Earning what you're worth

Even though last year's financial realities were tough on hospitals, hospitalist compensation has been staying strong.

In the fourth quarter of 2022, the median total compensation for U.S. hospitalist physicians was $353,002 per full-time equivalent, according to nationally representative payroll data from 1,563 hospitalist employers compiled by Kaufman Hall, a Chicago-based management consulting firm, and provided to ACP Hospitalist by request.

That figure is up by 6.2% from $332,387 in 2021 and by 7.5% from $328,461 in 2020. (View the company's Jan. 30 Physician Flash Report for more context.)

The cost of living has grown substantially too, but still, hospitalist salaries are increasing. “We can debate whether they're going up and keeping up with inflation in the last year,” said Matthew Bates, MPH, MS, a managing director with Kaufman Hall and the firm's physician enterprise service line lead. “But they're absolutely going up.”

There is significant variation in how much hospitalists are paid, though. “What we see nationally is those out West tend to command higher salaries—same tends to be true in the very Northeast as well,” said Erik Swanson, MPH, MS, a senior vice president with Kaufman Hall's data analytics practice. “Simply looking and saying, ‘Oh, I'm at the 50th or the 45th or the 65th [percentile]’ really will require more nuance to think about.”

To assess their compensation, hospitalists need to consider factors including number of shifts worked, hospital location, supply of clinicians, and demand for services, said experts, who also offered their advice on how to get the paycheck you deserve.

Knowing your worth

Such assessments should be made even before taking a hospitalist job, said Luci K. Leykum, MD, MBA, MSc, FACP, who is center lead for the Elizabeth Dole Center of Excellence for Veteran and Caregiver Research, chief clinical officer at Harbor Health, and an affiliate professor at Dell Medical School at the University of Texas at Austin. “They need to understand from the beginning: What are the measures by which they're being assessed? And what is their pay based on?” she said.

Given the difficulty of measuring each hospitalist's individual contribution, health systems often create incentives for hospitalist groups that emphasize quality and cost efficiency overall, Mr. Bates said. The four metrics he sees that are most commonly tied to incentives are length of stay, hospital-acquired conditions, readmissions, and migration of patients from higher- to lower-acuity beds.

Hospitalists should be clear on the details of the incentives at their hospitals, said Dr. Leykum. “People don't even realize the degree of nuance that they should consider,” she said. “If there's a productivity bonus, for example, and you want to have the opportunity to make more money, do you actually have the opportunity to pick up more shifts or to do the types of rotations or work that will allow for a productivity bonus to happen?”

Since the details can get unwieldy, Dr. Leykum recommended that hospitalists have an employment lawyer look over their contract before accepting a job offer. “They might pick up on things that either are concerning to them or just aren't spelled out very well that you might want to ask more questions about,” she said.

When weighing job offers, the most important information to know is the average compensation for local hospitalists, said Vladimir Dzhashi, MD, a hospitalist practicing in the Seattle area who writes a blog offering career and finance advice as the Locum Tenens Guy. “I think the best thing is to just know your worth and know what's the pay in the area,” he said.

Other hospitalists are often the best resource for that information, and they are usually more than willing to share, “maybe sometimes in incognito mode or semi-incognito,” he said. “A lot of doctors, or at least the administration, always tries to refer to things like Merritt Hawkins for stats on the salary. … But I would go in different Facebook groups where hospitalists are discussing these things and try to reach out to somebody who's local.”

When negotiating compensation in a job offer, there's not usually much wiggle room on the base salary, Dr. Dzhashi noted. “You won't be able to really get more than they typically pay,” he said. “One thing I noticed, though, is that the sign-on bonus is the thing that the hospitals are willing to budge on. … It's not going to make a huge difference long-term, but it can make a difference for your first year: $10,000, $15,000, or $20,000 would be a reasonable thing to ask.”

Mr. Bates agreed, adding that education reimbursement is also increasingly an area for negotiation. “Student loans are a pretty big hole these days, especially for new grads. If I have half a million dollars in student loans and if you'll help me pay those off, that can be an important part of that package,” he said. “It depends on the hospital type, but I've seen $50,000 all the way up to a couple hundred grand.”

Research has shown that women hospitalists are typically paid less, according to Dr. Leykum. “There's plenty of data that show that women physicians make about 70 cents on the dollar to male physicians,” she said. “Over the course of their careers, women physicians can make up to $2 million less than their male counterparts.”

One issue is that women are less likely to negotiate, and another part of the problem is that people respond differently to negotiation when it comes from a woman versus a man, said Dr. Leykum, who spoke up about her salary to her former employer and wrote about the ensuing legal ordeal in an Ideas and Opinions piece published on Feb. 3 (National Women Physicians Day) by Annals of Internal Medicine.

“As a female tenured professor and chief of by far the largest division in the Department of Medicine, with additional educational roles and a full-time research appointment in the Department of Veterans Affairs, I was told that I had few if any peers nationally against whom to benchmark my salary,” she wrote.

Dr. Leykum outlined ways to help make pay and work culture more equitable in her article. For example, she recommended using caution when determining salary inequities using benchmarks in academic medicine, such as those published in the annual Faculty Salary Report by the Association of American Medical Colleges.

Benchmarks obscure the large range of salaries and do not reflect the full extent of one's administrative and leadership responsibilities, efforts, or achievements, she noted. “There's such a regression towards the mean with the benchmarks so that the mean is often used as the cap,” Dr. Leykum said.

Moving on up

After taking a job, hospitalists should understand how their performance is assessed, Dr. Leykum advised. “People should be thinking about ‘How am I doing? Am I meeting expectations?’ and meet with their supervisors at least annually, so that they know where they stand,” she said.

Strategies for getting your performance rewarded with more money depend on whether you want to stay with your current employer or take an opportunity somewhere else, said Dr. Dzhashi.

“If it's really a big, frustrating moment for them, then they can definitely look at a different job, different location,” he said. “There's definitely more opportunities that may pay better, so you just have to explore other opportunities—as long as they're willing to move to new areas to really make the switch.”

If your current employer isn't paying you what you think you're worth, moving to another employer is the most efficient way to get a raise, Dr. Dzhashi said. “Especially if you're working for a bigger employer or a large or even midsize hospital system, those decisions about the pay raise, they're not individualized, so these decisions are made for the whole group,” he said. “You cannot just say, ‘Hey, I want the raise’ and everybody else not get the raise; usually those are collective decisions.”

For hospitalists who'd rather stay put, Dr. Dzhashi's advice is to investigate work relative value units (RVUs), which most hospitals offer in addition to a base salary. “Based on my personal experience and talking to other hospitalists, we actually underbill a lot of times, and as long as your employer is actually paying you based on RVUs, partially or completely, I think this is where there's a lot of money left behind,” he said.

For example, a hospitalist working in an open ICU can bill for critical care time, an advanced care discussion, or extended care, Dr. Dzhashi noted. “There's a lot of different billing codes that you can use, and just by increasing your RVUs, your overall pay tends to go up significantly as well,” he said. “Depending on your salary structure, this could be a trivial difference (trivial being like a few thousand per year), but it can be as much as $20,000 extra per year.”

Correctly capturing and documenting comorbidities in the medical chart can justify a higher reimbursement, which benefits the hospital and better reflects the hospitalist's work, Mr. Bates added. “Making sure that gets documented so it can get coded so you get paid more is a win-win all the way around,” he said.

Billing optimization isn't typically part of medical training, so Dr. Dzhashi recommended signing up online for an extensive training course. (ACP recently launched a new subscription series of self-guided coding education, Coding for Clinicians, that includes 13 interactive modules eligible for CME/MOC, as well as video recordings of ACP physician coding lectures and webinars.) “I got multiple trainings, but honestly, it took me almost 10 years to really get up to speed with some of those things,” he said, adding that talking to a member of your hospitalist group who is more productive with billing can also help.

Taking on more patients could also be an option, although in a poll in the Aug. 10, 2022, ACP Hospitalist, two-thirds of readers said their ideal maximum patient load was between 12 and 16 patients. “If you're willing to see more patients, of course, that's another opportunity for you to be more productive … but I think 15 is the ideal census for adult hospitalists,” said Dr. Dzhashi.

Switching to nights is another way to get a significant pay bump. “In the Northwest and West Coast, some hospitals, you work seven days on and you have 14 days off, and you have the same salary as the daytime hospitalists,” Dr. Dzhashi said. “You can essentially make more per hour, so to speak, and then you have more time off to maybe work extra.”

While taking on new roles or hours can bring in more money, experts also recommend considering the risk of burnout. “Let's say somebody took on a new role so that they were now a medical student mentor, for example, and that role came with a certain amount of money,” said Dr. Leykum. “Would you rather have the time, or would you rather have the money? And the decision you make today doesn't have to be your decision forever, because people's lives change.”

Even if it's intimidating, a candid talk with your division chief can help you make the best money moves for both your current situation and beyond, Dr. Leykum said. When she was an academic hospital medicine division chief, a few faculty members left to take more lucrative positions in the community.

“There was no way that they could make that kind of money working with us, and we said, ‘We wish you well, and stay in touch.’ One or two of them ended up coming back sometime later when they were at a different stage of their life,” she said.

Dr. Leykum said she appreciated that these hospitalists had explained their need to earn more. “I always felt like one of my jobs as division chief was helping people meet their goals,” she said. “I can't do that if I don't know what their goals are.”