Staffing evolution: Responding to a new environment

In the mid-19th century, Charles Darwin published On the Origin of Species by Means of Natural Selection, describing how species respond to their environment by adopting the traits that best enable survival. His theory of evolutionary change described how modern organisms are different from those that lived in the past and why separated populations adopt different forms and behaviors.

In many ways, medical groups exhibit a similar pattern of evolutionary change as practices respond to their local and national environments.

Among an administrator’s most complex tasks is staffing the right mix of skills and number of employees while keeping practice overhead as low as possible. Between meeting demands to increase patient volume and improve clinical support for providers, and complying with ever more complex regulations and demands from payers, staffing is one of the areas that no matter what a practice executive does, someone will not be pleased.

The need to balance demands and costs encourages practices to continuously examine staffing levels — one of the most frequently benchmarked metrics. Since staffing levels are a key performance indicator, it is important to know that they do not remain the same and that different types of practices have very different staffing levels and skill mix. Additionally, staff needs change over time as new demands are made on practices.

It is difficult for a practice to evaluate how staffing has changed over time, but MGMA’s national surveys offer insight into how practices staffed in the past and how they staff today.

Figure 1 compares clinical support staff per full-time-equivalent (FTE) physician as reported by participants in the MGMA Cost Survey in 2006 and again in the 2017 MGMA DataDive Cost and Revenue. During this 10-year period, many changes in clinical practice and in administration are reflected in staffing. Among the changes have been the widespread adoption of EHRs, a multitude of new clinical procedures, the implementation of digital technologies in the practice, and new data collection and reporting requirements associated with the shift from fee-for-service to forms of value-based payment.

The staffing data for multispecialty groups reflect an aggregation of different specialties and patients. Perhaps the most surprising observation is that while there are substantial changes in the different staff positions, overall staff levels have increased less than 6% in 10 years. Discussions with practice leaders suggest that the pressure to reduce costs while maintaining profitability keeps staffing levels as low as possible, therefore keeping the overall increase in staff to a minimum. Essentially, the relative stability in total support staff per FTE physician suggests that even though staff is added or new positions are created, other positions are eliminated.

While ancillary services staffing remained almost the same over the 10 years, there was a significant shift in both front-office and clinical staffing. Overall, clinical support staff increased 20%, predominately from an increase in medical assistants, the nursing staff position with the lowest cost. Also notable is the change in front office support staff. Due to the expanded use of EHRs, the number of medical secretaries or transcribers declined 70%, and medical records staff fell by more than 60%. At the same time, the added complexity of registering patients and managing copays is reflected in a 12% increase in medical receptionists.

The business operations support staffing levels experienced similar changes with information technology staff increasing 25%, managed care administrative staff increasing 43% and general administrative staff increasing by nearly 41%. These changes were somewhat offset by reductions in patient accounting and housekeeping staff, so total business operations support staff increased at about the same level as overall staffing.

Figure 2

The changes in clinical support staff are not unique to multispecialty groups. Figure 2 shows that single-specialty groups report a very similar pattern, suggesting that all types of practices are increasing nursing staff. In the external environment, medicine is changing as procedures that once were performed only in a hospital are now done in the physician practice, and physician productivity is enhanced by added nursing staff. The greatest increase was in family medicine, which has embraced the patient-centered medical home, a model that necessitates added nursing education and care coordination functions.
Darwin offered some excellent advice that could be applied to the evolution of medical groups and the general healthcare environment: “It is not the strongest of the species that survive, nor the most intelligent, but the one most responsive to change.”