Healing the healthcare staffing shortage *connectedthinking Table of contents 01 02 03 04 Executive summary l Key findings lFuture Forces lRecommendations lAbout the research 05 Background: Business policy issues around the supply of nurses and physicians 11 The challenges of inadequate supply 20 Overcoming the disconnect 22 23 25 27 31 Strategies for developing a workforce model for the future l Develop public-private partnerships l Encourage technology-based training l Design flexible roles l Establish performance-based metrics 35 Conclusion 36 Appendix
Executive summary Many nurses and physicians are among the baby boomers who will start to retire in the next three to five years. The federal government is predicting that by 2020, nurse and physician retirements will contribute to a shortage of approximately 24,000 doctors and nearly 1 million nurses. While hospital leaders voice much of the concern over possible shortages, the implications extend throughout the labor-intensive, trillion-dollar United States health system. It’s expensive to educate new nurses and doctors. Taxpayer-funded Medicare spends $8 billion a year for residence training of physicians alone.
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While the U. S. has more physicians and nurses today than ever before, they are not distributed or deployed efficiently. Shortage projections tend to be built around today’s often dysfunctional system, which makes them problematic. However, while future shortages are certainly worrisome, the bigger issue for health industry leaders today lies in orchestrating care in an increasingly complex and converging healthcare labor market. Shortages, or even talk of shortages, can manipulate markets, creating problems for health industry executives who face the daily issues of recruiting and retaining the best talent.
Yet because shortages have also been cyclical, short-term solutions have won out over long-term changes. Seeking solutions means understanding that while the challenges confronting nurse and physician shortages are very different, their roles and futures are starting to converge. Healthcare is a team sport: a dozen or more types of physicians and nurses can be involved in a single patient’s care, and the need for coordination and planning becomes more imperative and complex. It’s not a matter of determining the mix of nurses and doctors to deliver efficient and effective care.
Executives today must consider what kinds of nurses and doctors are needed, what tasks these clinicians are best educated to deliver, and how technology and lower-skilled workers can be used to supplement or replace them. PricewaterhouseCoopers’ (PwC) Health Research Institute (HRI) studied this evolving issue with the intent of providing a 360 degree view of current workforce challenges and providing a roadmap for a new, more sustainable workforce model. Key findings • Use of temporary nurses is no longer a stop-gap measure but has become a way of life for many hospitals.
Reacting to several years of nurse vacancy rates in the 7% to 10% range, hospital executives surveyed said they use temp nurses for an average of 5% of all nursing hours. Meanwhile, nearly three-fourths of hospital executives surveyed said their physicians are asking for on-call pay, and two-thirds said some of their physicians want to be employed by them. This data bolsters the trend of nurses moving away from hospital employment and doctors moving toward it. • The process of educating and retaining new nurses is broken. The number of denied applicants for nursing schools is at its highest ever, increasing more than sixfold since 2002. Turnover among newly hired hospital nurses is highest in the firstmmtwo years.
Failure to retain nurses is costly and wasteful. Every percentage point increase in nurse turnover costs an average hospital about $300,000 annually. Hospitals that perform poorly in nurse retention spend, on average, $3. 6 million more than those with high retention rates. • Hospital leaders are in a state of denial about nurse dissatisfaction. Hospital executives believe that the nurse workforce in general is dissatisfied, but not nurses in their own hospital. Hospital executives surveyed cited excessive administrative paperwork, patient workload strains due to rising patient acuity levels, and inadequate staffing as the top three factors for nurse dissatisfaction and turnovers. Inadequate compensation and disruptive physician behavior ranked fourth and fifth.
PricewaterhouseCoopers respectively. However, hospital executives may be underestimating the effects of these factors because many of those surveyed failed to recognize these complaints as a “very significant” problem in their own organizations. • A new wave of medical schools could repair the inequity of physicians in underserved areas and specialties. As more U. S. medical students graduate, they’ll likely displace some international medical graduates who have been filling the gaps.
After two decades of the status quo, a record number of new medical schools are slated to open in the next five to ten years, which could alter the future distribution of physicians. • Nursing education is stifled by perverse financial incentives. While medical education receives significant federal subsidies, the same is not necessarily true for nursing. Nursing education programs often lose money for colleges, limiting colleges’ willingness to expand their programs and raise faculty salaries. • The workforce is too often a second thought for executives, who are distracted by numerous payment and regulatory issues.
A significant disconnect exists between what hospital executives think about medical workforce shortages and how they address them. Three-fourths of hospital executives surveyed said workforce shortages are real. However, when asked to rank these shortages as a priority in their organizations, physician issues ranked sixth and nursing issues ranked seventh behind other priorities such as reimbursement, government regulations, clinical quality, and uncompensated care. Future forces These research findings indicate that the current medical workforce model is under great pressure and in many cases, is broken.
There are also new forces on the horizon, however, to which healthcare organizations must be able to recognize and respond. Nurse and physician roles are blurring in primary care, a specialty in which lower salaries have dissuaded debt-laden medical students. Threefourths of hospital executives surveyed said hospitals are using more physician extenders, such as nurse practitioners and physician assistants, and more than half said they will use them in the future. Competition for these clinicians is increasing, particularly with the advent of retail clinics, which heavily employ physician extenders. Schedules trump salary.
Organizations that focus on the work/life balance issues for physicians and nurses will have a competitive edge in recruiting and retaining top talent. Medical students say work/life balance is a top influencer of how they pick a specialty, and nurses say culture and schedules are the greatest influences on their job satisfaction. Advances in specialization and technology are shifting what is done and by whom. From radiologists to cardiologists, to digital telemedicine and virtual colonoscopies, traditional roles and descriptions are morphing and shifting. This shift holds promise for increased efficiency but may cause disruption for certain specialties.
Rainmaker roles may change for hospitals. Employment changes and pay-for-performance reimbursement may combine to flip the workforce dynamic in hospitals. Traditionally, physicians were rainmakers who brought in revenue, and nurses were overhead. Through new, pay-for-performance programs that focus on clinical quality and patient satisfaction, nurses will have significant impact on the key metrics that will drive reimbursement updates.
Recommendations Given these key findings and future forces, PwC’s Health Research Institute has developed a roadmap for a new workforce model based on the following recommendations: Develop public-private partnerships. Widespread shortages have created an environment in which key healthcare players may no longer operate in silos. Rather, these groups must work collectively to promote nursing and physician programs, forging alliances to provide not only education but also required funding. Encourage technology-driven training. Improving clinical outcomes requires the seamless coordination of treatment among all clinical professionals. Advances in technology have enabled caregivers to work in concert with one another, allowing the focus to remain on quality patient care.
Providers, for their part, must maximize available technology and encourage the adoption of and adherence to technical innovations to increase the productivity of medical staff. PricewaterhouseCoopers Design flexible roles. More than ever, physicians and nurses are placed in a stronger position to dictate the terms of their employment, and employers are increasingly finding that flexibility is central to attracting and retaining quality medical staff. The most successful employers will provide clinicians with options and integrate flexible work arrangements into their staffing models. Establish performance-based metrics.
Unlike other industries, healthcare has been able to delay the adoption of performance-based standards. Traditionally, reimbursement did not depend on quality or operational efficiency but rather only on the volume of services delivered. However, the landscape of reimbursement is evolving, with performance based metrics—such as clinical quality outcomes and patient satisfaction—as its centerpiece. About the researchh To provide research-based insight, HRI conducted more than 40 in-depth interviews with thought leaders and executives representing hospitals, academic associations, nursing schools, and the business community.
PwC conducted a thorough literature review of reports and guidance from associations, regulators, and academia to gather insights on current challenges and best practices. Publicly available data was analyzed relating to workforce projections and demographics. PwC also commissioned a survey of more than 240 hospital executives from throughout the U. S. in the following categories: • Chief Nursing Officer (CNO) • Chief Medical Officer (CMO) • Chief Executive Officer (CEO) • Chief Financial Officer (CFO) • Chief Operating Officer (COO) • Vice President of Human Resources (VP-HR)
While this report focuses on nurses and physicians, they are not the only professional occupations affected by workforce shortages. Other occupations include imaging technicians, pharmacists, lab technicians, and patient-care assistants. 2 While the scope of this report does not allow full exploration of each area, there is some commonality of supply and demand drivers among the different fields. To get the broadest possible input from PwC’s network of business advisers, HRI employed an innovative tool called the PwC Thought-Wiki, which is based on similar technology that powers Wikipedia, an online encyclopedia.
This tool incorporated a new level of collaborative authoring and knowledge sharing into HRI’s content development. The Thought-Wiki enabled PwC health industry practitioners to contribute their real-world knowledge to the research, and it was especially helpful in capturing the collective intelligence of our clinicians. HRI also enlisted the aid of PwC Saratoga, a service that focuses on teaming with executives and HR departments to help them measure, manage, and maximize the value of their workforce. What works* 4 Background: Business and policy issues around the supply of nurses and physicians
Registered nurses (RNs) and licensed physicians are the arms and legs of the health industry, and it seems there are never enough. Three-fourths of hospital executives surveyed by HRI for this report said clinical workforce shortages are real. As the healthcare industry grows and now consumes 16% of the overall economy in the U. S. , employment as a nurse or physician has delivered one of the most dependable paychecks around. The need for nurses and physicians in hospitals, nursing homes, health plans, pharmaceutical companies, home health agencies, and other health companies has exploded during the past 20 years.
How many is enough? It’s a difficult question to answer, considering the acknowledged inefficiencies of the system overall. In terms of global benchmarks, the U. S. has fewer nurses and physicians per capita than some other industrialized nations, yet it spends far more money per capita—twice as much as other industrialized countries—on healthcare. Would having more nurses and physicians raise costs even further? Would it increase quality? Would it make the system operate more effectively and efficiently? Chronic nursing shortages may double after 2010
The total number of registered nurses has increased by 75% since 1980 (Figure 1). Talk of nursing shortages has waxed and waned for generations. In recent years, at least a dozen states have initiated studies about the shortage of nurses, and in some regions, chronic shortages appear to be growing. For example, the Regional Medical Center in Memphis, Tenn. reported in 2007 it was so short of staff that it had to resort to diverting patients to other hospitals—even women in full labor. 3 Since 1999, hospitals have been on a construction binge, heightening competition for nurses.
Hospitals spent an estimated $30 billion on construction in 2006—a 30% increase in just one year—and 83% of hospitals report they plan to add capacity in the next two years. 4 In addition, Medicare’s case mix index for inpatients started to rise again in 2001,5 signaling sicker patients who need more care. This finding was supported by HRI’s hospital executive survey that ranked increased patient acuity as a top reason for nurse dissatisfaction. Not surprisingly, registered nurse full-time equivalents (FTEs) per adjusted admission have been inching up after dropping during most of the 1990s.
The need for more nurses to work in hospitals grew. Although hospitals are the single largest employers of nurses, they are increasingly competing for talent with non-hospital organizations, such as ambulatory centers, physician practices, health insurers, and disease management companies. The percentage of nurses working in hospitals has PricewaterhouseCoopers been dropping steadily over time (Figure 2). Competition is expected to heat up even more with the advent of retail and work site clinics, staffed by nurses, nurse practitioners, and physician assistants. Over 300 of these clinics have opened, and another 1,200 are scheduled to open by 2009. 7 Figure 1.
Licensed RN supply (past and projected) 3,000,000 2,500,000 2,000,000 1,500,000 1980 1984 1988 1992 1996 2000 2004 2010E 2015E 2020E Source: Health Resources and Services Administration8 Figure 2. Percentage distribution of RNs by employer 120 100 80 60 40 20 0 1980 1984 Other Nursing education 1988 1992 1996 Nursing homes/extended care Ambulatory care Source: Health Resources and Services Administration14 2000 2004 Public/community health Hospital In 2006, dire predictions about the shortage were tempered when policy makers observed a resurgence of students in their late 20s and early 30s going into nursing.
In addition to entering the workforce later than previous groups, those born in the 1970s are now entering the nursing profession in greater numbers than their previous cohorts did. 10 Even so, the future trend looks troubling. For the first time in decades, the total number of nurses is projected to begin going down after 2010 (Figure 1). Nurses will start to retire at the same time that baby boomers begin turning 65 years of age and start using more care. Currently, forecasts for a registered nurse shortage in 2020 range from 400,00011 to more than 1 million.
An important aspect of the shortage is that some 450,000 licensed nurses are not working at the bedside. 13 If by 2020 all registered nurses were to be clinically active and working, the shortage estimate for 2020 would decrease to just over 100,000, mirroring the shortage today. Predictions about the nursing shortage could become more acute when coupled with new predictions What works* about an impending physician shortage. The prospect of clinical shortages among both physicians and nurses may be more than the industry can bear. “There exists a certain ecology in the healthcare industry.
All of the pieces depend upon one another, but there is no incentive or structure to view it as a whole. We have a dysfunctional system that we’re trying to fix with silver bullets,” says Dr. Robert Templin, president of Northern Virginia Community College, one of the largest community colleges in the United States. Forecasts of physician supply and demand are more ambiguous than for nursing The basic demographic forces are the same for physicians as for nurses: an aging U. S. population demanding ever more care and en masse retirements of baby boomer physicians (currently one-third of all active physicians are over 55 years old).
As professionals on the high end of the income scale, physicians who have planned ahead financially may decide to retire earlier than nurses because they can afford to do so. As with nurses, the absolute number of physicians has increased steadily over the years, outpacing population growth. 16 However, the future is a bit murkier, complicated by specialization, geographic maldistribution, and blurring lines between primary care physicians and advanced-practice nurses. The best future strategy is another matter. In part, this may stem from studies showing that more nurses increase quality, but more physicians may add more cost.
Maldistribution of physicians by specialty and geography has existed for decades but is not easily solved by market forces. Factors influencing this are differences in pay, lifestyle, culture, uncompensated care, and risk of liability. Across all specialties, the Health Resources and Services Administration (HRSA) predicts a net shortage of 24,300 physicians by 2020 using a base or continuation case (Figure 3). 17 The federal agency also modeled other scenarios that included productivity improvements and increased use of nurse extenders. Under those scenarios, a surplus was predicted.
A wide range of opinions exist about the adequacy of future physician supply. At the high end is Richard Cooper, M. D. , professor of medicine at PricewaterhouseCoopers Figure 3. Active physicians: projected supply and demand 1,000,000 30% increase in enrollment 900,000 5,000 additional graduates in 2019 800,000 10,000 additional graduates in 2020 700,000 2000 HRSA supply 2005 2010E 2015E HRSA demand Source.
Health Resources and Services Administration and PricewaterwaterhouseCoopers’ Health Research Institute analysis20 2020E Leonard Davis Institute of Health Economics of the School of Medicine at the University of Pennsylvania, who predicts a shortage of up to 200,000 physicians by 2020. 18 At the low end are those who argue that the main problem is one of efficiency and distribution rather than absolute supply. The medical practice variation research started by John E. Wennberg, M. D. , director of the Center for the Evaluative Clinical Services at Dartmouth College, and continued by others, has shown that there is no correlation between greater physician supply (after a requisite threshold is reached) and better clinical outcomes.
There are still significant medical practice variations unexplained by population or disease characteristics. In fact, areas with higher numbers of physicians do not necessarily improve patient outcomes, but they do increase costs. 19 A recent population-based study demonstrated lower mortality rates where there are more primary care physicians, but no such effect with the supply of other specialists. 21 Another recent study found great variation between academic medical centers in terms of physician labor inputs used in caring for matched Medicare beneficiary cohorts in the last six months of life. 22 That is, there were differences in efficiency.
This data supports the idea that absolute supply of physicians is an insufficient variable for understanding the “shortage” problem. What works* International recruitment has filled the gaps but isn’t viewed as a sustainable solution Nurses have been emigrating to the U. S. for many years, especially from Canada and the Philippines. By 2000, 11% of all U. S. nurses were international nursing graduates (INGs). 23 By 2005, 13% of all newly licensed nurses were INGs. 24
The percentages can be much higher for an individual facility or geographic area. Martha Smith, former assistant chief nursing officer at Laredo Medical Center in Texas and currently CNO at Park Plaza Hospital and Medical Center in Houston, described how the situation can be different when located along the U. S. -Mexican border. “We occasionally reach full capacity and sometimes cannot open ICU [intensive-care unit] beds. We actively recruit international nurses—now 25% of our staff—and I have personally made two recruiting trips to the Philippines.
In terms of the physician workforce, international medical graduates (IMGs) made up 25% of all physicians in practice and 26% of new graduate physicians entering post-graduate training in 2005 in the U. S. 25 26 Graduates of U. S. medical schools are virtually guaranteed a residency slot to continue their education to become licensed physicians. However, when there aren’t enough U. S. grads, those slots, typically in primary care, go PricewaterhouseCoopers Personal story. Code Red in California Rakesh likes the excitement and job flexibility of the emergency department, where he can work as much or as little as he wants by picking the shifts he wants to work. “I really like the work because I don’t know what to expect.
In the emergency room there are times that can be mundane and times that can be really exciting. It keeps me on my toes, and I see a variety of patients. ” His career Tenure 5 years as emergency room attending physician and emergency medical service liaison Educational financing Scholarships and loans % of time in direct patient care 95% “My career in medicine stemmed from my interest in the subject matter along with my past experiences as a volunteer in the emergency department and as a lifeguard. ” The profession “Medicine has given me a great deal. I have really gotten a lot out of it and have met some great people.
I find a lot of doctors complaining and frustrated, but I feel this profession is a privilege. Doctors in many countries do not make as much money as they do in the U. S. , but they are passionate about it. ” Rakesh’s other thoughts about the profession: • People are not always aware of their own health • The emergency department concept can be abused, especially because access to primary care can be limited • Too little preventive care. “The emergency department really sees the effects of this. We fix the short-term problem, but long term; their health is not going in the right direction. ” to IMGs.
Of the approximately 6,500 IMGs entering U. S. residency training in 2005, about three-quarters went into first-year primary care residency positions. These IMG residents accounted for 42% of all internal medicine slots, 37% of all family medicine slots, and 24% of all pediatric slots. 27 However, only 23% of hospitals surveyed by HRI said they had actively recruited foreign graduates. In addition, according to the HRI survey, only 18% of hospitals surveyed said recruitment of foreign nurses and doctors was a desirable strategy to combat future shortages. Critics say the quality of non-U. S.
Medical schools is highly variable, and that concern is one of the reasons the Association of American Medical Colleges (AAMC) has called for an increase in the size of U. S. allopathic medical school classes and for new schools to be developed. While some foreign medical schools are accredited by recognized accrediting agencies, many have no accreditation or accreditation with standards appreciably different than those dictated by the Liaison Committee for Medical Education (LCME), which accredits U. S. and Canadian allopathic schools. For example, the quality of this training is illustrated in the passage rates on the U. S.
Medical Licensing Examination (USMLE). Passage rates for first-time test-takers on the 2006 USMLE Step 2 examination—which reflects four- year medical education—were 96% for LCME-accredited medical graduates and 77% for IMGs; for repeat test-takers, these percentages were 72% and 50%, respectively. Today’s LCME-accredited allopathic medical schools in the U. S. reflect both the art and the science of becoming and practicing as a physician, which goes beyond the licensing exam scores. A new emphasis on effective communication, empathy, and understanding the implications of patient discussions is embedded into the curriculum.
It is clear that physicians must be able to both communicate effectively and to artfully incorporate quantitative and qualitative information into patient care. What works* 10 The challenges of inadequate supply Nurses: More than 41,000 qualified nursing applicants were denied admission to nursing school (undergraduate and graduate programs) in 2005. 28 This represents a sixfold increase since 2002. High vacancy rates and continuous turnover of staff are stressing the financial and cultural fabric of healthcare providers. 29 It is telling that nearly half of all nurses do not work in direct patient care, and that a growing number of physicians are retiring early.
“We have an aging workforce and inadequate numbers of new nurses coming into the pipeline,” says Ann Hendrich, RN, M. S. N. , FAAN, vice president of clinical excellence operations at Ascension Health System. “Staffing demands at current levels are difficult. When you couple that with the new construction under way, it’s not a gap but a crevasse that will make it very difficult to avoid shortfalls in access, patient safety, and service.