Their are seven MedExpress Urgent Care offices in the Pittsburgh area, creating another option for patients in the region's healthcare network. Patients with nonlife-threatening illnesses or injuries can walk in to MedExpress offices without an appointment, see a physician and in most cases pay their typical co-payment.
These are challenging times for hospitals and groups trying to increase their ranks, but a strategic, responsive approach to the recruiting effort can make a big difference between hiring success and failure.
Last August, hospital executives and physician leaders at a hospital in rural Arkansas who had been trying to bring on a new general surgeon for nearly a year were elated when an ideal candidate delivered a glowing report on his interview experience. He liked the facility, and he couldn't imagine working with a more talented group of surgeons. Everyone he and his wife met had gone out of their way to make the couple feel welcome--as did all of the people they encountered in the small community, which was pretty much exactly the kind of place he and his wife hoped to raise their family.
But when the CEO tried to translate that positive experience into a statement that might elicit the young surgeon's likelihood of accepting the position, the balloon burst. He was interested, yes, but he had two more interviews that week, and was still working his way through the more than four dozen positions he was being asked to consider.
His final words were along the lines of "I'll keep you posted--and will let you know in a month or two." Two months later the surgeon took a position, one of the dozen he had interviewed for, elsewhere.
That kind of story is, unfortunately, not all that unusual these days--and it's happening not just in typically hard to recruit to rural communities but even in the urban centers that once had the relative luxury of simply tapping their top candidate. These days, more and more practice opportunities are open even in desirable urban markets such as Dallas, Chicago and Cleveland
As the physician shortage in our country becomes more acute, hospitals and physician groups desperately seeking more hands on deck are increasingly finding themselves in the "rejected" pile. In some cases that's because the offer isn't competitive or attractive (or both). But for the most part, it's because of the basic economic principles of supply and demand. There simply aren't enough physicians to fill the seemingly unending list of vacancies.
Physician job boards boast thousands of postings, and there are thousands more opportunities not being advertised on the Internet. The medical schools aren't expanding rapidly enough to address the void. In fact, the medical school graduation rate has been effectively flat since the 1980s, despite the population increase and growing demand for physician services.
For those who want to know just how severe the shortage situation is, there's no dearth of "bad news" numbers. In addition to the now widely accepted prediction that the United States will be short as many as 200,000 physicians by 2020 because of the aging population and a host of other factors, consider the following:
One in three of the nearly 800,000 physicians practicing today is over the age of 55, and a growing number of physicians are electing early retirement (before age 65), largely for personal reasons, according to American Medical Association data.
More than half of U.S. hospitals faced substantial, consistent gaps in specialist coverage in their emergency departments between 2005 and 2007, especially in orthopedics and neurology, according to American Hospital Association survey data.
The primary care shortage is worsening by the year, as evidenced by the fact that only 20% of internal medicine third-year residents chose primary care in 2005, down from nearly 55 percent in 1998, according to a recent report from the Center for Studying Health System Change.
The Bureau of Labor Statistics put the unemployment rate among U.S. physicians and surgeons at a miniscule 0.7 percent in 2006--which essentially means that there is no unemployment among doctors.
Shortages exist across the board, for all types of physicians, but the situation is especially dire--an estimated 20 percent or higher--in the following specialties and sectors: cardiology, family practice, general surgery, internal medicine, hospital medicine (hospitalists), oncology, orthopedic surgery, psychiatry and urology.
Strategic approach can yield success
That's the bad news, but there is a potential flip side: Hospitals and other hiring entities, in general, don't use all of the tools at their disposal to attract candidates and to differentiate their opportunities. And to those that make a concerted effort to recruit, a strategic and candidate-friendly approach to recruiting can increase the likelihood that, all other things--compensation and benefits, practice conditions and workload--being roughly equal, candidates might favor their opportunity.
In reality, however, most hospitals and groups in the hiring mode overlook their own opportunities to seal the deal. That's either because they're not truly cognizant of the current market conditions and challenges they face, or because they are not responsive enough to candidates who do exhibit an interest in the practice opportunity. Following are a few key areas in which a combination of reality check and recruiting-strategy readjustment might make a difference in the outcome:
Understand current market dynamics and the changing profile of the new generation of physicians, and adjust expectations accordingly. Competition for all candidates is stiff, and hiring entities should have a handle on both the local and national marketplace trends--especially in the areas of candidate supply, compensation, expected productivity and current trends within that specialty. Operating on old data, or designing and describing a new position based largely on a previous recruiting experience, are surefire ways to set up a search for failure. In short, an approach that worked five years ago likely won't work today, and as it's often said in the financial arena, past performance is no assurance of future success.
In short, facilities and groups absolutely must use every tool in their proverbial kits today when trying to recruit physicians. That means "sourcing" prospective candidates using every method possible including: Internet postings, journal advertisements, direct mail campaigns, cold calling, e-mail campaigns, physician career fairs and consistent communications with training programs. In the old days, using only one or two modes of getting the word out might have worked; now, savvy hiring entities understand that sourcing candidates is a process, not an event.
Similarly, hiring entities must understand that the physicians coming out of training today are a different breed than their predecessors. It used to be that doctors looking for a new practice opportunity asked two questions: Where is it, and how much does it pay? Now there is a third question: How hard do I have to work to make that sum? Most physicians today have no interest in working 70 or 80 hours a week, even for above-market compensation. The upshot is that the hospital or group may have to significantly adjust its expectations in terms of workload for the prospective physician; as some industry observers have put it, it takes about 1½ physicians today to fill the shoes of one who is retiring.
Likewise, hiring entities should avoid setting their sights on the stratosphere when envisioning their ideal candidate. We commonly encounter clients whose candidate parameters are not just broad, they're actually unrealistic and, often, unachievable in this market. The suburban community hospital that has its sights set on hiring an "American born and trained, board-certified surgeon who is under 40 and has strong personal ties to our area" is setting itself up for a very long search, at the least, and possibly an impossible task.
It's important to look not just at what the hospital or group wants, but at what it truly needs, which may mean letting go of certain expectations and not getting hung up on credentials or "pedigree." (Keep in mind that medicine's "superstars" may not always be top notch when it comes to colleague and patient relations, or may not be willing to toe the line when it comes to institutional policies and procedures.) It's not unlike what we recently saw in pro football, when formerly unremarkable--and now star--quarterbacks Tony Romo and Tom Brady persisted through six plus rounds of the draft. At the very least, the laundry list of parameters may have to be pared down and candidates should be evaluated based on their individual merits, not based on broad classifications that may apply.
Plan for, design--and deliver--a truly spectacular interview experience. It is surprising, frankly, how many hospitals and hiring organizations don't put the requisite effort into identifying and publicizing the positive differentiators for the position they're offering. That's an activity that should be thorough and thoughtful, and the ensuing script should be well communicated to everyone who will "touch" a prospective candidate--from the recruiter to the potential colleague and the practice administrator.
In some cases, that effort may ultimately entail being prepared to gently correct a misinformed candidate--the surgeon who has been told that she can earn $400,000 at a competing opportunity one town down the road, for example, may not be aware that the competing entity doesn't offer much in the way of a "soft landing" when the income guarantee expires, or that its physicians have a call schedule from purgatory compared to the one your group can ensure.
On a similar front, the hiring organization should ensure that a prospective candidate who inquires about the opportunity is met with a friendly, timely response. We have often heard that physicians' CVs sit on a desk unread for a week, or that a call goes unreturned for days simply because the recruiting physician in charge of the search is "too busy" to call the doctor back. That's not only rude; it's a recipe for disaster, given that in today's market that interested physician is likely to have six interview offers while he's awaiting that return phone call.
When the interested candidate does make the trip, prospective employers should plan not only a positive interview experience but also a thorough one--one that will give the candidate a real sense of the collegial atmosphere, the physical working environment and the community. Oddly, in our experience, about one third of hospitals pay scant attention to designing an actual interview itinerary, when ideally, that itinerary should be both well planned and robust. It should include not just the facility tour, meetings with key physicians, a guided excursion through the town and dinner at the best local restaurant, but also informal (but planned) friendly welcomes from other hospital or practice staff the physician would work with.
Sometimes, accomplishing that is a mere matter of sending a memo to other medical staff the day before the candidate's arrival, asking them to welcome the physician when they encounter her and express excitement about the visit. Little things go a long way in making individuals feel wanted, and pulling out all the stops can make an already positive experience more so. For example, ensuring that the visiting physician is picked up at the airport, and arranging for flowers or some sort of personalized welcome in the hotel room, should be considered musts in this competitive market.
On a final note, it's important--if understandably difficult--to keep a positive outlook even in the face of repeated turndowns. Hospitals and groups that have wooed and lost a half-dozen candidates in as many months may feel defeated, but they should avoid exhibiting that to the next candidate--or they could be headed for more disappointments. Remember the famous quote by Malcolm S. Forbes, who once said that "failure is success if we learn from it."
Jim Stone is a co-founder of the national recruiting firm Medicus Partners, based in Dallas.
Fast Company canvassed the experts, analyzed the products, and crunched the numbers. From visionary upstarts to storied stalwarts, here are companies that dazzle with new ideas--and prove beyond a doubt how business is a force for change. They call them the Fast 50.
Three orthopedic hand surgeons have lost the privilege to treat patients at Lehigh Valley Hospital in Allentown, PA, because they won't accept every hand injury case transferred to the facility's emergency room when they are on call. Specially trained hand surgeons are in short supply nationwide and the private practice is being inundated with cases from hospitals outside the service area, said one of the surgeons involved.
Specialty concierge practices are springing up and jostling for footing among internal medicine-based concierge groups in Collier County, FL. The Collier County Medical Society reports 14 physicians are operating concierge practices; but there may be more who aren't members of the medical society.
The Senate Finance Committee has banned the American Medical Association from discussions about an upcoming Medicare package that would stop a 10 percent cut to physician fees. "AMA lost the trust" of Finance Committee Chair Max Baucus "when it broke a confidentiality agreement about Medicare talks last year and informed state affiliates," according to CongressDaily. The cuts are scheduled to go into effect on July 1.
The opinions a physician forms about a new practice or hospital during the recruitment process set the tone for the remainder of the professional relationship. These initial impressions can determine whether the physician becomes an integral member of the facility or moves on after a short stint. But it's hard for physicians to come away with a good first impression if they don't trust the first person they typically meet during the recruitment process--the physician recruiter.
Unless a physician had a previous relationship with the facility or found the opening through word of mouth, it's increasingly likely that he or she was contacted by a recruiter, either from a search firm or based out of a hospital.
And there's a good chance that recruiter won't be well-received. A member of a physician-only social networking site recently asked colleagues if they had ever been lied to by a physician recruiter--only 6 percent of the 107 respondents to the online poll said no. More than 90 percent said they had been lied to directly or heard second-hand stories of recruiters being untruthful. Granted, this wasn't a scientific survey and the results should be taken with a grain of salt. But it does point to a growing distrust of recruiters that hospitals and practices should be aware of. Physicians often feel that recruiters in placement firms are salesmen who will say or do whatever it takes to get a commission, even if they aren't able to live up to the expectations they set, says Matthias Muenzer, MD, a Boston-based physician and author of the blog, "A Physician on Job Search and Practice."
The distrust isn't limited to professional recruiters--physicians have horror stories involving CEOs, administrators, and even other physicians involved in the recruitment process. In response to the poll question, one physician recounted being pressured by a hospital CEO and a board member to sign a contract that would have shortchanged him tens of thousands of dollars: "They made all sorts of promises that they couldn't keep. Subsequently another doctor came to town, signed up, and was met with financial and professional disaster. I have seen many doctors victimized."
As the editor of Physician Compensation & Recruitment, I regularly hear from physicians as well as recruiters and administrators, and though I understand physicians' frustrations, I don't think recruiters are bad people. At the heart of the distrust is the fact that the recruit and the recruiter have different, and often competing, interests.
Facing an estimated cost of nearly three times a physician's salary to find a replacement, facilities face mounting pressure to sign a physician as quickly as possible; professional recruiters get paid to make that happen. But it's in the physician's interest to delay the process, to shop around for a while to find the best opportunity. If these priorities don't align and both parties are up-front about it, they can usually reach a middle ground or recognize that it's not the right fit and move on.
However, problems arise when the two parties aren't on the same page and don't effectively communicate their intentions. Unfortunately, this miscommunication happens quite often, in part because physicians are at a disadvantage at the negotiating table. Doctors are trained to heal the sick, not rewrite contracts or haggle with recruiters. The lack of business training effectively leaves physicians holding a knife at a gun fight.
"Physicians, especially graduating residents, come from a completely different world," Muenzer says. "They work 100 hours a week and are in an education environment where what people tell them is important and is true. And now all of the sudden they meet a group of people that are not advisors and do not have the physician's interest at heart."
Unfortunately, the hurried pace of recruitment tempts many facilities to gloss over issues that don't fit with what the physician is looking for. In the long run, those facilities lose money and physicians. If the compensation, culture, or even the estimated driving time to the nearest city don't match what the recruiter or administrator promised, the physician isn't going to be happy and probably won't stick around.
There are some steps physicians can take to ensure they don't get a raw deal out of the recruitment process. It starts with communication; if you're a physician searching for a new opportunity, don't hesitate to provide feedback to the hospital or practice. And ask questions. If you're unwilling to move more than an hour outside a major city, tell the recruiter to stop sending you positions that don't meet your criteria. If you don't understand every word of a contract, don't sign it.
You can practice with me. If you have any questions or comments about what I write in this space, shoot me an e-mail. Let me know what you want to read more about and what you're tired of hearing. That's the only way to ensure we're on the same page.
The price you may pay for being in violation of the anti-kickback statute is nothing to take lightly. There are fines of up to $25,000, imprisonment of up to five years, or both. A violation of the anti-kickback statute could also result in exclusion from the Medicare program.
The bottom line is that physicians must learn how to stay in compliance with this statute to ensure no unwanted penalties or troubles with the law, says Joseph J. Russo, Esq., founder and senior partner of Russo & Russo, LLP, in Bethlehem, PA. He offers the following five tips to physicians who may be in danger of these circumstances:
1. Be aware of several safe harbors to the federal anti-kickback statute. The government is most concerned about any incentive providers may have to overutilize governmental services. The following is a list of safe harbors to consider in your practice:
Investments in large publicly traded entities
Investments in smaller ventures
Lease of space and equipment rental
Personal services and management contracts
The sale of a practitioner practice
Referral services
Warranties
Discounts
Employee groups purchasing an organization
Waiver of beneficiary coinsurance
Deductible amounts
2. Implement and follow a compliance program for your practice. For example, Compliance Program Guidance, issued by the U.S. Department of Health and Human Services Office of Inspector General (OIG), provides nonbinding compliance guidance to providers who conduct business with Medicare, Medicaid, and other federally funded healthcare programs.
3. Educate yourself about the risks. The OIG set forth various risk factors applicable to physician practices, including improper inducements, kickbacks, and self-referrals. They include:
Financial arrangements with outside entities to whom the practice may refer federal healthcare program business
Joint ventures with entities supplying goods or services to the physician practice or its patients
Consulting contracts or medical directorships
Office and equipment leases with entities to which the physician refers
Soliciting, accepting, or offering any gift or gratuity of more than nominal value to or from those who may benefit from a physician practice's referral of federal healthcare program business
In order to keep current with this area of the law, a physician practice may obtain copies of the risk areas available on the OIG Web site. "It will include all relevant OIG Special Fraud Alerts and Advisory Opinions that address the application of the anti-kickback and physician self-referral laws," Russo says. "This is to ensure that the standards and procedures reflect current positions and opinions."
4. Ask yourself whether certain gifts are legitimate. According to the Compliance Program Guidance, the OIG goes on to state that any arrangements involving pharmaceutical or other gifts should be scrutinized, taking into account the following factors:
Is the gift or other benefit made to a person in a position to generate or influence business for the paying party?
Does the gift or other benefit take into account, directly or indirectly, the volume or value of business generated (e.g., is the payment or gift only given to persons who have prescribed or agreed to prescribe the product?)
Is the gift or the benefit more than nominal in value and/or does it exceed the fair market value of any legitimate service rendered to a payer?
Is the gift or benefit unrelated to any services at all other than the referral of federal healthcare business?
5. Develop standards and procedures to address arrangements with other healthcare providers and suppliers. Physician practices should also consider implementing measures to avoid offering inappropriate inducements to patients. The following are examples of such inducements:
Routinely waiving coinsurance or deductible amounts without a good faith determination that the patient is in financial need
Failing to make reasonable efforts to collect the cost-sharing amount from the patient
Shannon Sousa is the editor of The Doctor's Office. She may be reached at ssousa@hcpro.com. This story was adapted from one that first appeared in the February edition of The Doctor's Office, a monthly newsletter by HealthLeaders Media.
A story about Medicare's looming deadline for "never events" traveled around the Associated Press wire earlier this week, informing the general public about what those of us who work every day in quality and infection control already know: As of October, Medicare has declared that it won't pay for certain hospital-acquired conditions and happenings and others--including state governments and private insurers--are following suit.
The article presents several examples of hospitals that are instituting new policies and procedures that will help their institutions avoid these "never events." At the University of Michigan Health System, the article says, surgeons are using sponges tagged with radio frequency identification (RFID) chips to make sure that a stray sponge doesn't get left in a patient during surgery. In Tennessee, Wellmont Hospital is using a portable machine that releases sterilizing vapors to help eliminate germs in patient rooms, the article says.
These examples--and the hundreds of others that my colleagues and I have written about--show what we already know: by examining their processes, hospitals have been able to improve their infection rates, prevent staff errors and other "never events." Sure, we can improve our statistics, but will we ever get to a point where there are no errors, no falls, and no infections? The reality is no. Only eternal optimists will tell you that someday we might have a healthcare system that provides care with zero chance of errors. Humans aren't perfect, and as long as humans are caring for humans there are bound to be mistakes. Still, Steven Gordon, MD, infectious disease chief at the Cleveland Clinic Foundation, tells the Associated Press that it isn't stopping hospitals from wanting to get to zero.
Some might question whether an unattainable goal has value. Much thought on leadership goes to the notion that goals should be realistic and manageable, and indeed at the hospital unit level, quality goals are meant to be measured and met. As an industry, reaching zero must continue to be the motivating goal behind the work we do at our hospitals. It should be the underlying message in our staff meetings, training sessions and quality improvement meetings. We must evaluate the steps we're taking to prevent infections, falls and errors and among our caregivers, stress the processes that will give us the best return on our investment. The questions coming in quality are not what gets us to zero, but what initiatives get us closer than the others.
In his 2001 book, Good To Great, author Jim Collins talked about research he and his associates had conducted on why some companies thrived during economic downturns and others in the same field floundered. Although the companies that Collins and his team studied didn't include medical group practices, there are a number of principles that are relevant to physicians trying to run a successful business.
So what makes a group practice great?
In many cases, marketing makes the difference between a mediocre group practice and an exceptional one. CEOs will tell you that the "moments of truth" for a business occur in daily operations. All the publicity, promotion, and advertising in the world won't matter one bit if the word on the street is that it is difficult to make an appointment or get in to see your physician. But those who would separate marketing from operations fail to see that the two are integrally wound together. Timely appointment-setting, friendly reception, respect for the patient's opinion, and protecting patients' rights are all things that happen through customer interaction--which is operations and marketing.
In a recent focus group I arranged, the facilitator asked participants what they felt truly equated to a great experience when seeing a physician. "I was concerned that there may have been wrong information in my medical record and asked if I could review it," one participant explained. "Not only did they let me review it, but they apologized after I pointed out mistakes in the record and promised to correct them. They also asked that I double-check with them later to make sure the corrections were made."
Another participant boasted that the nurse arranged for a pick up when she wasn't able to drive. Others lauded simple things like being able to make appointments online or in the evening, and for being informed of the doctor's progress every ten minutes when waiting for an appointment.
These are the things that Jim Collins would say are the mark of a great, not just a good, medical group practice. They are the result of truly listening to the patient, putting the customer (patient) first, and doing something as opposed to just talking about it. At first, employees and their managers are worried that implementing patient-driven enhancements will take too much time and cost too much. However, practices that operate with a focus on the patient have actually seen employee morale improve--without seeing costs skyrocket. In fact, in some cases, they have gone down because of spin-off efficiencies as a result of process improvements.
A number of progressive medical groups have learned the secret to building and sustaining patient volume. They have integrated market research into their efforts to improve operations, and they have fine-tuned their operations to incorporate marketing concepts. But even the best-run practices struggle with the ongoing throughput/efficiency vs. customer satisfaction challenge. There is an opportunity cost to an unused MRI machine or an empty exam room. Machines and buildings have sunk costs that must be covered by paying customers. To the degree that a practice can accommodate throughput without sacrificing clinical quality, it will achieve coverage of the fixed and variable costs that exist with all operations. But will it achieve customer satisfaction?
A recent study that was reported in the Denver Business Journal suggests that efforts at increasing efficiency can be compatible with customer service. The article claims that overbooking patients (similar to how airlines overbook flights) may be better for large practices where there can be a significant number of patient no-shows. Which leads one to ask: Wouldn't it make sense to find out why there are so many no-shows and devise a strategy that would cut down on them? This is where market research and strategy can be instrumental in not only improving operational efficiency but in increasing patient loyalty and satisfaction.
Together, operations and marketing help bring in patients and keep them coming back to a physician's practice (if medically necessary). There are many factors involved in attaining patient loyalty, including competent clinical management of chronic disease from specialists and pharmacologic management of cholesterol levels and blood pressure by primary care physicians. However, what makes a patient refer other potential patients to the practice (the "multiplier effect" of marketing), is primarily the skills and understanding of the physician in meeting the patient's specific health care needs. And what makes you're a great group practice is making your interaction with patients more than just a "get 'em in, get 'em out" experience.
Patrick T. Buckley, MPA, president and CEO of PB Healthcare Business Solutions, LLC, a consulting firm that assists healthcare organizations with strategy, marketing, and management. He is also the author of the new HealthLeaders Media book, Physician Entrepreneurs: Marketing Toolkit, which includes marketing techniques, sample forms, and templates geared specifically for physician practices.
