Researchers find that cigarette smoking is a leading cause of cancer-related death, with a significant economic burden.
In 2019, cancer deaths attributable to cigarette smoking resulted in more than 2.1 million person-years of life lost (PYLL) and $20.9 billion in lost earnings, a new research article says.
About 600,000 Americans succumb to cancer annually, making the disease the second leading cause of death in the country and generating a significant economic burden. Cigarette smoking is the most preventable cause of cancer death.
The new research article, which was published by International Journal of Cancer, estimates the proportions and numbers of cigarette smoking-attributable cancer deaths and associated PYLL and lost earnings among Americans between the ages of 25 and 79. The study generated several key data points.
In 2019, there were 418,563 cancer deaths among Americans aged 25 to 79 years. An estimated 122,951 of the deaths were linked to cigarette smoking, with 2,188,195 PYLL.
In 2019, the total lost earnings linked to cigarette smoking-attributable cancer deaths were estimated at $20.9 billion.
The estimated number of cancer deaths linked to cigarette smoking were higher among men than women (74,508 versus 48,425).
Lost earnings linked to cigarette smoking-attributable cancer deaths were higher among men than women (15.2 billion versus $5.6 billion). The study's co-authors said this difference was caused by higher employment rates and wages among men.
Lung cancer accounted for the most smoking-attributable lost earnings ($12.9 billion), followed by esophageal cancer ($1.5 billion), colorectal cancer ($1.2 billion), and liver cancer ($1.1 billion).
Utah had the lowest estimated proportion of cancer deaths linked to cigarette smoking (16.5%), and Kentucky had the highest estimated proportion of cancer deaths linked to cigarette smoking (37.8%).
Wyoming had the lowest estimated total lost earnings linked to cigarette smoking-attributable cancer deaths ($32.2 million), and California had the highest estimated total lost earnings linked to cigarette smoking-attributable cancer deaths ($1.6 billion).
If the PYLL and lost earnings rate of Utah had been achieved nationwide in 2019, more than half of the estimated total PYLL and lost earnings nationally would have been avoided.
In a prepared statement, the lead author of the study said the research shows the terrible toll that smoking takes on the country. "Our study provides further evidence that smoking continues to be a leading cause of cancer-related death and to have a huge impact on the economy across the U.S. We must continue to help individuals to quit using tobacco, prevent anyone from starting, and work with elected officials at all levels of government for broad and equitable implementation of proven tobacco control interventions," said Farhad Islami, MD, PhD, senior scientific director for cancer disparity research at the American Cancer Society.
Interpreting the data
There are 13 states in the South and Midwest—the "Tobacco Nation" states—that have generally weaker tobacco control policies and higher cigarette smoking prevalence than the rest of the country. Those states are Alabama, Arkansas, Indiana, Kentucky, Louisiana, Michigan, Mississippi, Missouri, Ohio, Oklahoma, South Carolina, Tennessee, and West Virginia.
Death rates were highest in the Tobacco Nation states. In addition, the annual PYLL rate for the Tobacco Nation states was 46.8% higher than in other states and the District of Columbia, and the lost earnings rate for these states was 44% higher than in other states and the District of Columbia.
Relatively low tobacco excise taxes in the Tobacco Nation states likely contribute to their worse outcomes, the study's co-authors wrote. "The highest state tobacco excise tax rate per pack of cigarettes in the 13 'Tobacco Nation' states as of March 2021 was in Oklahoma ($2.03), Michigan ($2.00), and Ohio ($1.60), while it was ≤$1.20 in the other 10 states, as low as $0.17 in Missouri. In contrast, the state excise tax rate per pack of cigarettes in the Northeast region was ≥$1.78 in all 9 states, and >$3.00 in 5 states. Increasing the price of cigarettes through excise taxes is the single most effective policy for reducing cigarette smoking prevalence."
Smoking restriction laws also play a role in smoking prevalence at the state level, the study's co-authors wrote. "States with the highest smoking-attributable PYLL and lost earnings rates also generally lack statewide comprehensive smoke-free policies that completely prohibit smoking in workplaces, restaurants, and bars."
Lung cancer screening is critical to address smoking-attributable mortality and lost earnings, the study's co-authors wrote. "In addition to reinforcing tobacco control policies and expanding access to care, strategies and efforts to increase uptake of lung cancer screening can substantially reduce PYLL and lost earnings due to lung cancer, which accounts for about two-thirds of the total PYLL and lost earning due to smoking-attributable cancer deaths."
At the national level, stronger tobacco control policies are needed to reduce smoking-attributable mortality and lost earnings, the study's co-authors wrote. "PYLL and lost earnings due to cigarette attributable cancer deaths are substantial in all states, although they are largest in states with weaker tobacco control policies. Broad and equitable implementation and enforcement of proven tobacco control interventions across all states could substantially reduce cancer deaths and the associated economic burden."
The Progressive Care Unit at Tampa General Hospital has generated impressive results, including an 83% ventilator weaning rate and 75% reduction in readmissions.
A unique partnership at Tampa General Hospital is generating positive results for patients on ventilators.
Ventilator-dependent patients are medically complex and often have multiple morbidities. Providing care for these patients is costly, and they have extended lengths of stay compared to many hospitalized patients.
In a partnership with Boca Raton, Florida-based Special Care Unit, Tampa General Hospital operates a Progressive Care Unit to wean patients off ventilators. "It is separate from an ICU. It is a step-down level of care from an ICU. It has its own dedicated area in the hospital," says Sam Nimah, CEO of Special Care Unit.
The Progressive Care Unit has staff members from Tampa General Hospital and Special Care Unit, he says. "It is a jointly staffed unit, with staff from Tampa General as well as Special Care Unit to provide a unique opportunity for ventilator-dependent patients to wean off the ventilator at a rate of greater than 80%. It is staffed with dedicated nurses, respiratory therapists, physical therapists, occupational therapists, speech-language pathologists, and case managers. All of the staff are dedicated to the unit."
The Progressive Care Unit provides an exceptional patient experience, with daily intensive rehabilitation efforts, Nimah says.
"Most hospitals have a rehabilitation department that is responsible for rehabilitation opportunities and consults throughout the hospital. They may have to go to dozens of patients on a given day across the hospital. But hospitals are controlled chaos—there are multiple activities going on at any given moment. So, a physical therapist may show up in a patient's room, and they may be off getting a CT scan, or they may have had a rough night and they are sleeping. In those circumstances, the physical therapist has to move on to the next patient. In the Progressive Care Unit, we have a dedicated team, so if a patient is not ready for their rehab it is no problem—we will be there when the patient is ready."
The consistency of staffing is a crucial part of the patient experience at the Progressive Care Unit, he says.
"On average, our patients are with us for about three weeks. We become their family, and they become our family. The average length of stay in a hospital is only a few days. If you have nurses working three shifts in a row—one at day and one at night—a patient will rarely see more than one set of nurses during their stay. But when a patient is in a hospital for three weeks, the patient can rotate through multiple nurses' shifts. Our respiratory therapists, our physical therapists, our occupational therapists, and our nurses are all on the unit six days a week. They see the family. The patient sees the team working together every day."
The patient experience at the Progressive Care Unit includes an intensive level of rehabilitation that is not common at acute-care hospitals, Nimah says. "The key part of this is that every patient interaction can become a rehabilitation opportunity. With a team that is dedicated to this unit, we go far beyond what payers will pay for. For example, one physical therapy session per day is reimbursable by Medicare. We go far beyond that—turning every patient interaction into a potential rehabilitation opportunity."
The rehabilitation activities in the Progressive Care Unit include activities of daily living, range of motion, and walking, he says. "We just had an example where we had a physical therapist, occupational therapist, respiratory therapist, and a nurse all walking with a patient who was on the ventilator and had multiple intravenous connections. They were walking with the patient to get rehabilitation accomplished. There are a lot of rehabilitation hindrances when a patient is on a ventilator with IV drips—it can get very complicated. But we have a whole team that is dedicated to working with the patient together. It's a rare opportunity in any hospital."
Playing an important role during the coronavirus pandemic
The Progressive Care Unit has helped Tampa General Hospital post impressive clinical outcomes for COVID-19 patients, says John Couris, president and CEO of the hospital. "During the height of the pandemic, our resources were stretched. We were able to transition the medically complex, ventilator-dependent patients to breathing independently smoothly and safely with the support of the Progressive Care Unit. When you look at the outcomes for patients with COVID-19 at Tampa General Hospital, we have been in the top quartile for clinical outcomes, and we have been in the top decile for length of stay. I attribute part of that success to having the relationship with Special Care Unit."
The Progressive Care Unit is well-suited to weaning COVID-19 patients off ventilators, he says. "Specific to COVID-19, the Progressive Care Unit contributed in a significant way to better results with a lower length of stay for our COVID patients who were being weaned off ventilators. With the Progressive Care Unit, we had quality, better outcomes, better safety, and better efficiency and effectiveness for our patients."
Delivering good results
Reducing length of stay is a primary benefit of the Progressive Care Unit, Nimah says. "You do not typically have a respiratory therapist 24/7. You do not typically have physical therapists, occupational therapists, and speech-language pathologists all converging on one unit. For the patients we serve, we reduce length of stay by up to 12 days. That is how our service is paid for—it is paid for through efficiency and effectiveness of care."
The Progressive Care Unit generates several positive results, he says.
The unit has weaned patients off ventilators at a rate of 83% over the past three years.
The unit has reduced length of stay by six and 12 days, respectively, for DRG 003 and DRG 004. DRG 003 is a patient with a tracheostomy who is on a ventilator for more than 96 hours, with additional complications such as extracorporeal membrane oxygenation. DRG 004 is a patient with a tracheostomy who is on a ventilator for more than 96 hours.
The unit has reduced hospital readmissions by more than 75%.
The unit increased hospital margin by about $2.3 million in fiscal year 2021.
The partnership between Tampa General Hospital and Special Care Unit has been beneficial for patients and the hospital, Couris says. "It is a contractual relationship that is predicated on volume and quality. It is fair market value. It is commercially reasonable. It is driven by the activity that Special Care Unit does, the volume that they handle, plus the quality and clinical outcomes that they are responsible for achieving in collaboration with us."
Special Care Unit has a ventilator-weaning partnership with one other hospital—University of Alabama at Birmingham Hospital.
Emergency department screening is an opportunity to boost individual and population health.
Health systems and hospitals should follow seven principles to conduct screening for disease or health risk factors in emergency departments, according to a new journal article.
Particularly for patients with limited resources, the emergency department is a key access point for care. Screening for disease and health risk factors in the emergency department can boost individual and population health.
There is a tremendous opportunity to conduct screening in emergency departments. Research has shown that about half of U.S. adults over age 35 have not received screening for common health risk factors such as tobacco use and depression.
The new journal article, which was published by Annals of Emergency Medicine, identifies seven principles for conducting disease and health risk screening in emergency departments.
1. Screening should be conducted with evidence-based practices from established sources such as the United States Preventive Services Task Force (USPSTF) and the Centers for Disease Control and Prevention. For example, the USPSTF has made several screening recommendations for substance use disorders, HIV, suicide, and other conditions in the emergency department setting.
2. Emergency department screening should account for local disease and health risk factor epidemiology.
"The epidemiology of a disease can vary substantially by geography. Furthermore, risk factors, including social determinants of health, are highly variable depending on community resources. Screening is most efficient when the prevalence of a disease or risk factor meets a clinically significant threshold in the screened population. However, epidemiology must be considered in conjunction with the potential morbidity and mortality associated with the disease or risk factor, test characteristics (including material and staff costs), and feasibility of the intervention," the journal article's co-authors wrote.
3. Screening should only be conducted in the emergency department as long as primary ED functions and quality metrics are not disrupted. "Although population health initiatives encourage a broader perspective on ED visits, screening should not detract from the primary purpose of the ED: management of acute illness and injury. Furthermore, an increased length of stay in the ED is associated with decreased patient satisfaction and increased morbidity and mortality," the journal article's co-authors wrote.
4. Screening should be designed to limit the burden on ED clinical staff. "Clinical staff in the ED often faces mismatched patient/staff ratios, boarding of admitted patients, and crowding. Adding numerous screening questions can detract from their care of emergency conditions. Shifting screening and referral roles to dedicated patient navigators or other nonclinical staff can focus clinician time on evaluation and treatment," the journal article's co-authors wrote.
5. Screening should be based on transparency and communication with patients and the community. "Many screening topics involve stigmatizing conditions, and those developing screening initiatives should attempt to educate patients and the broader community about the rationale behind the screening. Public awareness campaigns in the community, signage around the ED, and patient handouts can help patients anticipate the screening. Upfront discussions with the patient also help avoid surprise results, especially because a proportion of screening test results will be falsely positive. This is especially crucial for tests such as HIV or syphilis screening," the journal article's co-authors wrote.
Establishing community trust is crucial to avoid the perception that the ED clinical staff is "experimenting" on patients.
6. Screening should only be conducted when follow-up resources are available.
"Patients who screen positive for disease or risk factors should have support in addressing the identified concerns. First, health systems should develop processes to ensure that patients receive their screening results, including test results that return after discharge. Second, screening initiatives should develop mechanisms for patients to access further resources, regardless of their insurance status. Third, those developing screening programs should ensure that they have institutional support, including departmental and hospital leadership, as well as appropriate community partnerships to provide follow-up care or referral to social services," the journal article's co-authors wrote.
7. Screening should be financially sustainable for patients and the healthcare system. "Incorporating the ED as a screening location into national guidelines, such as those provided by the USPSTF or Centers for Disease Control and Prevention (CDC), can help ensure that costs are reimbursed by insurers. Continuing grants and community funding can also offset costs to promote sustainability," the journal article's co-authors wrote.
The partnership between Elevance Health and Aledade features a shared risk model, with a budget for the total cost of care for a population of patients.
A new partnership between Elevance Health and Aledade is designed to foster the transition to value-based care at independent primary care practices.
Elevance Health features several health plans, with independent primary care practices participating in Elevance Health's networks serving 47 million health plan members. Aledade is a Bethesda, Maryland-based primary care physician enablement company.
The partnership between Elevance Health and Aledade centers on a value-based payment model, says Farzad Mostashari, MD, co-founder and CEO of Aledade. "It is shared risk. We have a budget for the total cost of care for a population of patients. If we can reduce hospitalizations and healthcare costs come in less than the budget, Aledade and the practices share the savings with the health plans."
The value-based payment model in the partnership between Elevance Health and Aledade has several advantages over the fee-for-service payment model, he says. "Value-based payment arrangements can pay primary care doctors more for their services if they provide superior experience and outcomes for the patients. It means we have much more of an ability to do same-day appointments. If a patient has a need, instead of sending them to the ER our practices tell patients, 'Call us first.' In addition, when patients show up, the primary care doctors know more about the patient's needs than in a traditional system because one of the things the payer does as part of these agreements is give us access to their full claims history for the patient. So, the primary care doctor knows more about what is going on with a patient."
The partnership also promotes more engaged primary care for the patient, Mostashari says. "When my mom went to the emergency room, her primary care doctor was not told about it and the primary care practice did not have a workflow for calling patients who had been to the ER. Our practices call the patient if they have gone to the emergency room within 48 hours, and they find out whether the patient is OK or feeling better. Our practices have the incentives, the data, and the workflows to provide better care."
Independent primary care practices can benefit financially from value-based care, he says. "Hospitalizations are very costly. If we can prevent hospitalizations by doing better primary care, that can generate a lot of money for a primary care practice. With better primary care and prevention, we reduce hospitalizations and the primary care practices get a piece of the savings by keeping patients out of the hospital. For our average primary care practice in 2021, the average payment from the Medicare Shared Savings Program was $200,000. That is a lot of money for a primary care practice."
Improving finances is essential to sustaining independent primary care practices, Mostashari says. "At the end of the day, if we want to maintain independent primary care, we have to pay for it. Instead of squeezing practices out of existence or having them join a health system, which reduces choice and competition, primary care practices can make more money keeping patients healthy and out of the hospital. That is what doctors went to medical school to do."
The partnership between Elevance Health and Aledade also eases frictions between health plans and primary care practices, he says. "The practices are now on the same side with the payer. There are the same incentives—the payer is no longer concerned that the practices are going to drive up costs or provide unnecessary services because the doctors now have the same incentives on total cost of care. The payers can ease up on some of the administrative burdens that make doctors miserable. For example, there is less prior authorization. The payers do prior authorizations because they want to limit unnecessary procedures and medications; but doctors who are in our program have an expedited prior authorization process for hundreds of services."
Aledade gives independent primary care practices tools, support, and resources to make the shift to value-based care, Mostashari says. "That is what we were founded to do. That is how we serve independent primary care practices. We strive to be the 'easy button' for the practices so that they do not have to figure out how to get data out of the electronic medical record, they do not have to figure out how to connect with the health information exchange, and they do not have to understand the various options in government programs. They do not pay us a dime. We get paid when there are shared savings. There is no upfront cost."
One of the primary purposes the ER on Demand telehealth service is to direct patients to the most appropriate site of care.
Northwell Health's ER on Demand telehealth service has reduced utilization of emergency rooms and urgent care clinics, according to the New Hyde Park, New York-based health system.
Emergency departments are one of the most expensive sites of care. If patients can be treated via telehealth, services can be delivered with higher value.
ER on Demand, which is available to all residents of New York State, was developed in response to the coronavirus pandemic. The telehealth service was piloted with Northwell Health employees in November 2020, then it was offered to the public from 8 p.m. to 8 a.m. Now, ER on Demand is available to the public 24 hours a day, seven days a week.
One of the primary goals of ER on Demand is to determine whether a patient needs to go to an emergency room. To access the service, patients can call 833-556-6784 or download the Northwell Health app. The first point of contact is a certified paramedic, who determines the appropriate level of care. If the patient does not require a trip to the emergency room for life-threatening symptoms such as heart attack or stroke but needs care, the patient is connected within an hour to an emergency medicine physician via video on a smartphone, tablet, or computer.
"Our aim is to meet patients where they are at—help them get the right level of care as easily and affordably as possible," Jonathan Berkowitz, MD, medical director of emergency medical services at Northwell Health, said in a prepared statement. "We get patients of all ages—parents of infants to senior citizens—calling our service. If someone feels they need to go to the ER and is not sure, that's where we can help."
The health system has examined more than 3,000 patient visits through ER on Demand from January 2021 to April 2022, finding that 92% of patients did not need to visit an emergency room or urgent care center. "Our emergency medicine physicians are experts in telehealth, and are comfortable guiding patients through self-exams, such as abdominal or neurological exams or muscular skeletal tests. Patients are increasingly trusting of this modality of care, and appreciate spending more time with their doctors and are happy with outcomes," Berkowitz said.
ER on Demand accepts all types of insurance, but there may be a specialist copay depending on the patient's coverage. If a patient is directed to go to an emergency room, the telehealth visit copay is waived.
ER on Demand services
In addition to diagnosis and treatment recommendations, ER on Demand physicians can send prescriptions to pharmacies, order lab tests, and schedule imaging such as X-rays.
Many conditions and symptoms can be addressed by ER on Demand physicians.
All issues related to COVID-19
Gastrointestinal symptoms such as heartburn, constipation, diarrhea, minor abdominal pain, and vomiting
General symptoms such as fever, chills, body aches, and fatigue
Urine-related symptoms
Head, eyes, ears, nose, and throat symptoms such as eye irritation, earache, sore throat, sinus pain, and congestion
Musculoskeletal conditions such as minor sprains, bruises, joint pain, and minor back and neck pain
Neurological symptoms such as headache and dizziness
Respiratory concerns such as asthma and cough
Skin conditions such as dermatitis, eczema, cellulitis, rash, bug bites, minor burns, and cuts
If an ER on Demand physician refers a patient to an emergency department, the doctor calls the emergency room to alert the facility's staff. In some cases, ER on Demand physicians will refer patients to follow-up visits with a primary care practice or specialist. The day after an ER on Demand visit, a team member will call the patient to make sure their condition is improving and to answer questions.
Health systems and hospitals have an opportunity to open their own standalone infusion centers or to establish joint ventures with standalone infusion center companies.
The CEO of a standalone infusion center business says patient experience and low operating costs are key market differentiators for the facilities.
Standalone infusion centers have been experiencing strong growth, according to the American Society of Health-System Pharmacists. Most standalone infusion centers specialize in providing intravenous medications to patients with chronic or complex conditions such as cancer, Crohn's disease, multiple sclerosis, and rheumatoid arthritis.
"There is no question that infusion is moving in the direction of standalone infusion centers. I can't imagine that five years from today there will still be large numbers of patients going to acute-care hospital systems for monthly IVs," says Shane Reeves, PharmD, CEO of Murfreesboro, Tennessee-based TwelveStone Health Partners.
TwelveStone operates seven standalone infusion centers in Georgia, Tennessee, and Virginia.
The patient experience delivered at most standalone infusion centers is far better than the patient experience at hospital-based infusion programs, Reeves says. "You can't imagine sitting in a dental office with 30 people in one room getting their teeth cleaned. Why would you want to have 30 people sitting in one room at a hospital getting their IVs? We think standalone infusion centers where people have their own private suites is a market differentiator, and we are finding that patients love it. The patient experience is superior, and the five-star Google reviews we get daily prove that."
TwelveStone has tried to look at all aspects of patient experience, he says. "We are not simply trying to be the pharma side of care. From the second when you walk in the door at one of our locations, it feels like a spa. From the sights and the smells, it feels like a spa. When patients are in their individual suites, we offer comfortable massage chairs. We offer places for their family members to sit. We offer WiFi. We offer Netflix. We offer snacks. If people cannot get to us, we have a transportation service to get them in."
TwelveStone addresses the personal side and the clinical side of patients' needs, Reeves says. "We have a full-time chaplain service. For many patients with chronic conditions, they not only have clinical needs but also spiritual needs for comfort and hope. We have a holistic approach to taking care of the patient."
Convenience is a hallmark of standalone infusion centers, which are often closer to where patients live and work than hospitals. Standalone infusion centers are often located in suburban communities to avoid the traffic and parking challenges at downtown hospitals, he says. "We have sited our centers intentionally. If the patient has a two- or three-hour infusion, the family can leave and go to places in the local area such as restaurants and places to shop."
Competitive financial model
Standalone infusion centers are a lower-cost setting than hospital infusion programs, Reeves says. "Acute-care facilities are the most expensive setting to receive any medical service. We do not have nearly the overhead or expenses of hospitals. We can negotiate with payers at a lower price. Standalone infusion centers are more affordable, to the point where we have several payers who are referring patients to us. The payers are pushing patients our way because we are more affordable and have a better patient experience."
TwelveStone's services are reimbursed by Medicare, Medicaid, and commercial payers, he says. "We are contracted with all of them."
TwelveStone provides infusions on a fee-for-service basis and provides patients with price transparency, Reeves says.
"We are transparent with the patient from the very beginning. As soon as a patient gets admitted for our service, we have to go through the process of adjudicating claims and determining what the service is going to cost. We let our patients know about out-of-pocket costs at the very beginning, so they know exactly what they are getting before they walk in the door to get a service. The last thing anyone wants is to come in and get a therapy, then realize they owe thousands of dollars. We are transparent on the front end. We know what your out-of-pocket cost is going to be before you get infused."
Opportunity for health systems and hospitals
Market forces are boosting standalone infusion centers, he says. "There are three significant trends in the healthcare marketplace that have promoted standalone infusion centers. First are the payers—it is just cheaper to get services in our standalone settings than in acute-care settings. Second, the big pharma companies are developing new medications that require IV delivery as opposed to oral medications. Third is the patient experience—people want to get their medications in outpatient settings near where they live and where they work."
Health systems and hospitals should consider seizing on standalone infusion center opportunities, Reeves says.
"Is there an opportunity for health systems and hospitals to open their own standalone infusion centers? The answer is absolutely 'yes.' But I would encourage health systems and hospitals to reach out to companies such as TwelveStone. Let's do something together. As opposed to trying to reinvent the wheel, health systems and hospitals can do joint ventures with companies like TwelveStone. We can establish partnerships to take care of these patients. There is quite a bit of infrastructure that is involved. I would encourage health systems and hospitals to find standalone infusion centers in their markets and establish relationships."
TwelveStone is in joint venture conversations with several large hospital systems including HCA Healthcare and Memorial Hermann in Texas, he says. "We are working with Skyline, which is an HCA Healthcare hospital system in Tennessee. There are a couple of reasons they want to work with a company like ours. First, they are trying to open up hospital beds. So, rather than having a patient in a hospital bed receiving an IV antibiotic, they could come to us. Second, there are revenue-sharing opportunities."
Experts from Duke University School of Law and Stanford University say physician unions can empower clinicians employed at health systems, hospitals, and other corporate entities.
Given consolidation in healthcare such as health systems acquiring independent physician practices, physicians are missing an opportunity to form unions to improve their status, a new opinion article in the Journal of the American Medical Association says.
Over the past decade, the percentage of independent practicing physicians has declined sharply. In 2012, physicians owned 60% of practices and 5.6% of physicians were employed directly by hospitals, the American Medical Association reported. In 2022, 52.1% of physicians were employed by health systems or hospitals, with another 21.8% employed by other corporate entities, for a total estimate of 74% of practicing physicians working as employees.
The healthcare consolidation trend can have a negative impact on physicians, the co-authors of the new opinion article wrote. "This rapid transformation has largely followed an aggressive strategy, put forward by hospital and corporate leadership, that seeks scale and exploits market power. However, it is also a strategy that is increasingly at odds with the interests of the physicians working in these organizations. The strategic differences are revealed in a variety of important policy differences, spanning from payer contracting strategies, compensation incentive structures, and service line prioritization."
While physician unions have been formed for decades, there are relatively few unionized physicians compared to employees in other industries. As of 2021, 7.9% of surgeons and 5.8% of other physicians had joined unions, according to Unionstats.com.
Physicians considering the formation of unions should have three primary considerations, the co-authors wrote.
1. Value of collective bargaining versus contracting individually for services: "If collective bargaining is seen as advantageous, physicians need to determine who the union represents: all physicians within a system or only those at a specific hospital? All physicians across specialties or only specific departments? This latter concern reflects the potential challenge when different clinicians have different compensation and governance interests within a single organization," the co-authors wrote.
2. Value of collective bargaining for salary: "For example, primary care physicians and specialist physicians may decide to join the same union and participate in joint negotiation with the hospital in a fee-for-service payment model, but they might prefer different unions when the financial interests of primary care physicians and specialist physicians diverge under a capitated payment model (this diversity of interest is reflected when nurses and other clinical staff join different unions or different bargaining units under the same union)," the co-authors wrote.
3. Value of unionization to shape hospital policies: "Collective bargaining can help address strategic issues that are of great interest to employees, such as in 2022 when nurses at Sutter Health went on strike over staffing shortages and access to adequate personal protective equipment. Policies related to the practice of medicine may benefit from explicit consideration through collective bargaining. Physicians and hospital managers might disagree over patient discharge policies, documentation standards, quality improvement programs, and requirements for after-visit services," the co-authors wrote.
Physician unions have limitations, the co-authors wrote. "They may not provide as much leverage for input into strategy as physician-led organizational structures such as physician-owned practices or other professional corporation models. For example, Kaiser Permanente Medical Groups are independent regional entities that negotiate with Kaiser health plans and hospitals. Further, unions are likely to expose differences in perspectives and incentives between rank and file physicians and their leaders (such as department chairs). This divergence of interests might further complicate the advocacy of physician interests into governance."
In addition, physician unions are unlikely to undo negative consequences of healthcare consolidation, the co-authors wrote. "Physician unions will be unable to convert the capital-intensive nature of health care systems into a meaningfully different economic enterprise. Those who question the sustainability and wisdom of these US healthcare giants are unlikely to find that unions can be used to curtail the deleterious effects of healthcare consolidation."
Novant Health physicians play formal supply chain roles in reducing clinical variation and managing the adoption of new products.
Physicians play formal and informal roles in supply chain at Winston-Salem, North Carolina-based Novant Health.
Formal supply chain roles for physicians include serving on value analysis teams and participating in quality assurance processes. Informal supply chain roles for physicians include alerting supply chain departments when products go out of stock and when there are problems with products.
At Novant, physicians serve on a pair of formal supply chain groups, says John Mann, MD, senior vice president of Novant Health Institutes, and president and chief operating officer of Novant Health Clemmons Medical Center in Clemmons, North Carolina.
"We have a Clinical Variation Reduction Team. The CVRT was established in 2012. That is a group that includes the supply chain team combined with physicians who represent most of our institutes—the clinical delivery side of the organization including some of our chief clinical officers. Together, we partner with the sourcing team around recurring contracts for products that we use in our acute facilities. That spans a wide variety of specialties, including orthopedics, vascular, cardiac, neurology—any specialty that uses a product in our hospitals can be involved in clinical variation," he says.
The physicians who serve on the CVRT provide clinical input and clinical guidance that is useful in negotiations with vendors, Mann says. "We have found that this relationship brings more power to the conversation. Historically, vendors have used physician relationships to influence hospital administration. We have turned the tables on them. Our sourcing team partners with physicians and they go to the vendor and say, 'This is what the physicians want for their patients. This is what we need for Novant Health.' We have turned the dynamic around, so the vendors cannot undermine the efforts of the health system to drive value and savings for our patients."
The health system also has a formal supply chain group that includes physicians to manage the adoption of new products, he says. "If a physician wants a new product, whether it is clinically better, drives better outcomes, or drives a competitive advantage, those decisions are done in collaboration between physicians and the sourcing team, so we are driving the conversation with the vendors. Having doctors involved ensures that we keep the patient front-and-center in all of our conversations, and it disarms the vendors. When vendors approach our sourcing team, they may say, 'A doctor wants this product.' But we are going to make that decision ourselves and draw value to the health system and our patients."
Physicians participate in supply chain beyond formal roles
Building relationships between the supply chain staff and physicians has educated the sourcing team, says Mark Welch, MHA, senior vice president of supply chain at Novant.
"The relationship between the supply chain team and physicians has evolved over the years. When we first started out, we focused on clinical variation to understand why we had clinical variation. What we found out was that having a relationship between supply chain and physicians to talk about those things has been more valuable than just addressing variation. Physicians have a scientific background, and most of them love to teach—they have taught my sourcing team many things about different procedures that we probably would have never known if we had not built a relationship," he says.
Both new physicians and physician leaders play informal roles in Novant's supply chain, Welch says. "When we recruit new physicians, part of the recruiting process is our physician leaders talk about supply chain and how we approach supply chain along with expectations for physicians to participate. At our institutes and service lines such as neurology, orthopedics, vascular, and surgical services, the leaders are involved in sourcing from Day 1 when they come onboard. We get them up to speed on where our contracts are, listen to any concerns they might have, and many times they bring a different perspective."
Novant physicians are often engaged to influence supply chain decisions, Mann says. "If we have a product that is in a three-year cycle and is coming up for renewal, we will engage with many physicians to gain their input. We want to know their experience with the product over the past three years. We may need to look at a change. It can be challenging to engage with dozens of physicians across the organization, but we have found that investment of time gives us a better result at the end of the process."
Certain qualities help physicians play formal or informal roles in supply chain, Welch says. "They must have curiosity. They need to be innovative. They need to be somebody who wants to learn the business side of healthcare. Physicians are curious about a lot of things, and as they get deeper into their careers, they get interested in where the money is going and where the money is coming from. Healthcare is complicated, but most physicians are intrigued by how it works."
The patient safety group has set two categories for its recommended practices— Organizational Leadership & Systems and the Diagnostic Process.
The Leapfrog Group has published a unique report with 29 recommended practices for hospitals to reduce diagnostic errors.
Diagnostic errors are one of the most common adverse events in U.S. hospitals. One study estimated that 249,900 harmful diagnostic errors occur annually in hospitals.
In 2021, Leapfrog convened a National Advisory Group of medical experts to evaluate diagnostic practices in hospitals and to develop the first-of-its-kind report to improve diagnostic safety—Recognizing Excellence in Diagnosis: Recommended Practices for Hospitals.
"Clinicians and hospital leaders tell us they know diagnostic errors are harming too many patients, but they are less clear on how to fix the problem," Leah Binder, Leapfrog's president and CEO, said in a prepared statement. "Thanks to the incredible leadership of the multi-stakeholder group Leapfrog has convened, hospitals now have clarity on the steps to take. The faster hospitals act, the more lives they can save."
Leapfrog, which is a nonprofit organization founded in 2000 to promote patient safety, identified 300 potential practices that hospitals could adopt to reduce diagnostic errors. The potential practices were pared down to a list of 29 recommended practices in two categories— Organizational Leadership & Systems and the Diagnostic Process. There are 16 recommendations in the Organizational Leadership & Systems category and 13 recommendations in the Diagnostic Process category.
"It is recommended that hospitals start by identifying a small set of practices that are most feasible and/or most impactful for them and begin there. Additional practices can be added to the initial set as time goes on," the Leapfrog report says.
The 13 recommendations in the Diagnostic Process category are as follows.
Train all staff members involved in the diagnostic process to collect accurate health information. Using evidence-based tools and strategies to collect health information from patients and family caregivers promotes timely and accurate diagnosis.
Hospitals should correct inaccurate diagnoses and data in the electronic health record. For example, the EHR should have a process to review and correct inaccurate diagnoses on "problem lists."
Hospitals should provide professional medical interpreters when patients and family caregivers have a preferred language that differs from their care team's language. These medical interpreters, who should be available 24/7, should help get accurate health information from the patient and communicate accurate information back to the patient.
Hospitals should provide access to radiology experts 24/7 to read and interpret urgent imaging studies as well as to consult on imaging test selection.
On at least a quarterly basis, hospitals should have a process for radiologists and pathologists to identify and review cases where a biopsy, cytology, or autopsy result does not match clinical and imaging impressions. There should be an interdisciplinary process to reconcile these discrepancies.
Hospitals should ensure that emergency departments have access to clinical expertise and technologies that support timely and accurate diagnosis of conditions that are often misdiagnosed and result in harm to patients.
Hospitals should provide knowledge resources to clinicians to help them improve their diagnoses when there is diagnostic uncertainty. Clinicians should be incentivized to use these resources.
Hospitals should train clinicians to recognize and minimize cognitive errors. For example, diagnostic performance can be improved through training on critical thinking as well as recognizing cognitive and affective bias.
Hospitals should implement and monitor adherence to evidence-based diagnostic guidelines such as guidelines for care in the emergency department.
Hospitals should have written policies for managing patient handoffs when there is diagnostic uncertainty such as transferring patients from the emergency department to an inpatient unit.
There should be a policy when patients are discharged from a hospital with an uncertain diagnosis or when potential diagnoses involve high-risk conditions. Discharge summary notes should include test results and test results that are pending. The patient and family caregivers should be given condition-specific instructions on troubling symptoms, when to return to the hospital, and how to get follow-up care.
If a patient is discharged with pending test results, hospitals should have a process in place to list the pending test results along with instructions on how to obtain the pending test results.
Hospitals should have a written policy to promote "closed-loop" communications. The policy should specify that test results and pending test results will be viewed by care team members and communicated to the patient in a timely manner.
Offering more behavioral health services in primary care practices would help address lack of access to care.
Eight of the country's leading physician organizations recently issued a call-to-action urging support for primary care practices to integrate behavioral health services into their operations.
The country is arguably experiencing a behavioral health crisis. There is a nationwide shortage of psychiatrists. In 2019, about 50 million Americans experienced a mental illness, but more than half of U.S. adults with mental illness do not receive treatment, according to Mental Health America (MHA). The coronavirus pandemic has exacerbated behavioral health problems, according to data from the MHA Online Screening Program. From January to September 2020, there was a 62% increase in people who took a depression screen compared to 2019 depression screening.
The eight physician organizations that made the behavioral health integration call-to-action are members of the Behavioral Health Integration Collaborative: the American Academy of Child and Adolescent Psychiatry, American Academy of Family Physicians, American Academy of Pediatrics, American College of Obstetricians and Gynecologists, American College of Physicians, American Medical Association, American Osteopathic Association, and American Psychiatric Association.
HealthLeaders recently talked with a co-author of the call-to-action, Gerald Harmon, MD, immediate past president of the American Medical Association and a practicing family medicine physician based in South Carolina. Harmon was asked to comment on the call-to-action's five solutions to accelerate widespread adoption of behavioral health integration by primary care practices. The following transcript of that conversation has been edited for brevity and clarity.
HealthLeaders: How can payers expand coverage and fair payment for all stakeholders utilizing behavioral health integration models?
Gerald Harmon: The reason we do not have established resources for behavioral health integration is we have not had coverage or compensation to invest in the resources. Primary care practices want to be able to invest in technology and employ nonphysician providers, consultants, social workers, and case managers to help take care of the behavioral health needs of our patients.
It is critical for payers to expand coverage and give us fair payment, so we can invest in behavioral health. I need the resources and cash flow, so I can spend the time addressing behavioral health issues and keep my doors open.
We have a law—the Mental Health Parity and Addiction Equity Act of 2008—but many payers do not appear to be complying with this parity law. They need to cover mental health and substance use disorders like they cover physical and surgical benefits. This is medical care—it may not be for physical services such as endoscopy but addressing behavioral health conditions saves money in the long run and gives help to patients who need it.
HL: What are the primary considerations for evaluating how and when to apply cost-sharing for integrated services?
Harmon: I understand that cost-sharing and patient responsibility for certain services may be beneficial to the system. Otherwise, folks might just say it is convenient for them to go to the emergency department and consume the highest-cost resource because that is where they could find it available. Cost-sharing such as deductibles can be efficient governors on unnecessary medical expenses; but if you have deterrents such as high deductibles or co-pays for behavioral health services, you can create disparities. If you have high rates of cost-sharing, economically disadvantaged patients can be deterred from having timely access to services. The more people with behavioral health issues put off access to treatment, diagnosis, and care, the worse their morbidity and overall physical health will be, which can cost the system and the patients more.
We need to make behavioral health services as accessible as possible. Often, people seeking mental health care need it urgently. We need to catch these conditions early before they become a more complicated and expensive process for the patient and the system.
HL: What kinds of provider training and technical support can support primary care practices seeking to adopt behavioral health integration?
Harmon: The reason I have had a lot of on-the-job learning about behavioral health in four decades of family medicine practice is I did not have a lot of formal training. I was family medicine certified, which means I understood the wellness concerns about anxiety disorder, depression, and other behavioral health issues—but I was not a psychiatrist or a behavioral health specialist. If I am going to integrate behavioral health into my practice, I am going to need some support. I need to be trained on best practices.
I need to know the best approaches and staffing models. I need to maintain relationships with other community partners such as the Mental Health Commission and clinics in my area where we have intermittently staffed psychiatrists. We need training beyond on-the-job training to effectively integrate behavioral health into our practices at the best cost and with the best fiscal model.
We also need to fix Medicare reimbursement for physicians to support technological investments. If I am going to use telehealth to gain access to a psychiatrist to help me make a diagnosis and manage medications because I don't have a psychiatrist in the local community, then I am going to have to invest in technology, and that is not cheap. To have adequate technician support, I need to know that my Medicare physician payment is adequate to be able to make an investment in my physician practice.
HL: Why is it important to minimize or eliminate utilization management for behavioral health integration services?
Harmon: An example is prior authorization, which is a barrier to patient care and an impediment to physician satisfaction. We have prior authorization for medications and all manner of referrals including behavioral health specialists.
Narrow networks are also a concern. For many patients, there may not be a behavioral health specialist in network for more than an hour drive.
It is important to eliminate utilization management barriers such as prior authorization for behavioral health for the same reason as not having access to behavioral health specialists. If you put in a barrier for me to gain access to the limited number of specialists I have in a narrow network, that is a recipe for disaster and an impediment to patient safety.
All of us as a society are going to pay a price when we don't address behavioral health issues. We are in the midst of a crisis with substance use disorder and opioid deaths. We need to minimize or eliminate any barriers to this kind of care.
HL: Why is it important to launch whole-person, employer-based behavioral health programs that destigmatize behavioral health?
Harmon: If we can get some employer-based treatment and employer-based diagnosis such as a social worker or especially trained nonphysician provider, we can get people care before they are unable to work or are taken out of the workplace for an extended period. We need to get people support as soon as they notice degradation in their behavior or their performance. If an employee is over-stressed and worried about their family or all manner of things, they need to be able to seek help without stigma.
There can be stigma with substance use disorder, depression, anxiety, or feelings of self-worth. We should not label patients and have them be unable to work because of stigma. We need to avoid patients getting a permanent bias against them.
We need to make whole-person diagnoses. A holistic-medicine approach does not mean just taking vitamins, eating well, and meditating. We need to recognize that your behavioral health state does have an impact on your physiological response. If you get a burst of adrenaline, you can get a burst of catecholamines and burst of chemicals from your midbrain, which can depress you, agitate you, increase your heart rate, raise your blood pressure, affect your cognitive ability—all of these things become a physical reality.
You would not be embarrassed to seek help if you had blood pressure trouble, or you were having chronic headaches. So, if you have concerns about your emotional health, you should not be deterred from seeking that care, and we as healthcare providers should not label patients with mental health issues with any kind of disparaging comments.