumen, stripping him of his governance may be short-sighted. Geoff Anders' solution: Fix the amount of the senior doctor's buyout as soon as he announces he'd like to work less. "Although the doctor will get his buyout when he fully retires, he no longer worries that his dollars are at risk, so he can retain his voting rights and continue making good decisions for the practice," says Anders. The multispecialty group that created the category of shareholder emeritus for its senior doctors decided that a semiretired physician could retain two privileges of partnership: a share of the group's overall profits and voting rights for a maximum of two years. In all other respects, semiretired physicians became employees and were paid an hourly rate or a salary at the group's discretion. "It's much cleaner for the group to make semiretired doctors employees," agrees Jayne Oliva. And even though younger doctors step off the partnership track while they're working part time, some practice management consultants see no problem with junior physicians earning credits toward partnership based on the hours they do work. Others, like Max Reiboldt, draw a harder line and say that until part-time doctors take full call, contribute an equal share to the group's fixed costs, or generate significant revenue from ancillary services, the clock to partnership shouldn't start running. How long should part-time arrangements last? Only as long as they make economic sense for the group. Group leaders should reserve the right to review unconventional work arrangements annually and to require doctors to submit plans to work part time at least six months in advance. How to manage part-timers' patients When consultant Oliva walked into one group of 12 MDs, she was immediately drawn to a large bulletin board papered over with pink "While You Were Out" telephone messages, some days old, for the part-time doctors. "No one was managing their patient requests," she says incredulously, "and some, like prescription renewals, could have been taken care of by staff." Oliva recommends that staffers brief patients and referring physicians on part-time doctors' schedules when they call, so no one's annoyed or surprised at the delay in getting a return phone call. Groups should also prepare protocols to guide employees on whether the phone call can wait until the doctor returns to the office or whether another physician in the practice should follow up. (For plenty of tips on triaging phone calls, see "Can your staff answer the call?" in our Feb. 2 issue.) To manage a part-time doctor's patients, a group can either hire a nurse practitioner or physician assistant to see some of them, or gradually shift them to another physician. When the part-timer's patients call for appointments, Oliva suggests that staffers say, "Dr. Smith's first opening is in three months, but I'm sure he wouldn't want you to wait that long. I can give you an appointment with Dr. Jones, whom Dr. Smith trusts completely, in two weeks." While groups should be open to doctors' desires to work part time, the financial health of the group always comes first. "You can't do too many favors for the part-time or semiretired physician or you'll hurt the core group, which is the practice's legacy," says Reiboldt. "When negotiating these arrangements, you have to reserve most of the rights and leverage for the partners of the group, not the individuals you're trying to accommodate." Developing a policy for part-timers After saying Yes a few times to doctors' requests to work part time—and then struggling with the logistics of the decision—groups usually decide they need a policy regarding reduced schedules. "A policy not only removes the emotional aspect of the decision, it makes clear the group's expectations when recruiting new doctors, and guides midcareer doctors in planning their own retirements," says Lawrence Vernaglia, a partner with the law firm Foley & Lardner in Boston. A semiretirement policy should include at what age or after how many years of service a doctor can reduce his hours, how his shareholder rights will be affected, and how much notice he has to provide. Similarly, a policy for younger physicians may spell out under what circumstances the doctor can reduce his or her hours. Details such as how many hours the doctor will work and how much he will be compensated shouldn't be part of a policy but, rather, negotiated on a case-by-case basis. "A policy doesn't guarantee that everyone is treated equally," explains Geoffrey T. Anders, president of The Health Care Group in Plymouth Meeting, PA. "It provides a framework for what is supposed to happen, but as long as everyone is agreeable, exceptions can be made for specific individuals." When shareholders craft the policies, they should consider enlisting the help of an ad hoc, handpicked committee that comprises a cross-section of the group—women, younger doctors, and senior doctors. "You're asking for trouble if policies for part-timers reflect only the views of the senior doctors," warns Jon-David Deeson, senior manager of Pershing Yoakley & Associates, a consulting firm in Knoxville, TN. By Anita J. Slomski Medical Economics |
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