ACOs, other delivery reforms shift job roles at hospitals

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.

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.”

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.

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.”

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.”

Follow Melanie Evans on Twitter: @MHmevans