#442 - [Journal Club] - 📌 Does 24 hour in house staffing decrease physician productivity metrics?

Is your NICU considering the shift to 24 hour in house attending coverage? In this episode of Journal Club, we explore a provocative brief communication from the Journal of Perinatology. Ben and Daphna discuss the impact of moving from home call to on site presence at UC Davis. While the change was intended to improve patient care, the data reveals a surprising 15 percent decrease in work RVUs. We examine how proactive weaning and bedside presence might actually lower billing levels under current CPT codes. Are we being penalized for doing the right thing for our patients?

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From on-call to on-site: the impact of 24-hour in-house neonatology on billing patterns and physician productivity. Donohue L, Lakshminrusimha S.J Perinatol. 2026 Feb;46(2):289-292. doi: 10.1038/s41372-025-02530-8. Epub 2026 Jan 5.PMID: 41490931 Free PMC article. No abstract available.

Transcript

Ben Courchia (00:00.638) Hello everybody, welcome back to the Incubator Podcast. We're back today for another episode of Journal Club, Daphna.

Ben Courchia (00:10.114) Good morning. How are you?

Daphna Yasova Barbeau (00:10.114) I'm doing really well. I'm going to take a break from neurologic papers. I feel like every time a paper like this comes out, we have to cover it. I think people are talking about staffing, staffing models, compensation, and reimbursement.

Daphna Yasova Barbeau (00:37.07) This is coming from the Journal of Perinatology. It's a brief communication entitled, "From On-Call to On-Site: The Impact of 24-Hour In-House Neonatology on Billing Patterns and Physician Productivity". No surprise, this is by Lee Donahue and Satyan Lakshminarusimha.

Daphna Yasova Barbeau (00:37.07) Every time this topic comes up, everybody wants to hear about it. I want to tell people that we had two great interviews at Cool Topics just last month. Episode number 423 with Dr. Lakshminarusimha, "Should Neonatology Break Free from Pediatrics?". And number 427 with Dr. Steinhorn, "Are neonatologists being fairly compensated for the work they do?". To further round out the discussion, people should take a look at those.

Daphna Yasova Barbeau (00:37.07) What is the point of this paper? Attending coverage in many NICUs has shifted from a model where attending physicians do their rounds and dedicate the rest of the day to academic activities, taking night calls from home, to a newer model where attendings are present in the NICU 24/7. This change has been driven by factors including increased patient acuity, reduced availability of residents, decreased NICU exposure during medical training, and some state mandates.

Daphna Yasova Barbeau (00:37.07) They wanted to look at the CPT codes that were used, the work RVUs that were generated, and the billing practices. Their thought was that when the attending is in-house at night for admissions occurring before midnight, the initial care code is billed on the day of admission and a subsequent care code is billed on the following day. They had a hypothesis that there would be a slight increase in WRVUs generated with the shift to 24-hour in-house neonatologists to compensate for needing these in-house people.

Daphna Yasova Barbeau (00:37.07) They collected divisional work-related RVUs, collections, CPT code frequency, average daily census, number of admissions, average length of stay, number of deliveries, case mix index, and days of intubated assisted ventilation for two years prior to and three years following the 2021 transition to 24-hour in-house attendings. This is a 49-bed unit at UC Davis. They follow the CARTs model at their institution.

Daphna Yasova Barbeau (03:01.422) CART stands for Clinical, Administrative, Research, Teaching, and Service. The way that works, it assigns specific FTE time to various requirements of an academic neonatologist to determine what portion of the individual's full-time equivalent is considered their clinical FTE, or CFTE. They basically give credit to these other requirements that take up people's time.

Daphna Yasova Barbeau (03:01.422) When attending physicians took calls from home, the night on-call hours received 0.25 credits. The two physicians on service covered alternate night calls. When attending physicians stayed in the hospital, night calls received an additional 12.5% credit compared to day shifts. This was suggested by experts for "hazard compensation". These are the methods used to calculate the additional clinical FTEs required when transitioning to in-house.

Ben Courchia (04:19.902) Can we talk about that for a second? We don't get hazard pay in medicine. In any other job in the world, if you are asked to work nights, weekends, and holidays, you get hazard pay, but in medicine it is baked in. You just do this.

Daphna Yasova Barbeau (04:29.592) For sure, you get paid more elsewhere. Everybody has to do it here.

Ben Courchia (04:39.966) It's crazy because many people, you and I included, would agree to be paid less to do fewer nights and weekends. There are some people who would be very interested in getting paid more just to do nights and weekends.

Daphna Yasova Barbeau (04:54.882) Actually, I think it would help a lot of teams where there is a distribution of people who want one more than the other, or maybe you can incentivize people to do some of these off-shifts.

Ben Courchia (05:09.606) And you don't even have to make a permanent decision. You shift in your practice. If you're single and you need to repay loans, you work the shifts that pay you the most. Then you get married and have a family, and you say, "I'm going to start backing off and do more daytime shifts," even if I get paid a bit less. That is not even a decision that we can make. Anyway, we should still not call it the "graveyard shift" because it's not a good term.

Ben Courchia (05:37.81) Let's not take that from the real world.

Daphna Yasova Barbeau (05:41.272) So that was their setup, but I think even this CARTs model is a new term for a lot of institutions where we're giving people credit for work that they do that impacts the clinical work we all do. The clinical FTE required to cover the NICU increased from 6.24 to 7.67 with the transition to an in-house staffing model.

Daphna Yasova Barbeau (05:41.272) This required hiring two additional neonatologists, which makes sense because people are now sleeping in the hospital. I actually thought it would be more potentially. There was a 15% decrease in division work RVUs, while the number of admissions and the average daily census were relatively unchanged.

Daphna Yasova Barbeau (05:41.272) So there was an increase in clinical FTE needed and a decrease in work RVUs. Systems rely on work RVUs divided by clinical FTE, and the decrease in WRVUs led to a decrease in collections. The numerator went down and the denominator went up, making it less for everybody.

Daphna Yasova Barbeau (05:41.272) A closer examination of billing patterns revealed an increase in subsequent intensive care codes and a decrease in subsequent critical care codes between the two eras. The number of initial critical care codes also decreased, and initial intensive care codes increased, but the difference was not statistically significant. Why did the billing change? Why were the subsequent codes not also critical care? Their point is that possibly, now that you have this in-house attending, they are moving babies forward.

Ben Courchia (07:45.608) That is super interesting.

Daphna Yasova Barbeau (07:57.987) They are weaning respiratory support and trialing babies off support, and they were doing a good job. They were moving these babies from critical care to intensive care even by the subsequent days, which is not good for these equations, but it is very good for babies and families. We are doing a good job.

Ben Courchia (08:16.63) But that's their whole point. Better care is going to come with less pay, basically. I think this is the key not to miss. You could read the paper quickly and think they are advocating for leaving these babies alone overnight so we can bill more. That is really not what they are saying.

Daphna Yasova Barbeau (08:36.47) No, they are saying we should be compensated for the work we are doing overnight.

Ben Courchia (08:39.644) Yeah, because the problem is that you are going to wean the ventilator a little bit overnight and then suddenly the code is going to be different in the morning. But where do you capture this? The coding system is not designed to capture these interventions that are happening overnight. Then suddenly you bill less during the day, you have fewer collections, and then people say our staffing needs to change in the wrong direction when in truth it should go the opposite.

Daphna Yasova Barbeau (09:02.338) This system of CPT and RVUs just does not take into account the efficacy of the work you're doing. Otherwise, the unit metrics were relatively unchanged over the study period. I'll remind people that the study period was two years before 2021 to three years following. Notably, our practice in the NICU has not changed significantly during that time.

Daphna Yasova Barbeau (09:02.338) The number of admissions and average daily census remained stable. The case mix index increased, but this was not statistically significant. The days of intubated assisted ventilation were also unchanged. There were some staffing changes, but the median number of years out of fellowship was unchanged. The physicians had similar experience levels, so not much otherwise in the unit had changed because of the staffing changes.

Daphna Yasova Barbeau (10:26.754) Contrary to their hypothesis, the total divisional work RVUs decreased with in-house attending physicians. During this period, the number of subsequent critical care codes decreased while subsequent intensive care codes increased. This shift in billing resulted in an associated decrease in collections.

Daphna Yasova Barbeau (10:26.754) The decline in WRVUs despite a stable workload suggests that current RVU-based metrics undervalue physician effort in the in-house model. As institutions consider 24-hour staffing, it is important to account for these nuances in productivity metrics and finances when developing compensation models and staffing plans.

Ben Courchia (11:12.584) The business in general is very fortunate to have a body of neonatologists who are truly caring individuals. Can you imagine if neonatologists started saying, "I'm not getting paid for this, so I'm not going to try to wean the ventilator"?. I can confidently say on behalf of most neonatologists around the world, nobody will ever say that. All of us will go and do the right thing.

Ben Courchia (11:42.514) But can you imagine if that started happening? I am sure it is happening elsewhere. I think our adult colleagues are being stressed a lot more than pediatricians. We have the gratification of working with families and small children, which keeps you feeling.

Ben Courchia (11:42.514) I think our innate nature and the fact that we're dealing with a baby makes it so we will never not go. But there are some adult units where it is very busy and stressful. Physicians don't get recognition and are asked to do more faster and faster. At some point, they look around and say, "I'm not doing this". It's probably even more prevalent in adult medicine. Patients want to talk to their physician and spend ten more minutes, and the healthcare systems and insurance do not let them.

Daphna Yasova Barbeau (13:04.525) My take-home points were that we missed an opportunity probably two to three decades ago to adjust for the acuity and population change in the NICU. The acuity was already wildly increased before the study era. Nobody ever adjusted for that in neonatology, unlike other areas of medicine where the population is not changing so drastically.

Daphna Yasova Barbeau (13:04.525) The other thing that made me think is critical care codes. You can have a feeder-grower on CPAP plus five or six, and that's basically the same daily code as an intubated 22-weeker on inotropes. They are vastly different patients.

Ben Courchia (14:06.546) That's exactly right. A lot of the model is inherited from the past, but babies have gotten dramatically more complicated and diversified. Coding systems do not capture that intricacy or the complexity of the patients.

Daphna Yasova Barbeau (14:33.199) And the number of patients, right? In adult medicine or the PICU, this downgraded patient might have just been on a different unit or the floor. My last take-home point is that what can't be extracted from these numbers is the good work being done. People in-house checking on patients might prevent a catastrophic diagnosis at midnight instead of 8:00 AM.

Ben Courchia (15:02.588) For sure, and we don't want that to stop.

Daphna Yasova Barbeau (15:27.001) All right, more to think about.

Ben Courchia (15:29.306) More to think about for sure. All right, buddy, I'll see you tomorrow.

Daphna Yasova Barbeau (15:33.359)

Sounds good.