The Laborist: A Flexible Concept

Debra Gussman, MD FACOG MBA
William Mann MD FACOG MBA
 

Dept. Obstetrics and Gynecology
Jersey Shore University Medical Center
1945 Route 33, Neptune, NJ 07754

Corresponding author:  Dr. Gussman
Dept. Obstetrics and Gynecology
Jersey Shore University Medical Center
1945 Route 33, Neptune, NJ 07754 

email: dgussman@meridianhealth.com
phone:  732 776 3790
fax:  732 776 4525

As the successful implementation of hospitalists and intensivists has become progressively accepted, the idea of having a physician provide on site coverage of labor and delivery for emergent and non-emergent care has become a topic of frequent discussion at professional meetings, departmental sessions and in conversations among practicing obstetricians and gynecologists.  Weinstein has published a brief and thoughtful discussion of this, and popularized the concept of “the laborist,” a physician whose “sole focus of practice is managing the patient in labor.1

The laborist model offers the theoretical advantages of freeing the practicing OBGYN, with an office full of patients, from having office hours disrupted by a patient arriving on the labor suite; of markedly reducing on-call requirements, and improving family and personal life style; of improving patient care, as well as nursing satisfaction, by having a doctor always available to see patients in the labor and delivery suite, and of freeing the nurses from the need to find someone to answer their questions and needs; and of improving the quality of medical care, and reducing medical legal risk.  These potential benefits, by preventing physician “burn out,’ have been viewed as a possible part of the solution to diminishing numbers of medical students entering OBGYN, to obstetricians giving up obstetrics at progressively earlier points in their career, and to some communities facing a shortage of obstetricians.

Objections to the laborist model point out that there is a hand off from the office physician to the laborist which may introduce error, that this model will lead to their being office based OBGYN’s whose clinical obstetrical skills will diminish, that hospitals with small obstetrical volumes cannot afford such a model, and most importantly, that patients will not accept being delivered by a physician whom they have not met and established rapport with during their prenatal care.  Petrikovsky has pointed out that a laborist model has existed in Europe, and his perception is that patients do not receive the same individual care and rapport with their doctors as the current U.S.system offers.2

No data has yet been accumulated to address either the theoretical advantages or flaws to the laborist model.  Despite this, various hospitals have introduced variations of the laborist models.  This paper will discuss our experience with a laborist model, as well as variants we have reviewed.

The Laborist Model:  A fully trained obstetrician will be physically available 24 hours a day, on labor and delivery, with no assigned tasks or responsibilities elsewhere, to manage all patients who present to labor and delivery.

Implementation Process:  There is no need to require that all physicians participate in a laborist model at any given hospital.  Those doctors who wish to always cover their own patients can easily be accommodated.  Similarly, physicians can opt for coverage by the laborist at specific times, while opting out at others.  Depending on how the model is funded, there will need to be accommodations made for non-participating or occasionally participating physicians.  This model is asking obstetricians to make an enormous cultural change:  over and over in discussions with practicing obstetricians, one hears, “The laborist model sounds like a great idea, but my patients only want me and would never accept this plan.”  An obstetrician must have sufficient insight to recognize other obstetricians can deliver the same high quality care to his/her patients, and that it appears these same patients, who will change obstetricians when their husbands change insurance coverage, will accept these covering doctors if the system is presented to them in a positive manner emphasizing patient safety and doctor availability.  This requires education, discussion and meticulous attention to model presentation, with voluntary participation and maximum flexibility.

It must also be recognized that a laborist cannot be expected to manage a patient in a manner which is contrary to his/her perception as to best available clinical pathway.  Therefore, before implementing a laborist model, consensus has to be reached on various clinical approaches, i.e. indications for induction, management of pre-eclampsia, type of tubal sterilization to be used, pre- and post-partum order sets, etc.  This process can be rancorous. While standardization of pitocin infusions, insulin drips, and magnesium sulfate is necessary, suture materials, type of closure, and the like may be left to the personal discretion of the laborist.  Use of computer physician order entry, or printed standardized order sets, facilitates this process.  This standardization will also assist with QA reviews, and risk management. There must also be a standardization of the antepartum record to facilitate communication and avoid errors of omission.

Variations of the Model: 

TH Model:  Several aspects of the laborist model have in fact been in place in hospitals for many years, particularly in teaching hospitals.  Private attendings have always stepped in if they were present in the delivery suite and an emergency arose, or a patient began to deliver when her own physician was unavailable.  The problem was that one could not guarantee that a physician would always be present on labor and delivery.  But, as required by the ACGME, and the RRC committees, all resident activities in labor and delivery must be supervised by an attending physician who is physically present, so in fact in teaching hospitals, there is a guarantee of a physician presence.  In many hospitals, these faculty members are also expected to step in, or to supervise the residents as they step in, to cover emergencies which arise, or to deliver patients whose private physicians are absent for delivery, as well as patients who present in labor with no prenatal care.  The difference from the laborist model appears to be that no effort has been made to advertise this service to private doctors, encouraging use of the de facto laborist service.  At our institution, we have in fact emphasized to our community physicians that our attendings are available 24 hours a day and will happily assume the care of other physicians’ patients in emergencies, or if requested by the private doctor. Our experience is that solo practitioners, particularly during office hours, were quick to avail themselves of this service. If, when office hours ended, the patient was still undelivered, some chose to come in and assume care of their patients, while others allowed the laborist to continue on and deliver the patient. Other physicians occasionally avail themselves of the laborist service, at irregular intervals, often related to conflicts with OR cases, or when patients in labor are at more than one hospital. In our system residents are involved in all deliveries and this did not change.  In this system, the private doctors round on their patients post partum, and residents arrange discharge.  Complications, such as fever, pulmonary embolus, hemorrhage, etc. are managed by the residents and laborist, with input from private doctors and participation as they wish. In close to three years experience, and approximately 200 deliveries, we have received no patient complaints.

CH1:  In another model, in a community hospital setting, two groups, with a total of 8 obstetricians, came together to form a laborist model, in which one of the eight would be on call at the hospital for both groups deliveries every 8th day.  During that day, no gyn surgery can be scheduled, and only obstetric patients are seen.  A separate call schedule exists for gyn patients and emergency room coverage.  The morning after being on call the physician rounds on all OB patients, ensuring discharges are written in a timely fashion.  Standardized orders are used on all patients.  Doing close to 800 deliveries a year, in three years the group had one patient complaint about the coverage system, but that patient chose to stay with them.  There is no teaching program.

CH2:  In this model, the hospital has created a laborist model in which doctors are paid a set fee for covering the obstetrical suite for 24 hours.  During that time, the physician can have no other clinical responsibilities, and is physically present on labor and delivery.  The laborist doctor on call covers all emergencies, and is available for any private patients whose doctors are not available.  The laborist is also available to help private doctors who may require assistance, i.e. unplanned cesarean hysterectomy.  The overwhelming majority of private doctors choose to come in and manage their private patients. A resident service covers unregistered OB patients, and does not interact with the laborist.  Separate coverage is provided for the teaching program by the hospital.

CH3:  Similar to model CH2, this model occurs where no teaching program exists.  Therefore, the hospital pays a laborist fee to a private physician who covers the hospital for private patients, emergencies and unregistered prenatal patients.  Because of a low volume of deliveries, the hospital requires on site presence 12 hours a day, and beeper coverage the remaining 12.  If a patient arrives on labor and delivery, the laborist comes in to cover. The overwhelming majority of private doctors choose to come in and manage their private patients.   In a variant of this model, if enough private obstetricians were not interested in being involved in hospital coverage for other than their patients, the hospital could hire 3-4 full time employees to work with those private doctors who were interested, to cover the hospital, both in labor and delivery, the indigent OB/GYN clinic and in the ER.  These hospital employees would free uninterested private obstetricians from any indigent care, and would also serve as emergency back up for private patients.

Table 1 briefly compares these four models, as well as that suggested by Weinstein.  In his model, the laborists are employed by the hospital, and their costs are partially covered by billing fees for services provided.  For purposes of life style, we assume 4 physicians are hired.  During their days off, it would be possible for them to be employed elsewhere, i.e. outpatient indigent care clinic, establishing private practice, working at other clinical sites.

Funding the Laborist Model: 

It has been implied that the laborist could charge for the deliveries done, consults or assistant fees.  This revenue could be put towards costs incurred by the hospital, or returned to the laborist to make the position more attractive.  However, it is not clear this is actually a realistic consideration.  The physician who offered the prenatal care would presumably bill for that (CPT59426, 59430 ) while the laborist who did the delivery would bill for that portion of care (CPT59409, 59514).  The result could easily be that these two charges exceed the cost of global fees (59400, 59510) creating problems with third party payers.

In the TH Model, the supervising physicians are employed by the hospital, so there are no additional costs to the hospital.  Private physicians who avail themselves of this service are not charged, and no bill is submitted.  This is viewed identical to the situation where a doctor from one group cross covers with a doctor from another group, and while they may deliver each others’ patients, they both submit global bills only for their patients.

In the CH1 model, there are no additional salary costs.  However, periodically the two groups calculate how many deliveries each group has done for the other.  If a marked discrepancy has occurred, and one group has significantly done more deliveries for the other group, than a payment is made to the group which has done the excess deliveries from the other group.

In the CH2 and 3 models, the hospital sustains substantial salary costs.  In addition, the hospital runs the risk of facing increasing costs each year, similar to what is happening with hospitals that pay specialists for ER coverage. This may not be a sustainable financial model unless the revenue generated from the obstetrical service and other services the hospital provides exceeds the cost of laborist coverage.  Further, the salary costs directly reflect the stipend paid by the hospital to the laborists, and these costs must be consistent with local fair and reasonable wages to comply with Stark laws.

In all models, the value of the laborist in preserving an obstetrical service is incalculable, and will be largely determined by the hospital’s strategy for obstetrics in specific, and women’s service line in general.  Down line revenue from obstetrical services will vary for every hospital, but can be substantial, although volume related.  Hospitals with small obstetric volumes, probably less than a 1000 deliveries, will have difficulty with all of these alternatives.  The one exception would be if the laborist program was used to recruit new obstetricians, to build obstetrical volume.

In all models, there exists substantial opportunities over time for quality improvement initiatives with standardized, outcome based treatment management, and for reduction of medical legal risk.  Quantitating these savings will be difficult, but standardization of medications usually offers hospitals significant savings in pharmacy costs which can be measured.

Bringing together physicians and hospitals also offers potential opportunities for negotiating with third party payers, and in attempting to negotiate with malpractice insurance providers.  Again, quantization of any savings will be difficult.  Table 2 offers projected costs for various models, based on estimates we believe reflect northeastern United States.  Both costs and revenue are for hospital. 

None of these models saw a hospital system bring in a full time employee to offer the laborist service.  This probably reflects, at least in our area, a perception that these doctors could very well offer competition to existing practices if they chose to leave hospital employment.  In theory, geographic exclusion clauses could prevent this, and in some areas, bringing on doctors as laborists may offer a means of recruiting new physicians to an underserved area where they will establish independent, new practices.

Speaking with physicians involved with these various models, reveals that they continue to worry about diminishing patient reimbursement, rising overhead, the sense of needing increased patient volume to survive, uncertain pricing of medical malpractice insurance, and the stress of difficult cases.  A laborist program may not have a long term advantage in any of these areas. All of the models appear to offer less on-call responsibilities, less night call and less disruption of one’s schedule by unanticipated patient needs.  Certainly when recruiting new physicians, life style issues appear to weigh most heavily on negotiations, and all of these models are more attractive than offering once every 2nd or 3rd night call, although it is recognized large groups can accomplish the same thing.  An obstetrician, backed by the laborist model, may be the only salvation for solo obstetric practice.

Conclusion:   Implementation of a laborist program in obstetrics will see a large number of variations, determined by type of hospital (teaching versus non-teaching); size of service; and, degree of involvement and control the hospital desires, balanced against the need of obstetricians being entrepreneurial and independent.  No one approach can possibly fit all circumstances.  It remains important to recognize this inherent variability, as change continues to wrack medicine in general and especially obstetrics, because when data does begin to become available on the effect of a laborist program, its generality may be exceedingly limited.  Similarly, failure or success of a program, however that will be measured, may reflect more on individual community circumstances than the laborist concept.  All this being said, the laborist models offer potential responses to life style issues for obstetricians, quality improvement, and may be useful in recruiting new doctors, and developing practices, and supporting obstetric programs.  But a laborist program will require a cultural change in obstetricians, and in some models, may be associated with unsustainable cost.

Table 1:  Comparison of models

   TH model  CH1 model  CH2 model  CH3 model  Weinstein
 model
  24x7
 coverage 
 yes  yes  yes  yes  yes
 Coverage
 for indigent
 pts.
 yes  no  no  yes  yes
 Quality and
 life style
 advantages
 yes  yes  yes  yes  yes
 Doctor
 autonomy
 no  yes  no  no  no
 Impact on
 private OB
 billing
 none  none  none  none  global
 fee not
 possible
 Additional
 cost
 none  none  high  high  High(offset
 by delivery 
 revenue)

Table 2:  Funding Mechanisms

Employed Physicians                                                  Hospital compensates OB ’s to cover
(Weinstein Model)                                                                as laborists (CH2, CH3)
COST:                                                                        COST:
Salary per MD      $175,000                                       365 nights x stipend ($2500-3500)=
Benefits @28%         49,000                                                            $912,500-1,277,500
CME benefit                3,000
Coverage for CME                                                     Assume 1000 deliveries, this comes
  And vacation            13,000                                              to $912.50-1277.50 cost per
Liability Insurance     60,000                                              delivery
                               $300,000

For 4 MD’s        $1,200,000
(support staff, billing and other costs not                   Assume no charge to private OB ’s
included)                                                                            using laborist service

REVENUE:(assume 1000 deliveries)                         REVENUE: from deliveries, i.e.
@$1200/delivery = $1,200,000                                      down stream revenue (assume
Private OB ’s cannot charge global                                     $2500/delivery)=$2,500,000

Bibiliography 

  1. Weinstein L.  The Laborist: A New Focus for the Obstetrician.  Am J Obstet Gynecol 2003: 188; 310-312.
  2. Petrikovsky BM.  The Laborist:  Do not repeat the mistakes of other medical systems.  Am J Obstet Gynecol 2003: 189; 199. 

Contact:

Anne Diamond
Senior Director
adiamond@acog.org

American Congress of Obstetricians and Gynecologists
409 12th Street SW, Washington, DC  20024-2188 | Mailing Address: PO Box 70620, Washington, DC 20024-9998