For some physician leaders, pain management may become a significant boon to their business, especially as the U.S. population ages. In a Health Leaders Media Industry survey this year, 37% predicted pain management will grow 1 to 5% over the next five years.
But doctors are on a precipice as they prescribe pain medication, especially long-acting and extended-release opioid analgesics such as oxycodone. Most are aware of the persistent potential for abuse, misuse, or mistaken use of the highly potent prescription drugs among patients. And the stress is mounting – for the docs.
States are tightening treatment requirements, while the federal government weighs the possibility of mandatory educational plans for doctors in their handling of opioids, putting federal officials at loggerheads with much of the medical establishment.
Some physicians are so upset over what they term the "bureaucratic" infringements, that they are considering no longer seeing patients who seek pain treatment. Instead, they would prefer to refer those patients to colleagues who are willing to prescribe potent analgesics.
In an effort to reduce the painkiller overdoses and deaths, state and federal governments are stepping up their efforts to regulate, or at least better inform, physicians who prescribe the opioids. They aren't targeting just the "pill mills," those corrupt docs who loosely prescribe painkillers for big profits.
No, they are trying to reduce drug abuse or the mishandling of drugs by setting their sights on the ordinary physicians who stand on the front line between pain and prescriptions.
It is a constant, aching problem in the U.S. An estimated 60 million here have some type of chronic, nonmalignant pain. To treat that pain, extended-release, long-acting opioid analgesics are widely prescribed, with an estimated 22.9 million prescriptions dispensed in 2011, according to IMS Health, which provides information services to pharmaceutical firms. At least 320,00 physician prescribers who are registered with the Drug Enforcement Administration wrote at least one prescription for the drugs in 2011.
While most recipients of these prescriptions use opioid analgesics for pain control, some use these powerful drugs for non-medical purposes. In 2009, there were 425,000 emergency department visits involving non-medical use of the drugs, according to the Food and Drug Administration.
In addition, there were 15,597 deaths from opioid pain relievers in 2009, the Centers for Disease Control and Prevention reported – four times more deaths than in 1999.
The drug-pain scenario amounts to a "perfect storm" of two huge issues, says Glen Stream, MD MBI president of the 105,000-member American Academy of Family Physicians, which has been a major opponent of proposals in Congress to mandate continuing medical education (CME) related to the opioids as a prerequisite for licensing. The AAFP contends such actions would, among other things, place unfair "limitations on patient access to legitimate pain management needs that may occur."
Stream acknowledges that physicians may feel caught in the middle. "We want to make sure legitimate pain gets appropriate treatment and there is relief of suffering," he told HealthLeaders Media. "But we don't want to add to the opioid abuse problem by prescribing medication people don't have a legitimate need for."
Stream's own state of Washington has been among the strictest regulators involving opioid prescriptions, according to the American Medical Association. It includes rules with detailed instructions about how to evaluate and care for patients with chronic non-cancer pain, and requires "patient contracts" that call for mandatory, periodic urine screenings.
At least seven states, including Florida, require medical licensure contingent on whether physicians complete CME courses related to pain management or prescribing controlled substances, according to the AMA. Many other states have initiated prescription-monitoring programs.
"It seems well-intentioned, but if there is going to be legislation telling doctors every time they need to take additional training, there won't be enough hours in the day to take it all," Stream says, referring to the Washington law. Some states are considering fellowship-training requirements that could impact primary care physicians, he says. "We've been concerned about some states whose efforts to control opioid misuse is actually getting in the way of physician treatment."
In Washington State, some primary care physicians have opted out of the pain treatment business instead of complying with state regulations, Stream explains. "They are saying ‘I'm not going to treat (patients for chronic pain)." "(Patients) can find someone else. The trouble is, in rural areas, there isn't someone else. This is a huge concern." Oddly enough, Stream estimates that 40% of chronic pain among patients is not treated.
Federal agencies are also trying to enhance education programs about opioid analgesics. They are becoming mandatory for drug manufacturers, but voluntary for physicians – as of now.
Last month, the Food and Drug Administration released a Risk Evaluation and Mitigation Strategy (REMS) for extended-release and long-active opioid medications. The REMS is part of a multi-agency federal effort to address the growing problem of prescription drug abuse and misuse, with educational programs as a key component.
"Misprescribing, misuse and abuse of extended-release and long-acting opioids are a critical and growing public health challenge," FDA Commissioner Margaret A. Hamburg, MD, said in a statement when the REMS was released. "The FDA's goal with this REMS approval is to ensure that health care professionals are educated on how to safely prescribe opioids, and that patients know how to safely use these drugs."
While there is no current mandatory requirement that physicians take training as a precondition to prescribing long-acting and extended release opioids, an FDA statement notes that the Obama administration endorsed a mandatory training program on responsible opioid prescribing practices in April 2011 "as part of its comprehensive plan to address the epidemic of prescription drug abuse."
Such a program would be linked to a DEA registration by providers and "would require legislative changes that are being pursued by the administration," according to the FDA.
The FDA program will impact at least 20 drug manufacturers, which would be required to make educational programs available to providers based on an FDA Blueprint. Companies can meet their obligations by providing educational grants to continuing education providers, who will develop and deliver the training, according to the FDA.
The REMS also requires companies to make available FDA-approved patient education materials about the safe use of the drugs. It is expected that the first continuing education activities will begin March 1, 2013. The FDA expects the training to take about three hours, but the continuous education providers can determine the number of credit hours that will be offered at no cost.
The AAFP's Stream sees the FDA program as onerous. "This isn't a simple legislative and regulatory solution," he says.
Not all physician groups have been as upset as the AAFP about the government's educational efforts to deter opioid abuse. "Through proper education and training, opioids can be administered safely to patients and continue to be an important option in the treatment of chronic and debilitating pain that is suffered by millions of Americans," the 2,600-member American Academy of Pain Medicine said in a statement about the federal plan. The AAFP's Stream says his organization wants to battle the opioid issue on other fronts, such as advocating increased national funding to support research into "evidence-based strategies" for pain management to be included in patient-medical home programs.
Each day, Stream acknowledges there's a "fine line" that physicians must walk in the drug treatment-for-pain issue.
"We've got to treat people's pain so they aren't suffering so much they want to kill themselves, but we can't let them kill themselves with drugs, either," he says.
This article appears in the July 2012 issue of HealthLeaders magazine.
The 80-year-old cancer patient wanted to return to his Florida home to die, but the oncologist at the 400-staffed-bed Sarasota Memorial Hospital strongly suggested hormone treatment that required a longer hospital stay.
Eventually, the distraught patient's family intervened for the move home, much earlier than the cancer specialist would have advised. The hospital's palliative care team, which focuses on comfort, pain management, and spiritual assistance for the very sick, helped the patient make the transition to the comfort of home, where he wanted to spend his remaining days.
"There was this purpose of trying to make him live a little longer without anybody really listening to this patient," says Bruce Robinson, MD, MPH, chief of geriatric medicine, and director of the Sarasota Memorial
Hospital Medical Education Committee, who recounts the story of the octogenarian patient as an example of the value of palliative care. "The palliative care service sometimes is called in to try to help families and patients achieve their goals when the system has gotten out of hand," he adds.
Palliative care is among the least understood service lines, not only among patients, but also among hospital staff, including physicians and nurses, Robinson says. One reason this service confuses some medical staff is because palliative care is designed to help the chronically ill, but not necessarily the terminally ill. Indeed, palliative care teams often focus on patients with multiple chronic conditions who require highly specialized and individualized care.
About 40% of the country's hospitals have palliative care programs, many of them composed of multidisciplinary teams where social workers and chaplains work alongside physicians and nurses. Some hospitals have established full-fledged programs within departments, while others include teams who work in other areas of the hospital. Another iteration of this care occurs where hospitals use palliative care outpatient programs to improve patient satisfaction.
Ten years ago there were almost no palliative care programs in America. Today, about 63% of hospitals with 50 or more beds have a palliative care team, the Center to Advance Palliative Care reports. In the past five years alone, access to palliative care in the larger hospitals has more than doubled. The center's 2011 report card shows that the nation gets an overall grade of B for access to hospital-based palliative care, an improvement since 2008 when it received a C.
Overall, palliative care programs have increased 125% over the past decade, according to the American Hospital Association. For hospitals, palliative care is relatively inexpensive because it requires a low start-up investment, with an increasing ROI potential because of projections that more patients—elderly and with chronic conditions—may be suitable for this type of care. Such programs can have an immediate impact on overall resource usage, such as ICU utilization, when patients on palliative care decide to steer away from expensive procedures.
Communities throughout the country are reporting an uptick in palliative care programs, reflecting national statistics on this service. "We have seen a significant growth with the Iowa Health System in developing programs at all affiliate hospitals throughout the state," says Timothy Ihrig, MD, director of palliative care at the Iowa Health System, which has 10 hospitals in Iowa and one in Illinois. "In Fort Dodge, we have seen a 200% growth in monthly consults over the past few months, and it is still growing." Ihrig notes that Medicare reimburses for qualified members, but there are no reimbursements for non-Medicare patients—although Congress has discussed the possibility of changing this rule.
Palliative care is considered relatively new, yet studies reveal that it delivers clinical benefits to patients, who are found to have a higher quality of life and live longer after receiving standard care.
Despite the cost effectiveness, insurers typically don't reimburse for palliative care services beyond doctor visits and care related to hospitals. Current healthcare reform proposals include consultation reimbursements.
Michael Nisco, MD, MBA, medical director of the 436-licensed-bed Saint Agnes Medical Center's hospice and palliative care program in Fresno, Calif., says, "We get more testimonials from patients and families in tremendous distress that palliative care reduces stress on the patient, the family, the nurse, the physician. This is an understanding of what can and can't be done for a patient, and it is savings in the long run. This is patient-centered care."
Saint Agnes Medical Center has grown over the past five years with an average of 120 new inpatient referrals each month to an average of more than 400 total patient contacts, including follow-ups each month, according to the hospital.
Many healthcare systems are still evaluating their ROI for palliative care programs, which are relatively new.
At the 230-staffed-bed Gundersen Lutheran Hospital in LaCrosse, Wis., the palliative care program has shown improved fiscal performance and has resulted in "significantly reduced hospital costs," according to the hospital. In a 2008 report, the hospital cited a cost reduction of $3,500 per patient in billed costs, and a reduction of hospital readmissions for palliative care patients to 6%, compared to 18% in a control population. In addition, the hospital report cited "higher ratings of satisfaction with care from families of patients who die in the hospital."
In an extensive study in 2006, the Sutter Health Institute for Research and Education, part of Sutter Health in San Francisco, found that palliative care programs at 798-bed California Pacific Medical Center in that city resulted in estimated annual savings of $2.2 million, with daily costs for palliative care patients 14.5% lower compared to usual care patients.
Experts foresee potential for new palliative care programs across the nation. About 90 million Americans are living with serious and life-threatening illnesses, a number that is expected to double in the next 25 years, according to the Center to Advance Palliative Care. The organization's observation is that most people with serious illness experience inadequate and fragmented care from a variety of doctors. Communication is another issue the organization identifies as problematic, both between doctor and patient, and among the patient's medical caregivers.
Success key No. 1: Expanding into outpatient
Gundersen Lutheran Hospital has initiated a pilot program with the Centers for Medicare & Medicaid Services that enables prospective patients and their families to consider outpatient palliative care—even before they are admitted to the hospital.
"Our goal is to try to enroll patients much earlier, identifying them much earlier in their care," says Bernard Hammes, PhD, director of Respecting Choices, an organization owned and operated by Gundersen Lutheran that assists organizations and communities in implementing advance care planning practices. He also is Gundersen's director of medical humanities and chairs its institutional review board and ethics committee.
Essentially, the hospital works with patients and their families to integrate patient choices and direction before a time when the patients can't make their own medical decisions. Afflicted with complicated illnesses, these patients have progressive diseases that could result in functional decline and frequent hospitalizations and emergency department visits. Many patients' prognosis gives them two years or less to live—with the anticipation of continuous decline during those two years. Gundersen Lutheran's program features an interdisciplinary care team dedicated to providing high-quality, seamless medical care, individualized for each patient and his or her family.
Over the past three years, Gundersen Lutheran has enlisted 300 of its palliative care patients in the outpatient program under the advanced care demonstration project with CMS. The program started slowly because of contract problems with CMS, but has revved up, Hammes says. Reviewing patient electronic medical records, Gundersen Lutheran partners with primary care doctors to enlist would-be patients into the palliative care program. The idea is to improve care for patients to reduce readmissions, medical procedures, or pharmaceutical costs, says Hammes.
A team of primary care physicians, nurse care coordinators, palliative care providers, social workers, pastoral care counselors, and other professionals provides the disease coordination services, according to Hammes.
The palliative care team arranges meetings and phone calls with the patients and their families to help identify and manage symptoms and other kinds of medical care. "The goal is to help people with advanced conditions live successfully and with functionality as much as possible in their homes. We make sure they stay on their medications if need be, and prevent unnecessary acute illnesses," Hammes says.
"Let's say someone has heart failure, and under other circumstances, they might call their doctor, who might say, 'Come to the hospital.' Instead, the palliative care team will have an assessment over the phone, there would be someone for this person to call, and help them manage the disease over the phone.
"This model of care targets patients with advanced illness, patients who know they are going to get progressively worse," he adds.
"We feel these patients may see their primary care physicians, but the doctor is often so busy, that the patient isn't given that extra layer of support," Hammes says. "There may be a pain the patient can't deal with. We can dramatically decrease the need at this stage of their lives for this person to come to the hospital, and decrease the number of hospital days. We are offering them a very in-depth discussion about their goals and preferences for future care."
Hammes refers to an extensive study on palliative care, published in 2009 that showed that advance care planning "assists in identifying and respecting patients' wishes about end-of-life care, improves such care from the perspective of the patient and the family, and diminishes the likelihood of stress, anxiety, and depression in surviving relatives."
A more recent study, published in The New England Journal of Medicine last year, showed that getting early palliative care, in addition to regular medical treatment, helped people with lung cancer live three months longer compared to those given standard care. The study focused on 151 patients.
"We believe people want to stay functional in their homes," Hammes adds. "That's the goal. It's not only better for the patient but also turns out to be cheaper for healthcare. You invest this time, it's relatively low-tech and low-cost care, and you prevent three days of hospitalization and you come out ahead. That's not too difficult to figure out. We realize there are limits to how much a patient wants."
Success key No. 2: Palliative care across service lines
Whether it's massage therapy or harp music to soothe patients, the 739-staffed-bed University of Rochester (N.Y.) Medical Center includes varied services in its palliative care department, which has 12 private rooms. But a key element of the program involves serving a variety of other service lines, such as neurology and oncology.
"We are involved earlier and earlier in patient care in the hospital. We started in the cancer service. Now we're also seeing heart failure patients and neurological patients, and in the ICU, the full gamut," says Timothy E. Quill, MD, director of the center of ethics, humanities, and palliative care at the medical center.
In addition, the medical center has found that early palliative care interventions can reduce the length of stay for seriously ill patients in the medical intensive care unit by more than seven days without having an impact on mortality rates.
Rochester officials several years ago discovered that proactive palliative care consultation in the ICU has an unintended benefit of financial savings.
In its most recent study in 2007 at the medical center, Rochester found the palliative care intervention saved about 1,400 ICU patient days, at an average of about $450 a day.
"Recognizing these indirect financial effects is critical to ensuring palliative care consultation services continue to expand in hospital settings nationwide," the report said.
By going across service lines, palliative care programs team up their members with other specialists. "Palliative care docs work on a team, and for any individual patient you are highly selective [about] which members of the team you might involve," Quill says.
"Some people might have a spiritual crisis and try to get an experienced chaplain to work with them alongside the medical team. Really, comprehensive care and medical homes are trying to do the same thing," he says, noting that a palliative care team adds expertise in making sure pain, anxiety, shortness of breath, and depression are being addressed.
Over the past three years, palliative care inpatient consultation at the medical center has grown from 250 to 1,000 consultations per year, says Quill. And Rochester has received The Joint Commission's advanced certificate for palliative care, which recognizes hospital inpatient programs that demonstrate excellent patient- and family-centered care and optimize the quality of life for patients with serious illness.
Beyond that, the hospital system has improved palliative care services to the medical home as well as outpatient care, Quill says.
"It's a no-brainer to make palliative care part of the medical home, to provide comprehensive care to people with serious chronic illness. We are good at addressing a lot of symptoms and identifying and a lot of challenges, figuring out how best to use the medical system," Quill says. "Does this treatment work best for me? We help people sort through that. We help them choose the treatment that makes sense for them, given their condition and priorities. We are once removed from people providing high-tech equipment."
Success key No. 3: Children's palliative care
When the Iowa University Health System launched a palliative care program for children three years ago, hospital officials believed it was necessary because there was a "gap of miscommunication" involving kids with severe illnesses and their families, says Janine Petitgout, RN, ARNP, director of pediatric palliative care at the 194-staffed-bed University of Iowa Children's Hospital in Iowa City .
Starting a multidisciplinary program that focused on specific ailments for children seemed the perfect solution.
The Iowa program reflected findings of a study that found a palliative care program for children should acknowledge that their ailments are much different than adults', and the palliative care process might be longer.
Most children in palliative care programs are treated for genetic, congenital, neuromuscular, breathing, and stomach illnesses—much different from an adult palliative care population, which is often dominated by cancer diagnoses. Only about 20% of children had cancer, according to a study in Pediatrics.
"Palliative care teams need a broad understanding of many underlying medical conditions and the ability to skillfully address the complex chronic illnesses, in addition to the challenges of pain and symptom management," according to the Pediatric Palliative Care Research Network and Policy at The Children's Hospital in Philadelphia. The study focused on 515 patients from six hospitals in the United States and Canada in 2008, with follow-up a year later.
The study also noted that while the typical adult receives palliative care for between one to three months, two-thirds of the children survived past 12 months. "The average span of these patients was longer than many would have expected, and the study results help emphasize that children receiving palliative care services are living and that palliative care is principally about how to best live with grave life-threatening conditions," the report concludes.
After 56 consults the first year, the Iowa palliative care program has been constantly growing, from babies through children reaching adulthood. "We are providing comprehensive management of the physical, spiritual, and social being for children," Petitgout adds. The program has been directed to patients with myriad diseases such as cancer, cardiac problems, genetic disorders, and muscular dystrophy.
The palliative care team includes nurse practitioners, outpatient nurses, a child life therapist, social workers, a grief service coordinator, a psychologist, pharmacist, and medical director.
"It's about wellness for these children, but also the entire family," she says.
Palliative care programs for children have shown increased family satisfaction. In a 2009 report to the Agency for Healthcare Research and Quality that focused on a pediatric advanced care team at Dana-Farber Cancer Center and Children's Hospital in Boston, researchers found that palliative care and hospice care helped "ease patient suffering" and helped "parents feel more prepared." At least 92% expressed patient satisfaction in pain management, and 96% in patient support.
Petitgout says that palliative care support was illustrated in the case of a 12-year-old girl stricken with a rare and fatal blood disorder. The girl had surprised Iowa University Health System officials—as well as her parents—with talk about wanting to "write a will," recalls Petitgout.
The hospital's palliative care nurse worked with the child, for "hours and hours," helping her craft the words she wanted to say, Petitgout says. The writings became more than a will—they became a testament about the young girl's life. "That book was a connection for the mom to her [daughter], and has given [the mother] comfort," Petitgout says. The girl has since died.
Success key No. 4: What's in a name?
Palliative care experts describe what they term a "branding problem" in which patients, and even hospital officials, confuse palliative care with hospice programs that assist patients in their final stages of life. The confusion between palliative care and hospice care makes some people hesitant to choose palliative care, because they are not at the end of their lives, says Quill.
"What the heck is palliative care? Right away, palliative care has a name recognition issue," Quill says. "Its name recognition is relatively low at 20%. When people learn about it, they ask, 'Why didn't I get that earlier, why isn't that the care for all seriously ill people?' Hospice has a higher name recognition, but it's for people at the end of life," Quill adds.
The Rochester Medical Center has initiated educational programs to improve the awareness of palliative care, according to Quill. At Saint Agnes Medical Center, Nisco says the palliative care team at his hospital has had "clarifying discussions" about the nature of palliative programs with patients and other physicians.
Nisco concedes that when he initially meets patients and their families to discuss his program, he tries to avoid the word "palliative" because of so much misunderstanding. People immediately associate palliative care with hospice. Some hospitals have coined the term "supportive care" to describe their programs, Nisco says.
"There's this assumption that it is just for dying people," Nisco explains. "Despite the success at our hospital, you'll find similar themes. A provider may say from time to time, 'Why do we need that?' At institutions large and small, there's this blind spot. Part of the branding problem is that people think about death and dying. On the contrary, we are promoting life and quality of life."
Such barriers must be overcome, Nisco says, because it stifles the possibilities of palliative care. "People would misunderstand and think the treatment is not working and it means that they are going to die," he says. While some patients who receive palliative care have terminal illnesses, others have serious illnesses, but still can be cured and have longer lives and may benefit by using Saint Agnes' program for pain management and supportive care during all phases of treatment.
Too often, physicians believe that when palliative care is involved, that suggests treatment has been a failure. "In that way, it makes it difficult to promote the program," Nisco says. Palliative care is an integral part of the evolving standard to provide the best possible care to patients."
This article appears in the July 2012 issue of HealthLeaders magazine.
When the Atlanta-based healthcare staffing recruiter Jackson Healthcare recently took an online survey of physicians, it was pretty surprised and dismayed that 34% of physicians reported plans to leave the practice of medicine over the next decade.
"What one doctor told me really struck me," Sheri Sorrell, market research manager for Jackson Healthcare, told HealthLeaders Media. The unnamed physician said he was in a grocery store with his wife and had an epiphany after they discussed "how my office worked, what I charged, and what my accounts receivable meant, and it was really nothing. Really," he wrote to Jackson Healthcare. "The insurance companies and the government decide how much I got for my services."
"Why was more of my life in a career that is becoming more and more restricted, more controlled by managers, clerks and accountants, more demanding, less fulfilling, less respected, and less financially rewarding daily?" the physician asked.
After two months, the doctor quit, according to Sorrell.
It sounded like the doctor was cataloging the symptoms of a disease state. He represented the ailing state of physicians. Jackson Healthcare tallied the complaints: a "complex business environment, hassles with insurance companies, billing, collections, administrative work, hospital pressures and quality of life issues." Many physicians want to work fewer hours, spend more time with family, more time on vacation, provide less call coverage and gain a more manageable workload.
Among the public, "the perception is these guys are all filthy rich, but it's not true anymore, especially for those primary care docs," Sorrell says. "Some are just trying to keep their practices open."
But physicians are in the business of fixing ills, aren't they? Around the same time Jackson conducted its survey, The Physicians Foundation—a nonprofit organization that seeks to advance the work of practicing physicians and help facilitate the delivery of healthcare to patients—issued two reports that echoed what doctors view as their dismal state. But there was a twist: the reports said that physicians can take steps to control their own destiny and stay in business.
Stephen Isaacs, JD, an attorney and president of the Center for Health and Social Policy, and Paul S. Jellinek, PhD, former vice president of the Robert Wood Johnson Foundation, stated in their report that, "while it is indeed possible to survive and even thrive in private practice in the current environment, business as usual is not an option. Serious steps must be taken to the new realities and implementing these steps may well take some physicians outside of their comfort zones."
Jeff Goldsmith, PhD, associate professor of public health sciences at the University of Virginia, author of the other report, agreed. "Medical practice innovation holds the key to private practice being a viable alternative to salaried employment for the next generation of physicians," writes Goldsmith. "It holds the promise for both diversifying physicians' service offerings and for improving physician productivity."
In the reports, the authors offer suggestions for physicians that they should consider now, to get a handle on their practices—before they decide to get out of the business of caring for people. They cite physicians who "bucked the trend" of leaving and have maintained a sustainable practice. Among their immediate suggestions:
1. Fix your practice. It's like cleaning house, taking note of what can be quickly improved, for greater efficiency. You may decide you like what you have after you make tweaks—some large and small—involving paperwork and employment of staff. It includes contracting out billing and collections; collecting co-payments and deductibles at the time of service; reducing or cross-training administrative staff, and employing mid-level providers.
2. Try a new practice model. Consider launching an extremely no-frills "micropractice " or concierge practice. The micropractice model is basically a solo practitioner who has no staff, with low overhead, who sees fewer patients each day and spends more time with them when they visit.
It's curtailing the stress and spending more time on care. Isaacs and Jellinek noted a 57-year-old Chicago physician who talked of his "ideal medical practice," in which he sees just 15 patients a day and spends an average of 27 minutes with them.
A 43-year-old North Carolina physician moved into solo practice because of the "relentless pressure" from his previous job at a community health center. He has a load of only 650 patients and schedules 45 minutes for follow-up appointments with each patient.
As for concierge service, a patient pays an annual fee or retainer, for enhanced care. This arrangement offers flexibility for a physician. Some physicians also are embarking on "hybrid" practices that combines concierge, suited to patients who want specialized services and are willing to pay, along with their regular practices, Wayne Lipton, founder of Concierge Choice Physicians told me.
3. Improve your practice's digital technology now. Those that enable real-time claims management and payment, automate dictation and coding, and improve physicians' communication with each other and with patients "could lower overhead costs and enable more efficient practice," wrote Goldsmith. Medical practice innovation holds the key to private practice being a viable alternative to salaried employment for the next generation of physicians, he said.
4. Consider joining independent practice associations or merge with other independent practices that can provide "greater leverage" with hospitals and payers, as well as vendors. Although this move involves a loss of autonomy and control, it has a definite upside. Physicians' willingness to join organizations to manage population health risks will be essential to regaining control over their professional lives. "The alternative is to continue to have their clinical decisions micromanaged by health plans and Medicare," Isaacs and Jellinek state.
Obviously, these aren't panaceas, but the idea is to provoke some thoughts among physicians who will need to be flexible in a turbulent time.
"Both papers are saying that, with the amount of uncertainty created by all the paperwork requirements, the uncertainty over SGR (sustainable growth rate formula) payments, no one knows with clarity what the ultimate impact may be on healthcare reform," says Lou Goodman, PhD, president of The Physicians Foundation, and CEO of the Texas Medical Association.
In 2009, Isaacs and Jellinek wrote a report entitled, "The Independent Physician: Going, Going…" As they note in their recent report, the previous study discusses "the strong current of pessimism regarding the future of private practice."
"Such information as we were able to piece together about what has been happening since we wrote that paper, especially in many local health care markets, seemed to directly confirm that pessimistic outlook," the author wrote in the recent report.
"Yet as we started to learn more about some of those private practices that have somehow managed to buck the trend, and as we talked to the physicians who are running those practices, we began to wonder whether maybe, just maybe, this isn't the end of the private practice after all."
Of course, that remains to be seen. And yet another report by healthcare researchers may tell that story, ostensibly "written" by doctors themselves.
Should doctors warn patients about the risks of guns in the home?
In Florida, physicians who did just that could have lost their medical licenses—until recently.
Weeks before one of the worst gun violence incidents in U.S. history, a group of physicians won a court victory in a little-noticed case against a Florida law that threatened to strip doctors of their medical licenses if they warned patients about the risks of guns in the home.
Florida politicians, citing Second Amendment rights, were adamant that docs weren't in the gun-counseling business, and passed a statute to thwart such discussions. The physicians, however, prevailed in federal court to halt the measure.
It made me ask: How wrong can it be for physicians to raise questions about the presence of a gun in their patients' homes? And how far should physicians go with that discourse?
Of course, a constant drumbeat about the inanity of our gun laws mount as disclosures reveal how James E. Holmes, the suspected shooter in the Colorado movie theater massacre, stockpiled weapons, and bought 6,000 rounds of ammo in the weeks before he allegedly gunned down 70 innocent people July 20, killing at least 12. Included in the arsenal was a .40-caliber Glock handgun, a Remington 870 shotgun, an AR-15 assault rifle, and a high-capacity ammunition clip.
It's almost appallingly predictable how the gun law debate ebbs and flows with each tragic incident that haunts the country. And possibly no physician in the world could have counseled Holmes to steer him away from the madness. (According to media reports, Holmes allegedly mailed a notebook "full of details about how was going to kill people" to a University of Colorado psychiatrist before the attack.)
But the Florida legal action, which has been dubbed "Docs vs. Glocks" by the press, puts a twist on the gun debate, by showing how some docs want to get into the heads of their patients, and advise them to get guns out of their houses, if need be. Some of those discussions focus on whether kids are around the guns, or if a family member may have psychological issues that many believe should rule out having a weapon around.
Bernard Wollschlaeger, MD, FAAFP, a family practice physician in Miami, who is among the group of physicians who sued to successfully halt the Florida law, says he has counseled patients about gun use. As Wollschlaeger sees it, such conversations are important, not to clash with a person's privacy rights, but as an opportunity to improve a patient's health.
"It's about our right as physicians to ask questions. We often ask questions that can be intimate and very personal," Wollschlaeger told HealthLeaders Media. "As a patient, you have a right to refuse or not (when asked the question about guns)." Families with children are particularly impacted, he says. "If there are children in the household, we ask the question if you have a gun. Children disproportionately suffer accidental injuries from guns that are stored in the home, and the results can be tragic."
Wollschlagger, who also works in addiction medicine, says he counsels patients who have "psychiatric background issues" about the dangers of guns in the house.
Wollschlagger says his patients have reacted positively to his comments that may include questions about guns in their houses. "I never had a patient who reacted aggressively or was opposed to the fact I asked this question," he adds. "It doesn't trigger a negative reaction, as claimed by many gun advocates, who say that physicians should stay out of it." Some patients who may not have safeguarded weapons in their homes have told him "it's good you told me about it," Wollschlagger says.
The physicians' entanglement with Florida over the gun issue began last year after the Florida legislature passed The Privacy of Firearms Owners Act, (signed by Florida Gov. Rick Scott), which would have restricted physicians, nurses, and medical staff from asking a patient and patients' parents about firearms. Physicians accused of violating the law would have been sent before the Florida Board of Medicine for disciplinary action.
Woolschlaeger and other physicians disagreed, saying they were only doing their jobs to enhance patient care. The Florida chapters of the American Academy of Pediatric Physicians, the American Academy of Family Physicians, and the American College of Physicians joined Wollschlaegger and other physicians in the lawsuit.
Their collective contention was that the Florida law significantly curtailed their First Amendment rights to exchange information with patients about gun safety. The Brady Center to Prevent Gun Violence filed the suit, saying it represented 11,000 physicians in Florida.
The physicians first won a temporary restraining order, then a permanent injunction on June 29 after a judged ruled that Florida law violates the First Amendment about "truthful speech" concerning the dangers of easy access to guns.
U.S. District Court Judge Marcia Cooke found that the Florida legislature relied not on facts, but on anecdotal information about physicians asking patients about firearm ownership. That information included allegations that physicians misrepresented themselves by saying Medicaid would not pay claims if patients did not answer questions about firearms, or that doctors were refusing to examine patients who refused to answer questions about firearms ownership. Cooke also found that the law illegally "impairs the provision of medical care and may ultimately harm the patient."
Not all physicians are upset with the Florida law. Timothy W. Wheeler, MD, founder and director of Doctors for Responsible Gun Ownership, strongly questions whether doctors should ask about guns in a home. "It's wrong for a doctor to misuse the doctor-patient relationships to try to advocate for gun control in the doctors' office," Wheeler, a retired doctor in California, told HealthLeaders Media. "That's professional misconduct, and that is the reason the Florida law was enacted."
Physicians who specifically need to raise the gun issue do have a reason, however, if there is a "suspicion of mental illness, or homicidal or suicidal" tendencies, he adds.
Wollschlagger, a former military officer in the Israeli army, says he has a concealed weapon permit and enjoys shooting guns on a range. He characterizes America's gun laws as "absolutely insane." The country's laws concerning assault rifles, are "crazy," and, he says, illustrate how important it is for docs to keep on eye on patients and families when it comes to guns in a household.
"There is no rational way to allow an average citizen without any involvement in security or tbe military to carry an assault rifle, it's absolutely insane," Wollschlagger says. " If somebody purchased 6,000 bullets for a high-powered assault rifle, for crying out loud, is he going to war?"
The federal assault weapons ban expired in the fall of 2004, but gun control advocates such as the Brady Campaign have supported banning military style semi-automatic assault weapons along with high capacity ammunition magazines.
While the gun debate accelerates, physicians in Florida will continue to have discussions with patients about guns, Wollschlagger says. "We don't know if the state will continue the battle," Wollschlagger says, referring to possible state appeals of the court ruling.
Already, there are rumblings that the Florida Department of Health will appeal the court's ruling. Florida is the only state that has enacted legislation restricting physician speech on firearms safety counseling, but Alabama, Minnesota, North Carolina, Oklahoma, Tennessee and West Virginia have introduced similar bills in recent years.
This article appears in the July 2012 issue of HealthLeaders magazine.
Today, many hospital organizations are teeming with teams, forming physician groups to make decisions about bringing in new doctors, provide clinical care, and make recommendations about administrative planning:
In Maryland, a longtime CMO retires and the opening creates an opportunity to revisit the entire structure of physician involvement for a health system.
In Texas, a physician team lays the groundwork for how a new hospital is built.
In Wisconsin, a large medical group looks inside itself to revamp its physician team to coexist with a larger health system.
Developing teams
As various health systems work to put physician teams together, the organizations often abandon old models. They are looking to forge relationships bound by teamwork, cohesiveness, and coordination as never before. They also want team members who appreciate the fact that a hospital must operate as a business.
Hospitals that acquire physician groups need precise planning to integrate these new medical teams. "We recruit physicians who share our philosophy," says Paul Colavita, president of the Carolinas HealthCare System's Sanger Heart & Vascular Institute, which has more than 90 physicians and 24 locations in North
and South Carolina. CHS, based in Charlotte, N.C., has 6,300 beds in locations in both states. As Colavita evaluates physicians for his team, first and foremost "they must be team players to function well in our organization," he says. Sanger relies on references from the physician's instructors, partners, and colleagues. Putting patients first is the top priority. "The decision-making is evidence-based and appropriate," he adds.
Under the old medical staff model, physicians provided clinical care only within the appropriate silo in a top-down structure that walled off communication. Information might move up or down the ladder, but rarely from silo to silo, which impedes real discoveries and breakthroughs in advancing care and identifying efficiencies that can be shared.
Now hospitals are expanding their physician teams and revamping their leadership structures, establishing specialized committees to oversee various jobs and undertake new missions. And some are going further, establishing academies to cultivate physician leaders for various teams.
Developing leadership
Such leadership cultivation is what the Iowa Health System has done in preparation for a planned accountable care organization, says Bill Leaver, president and CEO of the 1,291-bed system based in Des Moines. Earlier this year, the system joined with Wellmark Blue Cross and Blue Shield of Iowa to form an ACO, in hopes of reducing hospital readmissions.
To prepare for the ACO, Leaver says Iowa Health System had little choice but to improve its physician team, concentrating on developing physician leaders, now and for the future. Two years ago, the Iowa Health System created a physician leadership academy, an intensive graduate-level course of study that focuses on individual development and advanced leadership training with an emphasis on strategic skills, quality innovations, and information technology. Physicians selected for the leadership academy participate in a confidential assessment to identify their strengths and weaknesses, as well as to pinpoint the knowledge and skills needed to be effective leaders.
"Developing our primary care base is really our overall strategy," says Leaver. "We felt we were more of a hospital-centric organization and needed a more integrated delivery of care, to be physician- and patient-centered. We won't be able to have physician buy-in to the [ACO] model unless we create physician leaders now." More than 30 graduates currently are being considered for leadership positions in the organization, he says.
Developing balance
As Barry P. Ronan, president and CEO of the 275-bed Western Maryland Health System in Cumberland, examines the current physician landscape and the needs of his facility, he says the organization works to maintain a balance among hospitalists, specialists, and subspecialists. "As more and more attending physicians give up their hospital inpatient privileges to focus on their office practices exclusively, we add additional hospitalists or nurse practitioners," Ronan says. "We also continue to recruit specialists and subspecialists in the community in order to complement our existing physicians and to support our extensive program requirements."
Hospitals must always look at costs when they are recruiting individuals for teams. It is estimated that a physician search can cost as much as $50,000. Another $20,000 may be spent on signing bonuses and other incentives. But the right physician is worth the recruiting investment, bringing in potentially millions of dollars for a hospital depending on the specialty—and adding that "perfect fit" so essential to a hospital's goals.
When assembling a physician team, Christine Griger, MD, president of the Affinity Medical Group, part of the three-hospital Affinity Health System based in Menasha, Wis., says her group is exploring different ways to improve physician relationships within the larger health system, especially as it forms teams for medical home care.
"We have people knocking on our door to get in," Griger says of physicians seeking the security of hospital employment within the Affinity Health System. "There are physicians who have been independent and in smaller groups, wanting that security and stability of a healthcare system. But we need them to function not just as a physician, but as a businessperson, too," she says. Affinity Medical Group includes 265 physicians and advanced practice providers and 26 clinics in northeastern Wisconsin.
With Affinity's unified medical staff, any member of the medical group can serve as a department chair or head of quality. Still, as Affinity executives examined its governance structure, it sought more physicians in leadership roles, says Griger.
"We need more physician leadership in operational issues, for quality and patient satisfaction and productivity," she says. "We are developing a title of a regional VP for physicians, who will be involved in physician leadership primarily in an administrative way," she says.
The health system enlisted "all types of team development and collaboration" across the sites as it initiated case-management changes and improvements in staff to stay on track with patient-engagement protocols, Griger says.
Developing accountability
Colavita of the Sanger Heart & Vascular Institute says his health system chooses team members who are responsible not only for various aspects of care, but also for documentation of specific metrics for procedures during a patient's stay—and sometimes even after a patient is discharged. A Carolinas HealthCare System quality committee reviews the patient data to improve patient outcomes, Colavita says.
The Sanger Heart & Vascular Institute stepped up its team concept in recent years after a large cardiology practice joined it. Regional and subspecialty medical directors are charged with overseeing operations divided into various aspects of care, such as cardiovascular surgery, Colavita says. Each physician group can be empowered with clinical decision-making and hire doctors. "We actually have a ‘delegation of authority' document," he explains. "This document defines who can recommend and/or approve a decision. The doctors can decide to hire another physician; the executive committee may decide to open another office."
The institute's executive committee is composed of members from the CHS administration, Sanger Heart & Vascular Institute, and Carolinas Physician Network. The officials are the SHVI president; the chair of the department of cardiovascular and thoracic surgery; the regional medical director; three CHS executive vice presidents; a CHS hospital president; the SHVI executive director; the CHS chief medical director; the Carolinas Physician Network senior vice president; and the Sanger metro (subspecialty) committee chair.
"What's necessary is a common culture, and an understanding where different physician groups are coming from," Colavita adds. "Each physician has a stake in this. There is nothing to be said about arguing with each other, but working together and doing a better job."
The physician teams have led to creation of CHS' Chest Pain Network, a network of nine area hospital and local EMS agencies that streamlines the transfer and treatment of heart attack patients. It also allows patients with less critical conditions to be appropriately cared for closer to home.
The system has also launched a Heart Success program, with a multidisciplinary team including an advanced care practitioner, patient navigator, dietitian, social worker, and pharmacist. This initiative has resulted in improved clinical outcomes, Colavita says. The program focuses on educating heart failure patients to better manage their disease and return to the care of their primary care physicians and cardiologists. The idea is to prevent readmissions and enhance the patients' quality of life.
Colavita credits this team concept to improvements in CHS' readmission rates. From the third quarter of 2011 to the first quarter of 2012, the 30-day readmission rates at CHS' Carolinas Medical Center decreased from 19.7% to 11.4%, according to the hospital.
Developing a council
Ronan saw an opportunity to do things differently by restructuring Western Maryland's physician team after his veteran CMO retired from the position and became a hospitalist at the facility. Ronan thought about the long list of challenges the system faced, even though it had just opened a new facility in late 2009.
Ronan knew that, in earlier years, the hospital would have replaced the CMO quickly to ensure continuity. But Ronan and his staff realized the landscape of healthcare was transforming so much that it was no time for a quick fix.
Following guidance from consultants, Ronan asked the president's six-member quality council to identify and bring on board six additional physicians to work directly with the C-suite. Besides participating in the search for a new CMO, the larger purpose was to help determine the direction of the hospital system.
These physicians were official and unofficial leaders. "This wasn't our medical executive committee; these were movers and shakers in the hospital. They included independent practitioners, as well as hospitalists," he says.
"Nothing at the hospital gets done that the medical staff doesn't agree with," Ronan says. "The medical staff feels very involved in the decision-making at the clinical level, but it's also important they feel involved in decision-making at the management level."
The 12 physicians on the president's council in turn led various subcommittees composed of three physicians each, focusing on an array of specific subjects: examining documentation and coding procedures; reducing readmissions and revamping the hospital's service lines; opening a new wound care center and considering a heart failure clinic; and improving programs to combat pneumonia. The hospital also relied on this subcommittee structure to look into ways to increase home healthcare, with the idea of reducing utilization. Another issue the subcommittee investigated involved evaluating community needs so patients would be less likely to seek hospital care in distant cities like Baltimore and Washington, D.C.
Developing cooperation
Cooperative physician teams were important for developing the hospital's heart failure clinic, Ronan says. At least 50 patients were enrolled in the clinic, with many referrals by hospitalists and providers in the hospital's observation unit. Multidisciplinary teams "identified several medication mismatches from discharge instructions and have intervened to make appropriate adjustments in medications," he says. Patients also have been screened for sleep apnea and referred for sleep studies, or to nephrology and home care when appropriate.
The hospital has increased its collaboration with "primary care physicians, and our focus is on disease management by setting personal goals," Ronan says. "We also help to achieve the goals through formalized individual and group teaching with collaboration with dieticians and pharmacy staff."
Hospital leadership consistently talks with primary care physicians about the potential of the heart failure clinic. "The chief medical officer is assisting by ‘talking up' the heart failure clinic to medical staff," Ronan says. "He is emphasizing that enrolling patients in the clinic will free some of their office time that is spent managing complex patients."
Developing a culture
When putting together a physician team, hospital leaders have to determine not only where the pieces of the puzzle fit, but also how to change the culture of the organization to conform with the new puzzle's shape. Nearly all medical systems employ medical directorship teams to evaluate quality and patient safety in their organizations. Others are broadening the roles of physician staff to further evaluate hospital needs, whether it's hiring a new administrator or defining what service lines to add for anticipated patient needs.
Hospital leaders who are forming and reforming physician teams examine their patient demographics to determine the demand for certain specialties—such as cardiologists, oncologists, and orthopedic surgeons, whether employed or independent—as well as the needs for its primary care base.
Developing a primary care base
As health systems consider accountable care organizations, development of teams with primary care at their base is crucial for a hospital, says Jim Stone, who is president of the Medicus Firm, a physician recruitment company with offices in Atlanta and Dallas, and serves as president-elect of the board of directors for the National Association of Physician Recruiters.
"I think with the concept of the ACOs on the horizon, and basically getting into a capitation type environment, the key component for a health system will be to manage care for that patient population," says Stone. "To do that, you need to control physician behavior, and you can't do that without having the influence of a primary care physician quarterbacking" overall patient care, he adds.
But hospitals must rely on a population foundation to develop their physician teams, and that rests with demographics, says Griger. When a hospital system balances deciding whether to get hospitalists or subspecialists in the most cost-effective manner, much of it is related to demographics, which must be evaluated closely.
"We have hospitalists, intensivists, invasive cardiologists, and cardiac surgeons here because there is a need and there is the population to support those services," she says. "We don't have a cardiac transplant service because there aren't enough patients here who need that service, either to support it economically or to maintain the level of technical expertise needed to do that kind of work."
Most hospitals are reporting an increasing need for psychiatrists and neurologists, accounting for 15%–20% of placements, according to Stone. Primary care placements remain the highest percentage of all—34%—with surgical specialties next at 20%.
Developing together
Performance improvement teams are an integral part of how hospitals are incorporating collaboration for the clinical future. Some hospital teams look into how they can better handle specific medical conditions, such as congestive heart failure or diabetes. Or, they focus on particular processes within their facility, such as a specialized physician team on readmissions.
The 187-licensed-bed Portneuf Medical Center, in Pocatello, Idaho, also has what it calls a physician roundtable that advises and is involved in day-to-day administrative and clinical concerns. In one instance, the group acted as an intermediary regarding an issue brought up by an emergency department physician about what he termed a "broken referral process" from critical-access hospitals, where a physician was not following up with referral sources in a timely manner. This operational issue was discussed by the roundtable, and ultimately addressed by the physician's practice manager, says Norman Stephens, president and CEO.
Sometimes, the results of physician team collaborations set the stage for new opportunities. For instance, Seton Medical Center Harker Heights has established a roundtable that CEO Matt Maxfield, FACHE, says was especially needed to coordinate independent physician groups when the hospital system built a new $100 million, 83-staffed-bed hospital in the central Texas area of Harker Heights, which held a grand opening last month. The physician advisory group was pivotal for reviewing and making suggestions for the new hospital, developing medical staff bylaws, and approving a physician recruitment plan.
The Seton Healthcare Family, which includes five medical centers and is a member of Ascension Health, is affiliated with the University of Texas Southwestern Medical Center in Dallas. Seton had a joint venture with LHP Hospital Group Inc. to build the new hospital. The joint venture's governing board includes representatives from LHP—a Plano, Texas–based company that owns, operates, and manages acute care hospitals through joint ventures—and Seton, as well as a board of trustees composed of physicians and community members.
The physician roundtable meets monthly to discuss any areas of concern involving physicians and administrative staff. "You have a representative of each house of medicine. It was truly by design that we were trying to get the representation of all different departments and primary care representation as well," Maxfield says. The multispecialty groups included physicians from Austin Heart and King's Daughters Clinic, medical groups in Texas whose doctors were closely involved in planning for the new hospital. The groups focused on service and culture, as well as clinical development and operational issues.
"It's a team collaborative effort, with complete transparency over the last two years," says Charles R. Day, MD, chief of staff at Seton Medical Center Harker Heights. "It's fair to say the local physician team has been quickly integrated into the management culture. The organizational structure encouraged physicians, who played a role in building this hospital and had a say about moving the dirt to what kind of MRIs to buy."
Seton Medical Center Harker Heights set the stage for collaboration before ground broke, and it plans to sustain that culture now that doors are opening. "We have had a physician team through the development of this hospital, the design, and my hope that it continues that way," says Maxfield.
This article appears in the July 2012 issue of HealthLeaders magazine.
Do you know about palliative care, the comprehensive treatment for the very sick, but not for those who are dying?
Some doctors do not.
As a physician, do you feel it is a sign of "failure" on your part, when longtime patients have grown tired of treatments, and simply want comfort as they approach end of life?
Some physicians think it is.
As the population ages, and hospitals prepare to care for more chronically ill patients, more physicians should get acquainted with palliative care, to not only to improve patient care, but as a potent cost-savings tool.
With palliative care, hospitals can avoid needless tests and procedures, in part, because patients no longer want them. Palliative care is the comprehensive treatment focused on pain, symptoms and stress of serious illness, or even spiritual assistance for the very sick. Some studies have shown it can extend life.
Still, although not widely practiced, palliative care is becoming part of the discussion among healthcare leaders to improve care, especially for the elderly. In May, a panel of healthcare leaders met in Chicago as part of a HealthLeaders Media Breakthroughs session that focused on improving readmission rates for hospitalized cardiac patients. The talks veered off into other topics, among them palliative care, as well as hospice, or end of life care.
"Obviously, it's probably one of the most complex topics we could discuss," said Greg Johnson, DO, chief medical officer for Parkview Health, Ft. Wayne, IN, during the panel discussion. "I also think that when we talk about end-of-life care, we need to approach it with more curiosity and information than with judgment and direction," Johnson says.
Although there were almost no palliative care programs in America a decade ago, about 63% of hospitals with 50 or more beds have a palliative care team, according to the Center to Advance Palliative Care. It is likely that palliative care is going to expand, but it is still largely misunderstood, even among physicians.
For those patients who are weary of dealing with their pain, tired of medical procedures, and who want to live their days as fully as possible, palliative care may be the answer. In cases of people even more seriously ill, and possibly closer to death, hospice may be the correct treatment option. Too often, physicians don't pose the question: Patient, what do you want to do?
Bruce Robinson, MD, MPH, director of the chief of geriatric medicine at Sarasota Memorial Hospital in Florida told me how, too often, physicians may articulate their hopes for patients, even when it's a terrible illusion.
"The patients want to keep that hope," he says. "The doctors want to just do what they do and that's how they make their living, so they are happy when a patient says, ‘I want you to do something. I want to pretend I'm not dying.' So stuff gets done."
Other physicians may not endorse palliative care, or even hospice care, because they wrongly feel those programs may reflect poorly on their own work, healthcare leaders tell me. Some doctors may see those programs as symbolic that they have given up hope, that all those procedures, all the plans for their patients, were for naught. That's too bad.
At the Breakthroughs session, panel member Johnson raised the point that physicians "feel like it's a failure" to have such discussions involving palliative or end of life care. That shouldn't be the case, he says. "We have to be willing to follow-up what the patients' goals are," Johnson says.
"Because what I've seen too frequently is the patient will have stated their goals of care and then somewhere that gets overwritten. And we see the 94-year-old patient that didn't' want anything who is on on a ventilator for a month. And that's a very sad thing."
The essential question for palliative care is "how do we manage symptoms so the patient can feel as good as possible, and have optimal life experience? The conversation in chronic care management goes a long way," said panel member Kathleen Martin, RN, vice president of patient safety and care improvement for Griffin Hospital, Derby, CT.
While palliative care is increasing, its generally poor name recognition, among the public, as well as among healthcare workers, including physicians, is a significant obstacle, Timothy E. Quill, MD, a professor of Medicine, Psychiatry and Mental Humanities at the University of Rochester School of Medicine and Dentistry tells HealthLeaders Media.
"Palliative care has a name recognition issue," Quill says. "About 20% of the public may know what it is, but once people and patients learn what it is, their question becomes: ‘why didn't I get that earlier, why isn't that the care for all seriously ill people?' Hospice care has a higher name recognition, but it's for people at the end of life," he says.
While there is some uncertainty what exactly is palliative care, some healthcare facilities are offering both palliative and hospice care programs, which they see as crucial to improve care among the elderly, and offering as many options to them as well as their families.
The Hospice of the Valley, in San Jose, CA, is one of those facilities that serves both populations. There is an increasing need for mental health or community-based programs to assist the patients, says Sally Adelus, president/CEO of the Hospice of the Valley, told HealthLeaders Media.
Because the scope of care is evolving for the elderly populations, it's important that physicians work closely with families to consider palliative or hospice care options. The Sutter Health system, a network of doctors and hospitals in northern California, has an advanced illness management program that partners with patients and families to better coordinate care for palliative patients and also consider end of life options, says Brad Stuart, MD, chief medical officer at the Sutter Care at Home in Fairfield, Calif.
Stuart says it's important that both disciplines (palliative and hospice) "collaborate for the best outcomes we can have." Much of the focus for improved patient care, especially those in palliative care, is moving toward " focusing on goals of patients in their own lives."
Even in the hospice and palliative care world, however, there are "turf" struggles, as in many other areas of healthcare, he says. "We're trying to change the medical culture. It's an uphill battle," Stuart says. Physicians gaining knowledge about such care is a start, he adds.
One of the great things about an eight-year study of emergency departments published last month in the Annals of Emergency Medicine is that it challenges some preconceived notions about the problems in EDs these days.
The National Trends in Emergency Department Occupancy report covers from 2001 to 2008, and yes, we know how some of the story goes, with the power of hindsight over the past four years. During those study years, patient visits increased 60% faster than population growth, according to the report.
Ouch. Major overcrowding. Aggravating throughput issues.
Those problems are expected to intensify since the U.S. Supreme Court has upheld the healthcare reform law, guaranteeing that more uninsured will be brought into the system, as far as emergency physicians see it.
And while the court has left it up to the states whether to expand Medicaid coverage, any increase in "the number of patients on Medicaid without an equivalent increase in the number of physicians willing to take that insurance will surely increase the flood of patients into our nation's ERs," David Seaberg, MD, CPE, FACEP, president of the American College of Emergency Physicians, said in a statement this week.
"While there are provisions in the law to benefit emergency patients, it is clear that emergency visits will increase as we have already seen nationwide,"Seaberg added.
Meantime, the crowding continues. Citing a General Accountability Office report, ACEP has stated that emergency patients who need care within one to 14 minutes are not always seen that quickly. For some it takes as long as 37 minutes.
As physicians and healthcare leaders evaluate ED improvements, the trends study is instructive because it delves into the weeds of the past to identify the causes of some of today's overcrowding.
Too many clinical tests and boarding, a pair of issues that often swirl around ED overutilization debates, were among the topics targeted in the report by Stephen Pitts, MD, MPH of the Department of Emergency Medicine at Emory University in Atlanta, GA, and Jesse M. Pines, MD, MBA, of the center for health care quality at the George Washington University Medical Center in Washington D.C.
Researchers found surprises in their evaluation of the data.
While imaging increased tremendously from 2001 through 2008, by 140%, routine tests had more of an overall impact on crowding in the ED, the physicians said in the report. Those tests included giving of intravenous fluids, blood tests, or other routine procedures.
The problem wasn't the time it took to perform the clinical tests and interventions, but the frequency of the tests and treatments, researchers found. While CT scans, MRIs or ultrasonography increased significantly, so did the volume of procedures, such as performing three or more diagnostic tests on single patient and issuing two or more medications.
The frequency and wait times for those patients in the ED increased from 26% to 76%, and the combination of all of the "routine" testing exceeded the crowding and delays wrought by imaging work, they said.
"These are things we do on an everyday basis," Pine told HealthLeaders Media, referring to the routine tests. The impact on ED crowding and waiting "was a surprise," he added.
Ironically, it is possible that innovations intended to speed ED throughput—such as authorizing the early ordering of blood testing, intravenous lines and radiographic testing at triage—may also be slowing down ED operations, Pines says.
All those clinical tests, which the report described as "greater treatment intensity," may reflect several factors, including the practice styles of physicians geared to order more testing, according to Pines. That could be pinned on a variety of issues that could range from docs seeking higher quality care, but also those practicing defensive medicine, or pursuing financial incentives.
Another major problem for EDs has been "boarding" which refers to patients waiting for an ED bed assignment. This is an all-too-frequent phenomenon that is often seen as a culprit in ED occupancy and duration of stay. Hospital officials have been working to relieve the pressure on boarding for years, which has often resulted in ambulances diverted, and critically ill patients traveling farther for care, adding delays to their treatment.
"That was the second surprise," Pines said.
While boarding practices are certainly factors in crowding, they contribute significantly less than "practice intensity," which again includes "more frequent blood testing, greater use of advanced imaging and more frequent administration of intravenous fluids," the study states.
"We hypothesized that increased boarding of hospital admissions in the ED would be the most important cause of increasing levels" of occupancy in the ED, the report states. "This was not the case."
"We found that boarding is important and a big contributor," Pines says. "If you looked particularly at the difference why length of stay was increasing over the eight-year period, it looked like it wasn't boarding going up, it was more practice intensity, taking the lab tests or blood tests. "
In their report, researchers analyzed data from the yearly National Hospital Ambulatory Medical Care Surveys from 2001 through 2008. The surveys abstract patient records from a national sample of hospital EDs.
These days, Pines agrees that hospitals are putting in place procedures to try to reduce boarding "without building new hospital towers." He also noted that while imaging increased dramatically between 2001 and 2008, "it has leveled off" in recent years, he says.
All good signs. But, there's still that one thing, Pines says.
"How can we get doctors to order fewer tests when patients come into the emergency department?" he asks. "That is a much heavier lift."
This article appears in the June 2012 issue of HealthLeaders magazine.
Before they met with vendors of joint surgery devices several years ago, top officials of the 1,674-licensed-bed Baptist Health System in San Antonio, Texas, didn't realize that millions of dollars were at stake that day.
The meeting included hospital officials, a team of orthopedic surgeons, and vendors. As Michael C. Zucker, FACHE, senior vice president and chief development officer of Baptist Health, recalls, hospital leadership had been talking with vendors for weeks seeking to lower costs for joint-replacement devices. But it wasn't working.
So they changed tactics, convincing a group of orthopedic surgeons to be involved in the process and attend the meeting. "We were aligned about the costs," says Zucker.
United with physicians, the hospital was able to establish price guidelines and vendors accepted terms of the negotiations. The hospital walked away from the meeting with seven-figure savings in price concessions over one year. "Surgeons representing multiple orthopedic groups were in the room with us, and we held the line on spending with the vendors," says Zucker. "We had a major reduction of $2 million as a result of meetings with vendors and representatives from orthopedics and cardiology," he says, referring to the hospital savings in one year under the program.
That session reflects the possibilities of bundling payments, bringing together physicians and hospitals in orthopedic programs with shared savings designed to improve quality and reduce costs, especially for joint-replacement surgery.
"The reason we had the surgeons with us with the vendors was the result of having connected them to us with the bundled program," says Wendy H. Solberg, FACHE, CPHQ, vice president of quality and patient safety at Baptist Health System. "The physicians now have some skin in the game for the hospital's cost of care. Prior to that, physicians only had to worry about their professional fee.
"With bundled payment, we got a lump sum from Medicare for both the hospital costs and physician costs," she says. "We made the physicians whole for their professional fee, but they received an incentive to help us with cost per case via their gainsharing methodology; that would not have been possible without a bundled payment arrangement."
Healthcare systems are getting involved in government-run demonstration projects that feature bundled payments, with some forecasting that good results portend important changes ahead for hospital and physician alignment, Zucker says. In the wake of healthcare reform and the move toward accountable care organizations, bundled payments are becoming an integral part of the healthcare landscape, he says.
Joint replacement is seen as an important niche for such programs.
As far as healthcare leaders are concerned, several major issues are at the heart of the need for improved financing schemes specifically for orthopedic programs, such as bundled payments, to counter increased costs in joint-replacement procedures. One is the expected continual demand for new cases, and another is the increased cost of medical devices. Overall, for orthopedics and other service lines, a major impetus toward financial reform is reflected in the move toward value-based payments determined by outcomes and penalties associated with readmissions.
About 500,000 knee-replacement surgeries and more than 175,000 hip replacements are performed each year. Hip replacements are expected to increase 174% in the next 20 years, and knee-replacement surgeries are expected to increase 673%, according to a 2007 study by the American Academy of Orthopaedic Surgeons.
"We are absolutely seeing an increase in volume of patients who have advanced arthritic changes that require surgery," says James Caillouette, MD, an orthopedic surgeon and chief of staff at the 70-staffed-bed Hoag Orthopedic Institute, which is part of the 498-staffed-bed Hoag Memorial Hospital Presbyterian in Newport Beach, Calif. "We are very busy seeing not only baby boomers, but younger patients, as well. We are seeing patients who are high-functioning, but their lives are increasingly compromised by hip or knee issues."
As demand for joint-replacement surgery grows, hospitals are grappling with a large variation in pricing of devices, says Francois de Brantes, MS, MBA, executive director of the Health Care Incentives Improvement Institute, a nonprofit organization in Newtown, Conn., that studies payment models associated with quality care.
Bundling payments is seen as a valid method to reduce costs, and the Centers for Medicare & Medicaid Services is testing various models, de Brantes says. "A fair amount of bundled contracts are being written across the country. Most of them that are pilots are in the process of being converted to a more permanent status," he says.
Surgery complications are among the key reasons for variability in total knee-replacement costs, de Brantes says. Strategies such as bundling payment to an episode of care could help reduce that cost variation, he adds.
Bundling services has a "built-in mechanism to encourage the reduction of those complications," de Brantes says. For instance, if a provider negotiates a bundled payment for knee replacement that's equal to the average cost of the surgery, which is about $27,500, the provider would earn a $2,000 margin on each bundle if complications are eliminated.
Baptist Health System is one of five healthcare systems in the country participating in Medicare's Acute Care Episode demonstration project related to bundled payment pricing for cardiac and orthopedic procedures.
"Bundling is already part of the everyday lexicon," Zucker says. "Everybody is realizing that aligning the incentives with physicians is important. We don't have a lot of ability to change without involvement of physicians, as they can influence cost decisions."
Success key No. 1: Negotiating with vendors
The vendor meeting that helped Baptist Health successfully save $2 million was a part of an initiative to reduce the number of vendors, says Zucker.
He says that health systems must incorporate procedures to reduce expenses for medical devices, which in some cases represent nearly half the cost of joint-replacement care. One red flag is the great variation in pricing from one hospital to another. Zucker says he's evaluated prices from certain vendors for hip-joint devices and contacted officials from other hospitals who tell him they were paying half the cost of the estimates he was given.
Through a relationship with the physicians, Zucker says the hospital was able to make inroads on pricing by eliminating some vendors from a preferred list. Baptist's ACE and physician health organization governing board has defined parameters for cost, quality, and other benchmarks, including protocols and metrics, he adds.
The committee structure, using the governing board protocols, has enabled the physicians to work with the hospital on vendor contracts. The ACE program also created a way for the hospital and independent physicians to be more aligned, Zucker says.
Without such a program, "very little incentive exists for physicians to collaborate with hospitals," he says. "The bundling and gainsharing components of ACE have enabled us to achieve these results. Hospitals realize much of the decisions about utilizing devices are based on physicians' preference.
"We recommended to the physicians that we would have to reduce the number of vendors in order to achieve significant pricing concessions," Zucker says. The hospital and the physicians then decided to limit the number of vendors and made clear there were certain prices that were off limits. "We told them the amount we were willing to pay in; it was up to the vendors to accept the price."
The 1,275-licensed-bed Oakwood Healthcare Inc. system based in Dearborn, Mich., also uses a committee structure involving physicians to reduce vendor costs, says Sandra Sneed, administrator of clinical services for Oakwood's Center for Orthopedics and Neurosciences. "We collaborate with our physicians and let them know that, in most cases, we try to maintain a physician preference and product price cap," says Sneed. "If that vendor wants to do business with our hospital, they have to meet the price cap."
Because of confidentiality clauses, Sneed declined to disclose specific amounts, but said, through physician alignment "we were able to achieve significant price discounts on orthopedic implants," and "we know we were able to save a significant amount when these contracts were up."
Success key No. 2: Physician alignment Initially, when he met with physicians at Baptist Health to go over proposed bundled payment programs, "physicians were lukewarm at best," Zucker recalls.
Physicians weren't thrilled about being involved in bundling projects—especially since they would not receive payment through Medicare; the hospitals would. Suddenly, "we were the bank," Zucker says. He portrays the independent physicians as being filled with anxiety, and with an attitude. "They were not excited about this. It was more like, ‘How can you do this to us?'" he explains. Within a year, when hospital physicians received more than $1 million in gainshare distribution under the bundled payment plan, they were certainly more enthusiastic.
Under the CMS ACE demonstration project, physicians received up to 125% of Medicare reimbursements, based on quality and overall cost improvements involving the treatment of 4,000 patients.
While the hospital has agreed to discount its fee, physicians still are paid 100% of the Medicare allowable rate and do not have to worry about collecting the 20% patient copayments; the hospital handles that. If quality and cost saving goals are achieved, gainsharing distribution is made to physicians who qualify on a monthly basis.
As more and more physicians received checks under the gainsharing plan, "all of a sudden it became intriguing," Zucker recalls. "It was an ‘Aha!' moment, and within months we had momentum. Physicians were interested in participating to achieve quality and cost savings to share in the success.
"It's challenging to move the bar very far. It's possible when physicians are aligned properly," he says. "We believed that creating this alignment also could help change the game in terms of quality; we could create much more value."
Success key No. 3: Order sets Standardized order sets are used in healthcare systems to improve quality, such as reducing transcription or medical errors as well as improving financial performance. It could involve physician workload regarding discharges, severity of illness, or risk of mortality. The protocols can improve compliance with recommended processes of care.
The use of standardized order sets has increased dramatically, from 31% to 97% in one year, according to Zucker. By improving its structure of order sets and removing variables within physician practices, the Baptist Health System worked within a bundled payment model that led to hospital savings in orthopedic and cardiology devices and other costs of at least $8 million from June 2009 to December 2011, Zucker adds.
The hospital system has improved physician engagement, with many doctors focusing on outcomes and data, Zucker says.
In examining the order sets, they looked at various process measures, such as "what lab tests this patient needs, what drugs were needed," says Solberg.
"The standardization of our practices ensures that we all know where we are going and are focused on managing a patient," Solberg says.
Baptist Health physicians were instrumental in putting the standardized order sets together, says Zucker.
"The standardized order sets, essentially evidence-based protocols, were developed by local physicians involved in the ACE program to define the ‘best way' to treat a particular admission," Zucker says. One of the order sets involved total hip-joint replacements, he adds. "The physicians quickly transitioned to the protocol because they saw the benefits to the patients, the hospital, and themselves. The clinical protocols are another way to further ensure that everyone is heading in the same direction."
By physicians developing the clinical protocols with the hospital, "They took greater ownership of them," Zucker says.
Zucker and Solberg say that before the procedures were established, physicians were often left in the dark about the overall price of items used for implants or other orthopedic procedures because they simply concentrated on their own techniques and were not aware of products used by other physicians.
"Oftentimes, the physicians had no idea how much something cost," Zucker says. "But this transparency of our costs and data is in effect ‘putting it all out there.'"
To overcome challenges to implement a bundling program, Zucker says healthcare systems should: - Identify opportunities for early wins to demonstrate effectiveness of partnership - Define the vision from the outset; establish a series of short-term, achievable objectives - Empower the physicians to own program leadership, governance, and decision-making - Use quality improvement as the main change agent with physicians
Success key No. 4: Data registry
The Connecticut Joint Replacement Institute uses its joint-replacement registry—with data on thousands of patients—to evaluate clinical protocols for improved outcomes for its total hip and knee patients. "That data from the registry was crucial while implementing our bundled payment program," says Steven Schutzer, MD, medical director.
The Connecticut Joint Replacement Institute at the 617-bed Saint Francis Hospital and Medical Center in Hartford, Conn., is an integrated program focused on implementing standardized best practices for hip- and knee-replacement surgery.
"The registry provides our rocket fuel; all of our outcomes data is derived from the registry, and this enables us to track our cost and clinical outcomes," Schutzer says.
The registry is important because it facilitates continuous process improvement projects, he says. The bundled payment program is known as the Step Ahead Plan and includes a package of goods and services for a single price, with an optional warranty. It is a collaborative effort among the Connecticut Joint Replacement Surgeons LLC, the Woodland Anesthesiology Associates, and the Saint Francis Hospital and Medical Center, Schutzer says. The program's warranty will be provided to some patients covering postoperative surgical-site complications.
"Without registry data, creating bundled payments or other risk-sharing, value-based healthcare products would not be possible," he says. "Under our bundled payment arrangement, the revenues are allocated to the three providers of the bundle based on the providers' cost for delivering services."
Schutzer says the institute, which opened in 2007, uses the data to monitor and review best practices and clinical protocols. The Step Ahead Plan is governed by a joint governing committee involving representatives from all three parties.
"Clean, credible data is a very powerful and persuasive tool," he says, because it is one the stakeholders—both physicians and administrators—"have difficulty refuting."
This article appears in the June 2012 issue of HealthLeaders magazine.
Reprint HLR0612-8
Physicians opposed to healthcare reform may feel like they're caught in a "Back to The Future" scenario. All that hope and hype over lawsuits against healthcare reform for the past two years has gotten physicians squarely back to 2010, when it all started. With the U.S. Supreme Court generally reaffirming the Patient Protection and Affordable Care Act, docs are trying to decipher their own diagnosis for what's ahead.
Many physicians who deride healthcare reform call it "Obamacare," just as disapproving non-healthcare professionals do. Should they now call it "Supreme Court care," too? In its 195-page decision, the court mentioned the word "physicians" only twice and "doctors" not at all.
In case you somehow missed it, the court was sharply divided, voting 5-4 to uphold the key provisions of the PPACA, including the controversial individual mandate that requires people to either purchase health insurance or pay a penalty. Chief Justice John Roberts was the deciding vote. The court also left it up to the states to expand Medicaid coverage.
Indeed, as the court was divided, so, it appears, is the population of physicians, much as they were before. Some say the court did the right thing, and the PPACA will properly bring millions more uninsured people into healthcare. Others contend it was a bungled effort at overregulation. Both sides seem to be uncertain over what the Medicaid ruling may bring. "It was the right thing to do," says one doc. "It was the worst decision ever," says another.
Amid the vehemence and vitriol, physicians appear to be diverging along two paths: embracing the court decision with some enthusiasm, or stepping up their political activism in hopes that the presidential election may make a difference. "Now is the time to take back medicine!" the Association of American Physicians and Surgeons roars on its website. "The Supreme Court has ruled and the fight has begun anew. Will it be easy? No. Does it have to be done? Yes."
Along the way, for moderates, liberals, cardiologists, and oncologists, there are loads of uncertainties with reimbursement and regulatory challenges, as well as key issues that the Supreme Court never touched on, such as tort reform and the Sustainable Growth Rate formula, which governs the growth of Medicare physician payments annually.
Building a consensus among physicians may be difficult. It's taken years for healthcare leaders to smooth rough edges and improve day-to-day care in hospitals, where physicians are far more comfortable than in the political arena.
Glen Stream, MD, MBI, president of the American Academy of Family Physicians, acknowledged to HealthLeaders Media that bridging the gap between physicians with opposing feelingscould be difficult, even within his own organization. "It's a challenge," he says, noting that some of his members are angry over the high court's action as well as the academy's support of the law. "My hope is that the angst of today passes, and we can work together tomorrow to find common ground," Stream says. He adds, "I was pleased to see it upheld. It's not perfect, but we can go forward with the structure it has."
Kim Bullock, MD, an emergency department physician who works in Washington, D.C., hospitals in both high- and low-income areas, says she's concerned about what will happen to various factions after the high court decision.
"Now there is either bridge-building by the different factions, or continued polarization," she says. "Bridges must be made within the profession, just as among the populace. The landmark legislation has generated strong opinions, and I do believe that was part of the intent by the authors. Finding consensus will make it easier for physicians to negotiate the changes in the details associated with the law."
The American Medical Association, which supported healthcare reform, also endorsed the Supreme Court decision. They especially favored the individual mandate provision, which will open the door for millions to obtain insurance coverage.
But many physicians don't believe doctors will be in a financial position to handle more patients, noting current shortages of primary care physicians and regular overflows in emergency departments. Moreover, many doctors don't believe the law can attain its insurance coverage goal. A survey of primary care physicians conducted by MDLinx immediately after the high court's decision found that 64% said they didn't think it would achieve the law's objective of 100% coverage of all Americans.
Adding an estimated 19 million people into Medicaid by 2014 also may strain payments to physicians, which currently come in at only slightly more than half of what private insurance pays, according to the conservative Heritage Foundation. The lower payments already discourage doctors from accepting Medicaid payments, says G. Keith Smith, MD, an anesthesiologist in Oklahoma City, OK, who opposes the Supreme Court decision. "It is a disaster for physicians," Smithsays. "It's incredible how much more difficult it will be [for physicians] to see Medicare patients. Many will opt out. We're all scratching our heads and not making any headway. This is so dysfunctional."
In addition, Smith says, many physicians oppose the Independent Payment Advisory Board to contain cost growth in Medicare. As IPAB cuts reimbursements, seniors will experience growing access problems. Congressional committees continue to examine the IPAB.
In the meantime, the Supreme Court's decision to leave Medicaid coverage up to the states clearly will impact physicians and their workload. Before the court's decision, hospitals and providers were expecting millions of low-income and disabled patients to join Medicaid's ranks. Now, Republicans are ramping up efforts to thwart state involvement in Medicaid.
"I think physicians generally want to provide quality healthcare and I think there are going to be barriers," says Michael Fleming, MD, FAAFP, chief medical officer for Amedysis, a provider of home and healthcare based in Baton Rouge, La. Fleming described himself as generally neutral about the Supreme Court decision.
For physicians, it's the uncertainty that confuses, frightens, and annoys, he adds.
"Physicians are among the most change-averse humans on the planet," adds Fleming says. "Docs have been burned [in reimbursement issues] and primary care docs have been burned more than most. Cardiologists have been burned, their fees have been slashed. Radiologists have had their fees cut. So basically you are asking physicians, ‘You want to accept something that doesn't have details yet?' How am I supposed to feel about that? That's where the negativity comes in."
But the PPACA decision also has immediate positive impacts in other areas, according to the AMA. It can begin to alleviate administrative burdens on physicians, such as streamlining insurance claims. In addition, the decision ensures that the act carries out important improvements in healthcare, AMA President Jeremy A. Lazarus, MD, said in a statement. Included in that assurance is putting an end to coverage denials for pre-existing conditions, and allowing 2.5 million young people up to age 26 to stay on their parents' health insurance policies.
Regardless of the Supreme Court decision, many physicians are on board for movement from fee-for-service to value-based care, as well as exploring payment options ranging from bundling to those included in accountable care organizations, with an emphasis on patient-centered care. "The devil will be in the details how it all works out," Fleming says.
As part of the crowd that amassed last week outside the Supreme Court, I was told the decision drew some of the loudest and most vociferous crowds in memory outside its marble walls, with many people carrying placards praising the decision or denouncing it, some with megaphones, some with drums, arguing or chanting for whatever position they held.
One physician who stuck out in the crowd was Michael Newman, MD, a Washington D.C.–based internist. He wore a white coat and carried blue binder notebooks. He wasn't part of a group of protesters, but simply a practitioner who works a few blocks away from the Supreme Court building and wanted to see history unfold. He identified himself as a supporter of healthcare reform. Newman acknowledges he may be in the minority of physicians who favor what the Supreme Court has done, but is pleased that it may result in more care for the currently uninsured, for instance.
"There is definitely disagreement about the law, but it's not up to the Supreme Court to fix the problems of healthcare. It's up to the people,." Newman says. "The Affordable Care Act is not the greatest piece of legislation, but the best piece that could be enacted."
In implementing the Patient Protection and Affordable Care Act, there's at least one provision that Congress possibly felt it couldn't afford—or simply didn't care enough about—to fully fund. The healthcare reform law, which was upheld by the Supreme Court today, called for the establishment of coaching programs for physicians. Yet without much federal money, this program has flourished anyway at state and grassroots levels.
Several groups have initiated their own coaching programs through a variety of different funding sources. A report issued by the Commonwealth Fund last month suggests that coaching helps physicians improve team-building, handle patients' chronic conditions, and enhance patients' access to care. Coaching also improves communication among staff, increases efficiencies, and saves costs. But the report also says there appears to be wide variation in the quality of such programs, and a need for standardization of training.
Generally, physician coaching programs are becoming more needed, as well as more popular, says Terry McGeeney, MD, MBA, a primary care physician who is president and CEO of TransforMED, a nonprofit firm created by the American Academy of Family Physicians (AAFP) to provide coaching services. The TransforMED program is headquartered in Leawood, Kan.
AAFP launched TransforMED in 2005 to advance practice improvement initiatives, such as those in medical homes, McGeeney says. Since then, TransforMED has worked with more than 500 primary care practices, impacting more than 11,000 providers and clinicians.
"Problems and challenges of primary care practices are pretty consistent across the board: access to care, communication, and local leadership," McGeeney says.
Physician practice coaching—often geared to hospitals that employ many physician groups—is particularly important in smaller communities that lack the "robust quality improvement infrastructures" found in larger hospitals and big medical groups, the Commonwealth Fund study states. "The majority of primary care practices simply lack the expertise, will, or resources to improve care for their patients, and they need help," the report says.
Surprisingly, practice coaching has its roots in agricultural models of the early 20th century, where agricultural experts and farmers would develop collaborative relationships and share best practices. "Just as small farmers were most in need of the kind of support, it is these smaller physician practices that are most in need of help," the Commonwealth study states.
Whether practices are big or small, it is becoming more difficult for primary care physicians to spend time on improving care, according to McGeeney, and the situation is likely to worsen with impending physician shortages.
Practice coaching programs are being developed across the country on state and regional levels. Although the PPACA created a nationwide Primary Care Extension Program—perhaps named after the agricultural extension concept that predates it—Congress did not appropriate funds for this program. It is estimated to cost $120 million annually.
The Commonwealth Fund study cites reports showing that the effectiveness of practice coaching can be related to care for patients and improvements in physician practices adhering to evidence-based guidelines.
TransforMED initiates mostly peer-to-peer coaching. "We go into a practice and let [physicians] tell their stories and create a peer support group," McGeeney says. "It really accelerates the transformation of a practice." The coaches come from a wide range of specialties, and include physicians, nurses, and other health professionals or counselors with advanced degrees.
Most physician groups and hospitals prefer to have coaches with real-world experience, McGeeney says. Each coach "has to be immediately credible when they walk into a busy primary care office practice, so everyone feels comfortable."
In addition, TransforMED grooms potential coach candidates within hospital organizations. "We train health system staff to be the coaches, so we can move out and be in the background and support," McGeeney says. Coaches work toward "assessing their ability to function as a team, [as well as] their leadership capabilities at the physician level and staff level," he adds.
Coaching physician practices, especially primary care, and prompting change "is a complex undertaking," the Commonwealth Fund report notes. The country would benefit from a more "systematic approach to the training and deployment of primary care practice coaches."
To improve coaching, curricula and best practices should be shared to convey information about what does and does not work in the field, the study says. In addition, the report recommends establishing centers of excellence and exploring the possibility of community college training programs. "Although rigorous research has demonstrated the value of practice coaching, more research and evaluation is needed to test different models of practice coaching and determine how to deploy practice coaching most efficiently," the study states.
Indeed, the physician coaching process isn't always easy, McGeeney says. "Doctors don't always like it; [they] view it as soft, fluffy stuff. But it's definitely not."