Physicians Practice Staff Salary Survey 2012

April 30, 2012

Strategic staffing: Get your pieces in the right places

Physician practices are being pulled in one direction by today and in another direction by tomorrow. Right now, most of you are struggling with declining reimbursements, increasing operating costs, and severe staffing shortages. Tomorrow you'll be struggling with all three of those challenges, plus a (likely) influx of new patients and mounting pressure from federal and commercial payers to improve quality of care while reducing costs.

"Everything looms before us," says Loretta Swan, who oversees daily operations at 40 small- to medium-size clinics in and around Tyler, Texas. "We have to really tighten our belt and reduce our cost, but we need to do this without affecting our patient care."

It's a lot for any practice to handle. But despite the mounting challenges, Swan, the vice president of operations at Trinity Mother Frances Hospitals and Clinics, says a strategic approach to staffing can provide a better outlook for your practice.

She would know. Changes made at Trinity over the past year, including staffing adjustments, have saved the organization several million dollars, she says. And she stresses, those are "sustainable savings."

Here's how Trinity did it, and how experts say you can restructure your staffing strategy to help your practice thrive now - and in the future.

*For more information on staffing trends and staff salary benchmarks, check out our 2012 Staff Salary Survey slideshow.

Dealing with today

In response to declining reimbursements and increasing operating costs, many practices are rethinking their staffing structure to support "volume-based" staffing, says Gary Van House, the consultant who helped Trinity through its changes. That means implementing changes that allow your practice to operate at its highest level of productivity at the lowest cost. "If they have excess staff, they need to dispose of them," he says. "… It's absolutely mandatory in today's environment that they take those costs out."

Van House, who is the managing director of Huron Consulting Group in Chicago, suggests practices begin a volume-based staffing analysis by using benchmarks to assess whether their staff is right-sized for success. The Medical Group Management Association (MGMA) Cost Survey Report for instance, shows the amount and type of full-time equivalent (FTE) employees needed at a practice per 10,000 work RVUs. This information is also broken down by practice specialty. "It's a more structured model of looking at how many staff you need per office, back office, based on really the volume of patients and revenue through the practice," says Van House.

This is the strategy Trinity used, and though it found it needed to reduce staffing in some areas, Swan says in other areas of the practice the analysis lead to staffing increases, such as additional nonphysician providers and physicians at some of the clinics. "The more productivity there is, then obviously the more staff you can support," she says.

Swan is on to something. Though it might seem counterintuitive, some of the most successful practices have the highest number of employees, says Brian Baker, a consultant with Baker Healthcare Consulting Group in Nashville, Tenn. A former practice administrator himself, Baker points to the MGMA's Performance and Practices of Successful Medical Groups Report, which finds that practices with the highest number of FTE employees per FTE physician are the most successful.

Practices also need to assess whether their staff is assigned the right responsibilities, says Chuck Gooder, a former administrator and senior adviser with Integrated Healthcare Solutions in Minneapolis. Look at job descriptions and "match requirements for operational needs with the kind of personnel that would be the most cost-efficient," he suggests. In other words, ensure that no staff member is overqualified for his responsibilities.

Looking toward tomorrow

Volume-based staffing has the potential to increase practice revenue - but there may be limits to its abilities. "Reimbursements have gone down and the only real way to increase your overall revenue has been to work harder and try and take more market share from competitors, but that's ultimately a losing business plan," says Todd Sagin, national medical director of HG Healthcare Consultants in Laverock, Pa. "The trouble that practices have today is that they have had limited ways to increase their margins."

Value-based reimbursements - which reward practices for achieving higher quality care at lower cost - could enable your staff to "get off the treadmill," he says. In other words, it could provide incentives for spending more time with patients, rather than performing service after service as quickly as possible.

This is something Trinity is exploring, notes Swan. It recently began participating in a Patient-Centered Medical Home, and though it isn't very far along in the process, she is optimistic about the approach. "Our primary reimbursement right now still is fee-for-service, but we definitely are moving into this other payer avenue with our payers as far as the patient-centered model of care, and it's really working out really well and our patients love it and our physicians love it," says Swan.

While switching to value sounds great, there's a catch. It's a long process, and for many practices, it's an expensive one, says Van House. "Everybody agrees that better patient care, better metrics in and around quality, more patient satisfaction is a good thing," he says. "The trick, however, is that it requires … more overhead."

That overhead includes, in many cases, additional staff members, he says. That's because improving quality requires more patient outreach, monitoring, and follow-up, says Sagin. Patient navigators, he notes, are a great addition to practices hoping to participate in new models of care.

These staff members help patients follow through with their instructions for follow-up care, such as helping them make appointments with specialists, making sure they obtain their prescriptions, ensuring they understand how to take their medications, ensuring they get recommended diagnostic testing, and answering their questions. The credentials of a navigator vary; for instance the role could be filled by a registered nurse, a trained case manager, or a health educator. In fact, Trinity employs care coordinators and nurse navigators to assist with patient outreach, says Swan. In addition to working in practices, navigators sometimes work for insurance companies, ACOs, IPAs, etc., says Sagin.

Physician assistants (PAs) and nurse practitioners are also great additions to practices hoping to improve care coordination, says Baker. They can help practices "deal with the issue of volume and continue with the quality of care," he says.

Still, if a practice is on its own in paying for these additional staff members, participating in value-based reimbursements will be a challenge. "Most practices don't have a margin to support that kind of additional staffing," says Sagin.

In between

With all this discussion about the difficulty of moving toward value, it may be tempting to ignore new staffing recommendations and continue staffing your practice as usual. But that's a bad idea, says Sagin. Practices need to keep the staff that they do have informed of new reimbursement methodologies. That way they'll be better situated to participate in new initiatives in the future.

"Frankly, payers or ACOs or other people you need to partner with to participate in these new methodologies aren't going to want practices that practice with historic patterns that don't create value," he says. "So unless you can get your staff to understand that care has to be delivered in a new way to accommodate a new business model and practice model, you're not going to be successful."

Here are some simple, low-cost ways to begin shifting your staff's focus toward value:

• Use measures and provide feedback. Implement patient satisfaction surveys so staff can gauge their performance based on patient comments, says Van House. Practices should also track quality metrics and provide that information to staff members so that they can begin focusing more on quality, he says. Tie some portion of physician compensation to quality and patient satisfaction.

• Improve patient handoffs. Since so many of these value-based initiatives rely on coordinated care, encourage your staff to begin focusing on that. One way is by ensuring that all of your staff members are working to their highest level of license, says Susan Douglass, founder of healthcare management consulting company Susan Douglass and Associates in Colorado Springs, Colo.

Physicians should work exclusively on the aspects of care that they alone may work on; the PAs and NPs can handle lower-level aspects of care, but only that which cannot be handled by a nurse or a medical assistant. That will naturally improve care coordination, she says, because it will necessitate patient care handoffs.

• Encourage a new mindset. Encourage staff members to move from a "me mentality" to a "we mentality," Douglass says. "They need to develop a commitment within the practice that this is how we're going to work. We're no longer going to poach off each other or just grab a patient to enhance our productivity numbers because that's not really the goal anymore. Our goal is really the coordinated care and the improving of patient outcomes."

• Expand roles. Cross-train staff members to help them broaden their knowledge and skills, says Baker. "A lot of times groups will keep existing staff but train them in different aspects of clinic care to be able to cover for increasing coordination," he says. For example, he cites a practice in which reception staff members became more involved in patient advocacy roles. These staff members began initiating more one-on-one interaction with patients and worked to ensure that patient visits went smoothly from start to finish.

Short staffed

The looming staffing shortage, meanwhile, threatens to complicate practices that seek to add staff in the context of emerging models of care. In 2014, 32 million Americans will (likely) gain health insurance as a result of the Affordable Care Act. "Physician offices could well be busier than ever before, if the current efforts of health reform are sustained," says Sagin.

The American Association of Medical Colleges anticipates a shortfall of 45,000 primary-care physicians and 46,000 specialists in the coming decade. Making matters worse, Sagin notes, up-and-coming physicians are showing a preference for employment with larger entities like hospitals, as opposed to private practice.

Though nonphysician providers may supplement the physician shortage, Sagin predicts that these individuals will become harder for practices to acquire as well. "You don't have enough training sites and programs to really dramatically increase the pipeline for nonphysician providers," he says.

Luckily, there are some steps to take to ensure you stand out from the competition when it's time to recruit:

• The BLT factor. Where a candidate is born, licensed, or trained is the "most powerful" player in determining whether he will join your practice, says Van House. Consult a recruiting database to identify physicians who have a connection to your area, and target your recruitment efforts to those individuals, he says. Keep in mind that a physician's spouse also plays into the BLT factor.{C}

• Meet expectations. Nonphysician providers don't want to be bogged down in administrative work - they want to be in on the action. "Practices need to be very thoughtful about how they are going to utilize PAs and nurse practitioners," says Sagin. These employees will "gravitate" toward practices that allow them to exercise their full scope of practice.

• Compensation. A nationally competitive salary and benefits package is hugely important to candidates - no matter where your practice is located, says Van House. Consult benchmarks to determine a proper salary and benefits range. Also, if a portion of physician compensation is tied to incentives, thoroughly explain it to candidates, he says. When they understand the package, they are "more satisfied and likely to be retained."

• New initiatives. Keep in mind that young physicians are attracted to practices on the cutting edge of health reform initiatives, says Sagin. They believe new models of care will allow them to spend more time with patients and therefore, have a more satisfying professional life.

Smart staffing

It's more important now than ever that practices have a proactive approach to staffing rather than a reactive one, says Douglass. Don't simply hire someone because you realize you need more manpower in the office, she says. Determine how that person will contribute to your practice now and in the future. "If your endgame is to have a 'we mentality' - to really have an interdependent coordinated care model - and you just throw someone in there, you don't know how that is going to affect your endgame," Douglass says. "… It's a lot better to step back and be deliberate about your hires."

Swan agrees that taking the time to determine the best staffing strategy for your practice will pay off in the long run. "I once heard a statement from someone that said that sustained success is never an accident, and it's not an accident," she says. "It takes a lot of planning and analysis."

Staffing transitions: standard practice to PCMH

Family physician Larry Shore's two-physician practice in San Francisco is well on its way to becoming certified as a Patient-Centered Medical Home (PCMH) by the National Committee for Quality Assurance. Shore and his partner have changed the schedule at their practice to allow for more same-day appointments and increased patient access to care.

To aid the transition, the practice has also made several staffing adjustments, including adding a second medical assistant (MA) to the team. That way, the clinical staff can operate in pairs, one MA to one doctor, says Shore. The MAs have taken on more responsibilities, such as recording vital signs and chief complaints from patients and reviewing patient charts before visits to identify which preventive services and immunizations are due, overdue labs, etc. That frees the physicians to focus more on the patient care elements that require a medical license, says Shore.

Yet the practice's ability to fully transition to medical-home status has been hampered by staffing issues. It needs more staff to improve chronic-care management while decreasing care costs, but "the problem is … in a private practice setting, there's no guarantee that anybody's going to fund that [cost] for you," he says.

Two years ago, Shore asked his local independent practice association, Brown and Toland Medical Group (BTMG), for help in making his practice a "model" PCMH. The idea: if Shore's practice becomes a successful PCMH, Brown and Toland can learn from its success and replicate it in other practices. It agreed. In March, BTMG opened up a new practice, My Health Medical Group, where Shore will serve as the lead physician. BTMG will help provide the additional staff members that Shore believes will help his practice become a successful PCMH. 

In Summary

In this shifting healthcare climate, it's critical to not only make the most of the staff that you currently have, but to begin making staffing changes that could help your practice thrive in the future. Here's how:

• Use benchmarks to assess whether your practice is operating at its highest level of productivity.

• Match job descriptions to responsibilities.

• Consider value-based reimbursements to allow your staff to spend more time focusing on patients.

• Rethink staff responsibilities to improve handoffs and care coordination.

• Cross-train staff members to broaden their knowledge and skills.

• Prepare for the staffing shortage.

• Implement smart recruiting practices.

*For more information on staffing trends and staff salary benchmarks, check out our 2012 Staff Salary Survey slideshow.

Aubrey Westgate is an associate editor at Physicians Practice. She can be reached at aubrey.westgate@ubm.com.

This article originally appeared in the May 2012 issue of Physicians Practice.