Unless new policies are adopted, a steady decline in the number of palliative care physicians is expected for the next 14 years.
The palliative care workforce is stretched thin and staffing shortages will worsen dramatically unless lawmakers and healthcare organizations adopt new policies, according to research published this week.
When palliative care teams are integrated into the care of the seriously ill, evidence shows improved outcomes for patients, caregivers, and healthcare organizations. There are already shortages of palliative care clinicians, and rapid growth of the older adult population is expected to increase demand for palliative care services.
There are about 7,600 physicians who are board certified in the specialty level practice of hospice and palliative medicine.
Staffing shortages forecast
The research published today in Health Affairs is based on survey data collected from more than 2,000 palliative care professionals and features several key findings:
Risk factors for intent to leave the field early include being a nonphysician clinician, symptoms of burnout, and poor work-life balance.
About 40% of the palliative care physician workforce was 56 or older, which is expected to increase retirements in the next decade.
Unless new policies are adopted, the wave of retirements combined with early departures from the field will result in a steady decline of palliative care physicians over the next 14 years. Under this "workforce valley" scenario, the number of physicians bottoms out at 6,600 in 2033 and does not recover to the 2019 level until 2045.
Patient-to-physician ratios are expected to worsen for at least 25 years. This year, there are about 800 Medicare beneficiaries eligible for palliative care for every board-certified physician. Unless new policies are adopted, there will be more than 1,300 eligible beneficiaries for every palliative care physician in 2038.
About one-third of the survey respondents reported they were burned out, and burnout was associated with 1.40 times higher odds of intending to leave the field early.
Compared to survey respondents reporting a good work-life balance, palliative care professionals with poor work-life balance had 1.36 higher odds of intending to leave early.
Adopting new policies to expand training opportunities and reduce burnout would reduce the worst depth of the expected workforce valley to about 7,400 palliative care physicians in 2024. Under these new policies, the estimated number of physicians would double the 2019 level, increasing to more than 16,000 in 2059.
"Our modeling revealed an impending 'workforce valley,' with declining physician numbers that will not recover to the current level until 2045, absent policy change. However, sustained growth in the number of fellowship positions over ten years could reverse the worsening workforce shortage," the Health Affairs researchers wrote.
Policy recommendations
The study authors recommend five policy changes at the legislative and healthcare organization level to address palliative care workforce shortages.
1. Legislation: Passage of the Palliative Care and Hospice Education and Training Act, which was reintroduced in the House of Representatives in January. Provisions of the legislation include fostering physician leaders with palliative care academic career development awards to provide salary support and funding for training centers.
2. Education funding: Expansion of funding for palliative care training should include increased Medicare graduate education support for palliative medicine physician fellowships. To encourage a team approach to palliative care that maximizes physician effectiveness, federal funding should also support increased educational opportunities for nonphysician palliative care professionals.
3. Research: Workforce shortages are expected among nonphysician palliative care specialists including nurses, social workers, and chaplaincy professionals. Research should examine the composition of these disciplines and their workforce needs.
4. Reimbursement: Current payment models such as fee-for-service Medicare are structured to reimburse the services of palliative care physicians and advanced practice professionals. New payment models should be structured to provide reimbursement to interdisciplinary teams.
5. Burnout: Although the prevalence of burnout among palliative care team members surveyed for this study was relatively low compared to other specialties, the forecast of worsening staff shortages raises the likelihood of higher burnout rates. Policy makers and healthcare organization officials should pursue policies that ease burnout and promote resilience.
New American College of Physicians guidance on impaired physicians features five prescriptions for struggling clinicians, their colleagues, and their employers.
When physicians are impaired, the clinicians, their colleagues, and their healthcare organizations are obligated to address the problem, according to new American College of Physicians (ACP) guidelines.
An impaired physician is incapable of providing patient care safely and effectively. There are several causes of impairment, including substance abuse, mental illness, profound fatigue, or deterioration of cognitive or motor skills linked to aging or illness.
The ACP Ethics, Professionalism, and Human Rights Committee has adopted five positions on physician impairment. The ACP Board of Regents approved the guidelines, which were published today in Annals of Internal Medicine, in November.
Position 1:"The professional duties of competence and self-regulation require physicians to recognize and address physician illness and impairment."
Self-regulation is essential in professions. In medicine, the profession is expected to uphold standards of competence that ensure safe, ethical, and effective patient care. At the personal level, impaired clinicians should try to see they are unable to offer safe and effective care, then seek treatment.
Peers have an obligation to assist or report impaired clinicians. If there is no threat of patient harm, a collegial conversation can raise concerns and provide an opportunity to urge physicians to seek help. If the threat of patient harm is high, colleagues should report concerns to licensing boards or clinical supervisors. When the threat of patient harm is unclear, concerns should be raised to designated organizational officials or other senior leaders such as a department chair.
Position 2:"The distinction between functional impairment and potentially impairing illness should guide identification of and assistance for the impaired physician."
An impaired physician is incapable of functioning safely and effectively. But the presence of illness does not always result in impairment.
Impairment may be linked to substance abuse, mental or medical conditions, effects of aging, or fatigue. The presence of these risk factors or treatment of them is not conclusive proof of impairment. Help should target the underlying illness or condition.
Best practices for helping a clinician with an impairing condition should be guided by the status of the condition and potential for patient harm. Whenever possible, rehabilitation should be the primary goal for physicians who face impairing conditions. Evaluation and treatment should be consistent with standards of care.
Position 3:"Best practices forphysician health programs(PHPs) should be developed systematically, informed by available evidence and further research."
Most PHPs are affiliated with state medical boards or medical societies. The organizations do not treat physicians directly, working instead to monitor and oversee treatment, contract with impaired physicians on treatment plans, and maintain compliance records.
There are PHPs in 46 states and the District of Columbia. Research is needed to determine which PHPs are most effective and their keys to success.
Position 4:"PHPs should meet the goals of physician rehabilitation and reintegration in the context of established standards of ethics and with safeguards for both patient safety and physician rights."
In the rehabilitation of impaired physicians, PHPs face several ethical considerations. For example, constituencies including hospitals, insurers, and medical societies can support PHPs, but they should not sway operations or case management. PHPs should also avoid competing interests such as entanglements with treatment programs or monitoring labs.
Patient safety is always a paramount concern, but PHPs should try to guarantee procedural fairness for impaired physicians. For example, monitoring is subject to administrative and legal oversight ranging from internal processes to civil procedures.
Position 5:"Maintenance of physician wellness with the goal of well-being must be a professional priority of the healthcare community promoted among colleagues and learners."
Healthcare organizations should establish an environment and culture that supports wellness and wellbeing, including assistance for clinicians with impairing conditions.
More broadly, fostering physician well-being involves outreach, education, and leadership throughout the field of medicine such as state medical boards, professional societies, and PHPs.
As part of the profession's commitment to society, physician well-being should be a quality marker at healthcare organizations. The more well-being is elevated, the greater the expectations of benefit in terms of physician recruitment and retention.
Researchers call physician turnover costs and lost productivity a 'substantial economic burden.'
The annual cost of physician burnout is conservatively estimated at $4.6 billion, research published this week shows.
A national survey conducted in 2014 found that 54% of physicians were experiencing burnout symptoms and prevalence of physician burnout was twice as high as in the general population. Other studies have associated burned-out physicians with higher rates of self-reported medical errors and poorer clinical outcomes.
The study published this week in Annals of Internal Medicine is one of the first attempts to estimate the cost of physician burnout to health systems, hospitals, and physician practices, the researchers wrote.
"Our study provides tools to evaluate the economic dimension of this problem. Together with previous evidence that burnout can be reduced effectively with moderate levels of investment, our results suggest that a strong financial basis exists for organizations to invest in remediating physician burnout."
The $4.6 billion national annual cost of physician burnout was calculated based on two elements:
1. Physician turnover: The researchers tried to account for two components of the cost associated with burned-out doctors leaving their jobs. The first component was the cost linked to physician replacement for search expenses, hiring, and new physician startup. The second cost was lost income from open physician positions.
2. Reduced clinical hours: To approximate the cost of physicians lowering their clinical hours, the net cost of turnover was adjusted by a fraction representing the average percentage difference in weekly work hours between physicians who were burned-out and physicians who were not burned out.
The researchers also estimated the annual cost of physician burnout at the organizational level. They found the costs linked to turnover and reduced clinical hours is about $7,600 per employed physician.
Burnout cost likely more than $4.6B
The $4.6 billion cost estimate almost certainly understates the economic burden of physician burnout, the researchers wrote. "Our analysis is conservative, omitting other burnout-related costs that are difficult to quantify."
The analysis does not account for several aspects of physician burnout that have financial consequences:
Physician burnout has been linked to reduced quality of care, lower patient satisfaction, and malpractice lawsuits
Some of the "friction costs" associated with replacing physicians were unaccounted such as the impact on other care team members
At the organizational level, the cost estimate for physician burnout does not account for patients who leave a practice after their burned-out doctor departs
The cost estimate does not include indirect revenue losses associated with a physician vacancy such as diagnostic tests and procedures
"Using data informed by the current state of research, our conservative analyses suggest that on a national scale, a substantial economic burden is associated with physician burnout in the United States," the researchers wrote.
To boost quality and reduce costs, an IHI initiative calls on clinical teams to focus on four evidence-based elements when caring for older adult patients.
An Institute for Healthcare Improvement (IHI) initiative to promote age-friendly clinical care for older adults is taking hold nationwide.
The number of Americans over age 65 is expected to double to nearly 100 million by 2060. With multiple chronic conditions and high costs of care at end of life, older adults have relatively higher healthcare costs compared to younger Americans. In 2010, citizens over age 65 were 13% of the population but accounted for 34% of healthcare spending.
IHI's Age-Friendly Health Systems initiative launched in early 2017. Now, 350 healthcare organizations including more than 125 health systems are implementing the effort in whole or in part.
Four-pronged intervention strategy
The main component of the IHI initiative is an evidence-based framework called the 4Ms:
What matters to the patient: With a potentially dramatic impact on medical decisions, determining what matters to patients may be the most momentous of the 4Ms, says Kedar Mate, chief innovation and education officer at Boston-based IHI. "Improving medical decision-making is a key element of attaining value. Of all the interventions, the first M—what matters—gets you to high value as defined by the patient. It gets you to services that offer value in the patient's eyes."
Medication: Managing medications is crucial for achieving therapeutic benefits and avoiding adverse drug reactions, which cause harm and costly complications. Annual costs in the United States associated with adverse drug reactions have been estimated at $30 billion, according to a December 2013 article in the Journal of Pharmacology & Pharmacotherapeutics.
Mentation: Addressing delirium in the inpatient setting generates significant mentation benefits, Mate says. "Delirium is extremely common among older adults in inpatient settings, and it is extremely costly both on the human cost side with complication rates and lengths of stay, and the financial side. Length of stay is often 20%–30% longer with delirium."
Mobility: Maintaining mobility also generates clinical and financial benefits, he says. "The data on functional impairment is stark. If you have a patient with one or two chronic conditions, then you add on functional impairment, the cost of care roughly doubles. Functional impairment is a big impediment in older adults' lives in achieving what matters to them, and it costs us a ton of money as a society."
In consultation with geriatricians and healthcare organization leaders, IHI selected the 4Ms after dissecting 17 evidence-based clinical practice models for older adults.
"To get to four things felt doable to folks. It felt conceivable for health systems to adopt, and achievable in a relatively short period of time for the average practitioner in the clinical service environment," Mate says.
Anne Arundel Medical Center benefits from 4M framework
At Anne Arundel Medical Center, asking older adult patients what matters to them has been a primary driver in adoption of the IHI initiative, says Barbara Jacobs, RN, chief nursing officer of the Annapolis, Maryland–based health system.
"We've changed our discharge plans and the way we interact with a patient and a family by asking that fairly simple question. We need to know what the patient wants in terms of the plan of care," she says.
Like most patients, many older adults want to go home after an inpatient stay, and Anne Arundel discharge teams have stepped up efforts to honor this desire, Jacobs says.
"If we don't ask patients where they want to be after discharge, we are not going to have a successful discharge. We have to work with patients if they say they want to go home. We can set up that support. It's a learning moment for us—listening to the patient."
Anne Arundel is pursuing all 4Ms, and a mobility intervention stands out, she says.
The main campus of the health system has an inpatient floor that specializes in care for older adults, the Acute Care for the Elderly (ACE) Unit.
At 11 a.m., medically cleared patients are encouraged to participate in "ACErcise," which features wheelchair-based exercises and walking. The age-friendly session has become a significant socialization event. "The patients enjoyed the togetherness, so the activity evolved into the opportunity to eat together. It has been very popular," Jacobs says.
The value of mobility is undeniable, she says. "If a patient stays moving, their chance of getting home is much better, which is where most people want to go."
Age-friendly care impact
Anne Arundel is implementing multiple age-friendly efforts simultaneously; so, it's difficult to gauge return on investment, but gains are expected, says Executive Vice President of Integrated Care Delivery and COO Maulik Joshi, DrPH.
"The age-friendly best practices are based on research and evidence that the interventions make a difference in outcomes. For us, we are strongly focused on quality and investing in quality. It can be hard to prove, but these best practices have been directly related to readmissions, patient satisfaction, length of stay, and other crucial outcomes," he says.
Anne Arundel is confident there will be clinical and financial gains from age-friendly efforts, Joshi says. "The evidence is incredibly profound. This is not weak evidence. We know mobility and medication management have a huge impact."
Jacobs says the value is apparent. "It's not like you are out on a limb with something that has barely been tested. It is palpable. You can see that this kind of care is better."
The early results at healthcare organizations participating in the IHI initiative are promising, Mate says.
"It didn't surprise us that the 4Ms improved the health of populations—they were derived from models that improved the health of seniors. And it didn't surprise us that patients were more satisfied when they were asked about what mattered to them and more satisfied when caregivers paid more attention to their mobility. What surprised us is that the 4Ms lowered costs significantly."
To help health systems, hospitals, and clinics track the financial impact of age-friendly efforts, the IHI initiative includes ROI calculators for the inpatient and outpatient settings.
In case studies conducted by IHI, two organizations reported significant ROI on their age-friendly activities, Mate says:
Ascension-affiliated St. Vincent Medical Group, Indianapolis: In an ambulatory setting where 4M care is being added to annual Medicare wellness visits, $600,000 of additional benefit was generated on a $3 million investment.
Hartford Healthcare-affiliated Hartford Hospital in Connecticut: The academic medical center implemented a delirium management program that generated a $3.6 million return on a $2.4 million investment in the program.
"If you want to figure out how you deliver higher-value care, then an age-friendly system is a good place to start," Mate says.
How healthcare organizations can implement the 4Ms
IHI published a list of steps for health systems, hospitals, and clinics to implement age-friendly care into their organizations:
Learn about age-friendly health systems
Inform IHI of your interest in participating
Identify an age-friendly champion
Send IHI a letter of commitment from a senior leader
Introduce clinical teams to the age-friendly framework
Describe how your healthcare organization will apply the 4Ms
Share your description of the 4Ms with IHI
Share the count of patients who are receiving age-friendly care with IHI for at least three months
An 11-member intervention team redesigns workflows, develops new EHR tools, and trains clinicians to use the EHR more efficiently.
An intense, two-week program to improve electronic health record systems at the clinic level improves clinician satisfaction with the EHR significantly, recent research shows.
EHR burden has been cited as a primary contributor to clinician burnout. Research indicates that nearly half of physicians are experiencing burnout symptoms, and a study published in September found burnout increases the odds of physician involvement in patient safety incidents, unprofessionalism, and lower patient satisfaction.
In a study published this month in Mayo Clinic Proceedings, researchers show the two-week "Sprint" EHR intervention developed at Aurora, Colorado-based UCHealth increased clinician EHR satisfaction. On a net promoter scale ranging from -100 (worst) to +100 (best), clinician satisfaction with the EHR was -15 before the Sprint intervention and rose to +12 after the intervention.
The Sprint intervention is led by an 11-member team that helps clinic staff improve the EHR to make the system more efficient and user-friendly. The Sprint team includes one project manager, one physician informaticist, one nurse informaticist, four EHR analysts, and four EHR trainers.
Sprint intervention components
The Sprint intervention has three primary components: training clinicians to use the EHR more efficiently, redesigning a clinic's multidisciplinary workflow, and developing new specialty-specific EHR tools.
1. Training clinicians: In a Sprint intervention, clinicians participate in a two-hour kickoff meeting, three 1-to-1 training sessions, and a two-hour wrap-up session. In the 1-to-1 sessions, clinicians meet with either a trainer or the physician informaticist to learn specific skills or address frustrations with the EHR. The training content for Sprint features 10 sets of efficiency tips such as chart review efficiency, medical ordering efficiency, and medication management.
2. Workflow redesign: To examine multidisciplinary workflow and patient flow, Sprint team members meet individually or in small groups with a clinic's non-clinician staff. After assessing strengths and weaknesses, trainers teach EHR best practices to the clinic staff, and the clinic manager redesigns common workflows to promote standardization. For example, a UCHealth clinic developed a pre-visit online patient questionnaire for neurological disorders that is used at every visit.
3. Specialty-specific EHR tools: Clinic leaders review all new EHR tool requests. Examples of popular new EHR tools are synopsis reports, flow sheets, patient-entered questionnaires, and customized note templates. New tools that receive approval are listed in a chart under five headings: backlog, to do, in process, done, and parking lot, with the last designation for tools that cannot be addressed during the Sprint intervention. The chart is available to the clinic staff and updated daily.
Sprint team strengths and ROI
Researchers found the Sprint intervention team model has several strengths:
The physician informaticist plays a crucial role, translating clinician requests for EHR changes into technical solutions and training opportunities
The nurse informaticist targets staff and team workflows
The project manager gives the team a dedicated leader
Having the Sprint team onsite boosts clinic staff engagement in the intervention and allows team members to confer easily and make decisions quickly
The researchers estimate that the Sprint intervention generates a significant positive return on investment.
For one Sprint team, the total annual cost of the invention program is about $1.7 million:
The annual cost of funding one Sprint team, which can engage 500 clinicians, is estimated at $1.2 million.
The annual cost of lost clinician productivity during Sprint interventions is about $500,000.
The researchers estimated that one Sprint team can reduce the number of annual burnout-related clinician departures by 2.5 staff members, which can generate annual cost avoidance as high as $2.5 million.
Research indicates that nearly half of physicians nationwide are experiencing burnout symptoms, and a study published in October found burnout increases the odds of physician involvement in patient safety incidents, unprofessionalism, and lower patient satisfaction. Burnout has also been linked to negative financial effects at physician practices and other healthcare organizations.
Since 2015, Providence St. Joseph's Own It program has been transforming how staff members interact with patients and each other.
"Number One, we focus on why people came into healthcare and help them reconnect with their purpose in healthcare. We talk and have training modules that are about compassion, empathy, accountability, and service cycle," says Kevin Manemann, executive vice president and chief executive of physician enterprise at the Renton, Washington-based health system.
The main component of the Own It program is a four-hour training session that emphasizes compassion and organizational values paired with communication standards, role playing, and storytelling.
About 35 people attend the training sessions, which group participants at tables of six to eight people. Facilitators lead the training sessions, with assistance from a peer facilitator seated at each table. "There's a leader at each table—someone who has been through the program and knows how to facilitate dialogue," Manemann says.
The emphasis on core healthcare values builds resistance to physician burnout, he says. "From a burnout standpoint, Own It reconnects people with why they came into healthcare in the first place. It also brings a reconnection with the organization and our purpose."
The training includes an introduction to "sacred encounters" among staff members and patients. Sacred encounters are caring and courteous conversations that establish connections between staff members and their patients and colleagues. "It's about connecting people with their daily interactions with each other," Manemann says.
As part of sustainment efforts for the Own It initiative, staff members share Own It Moments such as sacred encounters during routine employee huddles on inpatient floors and in other health system departments.
Own It by the numbers
So far, 12,000 Providence St. Joseph staff members have attended Own It training sessions and the initiative appears to be having a positive impact.
In staff surveys conducted immediately after Own It training sessions, 90% of session participants say the training better prepared them to improve the patient experience and interact with one another in a more positive way.
In Press Ganey scores, physician engagement rose from the 58th percentile in 2016 to the 71st percentile in 2017.
Physician engagement is currently trending above the 75th percentile.
Patient satisfaction scores have improved in three metrics: overall physician communication, overall caregiver helpfulness, and overall caregiver courtesy and respect.
"It’s really about behavior and attitude. The more that we understand how we treat each other, and the more that has an impact on our enjoyment in the work that we do, it impacts the patients' experience with us," Manemann says.
G.R.E.A.T. declarations and actions
Communication skills are an essential ingredient of Own It's G.R.E.A.T. principles:
Greet: Introducing yourself by name and role, greeting others in a manner appropriate to the situation, and using welcoming facial expressions and speech
Respect: Saying please, thank you, and you are welcome; facing the person you are speaking with for heart-to-heart conversation; respecting diversity, safety, and confidentiality; and working in an ethical manner
Engage: Providing opportunities for questions and engagement, listening with empathy, and validating needs
Assist: Explaining what you are doing and why you are doing it with good intent, working in partnership with patients, and conducting collaborative decision-making
Transition: Describing next steps and care coordination, escorting patients if necessary, and providing authentic departing remarks
Kenton Zehr wants DMC Heart Hospital to expand the for-profit health system's cardiovascular service line such as performing more open-heart surgeries.
An accomplished mechanic with an entrepreneurial spirit has his hands on the controls at Detroit Medical Center (DMC) Heart Hospital.
Kenton Zehr, MD, who earned his medical degree at Pennsylvania State University College of Medicine and completed a residency and fellowship in general surgery and cardiothoracic surgery at Johns Hopkins Hospital in Baltimore, was named executive director of DMC Heart Hospital in April.
The board-certified thoracic surgeon says a life-long interest in mechanics drew him to cardiac surgery as his field of interest.
"In sixth grade, we went to the grocery store to buy bottles and things, then I made a heart-lung machine out of bottles that pumped colored water with a syringe-type system. I won the science fair for that," Zehr told HealthLeaders.
"When I hit human anatomy at Penn State that became my favorite class with my mechanical background. My father and my brother and I built our house when I was a teenager. We pounded every nail. So, working in a mechanical healthcare subspecialty makes sense to me."
HealthLeaders recently spoke with Zehr about his vision for DMC Heart Hospital. Zehr wants DMC to perform more open-heart surgeries and expand the health system's cardiovascular service line.
Following is a lightly edited transcript of that conversation.
HL: Why do you find the mechanics of the heart and the vascular system appealing?
Zehr: First off, cardiac surgeons don't treat cancer, we treat something that is fixable. In large part, our patients do well; and once they are fixed, they are fixed with a durable result.
In some ways, it's like opening the hood of the car, fixing the car, and closing the hood. The cardiovascular system is very well circumscribed. You know your limitations—it's the pump and the vessels that come in and out of the pump.
HL: How has your medical background prepared you to lead DMC Heart Hospital?
Zehr: I've worked at several major institutions. I spent nine years training at Hopkins back in the day when we were on call every other night—before the resident work hours limited you to 80 hours a week. I did nine years working 100 to 120 hours per week. We were immersed in it very intensely.
After I finished my training at Hopkins, I went to the Mayo Clinic in Rochester, Minnesota. I spent eight years there. The mechanical portion of using the heart-lung machine started there as a tour de force.
I've worked at pioneering systems. The first successful pump support for heart surgery was done in Detroit in 1952. They made four of those machines. One is in the lobby here. One was given to the Smithsonian. I like to feel connected to the thread of history.
HL: How do you plan to strengthen the cardiovascular service line at DMC?
Zehr: For the past several years, the service line has been heavily oriented toward percutaneous interventions on coronary events, not so oriented to a balanced approach.
There has never been a study that has shown percutaneous interventions such as stenting are superior in terms of durability to open heart surgery. We need a balanced approach to cardiovascular care—more balanced than it has been here.
We need to expand into other areas like valvular work. We're not participating strongly in the surgical solutions for heart failure. We have durable pumps—ventricular assist devices—which are basically artificial hearts that are routinely used across the United States, but not in our program. These are the things I plan to bring to DMC.
HL: What are some of the key steps in that expansion effort?
Zehr: We'll start by expanding the surgical volume. I'm hiring another surgeon from Hopkins who will be starting in September and plan to hire another surgeon. So, I am expanding our surgical staff, and we will expand our internal staff at the Heart Hospital—we just hired two interventionalists for stents and percutaneous procedures.
We have hired an internationally known heart failure expert. With myself and the other surgeons we are recruiting, we will be able to put in artificial heart devices. Several years down the road, we hope to have a heart transplant program. Right now, some of those needs are being met by our competitors, which is fine, but it would be nice to offer that as part of being a comprehensive program.
We will have a full-on marketing strategy to market ourselves as available to our community.
HL: What is your vision for DMC Heart Hospital?
Zehr: I want to see us competitive with Beaumont, with Henry Ford, and with the University of Michigan. I would like to see somewhere between 500 to 1,000 open heart surgeries per year. We occupy a market in downtown Detroit that is not served by others in the area. It's a high-needs community, with high percentages of diabetics and high percentages of people with high blood pressure. The first system to be affected by those disease processes is the cardiovascular system.
One of the advantages we have at the Heart Hospital compared to other institutions is that we are in one building. We see patients in the same building. We drink coffee out of the same coffee pot. We have group meetings, where we have a team approach to discussing cardiac care, and we have cardiologists and cardiac surgeons sitting around the same table.
HL: You have a track record in medical entrepreneurism, including several mechanical device patents. Do you hope to involve DMC Heart Hospital in medical entrepreneurism?
Zehr: Historically in Detroit, there has been a lot of opportunity because we have the car companies here. The machine that did the world's first pump support for a heart operation in 1952 was called the Dodrill-General Motors Research pump. All of the engineers came out of General Motors. There are bioengineers who are still associated with those companies.
In Detroit, we have a history of being part of multi-institutional trials for devices like stents that open up clogged vessels and that will continue—one of our strengths is partnering with industrial companies.
The American College of Physicians is calling on policymakers to strengthen and expand the Patient Protection and Affordable Care Act.
The PPACA has achieved significant gains in access to healthcare, and policy makers should focus on nurturing and expanding the healthcare law, the American College of Physicians (ACP) says.
The healthcare law enacted by the Obama administration has notched several achievements, the ACP says in a recent article published by Annals of Internal Medicine. PPACA regulations such as barring coverage restrictions on pre-existing conditions have made health insurance more accessible. Premium tax credits and cost-sharing subsidies have made individual and family coverage more affordable. The essential health benefit package and preventive service coverage has made insurance more comprehensive. And Medicaid expansion has insured millions of previously uninsured adults.
The ACP, which represents internal medicine specialists and has more than 150,000 members worldwide, is making seven recommendations to improve the healthcare law:
1. Strengthen the PPACA: Efforts to undermine the PPACA such as decreased outreach and education funding should be reversed or eased. The PPACA should be redesigned to move closer to universal coverage. The current healthcare law falls short of universal coverage, with unaffordable premiums, coverage gaps, and weak insurer participation.
2. Individual insurance market affordability: Premium subsidies should be expanded and increased such as removing the 400% Federal Poverty Level cap for premium tax credits to boost enrollment and offset premium hikes. Incentivizing more healthy people to purchase insurance on the PPACA marketplace strengthens the individual insurance market.
3. Stabilize the marketplace: The federal government should take several steps to stabilize the PPACA marketplace, including adoption of a permanent reinsurance program and rollback of proposals to sell health plans that do not comply with PPACA regulations such as limited-duration plans. The reinsurance program provides financial protection to health plans with high-cost enrollees. Noncompliant health plans segment the risk pool and drive premiums for compliant marketplace plans higher.
4. Outreach, consumer assistance, and education funding: In 2017 and 2018, the federal government slashed funding for the PPACA's Navigator program and other efforts to provide education, outreach, and enrollment assistance. Federal, state and local agencies should fund initiatives to promote the PPACA's coverage options. These efforts should target people who are eligible for Medicaid or premium tax credits but are not enrolled in PPACA coverage.
5. Enrollment mechanisms: To increase patient participation in PPACA coverage, federal and state marketplace officials should strengthen enrollment mechanisms such as developing auto-enrollment programs, levying penalties for failure to enroll upon eligibility, and adopting an individual mandate.
6. Medicaid expansion: The expansion of Medicaid coverage to more adults in 36 states has increased access to care significantly, with more than 12 million newly eligible adults covered by Medicaid in September 2017. Medicaid should not be expanded with counterproductive conditions such as onerous work requirements that prompt patients to disenroll.
7. Public option: Congress should craft a public insurance plan to increase competition in the individual marketplace. For example, Sens. Tim Kaine (D-Virginia) and Michael Bennet (D-Colorado) have proposed "Medicare X," which would give PPACA marketplace enrollees a public insurance offering based on Medicare's provider network and reimbursement policies. Medicare X would have an expanded benefit package including services such as maternity and pediatric care.
PPACA by the numbers
The ACP says the health law has posted promising numbers:
With Medicaid expansion states leading the advance, the country's uninsured rate hit a historic low in 2016, dipping to 8.8%.
In 2017 and early 2018, the uninsured rate held steady at 8.8%.
With higher out-of-pocket costs, patients face significant financial side effects from their care.
With proactive communication and engagement, clinicians can ease the financial burden of their patients.
Out-of-pocket costs such as high-deductible health plans have expanded over the past decade. In 2018, 29% of patients with private insurance were enrolled in high-deductible health plans, up 25 percentage points from 2006. More than a quarter of Americans have trouble paying medical bills.
In this month's edition of Annals of Internal Medicine, researchers provide seven approaches to having effective cost-of-care conversations with patients:
1. Patient engagement: Most physicians take a passive approach to discussing patient finances. Months can be wasted before clinicians find out patients can't afford their medications. Patients should be screened for financial hardship.
2. Cost estimates: Clinicians make medical prognoses that allow patients to plan for their care, and they should make financial prognoses that help patients plan financially. Discussing costs early in care boosts awareness of available resources and increases patients' ability to plan for expensive treatments. Clinicians should consider financial burden as a side effect of medical treatment and try to prevent it.
3. Anticipate costs: Most patients are concerned about the indirect costs of their medical appointments such as lost income, transportation, and childcare. Through communication with patients, these costs should be anticipated.
4. Make exploring out-of-pocket costs routine: Hospitals and physician practices can give patients information about health insurance availability, local health-related resources, and tools for initiating cost-of-care conversations during clinic visits. Implementing a cost-conversation screening system should engage patients, ease shame patients feel about financial problems, and give patients options to speak with clinicians or ancillary staff.
5. Adjusting workflows: Clinicians should work cost-of-care conversations into their daily workflows. Effective strategies include assigning one staff member to serve as the out-of-pocket cost problem-solver to develop expertise and efficiency, using the electronic health record (EHR) to document patients' financial need, and mining the EHR for cost data and insurance coverage.
6. Ancillary staff play central role: Most practices involve ancillary staff—medical assistants, nurses, front desk staff, and financial counselors—in cost-of-care conversations. Ancillary staff generally have more flexibility in their workflows to accommodate financial conversations with patients, and their views on cost of care often align closely with patient views compared to clinician views.
7. Practice makes perfect: As clinicians conduct more cost-of-care conversations, the discussions become more effective and efficient. Clinicians who conduct cost-of-care conversations are more likely to consider cost in medical decisions.
Chronic conditions afflict more than 130 million Americans—more than 40% of the population. Costs for chronic illness and mental health account for about 90% of the country's $3.3 trillion annual healthcare expenditures.
Clinicians are not providing adequate lifestyle advice about chronic disease, the recent research indicates.
"Prevalence of lifestyle modification advised by healthcare providers is generally low among U.S. adults with chronic conditions, and worryingly low among those without chronic conditions, however overweight or obese. Prescribed lifestyle modification is a missing opportunity in implementing sustainable strategies to reduce chronic condition burden," the researchers wrote.
The study examined federal data collected from more 11,000 adults for weight status and five chronic conditions—high blood pressure, high blood cholesterol, osteoarthritis, coronary heart disease, and diabetes.
The study generated several key data points:
High blood pressure (32.7%) and cholesterol (29.3%) were the most common chronic conditions compared with osteoarthritis (7.4%), diabetes (5.7%), and coronary heart disease (3.7%).
Diabetes patients received considerably more frequent advice (56.5%) than patients with high blood pressure (31.4%) and cholesterol (27.0%).
A "remarkably low" number of overweight (21.4%) and obese (44.2%) adults free of chronic conditions reported receiving any lifestyle advice.
"Our analyses revealed that about 20% of overweight and about 40% of obese adults received any lifestyle modification advice when free of chronic disease, demonstrating that most healthcare providers are missing this crucial primary prevention opportunity recommended by numerous guidelines," the researchers wrote.
Lifestyle advice included in the study was increased physical activity, reduced dietary fat and calories, and weight control.
Chronic disease management
A co-author of the study told HealthLeaders earlier research indicated that physicians require more knowledge in lifestyle medicine and behavior modification.
"This would mean more emphasis on these issues during medical school but also during residency training, preferably across all medical specialties. This is very important given the high and still rising prevalence of overweight and obesity in the U.S. population," said Sinisa Stefanac, MSc, of the Institute for Outcomes Research at the Medical University of Vienna in Austria.
Clinicians need more time to dispense advice, he said.
"Physicians need more time per patient in order to discuss these issues and need to have structural support by hospital or health center management that allows them the extra time to work with their patients. These changes are more structural and would take more time and understanding from political stakeholders."