The March 2003 issue of this column reported the findings of a survey on part-time work conducted by Genie G. Blough, M.B.A., and Shena J. Scott, M.B.A., and presented at the 2003 Conference on Practice Management in San Antonio, Texas. This article summarizes their conclusions on how to define part-time work systems below.

Just as every group is different, every system will be different also. There are common factors and a basic process that every group considering implementing a method of reducing some anesthesiologists’ hours might find helpful.

Factors for the Group to Consider
One critical factor to address early is the group governance structure. It is important to assess honestly how decisions are made and whether the physicians support group leaders (especially if an individual does not agree with a majority decision of the group). Dysfunctional groups will encounter difficulty with this process just as they do in other areas.

The group must take into account financial issues, shareholder rights and the individual’s responsibilities to his/her job and to the group. The structure of a part-time position needs to accommodate not only the individual but also the group. The group should realize that many people may ultimately request reduced schedules and therefore assess its long-term ability to provide similar opportunities to others while maintaining fairness to both the individuals and the group. The final litmus test will be whether the majority of the members feel that the arrangement is fair for all concerned. Remember, too, that viewpoints, including one’s own, inevitably change over time as will the needs of the group. Therefore, everyone should understand the need for fluidity and periodic reassessment.

Process
The first step is to understand fully the needs of the group. The best way to do this is to take a census to understand the motivating factors, goals and objectives of every individual as well as each individual member’s vision for the group as a whole. As part of their monograph for the conference, Blough and Scott provided a sample census form that is available for downloading from <www.asahq.org/Newsletters/2003/05_03/survey.pdf>. Taking the census provides a forum for all members to be heard equally rather than a few individuals intent on a single course overshadowing the opinions of the silent members.

After a census has been compiled and summarized, the group should meet to review the findings and discuss the implications. A facilitator can help to gather and synthesize data and to ensure that all parties have an equal opportunity to be heard. The facilitator should be an administrator or an outside consultant, i.e., someone without a personal stake in the outcome.

The group needs to define the parameters of its future system. For example, is the group willing and able to let somebody out of call entirely? If so, is there a limit to how many people the group feels it can accommodate doing this at one time? Should there be a limit on the duration of the part-time positions, or should there be at least a periodic assessment of individual circumstances? Is there a minimum number of work hours the group feels is necessary to be a contributing member and/or to maintain clinical skills? The group does not need to determine the details of these answers, but it does need to provide a conceptual framework for those who will be charged with this responsibility (e.g., the committee discussed below).

The group should understand the intangible costs and consider its willingness/ability to absorb them. For example, there is an administrative burden and cost associated with each individual employee that does not vary with hours worked. Additionally, underlying resentments can easily materialize when an overtired physician must stay later in order to release a part-time physician. For this reason alone, Blough and Scott insist that there must be a financial penalty associated with working part-time and not just a commensurate reduction in pay and benefits. Individual physicians requesting part-time status must understand the existence of this inherent penalty in order for the system to work.

In addition, the group should provide overall guidance (but not details) on issues such as finances and acceptable reasons for part-time positions. The group should be aware that establishing any position may set a precedent. If the plan will work as long as only one physician uses the part-time option, the group may inadvertently create a discrimination problem. Even if race, gender, age, etc., are not determining factors in denying a subsequent request, a disgruntled physician could easily argue that discrimination on these prohibited grounds was the reason for the denial. The problem may be minimized if the group addresses the allowable number of concurrent positions up front. The risk for all forms of potential discrimination should be examined by counsel.

The group should assess whether it can accommodate nonemergency needs that arise on short notice. It also needs to define the parameters of “part-time.” For example, how many calls/hours can a person sell before that anesthesiologist is considered part-time? At what point does a person cease to be an effective member of the group? If the mix of buyers and sellers is such that a person could conceivably sell all of his or her work time and still have a paycheck, should the group step in and prevent this? The group needs to consider not only the current impact of these decisions but also how they will change behavior and the resulting long-term impact on the practice.

Committee Tasks
Once the group has established parameters and identified objectives, it should select a committee to decide on the nuts and bolts of the system. Blough and Scott recommend that the makeup of the committee should include physicians at different life-points, ones who are widely respected among group members for their ability to set aside personal objectives in favor of the greater common good, along with the administrator or outside consultant.

Group members must understand that there are multiple solutions to every issue and should empower the committee to determine the best solution within the parameters the group has provided.

The committee has a number of issues to decide before reporting back to the group, including job limitations and responsibilities, financial terms and shareholder status and voting rights.

Define Job Limitations and Responsibilities

• Identify types of positions (e.g., noncall, set schedule, job-sharing, etc.)

• Set the number of each type to be allowed (may be in context of numbers or percentage of the total group size)

• Define allowable circumstances (e.g., parent of a young child, individual approaching retirement, etc.)

• Establish mechanism for approving requests

• Establish time limit or frequency of periodic review

• Establish minimum work hours or call hours as appropriate to the type of position

• Define notice period required for nonemergency situations

• Define other responsibilities for the group (e.g., hospital committees, etc.)

• Define re-entry requirements and process

Define Financial Terms

• Establish the “relative value” of each position type versus that of a full shareholder position. As Blough and Scott have emphasized, this number is not necessarily directly proportional as many physicians might think. Determining the relative value for each position is the most critical step in this part of the process. Once it has been done effectively, the rest of the steps should just be “filling in blanks.”

• Identify a reimbursement method for each position type (e.g., salary, percentage of shareholder income, etc.)

• Determine direct compensation

• Describe how benefits, including professional liability insurance, pension, health insurance, disability insurance, education fund and other benefits will be provided (plan documents may govern participation, but how benefits are paid for is a committee decision)

• Define whether they will be paid at a 100-percent level by the corporation, prorated or otherwise partially paid

• Determine if the number of work hours, longevity with group or other factors will influence above structure

• Define vacation structure, including priority weeks and selection process as well as number of weeks

• Establish protocols for holidays and surrounding dates

• Define part-time member’s responsibility to contribute to fixed costs, overhead and operating expenses

Decisions on each of these issues need to be quantified and added together to ensure that the value of the total package matches the relative value of a full shareholder package that the committee first identified, which clearly needs to comply with the guidelines provided by the group.

Define Shareholder Status and Voting Rights

• Define which part-time categories will retain shareholder status

• Determine whether or not part-time shareholders may hold office

• Define voting rights

• Decide which voting rights will be full, prorated or otherwise partial

• Specify limitations of voting rights for certain issues (For example, the decision to hire an additional physician may not impact part-time shareholders, financially or otherwise. On the other hand, once a decision is made to hire another physician, everyone is affected by the selection. Should participation in one or both of these decisions be limited?)

• Address years of service and minimum work hours as they pertain to retention of voting rights

• Determine any time limit to retain voting rights

The committee will assimilate all decisions into a detailed proposal and bring it to the group for discussion and final approval. The group’s job is to determine whether the plan falls within the originally specified parameters.

Conclusion
Cumbersome as this process might seem, addressing part-time work questions before an urgent situation materializes will be in the group’s best long-term interest. With the shortage of anesthesia providers, aging population of anesthesiologists, changing mix of medical school graduates and the younger generation’s different approach to work/life balance, it is not a question of whether a group will face these issues, it is a question of when. If all group members can remain flexible in their expectations and focused on the good of the group as well as individual needs, this process will most likely result in a mutually satisfactory outcome. Most importantly, group members should understand that whatever is decided in the current group culture will almost inevitably be different in 10 years.

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TEE: Yes, Medicare Will Pay

IMedicare implemented a new policy restricting payment for intraoperative transesophageal echocardiography (TEE) on April 1, 2003, only to announce a reversal on April 18. The April 18 announcement was a victory for ASA and the Society of Cardiovascular Anesthesiologists. Together, both societies worked hard to persuade Medicare that it should continue to allow anesthesiologists to report (and be paid for) diagnostic TEE services performed together with an anesthetic.

This change will be implemented on July 1, but it will be retroactive to April 1. Anesthesiologists with claims for Current Procedural Terminology™ codes 93312-93316 that have been denied inappropriately should plan to resubmit those claims after July 1. Practices also may choose to hold on to their TEE claims and submit them only after June.

Further information, and a copy of the Medicare letter informing ASA of the change, is available at <www.ASAhq.org>.

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