Episode 24: This might hurt a bit—Diagnosing the nursing shortage with Rachel Schiff of IntelyCare

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Definitively Speaking is a Definitive Healthcare podcast series recorded and produced in Framingham, Massachusetts. To learn more about healthcare commercial intelligence, please visit us at definitivehc.com.

Justin Steinman:
Hello and welcome to Definitively Speaking, the podcast where we have data-driven conversations on the current state of healthcare. I'm Justin Steinman, Chief Marketing Officer at Definitive Healthcare and your host for this podcast. We've been talking for a while now about the staffing shortage in healthcare, primary care doctors, specialists, nurses. The simple fact is that there's just not enough caregivers out there to meet the growing demand. According to the Definitive Healthcare research actually, one in five healthcare workers have quit their job since 2020, and some reports suggest that up to 47% of healthcare workers plan to leave their position by 2025.
That's scary stuff. The problem is particularly acute in the nursing field. Anyone who's been to a hospital knows that nurses are the backbone of the hospital. They're the folks on the frontline delivering the compassionate care that everyone needs, and yet nurses are burned out, striking, and quitting in droves. In fact, one McKinsey report projects that by 2025, the United States may have a gap of between 200,000 to 450,000 nurses available for direct patient care. It's clear we need to do something. The question is, what can we do? And then it's quickly followed by, who's going to do it?
To try to answer these very difficult questions and to shed some light on the nursing industry more broadly, I'm joined today by Rachel Schiff from IntelyCare, a healthcare workforce management platform. IntelyCare uses AI to match healthcare facilities with nursing professionals in an on-demand environment. Rachel's the chief product officer at IntelyCare, and she spends her days thinking about how to get the right nurses to the right locations where they're needed most, and to do it in a manner where they're compensated fairly for their time. Rachel, welcome to Definitively Speaking.

Rachel Schiff:
Thanks so much.

Justin Steinman:
We're glad to have you here. Before I jump in, I just want to welcome my friend, colleague, and frequent co-host of the podcast, Todd Bellemare. Todd, just squeezes into your very busy schedule today between all your client commitments.

Todd Bellemare:
I am very excited to be here. Thank you.

Justin Steinman:
Awesome. All right, Rachel, let's get you going here. Tough question right off the bat. I rattled off a bunch of scary stats to start off the podcast, but my question to you is why. Why are so many nurses choosing to leave the profession?

Rachel Schiff:
The work itself is difficult and stressful, and the ratios have been getting worse and worse. The workload on nurses is heavier than ever, and so they're choosing to leave. I know we had talked a little bit in advance that the nurses often don't have the level of agency and autonomy that they would like in doing their job. Put all those things together and nurses are leaving for other jobs.

Justin Steinman:
When you said about the ratio, what does that mean? What's a typical ratio? Where has it gone to? How bad has it gotten?

Rachel Schiff:
I mean, it really depends on the level of care, but I think that what we're seeing is actually legislatures are stepping in to say that the levels that there are today in many places are not safe. It really depends on the specifics of the situation. But as you've said, as salaries have gone up, a lot of healthcare facilities have responded by cutting back on the number of nurses that are available.

Justin Steinman:
It seems like we're in a death spiral.

Rachel Schiff:
Well, something like that, but I do have some solutions to talk about.

Justin Steinman:
Excellent.

Todd Bellemare:
When I think about this, it seems like such an obvious thing. Right, yeah, there has to be a better ratio of nurses to patients. When I think about it from a common sense perspective or maybe even an outsider perspective, you would think that the proprietors of hospitals and physician groups and whoever it is employing nurses would say, "Oh yeah, obviously we need to figure out better ways to keep our nurses engaged and happy and going."
Not to lead the question, but do you think that it's a component of treating healthcare as a service that is like a sale, like they're selling healthcare, and so they're looking for better margin? Obviously everyone's trying to make money. It ends up just being a dollar figure that they're like, "Well, we have to hit a certain number so we can't have as much cost in salary, so we'll cut nurses first."

Rachel Schiff:
I think if you go very deep into the causes here, it is that essentially that the nurse salaries are bundled in that room rate rather than being tied to the actual procedures. It becomes a cost factor rather than something that can be billed out, even if there's a known standard for the type of nursing support that should be provided along with a given procedure.

Justin Steinman:
Right. You just said something really interesting, which is you're going to bill out nurses, which I get that, but aren't we at the same point in time where we're trying to control costs in healthcare and wouldn't billing those nurses out potentially even raise the cost of healthcare?

Rachel Schiff:
I mean, it's a difficult choice, but I think that the reason it gets treated so transactionally is because it's solely on the cost side and not at all on the-

Todd Bellemare:
Revenue side.

Rachel Schiff:
-the revenue side.

Justin Steinman:
Got it. You said earlier you got some solutions. What do you got?

Rachel Schiff:
Well, I mean, flexible work is really the one most central to what I do and we at IntelyCare do. We talked about a lot of reasons that nurses are leaving the workforce, but also a lot of it comes down to the lack of flexibility in nursing jobs as they're structured today. The fact that people often have to stay over because coverage doesn't arrive, because the nature of the work hours aligned with family responsibilities. Where we really have been able to expand the workforce pie is by saying no, some of these jobs can be more flexible.
Maybe someone who's caring for children or elderly relatives can pick up some shifts on the weekend. Because the work is divided into shifts, there is the potential to have a larger workforce that works less, and those people have more work-life balance and less stress in their lives.

Justin Steinman:
What's a typical nursing shift, like eight hours, 10 hours?

Rachel Schiff:
Eights and 12s are very common.

Justin Steinman:
And are you talking about maybe chopping that down to twos and fours?

Rachel Schiff:
There is some of that going on. I think that's certainly one approach where that's feasible, but the other thing is to say, sure, it's still a 12, but maybe someone who would've otherwise retired is working two 12s a month. Two 12s, that's not too much time. It keeps them busy and active, and it might cover weekend shifts that are really hard to cover.

Justin Steinman:
And that makes the employees 1099 employees basically.

Rachel Schiff:
No. All IntelyCare employees are W-2 employees. I think it's independent from the nature of the employment relationship, but the work schedule itself can be as flexible as the person wants.

Justin Steinman:
I didn't understand your business model. Let's dive down for one second here. IntelyCare actually hires pools of nurses and then you match make. I thought you were an eBay where you were just the middleman. It sounds like you actually have a pool of resources.

Rachel Schiff:
Exactly. They are IntelyCare employees working gigs through our app. But because of the amount of responsibility and liability associated with nurse work and the carefully controlled environment that it occurs in, where if you look at the traditional tests around who's a contractor and who's an employee, these are people who show up and all their supplies are provided for them, the hours of the shift are set. That really fits, in our opinion, much better into the model of what an employee is. We as IntelyCare are employing them to take on those responsibilities.

Todd Bellemare:
This will sound odd maybe, but it's almost like an Uber for nurses, but you're actually paying them a good wage. You're doing all the good things in the backend that maybe some other types of gig work doesn't always involve. That's fascinating. It reminds me a little bit of even just physicians.
There's plenty of models we've seen out there where physicians do that same thing, where they're paid by a physician group or a staffing agency and they're, for lack of a better word, rented out to hospitals for different shifts to do different specialties or whatever might be happening at the given time. A service line needs to be offered and they're almost outsourcing that from the hospital to an agency to pull them in.

Justin Steinman:
So then are you selling to hospitals? Is that your primary client?

Rachel Schiff:
Our primary client today is post-acute, but hospitals are absolutely in the mix for us.

Justin Steinman:
I mean, again, I read the papers. What gets covered in newspapers? Strikes, because strikes are sexy, newsworthy, everything else. When I think I saw some researches, according to betternurse.org, there were 14 strikes involving healthcare workers in 2021, and seven of those were strikes by nurses. You go back like 20 years, you never saw a strike by nurses. Why are they striking?

Rachel Schiff:
A lot is about the ratios that I mentioned at the beginning, that they're saying their work conditions are unsafe because there aren't enough nurses being hired to care for their patients. I mean, pay is an issue in every strike, but really looking at the nurse strikes happening in this country today, they're primarily around the ratios.

Justin Steinman:
Got it. Do you need a different set of skills to be a nurse in a hospital than in a post-acute facility?

Rachel Schiff:
Yeah, definitely. Again, even within a hospital, there are different specialties of different types.

Justin Steinman:
Got it. You're really targeting the post-acute, but do you see yourself going to the hospitals eventually?

Rachel Schiff:
Yeah, that's an area we're expanding into this year, and I think the hospitals are starting to see the benefit of the type of flexibility that we provide

Todd Bellemare:
In terms of that specialization, I think about physician specialization obviously. It's not like if a heart surgeon calls out, they're not going to call a podiatrist to come in and cover their shift. Is it a similar position you find yourselves in in terms of, hey, this is the pool of nurses we have. They're in gastro pediatric and something else, and it's hard for them to switch over. If the hospital or post-acute site needs a pediatrician nurse and you maybe don't have one available at the time, are there crossovers that happen when you can use that pool a little more liberally?

Rachel Schiff:
I mean, coming from the product side, as a product, I see it as just being sure that we know all the skills and qualifications that the nurses working for us have so that we can take that data and match them to the right things. Are there some that are very specialized? There are. The large majority of nurses in hospital settings are considered med-surg nurses and are fairly interchangeable. There could be specific skillsets that you need to make sure that it's a nurse who has a particular skillset set within that, and then there are a few specializations, but most of it is more med-surg.

Todd Bellemare:
That's interesting. I think we've talked to a bunch of staffing agencies about the process of just finding nurses or finding physicians even to get them into the pool, but it's like you guys have attached the software management of the categorization, the pooling and the availability management for the hospitals and post-acute sites to be able to pull that. It's a cool additional piece that seems like is missing in a lot of other agencies.

Justin Steinman:
Let's pivot and talk a little bit about the supply here. Do we think that there are enough nurses out there and we just can't get them to stick around? Are nursing schools producing enough nurses?

Rachel Schiff:
From the data I've seen, there are. There are enough nurses to fill new classes at the rate that you would expect nurses to retire. But you're seeing two trends that cause the nursing shortage. One is nurses retiring earlier, which I think again speaks to the lack of flexibility in the job. The second is that young nurses coming out of nursing school, again, given the lack of flexibility, the stressfulness of the job, are leaving for other professions because they're well-trained and they can do other things. Given the ratios, the stress, the lack of flexibility, a lot of young nurses who have come out of nursing school are leaving nursing.

Justin Steinman:
Aside from the flexibility, what else can we do as a industry, as a patient, as anything to make nursing more desirable?

Rachel Schiff:
Flexibility is certainly a big piece. I do think agency and autonomy and thinking about how we approach care and care plans and include nurses in that process. Within IntelyCare, Rebecca Love is our chief clinical officer and she has a number of hackathon type programs going with nurses to get their input on the types of tooling that are available at the bedside, where they have a lot of insight that often hasn't been tapped. That's certainly a piece. But I love that you mentioned patience because I think it absolutely is a piece to think about as we participate in the healthcare system. How can we make sure we're showing the appropriate appreciation and respect to the people who help us?

Todd Bellemare:
You had mentioned earlier that the nurses' salary or the nursing cost is built into the room rate as opposed to what is the revenue driver, which is the service that's delivered. I think that's similar for almost any industry where you have people working on a product versus people who are out there selling a consulting service. The consulting service is usually going to get a little more of the credit for things, even though they couldn't really do a lot of what they're doing without some of that backup on the product.
If you look at changing the billing cycle a little bit and Justin mentioned the rising costs, that cost was always there. It just wasn't always visible. If you have that as a feature of where hospital executives are seeing, "Oh, well, the more nurses we have, the more things we can do, and therefore the bottom line looks better than it did before," maybe the billing cycles will help align everybody's appreciation for what nurses are actually bringing to the table. And then they'll say, "Okay, yeah, we need more nurses," and therefore there are better flexibility, better options.
But the respect piece I think is always an undertone there, because certainly even just from TV shows and the general zeitgeist of how people look at nurses versus doctors, there's always that tension there that really needs to be flipped on its head.

Rachel Schiff:
Yeah, absolutely.

Justin Steinman:
But Todd, I'll be controversial for a second because that's what I like to do. You're talking about adding the cost here, but I'm telling you it's a tricky time to be a hospital administrator. I mean, seriously, I would not want to be a hospital executive right now. Talk about pressure job. It's inflationary environment with a workforce shortage. When I read some research preparing for today, Kaufman Hall did a report that showed that labor expenses at US hospitals rose 37% per patient between 2019 and 2022. That's ridiculous. 37% cost increase over three years.
I cross referenced that with our data and found it's particularly acute at hospitals with 250 beds. I don't know how we pull out those nurses and add that additional cost when we're trying to get that down, unless you can figure out some way to connect that to improvement in the quality of care to suck cost out some other way.

Todd Bellemare:
I think what you're saying is that with better flexibility, and I'm sure when nurses strike, part of their comments or their rationale is that more nurses, better flexibility, safer patients. Safer patients equates to lower fall rates, lower issues that happen, recurrences and readmissions, exactly. If we had more nurses, could we reduce the readmission rate by 5% for A, B or C? What does that dollar figure look like? And therefore, boom, there's your extra additional piece at the bottom.

Rachel Schiff:
I do think when you look at those costs and the fact that they're highest at the bigger hospitals, it does point a certain finger at travel nursing, that the hospitals have become very reliant on travel nurses, which obviously has additional costs because you have to pay for the housing of those nurses, the food and housing, as well as the labor.
I do think that what we're likely to see this year, this is an actual prediction, is a move on the part of hospitals to look at how to better use their own staff flexibly. We're working on some software tools so that hospitals can do with their own staff what we do with our staff and to use local contingent labor more to not rely as much on the travel nursing, which is particularly expensive.

Justin Steinman:
How much more expensive is a travel nurse versus a regular nurse on a percentage scale roughly?

Rachel Schiff:
I don't know that I can answer that. It is very dependent on place and time. There were huge spikes during COVID that were like in the 300% kind of range. That has been coming down. I don't have a specific answer, but it's certainly an extra layer of cost.

Justin Steinman:
You always want to make better use of your staff. But again, as I was reading some stuff in Becker's, just this past April, I guess, 69% of nurses said staffing has gotten worse over the past year. This stat scared me, which was 26% of nurses said they had been assigned to a clinical area that required skills they didn't have, which is nothing. You don't want some practicing... Todd made that analogy a couple seconds ago about saying the nurses who are the podiatrists trying to fix the heart surgeon. You don't want that. You got 26% of nurses assigned to clinical areas. How do we attack that problem when you're trying to optimize your staffing?

Rachel Schiff:
Well, one thing we are excited about is the potential for using technology in training as well. We have an Intel EDU group with some of the best nurse educators in the country. I think that one way, that's not the whole thing, is to say, "Well, what are skills that are more in demand and how do we help nurses get those skills and up level? How can we use technology to deliver those courses and then have whatever clinical components are necessary?"
That's one piece is to instead of sending someone in without the skills, see what the needs are going to be and upskill nurses. The second piece would go to tech and good matching algorithms so that in any environment, you're optimizing sending the people with the skills to the place where the skills are needed.

Justin Steinman:
Got it. Let's transition a bit. There's another shift going on in healthcare. There's all sorts of shifts going on in healthcare these days, right? Another one is a big movement to home healthcare, driven, again, by technology, remote patient monitoring. In fact, people want to be at home. How's that going to impact nursing?

Rachel Schiff:
Well, I think more nurses than ever will be needed. A lot of the innovation that's happening there is to see where can the hospital level care be almost centralized in some command center. And then you're having nurses typically go out to the home and deliver the care supported by tech to report into the doctors. We are seeing more and more of those models. I think that more nurses, if anything, will likely be needed by this greater distribution of care, but it is a perfect opportunity for the type of flexible work I've been describing because it could be something that's right in your neighborhood for one hour, that type of approach.
It's something that we're working with a number of clients to provide nurses to that type of work. It's absolutely a shift that we see. I think especially there's certainly a hospital at home, but there's also a big post-acute opportunity to say, where can people who want to stay home do that?

Todd Bellemare:
Do you see yourselves expanding into home health aids as well at some point in the future? Have read over and over about how the explosion in boomers going into the 65 plus range is going to mean an explosion in home healthcare. The need for those home health aids seems like it's just going to ramp up like crazy.

Rachel Schiff:
We do staff CNAs today. It's a big part of our business. A lot of those, depending on the state, is whether CNA is distinct from home health aide. There's also personal care. I do think that that is a big opportunity to see what are all the different skill levels that are needed and to have them. I think there've been some interesting innovative business models with even lower skilled caregivers giving them the training to check in. At the same time, we are seeing from some of our clients' needs for specific skills like phlebotomy and that coming to people's doors.
I know we've seen that a little bit with COVID testing and vaccination like models of particular healthcare procedures and them being done in the home. From what we're seeing, there's demand for all different kinds of healthcare professionals coming to the home. Certainly I agree that identifying what those skill sets and certifications are and certainly IntelyCare would be open to whatever's needed in those environments.

Justin Steinman:
It is a different environment though, because a hospital's purpose built, right? It's built for healthcare and my house is not. You need a different set of skills to work through that, and I think that's going to put initial pressure on nurses even more.

Rachel Schiff:
I think that is true. I think, again, as the product person, I can say on the tech side, there's all kinds of features that we never thought about in a healthcare facility environment. We have to ask, do you have pets? Are you allergic to pets? How many flight of stairs do you have to walk up? All of this type of question about care that's delivered in the home. But at the same time, I mean, home health has been a thing for long enough. We are finding that most of our nurses have some experience of delivering home health.
One thing we've actually heard, again, almost to this point of flexibility is that a lot of times nurses like doing different things, different times. Especially in post-acute, we sometimes hear that they're different pros and cons. In a way, there is more autonomy when you're going delivering care in the home. You might like that for a while, and then you might just be ready for the steady schedule and not the big dog jumping on you or whatever it is and switch to a facility.

Justin Steinman:
It seems like the flexibility that we're talking about, so that's good. All right, last big question before I go. Todd knows. That's asks the big question at the end of every podcast. Put our guests on the spot. We've talked about redefinition of healthcare, home healthcare, nursing, all sorts of stuff, but it seems like right now there's a lot of change going on in the areas of primary care and senior care. Every time I turn around, CVS, Walgreens, Walmart has purchased another care delivery organization. CVS just purchased Oak Street. To say nothing of Amazon's ambitions in this space, what's going to be the impact of all these business models on the nursing industry?

Rachel Schiff:
I'm going to say they all need nurses. It doesn't really matter where the care is delivered. Nurses are needed. I think some of what we just talked about that there could be more gradations, the same way CNAs and nurses are very prevalent today, home health aids, to think about different certifications to maybe expand the pool somewhat and make sure that people get specific training in those specific things. But I would say that from the nurse perspective, you pretty much need the same number of nurses, if not more nurses, no matter where the care is delivered.

Justin Steinman:
I think you raised an interesting point though. I think you're going to need a different level of specialization. We talk a lot about having people practice at the top of their license. Maybe you need a different skillset to practice at a CVS than you do to practice at the home than to practice at a hospital. You could potentially see a more subspecialization and different licenses and even ways to attract people more into the industry. I think we're seeing a lot of different changes. Telenurses, right? You got all this stuff like the Hims and the Romans. I feel like you can buy anything these days. You just talk to a nurse practitioner over the internet.
It's unbelievable. They all advertise during Sunday football. It's hysterical. But I think there's also another place for nurses to get those jobs and stuff like that. Well, fascinating, Rachel. Definitely an industry in the midst of transition. I can't wait to see where it's going to go, but let's shout out. Nurses, we love you. Thank you.

Todd Bellemare:
Absolutely.

Justin Steinman:
Good. Awesome. Todd, as always, thanks for joining me, my friend.

Todd Bellemare:
Thank you. Happy to be here.

Justin Steinman:
And for all of listeners out there, thank you for listening to Definitively Speaking, a Definitive Healthcare Podcast. Please join me next time for a conversation with Dr. Sameer Berry, the Chief Medical Officer at Oshi Health. Oshi Health is a virtual, multidisciplinary GI care company, and Dr. Berry is going to share the results of a recent research study that they conducted. Not to spoil the show, but his research shows that the new hybrid and virtual care models dramatically lower healthcare costs, ER visits, and improve the quality of care. That's pretty important considering digestive orders affect 70 million people and cost the US healthcare system more than $135 billion each year.
I hope you'll join in to listen to me and Dr. Berry talk a little bit about this. If you like what you've heard today, please remember to rate, review, and subscribe to the show on Apple Podcasts, Google Podcasts, Spotify, or wherever you get your podcast. To learn more about how healthcare commercial intelligence can support your business, please follow us on Twitter at @definitivehc or visit us at definitivehc.com. Until next time, take care, please stay healthy, and don't forget to hug your favorite nurse.