Healthcare organizations need to step up their efforts to recruit and retain physicians.
With demand outstripping supply for physicians in many specialties, Jackson Physician Search has released a new white paper to help healthcare organizations to recruit and retain clinicians.
"Demand for healthcare services is increasing due to an aging population, expanded access to health insurance, and a general public well-versed in the importance of preventative care. However, there are not enough physicians to meet the increasing demand for these services," the white paper says.
The white paper highlights several key developments in the physician job market:
As retirements increase, healthcare organizations are struggling to replace specialists such as neurologists and urologists who see a wide variety of cases. Subspecialists coming out of training want jobs where they can focus on their area of expertise.
Demand for mental health providers increased 85% from 2020 to 2022 as mental health problems spiked nationwide.
Physician expectations are changing—they want signing bonuses, flexible schedules, and a better work-life balance.
Specialists who can work in telehealth such as psychiatrists and radiologists are becoming increasingly hard to recruit for positions that require them to work in an office full time.
Healthcare organizations in rural areas are being particularly hard hit by retirements, and they face multiple challenges such as rising costs, lower reimbursement for services, and staffing problems.
At Jackson Physician Search, many of the 2022 physician placements had starting salary guarantees above the MGMA median.
Recruitment strategies
A pair of Jackson Physician Search executives talked with HealthLeaders about the nature of the physician job market and how healthcare organizations can rise to the challenge of recruiting and retaining clinicians.
"The physician recruitment market is tighter than ever," says Tara Osseck, regional vice president of recruiting at Jackson Physician Search.
To recruit physicians under the current market conditions, healthcare organizations must accentuate the positive aspects of their job opportunities, she says. "When you are looking at strategies to recruit physicians under increasingly competitive market conditions, first and foremost it starts with a very clear understanding of the need then developing a strategic approach to marketing a job's positive differentiators. That can be above average compensation, long-term earning potential, attractive recruitment incentives, a great location, and a fast-track to partnership or career growth. Whatever your positive differentiators or hooks are, you need to be able to leverage those to your advantage."
To be successful in physician recruitment, healthcare organizations need to know about the market for the specialties they are recruiting, Osseck says. "You need to have a keen understanding of physician supply and demand in the particular specialties you are recruiting. You need to understand the annual attrition rate and the people who are coming out of training each year to be able to focus on a realistic candidate pool. That helps establish candidate parameters."
It is also important to be open to candidate feedback and to adapt to market trends, she says. "If you want to be successful and competitive in today's marketplace, you need to be willing to adapt to how younger physicians want to practice, even if you have to deviate from how your older physicians have historically practiced."
Rural healthcare organizations have to be thorough in their physician recruitment efforts, says Brent Barnacle, regional vice president of business development at Jackson Physician Search. "When looking at these rural areas, you have a small candidate pool. So, for healthcare organizations seeking physicians, it is important to be clear about who you are looking for, the scope of work, the compensation, and what your community has to offer. … You can get laser-focused on the type of individual you are looking for culturally and put together an attractive package for job candidates."
In any physician search, it is important to have an efficient hiring process, but this is crucial in rural recruiting, Osseck says. "Before you are working with your first candidate, you need to know the key stakeholders and decision-makers. You need a hiring process that is functioning like a well-oiled machine, which keeps everyone moving with a sense of urgency."
When rural healthcare organizations put together a recruiting package, they need to know what candidates are looking for in a rural community, Barnacle says. "Pushing a five-day workweek can be a difficult thing to overcome because a lot of physicians who are working in rural communities are looking for a good work-life balance. A four-day workweek can be key."
Offering competitive compensation is essential, he says. "Compensation is important and you need to be competitive in your market. The closer healthcare organizations can get to median compensation, the more competitive they can be. If you are lower in compensation, it is going to take more time to find a physician."
Retention strategies
Under the current market conditions, retention of physicians is critical, Barnacle says. "Retention is the conversation of the times, in every industry but more so in healthcare because we have Baby Boomer physicians who are retiring and there are not enough younger physicians coming in to fill those opportunities. You do not want to lose a physician to another organization then have to go through a recruitment process."
Retention starts in the hiring process, he says. "It starts with finding the right cultural fit. It starts with finding the right physician who wants to be a part of your community. It starts with learning about the spouse and the kids such as having schools in the community that are going to be a good fit for the kids. All of those pieces play a role in retention."
Once physicians have been hired, giving them a voice in the organization is pivotal in retention, Barnacle says. "A lot of times, physicians feel there is a disconnect between the C-suite and the physicians. I know the CEO of a large physician group who routinely rounds on all of his physicians and asks, 'What else do you need from me to perform your job at a high level?' Even if he cannot get what a physician is looking for, the physician feels valued, appreciated, and like they have a voice."
Healthcare organizations must be receptive to improving work-life balance, particularly if they want to retain physicians for the long-term, Osseck says. "Flexible schedules and the four-day workweek are becoming increasingly standard. Things that support a flexible schedule include telemedicine partially or exclusively in the scope of practice, block-shift schedules such as seven days on and seven days off, and ways to reduce or eliminate being on call such as having advanced practice providers on call."
Healthcare organizations must design an environment that makes it difficult for physicians to want to leave, she says. "It could be pairing physicians with physician mentors. It could be having physicians participate in focus groups to build two-way communication. It could be working with a spouse and kids to get them networked within the community. It is making personal connections, which some healthcare organizations fail to focus on."
Peter Charvat shares his perspectives as chief clinical officer of the Bon Secours Richmond market.
Emergency medicine provides a solid foundation for serving in physician leadership roles, says Peter Charvat, MD, MBA, chief clinical officer of the Bon Secours Richmond market.
Bon Secours is part of Bon Secours Mercy Health. The Bon Secours Richmond market features seven hospitals.
Charvat's previous position was chief medical officer and vice president at St. Joseph's Main Hospital and St. Joseph's Children's Hospital in Tampa, Florida. Prior to working at St. Joseph's, he was chief medical officer and vice president at Johnston Health in Smithfield, North Carolina. He also served as a physician and Department of Emergency Medicine chair at St. Cloud Hospital in Minnesota.
HealthLeaders recently talked with Charvat about a range of issues, including clinical care predictions for 2023, the primary elements of physician engagement, and the keys to success in physician leadership. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: You have a clinical background in emergency medicine. How has this clinical background helped you serve as a physician leader?
Peter Charvat: First is the experience of working with a diverse group of clinicians and secondly working as a team. Emergency medicine is one of the specialties where you connect with physicians across the spectrum such as hospitalists, pediatricians, obstetricians, and surgeons. That has helped me because in my current role I work with physicians across all medical specialties.
The team-based care model has been just as important in serving as a physician leader. Emergency departments are definitely a place where you have a tightknit team—physicians, nurses, technicians, registration staff, and social workers. There is a full spectrum of frontline team members. We depend on each other and constantly work together. That gave me an appreciation for the skill sets that everybody on the team brings. In emergency medicine, the team makes the physician stronger, and the physician adds to the skill set of others.
HL: How do you rise to the challenge of clinical leadership in a broad and diverse market?
Charvat: First, a lot of my job is engaging, leading, and supporting teams. We have teams at the hospitals, at our service lines, and at our medical group. I try to find out the barriers they are having and how to support their work.
Second, in my role, there is a lot coming at me, and it would be easy to get reactive. I could spend my whole day just responding to what is coming at me. Instead, I do all I can to set aside about 25% of my time to be more proactive and forward-thinking. That's how I help keep the organization moving forward. A lot of that is creating vision—where are we now and how do we build on the success that we have had at Bon Secours Richmond?
HL: You are serving as a regional chief clinical officer. How do you balance overseeing clinical care at multiple facilities?
Charvat: Part of it is connecting with the staff. I make it a point to do rounding every week at our practices and hospitals, which helps me get to know people. That helps me identify the challenges at each of our sites of care and how I can help work through barriers. At lot of this role cannot be done in an office—you must get out and connect with people. I must appreciate the differences at the different sites of care and the market, and I must find ways to support those teams.
Peter Charvat, MD, MBA, chief clinical officer of the Bon Secours Richmond market. Photo courtesy of Bon Secours Mercy Health.
HL: Do you have any clinical care predictions for 2023?
Charvat: We will probably hear a lot more about long COVID and the chronic after-effects of acute COVID infections. We are learning that COVID has two phases: the acute phase, where we have gotten better at diagnosis and treatment, and the after-effect phase after infection, which affects multiple organs and can have multiple effects. We are challenged with how we diagnose long COVID, and we have few treatment options. This year, we are going to be increasingly focused on the long COVID syndrome, trying to come to a common understanding of what long COVID means, and supporting patients through their journey with long COVID.
In addition, toward the end of 2022 we saw a rise in non-COVID respiratory infections. We probably took our eye off the ball a little bit for influenza and RSV, and we saw them come on strongly at the end of last year. In 2023, we need to remain diligent—in addition to COVID, there are many other respiratory illnesses that we need to be aware of. We need to push for immunizations and preventive care.
HL: What are the primary elements of physician engagement?
Charvat: To sum it up in three words, it's credentials, objectivity, and similarity.
If you are going to engage and work closely with physicians, as a leader you must have credentials. We need to bring something to the table, whether it is administrative expertise or an understanding of what physicians need in their practice. We must bring value to the conversation with physicians.
In terms of objectivity, when we engage physicians, we must be open-minded and objective. We may not always be on the same page or see things exactly the same, but as leaders we need to be objective, to put ourselves in physicians' frame of reference, and to understand the challenges they are facing in clinical practice.
For similarity, we may have some differences, but we need to focus on what we agree upon such as high-quality patient care, safety absolutes, and putting the patient first. From there, how can we engage and have conversations about how we support physician practice and how physicians can support patients and the organization?
HL: What are the keys to success for physician leadership?
Charvat: One thing is to diversify your skill set. When I transitioned from clinical practice to an administrative role, I realized that I had a lot of gaps in nonclinical skills such as finance and human resources. We are constant students in medicine—there is research to follow, new techniques, new therapies, and diagnostic options available. In the clinical world, physicians are constantly learning, and when you take on administrative roles learning must continue.
Physician leaders also need to see the perspectives of those they work with and be part of a team. In medicine, you are working closely with clinical teams such as other physicians and nurses. When you get into leadership roles, you are spending time with non-clinician leaders. You need to be aware of everybody's perspectives and the unique skills they bring to the table. You need to complement each other and emerge stronger as a team.
HL: Now that the crisis phase of the coronavirus pandemic has passed, what are the primary clinical challenges at Bon Secours Mercy Health?
Charvat: Two things that come top of mind are clinical workforce and more complex patients.
Early in the pandemic, we saw a lot of frontline healthcare workers leaving the workforce or moving to different positions, s there were shortages, which we saw a lot in nursing. Fortunately, we have been able to develop some programs to respond to this challenge, and we have done a good job at attracting and retaining talent.
The other thing is that, overall, patients are becoming more medically complex. There is a lot more chronic illness, and we need to continue to prepare to provide higher levels of service to patients in our hospitals. There is a shift of care from the inpatient to the outpatient setting, but at the same time, the patients who are in the hospitals are very complex, with comorbidities and chronic conditions. Fortunately, we have a lot of diagnostic and treatment options. We need to position ourselves with education, training, technology, and resources to manage this increasingly complex patient population.
HL: What are the primary efforts you have in place to address workforce shortages?
Charvat: We are looking at educational opportunities for our associates—giving them opportunities for new degrees and training. We are giving associates opportunities for mobility within the organization. Fortunately, we are very broad and diverse, so we have a variety of opportunities within our markets. We are also providing appropriate work-life balance for the well-being needs of our associates.
For the physician workforce, we are focusing on physician well-being. We are trying to support the health of our practitioners. We also have many opportunities for physicians in our organization—different hospitals, different practices, inpatient settings, and outpatient settings. We can offer a range of work experiences that can draw physicians to our markets.
HL: Why is patient medical complexity increasing?
Charvat: One factor is we have become better at managing disease, so we are able to care for patients longer and longer through their diseases. We can manage chronic illnesses. If you look at the new technologies and therapies that we have compared to where we were 20 years ago, we have a lot more treatment options available.
There are also demographics. The population is getting older, and naturally they are going to have more illnesses and chronic disease. We are going to see more and more patients with a multitude of chronic illnesses that need management.
Primary care visits when mental health conditions were the main diagnosis increased nearly 50% from 2006 to 2018, a new study found.
The number of primary care visits for a mental health concern increased from 2006 to 2018, according to a new research article.
According to the National Institute of Mental Health, nearly one in five American adults had a mental, emotional, or behavioral condition in 2020. Mental health conditions have been associated with increased healthcare utilization.
The new research article, which was published in Health Affairs, is based on data collected from more than 100,000 primary care visits from 2006 to 2018. Data was drawn from the National Ambulatory Medical Care Survey.
The new research article has several key data points:
Primary care visits that had a mental health condition as a primary diagnosis increased from 3.4% of visits in 2006-2007 to 6.3% of visits by 2016 and 2018
Primary care visits that addressed a mental health concern including visits when a mental health concern was not a primary diagnosis increased from 10.7% of visits in 2006-2007 to 15.9% of visits by 2016 and 2018
Four factors were associated with a greater likelihood that a mental health concern would be addressed during a primary care visit: younger age, payment through Medicare or Medicaid, female sex, and the visit physician being the patient's usual primary care physician
Patients identified as Black or other race were less likely to have a mental health concern addressed in a primary care visit than White patients
Anxiety and stress-related diagnoses were the most common mental health concerns addressed in primary care visits, peaking at 38.0% of visits for a mental health condition in 2014-2015
The percentage of primary care visits to address depressive symptoms decreased from 32.4% in 2006-2007 to 20.8% in 2016 and 2018
The percentage of primary care visits to address serious mental illness decreased from 5.4% of visits in 2006-2007 to 3.0% of visits in 2016 and 2018
Nearly three-quarters of primary care visits to address a mental health concern resulted in treatment with psychotropic medication, counseling and psychotherapy, or referral to another physician
The most common treatment offered in primary care visits for a mental health concern was a prescription for a psychotropic medication
Interpreting the data
The increase in primary care visits to address a mental health concern during the study period raises questions about the sustainability of U.S. primary care, the research article's co-authors wrote. "Although the number of graduating medical students entering primary care specialties continues to be insufficient to meet the growing needs of an aging population, primary care physicians have been asked to provide more and more services, both within the context of the visit and during the intervals between visits."
To avoid strain on U.S. primary care, primary care physicians should have adequate preparation and resources to address mental health concerns, the research article's co-authors wrote. "In the context of policy and care delivery changes, equipping primary care providers to address mental health needs is crucial. Resources and systems that support primary care and behavioral health integration, including co-located therapy or psychiatry providers, e-consultation services, longer visit lengths, and billing and documentation systems that simplify addressing both mental and physical health needs may help ease the increasing pressure on primary care providers seeking to address their patients' needs globally."
Patients who had visits with their usual primary care physician were more likely to receive care for mental health conditions, the co-authors wrote. "Not surprisingly, mental health concerns were significantly more likely to be addressed in a visit with a patient's usual primary care physician than in a visit with another primary care physician. In addition, a patient's own primary care physician was more likely to prescribe a medication to a patient with a mental health concern."
The data indicate there is a healthcare disparity based on race for primary care visits to address a mental health concern, the co-authors wrote. "Black and Hispanic patients in our sample were disproportionately less likely to have a mental health concern addressed in the context of a primary care visit. The differences in our study in the likelihood of Black or Hispanic patients having a mental health concern addressed outweigh the differences in prevalence of any mental illness among Black versus White and Hispanic versus non-Hispanic people reported in recent national estimates from the National Survey on Drug Use and Health."
The study's findings can help guide changes in primary care in the United States, the co-authors wrote. "Given the significant prevalence of mental health diagnoses, the impact of comorbid mental health conditions on utilization, and shortages of mental health professionals, these findings have important implications for the future organization and financing of U.S. primary care."
The hospital association says it is focusing advocacy on workplace violence, Medicare residency slots, the nursing shortage, and workforce diversity.
Strengthening the healthcare workforce is one of the top priorities of the American Hospital Association's advocacy agenda for 2023.
Health systems and hospitals are facing workforce shortages across the full spectrum of their employees. In addition to a well-recognized shortage of nurses nationwide, health systems and hospitals are struggling to fill openings among physicians, technicians, and other job positions.
The American Hospital Association recently released the organization's 2023 advocacy agenda. In addition to strengthening the healthcare workforce, the AHA is targeting three other areas: ensuring access to care and providing financial relief; advancing quality, equity, and transformation; and enacting regulatory and administrative relief.
A pair of AHA executives spoke with HealthLeaders today about the organization's focus on strengthening the healthcare workforce. "Workforce is the Number One concern for hospitals across the country," says Priscilla Ross, executive director of executive branch relations and senior director of federal relations.
Addressing workplace violence
She says addressing workplace violence and intimidation is a key focal point for the AHA.
"Over the past few years and during the coronavirus pandemic, we have seen a sharp increase in the number of violent incidents at hospitals, particularly physical attacks on staff. It is demoralizing. It harms the quality of care because providers must spend time focusing on deflecting attacks and recovering from attacks, rather than focusing on patient care. It has become a big issue across the board. It is something we hear about from our hospitals on a consistent basis," she says.
Workplace violence and intimidation is taking a heavy toll on staff members, Ross says. "In addition to being demoralizing, workplace violence makes staff fearful of dealing with patients. It is causing stress, burnout, and prompting staff to decide they do not want to practice in a hospital setting anymore."
Increasing Medicare residency slots
The AHA is also focusing on increasing the number of residency slots eligible for Medicare funding to address physician shortages, she says.
"We have seen estimates that the physician shortage is going to reach 124,000 physicians within the next 10 years. That is going to jeopardize access to care in communities across our nation. The Medicare Graduate Medical Education program was created at Medicare's inception in 1965 to ensure that Medicare beneficiaries had access to providers. Congress decided that the Medicare program would play a role in funding graduate medical education. Unfortunately, back in the Balanced Budget Act of 1997, Congress decided to freeze the number of Medicare-funded residency slots to about 90,000 slots," Ross says.
The AHA has supported federal legislation that has been bipartisan and bicameral for several years that would add a significant number of Medicare-funded residency slots to the program, she says. "The most recent bill in the last Congress was the bipartisan Resident Physician Shortage Reduction Act, which would have added 14,000 new residency slots over seven years. We need to have additional funding so that communities can have an adequate number of physicians."
Tackling the nursing shortage
The AHA also plans to support measures that would help address the nursing shortage, says Akin Demehin, senior director of quality and patient safety. "The nursing shortage did not happen overnight. There have been structural shifts and demographic shifts in the nursing workforce. Prior to the COVID-19 pandemic, about half of nurses were age 50 and over, and about 30% were age 60 and over. So, just from that perspective, there was a need to replace the portion of the nursing workforce that was approaching retirement age. The pandemic served as a profound accelerant, with nurses facing wave after wave of COVID patients, experiencing increased incidences of violence, and many readying for the next phase of their lives in retirement."
Several efforts can increase the nursing workforce, he says. "The first is investing in faculty for training nurses. Nursing faculty are in significant shortage, so much so that about 80,000 applicants to nursing schools who were qualified to attend nursing school had to be turned away, in large part because there were not enough faculty to train them. We have supported legislation to help address the faculty shortage—the Future Advancement of Academic Nursing Act.
There are also short-term actions targeting regulation that could bolster the nursing workforce, Demehin says.
"We need to look critically at the range of regulations that affect nursing workload and increase burden without necessarily adding value in terms of quality of care. There were some flexibilities granted during the pandemic's public health emergency that were very helpful for the nursing workforce. For example, we would like to see changes to the discharge planning requirements that are administratively intense but are not necessarily leading to the better transitions in care that were the original intent. Another example is doing away with Medicare requirements around advanced practice nurses that are more restrictive than state laws—that could be a step forward in encouraging flexibility in the nursing workforce," he says.
Boosting healthcare worker diversity
The AHA is also planning to support efforts to increase diversity in the healthcare workforce.
Ross says the AHA has been supporting federal legislation that would boost diversity in the physician workforce.
"In the last Congress, there was a part of the Build Back Better Act called Pathways to Practice that established 1,000 new fully funded medical school scholarships for medical school or post-baccalaureate studies for people who came from disadvantaged backgrounds, rural areas, were the first in their families to attend college, or graduates of historically black colleges and universities. In addition to tuition, Pathways to Practice provided a stipend for students. It would have taken great strides toward increasing diversity for those who find pursuing a medical career out of reach. It passed in the House, but it did not make it through the Senate," she says.
The AHA is supporting work at the local level to promote diversity throughout the healthcare workforce, Demehin says. "What we hear from AHA members about their diversity work above and beyond the physician workforce is that the work takes place at the local level through partnerships with local schools and colleges to create linkages for those who are considering health professions as a career. Members are reaching out in intentional ways to diverse communities to encourage them to work in the healthcare field. Ultimately, improving diversity can help us take better care of the communities that we serve."
Education and communication are essential when healthcare providers address vaccine hesitancy for vaccine-preventable diseases.
At the national level, vaccination rates for vaccine-preventable diseases are stable, but healthcare providers need to address vaccine hesitancy at the local level, an infectious disease expert says.
Last year's polio outbreak in New York and a spike in measles cases in 2019 are recent examples of alarming flare ups of vaccine-preventable diseases in the United States. As of Jan. 4, about 81% of the U.S. population had received at least one dose of a COVID-19 vaccine, with about 69% of the population fully vaccinated.
While national vaccination rates for vaccine-preventable diseases such as measles are relatively high and stable, healthcare providers need to be on guard for vaccination lapses at the local level, says Susan Koletar, MD, a practicing physician and director of the Division of Infectious Diseases at The Ohio State Wexner Medical Center in Columbus, Ohio.
"Some of it is education and hesitancy among populations who have themselves benefited from vaccines. Vaccination rates are stable, but the world is small. You can get on a plane and be anywhere in less than 24 hours and be exposed to a range of diseases. The question is, why are vaccines not more broadly utilized? We don't talk enough to our patients about vaccines—that's not just doctors, it is also nurses and pharmacists. Something as important as vaccines requires some time and explanation and understanding of what drives people's behavior to get vaccinated or not," she says.
Social determinants of health are a key factor in local lapses of vaccinations, Koletar says. "We must pay attention to the social determinants of health. If you look at the vaccine surveys, while vaccination rates are pretty stable, there are clearly groups of people who are less economically advantaged or minority populations where the numbers are not as good. …. At the foundation, social determinants of health and vaccination intersect at access to healthcare and pharmacies. Do people have the means to have access to good healthcare? When you think about vaccines, you can walk into any Walgreens and get several vaccines, and you can get the COVID vaccine at several locations, but if you do not have the economic means or transportation to get to those places, that impacts vaccine uptake."
Addressing vaccine hesitancy
In addition to education, communication between healthcare providers and their patients is crucial to address vaccine hesitancy, she says. "With the communication, it needs to be a two-way street. We need to talk with our patients and find out what they know about diseases and what they know about the consequences of not getting vaccinated. We also need to dispel myths such as getting the flu from flu vaccination. Communication is key because healthcare providers need to understand what patients think and what drives their behavior on vaccination. Do they think they are going to get a disease from a vaccination? Do they think there is a nefarious plot to inject chips with vaccines, which was misinformation during the COVID pandemic. Are they worried that their children will be at risk for autism? So, you need honest conversation and to try to understand what people's concerns are. It takes time to deliver good healthcare, and we need to take time to communicate."
Effective communication is essential when patients have been misinformed about vaccinations, Koletar says. "You must ask patients what they think they know, what they have heard, and what their sources are. You must start with the basics. Where did you hear your information? You need to be nonjudgmental—did you get your information from respected authorities or respected community members? We have learned a lot about providing information during the COVID pandemic. Did you get your information from Tony Fauci or did you pick it up on Facebook?"
When dealing with vaccine hesitancy, healthcare providers must be honest with their patients, she says. "I am honest about what we know and what we do not know. That was critically important during the pandemic. There were a lot of questions that we did not know the answers to. One of those questions was about long-term side effects from the COVID vaccines, which we did not know. We could not tell patients what was going to happen in 10 years because the vaccines were new. Sometimes, that is comforting, but often it is not comforting. However, there is value in honesty."
Healthcare providers cannot force their patients to get vaccinated, and the best approach to encouraging vaccination is shared decision-making, Koletar says. "You must realize that you cannot always talk your patients into getting vaccinated. You give the best information you can and the best evidence of what the outcomes will be, then make the decision together. Shared decision-making is critical in the delivery of healthcare. You cannot hold someone down and give them a vaccine—all you can do is give your best advice."
The supply chain leader of Allegheny Health Network says it is important to manage expectations at this stage of the coronavirus pandemic.
At Allegheny Health Network (AHN), the top supply challenges include supply resiliency and inflation, the health system's senior vice president of supply chain says.
Alan Wilde, MBA, has been senior vice president of supply chain at AHN since June 2019. Previously, he served as interim senior vice president of supply chain at WellStar Health System, vice president of enterprise facilities management and supply chain at BayCare Health System, and vice president of supply chain at University Hospitals.
Wilde recently talked with HealthLeaders about a range of issues, including supply chain challenges at AHN, AHN's group purchasing organization, and involving clinicians in supply chain decision-making. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: What are the primary challenges of serving as the top supply chain officer at AHN?
Alan Wilde: Right now, it is about supply resiliency. Getting out of COVID, goods and labor for doing the things we need to do for the health system are key factors. We have had several inconsistencies in the supply chain during the coronavirus pandemic—we are trying to get out of that. Inflation is a challenge—a lot of our suppliers are saying they needed to raise wages for their labor that produces supplies for us. We have had pointed responses to them—we are not seeing increases in reimbursement from commercial insurance carriers as well as Medicare and Medicaid. So, we have no where to go.
Also, internally, I have been trying to manage expectations. There is a general feeling that COVID is over or significantly reduced. There is an expectation that we can get back to doing the things we were doing before the pandemic. I need to manage those expectations.
HL: What are the primary inconsistencies you have been experiencing in the supply chain?
Wilde: We are still on allocation for some supplies such as needles, syringes, and several plastic products. It is starting to fall off, but not as quickly as we would hope. We have made some switches to other suppliers because of the incumbents' inability to deliver for us. Some of our suppliers left us high and dry, so we have had some conversations about not going back to them.
HL: How is supply chain managed at AHN?
Wilde: We manage supply chain centrally. I have a corporate supply chain function. Within that is sourcing, procurement, our own warehouse and distribution function, our own pharmacy warehouse, and I have a group that does clinical integration—they help us work with physicians on product decisions and when we are going out to bid. The clinical integration team also helps us with standardization efforts and converting from one product to another. Our clinical integration team is our secret sauce—I have been able to hire some former sales reps, and they are adept at talking with physicians. They nurture relationships.
HL: How does your group purchasing organization function?
Wilde: We are a member of Vizient, so we use Vizient for most of our commodity items. For the physician preference items, we have created a local and regional GPO called Provider PPI. We have contracts for all of the different parts of the body. We also market those contracts to members in Delaware, Pennsylvania, and West Virginia. We have about 80 hospitals that are utilizing our contracts.
HL: How big of a challenge is it to have 80 hospitals utilizing your contracts?
Wilde: It is challenging. Most of our contracts are dual source or multi-source. And we are basically an a la carte kind of GPO. You can sign up for the orthopedic contract, you can sign up for shoulder implants—you do not have to sign up for pacemakers and defibrillators. You can pick and choose the contracts you sign up for. The challenge is whether we have the two or three orthopedic vendors on contract that hits the mix of another hospital. The other hospital may be a heavy user of Smith & Nephew, but we do not have Smith & Nephew on our contract.
Where there is a fit, we have seen a lot of traction. We have delivered a lot of savings to our members.
Alan Wilde, MBA, senior vice president of supply chain at Allegheny Health Network. Photo courtesy of Allegheny Health Network.
HL: What were the primary supply chain challenges AHN faced during the coronavirus pandemic?
Wilde: It was mainly about supply availability. There was not a lot of slack in the supply chain. There were a lot of just-in-time inventory practices. We were lucky that we had our own warehouse, which gave us about 20 days of buffer. That gave us an ability to go out and find new sources for products.
The other challenge we had was making decisions quickly. Traditionally, you would get samples of supplies and have your clinicians look at them. We would be told, "It's available. Buy it now or it is going to be gone in the next hour." So, we ended up having to take some leaps of faith with our clinicians.
There was a lot of fraud going on, which we got adept at figuring out. We had some suppliers who would take certifications from the Food and Drug Administration and slap them on their products—they would be certifications for another manufacturer. We ended up reaching out to law enforcement such as the FBI and educated them about some of the things that were going on.
HL: How did you rise to that fraud challenge?
Wilde: Before we would buy from a previously unknown supplier, we would ask for certifications. Then we used some tools—we would go to the FDA website and put in a manufacturer's number, and it would tell you where a product was manufactured, and we would compare that to what the supplier was telling us. If they did not match up, we had a pretty good idea that they were fraudulent.
I had some colleagues at other places and heard horror stories. It was a crisis. We started our day at 7 or 8 a.m. and ended at 7 p.m. It was just calling anybody and everybody. We were calling multiple suppliers for gloves and other supplies that we would have never thought of calling before.
We were lucky. There were a couple of times when I got worried that we were going to run out of supplies within a couple of days. But we were able to find those supplies quickly.
HL: How do you involve clinicians in supply chain decision-making?
Wilde: We will look at a category and benchmark it. We may get information from dealers about physician preference items. We will then engage our physicians in deciding how we are going to do a request for proposal. Are we using three vendors? Can we go down to two vendors? If we are using two vendors, can we go down to one? Are there other things in a category that we need to look at? For the physician preference items, beyond implants, is there instrumentation or other things that we can try to leverage?
Once we get buy-in from physicians, we will send out the bids. We will get the bids back. We will then share the results of those bids with the clinicians. We go through a process to reach the best decision. In some cases, we may include some of the physicians in the negotiation strategies, which can be helpful.
The clinical integration team is heavily involved in bid scenarios. Before we go out to bid, I may have them reach out to physicians and ask how their incumbent vendors are working out. They may ask physicians whether there is a new technology that needs to be incorporated in the bidding process.
HL: What are the primary keys to success in supply chain management?
Wilde: You need to always be open to change. You need to be open to new ideas. I have learned from vendors. I have learned from people in other industries.
You also need to look for opportunities to automate. How can you automate day-to-day activities that are routine and do not add a lot of value? You want to be able to take those people and have them do what I call knowledge work. I would rather be paying people for their brains than their ability to do data entry or other mundane tasks.
Another key to success is keeping your stakeholders involved. Whether that is clinicians, finance people, or operations people, you need to be thinking about keeping them involved.
You also need to be cognizant of the cost of doing change. We may save $100,000 with a change, but it may cost $200,000 to make the change.
There are two other things to consider from a finance perspective. You need to help your accounts payable department and manage the bills. You need to make sure that records are accurate and bills are getting paid on time, so you are not getting put on credit hold or shipping hold. You also need to look at your accruals—your purchase order accruals, your receiving accruals, and invoice accruals. You need to make sure those are accurate because you have a responsibility to make sure the financials of the organization are correct.
The chief medical officer of Allegheny Health Network shares predictions for 2023.
This year, financial pressures on health systems, hospitals, and physician practices will spur innovation, according to the chief medical officer of Allegheny Health Network (AHN).
Donald Whiting, MD, is CMO of AHN; president of the health system's physician organization, Allegheny Clinic; and chair of the AHN Neuroscience Institute. HealthLeaders recently talked with him about a range of issues, including predictions for clinical care in 2023, the challenges of being the top clinical leader at AHN, and physician engagement.
The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: What are your predictions for clinical care in 2023?
Donald Whiting: The financial troubles of 2022 made all providers decide what they needed to do to realign their footprints and realign how they work because the cost of doing business was not going to go down anytime soon with inflation. So, this year, all providers need to reinvent themselves in some way, whether it is consolidating the footprint, going more to virtual care than bricks-and-mortar offices, or changing the services they offer. I also expect a surge in consolidation of providers.
HL: What are the primary challenges of serving as CMO of AHN?
Whiting: The chief medical officer of any organization is the clinical voice of that institution. Over the past several years, there have been many challenges—there's been COVID, the weak finances of providers, and inflation. Helping to bring a clinical sensibility to the issues in healthcare has been a challenge. You need to get all of the providers to understand the issues and be part of the solution.
At AHN, I am concerned about common issues related to quality of care and maintaining access. But for us in particular, we are also part of a large payer, so I look at opportunities to evolve healthcare from taking care of sick people to figuring out how we can keep them healthier. That creates opportunities for us to look at things in a different way than many healthcare providers.
HL: What are some of those opportunities?
Whiting: With us, because we are a provider with a large payer in the same area, we can look at sites of service changes, where we can do better care that is more efficient for the patient. That is not necessarily something that a provider alone would do.
We look at longitudinal care of a patient over time. So, if we can keep patients healthier, then that creates cost savings overall in the healthcare system. We also are focused on providing value-based care.
Donald Whiting, MD, chief medical officer of Allegheny Health Network. Photo courtesy of Allegheny Health Network.
HL: You are also president of AHN's physician organization, Allegheny Clinic. What are the challenges of leading a large physician organization?
Whiting: First of all, managing any physician organization revolves around having standards—standards of behavior, standards of care, and standards of practice. So, maintaining the standards is part of the job, but there is also recruiting good talent and being part of the medical staff development and growth of the provider organization.
HL: What are the primary elements of physician engagement?
Whiting: Physician engagement comes from physicians believing in the mission of your organization. You need to have transparency about the organization's plans and physicians' roles in those plans. Physicians need to understand how they fit into the organization and what their contributions can be. Then, you need to appreciate physicians for what they do.
HL: How do you make sure physicians feel appreciated?
Whiting: We have a couple of ways of doing that. We have core values for the organization, and we conduct core values surveys. Those surveys ask physicians whether they feel appreciated by the people they work with, whether they have friends at work, and whether they get frequent updates on how they are doing. We act on the results of those surveys.
We also have wellness surveys and a robust set of workstreams around improving wellness and feeling appreciated at work.
HL: You are also chair of the AHN Neuroscience Institute. How do you balance your responsibilities as CMO, president of Allegheny Clinic, and chair of the institute?
Whiting: The short answer is I have a strong team that I work with in each of those areas. They help me balance my responsibilities. There is a lot of overlap in each of those roles. For example, being chair of the Neuroscience Institute gives me more on-the-ground information than if I was just the leader of the physician organization—I can give much more direct input on how things are going by being involved in the institute. In the chief medical officer role, it also gives me input and insight into what is going on at the hospital floor level and in the operating rooms. So, my roles are complementary in terms of sources of information.
HL: Are there any commonalities in these teams? How are you being supported?
Whiting: There are commonalities. In the institute, I have a dyad partner who is a service line vice president. As head of the physician organization, all of the service line vice presidents report to me, so I have ground-level information about what the service line vice presidents are dealing with, including trials and tribulations that I can help address. As CMO, I work with the president and the chief operating officer of the entire organization—between me as the CMO and the COO, we are in a dyad relationship that oversees the entire structure of clinical operations.
HL: What are your primary clinical challenges now that the crisis phase of the coronavirus pandemic has passed?
Whiting: Staffing is a big challenge. The people that left during the Great Resignation are not coming back. In our area, hospitals and ambulatory settings are not fully staffed, but the patient volume is coming back. The worry is that if we do not get relief for the people who are doing the work, more people are going to get burned out.
We are doing things to address workforce shortages. For example, on the nursing floors, we are piloting a half virtual, half in-person model, where somebody is at home doing part of the work and somebody is on the floor doing the hands-on work. This creates a pool of people you normally would not have been able to recruit, such as nurses who retired early but have good skill sets.
HL: What kinds of workforce shortages are you experiencing at AHN?
Whiting: It is across the board—we could use more of everything. We need CT techs, nurse's aides, medical assistants, nurses, and pharmacy techs. We need people in almost every area.
HL: What are the primary efforts you have in place to address workforce shortages?
Whiting: We are going upstream—we are working with high schools, community colleges, and trade schools. We are trying to get to people earlier. We are doing exploration visits such as bringing in high school and college students to shadow staff members to see what our jobs are like. We are providing scholarships to students if they commit to us when they are done with their studies. We are providing flexibility in our nursing schedules—someone can work just on weekends if they want that schedule, or work just four hours or eight hours if they are working somewhere else.
We are also working on retention. There has been lot of base salary increases to retain the people we have. There have been retention bonuses in certain areas. We try to care for employees as if they were family—we want them to feel as though they are cared for. We want to be a place where people want to work because we are a place that cares about their people.
A new healthcare report from The Commonwealth Fund finds that the United States does not compare favorably to other high-income countries.
Despite spending more on healthcare than other high-income countries, the United States lags peer countries in several measures of healthcare performance, according to a new report from The Commonwealth Fund.
The new report mirrors the findings of a 2020 report from The Commonwealth Fund. The 2020 report found that the United States spent nearly twice as much on healthcare as the average level of spending at Organisation for Economic Co-operation and Development (OECD) countries and had the lowest life expectancy and highest suicide rates among 11 OECD countries.
The new report, which was published today, compares U.S. healthcare to healthcare in Australia, Canada, France, Germany, Japan, the Netherlands, New Zealand, Norway, South Korea, Sweden, Switzerland, and the United Kingdom. The report also compares U.S. healthcare to average performance for the 38 high-income OECD countries for which data are available.
In 2021, the United States spent 17.8% of its gross domestic product on healthcare, which was nearly twice the level of spending of the average OECD country, according to the new report.
In the new report, the United States compared unfavorably with other OECD countries on several measures:
In 2021, 8.6% of Americans were uninsured, and the United States was the only high-income country with a substantial segment of the population with no form of health insurance.
In 2020, U.S. life expectancy at birth was 77 years, which was three years lower than the OECD average.
In 2020, the United States had the highest avoidable mortality rate among all of the countries in The Commonwealth Fund's analysis. Avoidable mortality is defined as deaths that are preventable and treatable through public health measures and primary prevention such as exercise.
In 2020, the U.S. infant mortality rate was 5.4 deaths per 1,000 live births, which was the highest rate among all the countries in the analysis.
In 2020, there were nearly 24 maternal deaths for every 100,000 live births in the United States, which was more than three times the rate in most of the other high-income countries.
The United States had the third-highest suicide rate among OECD countries.
The United States had far more deaths from physical assault including gun violence, with 7.4 deaths per 100,000 people compared to the OECD average of 2.7.
The United States has an obesity rate nearly two times higher than the OECD average.
In 2020, nearly one-third of U.S. adults reported being diagnosed with two or more chronic conditions in survey data. In other OECD countries, no more than a quarter of residents reported being diagnosed with two or more chronic conditions.
More Americans have died from the coronavirus than residents in other OECD countries.
Americans visit a doctor less than the OECD average, with four visits per American per year.
The United States has fewer hospital beds than most other OECD countries, with 2.8 hospital beds per 1,000 population compared to the OECD average of 4.3 hospital beds.
The United States has one of the lowest COVID-19 vaccination rates compared to other high-income countries.
Addressing U.S. shortcomings
The new report calls on the United States to boost the availability of affordable healthcare services. "While the United States spends more on healthcare than any other high-income country, the nation often performs worse on measures of health and healthcare. For the U.S., a first step to improvement is ensuring that everyone has access to affordable care. Not only is the U.S. the only country we studied that does not have universal health coverage, but its health system can seem designed to discourage people from using services," the report's co-authors wrote.
The new report says the United States can take three additional steps to generate better healthcare outcomes from healthcare spending:
Implementation of the Inflation Reduction Act, which reduces the cost of some drugs and caps out-of-pocket costs for older Americans.
Cost containment: "Other countries have achieved better health outcomes while spending much less on healthcare overall. In the U.S., high prices for health services continue to be the primary driver of this elevated spending," the report's co-authors wrote.
Improved prevention and management of chronic conditions: "Critical to this is developing the capacity to offer comprehensive, continuous, well-coordinated care. Decades of underinvestment, along with an inadequate supply of healthcare providers, have limited many Americans' access to effective primary care," the report's co-authors wrote.
Trinity Health operates its urgent care clinics in joint ventures with Premier Health.
Trinity Health is committed to urgent care growth, according to Daniel Roth, executive vice president and chief clinical officer at the Livonia, Michigan-based health system.
"Urgent care will continue to grow. One of the interesting things to be mindful of is that everybody is growing urgent care, which is creating a more competitive environment. That is why it is important for us to make urgent care easy for people and integrated with our delivery system. Another thing that is going to change in urgent care is that as we meet people's needs, there may be new services that we offer in the urgent care setting that are not delivered in the urgent care setting today," he says.
At Trinity Health, urgent care centers are a key access point and integral part of the health system, Roth says. "For us, it is about whole-person care and being available and accessible to patients. Our vision for urgent care is as an important access point, so people can get care when they want it, where they want it, but in an integrated way. So, urgent care is important for us because it is an accessible point for care when people have urgent issues, and it ties into the rest of our care delivery model including primary care as well as if people need additional care after they have been at an urgent care center such as specialty care."
Urgent care has been fully integrated with the health system, he says. "We want urgent care to be a seamless part of the care journey for patients. We want it to be there when people have an urgent issue, so they can get care when they want it. But urgent care is seamless when patients get follow-up care. If a patient has a fracture and needs follow-up care, we can provide that care. We make it easy for people to continue their care journey. It is important that we integrate a patient's clinical information across the continuum of care. We know the patient if they show up in an urgent care center and they came from one of our primary care practices, or if they end up in one of our hospitals after an urgent care visit."
Urgent care is also a way to lower costs for patients, Roth says. "Urgent care is also good for patients because it is at a lower cost than going to the emergency room. It allows us to partner with patients to lower their out-of-pocket expenses."
Urgent care has grown to be a significant care setting at Trinity Health, he says. "It has evolved a lot, and it will continue to evolve. It has grown to become a much more prominent part of our health system. Whereas in the past we may have relied on the emergency room as a point of access, more and more care is being delivered in an urgent care setting. That is what people want, and we are meeting people's needs. Another way urgent care has evolved at Trinity Health is as we grow our presence in primary care, urgent care has become an integrated partner with primary care."
Trinity Health operates its urgent care centers in joint ventures with Baton Rouge, Louisiana-based Premier Health. "We were looking for somebody who had demonstrated expertise in running high-quality, easy to access urgent care centers on a wide geographic footprint. We did not have that level of expertise within Trinity Health—there are unique skills involved in running urgent care centers. First, Premier Health has broad experience working with health systems and working as health system partners. Second, they have the same shared vision and history as we have around service and mission. Third, they have a focus on quality—we were impressed by their focus on quality of care and quality of service," Roth says.
Redlands Community Hospital has been offering inpatient behavioral health services since the mid-1980s.
Citing financial constraints and relatively low utilization rates, Redlands Community Hospital in California is closing its Behavioral Health Inpatient Adult Unit.
Financing is one of the top challenges for hospitals' behavioral health services. Primary strategies to address inadequate reimbursement of behavioral health services are subsidization and seeking grant funding.
Redlands has been offering inpatient behavioral health services since the mid-1980s. The Behavioral Health Inpatient Adult Unit, which features 18 locked adult beds, is set to close on Feb. 1. The closure will affect 27 staff members.
The hospital will continue to offer outpatient behavioral health services, including a partial hospitalization program.
The decision to close the Behavioral Health Inpatient Adult Unit was not taken lightly, James Holmes, Redlands president and CEO, told HealthLeaders. "Our decision to close the unit comes after a comprehensive review, including the assessment of multiple factors such as the cost of uncompensated care and a decline in patient volume."
Redlands is committed to continuing to offer outpatient behavioral health services, he said. "The inpatient and outpatient services have distinct purposes. Once a patient's mental health is stabilized, outpatient services can further assist the patient in their symptom management and treatment goals at a lower level of care with the goal of community integration. Our outpatient care programs help individuals get the services they need, while reducing the likelihood of hospitalization. Across the board, both culturally and medically, outpatient care is often the preferred method of care by patients and their families. We are committed to continuing to provide access to outpatient behavioral health services."
Redlands does not expect the closure of the inpatient unit to have a significant impact on mental health services in the region, Holmes said. "The Redlands Community Hospital inpatient volume has been down. Additionally, the Inland Empire has other behavioral health service providers that have larger capacity and specialize in a broader range of services. Redlands Community Hospital has informed these facilities of its closure to ensure a smooth transition."
Three hospitals in the region have larger inpatient behavioral health programs: Loma Linda Medical Center with 87 beds, Arrowhead Regional Medical Center with 90 beds, and the Community Hospital of San Bernardino with 99 beds.
Finances and related challenges were key factors in the decision to close the inpatient behavioral health unit, Holmes said. "Nationally and locally, hospitals and health systems have experienced financial challenges since the coronavirus pandemic began and Redlands Community Hospital is not immune. Like most industries, we have experienced staffing issues, supply chain disruptions, inflation, and the rising cost of doing business. The cost for uncompensated care is another factor in this challenging equation as we absorb additional costs post-pandemic."
Closing the inpatient behavioral health unit is in the best interest of the hospital and the communities it serves, he said. "Just as we did during the pandemic, by coming together, we are able to innovate and create initiatives that serve the greater good. We need to remain strong so we can keep individuals healthy and be there for our communities that depend on our services."
Redlands employs 1,700 staff members and about 300 physicians work at the hospital. The facility has an annual budget of $350 million.
