How many staff members do you need to maximize productivity and quality while containing costs?
The bible of practice staffing ratios, Rightsizing: Appropriate Staffing for Your Medical Practice by Deborah L. Walker and David Gans, notes that understaffing can negatively impact employee recruiting and retention, disrupt physician productivity, hinder patient service, and place patients and business operations at risk.
On the flip side, Walker and Gans note that overstaffing can lead to poor staff interactions with physicians, a decrease in productivity, and a decrease in the bottom line.
Adequate staffing is one of the more complicated and important issues in healthcare. It's a nettlesome problem that every practice manager will face at one or more points in his or her career.
The issue gets cloudier when you factor in the dearth of qualified clinicians in most areas of the nation and try to determine the impact of healthcare reform and the adaptation of meaningful use for EMRs in your physician practice.
Fortunately, the answer to the question of what determines adequate staffing is simple: It depends.
"It is a balancing act. The more physicians you have, the more patients you see, the more staff you should anticipate to take care of them," says Christopher Clarke, practice administrator at South Coast Orthopaedic Associates, an eight-physician practice in Coos Bay, OR. "But you can't get to a level where it's just going to be breaking even. You have enough staff to take care of everybody, but you aren't making money. That is where you have to push the efficiencies."
Clarke says South Coast Orthopaedic stresses cross-training with its five mid-level providers, four physician assistants, and 15 other staff members.
"We do a lot of cross-training—and not just within departments. Each billing staff [member] can do every job in billing," he says. "We also cross-train our medical assistants to work at the front desk; the chart room people too. Anyone can answer the phone. We try to make sure that everybody is cross-trained to the best level possible. That really helps with our efficiencies."
Generally accepted staffing ratios can vary greatly depending on the subspecialty. Clarke says the Medical Group Management Association best practices recommend 7.7 full-time employees (FTE) for each full-time physician at his orthopedic group. "We are at five FTEs, and a lot of it is the efficiency of our staff," Clarke says. "You have to make sure you have the right people in the right jobs being as efficient as possible, and you have to evaluate that and watch your staff."
Staff size by formula
Barbara Daiker, executive director of NorthwestEye, which serves the Twin Cities area of Minnesota, says the 21-physician group uses a formula to determine staff size. "But it's not by doctor. We do it by encounters. We look at how many encounters a doctor has, and we try to staff accordingly," Daiker says.
NorthwestEye, which has 150 employees serving eight clinics and one surgery center, has developed specific encounter ratios for clinical and front desk staff.
"We also use a different kind of number for our business office, based on revenues, FTEs per revenue, so they're handling dollars as well," Daiker says.
With its encounters, NorthwestEye also takes into account the number of tests ordered. For example, the patient visit itself is a single encounter, but some patients may have two or three tests during their visit, and those may have to be included.
Even using the ratio can be a bit of a challenge as the physician group encounters ebbs and flows of patients in the annual business cycle.
"It's a bit of a floating number," Daiker says, adding that NorthwestEye is currently in its seasonal lull. "We can't change our FTEs per se, based on the lull. We have to ask, 'What do we think will happen over the next six to nine months?' and see if we can flex the hours a little bit now based on where we think we are going to be once we hit our busy time. We don't want to do any kinds of layoffs or staffing up until we can be sure where we are."
Unexpected stability
The recession and overall economic malaise that have gripped the nation for more than two years have had at least one unexpected upside for office administrators: Staff is staying put.
"We have had no resignations for four or five months at this point, which is a long time for us. It's not like we are a place where people bail from, but people get relocated or they have babies or whatever, so it is kind of unusual to go that long," Daiker says.
When a job opening is posted, NorthwestEye gets flooded with applicants who aren't necessarily qualified. "That makes it hard because you have to sort through a lot of stuff to find qualified applicants," says Daiker. "It used to be recruitment was expensive when the labor market was tight. Now, it doesn't cost much to recruit, but it is the training, the orientation, that takes a lot. Even if they come from another eye group, they don't necessarily know how to do it our way."
Although cutting back hours to maintain adequate staffing is preferable to layoffs, it can still get tricky. "We try to solicit reduced hours from employees, but you can only do that so much before people get skittish," Daiker says. "We try to be fair. It's easier for everyone to lose an hour than it is for one person to lose eight hours. Also, because we are in Minnesota, when the weather gets nicer, people are a little more open to cutting back some hours and heading outside."
Regardless of how you feel about Andy Stern, president of the 2.2 million-member Service Employees International Union, there is no denying that he is the most important labor leader of his generation.
So, it came as a surprise when he announced last week that he would resign the position he has held since 1996. His resignation—two years before his term ends—comes at an apparent high point for organized labor. SEIU, with half of its membership from the healthcare sector, played a crucial role in raising money, and electing President Barack Obama and the Democratic majority in Congress. The union worked hard for the passage of the jobs bill and healthcare reform by targeting wavering Democratic lawmakers and bolstering their support. In return, Stern has had unfettered access to the White House, with nearly 40 trips since Obama took office, according to several media accounts.
Labor was expected to make a concerted push this year for the Employee Free Choice Act—or a watered down version of it—which still would be the most sweeping pro-labor legislation in decades. After the bruising healthcare reforms fight, however, the labor bill's fate is in limbo.
Why did Andy Stern quit? Pose that question on Google and you'll get rampant speculation and intrigue.
In a video message to SEIU's members, however, Stern touted his accomplishments, insisted he had no immediate future plans, and suggested that he is burned out. "I've seen too many leaders who've stayed on too long. I have no intention of being one of them . . . I leave the job I love by choice," Stern said. "But for all the joy, there has been sorrow as well. The loss of my 13-year-old daughter Cassie (in 2002) and the 24/7 responsibilities of this job have left me at times not paying enough attention to the personal dimensions of my life."
The news of Stern's departure brought swift and unequivocal reactions across ideological rainbow, from inside organized labor and well without. The Wall Street Journal said in a scathing editorial that Stern is leaving the SEIU $85 million in debt—right before Republicans are expected to make significant gains in November, thus weakening labor's hand.
Sal Rosselli, interim president of the breakaway National Union of Healthcare Workers, and a bitter foe of the SEIU, said Stern's "legacy is that he took control of an organization built by more than a million hardworking janitors, healthcare workers, and public servants, and used their resources primarily to secure his own political power."
Marick F. Masters, director of the Fraser Center for Workplace Issues and Labor at Wayne State University in Detroit, said he's inclined to take Stern at his word. "He had the presence of mind to leave when he is at the top rather than to stay longer," Masters says. "And the fact is he has been the leader of that organization since 1996. How many corporate executives stay at the helm for as long as he has? You are talking about 14 years being the head of an organization that has been at the center of most of the controversies that labor has been involved in that time period. It's reasonable that he could be a little tired."
Masters says Stern leaves now to ensure that new leadership is well in place to help Democrats in the fall elections. "If his union is going to play as effective a role as he wants, he would want somebody else at the helm to begin to take over the reins," Masters says.
Jim Trivisonno, president of Detroit-based IRI Consultants to Management, Inc., says Stern, with his Ivy League education, high articulation, and global perspective, was extremely effective, even though he didn't fit the classic image of the rough-and-tumble labor leader. "He will be difficult to replace," Trivisonno says. "From a strict leadership standpoint, folks like Stern don't come around very often and he accomplished a lot of organized labor generally and SEIU specifically."
Stern did not say exactly when he would leave. Secretary-Treasurer Anna Burger will serve for 30 days after Stern's departure, when a new president will be elected by the SEIU board to finish Stern's term.
"Some of the people being mentioned to replace him are probably capable, but they will definitely have a different style—some more aggressive, others not," Trivisonno says. "But the SEUI has a pretty good infrastructure and they are focused on healthcare, which is a right area for organized unions."
It's hard for me to imagine that someone like Stern—who joined the union as a 22-year-old and worked his entire life to make it the leading voice in organized labor—would suddenly walk away from his job two years before his term expires—just as the union appeared poised to enjoy the fruits of its labor. We are talking about the most powerful person in organized labor, the head of an organization representing 2.2 million people. It has been my experience–after covering politics for more than two decades—that people in power do not readily give up that power unless someone or something is shoving them out the door.
Burn out? Sorry, I don't buy it.
Note: You can sign up to receive HealthLeaders Media HR, a free weekly e-newsletter that provides up-to-date information on effective HR strategies, recruitment and compensation, physician staffing, and ongoing organizational development.
A federal grand jury in Cleveland has indicted three physicians and nine other people for allegedly running a multistate Internet painkiller pill mill, the Department of Justice announced.
Terence Sasaki, MD, 37, of Jersey City, NJ; Edward Cheslow, 50, of New York City; Dora Fernandez, MD, 35, of Ponce, PR; and their accomplices were indicted on 37 criminal counts, including drug trafficking, conspiracy, money laundering, and continuing a criminal enterprise, the Department of Justice announced.
Prosecutors allege the defendants used two companies—USMeds, LLC, in Cumming, GA, and Brennan & DePaoli, Inc., dba, Delta Health, in Jacksonville, FL—to sell hundreds of thousands of prescription painkillers—primarily hydrocodone products, such as Vicodin and Lortab, and anti-anxiety alprazolam products, such as Xanax illegally, over the Internet to customers across the country, DOJ said.
The Internet customers allegedly selected the type, strength, and quantity of the drug they wanted, and the defendants conducted a brief telephone "consultation" and approved the orders. The defendants either shipped the drugs directly to the customers, or sent them a prescription to fill at a local pharmacy not associated with the drug traffickers, DOJ said.
Customers were charged greatly inflated prices (eight to 10 times retail) when the drugs were shipped to them, and they were charged an inflated "consultation" price when the defendants wrote the paper prescriptions, DOJ said.
Other defendants were identified as: James Hazelwood, 39, of Cumming, GA, described by prosecutors as the alleged ringleader in the operation; Julie Toennies, 36, of St. Louis; Audrey Barbara Rovedo, 61, of Jacksonville, FL; Vinesh Darji, 39, of Tampa; Bruce Liddy, 53, of Lakeland, FL; Helen Kann, 50, of Atlanta; Jennifer Ryan, 32, of Cumming, GA; Diego Fiorillo, 33, of Metairie, LA; and Stephen Derks, 41, of Marietta, GA.
USMeds, LLC, is Hazelwood's company. Delta Health is owned by Rovedo, DOJ said.
Trustees at Harlingen, TX-based Valley Baptist Health System and Knapp Medical Center in Weslaco, TX, have signed a memorandum of understanding to create a new nonprofit health system for the Rio Grande Valley region of South Texas.
The deal is expected to be finalized by summer, the healthcare providers said in a joint statement.
"Residents have relied on Valley Baptist Health System and Knapp Medical Center for many years for their health and well-being," said James Eastham, president/CEO of Valley Baptist, a faith-based regional health system. "By coming together to form this new health system, we would be assuring that not-for-profit health care in this area would be preserved and strengthened. We are excited about the future and think this is great news for the Valley, our patients, and our two organizations including our employees and physicians."
"In light of the current environment surrounding healthcare and reform efforts, the new system would not only benefit patients, but also the founding organizations themselves," Eastham said. "The new organization would provide residents with broader access to services and physicians, streamline business operations, and maximize community resources by avoiding duplication of costs and leverage increased buying power for non-salary items."
The new healthcare system, subject to regulatory approval, would provide both founding organizations with the operational, clinical, and contract negotiation advantages of a larger organization while allowing each to maintain its focus on its community mission, said Jim Summersett, president/CEO of Knapp Medical Center, a nonprofit community hospital.
"As a not-for-profit entity, the new system would continue to invest in people, technology and facilities to continue to improve care and maintain the high standards of quality residents have to come to expect from us," Summersett said. "We recognize the equity that each health system has with the public in terms of its name and brand recognition. So, each would continue to use its own name and operate as not-for-profit members of the new health system."
PHC Holdings of Florida, which manages Medicare Advantage plan company Physicians Health Choice of Florida, has acquired Citrus Health Care, the company announced. Financial terms of the acquisition were not disclosed.
Tampa, FL-based Citrus Health Care primarily serves about 10,000 Medicare Advantage plan members through contracts with the CMS, and about 44,000 Medicaid plan members through contracts with the Florida Agency for Health Care Administration.
Physician-own Physicians Health Choice, based in San Antonio, TX, serves more than 30 Medicare Advantage plans with nearly 30,000 members in Florida, Texas, New Mexico, and Arkansas. PHC is a subsidiary of WellMed Medical Management, Inc., which specializes in care for seniors.
Healthcare reform will have a long-term negative credit effect on not-for-profit hospitals, even though it will reduce bad debt expenses and charity care, Moody's Investors Service said in a new report.
"The key longer-term challenge for the not-for-profit hospital sector is the reform's reliance on extracting long-term cost efficiencies from hospitals, probably resulting in diminished hospital revenues," said Moody's Vice President Mark Pascaris, author of the report, Long-term Credit Challenges of Healthcare Reform Outweigh Benefits for Not-for-Profit Hospitals. "The trend will become more pronounced over time as key provisions of the law do not become effective until 2014."
Pascaris said the reform will complicate negotiations for nonprofit hospitals with private health insurers because of the federal government's increased regulatory scrutiny of insurers. Hospitals will also face reimbursement pressures from CMS because the reform squeezes savings out of existing government healthcare programs, under the new Center for Medicare and Medicaid Innovation. The reform additionally creates a Medicare bundled payment pilot program, and other payment models that will mean further cuts to Medicare/Medicaid, Pascaris said.
"Even though many of the most efficiently operated health systems will take advantage of the new opportunities to leverage economies of scale and scope to broaden their market reach and strengthen their position, healthcare reform is a long-term net negative for the not-for-profit hospital sector because it will effectively reduce revenues to hospitals,” said Pascaris.
The reform will encourage even more consolidation of the industry, as bigger health systems leverage economies of scale and have greater access to credit.
"Many not-for-profit hospitals, especially single-site and small hospital systems, may struggle," said Pascaris. "In fairness to the new law, centralization is a market force well under way, but is one that may be exacerbated by healthcare reform."
The cost of hospital services, which grew by 1.1% in March and 8.6% in the last 12 months, almost quadruple the 2.3% increase in the overall Consumer Price Index for the same period, the Bureau of Labor Statistics announced today.
A further breakdown shows that the cost of hospital inpatient services rose 1.6% in March and 9.5% for the past 12 months, while the cost of hospital outpatient services rose 0.6% in March and 7.4% for the past year. Seasonally adjusted CPI data for all urban consumers also show that the overall cost of all medical services grew by 0.3% in March and 3.8% in the last 12 months.
The rising costs of virtually every healthcare-related index have easily outstripped overall CPI for decades. "I'm sure a lot of people have different opinions on why. In my opinion, a lot of it is demand-related," says BLS economist Steve Reed.
"Healthcare has just gotten better over time. There are more drugs that work. There are more treatments that work effectively. Despite our recent economic struggles, we have gotten richer over time," Reed says. "So, if you are becoming wealthier as a society and your healthcare sector is innovating and becoming better, naturally there is more demand for healthcare and that puts upward pressure on healthcare goods."
Adding to that upward pressure, Reed says, is a lack of financial disincentives to reduce consumer demand. "When we buy healthcare, we are not paying the whole cost of what we buy so we don't face the same incentives to limit our healthcare purchases, so that affects demand," he says. "In addition, demand for a lot of healthcare is very inelastic. If you have market power and inelastic demand generally the profit-maximizing price you charge is very high."
The CPI data also show that:
The cost of physician services fell 0.1% in March, but rose 3.2% in the last 12 months.
The cost of prescription drugs rose 0.6% in March, and 4.9% in the last 12 months.
The cost of nursing home and adult day care services rose 0.3% for the month, and 2.8% for the last 12 months.
The CPI is a measure of the average change in the prices of goods and services purchased by households. CPIs are based on prices of food, clothing, shelter, fuels, transportation fares, charges for doctors' and dentists' services, drugs, and other goods and services that people routinely buy.
Prices are collected each month in 87 urban areas across the country from about 4,000 homes and approximately 25,000 retail businesses, hospitals, and other service providers.
USRC, a privately held company based in Plano, TX, will open a tender offer for all outstanding common shares of Linthicum, MD-based DCA for $11.25 per share in cash, followed by a merger to acquire all remaining outstanding DCA shares at the same cash price, which represents a premium of 72% over Tuesday's closing stock price, the two companies said in a joint media release.
"For shareholders, the transaction provides a compelling opportunity to realize the value DCA has created," said Thomas K. Langbein, chairman of the board at DCA, which unanimously approved the deal.
Directors and executives at DCA hold approximately 23% of DCA's common stock and will tender their shares into the tender offer. USRC expects the transaction to close in May.
"USRC and DCA each have built strong regional operations and this transaction permits us to build a more efficient and stronger national operation," said Chris Brengard, chairman/CEO of USRC. "DCA, like USRC, has a commitment to building joint ventures with nephrologists."
When the deal is finalized, USRC will provide dialysis services to approximately 5,500 patients through 84 outpatient dialysis facilities in nine states, more than 12 home dialysis programs, and 24 dialysis programs within acute and specialty hospital facilities. USRC now operates 47 dialysis clinics in Texas and Arkansas.
A leading primary care physicians association is warning its members that Congress, bogged down by partisan squabbling, may not be able to delay the 21.2% cuts to Medicare reimbursements that go into effect Thursday.
"The physician payment extension has been caught up in much larger issues of unemployment insurance and the federal deficit," Kevin Burke, lead lobbyist for the American Academy of Family Physicians, said in a media release. "But while Congress is mired in its partisan battles, family physicians are faced with drastically reduced payments now and administrative nightmares in the near future."
The Senate today passed a procedural hurdle on a bill that would provide a Medicare payment extension through April 30, reversing the 21.2% reduction that took effect on April 1 under the sustainable growth rate formula.
Now, Senators will begin consideration of the bill reversing the payment reduction. If Senators don't agree to shorten the allocated debate time, however, they may not vote on final passage of the bill until after Thursday's deadline, Burke said.
The physician pay cut has been an ongoing drama on Capitol Hill. The House passed the Medicare extension bill on March 17. However, the Senate failed to act on it before a two-week spring break recess on March 26. The reimbursement cut went into effect on April 1, but CMS ordered contractors to hold payments delivered after April 1 for 10 business days, or April 14, anticipating that Congress would act on the cuts before they took effect.
Burke says the bill providing the payment patch through April 30 is expected to pass, perhaps by Friday, after which Congress will debate a bill to extend the current payment rate until Oct. 1. Both the House and the Senate have passed separate extension bills, but are negotiating how to pay for it.
If Congress doesn't approve the Medicare patch until after the April 15 deadline, physicians would see one or two days of claims processed at the reduced rate. AAFP has asked CMS if it will pay the difference between the reduced claims rate and the restored rate automatically or if physicians will have to resubmit their claims. AAFP also asked for guidance on how physicians should handle copayments they may have collected since April 1.
AAFP has additionally asked CMS if the deadline for physician nonparticipation in Medicare for 2010 has passed, AAFP said.
Whistleblower lawsuits and multimillion dollar Medicare fraud settlements involving otherwise reputable hospitals and health systems are becoming standard media fodder on the Department of Justice Web site.
As is almost always the case, the accused providers that are often paying millions of dollars to the federal government to settle whistleblower suits for self-referrals, or inflated outlier charges, or whatever the gist of the suit may be, are also claiming that the settlement is not an admission of guilt.
Most claim they are paying the fines to avoid costly and interminable litigation. "The lesson to be learned really in all of these similar cases is that the government is looking for fraud and will go after providers if they think there is a problem," says Anna Grizzle, an attorney with Nashville-based Bass, Berry & Sims, PLC.
She says there will be even more enforcement actions against healthcare providers in the coming months and years because the federal government believes it can pay for some of the health reform by cracking down on fraud.
"With the expansion of the False Claims Act and the enhanced penalties under the new health reform laws, the government has demonstrated that it is serious about tracking down healthcare fraud, and with increased funding under the health reform legislation will have the money to be able to do it," Grizzle says.
Health reform requires healthcare organizations to have compliance programs. Grizzle says these programs must proactively find problems before the government or contract auditors.
"It's much better for the organization to find it, fix it, and repay any money it shouldn't have received, rather than have the government find it. And in today's era of heightened scrutiny, healthcare organizations should assume that if there is a problem the government will find it," Grizzle says.
Strong compliance programs should include robust internal and external audits, with healthcare organizations conducting their own data mining to identify systemic problems that they can correct internally.
"A good compliance program should have a strong internal audit function, where you are looking over your own claims. It also should consider periodic external audits as well on risk areas," Grizzle says.
There are several sources for finding risk areas. HHS' Office of Inspector General issues fraud alerts about potential risk areas, and other sources include RAC audits, and detailed readings of whistleblower settlements.
A good compliance program starts with strong policies and procedures and a well-trained staff that understands appropriate billing and compliance with state and federal regulations.
"As you do your own internal audits, are you seeing a pattern of mistakes being made to indicate there is vulnerability in your systems? Through your employee hotline or other complaint reporting mechanisms, are you seeing the same complaints being made?" Grizzle says. "That could be a red flag for a potential issue you might want to explore to determine if any corrective action is necessary."
Even if a hospital is guilty of an honest mistake, Grizzle says they still have to be ready to defend against allegations that the mistake is potential healthcare fraud, and defending is expensive.
"With some of the proactive data mining and analysis, the government contractors are identifying outliers in a particular geographic area," she says. "Sometimes, there are good reasons why someone is an outlier. You can defend it. But if you are identified as a target because you seem to have a high utilization rate for a particular situation, then you have to be prepared to defend why you are an outlier."
