Additional support may be key to combat shortages in nephrology workforce
An aging population with more chronic metabolic disorders, an aging nursing workforce and a dearth of nephrology fellows may signal a continued decrease in the nephrology workforce, according to Healio | Nephrology News & Issues sources.
“A shortage of nephrologists since the start of the specialty has always put extra workloads on those in practice. Remember the projections of potential patients and costs in 1972 when Congress approved Medicare for dialysis payment? Legislators did not anticipate that the Medicare entitlement would grow to treat older, sicker patients and assumed younger patients would all get transplants and go back to work.” Martin Osinski, MBA, CVA, president of the recruitment firm NephrologyUSA, wrote in Healio | Nephrology News & Issues in July.
In 2024, although the number of nephrology fellowship spots had expanded, the fill rate was 66%, Osinski, who is a Healio | Nephrology News & Issues Editorial Board Member, wrote.
After the COVID-19 pandemic, the National Center for Health Workforce Analysis predicts a 21% shortage of nephrologists in 2037, with greater deficiency in rural areas. The center forecasts a continued but slight lessening in decline of the registered nurse workforce, projecting a 10% shortage in 2027 and a 6% shortage in 2037. As with physicians, fewer nurses are available in rural areas compared with cities and metro areas.
Nurse retirements
The nephrology nursing shortage has worsened since COVID-19, according to Sheila M. Deziel, MSN, RN, CNN, FNKF, a senior clinical consultant with Fresenius Medical Care North America and a Healio | Nephrology News & Issues Editorial Board Member.
“The average age of nurses is older, and during and after COVID, in 2020 and 2021, nurses were working like crazy to get through. We had a lot of nurses retiring,” Deziel told Healio | Nephrology News & Issues.
Nurses were emotionally affected by the deaths of so many of their patients, their own health was threatened and they were overworked, which likely led to many of their retirements, Deziel said.
“Nephrology nursing is different in that we typically have only one to two nurses in a facility that is an outpatient clinic, and there are unlicensed staff. So, when there is a shortage of nurses, the clinic does not open,” she said. “Typically, it is one nurse for every 12 patients, and most clinics tend to have 24 to 36 patients at a time. You would need three nurses, but if only one was there, one nurse would just cover the unit and be exhausted.”
At ASN Kidney Week in October 2024, researchers from Stanford University School of Medicine presented data that showed 1,297 dialysis facilities opened and 704 closed in the United States from 2018 to 2023. However, the closure rate steadily increased over time and exceeded openings by 2021.
Deziel said deaths of patients caused some dialysis centers to limit hours or close during the pandemic, but anecdotally, the loss of nurses appears to continue to contribute to center closures.
NP, PA numbers increase
Increasing the nephrology nurse workforce will take time, according to Deziel. Although nurses with no experience in the specialty can legally work in dialysis, they must be supervised by an experienced nurse for 1 year before working independently.
In addition, many new nurses are going straight to nurse practitioner (NP) programs, which might contribute to the projected nursing shortages, Deziel said.
At the same time, the National Center for Health Workforce Analysis report stated increased use of NPs and physician assistants (PAs) may mitigate physician shortages in some specialties. “Scope of practice for NPs and PAs has increased in recent years,” according to the report.
Numbers of NPs are expected to exceed demand through 2037, according to the report. Employment of PAs is expected to increase by 28% from 2023 to 2033, according to the U.S. Bureau of Labor Statistics.
Osinski said better utilization of NPs and PAs — together referred to as advanced practice providers or APPs — can help counter the nephrologist shortage.
“Physicians mostly have favorable opinions of working with them,” Orsinski said. “It took a while for some groups to add [APPs] into their practices, but the workload for most groups had gotten to the point where it made financial sense. Also, in many cases they could not find physicians to fill their need.”
More emphatically, APPs may be the solution to the nephrology workforce shortage, according to Jane Davis, DNP, CRNP, an NP in the nephrology division of the University of Alabama at Birmingham, and Kim Zuber, PA-C, MSPS, executive director of the American Academy of Nephrology Physician Assistants (AANPA), who spoke to Healio | Nephrology News & Issues in a joint interview.
The NP and PA roles both grew out of physician shortages in the 1960s. Incentive to employ these health care professionals in nephrology grew after 2004 when CMS changed physician reimbursement for outpatient dialysis to add more frequent face-to-face visits. CMS allowed APPs to fulfill part of that requirement while billing Medicare at 100% of the physician rate.
APPs are a good investment, Davis, who is a Healio | Nephrology News & Issues Editorial Board Member, emphasized. “We add value to, we are not a drain,” bringing in two to three times their compensation in revenue.
Since 2008, the National Kidney Foundation has conducted a biennial member survey of APPs. Unpublished 2024 survey data Zuber analyzed showed more than 70% of APPs reported providing hemodialysis and about 35% provided peritoneal dialysis; about 70% reported an office-based worksite and 45% hospital. Of those who worked in hemodialysis dialysis centers, more than 95% performed weekly rounds, and most managed care plans and medications and provided daytime call during weekdays.
Of APPs who worked in hospitals, about 85% performed patient rounds and consultations, and about one-third reported doing patient history and physicals and providing weekday call. Most office-based advanced practitioners reported duties in a chronic kidney disease clinic, patient consultations and hospital follow-up, and about one-third provided weekday call.
Workforce strategies beyond pay
Compensation is typically a first factor to implicate in workforce shortages. Making starting compensation in nephrology more commensurate with that of other internal medicine specialties could increase the number of nephrologists as could a focus on other revenue streams in nephrology, Osinski said.
However, compensation might not be the most important issue.
In a research letter published in the Clinical Journal of the American Society of Nephrology in January by Rasha Raslan, MD, assistant professor in nephrology at Duke University School of Medicine, and colleagues, researchers found current nephrology fellows perceived nephrology compensation to be lower than average among internal medicine specialties, but 29% of respondents said compensation was very or extremely influential in their choice of specialty. Most respondents reported educational debt. Of those, median debt was $209,000, yet 39% said debt did not influence their choice to specialize in nephrology.
Factors and strategies beyond pay may contribute to retaining nephrology professionals, most importantly, support from technology and other staffers.
“There is continuing discussion about the emphasis of work/life balance with the more recent physicians coming out of training and how they do not want to work the hours or take the call that earlier generations of physicians were willing to do,” Osinski said. “Obviously, this also adds to the shortage.”
For increasing the nephrologist workforce, Osinski suggested better use of APPs and coordination of responsibilities within the practice, more use of telehealth and artificial intelligence, and protocols to help physicians become more productive.
With nephrology fellowships going empty, hospitals can hire experienced APPs to perform that labor, Davis said. These professionals can have advantages over fellows, such as the ability to bill for inpatient services under their own national provider identifier number and no regulatory limitations on the time they can spend on call, Zuber said.
Davis and Zuber said the presence of APPs — because of their experience and ability to perform burdensome higher-level tasks — can attract nephrology fellows or even a particular fellow to a program. While fellows leave the program, APPs remain with their institutional knowledge and familiarity with their chronic patients.
Other types of support would go a long way in retaining nurses in dialysis, according to Deziel.
“A hospital nurse with 20 years’ experience said she thinks we would retain more nurses in the outpatient units if they first learned dialysis in the hospital system where they have more support,” Deziel said. “Another nurse said we are losing nurses in the outpatient settings because they are expected to do more than just their role. They must be the charge nurse — oftentimes the only one in the facility — the anemia manager, the medication nurse, a technician, a caregiver to family members, and sometimes the manager as well. The computer work is also daunting with all the other duties.”
April Peacock, FNP-C, DNP, is chief clinical officer at Hema-Tec, a family-owned provider of acute inpatient dialysis in Michigan. When asked what about her role concerned her most, Peacock said it was the well-being of the company’s 111 nurses and dialysis technicians, referred to as “team members.” Her job was to ensure they felt respected and supported.
“We encourage a team approach and giving everybody a voice, so if people have an issue or a concern, they have an avenue to bring that forward,” Peacock told Healio | News & Issues. “Some of our greatest ideas have come from our team members, so when you empower them, they have a sense of ownership and a sense of team and belonging. It gives people increased job satisfaction.”
Hema-Tec CEO Chris Gangnier said the company operates under the servant leadership business model, which prioritizes people over profits. Other companies considered to follow a servant leadership model include Southwest Airlines, Starbucks and Marriott.
“Our highest priority is not our patient, it is our team, who is then focused on the patient. If we’re focused on our team, they are going to be valued and appreciated and want to work here,” Gagnier told Healio | News & Issues. “We are combating this nursing shortage and retention of hard-to-find people in ways that, once we get them, we want them to stay. We are a company of people, and what we do is provide dialysis services. If you focus on it that way, you will have longevity in the industry and tackle any problem that comes.”
- References:
- National Center for Health Workforce Analysis. “Physician workforce: projections, 2022-2037.” https://bhw.hrsa.gov/sites/default/files/bureau-health-workforce/data-research/physicians-projections-factsheet.pdf. Published Nov. 2024. Accessed Jan. 10, 2025.
- National Center for Health Workforce Analysis. “Nurse Workforce Projections, 2022-2037.” https://bhw.hrsa.gov/sites/default/files/bureau-health-workforce/data-research/nursing-projections-factsheet.pdf. Published Nov. 2024. Accessed Jan. 10, 2025.
- Osinski M. https://www.healio.com/news/nephrology/20240708/how-to-make-opposites-attract-worklife-balance-needed-to-attract-fellows-to-nephrology. Published July 15, 2024. Accessed Feb. 14, 2025.
- Raslan R, et al. Clin J Am Soc Nephrol. 2025;doi:10.2215/CJN.0000000645.
- U.S. Bureau of Labor Statistics. Occupational outlook handbook. https://www.bls.gov/ooh/healthcare/physician-assistants.htm. Last modified Aug. 29, 2024. Accessed Feb. 14, 2025.
- Varkila M, et al. TH-OR05. Presented at: ASN Kidney Week; Oct. 24-27, 2024; San Diego.
- For more information:
- Jane Davis, DNP, CRNP, can be reached at jsdavis@uabmc.edu.
- Sheila M. Deziel, MSN, RN, CNN, FNKF, can be reached at sdeziel@cox.net.
- Chris Gangnier can be reached at cgangnier@hema-tecinc.com.
- Martin Osinski, MBA, CVA, can be reached at mo@nephrologyusa.com.
- April Peacock, DNP, can be reached at apeacock@hema-tecinc.com.
- Kim Zuber, PA-C, MSPS, can be reached at aanpa1@yahoo.com.
Collapse
Read more about