The rise in demand for PA's can be attributed to growing interest from large integrated health systems, retail clinics, health centers, and concierge physician practices, says one healthcare recruiter.
There is no corner of the healthcare job market that is hotter now than the search for physician assistants.
"PA searches are up 127% year-over-year in the numbers we do, which is insane. You just don't see that spikes like that," says Travis Singleton, senior vice president at healthcare recruiters Merritt Hawkins. "We are not quite at a feeding frenzy yet, but we are getting there."
And that demand is transitioning to reflect the broader transitions in healthcare delivery. Singleton says about 17% of Merritt Hawkins' PA searches are for rural areas and mostly in primary care, but that the demand for PAs in more-urban settings is intensifying.
"We attribute that to the alternative delivery sites that are now using PAs," he says. "It used to be the one- or two-doctor clinics which certainly still use PAs. Now, large integrated health systems are hiring them in mass numbers, as are retail clinics like CVS and Walgreens, federally qualified health centers, and concierge doctors."
"Certainly Walgreens and CVS and Walmart are a big part of that," he said, "because they are primary care givers. But even payers recognize the different services that PAs or nurse practitioners can bill for and the more that health centers see that, even if it is under MD supervision, the more they are going to put them on staff."
The annual survey of the American Academy of Physician Assistants also shows a strong demand that is reflected in a nationwide median compensation of $90,000 for PAs who are paid salaries and $100,000 when PAs earn a base plus a bonus.
For a little perspective, the national median household income [PDF] is about $55,000, so PAs are doing alright. However, by healthcare sector standards, they provide excellent bang for the buck. Consider that primary care physicians, who are also in high demand, had an average base salary of $185,000 in 2013, according to Merritt Hawkins.
"PAs are perhaps the single best bargain in healthcare right now and that is one of the reasons why people are snapping up PAs right as they graduate," says AAPA President Lawrence Herman, PA-C, MPA. "More hospital systems and employers are looking and asking 'where is my value?' They are looking at outcomes too."
"It's not a matter of buying a cheaper car. It's buying a car that may be less expensive, but has better statistics in terms of safety. So, when you are looking at patient satisfaction levels, there are high parallel to physicians and in some instances higher than physicians. When you are looking at other outcomes data there is substantial data that show that PAs do it as well as physicians in the primary care setting."
Across specialties and practice settings, 46% of PAs in the AAPA survey say they get bonuses in addition to their base salary, and that the bonuses are largely dependent on performance outcomes such as productivity and quality improvement. Three-fourths of the PAs say their base pay is from annual salary, 22% say they're paid an hourly wage, and 3% say they're compensation is based on productivity measures determined through relative value units, patient encounters, charges and collections.
Employer type also factors into compensation. Higher median PA base salaries are reported in university hospitals ($93,000) and other hospitals ($95,000), while the lowest compensation is in solo physician practices ($85,000). Thirty-seven percent of PAs provide medical services in hospitals and 10.3% work in solo practices, the survey found.
Nearly one-third of PAs (32%) are practicing in primary care. However, just as with physicians, PAs who gravitate towards specialties make more money. Average compensation for PA specialties such as dermatology ($117,000), emergency medicine ($108,000) and surgery ($105,000), were considerably higher than for PAs working in primary care and family medicine, who reported earning less ($94,000 and $93,400, respectively).
Singleton says the better compensation in specialty care has not gone unnoticed by PAs.
"Yes, PAs, just like MDs, make more as specialists. Yes, that has gravitated about two-thirds of PAs into specialty care," he says. "Unfortunately, the way the market has fallen out we need more primary care. If you are a PA you can't blame them. If they can make 20% to 30% more in specialty care and in some cases have an easier workload it is going to be tough to pull them back into primary care."
Herman says it's not just the relatively lower compensation costs that make PAs a good value. It's also their flexibility.
"If someone is a physician and they are board certified as a dermatologist that is what they do. PAs being trained as generalists are extremely nimble. PAs typically will change specialties or disciplines at least twice during their careers. Part of that is responding to workforce and healthcare needs and it may be the PAs find they want to do something different," says Herman, who in his PA career transitioned from an occupational therapist to the emergency department and then toward family practice.
Singleton says the demand for PAs and NPs reflects a broader trend in healthcare delivery.
"Whether or not you think there is a physician shortage, whether you think there is utilization mismanagement or mal-distribution or not, we are not going to get out of it without everyone practicing to the limit of their abilities, and a lot of that is going to fall on NPs and PAs, specifically. I don't expect this trend to stop. I expect NPs and PAs recruiting to go through what primary care physicians did," he says.
"Keep in mind that is all new. In the Dallas market 10 years ago 75% of the PAs were employed by independent physicians or practices. Now, 75% of PAs are controlled by health systems. You are going to see salaries escalate at least to the point they can. You are going to see health centers take a loss on an individual provider because of the downstream revenues and referrals they get. And you are going to see them get creative with signing bonuses and call coverage," Singleton says.
"We are already starting to see some of them mimic MDs as far as RVUs and other production bonuses. I don't see that changing, at least not in the next three or four years."
Healthcare providers, payers, the government, and other players in the ICD-10 changeover are not working in a cohesive and coordinated fashion and won't be ready for the transition in eight months, says an MGMA policy expert.
The looming Oct. 1 implementation for ICD-10 has healthcare providers antsy about a potentially rocky transition to the new diagnostic codeset in the midst of other fundamental and profound changes to the healthcare sector.
A Medical Group Management Association survey of more than 570 practices representing more than 21,000 physicians finds that less than 10% of them had made significant progress when ranking their overall readiness for Oct. 1, up from 4.7% in June, 2013.
MGMA Senior Policy Advisor Robert Tennant says providers, payers, the government, and other players in the ICD-10 movement are not working in a cohesive and coordinated fashion.
"ICD-10 is like a cascade. Things can't happen until other things happen," Tennant says. "What we are finding through research and discussions with our members and industry [is that] the pieces aren't coming together as quickly as the government had expected them to. That includes software vendors, clearinghouses, [and] health plans. Nobody seems to be out front and leading the pack, and that includes the government."
He notes, for example, that there are only eight months until the implementation date and Medicare has not yet released its payment edits. "They've not yet begun to test with providers and even when they do so in March they are only going to do front-end testing. They aren't going to test the claim from start to finish. This is a recipe for disaster if all of these pieces don't come together," he says.
ICD-10 was supposed to take effect on Oct. 1, 2013 but the Department of Health and Human Services in 2012 rolled back the deadline for a year after providers complained. MGMA has not called for another implementation delay, but Tennant says the likelihood of a smooth transition diminishes by the day.
"Can it get done in time? Let's just say that everything came together in September. That is not enough time," he says. "The industry is a little like the Titanic. It can turn, but very slowly. We are concerned that there won't be enough time for testing. The government experienced that with healthcare.gov."
"If you don't test, you run the risk of problems," Tennant says. "And ICD-10 impacts every part of healthcare on the practice side, the clinical, the administrative, the entire revenue cycle. So, if things don't go smoothly it could dramatically impact cash flow for practices and ultimately that could impact patient care."
Flipping the switch to ICD-10 will come at the same time that providers are grappling with interoperability and other complex issues under Meaningful Use Stage 2 that must be implemented to avoid financial penalties. In addition, no one really knows how the first full year of the Patient Protection and Affordable Care Act will play out for providers as the healthcare sector continues its shift towards population health, value-based payments and accountable care, and other fundamental changes.
Russ Branzell, CEO of the College of Healthcare Information Management Executives, doesn't believe the ICD-10 implementation deadline should roll back again, but he concedes that providers have too much heaped on their plates all at once.
"We need to allow providers and hospitals to really focus on ICD-10," he says, "but we are also concerned that there are too many competing initiatives that are converting around the same time frame—everything from meaningful use, security requirements, ACOs and population health—all of this is converging at the same time and distracting from getting ICD-10 appropriately resource staffed, process improved and implemented."
Instead of rolling back the ICD-10 deadline for a second time, Branzell says the federal government should give providers another six months or longer to implement Meaningful Use Stage 2 before suffering any financial penalties.
"In a medium-sized medical group, if you have too many competing initiatives for caregivers, there is not a lot of focus on anything. And with ICD-10 there so much that still needs to be done, especially on the provider end, training and understanding the documentation requirements and the new systems. If they have to do that while they are trying to figure out Meaningful Use Stage 2, something has to give."
Branzell believes that many providers will opt to delay Meaningful Use Stage 2 and suffer the penalties as they attempt to launch ICD-10.
"We share MGMA's concerns, especially for the provider side of this," he says. "We think most of the hospitals have a good grasp on ICD-10. They don't have all the training and work they are supposed to have had done but generally the hospitals have a good grasp on this. But even on the hospital side we think they need to focus and have the flexibility."
"It doesn't mean that they should delay anything, but they should have some flexibility so if anyone needs to move back Meaningful Use Stage 2 they are not suffering penalties so they can focus on this. If we allow everyone the flexibility they need, maybe six or 12 months, we can get all of these initiatives accomplished in an appropriate sequence and timing."
Why not rollback the ICD-10 deadline and allow providers to focus on Meaningful Use Stage 2?
"For ICD-10, the ship has already sailed," Branzell says. "Most hospitals have already upgraded their systems. Many are already running dual accounting systems to check on this. At this point so many have geared up and there is an expense that has been laid out for most organizations that if they were to delay this date there would be lost effort and they would have to turn around and do it all over again."
He says the previous delay to ICD-10 implementation in 2012 was done so far in advance that providers had yet to spend a lot of money on the project. "Now a lot of organizations have command centers and teams dedicated to this and they have already invested in training resources, all of which is in place for Oct. 1. What do you do with all of that? Shut it all down? That would be very expensive."
Tennant says the federal government needs to prepare some sort of contingency plan or a rollback for ICD-10 if the Oct. 1 deadline proves to be untenable. "They have to do something quickly rather than wait until the ninth hour and announce something in late September. Better to do it now to prepare for the transition," he says.
"They frankly haven't even created an environment where physicians are confident about why the government is moving toward this new code set. There is no evidence to suggest that it improves clinical performance. There is no evidence that there is a return on investment which is staggering when you consider the cost of this for practices. What we have learned in the last few months is that you have to be ready for major transitions. And if you're not, they must be put on hold."
If budget balancing gimmicks being considered by Congress take effect in the coming year, they could potentially mean the loss of billions of dollars in Medicare and Medicaid reimbursements for rural providers. Don't let it happen.
Rural providers, you already have enough on your plate tending to an older, sicker, poorer patient mix on a red-lined budget during a time of monumental transition for the healthcare sector.
It's no fun piling on.
Nonetheless, make sure that calling Congress is on the top of your list.
Regardless of your political affiliations or how you feel about the Patient Protection and Affordable Care Act, if you're a physician leader or an executive at your hospital, or if you're simply an average citizen who cares about maintaining quality healthcare in your community, you need to stay abreast of developments on Capitol Hill, and your elected representatives need to hear from you.
If budget balancing gimmicks being considered by Congress take effect in the coming year they could potentially mean the loss of billions of dollars in Medicare and Medicaid reimbursements for rural providers. It won't matter whether you're a blood red Republican or a blue dog Democrat when you're trying to balance the books on diminishing revenues.
One of the biggest potential icebergs out there is the permanent repeal of the widely reviled Sustainable Growth Rate funding formula for physicians' Medicare reimbursements. Virtually no one will weep over SGR's demise if Congress successfully installs a permanent 'doc fix' before the latest stopgap expires on March 31.
The potential trouble comes when lawmakers look for money to plug the estimated $116 billion hole over 10 years that would cover the cost of a permanent fix. This is a huge threat to hospitals in general and rural hospitals in particular because, well, it's happened before.
"Whether it's for the debt ceiling or a temporary doc fix or a permanent SGR fix it all has to be paid for and unfortunately the scenario that played out in the past is to rob Peter to pay Paul," says Maggie Elehwany, vice president of government affairs at the National Rural Health Association.
Do you recall how they paid for that latest temporary SGR bill that expires on March 31?
"They extended sequestration for rural providers for two years," Elehwany says. "A lot of people thought that it was solved when we had that last budget deal and Congress made a bunch of speeches about how we fixed the problems with sequestration. They did curb sequestration for discretionary spending only. For mandatory spending, Medicare, those sequestration cuts are still in effect. Not only are they still in effect, they were expanded for another two years. In 11 years from now we will be done with it, but that is a 2% cut across the board for the next 11 years and no provider can withstand that."
Fixing the SGR will help rural physicians, but not if it comes at the expense of the rural hospitals that provide safety net access for about 60 million Americans.
"What rural providers do is all part of the safety net," Elehwany says. "If you try to help rural physicians and fix the SGR problem that is wonderful, but not if you do that by cutting rural emergency medical services or cutting critical access hospitals or some of these rural Medicare (Preferred Provider Organization) hospitals where nearly every physician out there in rural areas is based."
"If you close the hospitals, the doctors aren't going to be able to practice," she says. "If you cut ambulance funding, there isn't going to be anyone to provider transportation. More than any other type of healthcare delivery system, the rural healthcare providers really are on a team that is united and they need to work together simply because there are so many challenges to overcome: the distances, the geography the weather, mountain ranges… just to serve the population."
More bad news: Attached to the SGR are Rural Medicare Extender provisions that will also expire with a permanent fix. These provisions were tacked on to the SGR after Congress saw the devastating effect on rural hospitals when Medicare switched to the prospective payment system in the 1980s. These include supplemental payments for Medicare-dependent hospitals, low-volume hospitals, and critical access hospitals.
As it stands now, rural hospitals face a potential double whammy. Not only could they be saddled with paying for the SGR repeal, they could also lose this supplemental money that comes with it. A Senate bill creating a permanent fix for SGR doesn't address how to pay for it, but continues some supplemental funding for rural hospitals in a number of areas including ambulance and transportation costs. However, two separate bills in the House don't include any supplement funding for rural health.
"That is our concern. That is where we think we need to do a big education pitch to the House," says Elehwany. "Even in the more urban states every Senator has rural constituents."
Understand that in the halls of Congress right now there are literally hundreds, if not thousands, of well-paid lobbyists trying to protect their particular special interest from any budget cuts. That's why it is so important for rural providers to take the initiative and contact their elected representatives. Groups like the NRHA and the American Hospital Association do a good job making the case for hospitals. But nothing makes an elected representative take notice like an active electorate. While Congress en masse appears to be out of touch with the rest of America, individual representatives and senators are not.
Elehwany offers a handful of effective talking points:
Rural providers are a safety net for about 20% of the nation's population. Serving this generally poorer, older and sicker demographic requires more federal funding because there is no place to cost shift. It is not hyperbole to say that when rural hospitals close, people will die.
Rural healthcare is cost effective. "Only an infinitesimally small portion of the federal budget is spent on rural healthcare providers but it's a good bang for the buck," Elehwany says. "It is 3.7% less expensive to treat the identical procedure in a rural community when compared with a suburban or urban community and the reason is that everything in rural is based on primary care."
Rural hospitals are economic engines for the areas they serve. "If you close that rural hospital or if you force a physician to leave a rural community you are taking a huge economic component out of that community," Elehwany says. "The hospital is often the largest employer in a rural community. If your critical access hospital closes, you lose on average 107 jobs instantly, and that isn't even talking about the ancillary jobs from linen services to restaurants in the areas. And when the hospital closes, the doctors are the next to go and then the pharmacists are the next to go. What business is going to relocate or what family or retiree will stay in a rural community if there isn't some type of quality healthcare?"
Elehwany notes that the last two Congresses have sworn in huge freshman classes in both the House and Senate so they may not completely understand the pressures you are under. Make sure that they do. Send them a letter. Call them on the telephone. Invite them to tour your hospital and meet staff and talk with patients and community leaders to talk about the role that your hospital plays in their lives.
Rural providers have a strong case. You just have to make sure Congress hears you.
The economic recession may be to blame for a downturn in demand for newly licensed registered nurses, suggests a survey from the Robert Wood Johnson Foundation. The lead author speculates, however, that demand will grow stronger as healthcare reform is implemented.
For years we've been told about the nursing shortage and the thousands of jobs awaiting newly minted registered nurses. Now a survey of newly licensed registered nurses suggests that this might not be completely accurate.
Compared with six years ago, newly licensed registered nurses (NLRNs) who completed their studies in 2010–11 have greater job commitment, but are more likely to work part-time, and to report that they had fewer job opportunities, according to the survey from the RN Work Project, a program of the Robert Wood Johnson Foundation.
Of those in the 2010–11 cohort who reported being unemployed, 31.1% said they could not find an entry-level RN job in their area, compared with only 11.8% reporting this in 2004–05. More specifically, one in 10 of the 2010–11 cohort said they could not find a job they liked.
Christine T. Kovner, RN, a professor at the College of Nursing at NYU and lead author of the survey, says that some of the perceived downturn in demand for nurses may have been a byproduct of the recession.
"It's more difficult to get jobs for new graduates now than it was prior to the recession," she says.
"We think what happened during the recession was that as people's partners lost their jobs, a lot of nurses increased the hours that they were going to work. We looked at data and found that nurses had increased their hours of work. Some of that was part time to full time. Some of it was doing extra overtime more often. That may have been one of the factors that for this group that graduated in 2010–11 made it more difficult for them to get jobs."
A Tighter Market, But Still 'Lots of Jobs'
Kovner concedes that the data and survey returns compiled by RN Work Project and other objective data compiled about healthcare employment are not granular enough to provide empirical evidence on the state of nurse employment.
"We think the best measure is how the nurses perceive what is going on because at the end of the day, that is all that matters," she says. "If they perceive that there is difficulty in getting jobs they are likely to be more reluctant to leave their current jobs. We think that is what's happening here."
While the job market may have tightened, at least temporarily for nurses, Kovner says there are still "lots and lots of jobs" with tremendous opportunities for career growth, especially when compared with the prospects of other recent college graduates.
"If you look at the data, most of them still all got jobs. At NYU our graduates have the highest average salaries than any of the other schools at NYU including the business school," she says. "People that aren't in the sciences, a lot of them work in publishing. A lot of them are unemployed, I don't know for NYU in particular, but in general, liberal arts graduates have a more difficult time finding jobs. So nursing is still a great job opportunity, but it is not as great as it was."
Fewer Hospital, ICU Jobs for New Nurses
As in past years, most NLRNs began their nursing careers in hospitals. However, that percentage dropped for the 2010–11 cohort, with 77.4% of the NLRMs finding jobs in hospitals, compared with 88.8% in the 2004–05 cohort. Of those in the 2010–11 cohort 13.5% were more likely to work in a magnet hospital compared with 10.3% of the 2004–05 cohort.
They are also less likely to work in intensive care units (18% in the 2004–05 cohort, compared with 11.6% in 2010–11) and more likely to be working part-time as a nurse (10.5% in 2010–11, compared with 7.8% for 2004–05), the survey found.
Kovner finds this movement away from hospital work for NLRNs over the past several years one of the more "telling" parts of the survey, but it's not quite clear exactly what the data is saying. Does this trend reflect the move toward lower inpatient volumes and toward outpatient services?
"I don't think so, but I haven't looked carefully at the number of occupied beds in those two time periods," she says. "Fewer baccalaureate graduates are getting jobs in hospitals than they were six years ago, but still way more on a percentage basis of baccalaureate graduates are working in hospitals compared with associate degree graduates in their first job."
And there does appear to be more interest in pursuing advanced degrees among the NLRNs, as 16.6% of them reported that they were enrolled in a formal education program compared with 11.4% in the earlier cohort.
"I don't know what that is going to mean long term," she says. "I don't know whether people did that because they were having difficulty getting a job or they could only get a part time job. A lot of the associate degree graduates are going back to school to get a bachelor's degree. I don't know about baccalaureate graduates and what they are planning to do. A lot depends upon the job opportunities. If you can work at an outpatient department and help people take care of their chronic illness as a registered nurse, which I believe you can, they may choose to do that."
Demand Expected to Grow
While she can only speculate, Kovner says she believes the trends in demand for nurses will grow stronger as the Patient Protection and Affordable Care Act takes hold, and as providers move away from fee-for-service care and toward value-based care and population health.
"They will have an easier time getting a job," she says. "First of all there are the numbers of older nurses who are going to start retiring. We thought that was going to happen earlier than it did but again we think that with the recession people decided who might have retired decided not to retire."
"Beyond that the opportunities for nursing are going to be humongous. Accountable care organizations, helping people manage chronic care, working in walk-in or outpatient departments; a lot of organizations are still thinking through how best to use the registered nurse. There are a lot of opportunities and even lot what nurse practitioners do registered nurses can do."
"There is going to be a demand for care coordination. You need to have skilled people doing that. It's not training someone who has a degree in English for how to make a list of what all the services are. You really need a skilled medical professional to make the judgment and the problem solving involved in that. We will see how it plays out."
Physician appointment wait times tracked in a Merritt Hawkins survey varied from one day to more than eight months. The average wait in all metro areas and specialties is 19 days. Boston has the longest waits (45 days); Dallas had the shortest (10).
A survey on wait times for physician office visits [PDF] in 15 cities across the nation could be a harbinger for access to healthcare providers under the Patient Protection and Affordable Care Act.
First the bad news: Even before Obamacare's expanded coverage really kicks in, patients hoping to schedule an appointment with a physician in 2014 should expect to wait for several weeks in most parts of the country. Those on Medicaid, stand about a 50–50 chance of being seen by a doctor.
Now the good news: The wait time for an office appointment in 2014 is 18.5 days in five specialty areas—cardiology, dermatology, obstetrics/gynecology, orthopedic surgery and family practice—an 11% decrease from 2004 when the average wait was 20.5 days.
What's not clear, however, is if this trend will continue as an estimated 16 million people gain health insurance coverage under Obamacare.
All of this data comes from Irving, TX-based physician recruiters Merritt Hawkins, which every five years conducts a survey of nearly 1,400 physicians' offices in 15 large cities to get an idea of the wait times for office visits.
Once again, Boston, the Hub of Romney care, has the longest average wait times for doctor appointments of the 15 metro markets examined in the survey:
72 days to see a dermatologist
66 days to see a family physician
46 days to see an OB/GYN/
27 days to see a cardiologist
16 days to see an orthopedic surgeon
On average, it takes more than 45 days to schedule a doctor appointment in the Boston area.
Merritt Hawkins has conducted the survey in 2004, 2009, and 2014 and each time Boston has averaged the longest wait times among the 15 cities surveyed.
Kurt Mosley, vice president of Strategic Alliances at Merritt Hawkins says it's not surprising that Boston has the highest wait times because 97% of Massachusetts residents are insured. And while Massachusetts has about 508 physicians per 100,000 people [PDF], one of the highest ratios in the nation, many of those physicians are in academia and aren't seeing patients regularly.
On the other end of the spectrum sits Dallas with the shortest wait times for physician office appointments: 10.2 days for specialists and five days for family physicians. Texas has 264 physicians per 100,000 people, the lowest ratios in the United States, which overall averages 373 physicians per 100,000 people.
Not coincidentally, Boston has the highest rate of Medicaid acceptance tracked in the survey at 73%, while Dallas has the lowest at 23%. One in three people in Texas have no health insurance, the highest percentage of uninsured residents in the nation. Texas has vehemently rejected Medicaid expansion money offered by the federal government under Obamacare.
"Texas is still a fee-for-service bastion. We never really caught on with managed care," Mosley says. "The doctors see patients with insurance and Medicaid acceptance is low. And they when you look to see how many doctors per state it's odd because we don't have many doctors per state here in Texas, but they do see people."
Mosley says a lot of the demand for physician services has been taken up by advance practice nurses. "That is a real growth area in Texas. The scope of practice has expanded a lot in the state," he says.
Overall, the average rate of Medicaid acceptance for all five specialties in all 15 markets is 45.7%, the survey shows.
Other average physician appointment wait times tracked by the survey include 28 days to see a cardiologist in Denver, 49 days to see a dermatologist in Philadelphia, 35 days to see an OB/GYN in Portland, OR, 18 days to see an orthopedic surgeon in San Diego, and 26 days to see a family physician in New York.
Physician appointment wait times tracked in the survey varied from as little as one day to over eight months, with an overall average in all metro areas and all specialties of about 19 days, the survey showed.
Mosley says the shorter waiting times seen in 2014 have a lot to do with the economy and the shift toward high-deductible health plans.
"We have lingering high employment, which means fewer insured people, many of whom are deferring seeing a doctor. And another area is a cultural shift as high deductable plans and high co-pays change people's mindsets. A lot of people no longer reflexively see the doctor when they have a problem now that they have more skin in the game. They think twice about it," he says.
"Nevertheless, even in cities with a large number of doctors per capita you are going to wait a few weeks before you see a doctor. In what other service arena does that happen? Last time I saw a lawyer she was open that day."
Mosley says the trend of shorter waiting times is about to be reversed as the growing numbers of people with health insurance collide with a rapidly aging physician demographic.
"(The Department of Health and Human Services) said that over the next seven years they estimate 250,000 doctors will retire. And we already know that the number of doctors over age 55 is 41%. So, then the wait times will dramatically go up," he says. "We see the storm coming and we need to be prepared for it."
The new head of the AHA's governing council representing small or rural hospitals discusses his most pressing challenges: addressing the shortage of health professionals, advancing population health, and preserving the critical access hospital designation.
Paul R. Bengtson,
CEO, Northeastern VT
Regional Hospital
Healthcare providers across the country will face a challenging environment in the coming year as ground-changing reforms take effect. For any number of reasons, however, meeting those challenges will be even harder for providers serving rural areas.
The patients they serve tend to be older, sicker, less educated, and poorer.
Access issues are far more challenging in rural areas, where the closest hospital or physician's office is more often miles away.
Every rural provider trying to recruit a physician, a nurse practitioner or any of a number of specialists understands the intense competition for clinicians.
Smaller and remote hospitals and other providers often cannot easily access the capital or the expertise for technology upgrades and interoperability mandates that can create economies of scale, improve care and reduce costs.
Many rural hospitals, through no fault of their own, over-rely on Medicare, Medicaid, and other government payers with lower reimbursements than private payers, which also makes it more difficult to offset the costs of charity care
I could go on, but you catch the drift.
Despite all of the challenges, Paul R. Bengtson, CEO of Northeastern Vermont Regional Hospital, a critical access hospital in St. Johnsbury, is upbeat about the work that rural providers accomplish.
"We are like many other critical access hospitals and the programs that we have here are very sophisticated and many are on the cutting edge of high quality," says Bengtson, who this month began a one-year term of office as chair of the American Hospital Association's Section for Small or Rural Hospitals in 2014.
"We have programs that are directed at improving the health of the populations we serve. I am excited just in general to pursue the Triple Aim: to improve care, to improve the health of the population, and to lower healthcare costs. We are a rural hospital, but we are working on all fronts."
The 21-person governing council represents small or rural hospitals in the AHA's policy process and member services initiatives, and through it, Bengtson says he's been exposed to "a large number of really smart and creative people working in rural healthcare settings all across the country."
'Crisis Mode'
"Having said that, many rural providers are in what I would call a crisis mode because the systems and many situations and the economy are rather fragile," he says.
Bengtson says in some rural areas "it is next to impossible to recruit qualified physicians."
"Just by way of statistical reminder, 20% of America's population is living in rural areas and we have probably less than 10% of America's physicians serving that population," he says. "That is true for a variety of reasons, but in some areas it is very difficult to recruit the kinds of physicians that are needed, particularly primary care physicians."
Bengtson sees that as "a real problem because we've got over 2,000 rural counties in America that are designated as health professional shortage areas. That does make the work really hard. One of the toughest jobs is going to be to replace the workforce we have now."
Bengtson says one of his priorities as leader of the AHA's Small or Rural Hospital's Section will be to advance population health.
"I want us to be learning from each other. I do see where the Small or Rural Governing Council has a think tank operation where we can figure out who's doing what that is going to be most effective to bring good programs to rural populations in the future, with the intent of improving care, with the intent of improving the health of the population and lowering costs," he says.
Emphasis on Population Health
"I would like to see a lot more emphasis on population health improvement; meaning hospitals in rural areas reaching outside of the walls, connecting with private practices, public agencies, departments of health, wherever possible to have a collective impact on the health of the populations they serve. Yes, we have to improve the quality of care in the hospitals themselves. But I am after improving the health of the population. That has always been important to me, and it will be this year too."
I asked Bengtson if he thought that the federal government, Congress, and other healthcare powerbrokers held a proper appreciation for the work of rural healthcare providers under challenging conditions.
"That varies greatly across the country. In the most rural of states like Vermont, the legislature, [and] the power brokers get it because they're in immediate contact with their constituents. Nobody runs around here anonymously doing things that are not good for the population," he says.
"But it is interesting across the country and there is a lot that I frankly don't understand. I don't know that people in powerful positions don't get it. I have to say I am not happy about the politics of healthcare when I think there is so much that can be served through the mission of healthcare. But politics and money make a difference. I am not sure that people don't get it, but I see a lot of action that would cause me to think they either don't get it or don't want to get it."
Preserving CAH Status
One of the best ways that the federal government can show its appreciation for the work of rural providers would be to outright reject or at least very carefully scrutinize any reconfiguration of critical-access status for small and isolated hospitals.
"If we lost our critical access hospital status that would have a very bad affect on the people we serve," Bengtson says "We have a primary service area of least 30,000 people, and there would be a lot of people around here who would automatically lose access to a lot of needed services. Would the hospital go out of existence all together? No. But it probably would have to morph into something that would be much less than what it is capable of doing now."
"Frankly, the benefit of what we have to offer the population would be much diminished and also the population would be very disappointed. When I ask people 'what do you need from us?' their answer is almost uniformly 'be there. Be there now. Be there in five years. Be there in 10 years. Be there in 20 years for my family.' That is what people are looking for."
Refuting "conventional wisdom" and citing slowing healthcare cost growth, the Federation of American Hospitals says healthcare industry consolidation improves services and care coordination, and ensures continued access to care.
A Federation of American Hospitals-commissioned report claims, not surprisingly, that hospital consolidation improves care quality and access and that the critics who claim these "hospital realignments" drive up healthcare costs are relying on old data that does not consider the sweeping effects of healthcare reform.
"Consolidation has probably always been a good thing, but in terms of today, it actually is the mother of necessity," says Chip Kahn, president/CEO of FAH, the Washington, DC-based group representing investor-owned and managed community hospitals and health systems.
"The expectations of consumers and patients, the revenue pressures to have enough resources for hospitals, the accountability and technological requirements and obligations that hospitals have today, and the expectation that we are going to be moving toward really taking care of the patients over a continuum of care change the dynamic."
"All too frequently, conventional wisdom suggested by media coverage is that hospital realignment, mergers and consolidations systematically result in pricing power, with anti-competitively higher prices for those needing care," the report states.
"Yet, in terms of prices for consumers, this study's extensive review of the literature finds no consistent statistical relationship between consolidation patterns and hospital prices across the studies. What also can get lost is that these claims about hospital merger effects often rely on outdated data that do not reflect today's dynamic market conditions."
Instead, the FAH report says consolidation improves services and care coordination, and ensures continued access to care that is not disrupted by financial straits that threaten to shutter hospitals that go it alone.
Also not surprisingly, America's Health Insurance Plans begs to differ.
"The evidence shows that increasing provider consolidations results in higher prices for consumers," says AHIP spokeswoman Clare Krusing. "The rhetoric about provider consolidation is that there is greater efficiency, but there is government data and research that shows the reality is higher prices for consumers. The rhetoric is efficiencies but the reality is higher prices."
"AHIP is missing the point," Kahn said. "You have to look at the big picture. All they are focusing on is simply their payment for the covered lives in their insurance book's business. They are not really concerned, I don't think, about the access of those people to hospital care," he added.
If hospitals are going to be available for all Americans, then we have to be honest with ourselves that Medicaid and Medicare and maybe even the plans that are coming in under the new exchanges are not paying sufficiently and are putting pressures on hospital revenues to such an extent that consolidation and hospitals needing to right-size is where we are going."
"The other side is if you go to the AHIP blog, most of the research that they base their conclusions on is old, based on data from the 1990s or the turn of the century. The environment then is not what the environment is today."
Krusing says AHIP cites a number of reports from independent sources that have been written in the past two or three years, all of which support the payers' claims that consolidation drives cost growth.
"I'm looking at something from PwC that came out in 2013 and it shows hospital merger and acquisition activity [PDF] has increased nearly 50% since 2009, reaching its highest point in 10 years," she says. "Even that report highlighted that the result of this trend of consolidation there are higher prices. This is a trend that continues. The research continues to show this. What is most striking is when you see what is happening across the country and there are tons of articles that actually show within the last year to 18 months that when patients go to these provider groups, their prices are increasing."
Kahn counters that the arguments about consolidation driving cost growth loses some steam with the news that healthcare cost growth has slowed to record lows. "It's probably the economy, but consistently economists and government officials and other studies are showing that a structural change is taking place," he says.
"Hospital services are paid for through this tremendous hydraulic that is Medicaid and Medicare payments, no payment, and then various types of private payment," he says.
"As far as we are concerned and as far as our study illustrates, to keep this hydraulic greased so that there are enough resources to provide the access that people expect and the quality that people expect, the freestanding hospital can't make it. You need to look at the big picture of hospital survival and the availability of hospitals. That is the point we are trying to make," Kahn said.
Until recently most physician compensation models focused on straight salary guarantees or pure productivity-based models. Those trends are falling by the wayside.
Physician compensation models are changing and evolving in practices and hospitals across the nation as providers transition away from fee-for-service reimbursements and toward value-based care and population health.
What's it going to take to make these models work?
Kristian Brokaw, a manager with the PwC's Human Resource Services practice, says the key constants for any physician compensation model include a focus on quality outcomes and building a sense of "citizenship" within the practice.
"Physician compensation is complicated and every changing. I realize that is a blanket statement but it really goes to the simple fact that these models need to be updated and changed every one, two or three years," Brokaw said at a PwC webinar this month.
Until recently most physician compensation models focused on straight salary guarantees or pure productivity-based models.
"Those tend to be going by the wayside," he says. "What we see now are more physician models that are designed to try to do everything. They are taking too many behaviors into account. At that point we get to the law of diminishing return. Because if there are 20 or 30 different metrics, that is way too much and there is nothing for physicians to truly put their focus on."
"Specifically, today's comp models are really designed for three key elements; first, to drive behaviors; second we need to build a culture; finally we need to ensure we are not just market-competitive. We want to be leaders in the market and attracting top talent."
Brokaw describes three phases in the process of transforming from fee-for-service to value-based compensation, all of which involve the move away from base salaries and towards increased incentives or risks. "In the introductory phase the majority of the revenue is still coming from the fee-for-service billing and low productivity from one provider doesn't directly impact other providers," he says.
"Pure procedure compensation models become problematic as organizations take on increasing amounts of risk. In the middle, as we look at the different models, what stands out is activities that once were profitable have the potential to negatively impact reimbursement reimbursements in the future. As we put our focus on readmissions and outcomes we need to keep that in mind."
"Finally, as we move to the population health phase, per patient per month and patient management and wellness are the keys to driving this. Your physicians have to be motivated to accept this risk. Productivity models needs to align with the objectives of the population that we are now managing."
Brokaw says a typical compensation model he's seeing now offers 80% base pay and 20% incentive, a ratio that will undoubtedly change as healthcare reimbursements evolve toward risk.
"The incentive side is in aligning this with the organizational cultures and behaviors we want to drive, based around quality patient satisfaction, alignment with our objectives, developing that culture, and citizenship," he says.
"As you think about those different buckets and creating the culture collaboration and transparency and how do you move to a model where all of your physicians are involved and they are working with each other to better their performance, you have to move away from an individual-based model and move to one that takes things into different accounts in different areas."
Brokaw stresses four key elements that should be in any compensation plan:
Aligning incentives to the new care model;
Incentivizing quality and "customer" outcomes;
Creating accountability for quality and outcomes; and
Promoting teamwork and collaboration
"We use the word customer. In the past we have always been patients," Brokaw says. "But more and more organizations are looking at their patients as customers because these customers realize they can go out and find care elsewhere—so how do we treat our customers?"
And as practices wean themselves of traditional fee-for-service models, physician leaders should ask themselves how their new compensation models will change unproductive or disruptive behaviors while building camaraderie and citizenship among physicians—traits that will become critical under value-based care.
The best way to get that result is to make the process transparent for every physician in the practice.
"Education is truly key," Brokaw says. "The physicians will have to be educated on how the model works down to the nth degree and you are going to have a lot of questions and a lot of great conversations. Finally, to make this model work it goes back to that development of a physician champion. You have to have them from the moment you start developing this model to the moment it is fully implemented."
"If they aren't out there talking to their colleagues and getting buy in," she says, "it will never be as successful as it could be."
In our September Intelligence Report, healthcare leaders, by far, cited physician engagement as the most difficult aspect of managing physicians. What elements of physician engagement have been most challenging at your organization and how is leadership addressing it?
Chris Van Gorder
CEO
Scripps Health, San Diego, CA
On engagement and culture: Engagement has not been an issue for us. Maybe it is because we have a physician leadership cabinet that we established 14 years ago where all of our elected chiefs and vice chiefs meet with us monthly to work on all the issues affecting the healthcare system. We established our ScrippsCare accountable care organization and brought all of our independent practice associations and medical group physicians together several years ago and they are extraordinarily engaged.
On expanding engagement: Technically the physician leadership cabinet is an advisory body but I would argue that it is the second most powerful organization at Scripps, second only to the board of trustees. And that was easy. That was just bringing them in and transparently sharing information. We did the same thing with our affiliated medical groups through what we call the physician leadership academy.
On trust and authority: Engagement is not just a word. You have to give physicians decision-making authority. If they have the same information, they make the same decisions we would have made but they make it faster. I feel better about the decisions in the end because I know that the clinical needs of the patients are being met. They aren't just business decisions being made. They are joint decisions. I am not going to abdicate my role as CEO but I am willing to share it with them. If you are not willing to share it then engagement is really going to be difficult.
David Tilton
President and CEO
AtlantiCare Health System
Egg Harbor Township, NJ
We looked at this in the context of the Baldrige journey we were on at the time. An important moment for us happened when we began to view physicians not as independent but as members of our workforce. With that we began to give the physicians the responsibility, the authority, and the accountability around key elements of our strategic and operational plans.
We brought them in at the top of the first inning rather than the bottom of the ninth. That just added to the full engagement of these physicians and their ownership of the efforts we have.
Physician-to-physician puts it on a very high professional level in an area where I don't play. I would like to, but I am not a physician. It's about professionals establishing a standard of performance and saying, "In this particular situation, you don't seem to be participating at that level." When those conversations are not prompted by the CEO or an administrator but by professionals talking to one another, it gains momentum and it changes the whole professional environment within an organization.
Like anything else it is never perfect and it is always evolving. We continue to shine a bright light on those professional relationships and demonstrate our willingness to make this a better practice environment for our physicians.
Jeffrey DiLisi, MD, MBA
Vice President and Chief Medical Officer
Virginia Hospital Center
Arlington, VA
To provide high value, quite simply you want to provide the highest possible quality at the lowest possible cost. And to do that you need physician leadership and to have good physician leadership you need physicians who are engaged and in tune with the idea of providing value and are likely in tune with the hospital's mission statement.
We have employed more physicians to try to provide more value to our patients and to our community, and we see that with our employed physician group. But you can't only have your employed physicians engaged. So how do you get the rest of the physicians engaged? To me it's about being very transparent about what our data looks like. That is one of the things I do personally as CMO. We have a very detailed physician quality scorecard that we put together every month. We want all of our doctors to know, whether they are employed or not, how well we are doing and what we look like with that communication-with-doctors metric on the HCAHPS survey. What are our mortality rates? What are our readmissions rates? If you can get the data in front of them and get them focused on the things we need to do better, it is easier to get them engaged. That has been effective as well for our nonemployed physicians in getting them engaged.
Scott Trott
Vice President of Payer Management and Faculty Services
UNC Health Care System
Chapel Hill, NC
What we've done in the last five years is really promote more physician executives in the system oftentimes creating new positions or formalizing their expected roles within the organization in ways that maybe weren't apparent before.
I have always had a physician committee to do managed care contracting–related guidance because I've been engaging them to help them understand what is happening in the financial world for them. We've tried to really enhance that committee and all of our physician governance committees' roles within studying the general directions for our healthcare system. There has been a lot more cross pollination of physicians getting involved more in what I would call hospital operational decision processes than we ever had before.
The CEO of our system is Bill Roper. He is an MD. He has invited or appointed physicians to be part of our senior leadership team. So they are sitting with him and hospital executives helping chart and debate things of importance to our health system. He engages doctors who weren't necessarily department chairs. They aren't necessarily division leaders. They are just either really astute clinicians or otherwise in some of those kinds of environments where they have helped build enthusiasm. We tell them: "We want to listen to your input. We want you to help guide us through this."
Kristine Aznavoorian, RN, MS, had been a practicing pediatric nurse in Boston for five years when she encountered subspecialists known as Pediatric Sexual Assault Nurse Examiners. Now she works with young victims of heinous crimes.
Kristine Aznavoorian, RN, MS, had been a practicing pediatric nurse in Boston for about five years when she became aware of the subspecialists known as Pediatric Sexual Assault Nurse Examiners, or pedi-SANEs.
"It fascinated me," Aznavoorian recalls. "These children are looking for certain help, and I really enjoyed that thought of helping them in a very crucial and traumatic time of need."
Now, in addition to her work as a pediatric emergency nurse at Boston Children's Hospital, Aznavoorian also works part-time as a pedi-SANE for the Massachusetts Department of Public Health at the Essex County Children's Advocacy Center, where she investigates two or three sexual abuse cases each week.
For pedi-SANEs, there is no such thing as routine. The one constant, though: Dealing first-hand with the young victims of heinous crimes is never easy.
"Every case is different," says Aznavoorian, who has been a pedi-SANE for two years. "Every child deals with a traumatic event a little differently. It depends on the developmental level of the child, how old they are. It plays into how they are going to handle the situation, but it is across the board."
In some cases, if there is an opportunity to gather physical evidence of sexual assault for prosecutors, Aznavoorian asks the victim or their families for permission to perform a physical examination.
"The older the children are, the more they kind of get what is going on exactly," she says. "And depending upon what their unique situation is depends upon if they are going to be open to coming to see me, or if they are open to having an exam done. I never know what kind of child we are going to get and if they are going to be willing to see me or even talk to me."
"I try to go in as if I were with any of my patients, such as when I work as a staff nurse in the emergency room. I go in. I introduce myself. I am as friendly as possible. Children feel afraid if they feel certain vibes from medical professionals so I try to give off an open and friendly vibe. Every child reacts a little differently," Aznavoorian says.
"We try to keep the parents in the room. As the children get a little older and become adolescents then maybe they want a little more privacy and they don't want the parents around. But when they're younger we typically have the parents stay because they know their child well and they know best how to comfort their child," she says. "It takes a lot of patience, especially with younger children. But you work as slowly as possible just to make sure they are not afraid. We have a 'stop' rule. If the child is scared or upset or crying, we stop. We don't force the children to do anything they don't want to do. When it comes to evidence collection and an examination, we just try to do it as efficiently as possible without traumatizing the child any further than they already have been."
It's important work. But it is also stressful.
"The burnout factor is actually a concern within our program. It's tough work. I definitely don't take things home with me. I do my job. I focus on the family and the child," Aznavoorian says. "We have monthly meetings where we share our feelings with the rest of the pedi-SANEs and talk about the struggles that we having doing the job and the work that we do. We rely on each other to talk about the tough days and the good days."
The rewards aren't monetary. The satisfaction comes with knowing you have played a role in helping a child recover from a potentially devastating ordeal.
"The older the children are the more they realize that what happened was wrong or wasn't supposed to happen. They tend to think that as a result something is wrong with their body and that people can tell what happened to them just by looking at them," Aznavoorian says.
"This particularly is true with the adolescent population and the young teens. They think something is wrong with them. It's happened to me on numerous occasions where I examine these children and they look at me and say, 'Really? You can't tell something happened?' I say 'No, I can't tell. Your body is perfectly normal just like every other 11-year-old body would look like.' And they are so excited about that. That is what keeps me doing what I do every day."
