Rusk County Memorial Hospital's nurse practitioner hospitalist program.

Ladysmith and the surrounding community - Rusk's service area is about 18,000 people - traditionally had good primary care access provided by 10 to 12 physicians in an independent medical group. A few years ago, the group began struggling to recruit physicians to Ladysmith. They said, 'We cannot recruit anybody because of the call burden, you need to have a hospitalist program.' "Oland says. The impact on the hospital was profound. By 2013, six physicians had left the medical group's clinic in the previous two years, forcing Rusk to suspend its obstetrical services. The remaining physicians increasingly referred patients to a hospital 45 miles away. Rusk's acute care inpatient days fell to roughly half the volume it had in 2010. To address the crisis, Rusk started its own primary care clinic. But Oland knew that she would face the same recruitment and retention challenges as the independent group. More and more, primary care physicians do not want to take call duty at the hospital, and many are no longer willing to round on their patients at the hospital. The key to our own success in keeping the hospital open was starting the hospitalist program so that we could recruit younger physicians that wanted a lifestyle balance," she says. The vast majority of American hospitals have launched hospital medicine programs in the past decade for just that reason. But Rusk and other small, rural hospitals have been slower to add hospitalists, mostly because of the cost. Although hospital physicians bill for their services, hospitals typically have to subsidize the program by at least $150,000 a year for each full-time hospitalist - and that's when the hospitalist has responsibility for 15 or more patients a day. In Rusk's case, the average daily census is just six to eight patients, meaning the hospitalists have less billing opportunity and require a larger subsidy from the hospitals.