Researchers compared moral injury experienced by combat veterans after Sept. 11, 2001, and healthcare workers during the coronavirus pandemic.
During in the coronavirus pandemic, healthcare workers have experienced moral injury at levels comparable to combat veterans, a new research article found.
The pandemic has put tremendous pressure on healthcare workers. Prior to the pandemic, healthcare workers burnout rates averaged in the range of 30% to 50%; now, average burnout rates range from 40% to 70%, a healthcare worker well-being expert recently told HealthLeaders.
The new research article, which was published by the Journal of General Internal Medicine, is based on information gathered from 618 veterans who served in a combat zone after Sept. 11, 2001, and 2,099 healthcare workers who have provided care during the pandemic.
Moral injury has been defined as the "psychological, biological, spiritual, behavioral and social impact of perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations." The new research article examined two kinds of potential moral injury: other-induced potential moral injury, which involves being disturbed by the immoral acts of others, and self-induced potential moral injury, which involves being disturbed by violating your own morals.
The study includes several key data points.
46.1% of combat veterans and 50.7% of healthcare workers reported other-induced potential moral injury
24.1% of combat veterans and 18.2% of healthcare workers reported self-induced potential moral injury
For healthcare workers, other-induced potential moral injury was linked to younger age and COVID-19 exposure
For healthcare workers, self-induced potential moral injury was linked to younger age, nonwhite race, working in a high-risk setting, and COVID-19 exposure
Healthcare workers who reported other-induced potential moral injury had higher levels of depression and lower quality of life compared to healthcare workers who did not report other-induced potential moral injury
Healthcare workers who reported self-induced potential moral injury had higher levels of depression and lower quality of life compared to healthcare workers who did not report self-induced potential moral injury
Healthcare workers who reported other-induced or self-induced potential moral injury experienced significantly higher levels of burnout compared to healthcare workers who did not report other-induced or self-induced potential moral injury
"The potential for moral injury is relatively high among combat veterans and COVID-19 [healthcare workers], with deleterious consequences for mental health and burnout," the study's co-authors wrote.
Interpreting the data
The time of reported events is an important difference between the combat veterans and the healthcare workers, the lead author of the study told HealthLeaders.
"Veterans in our sample were reporting on experiences from their military service. While they were all combat veterans, those we interviewed about morally injurious experiences reported on both combat-related events and non-combat related experiences. Healthcare workers were reporting on experiences that were more recent in most cases. This is an important difference, and it will be important to monitor healthcare workers over time," said Jason Nieuwsma, PhD, an associate professor at Duke University Medical Center in Durham, North Carolina.
There are other key differences between the combat veterans and the healthcare workers, he said.
"There are also of course differences between serving in the military during a deployment, where you don't go home at night and don't really have the option to quit or take leave, and in healthcare during a pandemic, where you do go home at night and can make decisions about quitting or leaving. These differences can cut both ways in terms of the stress involved. While there is clear potential for intense pressure and stress in a deployment situation that one can't escape, I've also known many service members and veterans who would rather not have easy contact with their families during deployments because switching between those mindsets can be difficult and jarring—something healthcare workers reported in juxtaposing their experiences in hospitals with how upon leaving the hospital outside parts of society seemed ambivalent at times," Nieuwsma said.
Among healthcare workers, younger age was associated with both other-induced and self-induced potential moral injury. He said demographic characteristics like this may be associated with lower social status or empowerment.
"Jonathan Shay, a psychiatrist who did a lot of earlier work on moral injury among Vietnam War era veterans, defined moral injury as a betrayal by a legitimate authority in a high-stakes situation. Among healthcare workers, we heard anecdotes from persons who felt betrayed by leadership and/or felt like they were in situations with no good options, sometimes leading to providing lower quality patient care and associated feelings of guilt about that. Younger persons are more likely to be earlier in their careers and potentially finding themselves in these kinds of situations more often," Nieuwsma said.
For healthcare workers, the relationship between burnout and potential moral injury can go in both directions, he said.
"When people feel exhausted and burned out, we know that we as humans make worse decisions. This includes our ability to make moral decisions. To cite Shay again, he talked about how important sleep was for service members in combat because sleep deprived combatants are more likely to make worse decisions, again including morally consequential decisions. For example, firing on a vehicle that you think is an enemy combatant but turns out to be civilians. We heard similar things from healthcare workers, who said that they felt so exhausted and burned out that they ended up at higher risk for violating their own values and standards of patient care. Conversely, those who felt they had experienced a potential moral injury also reported feeling further demotivated and burned out, so, it can be a cycle," Nieuwsma said.
New study raises questions about when telehealth is best used as a substitute for in-person care and when telehealth is best used to complement in-person care.
Early in the coronavirus pandemic, telehealth helped to offset a sharp drop of in-person mental health visits, but the volume of visits for several conditions such as bipolar disorder declined in part because of relatively low telehealth uptake by patients with these conditions, a new study says.
Stay-at-home orders and fear of contracting coronavirus at healthcare facilities drove down in-person visits for medical care early in the pandemic. Healthcare providers responded to the decrease in in-person visits with an unprecedented expansion of telehealth visits.
The new study was published by HealthAffairs. The study is based on an analysis of claims data from Office Ally, a claims clearinghouse for Medicare, Medicaid, and commercial payers. The researchers compared mental health service utilization from time periods before and during the pandemic: 2016 to 2018 and March to December 2020.
The claims data provided information on 101.7 million outpatient mental
health visits. Three-quarters of the visits occurred from 2016 to 2018 and one-quarter of the visits occurred from March to December 2020.
The study features several key data points.
In March 2020, there was a 21.9% decrease in in-person mental health visits compared to the same month in the pre-pandemic period.
In April 2020, there was a 49.6% decrease in in-person mental health visits compared to the same month in the pre-pandemic period.
In May 2020, there was a 55.9% decrease in in-person mental health visits compared to the same month in the pre-pandemic period.
Telehealth visits quickly led to recovery in outpatient mental health utilization. In April 2020, the combination of in-person and telehealth visits was 10.4% higher than average monthly visits in the same month in the pre-pandemic period.
The average number of monthly mental health visits was 2.12 million in the pre-pandemic period compared to 2.11 million during the pandemic period, which was a 0.7% decrease in service volume.
During the pandemic period, the number of average monthly visits decreased by 10.6% for bipolar disorders, 8.5% for schizophrenia and psychotic disorders, and 8.2% for depressive disorders.
During the pandemic period, the number of average monthly visits increased by 12.1% for anxiety and fear-related disorders.
During the pandemic period, telehealth visits compared to in-person visits varied for diagnosis groups. For schizophrenia, telehealth visits accounted for a lower proportion of total outpatient visits compared to in-person visits (1.7% versus 2.7%). For anxiety and fear-related disorders, telehealth visits accounted for a higher proportion of outpatient visits compared to in-person visits (27.5% versus 25.5%).
"We found substantial declines in in-person mental health services use in the initial lockdown phase of the COVID-19 pandemic, followed by a rapid rebound in utilization volume driven chiefly by uptake of telehealth appointments. … We also found relative reductions in encounter volume for certain groups of mental health conditions, specifically for serious mental illnesses such as bipolar and mood disorders and schizophrenia and psychotic disorders, whereas encounters for anxiety and fear-related disorders rose slightly," the study's co-authors wrote.
Interpreting the data
During the pandemic, decreases in average monthly visits for bipolar disorders, schizophrenia and psychotic disorders, and depressive disorders is a troubling, the lead author of the study told HealthLeaders.
"Evidence suggests that during the pandemic more people had mental health symptoms, and that those with mental health conditions had increased symptom acuity. So, our findings of reduced utilization for certain mental health conditions is concerning in this setting, because it suggests that some groups may have been more sensitive to care disruptions that occurred. Individuals with mental health conditions, including those with serious mental illness, are already facing challenges in accessing mental health care, due to socioeconomic factors, difficulty accessing or navigating care, clinician turnover and lack of continuity, financial barriers, and even the nature of the illness itself. It is likely that these factors were exacerbated during the pandemic," said Jane Zhu, MD, MPP, MSHP, assistant professor of medicine at Oregon Health & Science University in Portland, Oregon.
Telehealth appears to be a good care fit for anxiety and fear-related disorders, she said. "We found that telehealth encounters for anxiety and fear related disorders went up significantly during the pandemic, likely driving an increase in total outpatient volume. Many others have reported that rates of anxiety and depression increased substantially during the pandemic, particularly among younger people. So, for this population subgroup, telehealth may be a suitable and acceptable modality of care, and it helped bridge access gaps during the pandemic."
The finding that telehealth encounters for schizophrenia made up a lower proportion of total outpatient encounters relative to in-person visits in 2020 has a significant implication for telehealth and mental health care, Zhu said.
"Telehealth for mental health conditions has been shown to be as effective as in-person care for a variety of purposes, including diagnosis, psychotherapy, and medication adjustment. But it's not yet known the extent to which different groups might have different clinical needs and preferences that may change the acceptability, accessibility, and efficacy of telehealth. For example, as a primary care physician, I have patients with mental health conditions like schizophrenia who prefer in-person visits because they don't like using audio visual tools on the Internet. While our study doesn't evaluate specific reasons for this finding, it raises questions about introducing telehealth as a one-size-fits-all tech solution to mental health care," she said.
The appropriate use of telehealth relative to in-person visits has yet to be determined, Zhu said. "Telehealth is here to stay, it's certainly a critical tool to increase access to mental health care and its applications in this space are incredibly promising, but we need to understand when it's best used as a substitute for in-person care, and when it's best used as a complement, and for whom. Flexibilities may be needed to allow for hybrid models of care."
Vince Jensen says National Cancer Institute-designated comprehensive cancer centers need to deliver the newest therapies and discover new treatments.
City of Hope’s new chief clinical operating officer will lead clinical operations at the organization’s main campus in Los Angeles and throughout its network of more than three dozen care locations in southern California.
Vince Jensen, MBA, started his new position in February and has worked at City of Hope for 22 years. He joined City of Hope as a managed care executive and served as senior vice president of ambulatory operations before taking on his current role.
HealthLeaders recently talked with Jensen about his new position and a range of issues including growth opportunities, adding a physician group to City of Hope, and national centers of excellence relationships. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders:What are some of the major initiatives occurring within clinical operations management at City of Hope?
Vince Jensen: City of Hope is one of the largest cancer research and treatment organizations in the United States. In southern California alone, we have 37 care locations focused on bringing leading-edge oncology care and clinical research trials to those who need us.
My focus is to strategically position City of Hope's clinical enterprise for future growth, excellence in care, and efficiency. As a country, we have a long way to go in removing health disparities. Patients continue to face geographic, insurance, and socioeconomic barriers in accessing lifesaving care and research in oncology. Oftentimes, our most vulnerable populations have the least access to highly advanced care.
We are working to overcome some of these challenges through advocacy efforts on behalf of cancer patients and by operationally expanding our reach so we can care for patients closer to their home. We believe access to world-class and highly specialized cancer treatment should be widely available to those need it most.
Recently, City of Hope signed an agreement with Pacific Shores Medical Group that expanded our clinical network presence to thousands of patients in southern California—adding seven new locations: Glendale, Huntington Beach, Irvine, Newport Beach, Torrance, and two in Long Beach. In addition, earlier this month, we opened a new 32,500-square-foot cancer care location in Corona, expanding our programs and services to that community and significantly increasing the size of our site in that city to meet growing demand.
HL: What are the key benefits of adding Pacific Shores Medical Group to your network?
Jensen: Selecting physicians who have intense passion for City of Hope’s clinical and research mission is an important part of delivering excellence in cancer care. As cancer therapies become more complex, the power of knowledge really can save lives. Adding talented physicians gives us an opportunity to further share and collaborate in new and exciting ways.
For example, our Pacific Shores physicians brought with them a portfolio of new clinical research and ways of providing care in the community setting. Our goal is to share best practices, learn from each other, and develop an evolved organization that is constantly learning and adapting.
HL: You led the opening of a new 34,000-square-foot outpatient clinic. Why was this facility important to City of Hope?
Jensen: The Southeast Ambulatory Clinic is the first of a few planned outpatient expansions on City of Hope’s main campus in Los Angeles. The exciting part of this new development was the opportunity to think more strategically about how we can better utilize existing space to serve the needs of our patients. This will be done through a combination of new buildings and a redesign of existing spaces to achieve new capacity with reasonable speed.
This new center was unique in that we converted administrative space into a large clinical area—adding about 30% more exam rooms for patients and physicians. New capacity means we can reduce wait times for critical cancer care. As an added benefit, the new space is a beautiful and tranquil environment for our patients and physicians.
HL: What elements of clinical operations are unique to a cancer research and treatment institution?
Jensen: As a National Cancer Institute-designated comprehensive cancer center, City of Hope offers patients breakthrough cancer care not yet available to the general population. Every year, City of Hope conducts nearly 1,000 clinical trials. Compared to other diseases, operations in a cancer research and clinical medical institution is quite different. Our focus must be on speed—whether that’s delivering the newest therapies, discovering new treatments, or delivering a new cancer center to serve a population—we carry the responsibility of knowing there are newly diagnosed patients in need of these novel advancements now.
Among our priorities, we are working to ensure leading-edge cancer care is available to more people, not just to those who live near a comprehensive cancer center or an academic institution. As a result, City of Hope is offering clinical trials in our community practice sites, such as Antelope Valley, South Bay, South Pasadena, and more. We hire trained professionals, including clinical trial nurses, who are experienced in research operations and able to deliver high-quality clinical care in community locations. To succeed in this effort, we’ve created infrastructure where we have clinical trial champions—physicians who can help build that bridge from our campus in Los Angeles to our community practice sites. As we look to the future, City of Hope will continue to open new research care locations focused on bringing new and innovative trials to communities that may not otherwise have access to them.
HL: What are areas of future growth for City of Hope?
Cancer screening and precision medicine are important initiatives for us. The pandemic slowed cancer screening across the country, increasing the risk that cancers are discovered at later and more complex stages. City of Hope continues to be an advanced screening center for all cancers, and we continue to encourage the community to be diligent about routine breast, prostate, and colon screenings.
Our precision medicine program continues to transform care by delivering new treatments customized to a patient’s own diagnosis and personal genomics. We are also leading the country in cellular therapies designed to "teach" a patient's own immune system, such as its T cells, to find and destroy cancer by looking for specific proteins.
These new therapies offer exciting results and new possibilities for patients who did not respond to other types of cancer treatments. In the near future, we will see the most promising of these treatments become the preferred approach after cancer diagnosis. However, given the complexity of the therapies, it will be important that patients have access to an academic center that can deliver this critical care.
HL: What role have you played in the creation of national centers of excellence relationships?
Jensen: The role of a center of excellence is to highlight institutions that are among the best in the country for quality, volume, safety, and effectiveness. This determination is made only after a rigorous review of data, including clinical outcomes. In my early days at City of Hope, I was focused on the development of these center of excellence relationships. Today as chief clinical operation officer, my role is to ensure we can continue to exceed the rigorous quality and operational standards we are held to as a center of excellence.
To be successful, physicians who participate in supply chain must have good communication skills and curiosity about supplies.
Physicians play a variety of roles in supply chain at hospitals and health systems, a healthcare supply chain expert says.
Eugene Schneller, PhD, is a professor in the Department of Supply Chain Management at Arizona State University's W.P. Carey School of Business and cofounder of Healthcare Supply Chain eXcellence. He is also director of the Health Sector Supply Chain Research Consortium, which is a university-industry cooperative committed to advancing healthcare supply chain practice.
HealthLeaders recently interviewed Schneller about the roles that physicians can play in hospital and health system supply chains. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: Are there formal roles that physicians can play in a health system's or hospital's supply chain department?
Eugene Schneller: Physicians can participate in several ways. One way is as a member of a value analysis team organized and managed by supply chain. In many cases, these are standing committees to look at products such as in orthopedics or cardiology. These committees meet monthly or several times a year to look at products that the hospital is using. Physicians are demanders of products, and there needs to be a very clear relationship or mechanism by which physicians can provide input to supply chains. Value analysis teams are one way to do that.
As hospitals look at new products, they invite physicians to bring those products to them. In that case, the physician is a proposer.
Physicians can sit in on sessions where the hospital is looking at a class or category of goods, and physicians participate at looking at those goods. That happens frequently when a contract is ending.
Physicians can also serve as liaisons or "linking pins" to the supply chain department representing their clinical departments. If you think of supply-intensive admissions such as orthopedics and cardiology, those are areas where new products are evolving constantly, so you may have a physician working in a liaison role that is part of the physician's total responsibility.
Physicians can also participate in quality assurance processes that are conducted by supply chain.
Often, there are physicians who are full-time employees of supply chain departments. Some large health systems have physicians embedded within supply chain.
HL: For physicians more broadly, how can they play a role in supply chain functions and activities?
Schneller: Physicians can serve as scouts for new products because they go to meetings that frequently have demonstrations of new products.
Physicians can communicate when the relationship with a supplier is not what has been agreed upon in a contractual relationship in terms of the supplier providing support for the product.
Physicians can also communicate the criticality of a product in a procedure. Increasingly, we are thinking not just in terms of individual products but in terms of an episode of care. For example, you can have a hip replacement or a knee replacement with several products involved, so the interaction of several products is important. Physicians can communicate about that interaction. A group of surgeons may decide that a product is not necessary, so they need to communicate with supply chain about what is happening.
Physicians may be the first to find out about the absence of a product. They need to communicate with supply chain about these "stock outs."
Physicians also may be the first to know about problems with products such as products that are not working properly. There can be products that the Food and Drug Administration has not yet recalled but a clinician may recognize that the product is not performing correctly and communication with supply chain is important.
HL: For physicians who participate in supply chain management, what kind of qualities should they have to be successful?
Schneller: They need to be able to communicate in all directions. They need to be able to communicate with their physician colleagues about discussions related to products. If a hospital has several physicians within a specialty, those physicians collectively have an interest in what products are available and they have strong preferences. Physicians have preferences for brands on the basis of their perceptions of brand performance, on the basis of the outcomes they achieve, and their relationships with companies. As supply chain considers reduction in the number of products, addition of new products, or maintaining a robust mix of products, communication between physicians and supply chain is critical.
Physicians who work with supply chain also need to have curiosity about supplies. In most medical schools, there is relatively little education about supply chain or how supplies are chosen. So, a physician who plays a supply chain role needs to have curiosity about supplies, the information about supplies, and their relative effectiveness and comparability to other supplies.
HL: How should supply chain leaders communicate with physicians?
Schneller: The most important thing is establishing relationships and communication channels. A supply chain leader should not only show up when there is bad news such as a product not being available or when there is a delay in a product coming from overseas. There needs to be relationships so supply chain leaders are not just delivering bad news—they must understand the needs of the clinicians.
Critical to the relationship is bringing data. When you want to influence a clinician or a clinician is curious about a new product, it is important to have data about products and their performance that is provided by the supplier or generated through comparative work. At some of the more progressive health systems, artificial intelligence is being used to look at what products are used in an episode of care. For example, with hip and knee replacements, information systems can be used to understand which products contribute to the cost, quality, and outcome of the episode of care.
Increasingly, clinicians are being incentivized to reduce costs through bundled payments, where a hospital gets a single sum of reimbursement for an episode of care. Within a bundled payment for a surgery, there are all of the costs for the episode of care including the costs for supplies, and any savings can be distributed by the hospital through a gain-sharing arrangement. Under these circumstances, having data about supplies is important.
You need to be able to communicate with physicians about supply issues and anticipate them ahead of time. During the pandemic, we have seen problems related to the availability of products, and you need to let physicians know about these problems ahead of time and provide alternative products that are satisfactory. To have these conversations, you need to have relationships and to be able to communicate effectively.
The American Hospital Association's new Health Equity Roadmap provides a model for transformation and resources to make progress.
The American Hospital Association (AHA) has released a Health Equity Roadmap to help the organization's members make advancements in equity and inclusion.
Health equity has emerged as a pressing issue in U.S. healthcare during the coronavirus pandemic. In particular, there have been COVID-19 health disparities for many racial and ethnic groups that have been at higher risk of getting sick and experiencing relatively high mortality rates.
"The Health Equity Roadmap is a framework to support our member hospitals and health systems in their efforts to become more inclusive and more equitable organizations as we work toward dismantling the structural barriers that exist for some of our patient populations," says Joy Lewis, MPH, MSW, senior vice president of health equity strategies at AHA.
The AHA's Health Equity Roadmap has five components and resources, she says.
1. Transformation model: "There are six levers of transformation in the model. If our members focus on these six areas, they will be well-positioned to mobilize and make positive change toward becoming more equitable. The six levers of transformation are community collaboration for solutions, equitable and inclusive organizational policies, culturally appropriate patient care, collection and use of data to drive action, diverse representation in leadership and governance, and systemic and shared accountability," Lewis says.
2. Transformation assessment: "The transformation assessment serves as both a diagnostic of a hospital's current state and a baseline of where they are to help create a structure and process for continuous improvement toward transforming to more equitable and inclusive environments for both their workforce and the patients and communities they serve. The assessment calls out key performance indicators across each of the six levers of transformation," she says.
3. Transformation profile: "When a hospital conducts the assessment, they get the results in the form of a transformation profile. The profile says, 'Here is where you are. Here is your placement on the equity continuum.' There are five placements on the equity continuum—exploring, which is an embryonic stage of development; committing; affirming; immersing; and transforming, which is the most advanced stage. The profile provides data around where you are in each of the six levers of transformation. For example, a hospital could be transforming in their data collection and how they use data to improve care, but they could be exploring when it comes to addressing the issue of diverse representation in leadership and governance," Lewis says.
4. Action planners: "Once a member has the profile, they are then able to access the action planners, which are like a workbook. You gather a team of leaders from across the hospital who would be making contributions in each of the levers of transformation. This team thinks through and crafts actions that need to be taken to move from exploring to committing, for example," she says.
There 30 different action planners in total given the six levers in the transformation model and five placement levels of the equity continuum. Each action planner includes reflective questions that hospitals should ask of themselves and best practices.
For example, there is an action planner for the affirming placement level of the equity continuum for community collaboration for solutions. Reflective questions that hospitals should ask of themselves for this action planner include: What are the obstacles related to community collaboration for solutions at your organization? What are the impacts of these obstacles? Who is most impacted by these obstacles? Best practices for this action planner include: Conduct an audit to determine what barriers exist for individuals and marginalized communities in their ability to achieve good health and access healthcare services. Assess how well your existing services are reaching marginalized communities. Gather information on patient experience and disaggregate by race to determine common barriers for communities.
5. Health Equity Action Library: "When our members get their profile and they receive their placements on the equity continuum, they are also given a link to the resources in the Health Equity Action Library that can help them to mobilize and take actions to move from one placement to another on the equity continuum," Lewis says.
The Health Equity Action Library is accessible to all hospitals and health systems. Access to the rest of the Health Equity Roadmap is limited to AHA members.
Benefits of addressing health inequities
Addressing health inequities benefits patients, she says. "Given that the goal of the healthcare system is promoting health, it is clear that eliminating disparities is the right thing to do for patients. We want each patient to have the opportunity to achieve their optimal health status, and the same goes for communities. For example, if you look at racial health inequities, studies have shown that racial health inequities can cost billions of dollars in lost productivity and can result in premature death."
Addressing health inequities also improve the performance of hospitals and health systems, Lewis says. "For hospitals and health systems, eliminating inequities improves patient engagement, decreases readmissions, and improves health outcomes. Eliminating inequities also improves performance and reduces healthcare costs. Addressing health disparities allows hospitals and health systems to perform better in value-based payment arrangements. So, there is a business case for addressing health inequities."
Racial, ethnic, and linguistic concordance between healthcare providers and patients is low for people of color, a new report says.
Lack of diversity in the healthcare workforce risks undermining trust and patient health, according to a new report published by the Urban Institute.
Past medical mistreatment of people of color such as ignoring patients’ health concerns has resulted in mistrust of healthcare providers in these populations. “Perceptions of a shared identity between patients and their healthcare providers could be one way to improve the patient-provider relationship and foster trust and better communication,” the new report says.
Earlier research has shown benefits of having healthcare providers of the same race as patients or who speak the same language as patients. These kinds of concordances have “been associated with a greater likelihood of patients agreeing to and receiving preventive care, better patient experience ratings, and higher ratings on patient-reported measures of care quality,” the report says.
The report, which received funding from the Robert Wood Johnson Foundation, includes two key findings.
Only 22.2% of Black adults reported being of the same race as their healthcare providers compared to 73.8% of White adults.
Only 23.1% of Hispanic/Latinx adults reported racial, ethnic, and language concordance with their usual healthcare provider.
“Trust is part of the foundation of good patient-provider relationships and is especially important for communities of color, who have long been discriminated against in healthcare. Having a provider who looks like you and shares your experiences builds trust. Diversifying the healthcare workforce and increasing access to culturally competent care are significant opportunities to promote health equity and reduce disparities,” Jacquelynn Orr, DrPH, Robert Wood Johnson Foundation program officer, said in a prepared statement.
Addressing healthcare workforce diversity
Medical education should be a focal point in efforts to increase diversity in the physician workforce, the report says. “Because Black medical institutions play a key role in training Black providers and other providers of color, creating and supporting medical schools at historically Black colleges and universities and other minority-serving institutions could help increase the diversity of the healthcare workforce,” the report says.
Barriers for people of color who apply to medical school include the high cost of medical education programs, inadequate guidance in navigating admissions, and insufficient support systems to make sure people of color have the resources necessary to pursue a medical education, the report says.
“Cost barriers are particularly salient, given that the median cost of attending an in-state four-year medical school is about $260,000 for public institutions and more than $350,000 for private ones. … Tuition-free programs, debt-free medical education programs for students qualifying for financial aid, and scholarships and grants for underrepresented students are promising strategies for lowering the price of medical education and increasing the representation of Black students and other students of color,” the report says.
Importance of language
Earlier research has shown that patients for whom English is not the primary language have worse health outcomes than patients with English proficiency.
There are two primary strategies to address language gaps, the report says.
First, healthcare providers can offer interpretation services. “Most Medicaid programs reimburse for professional medical interpretation, but reimbursement ranges from $30 to $50 per visit, and interpretation for an encounter could cost up to $200; private insurers seldom reimburse for interpretation services. Stronger enforcement of language access regulations and higher reimbursement for medical interpretation services by health insurance payers could improve language access in healthcare,” the report says.
Second, healthcare providers can be encouraged to be multilingual. “Although some medical schools recommend students be fluent in a language other than English, making this a requirement or a heavily positively weighted factor for medical school admissions could also help diversify the languages spoken in the healthcare workforce. Offering bonuses and higher pay for healthcare workers who speak multiple languages could also incentivize providers to add staff who speak languages other than English,” the report says.
A chief medical officer for physician experience is tasked with boosting physician well-being and experience.
To address physician burnout and physician well-being, Altamonte Springs, Florida-based AdventHealth is focusing on the broader concept of physician experience.
Healthcare worker burnout was a top concern for health systems, hospitals, and physician practices before the coronavirus pandemic, and it has reached crisis proportions during the public health emergency. Prior to the pandemic, burnout rates averaged in the range of 30% to 50%; now, average burnout rates range from 40% to 70%, a healthcare worker well-being expert recently told HealthLeaders.
At AdventHealth’s Central Florida Division, Omayra Mansfield, MD, MHA, has been charged with boosting physician experience. She is an emergency medicine physician, chief medical officer for AdventHealth Apopka hospital, and chief medical officer for physician experience at the Central Florida Division.
HealthLeaders held a recent discussion with Mansfield about AdventHealth’s approach to physician burnout and physician well-being. The following transcript of that conversation has been edited for brevity and clarity.
HealthLeaders: How is your role different from a chief wellness officer?
Omayra Mansfield: I have two project managers that I work with. I have one manager for experience projects such as physician recognition, scribes, and leadership development. Those are experiential projects that we are moving forward with our physicians.
I have a second project manager who focuses specifically on the well-being and wellness of the medical staff. The well-being project manager focuses on the core elements of physical health, emotional health, spiritual health, and psychological health. For example, the well-being project manager can pursue opportunities for connections with families and other opportunities, like going to a kitchen to learn how to cook healthy meals.
The key is the three of us work collaboratively. Each of the project managers feeds into the other. Traditionally, chief wellness officers have focused more on the wellness space. What we have added is the experience project space. But there is overlap, and that is the beauty of having two project managers.
HL: What are the primary elements of physician experience at AdventHealth?
Mansfield: I define physician experience as what it is to be a physician at AdventHealth. What is your experience from day one? From the minute that you decide you want to join AdventHealth, what is your experience? How is it to navigate the system? How easy is it to be credentialled? Then once you are a medical staff member, what is your experience day-to-day? What is it like to be on call? How do people communicate with you?
All of those elements will ultimately contribute to or detract from a physician’s personal well-being.
The experience is how the physician interfaces with AdventHealth and all of the parts of the health system, our patients, the rest of the staff, and nurses. The primary elements of physician experience are understanding that concept, then what we have done is broken it out to say, “How would you define each of those components?”
Well-being is probably by far the most important component of physician experience because well-being is not just your well-being at work—it starts at home. We want to look at physicians as whole individuals and attend to their well-being at home. Is your work distracting you too much? What are we contributing to in your personal life? How are we enhancing your personal life? How are we engaging your family in your experience at work?
The way we break up the rest of physician experience is related to the vision we have as a company and what we aspire to be by 2030. We want to be known as the company that looks at patients as whole individuals and healthcare as one facet of being a whole individual. I’m looking at my physicians in the same way.
HL: Are there guiding concepts for physician experience at AdventHealth?
Mansfield: We have four service standards—love me, own it, keep me safe, and make it easy. These service standards apply to physician experience.
One of my elements of experience for physicians is what am I doing every day to show them that we love them. For example, what are we doing to make them feel like they are part of the campus and not siloed as a medical staff member? What are we doing to show them that we love them and their families? What are we doing at the campuses to organize family events?
From the "own it" piece, we want to know, what are the rocks in their shoes? There are a lot of big things that I can do to enhance physician experience—I can help their transition to our new electronic medical record. But in the end, there are little rocks in the shoes that each doctor has that we need to identify, because we can do big things, but if those little rocks are still there, the big things don’t matter as much as they should. It can be little things such as not being greeted when you walk onto a medical unit. It can be helpful to have someone say, "Good morning, Dr. Jones. How are you doing?"
"Keeping me safe" includes if doctors are facing hostile situations in the work environment, we are supporting them. If they are faced with a challenging patient, we are supporting them. We want to make sure doctors have the tools and the resources that they need to provide safe patient care.
An example of "making it easy" is one of the things that we identified to love our physicians—recognizing physicians for exceptional care. We had a once-a-year opportunity to recognize physicians for extraordinary service at the end of the year during our medical staff banquet. But the question arose, why are we just doing this once a year? Our medical staff do extraordinary things every day.
So, we created a physician recognition program, where physicians can be nominated by anybody. There is a service excellence pin, and physicians can be recognized for meeting one of the four service standards—how they demonstrated "love me" or how they demonstrated "make it easy," for example. When a physician gets recognized, they get two pins—one that they can keep for themselves, and a second pin the physician is tasked with finding a colleague to award that pin to. It’s a pay-it-forward mentality.
The physician recognition program is crafted in the "make it easy" spirit. To date, we have had more than 700 physicians recognized in nine months.
HL: What is the primary benefit of a positive physician experience?
Mansfield: If we take better care of our physicians and make sure they are having a positive experience, by default they take better care of our patients. We know that burnout has a direct correlation to adverse clinical outcomes. For example, we know that medical errors increase if a physician is burned out compared to a physician who is not burned out. That is regardless of your tenure—you can be a resident or an attending physician.
HL: How do you measure physician burnout at AdventHealth?
Mansfield: There are two relevant things that we trend and track over time. One is our SCOR survey, which is a safety survey that we take as an organization that allows us to benchmark against other organizations. Part of the SCOR survey looks to the questions of reflections of your own burnout, reflections of team members’ burnout, and questions about your personal resilience. For the most recent SCOR survey, physicians had higher levels of reported self and team member burnout. But what gives me hope is that there were high reported levels of resilience.
The other marker that we use is physician engagement surveys. Looking through those and the comments, we have an opportunity to address the burnout of our physicians.
We use the SCOR and physician engagement surveys because they give us historical data, and they also give us something that we can look at objectively. But I also take the surveys with a grain of salt because there is also the reality of people with boots on the ground. We have a well-connected group of chief medical officers across the Central Florida Division. I rely on this group to give me their feelings about levels of burnout. There are the numbers in the surveys, but there is also the sense that you get from your campus.
Although home health aides play a key role in keeping homebound older adults in their homes, there is a looming shortage of these workers.
Home health aides play a vital role in the care of homebound older adults and there is an alarming shortage of these key caregivers, according to researchers and a recent Alzheimer’s Association report.
Home health aides are critically important to keeping many older adults in their homes, a trio of researchers wrote in a recent Journal of General Internal Medicineeditorial. “Without a strong community support system, we can expect inadequately supported older adults to continue to cycle through illness, repeated unnecessary hospitalizations, and potentially unwanted nursing home admissions,” they wrote.
There is a looming shortage of home health and personal care aides nationwide, according to the recent Alzheimer’s Associationreport. There were 3,083,310 home health and personal care aides in 2018, and 4,146,220 of them will be needed by 2028, representing a 34.5% increase, the report says.
A co-author of the Journal of General Internal Medicine editorial recently discussed the importance of home health aides with HealthLeaders. “There is a significant group of older adults who, over time, lose the ability to perform activities of daily living. Home health aides help to fill in some of those gaps. So, things like bathing and meal preparation can become just too difficult for some older adults. Without the support of home health aides, these older adults will lose the ability to remain at home,” said Jennifer Carnahan, MD, MPH, a practicing physician, Regenstrief Institute research scientist, and assistant professor at Indiana University School of Medicine.
Home health aides can reduce healthcare costs, she said. “In terms of lowering healthcare costs, we know that nursing homes, which are where many older adults often end up, can be highly expensive. Home health aides are usually less than 24/7 service, but they can provide the support that often prevents the high-cost investment of living at a nursing home.”
Home health aides also improve health outcomes, Carnahan said. “Everybody wants to define what a better healthcare outcome would be. The most important person to ask is the older adult themselves and their loved ones. They would say that staying at home is a better outcome. Home health aides help them maintain community living. Home health aides can also help identify medical concerns before other people realize what is going on. At lot of times, home health aides see these older adults every day or every other day, and they will notice if there is a change in mentation or their ability to function.”
Home health aides undervalued
Home health aides do not get the credit they deserve in the U.S. healthcare system, Carnahan said.
“They are often labeled as unskilled laborers. We don’t learn about them in medical school, even though they provide support for many older adult patients. We need to understand better how they fit into the entire picture. They are an afterthought—I learned about home health aides when I was acquiring additional geriatric training. We should think of home health aides as a vital part of the healthcare team even though they are not prescribing medicine or doing some of the things we think of as traditional medical care. They are contributing to care,” she said.
Carnahan and her editorial co-authors found that home health aides are not adequately compensated. “We looked at Bureau of Labor statistics and found that the median salary for a home health aide is $13.02 per hour. So, if you think about the recent discussions about elevating wages in other sectors of the workforce to $15 per hour, you can see how it might be more attractive to look at other types of employment. Home health aides are definitely undervalued in terms of compensation,” she said.
Including home health aides in care teams
Integrating home health aides into care teams can be beneficial, Carnahan said.
“This is a potential solution for making the pathways for communication easier. It is always easier to communicate with colleagues who are part of your company or the institution you are working for. If we can integrate home health aides into care teams, it can make things a lot smoother and easier. I have witnessed this problem in other arenas in healthcare, such as struggling to communicate with other health systems to try to get more information about a patient. When everyone is in the same health system, it is just easier to figure out what is going on with a patient,” she said. “Integrating home health aides with care teams also makes it easier to raise red flags. If a patient seems to be declining, everyone, including home health aides, can be on the lookout for decline. That way, you can nip problems in the bud.”
There are options to integrate home health aides into care teams, Carnahan said.
“A lot of this requires thinking outside of the box. Health systems could hire home health aides or contract with them. The way it is now is fractured. I work for the Indiana University Health Physicians, and any of the home health aides who are working with my patients are working for different companies. So, it is hard for me to find the home health aide who is working with Mr. Smith. Integration of home health aides could come through bringing them into the fold of a health system or partnerships between health systems and home health companies, where we have huddles once per week.”
Impact of coronavirus pandemic accelerated national health spending growth to 9.7% in 2020.
National health expenditures are expected to be influenced significantly by the coronavirus pandemic from 2021 to 2024, then typical factors that drive changes in health spending such as demographics are expected influence spending trends from 2025 to 2030, a new analysis indicates.
The new analysis was conducted by the Centers for Medicare & Medicaid Services’ Office of the Actuary. The analysis features expected annual health expenditures and projected hospital spending growth.
The analysis includes chronological healthcare expenditure projections.
In 2020, unprecedented financial stimulus from the federal government and insurance market upheaval drove national health expenditure growth to a nearly two-decade high of 9.7%. In 2020, the health spending share of the gross domestic product (GDP) increased 2.1 percentage points from 2019, to 19.7%.
In 2021, national health expenditure growth is expected to decline sharply to 4.2%, largely due to reductions in federal coronavirus relief funding. The slower growth rate in healthcare spending combined with growth in GDP, which rebounded to 9.6%, is expected to result in a 0.9-percentage point drop in the healthcare spending share of GDP to 18.8%. Healthcare spending is expected to total $4.3 trillion.
In 2022, national health expenditures are expected to increase at 4.6%, driven in part by higher healthcare prices linked to inflation in the economy. Healthcare spending is expected to total $4.5 trillion.
National health expenditures are expected to increase 5.0% and 5.1% in 2023 and 2024, respectively. These growth rates are tied to an expectation that patient care patterns will return to prepandemic levels. From 2022 to 2024, healthcare spending’s share of GDP is expected to be just over 18%.
The healthcare spending impact of the pandemic is expected to wane progressively from 2021 to 2024.
From 2025 to 2030, traditional drivers of healthcare system trends such as economic, demographic, and health-specific factors are expected to return to prominence. During this period, healthcare spending is expected to increase at an average rate of 5.3% annually, reaching a total annual spending level of $6.8 trillion by 2030. Healthcare spending’s share of GDP is expected to be 19.6% in 2030.
The analysis also includes projections for hospital spending growth.
In 2021, hospital spending growth is expected to decline 0.7 percentage points to 5.7%. The primary reason for this drop in spending growth is a decrease in federal coronavirus relief funding. In 2021, total hospital expenditures are expected to reach $1.3 trillion.
In 2022, rebounding demand for care and hospital price growth linked to inflation are expected to drive hospital spending growth upward sharply to 6.9%.
In 2023 and 2024, hospital spending growth is projected to decrease to 5.6%, with a normalization of pandemic-related effects such as utilization, federal stimulus funding, and insurance market disruptions.
From 2025 to 2030, hospital spending growth is expected to decrease slightly to an average of 5.5% annually. Influencing factors are expected to include reduced Medicare and private health insurance spending for hospitals.
Projections dependent on pandemic
The projections presented in the analysis are based on the assumption that the effects of the pandemic will wane through 2024, the co-authors of the analysis wrote. “As the severity of the COVID-19 pandemic and its related health and economic impacts are projected to lessen during the next few years, it is anticipated that the health spending and enrollment trends observed in 2020 will unwind as well.”
Traditional factors are expected to influence healthcare spending trends from 2025 to 2030, but there is considerable uncertainty associated with the pandemic, the co-authors wrote.
“Economic and demographic factors are anticipated to reemerge as the most influential drivers of health-sector trends, resulting in more stable health spending trends and a slowly increasing share of the economy devoted to healthcare. However, this outlook is contingent on a virus that has evolved and surprised at every turn—and could do so again. So although a normalization of health spending and the economy underlie this projection, only time will tell how normal the next decade is,” they wrote.
Despite willingness to address social drivers of health, two-thirds of physicians report inadequate time or ability to act, according to a new survey.
Physicians view social drivers of health (SDOH) as critically important in the health of their patients and they want to do more to help address SDOH, a new survey report has found.
SDOH such as food insecurity, housing instability, and transportation problems can have a pivotal impact on health outcomes, with a far greater effect than clinical care alone. “Physicians know that reducing total cost of care and achieving health equity are only achievable by addressing SDOH. Despite the well-documented impact of SDOH on health outcomes and costs of care, our current healthcare system does not operate in a way that includes addressing them,” the new survey report says.
The survey was conducted by The Physician Foundation from Feb. 2 to Feb. 11. Data was collected from more than 1,500 physicians. One-third of the physicians who responded to the survey practice primary care, which was defined as family medicine, general practice, internal medicine, or pediatrics. The remaining survey respondents practice in one of two dozen specialties.
The survey report includes several key data points.
99% of physicians reported that at least one SDOH affected the health outcomes of all or some their patients
Financial instability (34% of patients) and transportation problems (24% of patients) were the top two SDOH experienced by physicians’ patients
61% of physicians reported having insufficient time and ability to affect the SDOH of their patients
87% of physicians reported wanting more time and ability to affect the SDOH of their patients
Physicians reported that the top three reported obstacles to addressing their patients’ SDOH were limited time during patient visits (89% of physicians), inadequate staff to connect patients with community resources (84%), and the lack of community resources or difficulty of accessing community resources (77%)
83% of physicians reported that addressing the SDOH of patients contributes to physician burnout
68% of physicians reported that addressing the SDOH of patients has a major effect on physician mental health and well-being
80% of physicians reported that addressing SDOH is essential to improve health outcomes and decrease healthcare costs
Interpreting the data
Physicians are willing to do more to address the SDOH of their patients, Gary Price, MD, president of The Physicians Foundation, told HealthLeaders. “It’s clear physicians recognize how critical it is for our patients and our country’s healthcare system to address SDOH—and they are very much eager to play a more proactive role in this work. In fact, our survey found that nearly nine in 10 physicians (87%) indicated that they would like greater time and ability to effectively address their patients’ SDOH in the future.”
Physicians have a key role to play but they need partners to address the SDOH of their patients, he said.
“We physicians know that reducing total cost of care and achieving health equity are only achievable by addressing the SDOH. We must remain central to this discourse and decision-making as we’re closest to these issues and our perspectives are critical to improving patient outcomes. But we cannot do it alone. Addressing SDOH requires a holistic approach, including comprehensive coordination among individual physicians, medical societies, health systems, social service systems, and policymakers. A Physicians Foundation grant partner, Health Leads, is a great example of cross-sector community collaboration to enact systemic change in integrating SDOH in healthcare delivery,” Price said.
The link between physicians working on SDOH and physician burnout is concerning and should be addressed, he said.
“Physician burnout is a complex challenge and according to physicians surveyed, multiple factors contribute to physician burnout rates—from administrative burdens to prior authorization requirements. However, eight in 10 physicians (83%) reported challenges in addressing patients’ SDOH contribute to physician burnout rates. Additionally, six in 10 physicians (68%) believe managing patients’ SDOH has a major impact on physician mental health and well-being. Much of this is due to lack of resources. More than half of physicians reported experiencing stress or frustration on a daily or weekly basis because of limited time during patient visits to discuss SDOH, insufficient workforce to navigate patients to community resources to address SDOH, existing payer reporting requirements taking time away from being able to address patients’ SDOH, lack of reimbursement for screening for or addressing SDOH, and community resources unavailable, inadequate or difficult to access,” Price said.
There are several changes that can be made to support physicians in their efforts to address the SDOH of their patients, he said. “In our survey, multiple SDOH policy steps were identified by physicians as important to improve health outcomes and ensure high-quality, cost-efficient care for all. These steps included reimbursing physician-directed efforts to address SDOH, incentivizing payers to invest in availability and quality of community resources to address patients’ SDOH, providing greater flexibility for Medicare Advantage to reimburse for addressing SDOH, and integrating SDOH into payment policy.”