On-site care slashed, but doctors' pay jumps

By CLARK KAUFFMAN

A policy change at the state-run Iowa Veterans Home has eliminated some of the overnight staffing by doctors while adding tens of thousands of dollars to the pay of a few physicians.

The medical director at the Marshalltown home, Dr. Melissa Bruhl, has eliminated the use of contracted "relief physicians" who for years provided on-site patient care overnight and on weekends at Iowa’s largest nursing home.

Bruhl has arranged for the facility’s four salaried physicians – including herself – to collect extra, hourly pay by covering those shifts on an on-call basis. The doctors can choose to cover the on-call shifts from home, at a rate of $29.75 an hour, or they can work on site for twice that rate. At the same time, the doctors continue to collect their regular salaries by working on site during the day, Monday through Friday.

The policy change has left residents concerned about the timeliness of the care they receive. It also has created some eye-popping numbers in state payroll records.

Bruhl, for example, was paid for every daytime and nighttime shift over six consecutive days in August, which means she was paid for working 144 hours, virtually nonstop. At the end of the first quarter, she was on track to earn $319,000 this fiscal year – a 30 percent increase over last year’s pay.

"We’re concerned about what might happen," said Mike Croskey, a long-time resident of the home. "If we need a doctor, all they can do is call 911 and get us to the hospital."

"It’s a real concern," said Marty Lieberman, a member of the home’s resident council. "If we don’t have a physician on the grounds, and one of our residents should have a seizure or heart attack and needs to be administered an injection or whatever, how are they going to get that done?"

Residents of the home have been circulating a petition calling for the administration to reinstate 24-hour, on-site physician coverage.

In the meantime, the staff physicians continue to collect a salary from the state for their daytime work, plus hourly wages for any night and weekends when they’re on call – including when they are asleep at home.

Does change add risk or consistency to care?

The Iowa Veterans Home is the only nursing home in Iowa – and one of only a few veterans homes nationally – that has a team of full-time physicians on the payroll.

Bruhl says the increased workload hasn’t created any problems for the home’s staff physicians. She says none of the doctors has ever had to forgo a regular weekday shift in the home’s clinic because of the overnight coverage they now provide.

"I don’t believe any of us have had any issues with our schedules," she said. "In general, you know, compared to private practice, it would be very similar as far as the number of hours that we’re putting in. At the Veterans Home, it is a less acute level of care, obviously, because we’re a nursing home. So the nursing-home level of care versus working in an ER five nights in a row is potentially a different situation."

She said that by replacing the contracted physicians who only worked nights and weekends, the home has reduced communication problems with nurses and pharmacists and brought greater consistency to each veteran’s care.

Dennis Mack, the home’s director of employee services, agrees.

"If a nurse calls at 2 in the morning about a resident, well, our own docs know that resident – as compared to somebody out of Des Moines," he said. "And it makes a difference in the quality of the care."

But residents of the home question that. They say most of the 700 residents have one regular physician, which means that on any given night there’s only a one-in-four chance their doctor will be working the overnight shift.

Historically, the home has a good record of providing quality care – though lately there have been problems. In December, the federal government awarded the home a two-star ranking out of a possible five stars. The poor rating appears to be the result of problems uncovered by state inspectors over the past 18 months.

During that time, inspectors have fined the Veterans Home $14,000 for alleged violations related to medical errors, failure to respect residents’ right of privacy, failure to provide adequate infection control and other problems.

The home’s top administrator, Commandant Dan Steen, said the home provides top-quality care, and the staffing changes have only enhanced the effort.

"We are using our physicians who know their patients and, you know, we’re not bringing somebody up who doesn’t know one of the patients and doesn’t know the history of that patient," he said. "We’re providing a level of service that you won’t see in a long-term care facility anywhere."

Croskey and other veterans at the home agree they’re getting first-rate care, but they argue that the reduction in on-site physician coverage is a step backward.

Higher-than-average pay doesn’t cut costs

Although it’s not unusual for some health care providers to pay doctors for their off-site, on-call hours, the pay at the Iowa Veterans Home is relatively generous, and the requirements imposed on the doctors are less onerous.

Most health care providers that pay doctors for on-call coverage require those doctors to be within 30 minutes of the facility in case they’re needed on site. The four Iowa Veterans Home doctors who are collecting on-call pay live 50 to 65 minutes away from the facility, in Ames, Ankeny, Des Moines and Runnells.

Bruhl says that’s not a problem since residents can be taken to a nearby hospital if physician treatment is urgently needed.

"Whether I’m sitting in my office or I’m 45 minutes away, it’s my responsibility for that patient to get the care that they need," she said. "In any situation where it would be so urgent that a doctor needed to be there, we would function just like any other nursing home in that EMS would be called."

According to a 2008 national report on physicians’ on-call pay, only 24 percent of care providers pay non-specialist staff physicians any extra compensation for being on-call while remaining off-site. Among those that do pay for such a service, the national median pay is $17.71 per hour significantly less than the $29.75 per hour paid by the Iowa Veterans Home.

In a memo announcing the staffing change last June, Bruhl told the medical staff she regretted having to make the changes but major budgetary issues left her with no choice.

She wrote: "This was a very difficult decision. … This was unavoidable and deemed necessary in order to meet the constraints of our new fiscal year budget."

But the staffing change has not generated any savings at the home. In fact, the home budgeted more this year for overnight-and-weekend coverage than it did the previous year. Financially, the biggest effect of the policy change is that the money is now being paid to a different set of physicians.

Bruhl said she didn’t realize the full impact of the policy change on her salary until it was pointed out by a reporter.

"My rate of pay is the same as anybody else’s," she said. "As the medical director, I tend to cover when somebody’s not available because that’s my responsibility as their supervisor – so some of that falls in my hands inadvertently just by way of the position I’m in."

She said there could be some savings realized by the staff physicians working more of their on-call shifts from home, at $29.75 an hour, rather than on site, at $59.50 an hour. But, she said, it’s up to each doctor as to how he or she wants to work those shifts.

Steen, the home’s administrator, said the quality of care remains second to none.

"I know I have comrades or peers around the country that envy us because not only do we have the four physicians, you know, we have a full-time psychiatrist and four psychologists," he said.

"We have a drug-and-alcohol therapist here. The things that Iowa veterans have here, the state of Iowa has made a commitment to them. And even with the upcoming budget problems, we’re trying to make that commitment stand. We think it’s important that our budget not affect the quality of care."