NEW YORK (360Dx) – While reimbursement cuts driven by the Protecting Access to Medicare Act (PAMA) have taken center stage in many discussions of the difficulties facing the clinical lab business, the industry's ongoing staffing shortage is perhaps an even larger challenge.
With a decades-long decline in medical technician training programs and large numbers of retirements looming, staffing concerns "trump everything else," said Toni Burger, administrative director for laboratory services at Ithaca, New York's Cayuga Medical Center. "I consider it a crisis throughout the nation for laboratories."
"It's a huge issue," agreed Glenn George, a clinical associate professor at the University of Wisconsin-Milwaukee and director of laboratory services at Kenosha, Wisconsin's Froedtert South hospital. "We are really struggling."
Survey and other data back up such anecdotal assessments. According to the US Bureau of Labor Statistics, the country will see demand for medical lab technologists (MLTs) increase by 13 percent by 2026. That compares to an anticipated baseline 7 percent increase for all occupations.
Meanwhile, the US Department of Health and Human Services' Human Resources and Service Administration puts the projected increase in demand for clinical lab techs at 22 percent by 2025.
According to the American Society for Clinical Pathology's 2016-2017 medical laboratory vacancy survey, 2016 vacancy rates ranged from a high of 11 percent in lab LIS/QA/PI (Laboratory Information System/Quality Assurance/Performance Improvement) departments to a low of 4.7 percent in anatomic pathology departments.
Those vacancy rates are actually lower than those reported in ASCP's 2014 survey, but that masks an anticipated departure of experienced personnel from the field. In 2016, for instance, more than 20 percent of respondents in lab hematology/coagulation, chemistry/toxicology, blood banking, core lab, and microbiology departments said they would retire in the next five years. In 2012, that number was less than 10 percent for each of those departments. Supervisory retirement rates are projected to be even higher, ranging from 23 percent in molecular departments to 48 percent in cytogenetics departments.
"Fifteen years ago people were saying that in 10 to 15 years there would be a mass exodus of techs retiring — and that is now," noted Carlo Ledesma, director of phlebotomy and medical lab technology at Rose State College in Midwest City, Oklahoma.
The decline in vacancy rates since the 2014 survey are also due in part to the fact that labs are more frequently hiring employees either with less experience than they would prefer or from outside accredited laboratory training programs. Asked to name their main concern regarding laboratory workforces, 24 percent of respondents to the 2016-2017 survey cited staffing their labs with "qualified laboratory professionals."
"Even though these positions are being filled, a lot of times the individuals who are being hired are not from [accredited programs]," said Edna Garcia, director of scientific engagement and research at ASCP and first author on the ASCP survey.
This points to one of the major factors that Garcia and others identified as driving the staffing shortages: the decades-long decline in accredited lab training programs.
"If you go back 20-plus years or so, the number of accredited training programs has decreased markedly," said Matthew Schulze, director, government relations at ASCP.
For programs that have remained open, finding laboratories willing to host students during their clinical rotations has become a major challenge, Ledesma said. This has led to something of a chicken-and-egg problem, with labs reluctant to supervise students' clinical rotations due to staffing shortages caused by a lack of lab training graduates.
"They don't want to invest time in the students because they don't have the staff, but [the students] are your future staff," Ledesma said.
Increased centralization of labs has also reduced the number of slots available for clinical rotations, he noted, particularly in areas like blood banking and microbiology.
He gave the example of Mercy Health System, which serves areas around Rose State.
"They have taken the microbiology labs out of their smaller hospitals and [centralized it] in the main hospital," he said. This makes for a more efficient and cost-effective operation, but it also means that where there were once, say, five hospital microbiology departments that could host students, there is now only one.
As both a lab scientist and a medical lab technologist training program director, Ledesma has a view into both sides of the issue. He said that his lab itself is only able to take on one student at a time for clinical rotations given the labor-intensive nature of that training.
Recruitment is also a challenge, especially given that other medical professions like nursing often offer higher salaries while requiring less education, said Froedtert South's George.
"When you take a look at other similar educational-level positions in healthcare, whether it's a [radiology technician] or a respiratory therapist or a nurse, they get paid more," he said. "And until that gets rectified, it's going to be really hard to keep people in the field."
While PAMA-driven reimbursement cuts have placed financial pressure on many labs, George said he believes well managed facilities should have money to pay their staffs competitively. "We actually subsidize cost centers for the hospital system, so the money is there," he said.
Generating better awareness among high school and college students of the clinical lab profession is also needed, Ledesma said.
"With the realization that there is a need for qualified techs in our area we have gone and promoted our profession to area high school students and to different [science] courses in our college to tell people," he said, noting that this has led to a 100 percent increase (from 10 to 20 students per year) in the number of students the school has placed over the last three years.
Ledesma said that many educational programs are exploring simulation-based training, as well. Last year, the Canadian Society for Medical Laboratory Science announced that it was exploring the possibility of using more simulation-based training to address the shortage of clinical rotation slots for lab trainees, which is an issue in that country, as well.
George said many programs have reduced the required clinical rotation hours in response to the shortage of slots.
"A lot of places are reducing their number of clinical weeks — cramming a lot more into 12 weeks instead of 24 or the more traditional 26," he said, adding that 20 years ago, as many as 48 weeks of clinical training was common.
He said, however, that he believed shortening clinical rotation time would not actually impact the amount of on-the-job training labs have to provide new employees.
He said that his lab typically has to provide new employees six months of training, even for graduates of accredited training programs.
Clinical labs "are highly regulated, but it is not dictated how you meet those regulations in many ways," George said. "A lot of labs have different ways of skinning the cat, and so [new employees] need to learn the idiosyncrasies of the labs they are working in. I don't think shortening clinicals will add a heck of a lot to the time [needed to train a new employee]."
Industry organizations like the American Society for Clinical Laboratory Science have suggested steps the federal government could take such as expanding Title VII authorization to make clinical laboratory science education eligible for certain forms of federal funding available to other healthcare professions and to include lab science in the US Department of Education's STEM programming, which could provide additional grant funding to support training of clinical lab professionals.
In the meantime, however, labs must staff their operations in the labor environment as it currently exists.
One approach is temporary staffing, George said, noting that Froedtert South makes use of this option.
"It offers some relief," he said, but he added that it is a less efficient route than being sufficiently staffed with full-time employees, who can be trained to operate across departments as needed.
"Say a clinical lab consists of around six departments," he said. "Normally, we have two techs working to fill all six of those departments because they can interoperate between departments. But for these [temporary] techs, we need four or five to fill in."
Froedert South also launched this January a program wherein it hires candidates with science bachelor's degrees but without clinical lab training as clinical lab assistants making roughly half the wage of an accredited lab technician. The employees are then required to enter an accredited clinical lab training program to get a clinical lab science degree, which Froedert South pays for in exchange for a five-year commitment (two years during school, three years post-school).
George said his lab's two most recent hires — the only ones it has made in the last two years — came through this program.
Mercy Health System similarly offers employees scholarships for medical technologist training in exchange for a two-year work commitment.
Ledesma said he is also seeing rural hospitals, where the staffing problem is particularly pressing, looking to bring in trained staff from overseas.
"From Nepal, the Philippines, they are sponsoring them with work visas to help address the staffing shortages," he said.
George said he believes the field has become better about actively recruiting future employees to the field, but he added that he thinks "attrition to the field, whether due to retirement or people being burned out, will continue to outpace people entering the field for a while."
"I think [staffing] will continue to be a struggle for probably the next five to 10 years," he said.