Researchers find that 98% of emergency medicine residents are working in urban areas of the country.
Emergency medicine residents are disproportionately located in urban areas of the country, which is contributing to an emergency physician "desert" in rural America, a new research articlesays.
Earlier research on clinically active emergency physicians found that the number of emergency physicians increased by more than 9,000 from 2008 to 2020. However, 92% of emergency physicians were located in urban areas, with only 6% located in large rural areas and 2% located in small rural areas.
The new research article, which was published by Annals of Emergency Medicine, identified emergency medicine residents in the 2020 American Medical Association (AMA) Physician Masterfile and compared 2020 to 2008 data. The researchers also compared the number of Accreditation Council for Graduate Medical Education-accredited emergency medicine residency programs from 2013 versus 2020.
There were nearly 7,000 emergency medicine residents in the 2020 AMA data set. The overwhelming majority of the emergency medicine residents (98%) were located in urban areas, with 6,850 of the clinicians in urban areas, 114 in large rural areas, and 23 in small rural areas.
The number of residency programs increased significantly, from 160 in 2013 to 265 in 2020. However, the new residency programs were disproportionately added in states that already had a high number of programs.
In California, the number of residency programs increased from 14 to 22
In Florida, the number of residency programs increased from 5 to 19
In Michigan, the number of residency programs increased from 11 to 25
In New York, the number of residency programs increased from 21 to 31
In Ohio, the number of residency programs increased from 9 to 18
In Pennsylvania, the number of residency programs increased from 12 to 21
Several, mostly rural, states had no emergency medicine residency programs in 2013 or 2020: Alaska, Hawaii, Idaho, Montana, North Dakota, South Dakota, and Wyoming.
"The number of emergency medicine residency programs has increased; most new programs were added to the states that already had emergency medicine residency programs. There is an emergency physician 'desert' in the rural United States, lacking both residents and residency training programs," the co-authors of the new research article wrote.
Telehealth could help address the shortage of emergency medicine physicians in rural areas, the co-authors wrote. "One potential means of bringing emergency physician care to these rural areas without necessarily bringing the emergency physicians there could be an expansion of telehealth infrastructure and increased uptake of telehealth in the rural areas where emergency physician care is most needed."
Having emergency medicine residents work in rural areas is an attractive option to relying on telehealth, they wrote. "Increased emphasis on and availability of rural rotations for emergency medicine residents could alternatively provide residents exposure to clinical sites not routinely encountered in their training and increase the rate of graduating emergency physician residents relocating to these environments. Ultimately, if we are not increasing the opportunities for residents to practice in rural, more resource-limited environments, it is likely that many will be unprepared for the unique challenges of working in these environments and subsequently more unwilling to take more jobs in rural areas."
The internal medicine specialist society urges renewed effort to shift from volume-based physician payment to value-based payment models.
The American College of Physicians (ACP) has proposed a seven-part set of reforms to link physician payment to value and equity rather than volume of services.
Policymakers and lawmakers have been seeking to replace fee-for-service reimbursement in healthcare with value-based payment models since passage of the Patient Protection and Affordable Care Act in 2010. Despite more than a decade of effort, a recent study found that physician payment remains overwhelmingly based on service volume rather than service value.
ACP consists of internal medicine specialists and subspecialists. With more than 160,000 members in several countries, ACP is the largest medical-specialty society in the world.
This week, ACP published the organization's seven-part set of physician payment reforms in a position paper in Annals of Internal Medicine. Physician payment models dominated by fee-for-service approaches do not promote value or equity in U.S. healthcare, the position paper says. "Socioeconomic factors remain one of the most clinically significant contributors to health outcomes in this country, yet the current fee-for-service payment structure incentivizes volume and does not address such factors. The American College of Physicians proposes specific policy recommendations on reforming payment programs, including those designed to treat underserved patient populations, to better address value in healthcare, and achieve greater equity."
The position paper says there is a need to design "smarter" healthcare payment models. "The approach of building a healthcare system that is smarter about how dollars are spent to make people healthier must shift to one with a clear intention of decreasing health inequities and addressing social drivers of health."
The position paper urges more meaningful efforts to create value-based payment models. "Policy leaders and the clinical community must work together to make progress toward equity using value-based payment. For more than a decade, policy goals have highlighted the need to achieve greater equity, yet the fact remains that execution of these policies continues to lag. Now is the time to set a national intention to build on that experience and support implementation and assessment of payment approaches to advance health equity and overcome social drivers and other disparities that lead to poorer health outcomes."
Position one
ACP calls on Medicare and other payers to craft population-based, prospective payment models for primary and comprehensive care. These payment models should promote access to care and address healthcare disparities and inequities that are related to personal characteristics and/or social drivers of health. New payment models should be designed to improve care for underserved patient populations.
Position two
Research should be conducted to measure the cost of caring for patients who are impacted by healthcare disparities and inequities based on personal characteristics and/or social drivers of health. In value-based payment models, performance and cost measures should be adjusted for risk, health status, and social drivers of health. Performance and cost data should be used to improve the value of primary and comprehensive care.
Position three
Medicare law should be modified to establish a way to calculate savings from increased investment and payments for primary care and preventive healthcare services (Part B) that reduce emergency room visits and hospitalizations (Part A). These savings should be reinvested in primary and preventive care as well as social and public health services. Investment in primary care should not be based only on short-term cost savings because primary care improves population health, and some savings are generated over several years.
Position four
The federal secretary of health and human services should reform the Medicare Quality Payment Program to ensure the program addresses inequity, healthcare disparities, and social drivers of health. New policies and financial approaches should encourage physician practices to adopt value-based payment models.
Position five
Delivery and payment systems should support clinicians and healthcare facilities in offering care to patients when and where they need it in a range of modalities, including in-person visits and telehealth. This approach to care is particularly important for patients experiencing healthcare disparities and inequities based on personal characteristics and/or social drivers of health. These delivery and payment systems should not add administrative burdens on clinicians or inappropriately question clinician judgment.
Position six
Money should be allocated for the development of health information technology systems and communication capabilities such as broadband so that delivery and payment reforms address the needs of all patient populations. These capabilities should help patients who are experiencing healthcare disparities and inequities linked to personal characteristics and/or social drivers of health. Policies fostering these capabilities should not unintentionally redistribute resources away from at-risk patients or create incentives to avoid at-risk patients.
Position seven
Healthcare stakeholders including policymakers, payers, health systems, private-sector investors, and philanthropic organizations should develop financing mechanisms other than direct payment to clinicians such as grants to address inequities, healthcare disparities, and social drivers of health.
The new top doctor at Atlantic Health System views mentoring as one of her favorite job responsibilities.
Every member of a health system has a responsibility to promote quality care, the new chief clinical officer of Atlantic Health System says.
Suja Mathew, MD, was hired recently to serve as executive vice president and chief clinical officer of the Morristown, New Jersey-based health system. Before joining Atlantic, she was the chair of medicine for the Cook County Health and Hospitals System in Cook County, Illinois.
HealthLeaders recently talked with Mathew about a range of issues, including quality care, patient access, research and academic programs, and mentoring. The following is a transcript of that discussion, which has been edited for brevity and clarity.
HealthLeaders: As chief clinical officer, how can you promote quality care?
Suja Mathew: Every individual in this organization must promote quality care. That applies to every clinical individual and every non-clinical individual. We all need to be committed to providing quality care.
Having said that, as chief clinical officer, our quality and patient safety programs roll up to me, so I have direct accountability. We have a long history of being recognized as a high-quality provider of patient care and a safe provider of patient care. I will be looking at our programs—always looking to see where we can improve. My goal is to be better. We are great now and we are going to be better. As our environment continues to shift and as challenges in our industry continue to affect us, we will be looking for opportunities to improve.
HL: How are you going to approach improving patient access to Atlantic's network of care?
Mathew: The key is to ensure no matter where a patient or family member enters the Atlantic Health System that individual will have access to the very best care that we offer should they need it. My goal is to make sure that we continue to look at what our patients and our communities need in place where they are and to match that up with the resources that we have in local communities.
I also want to create clear routes where patients can, if needed, access our secondary and tertiary services. So, when they need to stay healthy, we want to achieve that locally; but when they need a higher level of care, they will be able to access all of the resources that we have at Atlantic.
HL: How are you going to approach elevating the health system's research and academic programs?
Mathew: Clinical work and academic programs are symbiotic. We provide outstanding clinical care at Atlantic, and that is exactly the type of system where you want to educate learners. That is also the type of system where you want to conduct research. These areas fuel each other.
We are already providing excellent clinical care, we are already doing meaningful research particularly in clinical trials, and we are already doing impactful medical education. We are going to try to continue to build the connections between each of those three pieces of work so that our research and our clinical trials elevate the clinical services that we can provide to our patients. We want our educational programs to elevate the clinical interaction that we have with our patients. We want the great clinical work that we are doing to be fully leveraged to educate our learners and clinicians of tomorrow.
HL: How did serving as chair of medicine for the Cook County Health and Hospital System prepare you for the role as chief clinical officer at Atlantic?
Mathew: I was at Cook County Health and Hospital System for 22 years. I grew up professionally in that system. In my last role there, which was as chair of medicine, I oversaw delivery of internal medicine and oversaw education and research activities throughout the department. So, that range of work is similar to what I am doing at Atlantic as chief clinical officer; however, the scope of what I do at Atlantic is larger.
Cook County was a wonderful place for me to be for so long. It is a public health system that does great work but does so within a very challenging environment. Learning as a clinician in that environment and learning how to lead in that environment has prepared me for working at Atlantic. I learned how to hone my creativity and my ingenuity while working in an under-resourced environment. I will bring that skillset to Atlantic.
HL: What are the key elements of promoting career sustainability and professional satisfaction among physicians?
Mathew: There are three pillars of professional satisfaction for physicians. First is ensuring a long and sustainable career in medicine. I would break that down to looking at the system within which we practice medicine—we need to ensure that the system promotes high-level activity. Everyone on the care team should be working at the top of their license. So, physicians should be involved in activities that are designed to fully utilize their skillset and knowledge base.
The second element of sustainable professional satisfaction is to look at the individual's resilience. By and large, the clinical workforce has highly resilient people. We have gone through many years of training and preparation for this work. We are strong. Still, we need to make sure we are allowing our clinicians to invest in themselves. We must support their time away from work.
The third element of creating sustainable professional satisfaction is to look at our leadership. The leadership under which clinicians practice is very impactful in the level of professional satisfaction that they feel. Leaders must have the right qualities—their communication skills must be optimal, they need to be able to motivate the folks who report up to them, and they need to provide an environment that promotes career growth.
HL: What are the primary elements of serving as a mentor to residents and faculty members?
Mathew: This is one of my favorite things to do. I served as a program director and medical educator for most of my career. As a medical educator, what you do as a course director or a program director is you have direct contact with a lot of learners. As the chair of medicine, I had direct contact not only with learners but also with faculty and young leaders. I delight in the opportunity to be part of people's success stories.
There are formal programs that can facilitate mentoring. But at the end of the day, it takes individuals who will be generous with their time to invest in learners and younger colleagues. For us as leaders, it is often a matter of a little bit of our time and energy for a significant payoff. I have been the recipient of strong mentoring over the years as well as sponsorship, both of which have propelled my career in ways that I could not have imagined. I feel it is a responsibility to pay that back, but it is also a great joy to be a mentor.
Researchers have compared Medicare Part D generic drug pricing with pricing at the Mark Cuban Cost Plus Drug Company.
The Medicare program could realize significant generic prescription drug cost savings if it could match the prices of the Mark Cuban Cost Plus Drug Company (MCCPDC) direct-to-consumer model, a new research article shows.
Nationwide spending on prescription drugs has increased sharply in recent decades, increasing from $30 billion in 1980 to $335 billion in 2018. In 2019, the United States spent more than $1,000 per capita on prescription drugs, a spending level higher than other high-income countries.
The new research article, which was published today by Annals of Internal Medicine, is based on an analysis of 109 generic drugs sold by MCCPDC in February 2022. The researchers found comparable Medicare Part D plan pricing for 89 of the generic drugs, and they calculated pricing differences for the maximum (90 count) and minimum (30 count) quantities available.
The research article features several key data points.
The estimated annual Medicare spending on the 89 targeted generic drugs was $9.6 billion.
If Medicare purchased generic drugs at the maximum quantities available from MCCPDC, the program could have saved $3.6 billion on 77 of the 89 generic drugs. This represented a 37% cost savings.
If Medicare purchased generic drugs at the minimum quantities available from MCCPDC, the program could have saved $1.7 billion on 42 of the 89 generic drugs. This represented an 18% cost savings.
The drug with the highest cost savings was esomeprazole at $293 million in savings.
"Our findings suggest that Medicare is overpaying for many generic drugs, which is consistent with findings that Medicare overspent on 43% of generic prescriptions in 2018 relative to Costco member prices," the research article's co-authors wrote.
In the United States, the system used to purchase generic drugs is not cost-effective, the research article's co-authors wrote. "Generic drug competition is a major source of prescription drug savings in the United States, but the lower prices from a direct-to-consumer model highlight inefficiencies in the existing generic pharmaceutical distribution and reimbursement system, which includes wholesalers, pharmacy benefit managers, pharmacies, and insurers. By one estimate, this supply chain retains 64% of every dollar spent on generic drugs."
The research article's co-authors offer a prescription for improving the cost-effectiveness of U.S. generic drug spending. "Although direct-to-consumer private companies like MCCPDC may offer savings for some patients on select drugs, policy reforms that improve price transparency, increase competition for high-cost generic drugs, prevent annual price increases, and limit pharmacy and distribution costs could increase affordability of essential generic medicines for all Americans."
The AMA is urging states to create 'safe-haven' programs to encourage treatment for physicians suffering from burnout and mental health conditions.
The American Medical Association adopted several new policies during the organization's Annual Meeting this week.
The AMA is the largest national association representing physicians, convening more than 190 state and specialty medical societies as well as other key stakeholders. Activities of the AMA include advocacy in courts and legislatures, prevention of chronic disease, addressing public health crises, and training physician leaders.
Decisions made at this week's AMA Annual Meeting include the following 10 policy areas.
Poverty-level wages: A new AMA policy says poverty is detrimental to health, and it committed the organization to advocate for federal, state, and local policies regarding minimum wage that include adjusting the wage level to keep pace with inflation. The AMA also affirmed that minimum wage policies should be consistent with the AMA’s principle that the highest attainable standard of health is a basic human right and that optimizing the social determinants of health is an ethical obligation of a civil society.
Climate change: The AMA declared climate change a public health crisis that threatens the health and well-being of all people. Building on existing efforts to address the climate crisis, the new policy mobilizes the AMA to advocate for policies that limit global warming to no more than 1.5 degrees Celsius, reduce U.S. greenhouse gas emissions aimed at carbon neutrality by 2050, support rapid implementation and incentivization of clean energy solutions, and push for significant investments in climate resilience with climate justice in mind.
Addressing disinformation: With disinformation continuing to have a negative effect on efforts to deal with the coronavirus pandemic, the AMA adopted a policy to address health-related disinformation by health professionals. As part of a report developed by the AMA Board of Trustees, the new policy provides a comprehensive strategy aimed at stopping the spread of disinformation and protecting the health of the public, including actions that can be taken by the AMA, social media companies, publishers, state licensing bodies, credentialing boards, state and specialty health professional societies, and organizations that accredit continuing education.
Rural public health: With rural local health departments often limited by budgets, staffing, and capacity constraints that affect their ability to provide sufficient public health services, the AMA adopted a policy advocating for adequate and sustained funding for rural public health programs. The policy also supports equitable access to the 10 Essential Public Health Services and the Foundational Public Health Services to protect and promote the health of all people. The policy calls for more research to identify the unique needs and models for delivering public health and healthcare services in rural areas.
Combatting loneliness: The AMA adopted a policy identifying loneliness as a public health issue that impacts people of all ages. The new policy supports evidence-based efforts to combat loneliness. Studies show that loneliness is not only a significant predictor of functional decline and premature death similar to the risk from obesity, but loneliness in adolescence is associated with impaired sleep, symptoms of depression, and poorer health in general.
Criminalization of reproductive health: Responding to more policing and surveillance of reproductive health services, the AMA adopted a policy recognizing that it is a violation of human rights when government intrudes into medicine and impedes access to safe, evidence-based reproductive health services, including abortion and contraception. As part of the new policy, the AMA will seek expanded legal protections for patients and physicians against government efforts that criminalize reproductive health services.
Physician mental health: For physicians who seek care for burnout or other mental health-related issues, the AMA adopted a policy to urge states to create "safe-haven" programs to encourage counseling and treatment. The programs would complement Physician Health Programs to add additional, evidence-based options for physicians to receive care and enable them to continue practicing as long as public safety is not at risk.
Cannabis legal records: The AMA adopted a policy to call on states to expunge criminal records of people who were arrested or convicted of cannabis-related offenses that later were legalized or decriminalized. The policy aims to introduce equity and fairness into the fast-changing effort to legalize cannabis. "This affects young people aspiring to careers in medicine as well as many others who are denied housing, education, loans, and job opportunities. It simply isn't fair to ruin a life based on actions that result in convictions but are subsequently legalized or decriminalized," AMA Trustee Scott Ferguson, MD, said in a prepared statement.
Gun violence: The AMA adopted three policies related to firearms violence:
The AMA is advocating for school drills related to active shooter scenarios to be conducted in an evidence-based and trauma-informed way that takes children's physical and mental wellness into account, considers prior experiences that might affect children's response to a simulation, avoids creating additional traumatic experiences for children, and provides support for students who may be adversely affected.
The AMA called on state and federal lawmakers to subject homemade "ghost guns" to the same regulations and licensing requirements as traditional firearms.
The AMA committed to advocating for legislation requiring that packaging for ammunition carry a boxed warning. At a minimum, the AMA favors a warning with text-based statistics and/or graphic warning labels related to the risks, harms, and mortality associated with gun ownership and use.
Sexual assault examination kit backlog: The AMA called on state and federal officials to process all backlogged and new sexual assault examination kits upon patient consent and in a timely fashion. The kits have played a significant role in identifying and incarcerating perpetrators of violent sexual crimes. Even when a suspect cannot be instantly identified, the information can be uploaded to the Federal Bureau of Investigation's Combined DNA Index System and assist in the later identification of a criminal. The AMA also called for additional money to facilitate the immediate testing of the kits.
A new study compared the telehealth perceptions of mental health, primary care, and specialty care clinicians, as well as use of video versus phone telehealth.
Perceptions of telehealth vary between mental health (MH), primary care (PC), and specialty care (SC) clinicians, with an impact on remote care utilization rates, a new research article says.
Utilization of video and phone telehealth has expanded exponentially during the coronavirus pandemic as a way to limit patient and staff exposure to infection. Clinician perceptions about telehealth may affect utilization—a survey conducted early in the pandemic found Veterans Health Administration PC and SC clinicians were more likely to prefer phone over video care but MH clinicians were inclined to prefer video care.
The new research article, which was published by JAMA Network Open, features survey data collected from more than 800 clinicians in the Department of Veterans Affairs New England Healthcare System, which serves about 260,000 veterans annually. The survey was conducted from August to September 2021.
The study generated several key data points.
Relative to PC and SC clinicians, MH clinicians gave video care the highest rating, and they had a greater preference for treating new and established patients remotely with video
PC and SC clinicians had a greater likelihood of rating the quality of phone care as at least equivalent to video care for new and established patients
PC and SC clinicians were more likely to note challenges of video care such as patient barriers and inability to have a physical examination
In providing remote care to established patients, the majority of PC and SC clinicians either had no preference for telehealth modality or preferred phone care
Utilization rates reflected clinician preferences and perceptions, with MH clinicians significantly more likely to conduct telehealth visits with video compared to PC and SC clinicians
"This survey study found significant specialty-level differences in clinician attitudes toward video and phone telehealth care, many of which aligned with observed differences in actual utilization of these modalities. Our findings suggest that in the absence of financial incentives, clinician beliefs, particularly regarding the quality and ease of use of telehealth, played an important role in the care modalities that were ultimately used with patients," the study's co-authors wrote.
Interpreting the data
MH clinicians conducted the highest proportion of video visits during the time of the survey. "MH clinicians were also more likely to report that their selection of care modalities was influenced by leadership guidance and data regarding the relative effectiveness of video, phone, and in-person care. Indeed, given that telehealth was being used for MH care well before the onset of the COVID-19 pandemic, there is a strong body of evidence demonstrating that video care is noninferior to in-person MH services, as well as an emerging literature suggesting that phone care may sometimes be inferior in quality to video care," the study's co-authors wrote.
PC and SC clinicians were less likely than MH clinicians to prefer video over phone telehealth visits, the study's co-authors wrote. "PC and SC clinicians, who conducted substantially less video care than MH, had multiple similarities in their responses across the survey. These clinicians were more likely to rate phone care as being at least equivalent in quality to video. They were also more likely to endorse challenges of video care, including patient barriers to use and the inability to conduct an adequate physical examination. Importantly, most PC and SC clinicians either had no preference or preferred phone for remote care of established patients."
PC clinicians provided the highest proportion of phone visits for established patients. "This could be owing, in part, to their increased likelihood of endorsing challenges of video care coupled with a tendency to believe that video and phone care are equivalent in quality, particularly for established patients. Indeed, most PC clinicians either preferred phone or had no preference between phone and video for the remote care of established patients. This finding underscores the importance of complexity in influencing adoption of new technologies; if PC clinicians believe that phone and video care are equivalent in quality, ease of use may then drive the choice of phone over video, particularly when treating patients whom they have already seen in-person," the study's co-authors wrote.
Most of the MH, PC, and SC clinicians reported that patient preference was a major contributor to selecting a telehealth modality. However, even though there is evidence that patients increasingly prefer video over phone visits, utilization data show that a significant proportion of telehealth visits are being conducted by phone. "It is unclear how often what we refer to as patient preference is instead a measure of patient readiness for telehealth (i.e., that the patient owns a video-enabled device or is comfortable navigating a telehealth platform). A patient without a smartphone may be viewed as preferring a phone appointment because they do not have access to the appropriate technologies. Indeed, COVID-19 has revealed a stark digital divide in which patients who are older and/or have lower income are less likely to be video-ready," the study's co-authors wrote.
The prevalence of high-risk pregnancies is on the rise in the United States.
Health systems, hospitals, and physician practices need to step up their efforts to provide care in cases of high-risk pregnancies, an expert at San Diego-based Scripps Health says.
A national study of women aged 18 to 44 showed that complicated pregnancies are growing more prevalent in the United States—they rose by 16.4% from 2014 to 2018. The same study, which looked at 1.8 million pregnancies, revealed that childbirth complications increased by about 14% from 2014 to 2018.
These are high numbers in the span of just four years, says Sean Daneshmand, MD, medical director of the Maternal-Fetal Medicine Program at Scripps Clinic. "The study also found a significant increase in chronic health conditions in women before becoming pregnant—issues such as high blood pressure and obesity have become much more common, which can make pregnancy a challenge to manage. Also on the rise are conditions that begin during pregnancy such as hypertensive-related crises, which are better known as pre-eclampsia, and gestational diabetes. These conditions increased by 19% and 16%, respectively."
A significant percentage of pregnancies involve medical challenges, he says. "While 80% of women have healthy pregnancies and deliveries, the others have one or more risk factors that can cause serious complications. These could be stemming from heart disease, hypertensive-related crises, diabetes, obesity, and depression and anxiety. For babies, there can be genetic or chromosomal abnormalities, structural defects such as heart or spine defects, and pre-term birth."
Health systems and hospitals should have integrated care teams to provide services for women with high-risk pregnancies, Daneshmand says. "One of the major failings of our country's healthcare system is, too often, we do not have the right team in place to provide the best care for high-risk pregnancies. We need to make sure that the physical and mental health of pregnant women are addressed. A major problem in caring for high-risk patients is inadequate access to mental health services. There was a recent report from USAFacts, which is a clearinghouse for U.S. government data, that showed 37% of Americans live in areas with shortages of mental health professionals. The nation needs nearly 6,400 mental health professionals to fill in the gaps."
Depression and anxiety among women during and after their pregnancies can have a negative impact on their babies, he says. "There was a recent study published in JAMA Pediatrics that suggested maternal depression and anxiety during the perinatal stage spanning from conception to the baby's first year of life is associated with negative developmental outcomes in the offspring through adolescence, including deficits in language and motor development. What happens during pregnancy can impact a child in a positive or a negative way."
Scripps' approach to high-risk pregnancies
Daneshmand says Scripps Health has several key elements in place for care of high-risk pregnancies, including helping patients manage health issues before they become pregnant, close collaboration between various subspecialties such as cardiology and endocrinology, and pre-conception counseling. The health system has recently taken two vital steps, he says.
"One is creating a complex care coordinator—better known as a patient navigator—to help keep patients from falling into dangerous spirals. Scripps added this new role to our Maternal-Fetal Medicine Program in October 2021. The complex care coordinator role is seen more commonly in cancer and organ transplant clinics. We also have expanded access to mental health therapists. Scripps recently began a unique collaboration with a local nonprofit organization to expand access to mental health therapists for high-risk moms, with the goal of identifying these new mothers and delivering care to them within a 72-hour period after diagnosis. We can screen these patients but getting them help in a timely fashion is a challenge for most healthcare professionals."
The two recent initiatives are adding value to Scripps' high-risk pregnancy care, Daneshmand says. "By embedding a complex care coordinator inside our clinic and teaming with a community partner for additional mental health resources, we are building a bridge to connect vulnerable patients to more of the care they need."
Complex care coordinator
Adding a complex care coordinator to the Maternal-Fetal Medicine Program has improved care for high-risk pregnancies, he says. "With our complex care coordinator, we have someone who has clinical experience who is emotionally intelligent and compassionate. We have embedded this role within the clinic, so that when the patient sees me and has an abnormal finding, they can have a consult with the complex care coordinator and follow-up visits with the complex care coordinator."
The complex care coordinator has become a crucial care team member, Daneshmand says. "The complex care coordinator is available for every one of our high-risk patients, making sure they are receiving necessary testing and follow-up care as well as answering questions. She plays a critical role in determining which patients need additional help. She keeps an eye out for warning signs that may emerge between screenings because early intervention is important for issues such as depression and anxiety."
The complex care coordinator is like a consultant, he says.
"For example, a woman could come in at 20 weeks of her pregnancy, have an ultrasound, and we suspect the baby has a heart defect. This patient is then referred to pediatric cardiology to get a fetal echocardiogram and referred to our complex care coordinator. The complex care coordinator either sees the patient immediately or within 48 hours. The patient is also scheduled for an appointment within a week for mental health screenings to assess whether they are exhibiting any signs of depression or anxiety. From that point forward, care depends on the diagnosis and whether the complex care coordinator feels the patient should be seen more frequently. If the patient exhibits any signs of depression or anxiety, the complex care coordinator refers the patient to a program called My Brain & My Baby."
Improving care for high-risk pregnancies
Daneshmand offered advice for other health systems seeking to improve care for high-risk pregnancies. "First, we need to recognize that complicated pregnancies are becoming more common. Secondly, we need to move beyond the status quo and find ways to improve care for these vulnerable moms and their children. Putting an integrated care team in place to surround and support these patients is important. For example, this can ensure that mothers-to-be who need mental health services receive care in a timely fashion—this is one of the main challenges in our country."
The stakes are high, he says. "We have a responsibility to provide the care that is desperately needed by these moms and their babies. This impacts entire families—it is not just the mother who struggles with depression or other complications. The fetus can be impacted, as well as other children, the woman's partner, and the workplace. Their future hangs in the balance."
The Wisconsin-based physician was on the AMA Board of Trustees from 2014 to 2020, including serving as chair of the board.
The American Medical Association has voted a Wisconsin anesthesiologist to serve as the organization's president-elect.
Jesse Ehrenfeld, MD, MPH, was elected at the Annual Meeting of the AMA House of Delegates. He will become president of the AMA in June 2023.
"I am honored to be elected by my peers to represent the nation's physicians and the patients we serve. It is a pivotal and challenging time for medicine, physicians and our health system, and as president-elect, I am committed to advancing the AMA's immediate goals around the Recovery Plan for America's Physicians, as well as the longer-term advocacy efforts aimed at shaping the future of medicine and improving the health of the nation," Ehrenfeld said in a prepared statement.
He is the first openly gay individual to serve as AMA president-elect and is an inaugural recipient of the National Institutes of Health Sexual and Gender Minority Research Investigator Award.
Ehrenfeld has served in several AMA leadership roles. He was elected to the AMA Board of Trustees in 2014 and served as chair of the board from 2019 to 2020. He has served as a member of the governing councils of the AMA Young Physicians Section and the AMA Resident and Fellow Section.
Ehrenfeld is a practicing anesthesiologist, senior associate dean, and tenured professor of anesthesiology at the Medical College of Wisconsin. He is also an adjunct professor of anesthesiology and health policy at Vanderbilt University and adjunct professor of surgery at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.
Ehrenfeld is the co-author of 18 clinical textbooks and more than 200 peer-reviewed articles. His areas of research include using digital technology to improve surgical safety, patient outcomes, and health equity.
He is a graduate of Haverford College, the University of Chicago Pritzker School of Medicine, and the Harvard School of Public Health. He conducted his post-graduate work including a residency in anesthesiology at Massachusetts General Hospital in Boston.
A combat veteran, Ehrenfeld served in Afghanistan during Operation Enduring Freedom and Resolute Support Mission. He lives in Milwaukee with his husband, Judd Taback, and their son, Ethan.
Before the coronavirus pandemic, physician burnout was a national concern, and the pandemic has driven physician burnout to crisis proportions. The Association of American Medical Colleges projects there will be a shortage of physicians between 37,800 and 124,000 clinicians by 2034.
In comments before the AMA House of Delegates, AMA President Gerald Harmon, MD, said the need for action is urgent. "America's doctors are a precious, and irreplaceable, resource. Physician shortages, already projected to be severe before COVID, have almost become a public health emergency. If we aren't successful with this Recovery Plan, it'll be even more challenging to bring talented young people into medicine and fill that expected shortage."
The Recovery Plan has five key elements:
Supporting telehealth services including insurance coverage
Reforming the way Medicare pays for physician services
Stopping "scope creep" that expands the scope of practice of non-physicians such as nurse practitioners
Reforming prior authorization of medical services to reduce administrative burden on physician practices and to avoid care delays for patients
Tackling physician burnout and reducing stigma around physician mental health
Expanding telehealth
The pandemic spurred unprecedented growth in telehealth, with 90% of physicians shifting to telehealth to provide patient care, and a continuation of telehealth services is in the best interest of physicians and patients, Harmon said.
"[The Centers for Medicare & Medicaid Services] made changes to ensure that telehealth payment rates were equivalent to in-person services including audio-only visits—meaning a telephone call! And then a funny thing happened: doctors and patients discovered that this wasn't such a bad idea in many circumstances. It's safe, convenient, and certainly for patients, less time consuming than a visit to the office. In my rural community, patients have substantial geographic barriers like rivers, swamps, and islands that contribute to long travel delays. Digital health is a godsend to these patients," he said.
Telehealth gains achieved during the pandemic must be preserved, Harmon said. "We know the vast majority of patients and physicians want this type of care to continue after the declared Public Health Emergency is over. Telehealth is here to stay, and we are fighting to update our laws and regulations to reflect that fact."
Reforming Medicare physician payment
Medicare reimbursement for physician services has been inadequate for years, and annual uncertainty about Medicare physician payment is crippling for physician practices, he said.
"Medicare physician payments are the only component of healthcare delivery subject to budget neutrality and have fallen 20%, adjusted for inflation, since 2001—an average of about 1% a year. As a result of various legislative and regulatory provisions implemented prior to and during the COVID pandemic, we were threatened with a 10% cut in Medicare payments this past January. Thanks to the pressure of the AMA and others in organized medicine, Congress acted at the last minute to avert the cuts. This was a major victory. But we should not have to suffer this annual cliffhanger. We need a permanent solution to end the annual battles that threaten the economic survival of physician practices."
The need for payment reform is undeniable, Harmon said. "We must be able to predict financial returns with some reliability in order to invest in costly infrastructure like new technologies and treatments. In short—we're done with short-term patches and looming cuts."
Stopping 'scope creep'
Physicians are better equipped to play leading roles in care teams than other clinicians, he said.
"Quality, affordable healthcare is only possible with teamwork. We rely on nurses, physician assistants, and office workers to do the invaluable work they are trained to do. My practice, for example, has a superb team of staff delivering this team-based care. We currently have physicians, [advanced practice registered nurses], physician assistants, licensed social workers, dedicated office staff, and others under one roof. But patients need to trust that a physician is leading their care and leading the team. We have years' more education, and thousands of hours' more clinical training than other members of the team, and are better prepared to treat complex cases and complications."
Reforming prior authorization
Prior authorization for medical services by payers places an unnecessary administrative burden on physician practices and is bad for patients, Harmon said.
"In a recent AMA survey, 93 percent of physicians reported that hurdles imposed by prior authorization for medication, tests, and procedures resulted in care delays for their patients. Four out of five doctors said these processes have led patients to abandon their treatment! Can you believe it? And navigating these hurdles is also a burden for physicians and staff, who must spend valuable patient care time doing this. I have personally done this more times than I can count, to ensure that my patients get the care they need. Four years ago, the AMA developed a Consensus Statement on Improving the Prior Authorization Process together with other national organizations representing health plans and providers. Unfortunately, since then, insurers have done precious little to implement agreed-upon improvements."
Physician burnout and mental health stigma
Physician well-being needs to be a top priority, he said.
"The final element of our Recovery Plan—and potentially the most important—is to develop a health system that retains existing physicians, attracts new physicians, and reduces burnout. For over a decade, the AMA has worked to remove administrative barriers like prior authorization to care that can lead to burnout. But we know solutions must go even further. We must find ways for physicians to address their mental health needs without fear of negative repercussions, and to practice their skills without threats of hostility or violence. This March, we took a great step forward with the passage of the Dr. Lorna Breen Health Care Provider Protection Act. This new law—named after a young physician who took her own life early in the pandemic—will direct more funding and resources to support the mental health needs of physicians."
Reducing mental health care stigma for physicians is essential, Harmon said. "The AMA is working at the state and national levels to reform outdated language on medical licensing applications and employment and credentialing applications that may be stigmatizing. We are also supporting legislation to create confidential physician wellness programs so that physicians and medical students will have somewhere to go when they need help."
A physician involved in the move to seek union representation says the main reason for the effort is to gain influence on administrative decision-making.
Physicians and other healthcare workers at Bend, Oregon-based St. Charles Medical Group have filed for union representation from the American Federation of Teachers.
Union representation of physicians is relatively rare. Several factors are contributing to efforts to unionize physicians, including burnout, the growing physician as employee model, and desire among physicians to have a stronger voice in healthcare organization administration.
St. Charles Medical Group is affiliated with St. Charles Health System, which features four acute-care hospitals in central Oregon. In addition to physicians, the union effort at St. Charles Medical Group includes nurse practitioners, physician assistants, behavioral health clinicians, licensed clinical social workers, and other healthcare workers.
The American Federation of Teachers is a national union with 1.7 million members, including about 200,000 healthcare workers.
A physician involved in the move to seek union representation at St. Charles Medical Group says the primary impetus of the effort is to gain decision-making authority at the medical group and St. Charles Health System.
"It is mainly concern about bad administrative decisions. It has gone from bad decisions to frustration and concern about the healthcare that we are providing. The term union tends to make people think about things like pay and strikes, and that is not a major part of the discussion. It is concern about patient care," Lester Dixon, MD, an emergency room physician at St. Charles Medical Group, told HealthLeaders.
A recent event cemented the move to unionize, he said. "There is a group called the Medical Governance Board that is about 10 providers that St. Charles Health System has supported, theoretically. The Medical Governance Board is supposed to provide guidance in monthly meetings with the administration to help steer the St. Charles Health System and St. Charles Medical Group. About three months ago, when things were starting to get heated up regarding finances, the leader of the Medical Governance Board, Dr. Richard Freeman, did not show up to a meeting. The health system CEO and chief medical officer said they had fired him. Members of the Medical Governance Board said they should be part of that decision, and they were essentially told they had no power."
Forming a union will boost the voice of physicians and other healthcare workers, Dixon said. "The expectation is that if you have a union, the administration cannot make unilateral changes because there is a contract. A union gives you a guaranteed decision-making position that would be much more powerful than what we have had in the past."
Clinicians have also been frustrated by the health system administration's handling of COVID-19 patients, he said. "They closed the main hospital to everything except COVID patients, which completely eliminated elective surgery in the operating rooms of the main hospital. That put us behind on surgeries and affected patient care, when we had three other hospitals that could have absorbed some of the COVID patients."
Health system's response
Jeff Absalon, MD, chief physician executive at St. Charles Health System, responded to the union effort in a prepared statement.
"As always, we want to reassure our community that patient care is and will continue to be our top priority. We greatly value our employed providers and respect their right to take this step, although we'd far prefer to work directly with them in partnership while navigating these unprecedented times. We know many healthcare workers are frustrated and exhausted after the past two years of the COVID-19 pandemic. Our focus as individuals and a health system needs to be on healing and recovering from the pandemic and stabilizing our finances so that we can preserve and strengthen the vital healthcare services that we provide to our community," he said.
Other union benefits
Forming a union will benefit physicians and other healthcare workers in three areas beyond the ability to have more influence on administrative decisions, Dixon said.
"It will give us assurances that we can staff adequately. The administration has just announced that as part of their cost-cutting measures, they are going to go from two to one provider at some of the facilities. That is obviously not patient-focused."
"There has also been talk that compensation is going to be related to productivity in the clinics, where you will be required to see a certain number of patients per hour or per shift. There are huge concerns about how that is going to work, especially if the administration is cutting back other staffing."
"Forming the union will also open the accounting book. The administration has made a lot of claims—sometimes stepping on their own prior claims—about how money is being spent. By opening the accounting book, we should be able to make sure that financial claims are addressed directly."