2006 Salary Survey Results
Times are good for emergency staffers, but for managers, the frustration continues
The continuing shortage of nurses and a growing shortage of physicians has created a twofold challenge for ED managers, say the experts. The first challenge: How to attract and retain talented staff. The second: Dealing with the sad fact that while staff salaries are surging, ED director and manager compensation lags behind.
"Unfortunately, compensation has not held up as much for managers as it has for staff nurses," says Nancy Bonalumi, president of the Emergency Nurses Association and director of emergency and trauma nursing at Children's Hospital of Philadelphia. "There's been an increase across the board [for staff nurses] because it has become so competitive."
For the ED Management 2006 Salary Survey, 892 surveys were disseminated. There were 17 responses, for a response rate of 2%. The greatest percentage of ED physician and nurse managers (38.98%) received a modest increase of between 1% and 3% over the previous year. Another 27.12% received increases of between 4% and 6%. While 23.08% of survey respondents in 2004 reported annual gross income of between $80,000 and $89,999; this year, 21.67% said their income fell within that range. The figures for those making $90,000-$99,999 rose slightly, from 13.85% of respondents to 15%; for those making $100,000-$129,999, the increase was from 13.85% of respondents to 21.67%. (See charts.)
According to Bonalumi, however, individuals in ED management often end up in what she calls a "compression" situation, where staff nurses actually make more than they do. "The additional incentives offered staff nurses can be frustrating for managers," she explains. "We also need to be sure we are compensating our leaders as well."
Nor are ED physician managers faring as well as the physicians they supervise, according to a survey of emergency physicians conducted by Daniel Stern & Associates, a Pittsburgh-based physician recruitment firm specializing in the field of emergency medicine, in partnership with PhysicianWork.com. According to their 2006 National Emergency Physician Salary and Compensation Survey, while total compensation for emergency physicians increased 6%, ED directors' total compensation remained basically flat.
"In cases where the staff people got more of an increase, it is because recruiting has become a major headache," says Daniel Stern, president of the firm that bears his name. "There is a shortage of ED docs — especially those who are credentialed — and it's a real competitive situation."
The disparity between staff and management increases is not always resented by ED managers, he says. "Some of the ED directors are older and looking to do less clinical time," he says. "You can work 30%-40% less clinically and not get paid as much, but your quality of life is better."
Becoming recruiters
The harsh realities of staffing shortages have made it increasingly difficult for ED managers to recruit.
There have been some adjustments made in the last couple of years for recruitment and retention purposes, says Peggie Parniawski, MSN, RN, director of emergency medicine and oncology services at Bridgeport (CT) Hospital. "Usually, what we will do is the human resources department will scan the environment to see what salaries are and go through and make adjustments."
Bridgeport Hospital tries to simply raise the hourly base salary to be competitive, she continues. "This year, we went up $2 an hour," she reports of nurses' and managers' salaries.
For physician directors, it's the same story in terms of recruitment. There are several different approaches, says Stern. "One is to try to entice staff with more money and benefits," he says. If they're not successful, often the hospital will turn to management companies such as Emergency Medical Associates (EMA) in Livingston, NJ, or EmCare in Dallas, "and turn the whole recruiting headache over to that group," Stern says.
Turning over that responsibility is not necessarily a good thing for the director, he says. "Sometimes the director loses his job and the group takes over. Then the now ex-director may or may not stay [to practice as a physician] with the new group," Stern notes.
How can this situation be avoided? "You need to improve your negotiating skills," he advises. "A good ED director today needs diplomatic skills, quality skills, and a head for management."
These are definitely skills that were not part of the ED manager's skill set 10 years ago, Stern notes. "However, if directors are not successful in recruiting, it could cost them their job."
What attracts staff?
To be a more effective recruiter, say the experts, it's critical that an ED manager understand what attracts staff to a facility — and it's not always money. That knowledge can be especially important if your hospital's budget doesn't allow you to be competitive when it comes to salary.
"One of the biggest reasons a nurse will choose a facility is the work/life experience," says Bonalumi. "They are looking for work that is meaningful and rewarding, and they want to do it in a way that doesn't wear them out." Accordingly, she says, organizations are looking at creative scheduling, such as weekend only, so their staff can maintain a sense of balance.
"ED nurse managers have the ability to advocate within their organizations [for such arrangements]," says Bonalumi. "I encourage them to make a coalition with other nurse managers in their hospital; in fact, the ED nurse managers should be the leaders."
Bridgeport Hospital just put in a 403B with an employer match — which is important to employees, Parniawski says. The contribution, she says, varies from 3% to 8%, depending on years of service.
She, too, stresses the value of noneconomic incentives. "The key is creating a work environment that will attract providers," Parniawski says. "That includes collaborative relationships, good communication, having the equipment that is necessary to do your job in good working condition, a clean workplace, and management that allows employees to have a voice in decision making."
Attracting ED physicians in areas where salaries are lower is very difficult, admits David McKenzie, CAE, director of the reimbursement department for the Dallas-based American College of Emergency Physicians (ACEP). "If your physicians are on salary, perhaps they might work shorter shifts for the same pay — or someone else might pay their malpractice insurance premiums," he suggests.
What you can't control
Knowing what attracts staff becomes even more important when you factor in issues over which you have no control — such as geography. In the Southeast and North Central areas, for example, ED physicians are paid up to 20% more than those in the Northeast and South Central areas, according to Stern's survey. At present, the largest number of ED managers who responded to the 2006 Salary Survey (38.33%) are located in Region 3 — the Midwest — and 25% are located in Region 2 — the South, and these statistics closely reflect the greater desirability of working in those areas where physician pay is highest and recruiting may be easiest. (See map and corresponding chart of regional salaries.)
Geographic preferences also are related to malpractice costs, says Stern, noting that states which cap malpractice awards are seen as more attractive. "When I talked to the doctors, they said they would not move to a state that had no caps because it was too stressful," he shares. ED directors, he adds, tend to be generally less mobile than their staffs, but they are moving from state to state because of their own rising malpractice insurance rates and general demographic trends, such as cost of living.
More money to recruit?
Malpractice costs also affect the ability of the ED director to recruit physicians, says McKenzie. They may be high in seniority in their group, "But in terms of the director having to come up with more money to retain or recruit clinical physicians, that's a factor of the group structure," he says
Group structure is one of the key factors in compensation for ED physicians and managers, notes Stern. "The most lucrative is the private group," he reports. "Fee for service can also be lucrative if you are well-organized and have a good patient mix." At the low end of the spectrum are academic groups, Stern says.
For nurse managers, geographic disparities in salary can be an added frustration. 'While there is an awful lot of regional variance [in compensation], what's not being reflected is how challenging the work is becoming for the nursing leader, regardless of region," says Bonalumi. "The cost of living may be different in some areas, but they are still not compensating you for the hours you put in."
The road to greater pay
The good news is that the future may bring greater increases for ED managers, Stern says. "As the baby boomers slowly but surely retire and a younger cadre of doctors moves into their slots it will aggravate the staffing problem, but that means an overall shortage of doctors on all levels," he notes. "It'll bode well for compensation of ED directors."
The proposed movement of Medicare to a pay-for-performance model of reimbursement also could create additional earning opportunities for ED directors, says McKenzie. 'This involves the management of the entire ED staff, and documenting the clinical behaviors tied to [Medicare's] performance measures," he notes. "There could well be incentives tied to that." It follows, then, that if you have a group that does well in terms of those performance measures, there will be more money — and if you do poorly, you will receive less, McKenzie says. "Physician payment will be directly tied to that very soon," he says. "It would benefit your department as well as the docs if they earn more." If your hospital pays staff salaries, "it is very important for them to maximize the revenue they are generating so they can cover salaries and hopefully keep something for themselves," McKenzie says.
How to benefit
How can ED directors put themselves in a position to benefit from this new reality? "They will have to understand exactly what the measures are and what documentation will be required to allow whoever is extracting the data to recognize whether the performance measures are met, are not met, or are not met unintentionally due to extenuating clinical circumstances," McKenzie says.
ACEP will be in a position to provide such instruction, or the directors can learn from the payers, McKenzie says. "Medicare is currently designing a pay-for-performance program, but private payers have pay-for-performance programs, too, so the physicians would have to work with their payers to identify what performance measures are in place and how they should be documented," he says.
Parniawski agrees that meeting quality performance measures is taking on greater importance for ED managers. However, recognition can be as important as additional compensation, she says. "You want to work for an organization that is committed to recognizing and rewarding employees thoroughly and competitively — especially when you have achieved recognized outcomes," Parniawski says. Recognition does not always have to be financial, she says. "It can simply be a thank you from the CEO, or recognition programs where your name is mentioned at forums or in organizational publications."
How Long Have You Worked in Your Present Field?
The continuing shortage of nurses and a growing shortage of physicians has created a twofold challenge for ED managers, say the experts. The first challenge: How to attract and retain talented staff. The second: Dealing with the sad fact that while staff salaries are surging, ED director and manager compensation lags behind.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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