Using Qualitative Measures to Guide Workforce Planning (Part 2 of a 3-Part Series)

Tuesday, April 26, 2016 | Joel Sauer

Night call


The first step in any workforce assessment, whether related to providers or any other employees in the organization, is a review of the mission and/or vision statement. Why does our organization exist and what are we trying to achieve? Our workforce then should be engineered to drive this vision. Absent this overarching goal, we’re simply reacting to what happens to us and letting the outside environment create a plan. Never a good idea.

In addition, most organizations (regardless of ownership model) create a strategic plan around its vision, with very specific tactics defined to guide the enterprise during the next two to five years. If you are part of a larger, integrated entity, then I hope this plan boils down specifically to the cardiovascular service line to provide granular focus. If such a detailed strategy plan does not exist, I strongly encourage you get one. Our workforce plans should be consciously designed around achieving these longer-term objectives. 

For instance, if there’s a particular area within our primary or secondary service area that has been identified as a significant potential growth opportunity, we will need to understand the staffing impact that going after this market will require. 

Understand and Agree on Expectations for Work

This may seem simple on the surface, but it actually has many different layers of complexity.  Work is very specific to each group’s culture and values, so expectations need to be established internally. Let’s examine some of the more significant components of work.

Probably the most obvious and often wrangled-with area of work assessment is around individual productivity. This can be measured by wRVUs, patient encounters, time value units, or a myriad of other methodologies. Some groups reconcile work differences with their compensation distribution, which is fine; however, for planning purposes, we need to have a handle on what can be expected from each provider. That will drive some of the quantitative measures discussed in my next blog post.

For instance, if a group determines that work is appropriately measured by wRVUs, what is our expectation for production? Is it less than the median, the median, or 75th percentile? If the measurement is encounters, do we have the same expectations across all sub-specialties? Answering these questions formally provides key performance expectations that are invaluable when forecasting workforce needs. 

In today’s value-oriented reimbursement economy, many groups are wrestling with the question of sub-specialization. Who should be doing what? This question may be asked in response to a perceived or real skill gap, or in response to market forces.

For instance, heart failure has become a major focus for cardiology practices, driven, in part, by substantial reimbursement risk. When looking at workforce needs, we need to understand whether our program will be moving to deeper sub-specialization, such as automated referrals for heart failure patients to a standardized heart failure clinic. This migration would not only impact our physician needs, but also our recruitment and development of Advanced Practice Providers (APPs) and other care team members. 

Likewise, in an effort to promote efficiency and consolidate volumes, some programs are moving to have all invasive procedures performed by interventional physicians. This, too, has an impact on physician needs, but also impacts another important qualitative area: call coverage. As part of the planning process, groups need to define the minimum requirements necessary for appropriate night and weekend call coverage, both from an interventional (STEMI) and general perspective. Included in this conversation is not just what the clinic needs are, but what physician expectations are for call frequency, from a lifestyle and sustainability viewpoint.

If You Don’t Know, Ask

As was detailed in Part 1 of this blog, the cardiovascular provider community is aging, with nearly one-third of the workforce 59 or older. Given the impact age distribution can have on work, it is important to understand your own internal demographics. Creating an age distribution and work comparison grid will be covered in Part 3 of my blog (on quantitative measures). For qualitative measures, it’s important to understand our provider’s future plans.  Who plans to cut back or retire in the near future? 

The easiest way to find out this information is simply to ask. For larger groups, this can be accomplished through anonymous polls or surveys. For smaller groups, it can be accomplished through interviews. Although the results of these assessments are never exact (not because providers aren’t truthful, but because personal plans may not be solid), they do provide us directional data that’s useful for longer-term needs. 

Call and Physician Slow-Down

At each of its three annual meetings, MedAxiom hosts a physician breakfast each morning prior to the start of the agenda. This is a forum for doctors to get together and candidly discuss items specific to their profession. Every year, like clockwork, physician slow-down comes up and becomes a dominant theme.

Who tend to be the first physicians to request reduced schedules? Our founders. This gets into all sorts of dialogue on sweat equity, loyalty, intangible value, etc. Get the tension?

It’s not a big surprise, given the age distribution and how much pressure slow-down can have on a group. For instance, in a group of 15 (our median-sized practice), if two physicians come off call, but continue to carry full-time day schedules, this can push a huge call burden to the remaining doctors. At the same time, there’s not enough daytime work to justify recruiting, unless everyone’s comfortable with the corresponding pay cuts. Further, who tend to be the first physicians to request reduced schedules? Our founders. This gets into all sorts of dialogue on sweat equity, loyalty, intangible value, etc. Get the tension?

Given this, as part of the planning process, groups are strongly encouraged to have formal slow- down plans. The worst time to create these plans is after someone has made a request to cut back or come off call. At that point, it inevitably becomes a more personal discussion, rather than a philosophical one. Regardless of timing, however, it’s important that a formal process is in place. I’ll add an editorial comment here based on my own experiences leading a large group—and working with other groups to formulate a plan as a consultant. Even the most thoughtful policies will be challenged by real life, so build some flexibility into your rules. 

Below are some major questions to consider when creating a physician slow-down path. (For simplicity, I’ll include cutbacks from call and/or clinical duties in these discussions.)

  1. Will the option for slow-down be available to all physicians, or only to those who meet certain requirements? For instance, many groups include a “seniority” provision, where slow-down is only available to those who have provided some minimum years of service to the group, or where age plus group seniority has to exceed a certain threshold. My group, for instance, had a “Rule of 70” in which age plus years of service had to exceed 70, before a physician was even eligible to request a slow-down.
  2. Is there a maximum number of physicians who can be in a slow-down mode? This metric is obviously very dependent on group size and will change over time, so it needs some vigilance from leadership; however, allowing one or two physicians to cut back may be absorbable by a median-sized group. That policy suddenly becomes untenable, though, if the number swells. Putting limits in place prospectively can avert a lot of group tension. 
  3. How long can a physician remain in a slow-down mode? Putting limits on the amount of time a physician can be in a part-time status is often overlooked by groups—and is very related to item two above. If we allow physicians to have reduced schedules indefinitely, it can impede our ability to appropriately recruit and will constipate other physicians’ ability to cut back as they reach eligibility. From conversations on the MedAxiom Listserv related to this topic, it appears the “sweet spot” for this limit is two years. After two years, many groups provide themselves the option to discontinue allowing a reduced schedule. In other words, the physician either returns to full-time status (often including call), or must retire completely. 
  4. How will slow-down impact compensation? There are two major buckets with respect to compensation discussions: clinical duties and call. In most groups, call is multi-faceted, as well, with interventional duties (including STEMI coverage) and general call.  Weeknights and weekends, too, are often segregated. Although there is no right answer for the value of call—this is a very group-centric calculation—data from the MedAxiom Listserv shows that an aggregate call is valued at 20 to 50 percent of total cardiology compensation within our membership. Additionally, most groups remove physicians who have entered an abbreviated clinical schedule from the normal distribution plan and put them on a compensation plan unique to their particular arrangement. This is sometimes a fixed salary, a straightforward “per wRVU” plan, shift-based, or myriad other arrangements. The key is to have a prospective understanding of the economic impact of a reduced schedule. 

Work/Life Balance

Another qualitative measure that enters into workforce planning is the amount of time off physicians are allotted. Figure 1 below shows the variability amongst groups for the number of days physicians can take away from work, such as vacation time. Like the value of call, this, too, is a very culture-oriented benefit and has to be negotiated by each group. Clearly, the amount of vacation time has to be considered when creating a workforce plan. Additionally, in today’s dynamic environment, the answer from yesterday may need to be revisited today, particularly in many of our integrated environments, where multiple groups may have been acquired and brought together with disparate allotments. 

In Part 3 of my blog, I’ll show how these qualitative measures help us create quantitative tools that can guide our workforce planning process. Stay tuned.


Joel Sauer is Vice President of MedAxiom Consulting. His work includes full-service line development, co-management arrangements, workforce planning, compensation planning and integrations.

About the Author
Joel Sauer

Joel Sauer, MBA, is Executive Vice President of MedAxiom Consulting. Joel consults around the country in the area of value-oriented physician/hospital partnerships preparing health organizations for the value economy. His work includes vision and strategy setting, creating and implementing effective governance and leadership structures, co-management development, joint venture and other innovative partnerships, and provider compensation plan design. Beyond the above, Joel has a wealth of experience in service line development, clinical strategy development, provider workforce planning; including care team creation and physician slow-down policies, MACRA and bundled payment planning, and operational assessments.

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