Get More Out of Medical Practice Staff

Travis Singleton works with healthcare provider organizations of all sizes and lately, he's seen an overwhelming similarity among all of them.

"You'd be hard pressed to find one [that isn't at a self-imposed [staff] capacity or just at an operational capacity. I don't know if I have seen our [healthcare] system stretched to this point, probably in the 20 years I've been doing this," says Singleton, senior vice president for Merritt Hawkins, the Dallas-based physician-focused staffing and recruiting firm.

The data from this year's Physicians Practice Staff Salary Survey essentially confirms this. Of the more than 1,000 physicians and practice managers polled for this year's survey, 44.9 percent said their biggest staffing challenge was increased workload and employees performing dual roles. The next closest staffing challenge - staff training and skills not being up to par - came in at a mere 12.5 percent. Moreover, 31.4 percent of respondents say they have increased staff workload without increasing salaries and 28.7 percent say they are understaffed.

Experts say there are various reasons for this trend. Derek Kosiorek, principal consultant at the Medical Group Management Association Healthcare Consulting Group, says it's because job responsibilities are evolving and changing. "We're seeing higher patient responsibility for cost, which means resources have to be dedicated to following up with the patient and collecting that money. Five years ago, it wasn't that much of an issue," he says. For instance, Kosiorek notes talking to patients about payment is a much different experience, he notes, than talking to insurance companies.

Another challenge is finding qualified people to come to small, private practices, according to Emily Glaccum, a Tallahassee, Fla.-based principal at the Medicus Firm, a physician recruiting firm. Struggling to find qualified staffers, whether it's a clinical or administrative role, is especially challenging for private practices in rural areas, she says. "The challenges [at rural medical practices] are huge. Doctors want to be in a big city. Smaller places have to compensate by paying more," she says.

Deb Pharis, president of Practice and Liability Consultants, says it's not just rural areas that are experiencing location-based staffing challenges. In San Francisco, where she is located, practices have a hard time finding capable medical staff when there is a tech boom, as people would prefer to go into a potentially more lucrative field.

Singleton adds that the aging population is another reason practices are being stretched out. Not only are there more baby boomers using the healthcare system, he says, but they are using it more frequently. "When you look at someone 60 years or [older], they are accessing the healthcare system 3 to 4 times more than [someone younger]…the demand has escalated," he says, noting that there isn't enough supply to meet this demand, especially when it comes to doctors. This has led to a trickle-down effect, where staff members have to take on additional responsibilities. For instance, he notes physician assistants and nurse practitioners are taking on more clinical duties from physicians.

*The ninth annual Physicians Practice Staff Salary Survey is here! We surveyed 1,082 practices on the makeup and salaries of their staff. Here are the complete results for national salary data.

Doing More with Less

Naturally, the ideal scenario would be for practices to add staff, but for various reasons that's not always possible. Sixty percent of respondents in the Staff Salary Survey said they either had to let staff go or maintain operations with the same number of employees. Perhaps the reasons are regional or a dearth of talent, as outlined above. For other practices, it simply may be they can't afford to bring on more people. Whatever the cause is, the good news, experts say, is there are plenty of ways to do more with less.

"It's all about training…it's about asking your staff members how to improve their jobs by [using] more efficient methods. It's doing things like Lean Six Sigma, all those techniques that look for ways to increase efficiency but maintain quality… by looking at process and procedure. That goes along with the increased responsibility for staff," says Pharis.

She says using technology and operational efficiency techniques (such as implementing Six Sigma) can improve process improvement, as well as undergoing a cost benefit of analysis of current processes. One example, Pharis says, is reminding patients about their upcoming appointments. Automated calls and secure text messaging can avoid patients and practices playing phone tag, saving time and effort.

Kosiorek agrees with Pharis' mindset, saying not enough practices are analyzing their work flow and processes for greater efficiency.

"I was working with a practice two months ago…[where] one of the people in the billing office, one of their jobs was to take a look at the encounter forms from the previous day and make sure they were correct. She spent three hours per day looking through the encounter forms. I asked her how many she corrected and she said….’one or two [per] month.’ This is a tremendous waste of time and resources," he says.  Practices, Kosiorek says, are adding responsibilities without seeing what can be eliminated, consolidated, or reconfigured.

Singleton also says training is the best course of action in getting the most of current staffers, especially if you can't bring on someone new.  He says practices should send current staff members to training courses, especially on coding and other regulatory compliance.

MACRA Staffing

Speaking of which, an area where additional staff training might come in handy is familiarization with CMS' Quality Payment Program (QPP) under the Medicare Access and CHIP Reauthorization Act (MACRA), which will represent a significant shift in how physicians are compensated for Medicare patients. While the QPP is in place for 2017 for a payment adjustment in 2019, reduced requirements have made it easier for practices to adhere to it. However, future years may present a greater challenge, as MACRA's Merit-based Incentive Payment System (MIPS) combines elements of Meaningful Use, the Physician Quality Reporting System (PQRS), and the Value-based modifier, as well as monitoring the cost of care from individual physicians.

Despite this, practices say they aren't planning on bringing in staff to adhere to MACRA. In total, 87.2 percent of respondents to the Staff Salary Survey say they won't be adding staff to assist with QPP guidelines. The number one reason why, according to those respondents, is because they plan on training current staff, which many say is a perfectly acceptable approach.

"Giving staff the opportunity to familiarize themselves [with MACRA] and the changes that need to be made is the better way to go," says Kosiorek. Pharis agrees, saying there are plenty of resources, such as medical societies, that can provide free training for current practice staff.

On the flip side, some experts say there might be valuable reasons for bringing someone in. Glaccum says investing in additional personnel can prevent current staff from burning out. She says an employee will have expanded responsibilities if they are working one or two roles and then someone quits and they have to on even more. "They might love what they are doing…but they're not getting paid to work 10-12 hour days," she says.

Medical assistants (MAs) are one area where practices might be able to find cost effective staff members. Researchers at The University of California at San Francisco (UCSF) School of Nursing, Healthforce Center conducted a study in 2016 that found that medical assistants, when utilized correctly, could capably take on a number of innovative roles in primary-care practices to relieve the burden of physicians. These roles include health coach, medical scribe, a possible translator for bi-lingual patients, health IT super user, and more.

There are other advantages, says Susan Chapman, PhD, RN, professor at the UCSF School of Nursing’s Department of Social and Behavioral Sciences. "MAs are available. [It takes] a short training period [to get them up to speed]. They're among the lower paid members of the team, so they're affordable in that sense," she notes.

Don't Be Thrifty

Staffing challenges will only intensify as MACRA and private payers shift compensation to value-based care . Singleton says practices have to understand that the world of value-based care isn't going away and can't just put their heads in the sand to avoid it. Practices will have to get staff ready for these changes, he says, or bring on people who will be prepared.

"Don't wait two years and then send your office manager of 30 years to a training class on [MACRA]. …  That’s probably not the best way to prepare your practice for what's coming," Singleton says. "You don't have to dive into the deep end, but you have to start making changes now."

Kosiorek and Glaccum say it's important for practices, especially those whose staff members are taking on dual responsibilities, to ensure they are monitoring any staff discontent. "Make sure staff is satisfied with their work and feel like they are contributing to the organization," Kosiorek says. A toxic environment can be built up over by unhappy staff members, he notes, and the cost of replacing people is considerable. Glaccum says a practice should be willing to continually train and invest in its current employees to keep them happy.

Pharis' closing advice to practices is simple: Spend some money and hire a decent manager. The manager will be able to understand the financial, operational, business development, and human resource aspects of the practice. They can analyze staffing patterns, use benchmarking data such as expense and staff ratios, look for areas that are over and under-resourced, and seek out overall better efficiencies.

"A manager will make or save the practice their salary if they are really sharp. Being pennywise, pound foolish doesn't make a lot of sense…they'll look for ways to save or make you money," she says.