A few years ago, hospital leaders like William Leaver were hiring radiologists, cardiologists and other specialists to maximize fee-for-service payments. Today, the CEO of Des Moines, Iowa-based UnityPoint Healthcare seeks patient navigators, care coordinators and mid-level nurse practitioners to guide patients' care outside its 30 hospitals. Leaver is outfitting his nonprofit integrated health system as a hospital of tomorrow. In doing so, he is busy standardizing operations across UnityPoint's hospitals, 280 clinics and home care operations in eight Iowa and Illinois markets, and making very different hiring choices than he used to. "The jobs in the future will be different from the jobs in the past," Leaver says.
That's a far cry from the heyday of fee-for-service medicine. In 2004, the three biggest in-demand specialty physicians were radiologists, anesthesiologists and cardiologists, according to physician recruiting firm Merritt Hawkins. Today, the first two don't crack the top 20, and cardiologists were No. 15, according to the 2013 Merritt Hawkins survey.
Instead, hospitals overwhelmingly seek primary care providers. "Primary care, across the nation, is everybody's No. 1 search," says Mike Houttekier, manager of physician recruiting at Allegiance Health, a 411-bed hospital in Jackson, Mich. fFamily medicine, internal medicine and hospitalist physicians (primarily internists who work exclusively in the hospital) were the top three physician searches Merritt Hawkins conducted over the last year. "Demand also is increasing rapidly for nurse practitioners and physicians assistants," says Susan Salka, president and CEO of AMN Healthcare, a health care workforce solution company. For the first time in 20 years, Merritt Hawkins—which is owned by AMN—saw nurse practitioners and physicians assistants crack the top 20 searches conducted, at No. 10 and No. 12, respectively.
Hospital staffing changes are driven by an aging population, a physician workforce shortage and health care reform. The Affordable Care Act emphasizes prevention, encourages value-based payment and, in January, begins to provide insurance coverage to more than 30 million newly insured patients. Payment is shifting from predominantly fee-for-service to one that puts hospitals at risk for patient care both in- and outside the hospital's walls. Besides hiring more primary care providers, hospitals also are aggressively hiring emergency physicians—more newly insured patients are expected to boost emergency room use—care coordinators and other patient care advocates, clinical pharmacists, health IT and data experts.
"Health care reform only makes the staffing shortages worse," notes Salka. A variety of payment changes and care delivery models have proliferated under Obamacare, including Accountable Care Organizations, patient-centered medical homes, bundled payments, readmission payment penalties, adherence to treatment protocols and other quality-based metrics. The focus on value-based care puts a premium on prevention and team-based care coordination, led by primary care practitioners. This is challenging hospital executives, who are operating under two conflicting payment systems. Houttekier says it's akin to straddling a "crevasse."
"Staffing is the linchpin" of moving to the hospital of tomorrow, notes John R. Thomas, CEO of MedSynergies, a physician alignment firm. It's why staffing has captured the C-suite's attention. This year, 42 percent of hospital executives cited it as the top priority for their facility—compared to 9 percent in 2009—according to a forthcoming AMN survey. Furthermore, nine out of 10 CEOs responding to a U.S. News survey said they planned to reduce reliance on independent doctors in favor of a staff model.
At UnityPoint, Leaver has included physicians on the leadership team in efforts to remake the former hospital-centric Iowa Health System into a doctor-driven, patient-centered system. As it transitions, UnityPoint created a year-long Physician Leadership Academy for promising MD leaders to hone their skills. "It's building capabilities they didn't necessarily get in medical school," Leaver says. Getting MD input and buy-in is essential as the system standardizes operations, integrates its home health care operation and care coordination efforts across all markets, while refashioning all its 250 clinics into patient-centered medical homes.