Piecing Together Your Medical Practice Staffing Puzzle

When it comes to staffing, many practices are at a crossroads between recession and reform.

America's worst economic downturn since the Depression did a number on every industry, including the usually recession-resistant healthcare, where hiring slowed and even some layoffs were seen.

But now the recession is ending, albeit slowly. And the Patient Protection and Affordable Care Act, passed in 2010, has many practices scrambling to figure out how to staff up to handle the anticipated massive influx of newly insured patients, while also dealing with other changes, including fundamental payment-model reforms.

"We are in a unique circumstance where, [if not for] a horrible recession we are just climbing out of, you would see hiring across the board," says Richard B. Wagner, managing director of Wagner Healthcare Consulting in Chicago, Ill. "Now, we are seeing [practices] getting beefed up for patients, due to reform, especially for the primary-care physicians."

Enter the 2011 Physicians Practice Staff Salary survey. In these pages you'll find detailed data on how much practices around the country are paying their various staffers. And we turned to several experts to help us understand how practices are handling staffing while existing in the limbo between a steadying economy and a changing industry.

Access national data from the 2011 Staff Salary Survey.The recession's impact

Wagner says primary-care practices are anticipating a greater number of insured individuals by 2014, when the insurance mandates on businesses and individuals and other coverage expansions will take full effect. They're also awaiting the dawn of accountable care organizations and patient centered medical homes. These changes will mean not only more staff are needed to manage patients, but practices will need the right kind of staff to handle increased patient volume.

There is no denying that the recession has impacted the day-to-day operation of practices nationwide. While smaller recessions in years past have tended to leave healthcare alone, the so-called Great Recession took its tool, according to our most recent Staff Salary Survey, which ran during the last three months of 2010 and gathered 1,076 respondents. For example, practices initiated across-the-board decreases in benefits offered to staffers compared to the previous year, and a nearly 5 percent increase in layoffs of staff.

In our previous survey, conducted in late 2009, 53 percent of respondents indicated the recession had "no impact" on their practice. A year later, the number of unaffected practices was down to 41 percent.

Looking for salary information and insight from your region? Check out our comprehensive regional results here.

Yet some practices are viewing the changing landscape as an opportunity to grow. That's what West End Internal Medicine in Richmond, Va., is doing. According to its administrator, Susan Waldrop, the practice has added nonphysician providers and other support staff to complement its five full-time physicians while it adopts a medical home model.

"In my mind, the successful adoption of the medical home is getting us ready to take the next step - more proactive patient care rather than waiting for someone to make an appointment," Waldrop says.

Deborah Walker Keegan, president of consulting firm Medical Practice Dimensions in Arden, N.C., says that in the past, practices staffed for the physician. But with money tighter and most practices seeking to reduce costs, there is now a shift to staffing for the work.

"People are looking at the right staff doing the right things - the right level of the staff involved in doing those things and really scrutinizing what they've done in the past," she says.

Walker Keegan knows of a pediatrician with five staff members who went through an analysis of his staff situation. The practice had two employees who were less engaged than the others and he decided to lay them off. He then asked the remaining staff whether he should recruit replacements, or if they could shoulder the workload. The staff chose the latter option and in return, the pediatrician divvied up part of the salary of the two former employees among the remaining staff members.

"This was an opportunity to reduce costs … and at the same time, he really engaged these staff, his best and brightest, to really be part and parcel of his team," Walker Keegan says.

Charlene Mooney, a practice consultant with the Halley Consulting Group in Westerville, Ohio, says most practices that she works with are operating at "bare bones," meaning no layoffs, but making the most of the staff on hand, asking them to pitch in for extra tasks while also ensuring staff - and physicians - maximize their credentials.

"I am a real proponent of cross training," Mooney says. "It not only helps where you need coverage, but people also learn more and, I think, feel more valuable to the practice when they know other things."

Walker Keegan agrees, indicating that a growing trend is to create "super medical office assistants," "clinical associates," and others to be deployed anywhere in the practice.

"These are more flexible staffing models, very cost-appropriate, and really back to the theme of staffing to the work," Walker Keegan says.

Who's coming into your practice?

One curious finding in our 2010 Staff Salary Survey is the 9 percent decrease in the use of registered nurses in private practice versus our 2009 data. Only 41 percent of 2010 survey respondents indicated the presence of an RN in their practice, while 50 percent of surveyed practices in 2009 employed an RN.

Where are the nurses?

Marc Halley of Halley Consulting Group says most markets are facing a shortage of RNs, making it more difficult to recruit them into practices when hospitals can pay better, especially with payer reimbursements in flux for private practices.

Medical Group Management Association data also point to a drop in practices utilizing the services of an RN. In looking at multispecialty groups not owned by a hospital, the percentage of practices with an RN has gone from 84 percent in 2000 to 79 percent in 2010, according to Dave Gans, vice president of practice management resources for MGMA.

Yet Gans notes that overall staffing levels have remained about the same over the last several years.

The MGMA data indicate that 5.13 support staff per full-time physician was the norm a decade ago; today that number is at 5.31. Medical assistants and other nonphysician providers have filled the staffing gaps in private practices, which don't necessarily require the skills of registered nurses, but rather "a different set of skill needs," says Gans.

"Often times, RNs have supervisory roles and responsibilities for managing quality and safety in the practice," he says. "But as far as their direct nursing skills - they are not working to their license. Whereas you can very well utilize medical assistants to the limit of their skills and framing, as well as LPNs. Then, practices don't have RNs at all; they staff with LPNs, especially in primary care."

Karen S. Schechter, director of healthcare services for consultant Stone Carlie in St. Louis, says practices she works with often debate hiring an RN or nurse practitioner. While an RN can "relieve the doctor of a lot of responsibility," she says, NPs "can be huge revenue generators" in getting patients seen and care delivered.

"If you have the capacity and the room to have an NP … and you have a patient population open to it, in the long run, I think you are a little better off," she says.

First, however, it's necessary to determine whether your practice can support a nonphysician provider. For a primary-care practice, it's worth considering if physicians are seeing at least 24 patients a day, and if you can get patients in the door in a timely manner.

"Once you do that," Schechter says, "the questions are: Do you need more help? If yes, what kind of help do you need?"
 

Finding the right fit

At St. Louis-based Clayton Medical Associates, the three-physician internal medicine/rheumatology practice has utilized physician assistants with great success, according to practice manager Maria Thompson. The practice's PAs "see as many patients as our physicians - 15 to 18 patients a day," Thompson says.

Clayton Medical Associates underwent a transition with its patient base a few years ago, shifting most internal medicine patients to PAs for three visits and with a physician at the fourth visit.

Under its medical home model, West End Internal Medicine is utilizing a rooming medical associate, a supervising LPN, case manager RNs, and others to move away from the traditional one-nurse-per-physician model of the past.

"We are trying to make the highest and best use of staff," Waldrop says. "We pre-planned for staffing. We increased our staffing and when we become certified [as a medical home] then comes additional reimbursement from payers who recognize what we are doing to keep their patients healthy and reduce their overall costs in terms of reimbursements to primary-care physicians."

Waldrop also says that by each staff person doing what she is licensed and trained to do, "you gain more time during the day and allow the physician to be much more a physician."

Staffing for the future

Our experts are clear on the outlook for the future: There will be more hiring in the healthcare industry and the majority of those hires will be nonphysician providers.

Gans says there are sure to be increases in NPs and PAs due to several factors. One is economics - greater use of nonphysician providers free up physicians, dedicates staff to acute care and patient education, and increases continuity of care. Second is the national shortage of primary-care physicians, meaning more staff to fill in the gaps, he says.

And, of course, in 2014 an additional 30 million Americans are set to gain health insurance through the Affordable Care Act.

"What we are going to see is an increased demand for physicians' services under healthcare reform and the good news is that people [will] have insurance and will use it," Gans says. "It is well-shown that if you are insured, you are much more apt to see a physician as opposed to either self-medicating, self-managing, and … going to the emergency room."

Beyond the health coverage expansion are several reform initiatives that will prompt staffing adjustments, according to our experts:

Medical homes. Walker Keegan says practices transitioning to the medical home model are adding between 5 percent and 15 percent clinical support staff to accommodate 24/7 patient access, including secure messaging via e-mail and other efforts. She is also seeing an increase in nursing in clinical support for medical homes.

Halley agrees, noting that in this model, "physicians are not going to do the case management," so more clinical staff will be required for that role and statistical analysis of patient data.

"I anticipate that what there will be [with medical homes] is what we call 'highest and best use staffing,'" he says. This will ensure that the physician is doing everything he can in order to see the largest patient population, while spending less and less time on clerical and other work - tasks that can be delegated to other staff.

This means putting primary care's traditional one-nurse-per-doctor model behind us.

West End Internal Medicine's data indicates that the medical home model is increasing patient satisfaction. It's pleasing patients with benefits like increased in-office testing and better, more comprehensive care for patients with chronic illnesses.

"With the medical home, you are doing much more outreach," says Waldrop. "You are making sure patients are getting follow-up - you are closing the gap."

Accountable Care Organizations. Another key driver of an increased demand for nonphysician providers is the ACO, creating healthcare teams of various stakeholders to reduce costs and improve Medicare services through better communication.

"Accountable care is going to be a driver of hiring for those midlevel providers, PAs and NPs especially, as they are high-value individuals in accountable care," says Wagner.

CMS is still writing the regulations that will ultimately govern ACO payment models. But most observers expect that physicians will share in any savings they produce by meeting certain quality thresholds. This means a "huge drive" in hiring NPs, Wagner says, since they will be able to do more of the things that, in the past, CMS would only pay physicians to do.

"Because of this, organizations can hire someone who can do a job at a much smaller price in terms of the labor costs associated with it, so ACOs, whether they are physician-based or a mix of hospitals and physicians, are going to pick up these high-value individuals," he says.

Virtual visits. As part of examining the best means to treat a patient, Walker Keegan says there are three main patient flow processes: internal (patients visit the practice); external (typically over the phone); and now, virtual.

The latter applies to e-visits, e-consults, and secure messaging via e-mail.

For example, rather than bringing a patient to the practice for three visits, perhaps one visit is accompanied by two follow-up, secure messages regarding test results or other follow-up instructions or discussions. However, one problem with this type of patient contact is that practices are not usually reimbursed for virtual visits and e-mail communications.

But, says, Walker-Keegan," if you can picture moving to a bundled [payment] environment … and picture 24/7 access to patients via phone and via secure messages, then you really start to rethink the staffing structure and get beyond the face-to-face patient visitor to other access channels that need to be staffed," Walker Keegan says.

Practices will need to ask themselves how they will staff for that kind of structure. They should determine the best staffers to communicate clinical information and be sure that they are ready to interact virtually with patients. There is nothing worse than using a technological tool aimed at making patient interaction faster, but then having no one at the helm to be in charge of patient encounters.

"We are truly trying to shrink the entire episode of care for the patient," Walker Keegan says. "When we start to focus on that and when the finances are aligned, we'll really see some innovation. Physicians are starting that now."

Value over volume. Another key part of healthcare reform is greater scrutiny of physicians by payers, and the concept of "value" - a key driver of incentives in 2015 under the Affordable Care Act.

Wagner says the law stresses wellness and prevention as opposed to reaction. "With NPs, it is kind of their mission as professionals to focus on wellness and prevention," so expect to see a greater use of these nonphysician providers in the coming years, if not sooner.

"They are to be embraced with the healthcare reform law and all the provisions, whether you look at one individual provision or not," he says. "As a whole … anyone who embraces wellness prevention …will be boding well. That's why you see a lot of physicians going out and hiring NPs right now."

In Summary

With healthcare reform on the horizon, now it looks like some of the work your staff might do will change. Here are some tips to prepare for tomorrow, today:

• Staff to the work - Assess what is happening daily at your practice and be sure you have the right people doing the right things to keep moving forward. Don’t staff for your physicians, but for the work of your practice.

• Add properly - Need some more help at your office? Look at nonphysician providers and the benefits they offer if used properly.

• Love the license - Each person in your office should be doing what they are legally licensed to do; anything extra needs to be carefully weighed in terms of workload.

• Get ready for reform - The Affordable Care Act will change the way patients are treated, so explore the impact on your practice today and how you can prepare to staff for new care delivery models, and other changes.

*Looking for salary information and insight from your region?Check out our comprehensive regional results here.**How can the staff you have today be a part of moving your practice into the future? Check out our tips on staff retention and ensuring the best employees are in place by reading "Keep Today's Practice Staff Tomorrow."

Keith L. Martin is the managing editor of Physicians Practice. He can be reached at keith.martin@ubm.com.

This article originally appeared in the May 2011 issue of Physicians Practice.