Hospitals’ labor costs rose by more than a third from pre-pandemic levels by March 2022, according to a report out Wednesday from Kaufman Hall.
Heightened temporary and traveling labor costs were a main contributor, with contract labor accounting for 11% of hospitals’ total labor expenses in 2022 compared to 2% in 2019, the report found.
Contract nurses’ median hourly wages rose 106% over the period, from $64 an hour to $132 an hour, while employed nurse wages increased 11%, from $35 an hour to $39 an hour, the report found.
The new data from Kaufman Hall supports concerns hospital executives expressed while releasing first quarter earnings results, as higher-than expected labor costs spurred some operators, like HCA, to lower their financial full-year guidance.
The ongoing use of contract labor amid shortages driven by heightened turnover was a key factor executives cited for higher costs, and follows the findings from Kaufman Hall’s latest report.
More than a third of nurses surveyed by staffing firm Incredible Health said they plan to leave their current jobs by the end of this year, according to a March report. While burnout is driving them to leave, higher salaries are the top motivating factor for taking other positions, that report found.
Kaufman Hall’s report, which analyzes data from more than 900 hospitals across the country, found hospitals spent $5,494 in labor expenses per adjusted discharge in March compared to $4,009 roughly three years ago.
Costs rose for hospitals in every region, though the South and West experienced the largest increases from pre-pandemic levels as those expenses rose 43% and 42%, respectively.
The West and Northeast/Mid-Atlantic regions saw the highest expenses consistently from 2019 to 2022, according to the report.
“The pandemic made longstanding labor challenges in the healthcare sector much worse, making it far more expensive to care for hospitalized patients over the past two years,” said Erik Swanson, senior vice president of data and analytics at Kaufman Hall.
“Hospitals now face a number of pressures to attract and retain affordable clinical staff, maintain patient safety, deliver quality services and increase their efficiency,” Swanson said.
The report also notes that hospitals are competing with non-hospital employers also pursuing hourly staff, though those companies can pass along wage increases to consumers through higher prices “in a way healthcare organizations cannot,” the report said.
Some hospitals, like HCA Healthcare and Universal Health Services, are looking to raise prices for health plans amid rising nurse salaries, according to reporting from The Wall Street Journal.
Another recent report from group purchasing organization Premier found the CMS underestimated hospital labor spending when making payment adjustments for the 2022 fiscal year, resulting in hospitals receiving only a 2.4% rate increase compared to a 6.5% increase in hospital labor rates.
To match the rates hospitals are now paying staff, an adequate inpatient payment update for fiscal 2023 is needed, that report said.
The CMS proposed its IPPS rule for FY 2023 on April 18 that includes a 3.2% hike to inpatient hospital payments, which provider groups like the American Hospital Association rebuked as “simply unacceptable” considering inflation and rising hospital labor costs.
Hospitals are experiencing significant increases in expenses for workforce, drugs and medical supplies
For over two years since the outset of the COVID-19 pandemic, America’s hospitals and health systems have been on the front lines caring for patients, comforting families and protecting communities.
With over 80 million cases1, nearly 1 million deaths2, and over 4.6 million hospitalizations3, the pandemic has taken a significant toll on hospitals and health systems and placed enormous strain on the nation’s health care workforce. During this unprecedented public health crisis, hospitals and health systems have confronted many challenges, including historic volume and revenue losses, as well as skyrocketing expenses (See Figure #1).
Hospitals and health systems have been nimble in responding to surges in COVID-19 cases throughout the pandemic by expanding treatment capacity, hiring staff to meet demand, acquiring and maintaining adequate supplies and personal protective equipment (PPE) to protect patients and staff and ensuring that critical services and programs remain available to the patients and communities they serve. However, these and other factors have led to billions of dollars in losses over the last two years for hospitals, and over 33% of hospitals are operating on negative margins.
The most recent surges triggered by the delta and omicron variants have added even more pressure to hospitals. During these surges, hospitals saw the number of COVID-19 infected patients rise while other patient volumes fell, and patient acuity increased. This drove up expenses and added significant financial pressure for hospitals. Moreover, hospitals did not receive any government assistance through the COVID-19 Provider Relief Fund (PRF) to help mitigate rising expenses and lost revenues during the delta and omicron surges. This is despite the fact that more than half of COVID-19 hospitalizations have occurred since July 1, 2021, during these two most recent COVID-19 surges.
At the same time, patient acuity has increased, as measured by how long patients need to stay in the hospital. The increase in acuity is a result of the complexity of COVID-19 care, as well as treatment for patients who may have put off care during the pandemic. The average length of a patient stay increased 9.9% by the end of 2021 compared to pre-pandemic levels in 2019.4
As hospitals treat sicker patients requiring more intensive treatment, they also must ensure that sufficient staffing levels are available to care for these patients, and must acquire the necessary expensive drugs and medical supplies to provide high-quality care. As a result, overall hospital expenses have experienced considerable growth.
Data from Kaufman Hall, a consulting firm that tracks hospital financial metrics, shows that by the end of 2021, total hospital expenses were up 11% compared to pre-pandemic levels in 2019. Even after accounting for changes in volume that occurred during the pandemic, hospital expenses per patient increased significantly from pre-pandemic levels across every category. (See Figure #1)
The pandemic has strained hospitals’ and health systems’ finances. Many hospitals operate on razorthin margins, so even slight increases in expenses can have dramatic negative effects on operating margins, which can jeopardize their ability to care for patients. These expense increases have been more challenging to withstand in light of rising inflation and growth in input prices. In fact, despite modest growth in revenues compared to pre-pandemic levels, median hospital operating margins were down 3.8% by the end of 2021 compared to pre-pandemic levels, according to Kaufman Hall. Further exacerbating the problem for hospitals are Medicare sequestration cuts and payment increases that are well below increases in costs. For example, an analysis by PINC found that for fiscal year 2022, hospitals received a 2.4% increase in their Medicare inpatient payment rate, while hospital labor rates increased 6.5%.5
These levels of increased expenses and declines in operating margins are not sustainable. This report highlights key pressures currently facing hospitals and health systems, including:
Each of these issues separately presents significant challenges to the hospital field. Taken together, they represent conditions that would be potentially catastrophic for most organizations, institutions and industries. However, the fact that the nation’s hospitals and health systems continue to serve on the front lines of the ongoing pandemic is a testament to their resiliency and steadfast commitment to their mission to serve patients and communities around the country.
Hospitals and health systems are the cornerstones of their communities. Their patients depend on them for access to care 24 hours a day, seven days a week. Hospitals are often the largest employers in their community, and large purchasers of local services and goods. Additional support is needed to help ensure hospitals have the adequate resources to care for their communities.
I. Workforce and Contract Labor Expenses
The hospital workforce is central to the care process and often the largest expense for hospitals. It is no surprise then that even before the pandemic, labor costs — which include costs associated with recruiting and retaining employed staff, benefits and incentives — accounted for more than 50% of hospitals’ total expenses. Therefore, even a slight increase in these costs can have significant impacts on a hospital’s total expenses and operating margins.
As the pandemic has persisted for over two years, the toll on the health care workforce has been immense. A recent survey of health care workers found that approximately half of respondents felt “burned out” and nearly a quarter of respondents said they anticipated leaving the health care field.6
This has been mirrored by a significant and sustained decline in hospital employment, down approximately 100,000 employees from pre-pandemic levels.7 At the height of the omicron surge, approximately 1,400 hospitals or 30% of all U.S. hospitals reporting data to the government, indicated that they anticipated a critical staffing shortage within the week.8This high percentage of hospitals reporting a critical staffing shortage stayed relatively consistent throughout the delta and omicron surges.
The combination of employee burnout, fewer available staff, increased patient acuity and higher demand for care especially during the delta and omicron surges, has forced hospitals to turn to contract staffing firms to help address staffing shortages.
Though hospitals have long worked with contract staffing firms to bridge temporary gaps in staffing, the pandemic-driven-staffing-shortage has created an expanded reliance on contract staff, especially contract or travel registered nurses. Travel nurses are in particularly high demand because they serve a critical role in delivering care for both COVID-19 and non-COVID-19 patients and allow the hospital to meet the demand for care, especially during pandemic surges.
According to a survey by AMN Healthcare, one of the nation’s largest health care staffing agencies, 95% of health care facilities reported hiring nurse staff from contract labor firms during the pandemic.9Staffing firms have increased their recruitment of contract or travel nurses, illustrating the significant growth in their demand. According to data from EMSI/Burning Glass, there has been a nearly 120% increase in job postings for contract or travel nurses from pre-pandemic levels in January 2019 to January 2022. (See Figure #2)
Similarly, the hours worked by contract or travel nurses as a percentage of total hours worked by nurses in hospitals has grown from 3.9% in January 2019 to 23.4% in January 2022, according to data from Syntellis Performance Solutions. (See Figure #3) In fact, a quarter of hospitals have experienced nearly a third of their total nurse hours accounted for by contract or travel nurses.
As the share of contract travel nurse hours has grown significantly compared to before the pandemic, so too have the costs of employing travel nurses compared to pre-pandemic levels. In 2019, hospitals spent a median of 4.7% of their total nurse labor expenses for contract travel nurses, which skyrocketed to a median of 38.6% in January 2022. (See Figure #3) A quarter of hospitals — those who have had to rely disproportionately on contract travel nurses — saw their costs for contract travel nurses account for over 50% of their total nurse labor expenses. In fact, while contract travel nurses accounted for 23.4% of total nurse hours in January 2022, they accounted for nearly 40% of the labor expenses for nurses. (See Figure #3) This difference has grown considerably compared to pre-pandemic levels in 2019, suggesting that the exorbitant prices charged by staffing companies are a primary driver of higher labor expenses for hospitals.
Data from Syntellis Performance Solutions show a 213% increase in hourly rates charged to hospitals by staffing companies for travel nurses in January 2022 compared to pre-pandemic levels in January 2019. This is because staffing agencies have exploited the situation by increasing the hourly rates billed to hospitals for contract travel nurses more than the hourly rates they pay to travel nurses. This is effectively the “margin” retained by the staffing agencies. During pre-pandemic levels in 2019, the average “margin” retained by staffing agencies for travel nurses was about 15%. As of January 2022, the average “margin” has grown to an astounding 62%. (See Figure #4)
These high “margins” have fueled massive growth in the revenues and profits of health care staffing companies. Several staffing firms have reported significant growth in their revenues to as high as $1.1 billion in just the fourth quarter of 202110, tripling their revenues and net income compared to 2020 levels.11
The data indicate that the growth in labor expenses for hospitals and health systems was in large part due to the exorbitant rates charged by contract staffing firms. By the end of 2021, hospital labor expenses per patient were 36.9% higher than pre-pandemic levels, and increased to 57% at the height of the omicron surge in January 2022.12 A study looking at hospitals in New Jersey found that the increased labor expenses for contract staff amounted to $670 million in 2021 alone, which was more than triple what their hospitals spent in 2020.13High reliance on contract or travel staff prevents hospitals and health systems from investing those costs into their existing employees, leading to low morale and high turnover, which further exacerbates the challenges hospitals and health systems have been facing.
II. Drug Expenses
Prescription drug spending in the U.S. has grown significantly since the pandemic. In 2021, drug spending (including spending in both retail and non-retail settings) increased 7.7%14, which was on top of an increase of 4.9%15 in 2020. While some of this growth can be attributed to increased utilization as patient acuity increased during the pandemic, a significant driver has been the continued increase in prices of existing drugs as well as the introduction of new products at very high prices. A study by GoodRx found that in January 2022 alone, drug companies increased the price of about 810 brand and generic drugs that they reviewed by an average of 5.1%.16 These price increases followed massive price hikes for certain drugs often used in the hospital such as Hydromorphone (107%), Mitomycin (99%), and Vasopressin (97%).17 For another example, the drug manufacturer of Humira, one of the most popular brand drugs used to treat rheumatoid arthritis, increased the price of the drug by 21% between 2019 and 2021.18 A study by the Kaiser Family Foundation found that in Medicare Part B and D markets, half of all drugs in each market experienced price increases above the rate of inflation between 2019 and 2020 – in fact, a third of these drugs experienced price increases of greater than 7.5%.19 At the same time, according to a report by the Institute for Clinical and Economic Review (ICER), eight drugs with unsupported U.S. drug price increases between 2019 and 2020 alone accounted for an additional $1.67 billion in drug spending, further illustrating that drug companies’ decisions to raise the prices of their drugs are simply an unsustainable practice.20
As hospitals have worked to treat sicker patients during the pandemic, they have been forced to contend with sky-high prices for drugs, many of which are critical and lifesaving for their patients. For example, in 2020, 16 of the top 25 drugs by spending in Medicare Part B (hospital outpatient settings) had price increases greater than inflation — two of the top three drugs, Keytruda and Prolia — experienced price increases of 3.3% and 4.1%, respectively.21
As a result of these price increases, hospital drug expenses have skyrocketed. By the end of 2021, total drug expenses were 28.2% higher than pre-pandemic levels.22 When taken as a share of all non-labor expenses, drug expenses have grown from approximately 8.2% in January 2019, to 9.3% in January 2021, and to 10.6% in January 2022. (See Figure #5) Even when considering changes in volume during the pandemic, drug expenses per patient compared to pre-pandemic levels in 2019 saw significant increases, with a 36.9% increase through 2021.
While continued drug price increases by drug companies have been a major driver of the growth in overall hospital drug expenses, there also are other important driving factors to consider:
Drug Treatments for COVID-19 Patients:Remdesivir, one of the primary drugs used to treat COVID-19 patients in the hospital, has become the top spend drug for most hospitals since the pandemic. This drug alone accounted for over $1 billion in sales in the fourth quarter of 2021.23 Priced at an average of $3,12024, Remdesivir’s cost was initially covered by the federal government. However, hospitals must now purchase the drug directly.
Limitation of 340B Contract Pharmacies: The 340B program allows eligible providers, including hospitals that treat many low-income patients or treat certain patient populations like children and cancer patients, to buy certain outpatient drugs at discounted prices and use those savings to provide more comprehensive services to the patients and communities they serve. Since July 2020, several of the largest drug manufacturers have denied 340B pricing to eligible hospitals through pharmacies with whom they contract, despite calls from the Department of Health and Human Services that such actions are illegal. Because of these actions, many 340B hospitals, especially rural hospitals who disproportionately rely on contract pharmacies to ensure access to drugs for their patients, have lost millions in 340B drug savings.25 In addition, these manufacturers have required claim-level data submissions as a condition of receiving 340B discounts, which has increased costs to deliver the data as well as staff time and expense to manage that process. The loss of 340B savings coupled with increased burden of providing detailed data to drug companies have contributed to increasing drug expenses.
Health Plans’/Pharmacy Benefit Managers’ (PBMs’) “White Bagging” Policies: Health plans and PBMs have engaged in a tactic that steers hospital patients to third-party specialty pharmacies to acquire medication necessary for clinician-administered treatments, known as “white-bagging.” This practice disallows the hospital from procuring and managing the handling of a drug — typically drugs that are infused or injected requiring a clinician to administer in a hospital or clinic setting — used in patient care. These policies not only create serious patient safety concerns, but create delays and risks in patient care; add to administration, storage and handling costs; and create important liability issues for hospitals.
Taken together, these factors increase both drug expenses and overall hospital expenses.
III. Medical Supply and PPE Expenses
The U.S., like most countries in the world, relies on global supply chains for goods and services. This is especially true for medical supplies used at hospitals and other health care settings. Everything from the masks and gloves worn by staff to medical devices used in patient care come from a large network of global suppliers. Prior to the global pandemic, hospitals had established relationships with distributors and other vendors in the global health care supply chain to deliver goods as necessitated by demand. After the pandemic hit, many factories, distributors and other vendors shut down their operations, leaving hospitals, which were on the front lines facing surging demand, to fend for themselves. In fact, supply chain disruptions across industries, including health care, increased by 67% in 2020 alone.26
As a result, hospitals turned to local suppliers and non-traditional suppliers, often paying significantly higher rates than they did prior to the pandemic. Between fall 2020 and early 2022 costs for energy, resins, cotton and most metals surged in excess of 30%; these all are critical elements in the manufacturing of medical supplies and devices used every day in hospitals.27 As COVID-19 cases surged, demand for hospital PPE, such as N95 masks, gloves, eye protection and surgical gowns, increased dramatically causing hospitals to invest in acquiring and maintaining reserves of these supplies. Further, downstream effects from other global events such as the war in Ukraine and the energy crisis in China, as well as domestic issues, such as labor shortages and rising fuel and transportation costs, have all contributed to drive up even higher overall medical supply expenses for hospitals in the U.S.28 For instance, according to the Health Industry Distributors Association, transportation times for medical supplies are 440% longer than pre-pandemic times resulting in massive delays.29
Compared to 2019 levels, supply expenses for hospitals were up 15.9%30 through the end of 2021. When focusing on hospital departments involved most directly in care for COVID-19 patients − primarily hospital intensive care units (ICUs) and respiratory care departments − the increase in expenses is significantly higher. Medical supply expenses in ICUs and respiratory care departments increased 31.5% and 22.3%, respectively. Further, accounting for changes in volume during surge and non-surge periods of the pandemic, medical supply expenses per patient in ICUs and respiratory care departments were 31.8% and 25.9% higher, respectively. (See Figure #6) These numbers help illustrate the magnitude of the impact that increases in supply costs have had on hospital finances during the pandemic.
IV. Impact of Rising Inflation
Higher economy-wide costs have serious implications for hospitals and health systems, increasing the pressures of higher labor, supply, and acquisition costs; and potentially lower consumer demand. Inflation is defined as the general increase in prices and the decrease in purchasing power. It is measured by the Consumer Price Index (CPI-U). In April 2021, the Bureau of Labor Statistics (BLS) reported that the CPI-U had the largest 12-month increase since September 2008. The CPI-U hit 40-year highs in February 2022.31 Overall, consumer prices rose by a historic 8.5% on an annualized basis in March 2022 alone.32
As inflation measured by consumer prices is at record highs, below are key considerations on the potential impact of higher general inflation on hospital prices:
Labor Costs and Retention: Labor costs represent a significant portion of hospital costs (typically more than 50% of hospital expenses are related to labor costs). As the cost-of-living increases, employees generally demand higher wages/total compensation packages to offset those costs. This is especially true in the health care sector, where labor demands are already high, and labor supply is low.
Supply Chain Costs: Medical supplies account for approximately 20% of hospital expenses, on average. As input/raw good costs increase due to general inflation, hospital supplies and medical device costs increase as well. Furthermore, shortages of raw materials, including those used to manufacture drugs, could stress supply chains (i.e., medical supply shortages), which may result in changes in care patterns and add further burden on staff to implement work arounds.
Capital Investment Costs: Capital investments also may be strained, especially as hospitals have already invested heavily in expanding capacity to treat patients during the pandemic (e.g., constructing spaces for testing and isolation of COVID-19 patients). One of the areas that has seen the largest increase in prices/shortages is building materials (e.g., lumber). Additionally, a historically large increase in inflation has resulted in increases in interest rates, which may hamper borrowing options and add to overall costs.
Consumer Demand: Higher inflation also may result in decreases in demand for health care services, specifically if inflation exceeds wage growth. Specifically, higher costs for necessities (food, transportation, etc.) could push down demand for health care services and, in turn, dampen hospital volumes and revenues in the long run.
Health care and hospital prices are not driving recent overall inflation increases. The BLS has cited increases in the indices for gasoline, shelter and food as the largest contributors to the seasonally adjusted all items increase. The CPI-U increased 0.8% in February on a seasonally adjusted basis, whereas the medical care index rose 0.2% in February. The index for prescription drugs rose 0.3%, but the hospital index for hospital services declined 0.1%.33
This is consistent with pre-pandemic trends. Despite persistent cost pressures, hospital prices have seen consistently modest growth in recent years. According to BLS data, hospital prices have grown an average 2.1% per year over the last decade, about half the average annual increase in health insurance premiums. (See Figure #7) More recently, hospital prices have grown much more slowly than the overall rate of inflation. In the 12 months ending in February 2022, hospital prices increased 2.1%. In fact, even when excluding the artificially low rates paid to hospitals by Medicare and Medicaid, average annual price growth has still been below 3% in recent years.34
While we hope that our nation is rounding the corner in the battle against COVID-19, it is clear that the pandemic is not over. During the week of April 11, there have been an average of over 33,000 cases per day35 and reports suggest that a new subvariant of the virus (Omicron BA.2) is now the dominant strain in the U.S.36As a result, the challenges hospitals and health systems are currently facing are bound to last much longer.
As COVID-19 infections and hospitalizations are decreasing in some parts of the U.S. and increasing in others, hospitals and health systems continue to care for COVID-19 and non-COVID-19 patients. With additional surges potentially on the horizon, the massive growth in expenses is unsustainable. Most of the nation’s hospitals were operating on razor thin margins prior to the pandemic; and now, many of these hospitals are in an even more precarious financial situation. Regardless of potential new surges of COVID-19, hospitals and health systems continue to face workforce retention and recruitment challenges, supply chain disruptions and exorbitant expenses as outlined in this report.
Hospitals appreciate the support and resources that Congress has provided throughout the pandemic; however, additional support is needed now to keep hospitals strong so they can continue to provide care to patients and communities.
While healthcare workers battle burnout, hospitals have been ramping up wages and other benefits to recruit and retain workers. It has created a culture of competition among health systems as well as travel agencies that offer considerably higher pay.
But other healthcare organizations are not hospitals’ only competitors. Some hospitals, particularly those in rural areas, are struggling to match rising employee pay among nonindustry employers such as Target and Walmart.
“We monitor and we’ve been looking and we ask around in the community and we can ask who’s paying what,” Troy Bruntz, CEO of Community Hospital in McCook, Neb., told Becker’s. “So we know where Walmart is on different things, and we’re OK. But if Walmart tried to match what Target’s doing, that would not be good.”
At Target, the hourly starting wage now ranges from $15-$24. The organization is making a $300 million investment total to boost wages and benefits, including health plans. Starting pay is dependent on the job, the market and local wage data, according to NPR.
Walmart raised the hourly wages for 565,000 workers in 2021 by at least $1 an hour, The New York Times reported. The company’s average hourly wage is $16.40, with the lowest being $12 and the highest being $17.
Meanwhile, Costco raised its minimum wage to $17 an hour, according to NPR. The federal minimum wage is $7.25.
Estimated employment for healthcare practitioners and technical occupations is 8.8 million, according to the latest data released March 31 by the U.S. Bureau of Labor Statistics. This includes nurse practitioners, physicians, registered nurses, physician assistants and respiratory therapists, among others.
In sales and related occupations, estimated employment is 13.3 million, according to the bureau. This includes retail salespersons, cashiers and first-line supervisors of retail salespersons, among others.
While retail companies up their wages, at least one hospital CEO is monitoring the issue. Healthcare leaders weigh their options
Mr. Bruntz said rising wages among retailers is an issue his organization monitors. Although Target does not have a store in McCook, there is a Walmart, where pay is increasing.
“I was quoted a few months ago saying Walmart was approaching $15 an hour, and we can handle that,” Mr. Bruntz said. “But when it gets to $20 or $25, it’s going to be an issue.”
He also said he cannot solely increase the wages of the people making less than $15 or less than $25 because he has to be fair in terms of wages for different types of roles.
Specifically, he said he is concerned about what matching rising wages at retailers would mean for labor expenses, which make up about half of the hospital’s cost structure.
“I double that half, that’s 25 percent more expenses instantly,” Mr. Bruntz said. “And how is that going to ratchet to a bottom line anything less than a massive negative number? So it’s a huge problem.”
Clinical positions are not the only ones hospitals and health systems are struggling to fill; they are encountering similar difficulties with technicians and food service workers. Regarding these roles, competition from industries outside healthcare is particularly challenging.
This is an issue Patrice Weiss, MD, executive vice president and chief medical officer of Roanoke, Va.-based Carilion Clinic, addressed during a Becker’spanel discussion April 4. The organization saw workforce issues not just in its clinical staff, but among environmental services staff.
“When you look at what … even fast food restaurants were offering to pay per hour, well gosh, those hours are a whole lot better,” she said during the panel discussion. “There’s no exposure. You’re not walking into a building where there’s an infectious disease or patients with pandemics are being admitted.”
Amid workforce challenges, Community Hospital is elevating its recruitment and retention efforts.
Mr. Bruntz touted the hospital as a hard place to leave because of the culture while acknowledging the monetary efforts his organization is making to keep staff.
He said the hospital has a retention program where full-time employees get a bonus amount if they are at the employer on Dec. 31 and have been there at least since April 15. Part-time workers are also eligible for a bonus, though a lesser amount.
“It also encourages staff [who work on an as-needed basis] to go part-time or full-time, and [those who are] part-time to go full-time,” Mr. Bruntz said. “That’s another thing we’re doing is higher amounts for higher status to encourage that trend.”
Additionally, Community Hospital, which has 330 employees, offers a referral bonus to staff to encourage people they know to come work with them.
“We want staff to bring people they like. [We are] encouraging staff to be their own ambassadors for filling positions,” Mr. Bruntz said.
He said the hospital also will offer employees a sizable market wage adjustment not because of competition from Walmart but because of inflation.
Graham County Hospital in Hill City, Kan., is also affected by the tight labor market, although it has not experienced much competition with retail companies, CEO Melissa Atkins told Becker’s. However, the hospital is struggling with competition from other healthcare organizations, particularly when it comes to patient care departments and nursing. While many hospitals have struggled to retain employees from travel agencies, Graham County Hospital has mostly been able to avoid it.
“As the demand increases, so does the wage,” Ms. Atkins said. “In addition to other hospitals offering sign-on bonuses and increased wages, nurse agency companies are offering higher wages for traveling nurse aides and nurses. We are extremely fortunate in that we have not had to use agency nurses. Our current staff has stepped up and filled in the shortages [with additional incentive pay].”
To combat this trend, the hospital has increased hourly wages and shift differentials, as many healthcare organizations have done. It has also provided bonuses using COVID-19 relief funds.
Overall, Mr. Bruntz said he prefers “not to get into an arms race with wages” among nonindustry competitors.
“It’s not going to end well for anybody. We prefer not to use that,” he said. “At the same time, we’re trying to do as much as possible without being in a full arms race. But if Walmart started paying $25 for a door greeter and cashier, we would have to reassess.”
Even as COVID admissions continue to wane, hospitals report that workforce shortages persist. The impact on hospital finances is stark: as shown in the graphic above, there has beenan eight percent increase in clinical labor costs per patient day since the start of the pandemic, amounting to an additional $17M annually for an average 500-bed hospital.
Two of the primary factors driving this increase—higher turnover among clinical staff and a continued reliance on travel nurses—are mutually reinforcing.
Quarterly turnover rates for some nursing positions doubled from Q4 2019 to Q2 2021, as hospitals turned to expensive agency labor to fill resulting vacancies. Spiking demand for travel nurses, still running nearly three times higher than the pre-pandemic baseline, fueled more turnover, as more nurses left for these lucrative roles.
It’s unclear how long increased labor costs will persist.
Some HR tactics, like signing and retention bonuses, are one-time expenditures. But total hospital employment is still down two percent from pre-pandemic levels, pointing to a diminished healthcare labor supply.
Permanent wage increases may end up being unavoidable, especially for lower-wage jobs, where a new compensation baseline for talent is being set by the market, both inside and outside the healthcare industry.
As the workforce shortages worsened and the pandemic caused widespread burnout, many hospitals and health systems saw their labor expenses significantly rise as they were forced to pay more to attract and retain workers.
Hospitals and health systems ramped up wages, provided hiring bonuses and offered new benefits to ensure they could staff beds. However, it left us with one question: Are these rising labor expenses sustainable?
The answer to the question appears to be multifaceted and dependent on an organization’s vantage point. For example, unions say hospitals can afford wage increases and bonuses, while CFOs argue that there needs to be more sustainable methods.
Northwell Health CFO Michele Cusack lays it out very clearly: “Growth in wages more than revenue trends is not sustainable.”
Moving to a more sustainable method
At the start of the workforce shortage, hospitals and health systems turned to more immediate retention and recruitment efforts: bonuses and pay increases, according to Kaufman Hall’s Senior Vice President Therese Fitzpatrick, PhD, RN, and Managing Director Dawn Samaris. However, now that the staffing shortage has stabilized in some parts of the country — though not all — hospitals are turning to more strategic, long-term strategies to ease the labor shortage, they said.
“Initially, there was a scramble to find bonus structures and increase everybody’s pay,” Ms. Samaris said. “Now, folks are stepping back and saying, ‘Well, that can’t be the only tool. We’ve got to have other options available.”
New Hyde Park, N.Y.-based Northwell Health, for example, has been focused on bending this unsustainable cost curve of rising labor expenses “by focusing on culture, our mission and ensuring that the employees know and recognize their contribution to their communities and that they are special and are making a difference,” Ms. Cusack told Becker’s Hospital Review.
For Andrew Gaasch, CFO of Centennial, Colo.-based Centura Health, a health system with about 21,000 employees, recruitment and retention is about remaining competitive with the market when it comes to pay, while also keeping the sustainability of the organization in mind.
“That’s paramount for us to be able to deliver high-quality, whole-person care across all of our flourishing communities in Colorado and western Kansas,” Mr. Gaasch said. “At the same time, we have to maintain a healthy margin to be able to continue to invest in our communities, both from a human capital and physical capital perspective. It really is a tightrope between the two.”
He said his health system’s motto around this is, “Save where we can to spend where we should.”
“We need to be able to spend and should be able to spend on employees and in our communities,” Mr. Gaasch said.
Are hiring bonuses in healthcare here to stay?
In the fall, Centura Health offered a market bonus for bedside registered nurses. The $15,000 one-time payment, which was tied to a certain time commitment to the health system, helped reduce RN turnover from 41 percent last October to 28 percent currently.
“We took a moment and took a step back and said, ‘We have to do something more creative than just adding more dollars just to the average hourly rate. We need to do something different.’ So that’s why we approached the market bonus for bedside caregivers,” Mr. Gaasch said.
About 2,500 employees accepted the market bonus and of those, only 19 have left Centura Health. About 850 employees turned down the market bonus and of those, 137 have left Centura Health.
One thing that is staying at Centura Health: sign-on bonuses for hard-to-fill positions.
Mr. Gaasch said there are different tiers of eligibility around the sign-on bonuses, which are based on factors such as market conditions and vacancy rates. The range for sign-on bonuses at Centura Health is $7,500 to $20,000.
Over the last 14 months, Centura Health has invested more than $200 million in additional employee compensation and benefits. Additionally, the health system recently announced another $31 million investment in employees through market adjustments and benefits including student loan assistance and child care assistance.
“We’re really trying to listen to the needs of our incredible people because it’s not just about base wages, it’s about the total package and it’s about benefits,” Mr. Gaasch said.
Unions: Hiring bonuses are great, but more long-term change is needed
One of the health systems that has recently offered major sign-on incentives is Providence in Renton, Wash. In September, the health system announced $1,000 bonuses for all caregivers, referral bonuses of up to $7,500 and sign-on bonuses for 17,000 positions.
The Providence perks were designed “to reward, retain and recruit,” amid a lack of staff and rising numbers of COVID-19 patients. Though the perks may be successful at attracting more workers, Tyler Kissinger with the National Union of Healthcare Workers says those workers won’t stay for long unless underlying issues are addressed.
“Hospitals were chronically understaffed before the pandemic. Short-term bonus programs might help get more workers hired, but they won’t stay if the hospital is chronically understaffed and their patients aren’t getting the care they need,” Mr. Kissinger said.
Mr. Kissinger is an organizing coordinator with the NUHW in Northern California, focused on Providence hospitals located in Sonoma and Napa counties. He believes incentives like sign-on and referral bonuses only go so far, and improving the workplace itself is key to attracting and retaining employees.
“The only way to sustainably attract and retain workers is to increase staffing to sustainable levels so healthcare workers don’t burn out trying to do everything they can to care for their patients,” Mr. Kissinger said. “Healthcare workers get into this field because they want to help people get better. When they see hospitals skimp on staffing, while paying their CEOs millions of dollars, it’s disheartening, and it results in people leaving.”
The same week Providence announced their incentive programs, a Gallagher survey reported a 75 percent increase in average hourly rates for agency RNs nationwide, rising from $75 pre-pandemic to more than $130 in September 2021. Despite the major increase in pay, the national RN vacancy rate stood at 19 percent, more than double pre-pandemic levels. To find enough nurses, 75 percent of healthcare organizations are turning to agency and travel RN companies.
“We’re seeing major healthcare chains like Providence rely more heavily on travelers and hiring bonuses. That’s not a sustainable solution,” Mr. Kissinger said. “The sustainable solution for hospital chains like Providence is to change their business model to focus less on profit and more on providing care, and that starts with hiring more caregivers and making the work more manageable so more people will enter and stay in the field.”
Other healthcare unions such as the Illinois Nurses Association signaled their full support for sign-on bonuses to boost critical staffing levels, but say these types of incentives may be sustainable for health systems because they aren’t necessarily spending more to fund them.
“INA understands and supports hospitals that offer signing bonuses to attract nurses if these are used as part of a comprehensive and fair compensation strategy that treats nurses with respect and dignity,” an INA spokesperson said. “All too often, we have found that these bonuses replace compensation and benefits that could be used for senior nurses who have worked several years for institutions that have not treated them well, especially during the last two years.”
It’s a sentiment shared by Mr. Kissinger, who says nurses and physicians may be offered major sign-on bonuses, increased pay and benefits like child care subsidies, but support positions won’t be offered nearly as much, if at all.
“At Providence hospitals, we’ve secured better wages for many workers in certified and licensed positions, but Providence has so far refused our proposals to increase pay for lower-paid workers such as housekeepers, nursing assistants, transporters and kitchen staff,” Mr. Kissinger said.
Reducing or sunsetting other expenses
Dr. Fitzpatrick of Kaufman Hall said the focus is now on creating a robust pipeline of staff, whether it’s professional staff, technical staff or entry-level staff. One example of how organizations are doing this is through partnerships with higher education to train students and then move them to employment. Ms. Samaris said some places are also creating simulation labs that imitate a real hospital setting for community colleges to train their students.
Another example is through “shadow traveler” programs, or internal travel nursing, Ms. Samaris said. This gives nurses the opportunity to travel within the system for slightly higher pay, rather than forcing them to move to an external agency. Pittsburgh-based UPMC is among the organizations using this approach.
Ms. Samaris added that hospitals are enacting strategies to lower costs in other areas. This includes optimizing staffing in the areas that need it most, analyzing where there is a duplication of services and creating partnerships with other organizations to offer services, like behavioral health or home health.
At Northwell Health, Ms. Cusack said that in response to wage pressures and other COVID-19 costs, the health system has reduced discretionary spending and placed a great focus on increasing product standardization and other operating efficiencies. Northwell is also reducing costs through the remote-work shift.
“With the growth of the hybrid work environment, we can reduce our administrative real estate portfolio to further counterbalance the expense pressure from wage growth,” Ms. Cusack said.
Mr. Gaasch cited examples of where the health system is using its motto to save costs to offset this labor pressure, such as leveraging Centura Health’s size and scale where possible; automating processes where possible; considering centralization of services as appropriate; ensuring overhead functions operate as efficiently as possible; and reviewing work-from-home policies and corresponding real estate costs.
He said Centura Health is also reducing premium pay categories that the health system has been heavily reliant on through the pandemic.
“The pandemic has slowed as far as the number of COVID-19 patients we’re treating, so we’re starting to look at premium pay categories that we instituted and how can we start to ratchet those down, in a corresponding timeline with the number of COVID patients decreasing and regaining our footing on staffing,” he explained.
He said Centura Health is also considering its supply chain and is trying to standardize where possible on products and use across the health system.
Is there a hard stop for how high labor expenses can grow?
Overall, Mr. Gaasch said he doesn’t have a set ceiling on how high labor costs can grow, because paying clinicians is vital to remain competitive.
Ms. Cusack agreed that there’s not a “hard stop” on how high labor expenses rise, saying that the health system must “ensure we have the appropriate staffing levels in the various clinical functional areas in response to the volume of patients that we care for every day.”
Dr. Fitzpatrick agreed, saying: “There really is no hard stop. … This is a continually evolving situation. … I think the solutions will continue to evolve as well.”
Economists are curious as to whether baby boomers who accelerated their retirement during the pandemic will return to the workforce, and if so, at what rate.
About 2.6 million older workers retired above ordinary trends since the start of the pandemic two years ago, according to a Bloomberg report citing estimates from the Federal Reserve Bank of St. Louis. Despite this boom, applications for Social Security benefits have remained fairly flat, based on calculations by the Boston College Center for Retirement Research. About 0.1 percent of the U.S. population 55 and older have applied each month, which is in line with pre-pandemic applications.
Pandemic surges in stock and real estate values made this an “opportune time for some workers to step out of the labor force and stay out of the labor force,” Lowell Ricketts, data scientist for the Institute for Economic Equity at the St. Louis Fed, told Bloomberg. “But we’re still expecting a steady, steady trend that some might want to come back,” he noted, citing remote and hybrid work as attractors for seniors eyeing a return to the job market, particularly amid high inflation.
Bureau of Labor Statistics data on labor participation shows that some baby boomers have come back, while many remain on the sidelines. Pre-pandemic, “unretirement” was not uncommon in the United States, due to financial hardship or personal choice. It’s still too soon to say whether the pandemic has challenged this dynamic.
Some “retirees” may have only one foot out the door, too. The Social Security Administration’s Office of the Chief Actuary suggested older people may have “retired” from one job and continued working in another, which explains why they haven’t applied for benefits, Bloomberg reports.
Early retirements have stood to further disrupt the healthcare labor force throughout the pandemic. For instance, census microdata from the Current Population Survey provided by the University of Minnesota shows 14,500 nurses had recently retired as of March 2021, an increase of 140 percent over that figure in March 2019, according to a Pew report. The figure represents people who worked in the profession the past year but said they were now retired and not looking for work.
Initial jobless claims, week ended March 19: 187,000 vs.210,000 expected and a revised 215,000 during prior week
Continuing claims, week ended March 12: 1.350 millionvs.1.400 million expected and a revised 1.417 million during prior week
At 187,000, new jobless claims improved for a back-to-back week and reached the lowest level since September 1969. Continuing claims also fell further to reach 1.35 million — the least since January 1970.
The labor market has remained a point of strength in the U.S. economy, with job openings still elevated but coming down from record levels as more workers rejoin the labor force from the sidelines.
Going forward, however, some economists warned that new cases of the fast-spreading sub-variant of Omicron, known as BA.2, could at least temporarily disrupt mobility and economic activity across the country. As of this week, about one-third of COVID-19 cases in the U.S. have been attributed to the sub-variant, though overall new infections have still been trending down from January’s record high. The impact on the labor market — and on demand in the service sector especially — remains to be seen.
“Right now, U.S. cases are in the sweet spot between the bottom of the initial Omicron wave and the impending explosion in BA.2 cases, but this probably won’t last long,” Ian Shepherdson, chief economist at Pantheon Macroeconomics, wrote in a note this week. “Our bet … is that the coming BA.2 wave will trigger a modest but visible pull-back in the discretionary services sector, thereby dampening consumption in the first month of the second quarter.”
Still, many economists and policymakers have pointed out that the labor market withstood prior disruptions due to the Omicron wave earlier this year. Non-farm payrolls grew more than expected in each of January and February despite the outbreak.
“The labor market has substantial momentum. Employment growth powered through the difficult Omicron wave, adding 1.75 million jobs over the past three months,” Powell said in a speech Monday. “By many measures, the labor market is extremely tight, significantly tighter than the very strong job market just before the pandemic.”
The tightness of the labor market has also strongly informed the Fed’s decisions in pressing ahead with tightening monetary policy, with the economy showing clear signs of strength and the ability to handle less accommodative financial conditions. Last week, the Fed raised interest rates by 25 basis points in its first rate hike since 2018. And St. Louis Fed President Jim Bullard, the lone dissenter of that decision who had called for a more aggressive 50 basis point rate hike last week, justified his vote in part given the strength of the U.S. labor market even in the face of decades-high rates of inflation.
“U.S. labor markets are today already stronger than they have been in a generation,” Bullard said in a statement.
It was a winter of surging job creation. Employers created jobs on a mass scale, Americans returned to the workforce, and the labor market shrugged off the Omicron variant and its broader pandemic funk.
That’s the takeaway from the February jobs report, which showed employers added 678,000 jobs last month. December and January job growth was better than previously thought, and the unemployment rate fell to 3.8%.
Why it matters: Yes, inflation is high as prices rose 7.5% over the last year as of January, and could rise higher as disruptions from the Ukraine war ripple through the economy.
But rising prices are coming amid an astonishingly rapid jobs boom.
Between the lines: The report shows the pandemic impact is fading. But some analysts warn not to expect this level of gains to continue as the crisis in Ukraine cuts into growth.
“The improvement in the American labor market is now very much a rearview mirror phenomenon,” economist Joe Brusuelas wrote in a research note.
One big surprise: Wage growth was essentially nonexistent, with average hourly earnings rising only a penny to $31.58.
That may reflect the nature of the jobs being added — disproportionately in the low-paying leisure and hospitality sector.
That is good news for those worried that rising wages and prices will drive further inflation. It is worse news for workers, whose average pay gain of 5.1% over the last year is far below inflation.
The share of adults in the labor force — which includes those looking for work — ticked up, as did the share of the population that’s actually employed. That suggests the robust job growth is pulling people back into the workforce, if gradually.
The labor force participation rate was 62.3% in February, more than a percentage point below its level two years ago, before the pandemic.
State of play: The Federal Reserve is set to begin an interest rate hiking campaign on March 16, amid high inflation and new geopolitical uncertainty from the Ukraine war. The new numbers are unlikely to change that one way or the other.