"We need to master care coordination, because that's what we'll get paid for," observes Leaver. To pull that off, his biggest staffing needs include care navigators, mid-level nurse practitioners and other care extenders, in addition to primary care doctors. The system is also recruiting those with experience or acumen in analytics, health assessment and actuarial science. Today, 20 percent to 25 percent of UnityPoint's business is risk-based. "Over the next three to five years, that will grow to 50 to 60 percent," he says.
Physician alignment, along with retention and retraining efforts, is helping San Diego's Scripps Health staff its changing organization to compete in a metamorphosing hospital industry. In 2010, Scripps transitioned from a vertical to a horizontal organization and tapped doctors to co-manage Scripps, which serves a quarter of San Diegans. Capitation has long been popular in southern California, although Scripps predominantly is a fee-for-service animal. In 2010, it realized the future was changing, and restructured to better control costs and beef up its outpatient processes as inpatient offerings stand to shrink going forward.
Scripps leaders worked with physicians and employees to eliminate redundancies, reduce variations and adopt consistent best practices in policies, procedures, equipment and services. "They could identify the variance in our organization better than we could," says Victor Buzachero, Scripps' corporate senior vice president for innovation, human resources and performance management. As a result, Scripps has saved about $200 million in three years by consolidating clinical medical lab function previously performed in hospital settings, cutting variation and waste in its pharmacies, standardizing supplies across the system and other actions.
"We've done this with a no-layoff approach," he says. As Scripps examines is costs—labor accounts for half of it—it is retraining workers for the jobs needed in a reformed health system. Examples: some bedside nurses now act as patient navigators, working in teams with one-time hospital pharmacists who today are on the floor or in the field doing medication management therapy, or coaching patients on how to take their medicines to prevent re-hospitalizations. "We entered into the hospice business this year and redeployed staff there," Buzachero adds. A decade ago, 75 percent of Scripps hires came from outside the system; today two-thirds are internal transfers.
At Allegiance, "we've had to take a look at the return on investment of each position here, even physicians, nurse practitioners and physicians' assistants," says Houttekier. "Everybody undergoes scrutiny and executive review. That's a big change for us." That increased intensity on hiring, says Salka, is reflective in the growth of AMN's managed services business, which has grown from about 5 percent of AMN's business three years ago to one-third today. Hiring doctors—who are working fewer hours overall—projecting seasonal staffing demands, matching hospital staffing with patient acuity and being able to deftly adjust workforce needs and filling in gaps with temporary staffing has become tricky for hospitals, who have followed employers in other sectors by tapping managed services programs and recruitment process outsourcing.
The pressure is intensified as Houttekier tries to meet future and today's hiring needs. For some hospitals, today's needs are front and center. Between hiring primary care providers, Houttekier must meet the hospital's immediate needs, such as hiring a neurosurgeon or two to replace a retiring veteran surgeon. That's key as Allegiance makes itself into a trauma center that is also introducing a graduate medical education program and open heart center. Allegiance is trying to extend its brand, as its primary competitors are in Ann Arbor, 35 miles away. In doing so, Houttekier is leaning on AMN for temporary and other staffing needs. "Staffing has become more challenging and will continue to be challenging," he says.