354 - Financial and Productivity Implications of the Transition to In-House Attendings in an Academic NICU

Publication Number: 354.4751

Lee Donohue, University of California Davis Children's Hospital, Sacramento, CA, United States; Satyan Lakshminrusimha, UC Davis, Sacramento, CA, United States; Janette Lee, University of California, Davis, School of Medicine, Sacramento, CA, United States

Background: Over the past 5 years, many NICUs have shifted to a staffing model where attendings take in-house night calls instead of at-home calls. The effects of this change on the clinical care of infants and the impact on trainees have been described. However, the productivity and financial implications of this change have not previously been explored.

Objective: We sought to examine the financial and productivity impact of transitioning to a 24/7 in-house attending model in a 49-bed level IV academic NICU.

Design/Methods: The division had 9 full-time neonatologists when the decision was made to transition to in-house nights in 2021. We collected CPT code frequency (critical care codes with higher work revenue value units (wRVUs) vs. intensive care codes with lower wRVUs), productivity data, financial data, and unit metrics for 2 years prior to and 3 years following the transition.

Results: The clinical FTE (cFTE) required to staff the NICU increased by 1.3 cFTE annually, necessitating the hiring of 2 additional physicians. The annual salary and benefits for these positions are estimated at $836,820, based on the median associate professor salary from recent Association of American Medical Colleges data. Recruitment costs add an additional $1,634,165.

There was a decrease in division wRVUs when we transitioned to an in-house attending model while the number of admissions and the average daily census remained steady (table 1). Notably, there was a shift in coding with fewer critical care codes and more intensive care codes billed, which explains this decline in wRVUs (figure 1). This RVU decrease, combined with the increased cFTE required, resulted in a significant decrease in wRVUs per cFTE (figure 1). The inflation-adjusted collections for the division decreased in a comparable manner to wRVUs leading to a loss of 1,002,988 in annual revenue (table 1).

The shift to in-house nights led to retirement or departure of 5 out of 9 faculty compared to 2 faculty who left in the 3.5 years prior to the transition. The cost to replace these additional 3 neonatologists was $2,451,621.

Conclusion(s): At a single institution, transitioning to an in-house neonatologist model added an annual cost of $1,839,808 (table 2) and led to a significant reduction in wRVUs. This shift in productivity was likely due to in-house attendings providing decisive care such as weaning respiratory support at night, which led to a decrease in critical care coding but positively impacted patient care. The expenses and morale impact of in-house night calls must be weighed alongside the clinical benefits to assess the model’s overall value.

Table 1
Change in productivity, revenue, and unit data between period before in-house neonatology attendings (2019-2021) and period after transition (2021-2024)

Figure 1
Impact of the transition to in-house neonatology attendings on clinical productivity

Table 2
Costs of transitioning to in-house neonatology attendings