Staffing the Hospital of Tomorrow

“The jobs in the future will be different from the jobs in the past,” one industry executive tells U.S. News.

A few years ago, hospital leaders like William Leaver were hiring radiologists, cardiologists and other specialists to maximize fee-for-service payments. Today, the CEO of Des Moines, Iowa-based UnityPoint Healthcare seeks patient navigators, care coordinators and mid-level nurse practitioners to guide patients’ care outside its 30 hospitals. Leaver is outfitting his nonprofit integrated health system as a hospital of tomorrow. In doing so, he is busy standardizing operations across UnityPoint’s hospitals, 280 clinics and home care operations in eight Iowa and Illinois markets, and making very different hiring choices than he used to. “The jobs in the future will be different from the jobs in the past,” Leaver says.

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That’s a far cry from the heyday of fee-for-service medicine. In 2004, the three biggest in-demand specialty physicians were radiologists, anesthesiologists and cardiologists, according to physician recruiting firm Merritt Hawkins. Today, the first two don’t crack the top 20, and cardiologists were No. 15, according to the 2013 Merritt Hawkins survey.

Instead, hospitals overwhelmingly seek primary care providers. “Primary care, across the nation, is everybody’s No. 1 search,” says Mike Houttekier, manager of physician recruiting at Allegiance Health, a 411-bed hospital in Jackson, Mich. Family medicine, internal medicine and hospitalist physicians (primarily internists who work exclusively in the hospital) were the top three physician searches Merritt Hawkins conducted over the last year. “Demand also is increasing rapidly for nurse practitioners and physicians assistants,” says Susan Salka, president and CEO of AMN Healthcare, a health care workforce solution company. For the first time in 20 years, Merritt Hawkins—which is owned by AMN—saw nurse practitioners and physicians assistants crack the top 20 searches conducted, at No. 10 and No. 12, respectively.

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Hospital staffing changes are driven by an aging population, a physician workforce shortage and health care reform. The Affordable Care Act emphasizes prevention, encourages value-based payment and, in January, begins to provide insurance coverage to more than 30 million newly insured patients. Payment is shifting from predominantly fee-for-service to one that puts hospitals at risk for patient care both in- and outside the hospital’s walls. Besides hiring more primary care providers, hospitals also are aggressively hiring emergency physicians—more newly insured patients are expected to boost emergency room use—care coordinators and other patient care advocates, clinical pharmacists, health IT and data experts.

“Health care reform only makes the staffing shortages worse,” notes Salka. A variety of payment changes and care delivery models have proliferated under Obamacare, including Accountable Care Organizations, patient-centered medical homes, bundled payments, readmission payment penalties, adherence to treatment protocols and other quality-based metrics. The focus on value-based care puts a premium on prevention and team-based care coordination, led by primary care practitioners. This is challenging hospital executives, who are operating under two conflicting payment systems. Houttekier says it’s akin to straddling a “crevasse.”

“Staffing is the linchpin” of moving to the hospital of tomorrow, notes John R. Thomas, CEO of MedSynergies, a physician alignment firm. It’s why staffing has captured the C-suite’s attention. This year, 42 percent of hospital executives cited it as the top priority for their facility—compared to 9 percent in 2009—according to a forthcoming AMN survey. Furthermore, nine out of 10 CEOs responding to a U.S. News survey said they planned to reduce reliance on independent doctors in favor of a staff model.

At UnityPoint, Leaver has included physicians on the leadership team in efforts to remake the former hospital-centric Iowa Health System into a doctor-driven, patient-centered system. As it transitions, UnityPoint created a year-long Physician Leadership Academy for promising MD leaders to hone their skills. “It’s building capabilities they didn’t necessarily get in medical school,” Leaver says. Getting MD input and buy-in is essential as the system standardizes operations, integrates its home health care operation and care coordination efforts across all markets, while refashioning all its 250 clinics into patient-centered medical homes.

“We need to master care coordination, because that’s what we’ll get paid for,” observes Leaver. To pull that off, his biggest staffing needs include care navigators, mid-level nurse practitioners and other care extenders, in addition to primary care doctors. The system is also recruiting those with experience or acumen in analytics, health assessment and actuarial science. Today, 20 percent to 25 percent of UnityPoint’s business is risk-based. “Over the next three to five years, that will grow to 50 to 60 percent,” he says.

Physician alignment, along with retention and retraining efforts, is helping San Diego’s Scripps Health staff its changing organization to compete in a metamorphosing hospital industry. In 2010, Scripps transitioned from a vertical to a horizontal organization and tapped doctors to co-manage Scripps, which serves a quarter of San Diegans. Capitation has long been popular in southern California, although Scripps predominantly is a fee-for-service animal. In 2010, it realized the future was changing, and restructured to better control costs and beef up its outpatient processes as inpatient offerings stand to shrink going forward.

Scripps leaders worked with physicians and employees to eliminate redundancies, reduce variations and adopt consistent best practices in policies, procedures, equipment and services. “They could identify the variance in our organization better than we could,” says Victor Buzachero, Scripps’ corporate senior vice president for innovation, human resources and performance management. As a result, Scripps has saved about $200 million in three years by consolidating clinical medical lab function previously performed in hospital settings, cutting variation and waste in its pharmacies, standardizing supplies across the system and other actions.

“We’ve done this with a no-layoff approach,” he says. As Scripps examines is costs—labor accounts for half of it—it is retraining workers for the jobs needed in a reformed health system. Examples: some bedside nurses now act as patient navigators, working in teams with one-time hospital pharmacists who today are on the floor or in the field doing medication management therapy, or coaching patients on how to take their medicines to prevent re-hospitalizations. “We entered into the hospice business this year and redeployed staff there,” Buzachero adds. A decade ago, 75 percent of Scripps hires came from outside the system; today two-thirds are internal transfers.

At Allegiance, “we’ve had to take a look at the return on investment of each position here, even physicians, nurse practitioners and physicians’ assistants,” says Houttekier. “Everybody undergoes scrutiny and executive review. That’s a big change for us.” That increased intensity on hiring, says Salka, is reflective in the growth of AMN’s managed services business, which has grown from about 5 percent of AMN’s business three years ago to one-third today. Hiring doctors—who are working fewer hours overall—projecting seasonal staffing demands, matching hospital staffing with patient acuity and being able to deftly adjust workforce needs and filling in gaps with temporary staffing has become tricky for hospitals, who have followed employers in other sectors by tapping managed services programs and recruitment process outsourcing.

The pressure is intensified as Houttekier tries to meet future and today’s hiring needs. For some hospitals, today’s needs are front and center. Between hiring primary care providers, Houttekier must meet the hospital’s immediate needs, such as hiring a neurosurgeon or two to replace a retiring veteran surgeon. That’s key as Allegiance makes itself into a trauma center that is also introducing a graduate medical education program and open heart center. Allegiance is trying to extend its brand, as its primary competitors are in Ann Arbor, 35 miles away. In doing so, Houttekier is leaning on AMN for temporary and other staffing needs. “Staffing has become more challenging and will continue to be challenging,” he says.