Simple conversations help strike staffing balance

A gradual shift toward value-based health care is putting a greater premium on the extra staff members who may be needed to achieve it, and there are simple ways for practices to make the staffing choices that are right for their practice and the real world.


Staffing can be a challenge in today's primary care environment, but creative thinking and strategic planning can help practices make wise investments in their human resources.

The number and type of staff members needed to make a practice run smoothly can vary widely by patient census and demographics, among other factors. A study published in July 2018 by the Journal of General Internal Medicine used staffing models and data from 73 high-performing primary care practices to develop four separate models for staffing, each based on different patient populations.

A shift toward value-based health care is putting a greater premium on higher-quality care and the extra staff members who may be needed to achieve it Image by jacoblund
A shift toward value-based health care is putting a greater premium on higher-quality care and the extra staff members who may be needed to achieve it. Image by jacoblund

To consistently provide comprehensive care, researchers concluded that a practice serving 10,000 adults needs a mix of 37 team members, including eight clinicians, at a cost of $45 per patient per month (PPPM). A practice with the same number of patients but a higher proportion of older patients requires 52 staff and 12 clinicians at $64 PPPM. A practice serving patients with greater social needs requires 50 staff and 10 clinicians at $56 PPPM, while a rural practice with 5,000 adult patients needs 22 team members and four clinicians at a cost of $46 PPPM.

Along with physicians and other clinicians, the report includes professionals like pharmacists, social workers, and community health workers, with their involvement varying by model. Researchers defined “comprehensive care” to include functions such as care transition and coordination, behavioral health integration, and medication management, along with traditional functions like reception and actual care delivery.

Study coauthor David Meyers, MD, chief physician at the federal Agency for Healthcare Research and Quality, said the models were developed primarily as a reference for primary care financing discussions and are not meant to establish firm boundaries. He noted, however, that individual practices may also have interest in using the materials as a guide for internal discussions on functions and staffing ratios.

The obstacles to any workforce discussion are well known. Most primary care practices operate with narrow margins, and the cost of new staff members can be substantial.

On the other hand, a gradual shift toward value-based health care is putting a greater premium on outcomes, meaning that higher-quality care, and the extra staff members who may be needed to achieve it, are becoming more important.

In all cases, the inclination among many practice leaders is to stick with the status quo for the sake of convenience or the near-term bottom line, experts said. But there are simple methods for helping practices make the staffing choices that are right for their practice and the real world.

“The common knee-jerk reaction is that staff is the most expensive commodity, so you want to get away with as few as possible,” said Margo Williams, ACP's Senior Associate of Practice Management. “But in fact I think over time the better-performing practices have more staff because the physician, which is highest paid, can do the high-level work they're trained to do and offload other things on to other staff members. They can see more patients and thus bill more.”

Edward Stehlik, MD, MACP, is an internist who once led an effort to optimize staffing in his 25-employee practice in Buffalo, N.Y. He said it ultimately resulted in “two or three” new hires, better care, and better quality of life.

It started with a simple conversation.

The key was what Dr. Stehlik called a “top-of-the-license” exercise, which involved all of the practice's 25 employees.

“We listed every single thing each person does, and we put it on Post-It notes,” he explained. “We started with the physicians and moved down from there. The entire office participated. We wanted everyone working at the top of their license, and none below.”

The office sorted the job functions into categories, identifying the most appropriate staffer to perform each.

“For each task, we defined who was best to do it,” he said. “The physician could greet patients at the front desk, for example, but others could also do that. Then, we asked, ‘What do we need?’”

Dr. Stehlik and his team found that the highest proportion of tasks fell to nurses and administrative staff. As a result, the practice hired new employees to address those areas.

“The physician doesn't sign off on prescription refills anymore,” Dr. Stehlik said. “I'm not doing the rote process of reviewing normal reports. My time is more freed up for things that only I can do. You shouldn't have one $300-an-hour physician reviewing reports that a $25- to $30-an-hour nurse could be reviewing instead.”

The process also can work in reverse. Instead of or in addition to identifying need areas in the practice, physicians and other managers can assess the capabilities of different professionals to determine whether their job functions and salaries might fit with their operations.

Joseph Frolkis, MD, FACP, president and chief executive officer of the New England Quality Care Alliance, the physician network of Tufts Medical Center in Boston, had one clear suggestion: medical assistants. According to the federal Bureau of Labor Statistics (BLS), in 2017 the national mean salary for medical assistants was $33,580. That, Dr. Frolkis said, makes medical assistants a bargain for their skill set, which tends to involve a blend of administrative tasks, like coding, and clinical duties, like taking blood and supporting the physician during exams.

“Medical assistants are a good investment. Physicians should have at least a 1:1 relationship with a medical assistant,” Dr. Frolkis said. “They come at a relatively low price point. If you have that dyad, you can coach them up and you can see more patients. They can do all the pre-appointment work.”

The physician assistant and the nurse practitioner have a wider scope of capabilities, including the ability to examine patients and make diagnoses. With respective mean salaries of $104,760 and $107,480 in 2017, per Bureau of Labor Statistics figures, they also make a bigger impact on the bottom line.

However, this level of clinician can enhance quality of life as well as quality of care in a practice, making them a valuable addition to practices seeking efficiency and better outcomes.

“At a higher price point, advanced practice clinicians can actually save money,” Dr. Frolkis said. “They see your stable patients, while the physician sees the more complex cases. You can ideally break even or do better financially with these hires, and you can go home before eight o’clock.”

With electronic medical records (EMRs) ever more pervasive, some practices are using medical transcriptionists or scribes to handle note-taking, data entry, and similar tasks. The Bureau of Labor Statistics estimates the mean salary for this profession at $35,250 per year. These professionals can almost instantly relieve administrative burdens on clinicians, leading to more productivity, said Dr. Stehlik.

“We hired four scribes to do all the documentation, from preparing progress notes to entering data into the EMR,” Dr. Stehlik said. “I spend my time face to face with the patient, not with my head buried in a computer or doing progress notes at night.”

“Providing comprehensive, team-based care can be especially challenging for smaller practices,” noted Dr. Meyers. One solution his team saw among exemplars in their study was small practices pooling resources to jointly hire professionals such as pharmacists, social workers, and behavioral health specialists who then worked part-time at each of the practices. “Another solution we saw was practices promoting team members to develop new skills, such as helping a community health worker become certified as diabetes educator,” he said.

Although they cannot replace a human staff member per se, familiar technologies can support a move toward more efficiency. Tools like telemedicine and patient portals can expand the walls of a practice and achieve enough efficiency to either reduce staffing needs or increase the ability to afford new hires.

ACP, through its Department of Medical Practice, also offers free consultation services for members. Members can receive expert guidance in areas such as the Quality Payment Program, patient-centered medical home certification, coding and payment, health IT, quality improvement, high-value care coordination, and practice management. (Interested parties may contact Jillian Schneider, ACP's Manager of Practice Support, at jschneider@acponline.org.)

In a day-to-day context, simple conversations, led by the physician or the office manager but engaging staff members across the practice, are the bedrock of any staffing assessment and are effective in identifying gaps. Everyone needs to know what is expected of them in order to do the best work possible and feel good about what they are doing, Ms. Williams noted.

“Practice managers and owners should ask themselves what the practice needs,” she said. “Some practices might not even have job descriptions. When setting expectations, it is important to get input from the staff as well as clinicians about what each person can and should be able to do. It can be as simple as providing clear expectations and appropriate incentives.”

Ultimately, experts said, ignoring the issue may be ignoring an opportunity to ensure the long-term health of a practice and its people, as well as patients.

“People I talk to say they can't afford to hire more staff, but I say they can't afford not to,” Dr. Stehlik said. “Internists are great doctors, but they're not workflow experts. With the EMR, you kind of need to be in order to succeed. Patients are very happy and our staff feels empowered.”