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How Has the Rise of Physician Employment Changed Hospitals' Recruitment Strategies?

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The appeal of hospital employment to physicians is no secret. Upon completion of their training, more physicians are looking to work in either larger, independent group or hospital-owned practices, whether for financial reasons, lifestyle preferences or a combination of the two. The number of independent physicians, or providers with a financial stake in their practice, shrunk from 57 percent in 2000 to 39 percent in 2012 and a projected 36 percent in 2013, according to data from Accenture.

In the latest annual Residents and Fellows Survey conducted by Cejka Search, 46 percent of respondents from medical schools' 2012 graduating classes said group practices were the ideal choices, while 29 percent said hospital-affiliated practices were most preferred. And interest in employment is not restricted to fresh-faced residency graduates, either. Many established physicians in private practice are losing interest in entrepreneurship and the risks associated with it.

"The fact that established physicians also want to become employed has changed hospitals' attitudes toward recruitment," says Max Reiboldt, CPA, president and CEO of healthcare consulting firm Coker Group.

These findings suggest a natural and progressive physician exodus from private practice into group practices and health systems, begging the question of whether physician recruitment is still imperative to hospitals these days.

The answer? Very much so.

"Recruitment efforts are still very much an issue for hospitals," says Marc Halley, president and CEO of Westerville, Ohio-based Halley Consulting Group, a physician practice management and consulting firm. "Regardless of the model used, whether employment or an income guarantee, hospitals still have to recruit. In fact, for some specialties like primary care, recruiting is a lot tougher today."

Phoenix-based Banner Health's goal for 2011 was to hire 220 physicians. "We successfully met that goal," says Anne Folger, senior director of physician recruitment for Banner. One of Banner's strategies is to build Banner Medical Group, which is about three years old and has just over 800 employed physicians. "That number will continue to grow," says Ms. Folger. "The trend we're seeing nationally is that both new graduates as well as seasoned practitioners are more interested in employment model."

Certain demographic conditions and emerging models of care delivery are calling for hospitals to revisit their recruitment strategies to not only attract the number of providers they need, but specific qualifications as well. Here, experts weigh in on new trends in recruitment strategies, the responsibilities of hospital CEOs in the process, challenges facing rural hospitals and how accountable care organizations are changing traditional employment requirements.

Role of the hospital CEO in physician recruitment
"Is the hospital physician-friendly, or not so much?" That's a crucial question physicians want answered when considering a hospital's employment opportunities. The answer depends on whether physicians are appointed to leadership positions, whether incentives are aligned, and other determinants. But the hospital and/or health system CEO plays a huge role in physicians' perception of the organization. The physician culture will become evident during the recruitment period, meaning CEOs best be mindful of how they interact with medical staff. Word travels fast.

"Physicians will be exposed to other members of the medical staff, and medical staff will be very honest about what the institution and the CEO are like," says Aimee Greeter, senior manager at Coker Group. "I can name certain CEOs who have pro-physician reputations. They're communicative with medical staff, and even when making unpopular decisions, they are not hiding back in their office. They tend to be held in higher regard by the medical staff as a result."

Aside from developing and maintaining a pro-physician hospital culture, CEOs can reinforce recruitment by acting as market managers. In this role, the CEO looks at the physician workforce holistically and continuously identifies opportunities for hospital-provider alignment. "Instead of CEOs being concerned about new pieces of diagnostic equipment, they're very much concerned about having primary care physicians in the right neighborhoods to feed subspecialists affiliated with their hospitals," says Mr. Halley. "Those market managers are, by nature, good physician partners. They understand the world does not revolve around the hospital — it revolves around an integrated system of care delivery."

The curveball of accountable care organizations
With their emphasis on care coordination, team-based care delivery and evidence-based medicine, ACOs are demanding new qualities from physicians. According to a recent survey from the Mediscus Firm, 73 percent of healthcare executives involved in ACOs said the delivery model will change their physician recruitment goals or processes. Specifically, the majority of executives said they expect to increase recruitment efforts for non-physician providers, such as nurse practitioners and physicians assistants, to build up their provider ranks for ACOs.

ACOs are not only influencing the type of providers recruited by hospitals, but also the professional qualities and attitudes those providers hold. There is a delicate balance between attracting a large number of physicians to develop an integrated team, and recruiting physicians who have demonstrated potential throughout their residency. It's not always easy to differentiate subpar from high-quality physicians, especially if the individual has just left residency. But hospitals still keep an eye out for time-tested predictors among candidates, such as productivity.   

Hospitals want physicians who are quick to accommodate larger patient volumes. "When we start looking at potential folks coming out of training, we want to know how busy their residency was," says Mr. Halley. "If they had a busy residency, they may have seen half a day's work by their third year and be comfortable with that volume. If they saw eight to 10 patients in half of a day by their third year, and you say, 'You need to get to 25, 28 patients a day,' the doctors can say, 'OK, I was almost there in my residency program.'"

Hospitals are also seeking nimble physicians who are open to team-based care, which is especially critical since advanced practitioners will play an expanded role in care delivery. In the Mediscus Firm survey, 78 percent of healthcare executives said a team-oriented outlook is necessary for physicians participating in an ACO. Ms. Folger says this trait is in high-demand at Banner, as well. "We are very much looking for folks that work well on teams. We look for someone who is very collaborative and has a high tolerance to changing environments, because we know we have to evolve," says Ms. Folger.

Physicians who are motivated by quality incentives, familiar and adept with technology and use an evidence-based approach to medicine are also sought after by hospitals and ACOs, according to the survey. The catch is that few hospitals or healthcare organizations currently employ physicians with these skill sets in the present day: Only 2.4 percent of survey respondents said all of their physician staff meets criteria they outlined as desirable.

This suggests that while physicians may be seeking hospital employment in droves, hospitals — as employers — still need to identify the best hires who are compatible with the organization's plans for ACOs, patient-centered medical homes and other integrated delivery models.

Urban versus rural markets
To approach physician recruitment discussions as a one-size-fits-all subject is inexact, as strategy varies depending on a hospital's market and location. Rural areas are facing an especially challenging recruitment environment right now, since the nationwide physician shortage is exacerbated in markets or states that do not include major medical schools.

That setback is compounded by the fact that fewer physicians consider rural areas attractive for work. In the most recent Residents and Fellows Survey, 32 percent of respondents said they would not consider practicing in a rural area. On the flip side, 95 percent said suburban communities were their first or second choice for a practice location, while 84 percent named a metropolitan area in their top-two locations.  

Here are a few specific trends and challenges facing rural hospitals in their recruitment efforts.

Handling call. Compared to their urban counterparts, rural hospitals rarely have as large of a physician panel to handle call. This can hinder physicians' interest since it poses a threat to work-life balance. "No physician wants to be on call every other day. That's an infringement on their lifestyle," says Ms. Greeter. To overcome this, some rural hospitals hire locum tenens physicians to provide coverage on those days the recruited specialist cannot or will not be on call.

Another less popular arrangement is when hospitals tell physicians outright that, upon employment, they are responsible for a specific number of days of call coverage, such as 10 days per month. Once the physician meets that responsibility, hospitals can send patients elsewhere for that specific specialty — something hospitals don't prefer to do, especially for surgical or other high revenue-generating services, according to Ms. Greeter.

Finding physicians connected to the area. Sourcing candidates is a fine art for rural hospitals, as physicians who have lived within 100 miles of its location or have regional experience with the hospital are more likely to relocate to and stay in the area. The challenge is in identifying these men and women, which Mr. Halley recommends be done proactively. "Some communities will say we can't recruit to our community and I'll say, 'Wait a minute. Where are all the medical students and residents from this region studying medicine today? Do you know where they are? What if we brought them home? Let's go get them,'" says Mr. Halley.

Perception of quality of life. Compared to their urban counterparts, rural areas are generally perceived as less robust when it comes to schools, cultural diversity, entertainment and recreational opportunities. Isolated areas pose a significant barrier in physician recruitment efforts, but not all candidates are deterred from non-urban markets. Interestingly, some physicians' inherent attraction to rural areas can outweigh financial considerations when choosing a practice setting.

In a survey, the Colorado Health Institute asked 711 rural physicians what factors they consider "very important" when choosing a practice setting. Respondents could choose more than one answer. Three of the top four responses related to lifestyle: 70 percent cited recreational and leisure activities as a very important factor, 55 percent said the setting must be a good place to raise children, 44 percent said opportunity for professional independence and 40 percent said the desire to retire in rural Colorado.

Professional factors, however, did not rank as high. Fourteen percent of physicians cited the chance to buy a practice or become a partner as a factor, while 13 percent cited earnings potential and 8 percent mentioned recruitment strategies as "very important."

Innovative recruitment strategies
What are some recent developments in recruitment strategies from the past five or 10 years? Many hospitals have refined and retuned their strategies to become more business-savvy, aggressive and appealing to physicians just completing their training. Here are four tactics our experts have seen more of in recent years.

Promotional tools. More hospitals and health systems are developing formal promotional documents to inform physicians about their hospital's culture, community and employment benefits. Hospitals are creating and distributing a document called a "practice opportunity prospectus," which outlines information about the practice opportunity, the physician's potential compensation, the hospital's medical staff and surrounding competition, the greater community, and other key points of consideration.

Such promotional tools are a change from what used to be a more relaxed approach to recruitment, according to Mr. Halley. "It was more like, 'Give me your curriculum vitae and I'll tell you more about the practice. If we like one another, we'll chat and visit, and then maybe we'll give you an offer.' Now hospital recruiters are trying to truly understand what the physician is after, and do a better job matching those desires to what [the practice has] to offer," says Mr. Halley.

Current recruitment efforts have also become a bit more slick and savvy, largely due to tools like social media and other technological perks. "We use everything," says Banner's Ms. Folger. "We use video-conferencing for interviews so we can have live discussions with [candidates]. We tap into residency programs around the nation. We use technology that allows us to identify physicians who may have family in a particular region and may want to return to it. It's a full-court press with all the technology available to us."

Recruiting in high schools. Connection is the keyword for rural hospitals' recruitment efforts. Does the physician have family in the area? Did the physician grow up nearby? Rather than retroactively trying to recruit physicians who moved away to complete their training, some rural hospitals and health systems begin recruitment efforts proactively and early — even when students are still in high school.

"Some hospitals will go into the high school and say, 'Look, if you're interested, we'll support you if you come back and agree to work in the community," says Mr. Reiboldt. Hospitals will offer to fund a portion of students' medical school expenses if he/she agrees to return and practice in the community for an agreed-upon amount of time. "This will try to help motivate [students] to go all the way through medical school and then come back."

Incubation models. Another recruitment strategy, known as the incubation model, has been implemented for a while in the healthcare community, but Ms. Greeter said it is picking up speed. Under this model, a physician is recruited to the community by the hospital or health system. The physician becomes an employee of that organization, but is placed in a group practice setting with other physicians who are, oftentimes, not hospital-employed. The hospital then leases the space and pays the other physicians a management fee for overseeing the newly recruited physician.

After the recruited physicians complete the incubation period, which typically lasts two to three years, they still have to work off a commitment to the community, which is often another two or three years. In that time, the physicians have an option to continue practicing in the group setting in which they completed their incubation period. This model is attractive to hospitals and health systems, as they will essentially recoup what it spent on the physician recruitment through a committed provider and the increased stability of the service line.

The model has its perks for all parties, according to Ms. Greeter. "For the practice physicians, it's like having another partner, but they don't have the financial risk," she says. "For many physicians coming out of medical school who want to be employed, this is an attractive model. It has the security of employment and the autonomy that comes with private practice."

Opportunities for philanthropy. A 24-bed hospital in the rural Midwest made headlines this year for its unique recruitment strategy. Located in a town with no more than 900 people, Ashland (Kan.) Health Clinic offers potential candidates eight weeks off for missionary work overseas. The tactic is rooted in the idea that a physician who is willing to endure harsh conditions abroad, such as practicing in the aftermath of a natural disaster, might be willing to relocate to a rural location to eliminate disparities in care.

Conclusion
Although physicians are increasingly interested in hospital-affiliated practice settings and less in independent models, hospitals still need to ensure their recruitment strategies are reflective of the latest market trends and demands. A refined recruitment strategy can better attract physicians with qualifications that will be more valuable in team-based care delivery and ACOs; identify physicians with connections to rural areas; ensure C-level involvement and support; and balance physicians' longings for autonomy and security. It's imperative for hospital executives to remain rooted in these efforts, so their organizations will attract not only the quantity of physicians needed, but the quality as well.    

More Articles on Physician Recruitment:

Changing Physician Desires Affect Recruitment
How ACOs Will Affect Physician Recruitment
Tricky Business: Acquiring, Losing and Changing Physicians


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