A depleted workforce and no finish in sight: An inside have a look at America’s ailing well being care trade

America’s pandemic response has suffered from a well-publicized lack of PPE, of assessments, of contact tracers. However 10 months into the worldwide pandemic, with COVID circumstances and hospitalizations reaching staggering new ranges throughout the county, probably the most dire and difficult-to-address of shortages is just getting worse—that of the well being care employees wanted to are likely to sufferers.

As CEO of AMN Healthcare, America’s largest well being care staffing firm, Susan Salka finds herself on either side of this disaster, sending in AMN’s reinforcements to short-staffed services—the corporate has made greater than 50,000 placements this 12 months—whereas scrambling to discover a provide of prepared well being care employees to fill the remaining gaps.

Susan Salka, CEO of AMN Healthcare.
Courtesy of AMN Healthcare

Salka, a 30-year veteran of the Texas-based firm, which recorded $2.2 billion in income in 2019, spoke with Fortune final week concerning the present state of affairs, the challenges of the pandemic, and the long-term outlook for the well being care workforce. Spoiler alert: COVID vaccines received’t resolve every little thing.

This interview has been edited for readability and size.

Fortune: You run the biggest well being care staffing agency within the nation. Are you able to inform us about AMN and its historical past?

Salka: I’ve been lucky to be right here over 30 years and once I began, it was a journey nurse firm. That’s nonetheless the biggest a part of our enterprise. That section of the trade has grown, however again then it was only a cottage trade. There have been a bunch of small firms that have been touring nurses across the nation to the place they have been wanted most based mostly on shortages or seasonal wants. We grew to be the biggest journey nurse firm within the trade, however our shoppers have been actually wanting extra from us, and we have been seeing the must be a extra diversified and holistic well being care staffing firm. We both de novo invested in or acquired different well being care disciplines akin to doctor staffing, allied staffing, pharmacists, well being care leaders, billing, coding, income cycle, and so forth.

Proper now, most firms of any measurement in our trade are diversified, however we have been the primary mover to maneuver from being a single service/single product firm right into a multidiscipline, diversified well being care staffing firm. That actually served us very properly within the trade and additional expanded our management place. In 2010, we launched right into a journey of offering completely different workforce options and know-how options to assist [clients] be extra environment friendly at how they contract their contingent employees and rent and handle their everlasting employees—issues like managed providers applications and scheduling, predictive analytics, after which extra not too long ago, telehealth choices that create a digital workforce means of issues like distant language interpretation or distant speech remedy providers to college students in colleges.

I consider our evolution as type of going means of these vital step modifications in response to the market but additionally in response to the practicality of you may’t have well being care employees in every single place they’re wanted bodily. Wherever you may introduce know-how and telehealth or simply create efficiencies in order that the valuable employees that they’ve is most effective, that’s what we’re making an attempt to do.

What are workforce options—is that outsourcing?

Beforehand and nonetheless for some hospitals or methods, they’ll work with 50 or 100 completely different businesses that present contingent employees. A managed providers supplier contract centralizes that operate with an outsourced associate like AMN. We deal with all the procurement and billing and contracting and credentialing for all of the contingent employees. We’ve obtained large shoppers like Kaiser and different giant methods that simply outsource all of their contingent staffing to us—primarily medical—however we do associate with Randstad for the nonclinical half for what their wants is perhaps. The hospital then has a form of centralized means of making certain that they’ve obtained good processes and consistency of the standard of clinicians which might be coming means of their doorways, even when they’ve a number of settings, which in fact, lately any decent-size system has hospitals, they’ve clinics, they’ve dwelling well being. Their workforce wants are rather more numerous than they have been perhaps 20 years in the past.

What has enterprise been like in the course of the pandemic?

When it began to flare up in March or late February, I don’t suppose anybody anticipated it could be on the ranges that we noticed within the subsequent few months or now. We took all of the precautions you’d count on and transferred our personal company workers to do business from home. Somewhat over 3,000 company workers moved to distant work, and that truly went pretty seamlessly.

Because the nation shut down, at non-COVID-related well being care settings we noticed a direct decline in all of our companies, apart from nursing and [a few specialties] as a result of there simply weren’t procedures occurring, and for those who weren’t a affected person associated to COVID, they don’t need you strolling means of the door for something. We felt that impression, and a few of our enterprise declined as a lot as 20%, 30%, 40%. Nursing spiked up, and a few areas like respiratory therapists and lab techs additionally spiked up a bit, nevertheless it wasn’t sufficient to completely make up for a number of the declines within the different companies.

We noticed that first wave, and it was very concentrated in sure states like New York and Washington and sure areas, after which that shortly fell off, which was, in fact, great. We thought it was form of behind us and that we’d have just a few little hotspots pop up. We have been really anticipating that our enterprise would then begin to get better within the third quarter slowly, however it could type of return together with volumes coming again into the well being care system. What occurred was that, sure, the quantity began to come back again in non-acute settings and in additional regular affected person flows, nevertheless it was sluggish. On prime of that, in fact, the COVID spikes began to emerge throughout the nation. What’s been very completely different between July means of now versus the primary wave is that the primary wave was very concentrated in just a few states. Now it’s type of in every single place.

What demand seems to be like now versus a 12 months in the past, versus what it appeared like within the March, April, Could timeframe? It’s significantly completely different. And that modifications the dynamic loads. Initially, the sheer numbers are monumental. By way of the variety of open positions that we’ve got for nurses, they’re roughly 4 instances the degrees that we noticed in the course of the first part of the pandemic. Then it was just about all simply ICU and COVID-related; now it’s that plus simply regular positions that may’t get crammed.

The opposite factor is that it’s regionally in every single place. I believe there’s solely three or 4 states that don’t have demand ranges greater than the prior 12 months. And in some areas, it’s twice as a lot as prior years. It’s very tough to maneuver that many individuals across the nation that shortly. Our trade is doing an amazing job total, however there’s simply not sufficient clinicians. It’s very tough to be sure that we’re simply doing all that we are able to, but additionally realizing that we in our trade can’t presumably fill all the roles on the market.

Map shows growth in demand for traveling nurses

There have been shortages of well being care employees earlier than the pandemic. Why is that?

We have been already feeling the pains of what was anticipated to be the worst scarcity the nation has ever seen for nurses and actually all well being care professionals. It’s pushed the demand rising for well being care providers due to an growing old inhabitants. But additionally, the provision of pros is just not maintaining with that demand as a result of you’ve gotten an growing old medical workforce as properly. That is a kind of issues that for those who’re not in well being care, you in all probability wouldn’t notice that the common age of nurses and physicians goes up.

We don’t have sufficient capability in our colleges and residency applications to carry extra candidates means of to graduate, so we’re hitting this level the place demand was rising considerably, even pre-pandemic, and the availability of clinicians was beginning to plateau and sooner or later would even be declining with an growing old medical inhabitants. The shortages have been already very tough. The pandemic accelerated that a few years as a result of many present nurses [have decided] to not return to the workforce in the course of the pandemic, or perhaps they only have to remain dwelling, significantly ladies—over 90% of nurses are nonetheless ladies—to supervise childcare and on-line schooling and/or simply not eager to take the danger of getting uncovered and having to quarantine or worse but, get their household sick. They’re opting to not come again to work. And actually, a number of the older nurses, say of their fifties, are selecting to retire. The emptiness charges at hospitals proper now’s means of the roof; they’re the best that a lot of our shoppers have seen in a while as a result of their present nurses are burned out or they’re simply not wanting to come back again. As volumes are rising, even when they’re not at full capability—that is the wonderful factor, most hospitals aren’t at full capability—they is perhaps at 70% or 80% capability, however even with that, their demand for well being care employees is thru the roof.

We’re going to have a lingering impact of this accelerated scarcity for a few years to come back. It’s an enormous concern of nurse executives and educators that we’ve all of the sudden misplaced some portion of the well being care workforce, nurses specifically, that received’t be returning. It’s true for physicians, as properly. We had made such nice progress as a rustic in having extra ladies going into drugs. We have been on the level the place about half the brand new residents coming into the workforce have been ladies. Girls have been working much less hours as a result of they typically had children at dwelling and wished to work a part-time schedule, however this has simply prompted us to take many steps backward when it comes to ladies in drugs.

Do we’ve got knowledge but on the numbers leaving the workforce?

I believe it’s too early to know the place it’s going to settle. Actual-time knowledge is just not actually out there. What I’m sharing with you is extra anecdotal. It’s why, for instance, our demand for journey nurses is the best that we’ve ever seen traditionally. It’s considerably greater than when the pandemic began. It’s greater than double what our demand was final 12 months. That, I believe, is an indicator of the severity as a result of, once more, most well being care methods are saying they’re not full when it comes to volumes, however they only can’t get the employees. They’ll’t get their very own employees to come back again.

How does journey nursing work?

Most of our clinicians are vacationers. We do native staffing as properly, however more often than not, the native nurses are already working with their native hospitals on a per diem foundation or perhaps they’re of their float swimming pools. Our larger enterprise and worth add is to carry clinicians in from exterior the area, perhaps throughout state strains. Throughout the pandemic, one of many constructive issues that has occurred is states have made [regulatory] modifications when it comes to their willingness to simply accept a license from one other state. Most individuals are stunned that licensure continues to be managed at a state stage. There isn’t a nationwide licensure for nurses: Should you’re a nurse from Nebraska, and also you wish to go work in Texas, you need to get a brand new license whenever you go to Texas. There’s a state compact the place they may reciprocate and acknowledge components of their license or schooling, however you continue to often must undergo a course of and it takes weeks even when they’re a part of that compact. We wanted to get the states to place in place new guidelines on a short lived foundation, at the very least, that may permit you to simply actually stroll throughout state strains with out having to undergo a number of weeks of processing. That has helped to maneuver folks round and mobilize them extra shortly.

We now have lots of of 1000’s of clinicians in our database, after which we’re recruiting extra every single day. We now have really very excessive numbers of latest candidates coming in, however nonetheless, you’ve obtained to have the proper job in the proper place, and a few folks join, after which they alter their thoughts or one thing else modifications of their life that causes them to not wish to go. This 12 months, we’ve got revamped 50,000 placements, a few of these are duplicate those who perhaps took a few assignments, however that provides you context of how many individuals we’re shifting round. We place what we are able to, however for our managed providers shoppers, we additionally subcontract with different firms. It’s a part of the worth proposition to the hospital that they don’t must cope with 50 completely different businesses: They only cope with us, after which we cope with all the subcontractors. We now have a superb community of affiliate distributors, basically rivals who’ve subcontracted with us. That makes it extra streamlined for them to have the ability to simply get the orders, recruit the clinicians, get them positioned, and do what they do finest in getting clinicians the place they’re wanted most. They usually don’t have the shopper aspect of the equation; we have been dealing with that for them. We had numerous assist from our affiliate distributors this 12 months in ensuring that we’re doing all we are able to.

What kind of particular person is a journey clinician? Do they have a tendency to have a full-time job?

We’re at all times recruiting for candidates that may wish to work now or down the highway. Typically they wish to work only one task. Typically they wish to make it a full-time profession of shifting round and taking three-month assignments in numerous places. Somebody could have signed up with us two years in the past and no means traveled and took a job with us for some purpose, nevertheless it doesn’t imply that they aren’t nonetheless a viable candidate. Most of them have some type of full-time job.

In the event that they’re signing up for a journey job, they’re both leaving a everlasting job or they’re already touring with one other group. In just a few circumstances, they could have been retired and determined they wish to soar again into the workforce. A number of the those who we’ve got working now are what we name lapsed vacationers, the place they took an task with us beforehand, let’s say two or three years in the past, and perhaps they went right into a everlasting job, and now they’ve determined they wish to take a journey task once more. We’re at all times re-recruiting folks to some extent. You’ve got your brand-new, no means traveled with us earlier than, then you’ve gotten your lapsed vacationers, after which you’ve gotten those who type of make a profession out of this.

Can you meet demand? What does that imply for the well being care system? How unhealthy is the state of affairs?

We will’t meet all the demand—it’s not simply us, however as an trade. I don’t suppose each job is getting crammed. We do higher, I believe, the most effective inside the trade. We now have that dedication to our shoppers—one of many issues about being a managed service supplier is we make ensures round our fill charges and the way a lot of the demand we predict that we are able to meet and fill. That’s very challenged proper now. We really feel fairly assured we’ve got greater fill charges than our rivals, however for people who go unfilled, it is dependent upon the place—both the hospital has to take the sufferers and unfold them over fewer nurses, which isn’t ultimate as a result of sooner or later that simply burns out the nurses that rather more, or a hospital can have sufferers transferred to a different facility in the event that they don’t have correct staffing.

Simply anecdotally, I used to be having dinner with a pal who’s a surgeon right here in Dallas, and he was speaking a few affected person he needed to do eye surgical procedure on, and so they needed to name eight completely different hospitals earlier than they might discover a place the place they’d room not as a result of a mattress wasn’t out there—however as a result of they didn’t have employees to have the ability to open the mattress. You possibly can have a mattress, and you may have tools, however for those who don’t have sufficient employees, then you need to route that affected person to a different facility.

Are you stunned how this has performed out and simply how dire the staffing state of affairs has turn out to be?

I might have no means foreseen the pandemic and the way extreme it could be and all of the havoc it could wreak inside the well being care system. Nonetheless, it’s not shocking to me that the scarcity is as extreme as it’s, understanding what we learn about how unhealthy the scarcity already was. Nurses specifically are these frontline well being care heroes which might be actually put within the line of fireplace, as you would possibly say, of the pandemic. And so, the burnout that’s creating and the stress that that’s creating on the workforce, I’m not stunned that it’s creating such a extreme scarcity. It’s not going to finish in a single day.

We simply really had a dialogue with a few giant well being care system leaders who’re answerable for their staffing. They have been requested the query concerning the vaccine and whether or not that may create some rapid aid for the workforce. They stated no, they don’t imagine it can, as a result of their present nurses who would possibly get the vaccine are burned out, and they should give them a while to recuperate. Not each clinician will wish to come again. They suppose that this scarcity setting will final properly past 2021. And to a point, there can be a everlasting lack of the workforce.

Do you agree with that view?

I agree. I’ve heard this from different well being care executives and leaders. Clearly, [COVID vaccines] are going to be extremely useful, however so far as the medical workforce, it’s not going to be a fast repair to all the underlying points.

At AMN, and I personally really feel this manner, we really feel as if we’ve skilled our complete careers for this second. We simply no means knew it could come and, in fact, wished it hadn’t. However the issues that we’re doing now to assist in the course of the pandemic are the issues that we’ve been coaching and bettering and doing properly for a lot of, a few years, and now’s when it issues most. We really feel honored to have the ability to do our half. We’re serving to get these clinicians to the place they’re so desperately wanted most, supporting them in each means that we are able to. Our work issues extra now than it ever has earlier than. And I can say that, with over 30 years on this enterprise, that is an important 12 months for this firm.

We’ve heard numerous tales of well being care employees struggling to get ample PPE and assessments once they want them. What have you ever noticed along with your workforce? Is it the hospital’s duty, or AMN’s, to care for these wants?

Relating to PPE, it truly is the hospital’s major duty. After all, we’re speaking with them to be sure that if there’s something that we are able to do to be useful, we’re doing that. However hospitals often wish to and, in reality, insist on offering their very own PPE. They could have specific sorts of tools that they need folks to make use of; they don’t essentially need clinicians to at all times be bringing in their very own PPE. So we’re usually simply making an attempt to be in a supportive place. Clearly, if we might be useful in getting them PPE—we’ve despatched masks and robes and goggles to shoppers making an attempt to ensure they’ve what they want. We’ve despatched some gadgets to our clinicians instantly, as properly. However the major duty actually does reside with the power to be sure that their employees have the suitable PPE.

We do talk with our clinicians on conditions once they might need been uncovered, and they should get examined. We now have a medical care crew that interfaces with them, and we’ve got our personal nurses on employees at a company stage that then turn out to be a care crew to speak with these clinicians about what they should do to quarantine, to get examined, getting them the assets they want shortly, but additionally offering emotional help, and if wanted, referring them to mental-health professionals. It may be a very worrying time for clinicians as they’re quarantining and so they’re apprehensive about their very own well being, however they’re additionally eager to be on the hospital caring for sufferers. There’s a reasonably large community of mental-health assets that we’ve created to attempt to make sure that our nurses and clinicians are getting the help they want. For nurses which might be on that entrance line, a lot of them have referred to having basically PTSD, and we wish to be sure that we’re giving them the assets to get means of the state of affairs, however then even afterward, that we’re being supportive.

You’ve spoken about varied challenges. What points are you most involved with now?

First is ensuring that we’re supporting our clinicians, and for that matter, all clinicians out within the discipline to make sure that they will do their finest work and that we’re doing every little thing we are able to to get them there shortly, effectively. It contains easy issues like expressing gratitude and appreciation for them at each flip. Second, we’re very centered on our personal company crew members as properly. Whereas they’re not on the entrance strains, it’s nonetheless very worrying, and numerous hours and numerous emotional toll that will get taken means of the work that we do as a result of we so desperately wish to get each job crammed and each clinician to the place they’re wanted. We’re supporting clinicians which might be in tough conditions themselves.

We find yourself being the associate—for those who’re a recruiter, you’re on that journey proper alongside along with your clinician. We’re ensuring that we’re supporting our personal company crew members: methods to deal with psychological well being at work in the course of the pandemic. We’re very conscious of that, and all of our crew members are nonetheless working remotely, which they wish to be, and we’re supportive of that, however we’ve got to be sure that our leaders are studying methods to lead in a distant setting. We’re very pleased with the tradition at AMN. It’s been considered one of our strengths and, I believe, an enormous a part of our success. And now that tradition is distant. So how can we make sure that all of our crew members really feel appreciated, supported, and have entry to the assets that they want? I believe we’re doing very properly, however we’re going to be on this for fairly a while. We’ve made the choice not to return to workplaces till at the very least July of subsequent 12 months, apart from perhaps a pilot—I fairly truthfully suppose it’s going to be longer than that. We’re going to be feeling the challenges of the pandemic far previous the summer time.

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