Phoenix obstetrician Megan Cheney no longer makes hours of telephone
calls on Thursday nights to report routine results of laboratory tests to
waiting patients. The calls, however, still get made every week.
A medical assistant with experience in obstetrics and gynecology now
handles calls involving routine findings. That has freed time for Cheney to
draft the lectures she delivers twice a week to her medical resident trainees.
The shift in responsibilities may be minor, a matter of hours in a lengthy work
week. But it is one of many underway at Banner Health, where the drive to cut
costs has triggered an extensive overhaul of employees' roles and patient care.
Labor is the largest expense for health systems, and Banner officials
see potential savings in freeing up their highest-paid professionals—doctors,
pharmacists, advanced practice nurses, physician assistants—for work only they
are qualified to do. “We certainly don't need physicians calling back on routine
results,” said Mindy Smith, chief operating officer of the Banner Medical
Group. To do that, Banner is delegating new responsibilities across a team of
clinical and clerical workers. Not only has that shifted work from doctors to
medical assistants, but also from medical assistants to clerical staff, whose
numbers will soon grow in Cheney's clinic to accommodate the domino-like
transfer of duties.
New financial incentives
The same strategy is playing out at health systems across the country
as new financial incentives to cut costs proliferate under Medicare and private
insurance. The focus on more tightly defined roles has grown. Some have done so
strictly to cut costs. Others have sought to maximize the efficiency of teams
used to manage patients' care. The result has been an ongoing, sometimes
uncertain evolution in the daily tasks of healthcare's front-line workforce.
As a result, roles for medical assistants, pharmacy technicians and
other workers, including clerical staff, have expanded. Those without extensive
medical credentials or a high salary are being asked to work more closely with
patients. Advanced practice nurses see primary-care patients. Medical
assistants meet with clinic patients to collect basic information once gathered
by nurses.
These practices have increased demand for such workers, including
occupations with more advanced clinical training such as advanced practice
nurses and physician assistants, whose median salaries are nearing $100,000
less than those of physicians. Advance practice nursing hires represent the
fastest-growing segment for recruiter Merritt Hawkins, said Travis Singleton, a
senior vice president for the firm. Jobs for medical assistants are projected
to grow 29% by 2022. Physician assistants and advanced practice nurses will see
demand increase 38% and 31%, respectively.
The pressure to squeeze labor expenses has been amplified as health
systems invest in workers to more heavily promote prevention and manage medical
care, regardless of its location, from hospitals to clinics to homes, and to
provide support as patients move between them.
The upfront employee investment, industry executives say, is expected
to yield a return by preventing disease complications and costly hospital
visits and producing the quality of care required to earn incentives under new
payment contracts, such as accountable care. But managing labor costs is a top
priority.
Accountable care organizations have hired scores of care coordinators
as they launch their efforts. Advocate Health Care in Illinois initially hired
60 coordinators. Partners HealthCare, Boston, doubled its care coordination
staff to 50 as it ramped up its early ACO efforts. But that investment can drag
down margins. Universal American, a publicly traded insurer that owns the most
Medicare accountable care organizations, said its $63 million investment in
care coordination and information technology last year eroded its earnings.
Greater investment in care coordination has also intensified efforts to
reorganize roles and shift responsibilities, not solely to increase efficiency
but to better coordinate medical care among multiple professionals who jointly
care for those patients at the highest risk for costly complications.
Care coordination strategies increasingly rely on teams of social
workers, health coaches, doctors, nurses, physician assistants and medical
assistants who collaborate to provide patient care. A team model seeks to
leverage each individual's expertise to increase efficiency, said Dr. Dave Krueger,
executive director and medical director for the Bellin-ThedaCare Healthcare
Partners.
“We shouldn't be asking the nurse to become an expert on the social
work side and vice versa,” he said. “A group of us is going to be taking care
of a group of patients. Instead of a doctor with a patient panel, it will be
more of a clinic with a clinic panel.”
'Big economic lift'
That care team is expanding to include pharmacists, pharmacy
technicians and psychiatrists to tackle medication errors and prevalent but
untreated mental illness that can undermine patients' ability to care for
themselves. Advocate Health Care soon will add psychiatrists and psychologists
to teams that meet with hospitalized patients. Dr. Lee Sacks, chief medical
officer for Advocate and chief executive of its physician group, said a 2011
study of its hospitalized patients found one-third had mental health
conditions, and those patients spent more time in the hospital and were more
likely to return.
Advocate also will add mental-health professionals to
emergency-department teams and primary-care clinics, with the hope of improving
care and lowering costs. “If we did a better job, there would be a big economic
lift,” he said.
But the switch to teams and newly defined roles isn't straightforward
or without risk, experts say. Communication breakdowns among team members can
compromise care. Tensions may arise as roles are reassigned.
Health systems do not yet know what configurations work best for
various patients or settings, and efforts vary as organizations test and tweak
different models. “We're experimenting,” Banner Health's Smith said.
Banner has shifted numerous responsibilities to medical assistants,
reducing its reliance on registered nurses. Banner now sees an expanded role
for registered nurses to work with more complex patients. And Advocate patients
who call to speak with a nurse now are triaged to clerical staff unless the
request is medical in nature.
New roles, new relationships
Some doctors and other professionals are struggling to adapt to the new
roles and new relationships required to make care coordination successful.
Older physicians who have long been in the workforce typically struggle more to
work within a team after years of independence and more entrepreneurial
practice, recruiters say. Conversely, younger doctors are often more eager to
make the switch to teams, despite limited training.
Medical groups are looking for cost-effective alternatives to replace
retiring physicians as Medicare and private insurers squeeze reimbursement and
new financing models grow more common, said David Cornett, a senior executive
vice president at Cejka Search, a healthcare recruiting firm. “The initial
waves of bundled payments are telegraphing that doctors will be paid less and
not more,” he said.
Employers increasingly hire doctors, young or old, who can embrace the
common goal of team-based care, Singleton said. They can be difficult to find
when training does little to prepare doctors to work collectively. “A team of
experts does not equal an expert team,” he said. “We've trained them to work
alone, and we're asking them to practice completely differently.”
Banner's Cheney, who joined the same practice where she was a resident
until last summer, said she feels more comfortable delegating now that she has
built a relationship with a medical assistant. Assigning tasks to the medical
assistant clearly can improve her efficiency, but she says she must resist the
urge to do more, as was the case when she was a resident. “You're used to doing
everything,” Cheney said. “I know the ins and outs of the office. It's been an
adjustment.”
Alleviate frustrations
Patients, too, must adjust. Diane Ekstrand, vice president of human
resources for Banner, said it was a medical assistant who called to remind her
of an upcoming annual physical and who initially discussed her medications,
weight and family life during the appointment.
Too little time with a doctor, however, may frustrate many patients.
Teams should not be a barrier to appropriate physician visits, said Dr. Bob
Williams, a director with consulting firm Deloitte who helps oversee the
company's accountable care consulting.
But teams with clearly defined responsibilities can help alleviate
workers' frustration and boost job satisfaction, executives and
consultants say. Jobs with more responsibility can be more fulfilling
and show an employer values workers' expertise and talents. That can be
an asset for employers in a competitive labor market, said Jennifer
Radin, a principal with Deloitte who specializes in workforce and
operations. “Those who are more satisfied are more likely to stay with
the organization.”
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