Clarity is crucial to the success of medical groups, the chief medical officer of Monument Health says.
Physician groups should have a clear definition of who they are, says Brad Archer, MD, chief medical officer of Rapid City, South Dakota-based Monument Health.
Archer has been CMO of Monument Health since September 2017. Prior to joining Monument Health, he was chief clinical officer at University of Iowa Health Alliance. His prior experience includes serving as executive medical director of MercyCare Community Physicians.
HealthLeaders recently talked with Archer about a range of topics, including the challenges of serving as CMO of Monument Health, physician group leadership, and value-based care. The following transcript of that conversation has been lightly edited for clarity and brevity.
HealthLeaders: What are the primary challenges of serving as CMO of Monument Health?
Brad Archer: Initially, going back about six years ago when I got here, the biggest challenge was the lack of structure, which led to a lack of engagement from the physician staff. So, we have focused on building our culture starting with building a consistent structure that sought to generate physician input on a regular basis as opposed to an ad hoc basis. We worked on the leadership infrastructure.
We have also created an atmosphere of psychological safety and transparency in terms of error reporting and process improvement.
Our geography is a challenge. We have a large region to cover without any other population centers nearby. There are no other hospitals or health systems to share some of the responsibility that comes with our geography. Our healthcare partners are in places such as Sioux Falls, Billings Clinic, and Denver, which are quite distant from us, so one of our challenges is providing the latest and best care for our patients given that we have distant healthcare partners.
Another challenge we face is that we have a disproportionate government payer mix. So, in addition to the large geography, we have some issues with affordability.
HL: Do you have a high percentage of Medicare and Medicaid patients?
Archer: Yes, and we have a high percentage of government payers in general. For us, that also includes the Indian Health Service, which is a significant component of our tertiary referral base. For the tribes, we are their tertiary facility. Like all government payers, IHS is paying us below our costs to provide services.
HL: How are you rising to the challenge of having government payers that do not cover the totality of your costs?
Archer: It is a challenge, and it got worse with COVID with the increase in supply chain costs and the increase in labor costs. We are having to be careful as we look at our expansion into different service lines. So far, the payer mix has not kept us from launching new service lines, but it is a consideration. Like a lot of places, we are becoming leaner in terms of our efficiency. As we maintain and improve quality, we are looking to do so in a way that is most efficient and financially feasible.
We are getting better with our revenue cycle—connecting our clinical teams to our revenue cycle and finance teams to achieve the best possible financial outcome for patients. We do not want to burden patients with unnecessary medical bills or expenses because we did not get prior authorization or because we did not document in a way that resulted in a reimbursement denial.
Brad Archer, MD, chief medical officer of Monument Health. Photo courtesy of Monument Health.
HL: Your previous experience includes serving as executive medical director of MercyCare Community Physicians. What are the keys to success in physician group leadership?
Archer: You need a clear definition of who you are as a physician group and how you do things. You need to put these definitions in writing. I tell young physicians who are considering joining a physician group to make sure the organization has a clear mission, a committed leadership structure, and an operational structure that reflects the organization's values and leadership structure. Clarity is crucial to a successful medical group.
The CMO of a successful medical group needs to function like an air traffic controller. You need to navigate people to get things done and stick to it.
HL: What are the primary elements of physician engagement?
Archer: It goes back to structure. You need to create a structure that is consistent and has physicians involved on a regular basis. I always say the worst thing you can do with physicians is to try to not bother them much then have ad hoc meetings where you ask their opinion. Under those circumstances, physicians will often feel that they do not get follow-up. The consistency of the governance structure and the inclusion of all the operational decisions within the organization on the physicians' agenda are essential. You do not want to make assumptions or bypass the physician leadership.
There are different ways to conduct physician engagement. At Monument Health, we are fully integrated with our non-physician leadership in a way that provides open dialogue for our decisions with physicians.
HL: What role do physicians play in administrative leadership at Monument Health?
Archer: When I got here, there was a separate physician group and seeking input was primarily on an ad hoc basis. We dissolved that group and chose a fully integrated model. So, we have medical directors at every level of service in a market-based operational structure.
We have the system-level operations structure, then each market has their own unique operational structure. Within those markets, there are physicians who are paired at the director level and the vice president level in every department. So, we have department-specific medical directors who are paired with their department directors, and we have executive medical directors who are paired with the operational vice presidents. These leaders are engaged in all of the decision-making.
HL: You have a large rural population. What are the keys to success in providing value-based care in this kind of an environment?
Archer: With value-based care, you need to change information systems and the workflows to more of a proactive management, where we are focusing on our panel of patients that we are responsible for and trying to predict their needs ahead of time. We need to make sure patients are getting preventative care and not be reactive. In our case, this is particularly challenging because tertiary care is a big part of our value in the region, and it is largely reactive and emergent care. We must do tertiary care well while we shift our focus to managing populations and focusing on population health. Traditionally, our data systems have not supported that type of management as readily as we would like them to.
Things are getting better now. Claims information that we can get from the Centers for Medicare & Medicaid Services and other payers that are promoting value-based contracts is certainly helpful. But we must alter our workflows, particularly in our primary care clinics, in order to accommodate a value-based approach to care.
One of the keys to success is contractual, where you seek to appropriately document and code your patients' conditions. That is a separate component of success that is not inherently part of a general medical education or of a medical practice necessarily.
Another factor is having the appropriate access, which is a challenge for us and many other health systems across the country. Primary care access is not always easy, and in rural areas such as ours it can be even more challenging. In particular, when you are trying to do outreach and to get people to come in, we have some distance to cover to bring people in to see their providers. So, transportation becomes a challenge for us.
HL: What are the primary elements of patient safety at Monument Health?
Archer: First and foremost, it is about promoting a just culture and getting our errors reported, including near misses. These are opportunities for us to learn and improve our processes.
To support a just culture, we have a good quality assurance structure in place. We have the correct technology and data tools to provide opportunities for improvement. We also have promoted the lean methodology.
About 371,000 Americans die annually after a false negative diagnosis for a serious illness, according to researchers.
False negative diagnoses are likely the largest source of death linked to medical errors in the United States, a new research article found.
The U.S. National Academy of Medicine says improving diagnosis is a "moral, professional, and public health imperative." In a 2015 report, the National Academy of Medicine estimated that most Americans have at least one diagnostic error in their lifetime that can lead to "devastating consequences."
The new research article, which was published by BMJ Quality & Safety, extrapolates total false negative diagnoses that result in death or permanent disability from "The Big Three" disease categories for misdiagnosis with serious harm: vascular events, infections, and cancers. The researchers focused on 15 diseases in The Big Three categories: stroke, venous thromboembolism, arterial thromboembolism, aortic aneurysm/dissection, myocardial infarction, sepsis, pneumonia, meningitis/encephalitis, spinal abscess, endocarditis, lung cancer, breast cancer, colorectal cancer, melanoma, and prostate cancer.
The study features several key findings:
About 795,000 Americans suffer death or permanent disability after a false negative diagnosis for a serious illness at an ambulatory clinic, emergency department, or inpatient setting, with 371,000 deaths and 424,000 permanent disabilities
The 15 serious diseases that were the focal point of the study account for 50.7% of deaths and permanent disabilities linked to false negative diagnoses
Five of the 15 diseases that were the focal point of the study account for 38.7% of deaths and permanent disabilities linked to false negative diagnoses: stroke, sepsis, pneumonia, venous thromboembolism, and lung cancer
The overall average diagnosis error rate was estimated at 11.1%
The disease with the highest rate of death and permanent disability linked to false negative diagnosis was stroke, which was missed in 17.5% of cases
Interpreting the data
The study is the first rigorous national estimate of death and permanent disability linked to diagnostic errors, David Newman-Toker, MD, PhD, lead investigator of the research and director of the Johns Hopkins Armstrong Institute Center for Diagnostic Excellence said in a prepared statement.
"Prior work has generally focused on errors occurring in a specific clinical setting, such as primary care, the emergency department, or hospital-based care. These studies could not address the total serious harms across multiple care settings, the previous estimates of which varied widely from 40,000 to 4 million per year. The methods used in our study are notable because they leverage disease-specific error and harm rates to estimate an overall total," he said.
Efforts to improve diagnosis should focus on diseases accounting for the greatest number of serious misdiagnosis-related harms and with high diagnostic error rates, Newman-Toker said. "A disease-focused approach to diagnostic error prevention and mitigation has the potential to significantly reduce these harms. Reducing diagnostic errors by 50% for stroke, sepsis, pneumonia, pulmonary embolism, and lung cancer could cut permanent disabilities and deaths by 150,000 per year."
There is an urgent need for more research designed to examine diagnostic errors and point to possible solutions, he said. "Funding for these efforts remains a barrier. Diagnostic errors are, by a wide margin, the most under resourced public health crisis we face, yet research funding only recently reached the $20 million per year mark. If we are to achieve diagnostic excellence and the goal of zero preventable harm from diagnostic error, we must continue to invest in efforts to achieve success."
The researchers found conservative estimates of serious harm from diagnostic errors compelling, the study's co-authors wrote. "Even with the most conservative assumptions about disease incidence or disease-specific harms, we estimated the number affected [patients] to be over 500,000. The number of affected patients is large, and this makes diagnostic error a pressing public health concern."
Diagnostic errors could be the most deadly medical errors in U.S. healthcare, the co-authors wrote. "Our results suggest that diagnostic error is probably the single largest source of deaths across all care settings (~371,000) linked to medical error."
A joint steering committee will identify projects and track the progress of projects.
Riverside Health System and UVA Health have formed a strategic alliance to generate benefits in complex care, medical education, care coordination, and clinical research, the Virginia-based health systems announced last week.
The top executives at the health systems say the organizations are joining forces from positions of mutual strength, including strong financial standing. The agreement provides UVA Health with a 5% ownership stake of Riverside.
"The question that often comes up is, how is an alliance like this superior to a straight up merger? This alliance allows us to focus on our communities and our unique missions in a way that gives strength to both health systems, but that does not require a merger. We feel it is the best of both worlds—we gain the strengths of each institution while allowing us to focus on the needs of our local populations," says Michael Dacey, MD, Riverside's president and CEO.
The overall goal of the alliance is to improve the quality of care for nearly 2 million people in Eastern Virginia, he says. "The types of resources that are being committed fall into a number of categories. Certainly, there are some financial resources, but it's not about the money because both health systems are doing well financially. It is more about the expertise and the coordination of care."
A primary goal of the alliance is to keep complex care local, says K. Craig Kent, MD, CEO of UVA Health and executive vice president for health affairs at University of Virginia. "We believe all care should be delivered locally. With this alliance, 95% of care should be able to be provided locally. There will be rare instances when someone has to leave Eastern Virginia for something incredibly complex, but the idea is to partner with Riverside to provide as much complex care locally as possible. That is one of the underlying concepts of the alliance."
An example of collaboration on complex care and care coordination in the alliance is transplant medicine, Dacey says. "Riverside is not going to do organ transplantation, but UVA Health is one of the best transplant centers in the world. If we can help coordinate patient care and get patients into the transplant process earlier, that will help save lives, and all of the pre- and post-transplant care can be done locally."
As part of the alliance, UVA Health will have a transplant coordinator for Eastern Virginia, Kent says.
"In terms of solid organ transplantation, 90% of the work involved for patients is the pre-operative evaluation and the post-operative care. All of that can be performed extraordinarily well in Eastern Virginia by Riverside. The other 10% of the care can be provided by UVA Health. Patients that need transplantation are complex patients and care coordination is critically important. Part of our alliance is making sure that we have our teams working together closely, so patients can be cared for in the best possible way," he says.
Boosting clinical research is an important element of the alliance, Dacey says. "One of the things that we both have a joint interest in is research, particularly clinical trials. Riverside has a large number of patients. We have about 1.2 million ambulatory visits annually. A lot of those people would benefit from access to clinical trials, and the opportunity to work with UVA Health on clinical trials is one of the things we were attracted to."
Medical education is another key component of the alliance, Dacey says. "At Riverside right now, we have our own residencies in family medicine, emergency medicine, and obstetrics. We hope to grow both the number of residencies such as adding internal medicine next year and the opportunities for the residents to work with the resources at UVA Health, whether it be developing research projects or sharing faculty back and forth. We hope to grow those areas of medical education, particularly at the residency level."
Bolstering residencies is part of Riverside's strategy to address physician workforce shortages, he says. "There is a huge shortage of doctors coming, probably a shortage of 80,000 to 100,000 doctors nationally in the next 10 years. The problem is not necessarily medical schools, it is the ability to train at the post-graduate level. By growing residencies above what we have right now, we hope to help address that problem. Where a resident trains is the most important determining factor for where they end up practicing medicine. So, we feel growing residencies in Virginia will help with the physician workforce in Virginia, and UVA Health can clearly assist us in that effort."
Riverside and UVA Health are ideal partners, Dacey says. "We both share the same mission and values, which is to do what is best for our patients. We are both committed to providing the right care, at the right place, at the right time. So, it was a cultural fit. In addition, our medical staffs already collaborate in several areas in terms of specialty referrals back-and-forth. So, we already had pre-existing clinical relationships. Plus, there is the world-class reputation of UVA Health combined with the substantial patient base of Riverside, which was an additional attraction from Riverside's standpoint."
UVA Health and Riverside will each retain their governance and administrative structures, but there will be a formal mechanism to manage the alliance, he says. "We will have a joint steering committee, where members from UVA Health and members from Riverside will jointly identify projects and track the progress of projects, whether that is in clinical areas, educational areas, or clinical research areas."
The American Medical Association says financial and administrative pressures on physicians are driving the shift away from independent practices.
Physicians are less likely to work in private practices than they were a decade ago, according to a new Physician Practice Benchmark Survey conducted by the American Medical Association (AMA).
The AMA launched its first Physician Practice Benchmark Survey in 2012. The surveys, which are published every other year, are nationally representative of post-residency physicians who provide at least 20 hours of patient care per week. The latest survey, which was conducted from September to November 2022, features data collected from 3,500 physicians.
The results of the latest survey reflect financial and administrative pressures on physicians, AMA President Jesse Ehrenfeld, MD, MPH, said in a prepared statement.
"The AMA analysis shows that the shift away from independent practices is emblematic of the fiscal uncertainty and economic stress many physicians face due to statutory payment cuts in Medicare, rising practice costs, and intrusive administrative burdens. Practice viability requires fiscal stability, and the AMA's Recovery Plan for America's Physicians is explicit in calling for reform to our Medicare payment system that has failed to keep up with the costs of running a medical practice."
The Physician Practice Benchmark Survey released yesterday has several key data points in four areas.
1. Practice ownership
From 2012 to 2022, the proportion of physicians who work in private practices fell from 60.1% to 46.7%
From 2012 to 2022, the proportion of physicians who work in a hospital-owned practice increased from 23.4% to 31.3%
In most specialties in 2022, the proportion of physicians in private practice ranged from 41.2% for general surgeons to 49.7% for radiologists
In 2022, the specialty outliers for physicians in private practice were emergency medicine physicians at 37.0% and surgical subspecialists at 63.3%
The primary reason cited for hospital and health system acquisition of physician practices was the need to negotiate higher payment rates with payers, with 46.1% of survey respondents saying this reason was very important and 33.4% saying this reason was important
2. Practice size
From 2012 to 2022, the proportion of physicians working in practices with 10 or fewer physicians decreased from 61.4% to 51.8%
From 2012 to 2022, the proportion of physicians working in practices with 5 to 10 physicians decreased from 21.4% to 19.0%
From 2012 to 2022, the proportion of physicians working in practices with fewer than 5 physicians decreased from 40.0% to 32.8%
From 2012 to 2022, the proportion of physicians working in practices with at least 50 physicians increased from 12.2% to 18.3%
3. Practice type
In 2022, single-specialty practices represented the largest proportion of physicians (41.8%) followed by multi-specialty group practices (26.7%), solo practices (12.9%), and a direct employment or contracting relationship with a hospital (9.6%)
Over the past decade, the proportion of physicians in multi-specialty practices and a direct employment or contracting relationship with a hospital have increased about 4 percentage points
Over the past decade, the proportion of physicians in solo practices and single specialty group practices has decreased about 4 percentage points
At more than 50% of physicians in 2022, obstetricians/gynecologists, anesthesiologists, and radiologists had the largest proportion of physicians who practice in single specialty practices
At 27.8% of physicians in 2022, general internists were least likely to work in a single specialty practice
Psychiatrists and general internists were the most common specialties working in solo practices in 2022 at about 22% of physicians
4. Employment status
In 2022, 49.7% of physicians were employees and 44.0% were practice owners
In 2012, 41.8% of physicians were employees and 53.2% of physicians were practice owners
The chief medical officer of Cape Cod Healthcare embraces servant leadership.
Servant leadership involves preparing people to do the right thing, getting them the tools they need to do the right thing, then getting out of their way, says William Agel, MD, MPH, senior vice president and CMO at Cape Cod Healthcare.
Agel has been the top clinical officer at Cape Cod Healthcare since April 2020. He has also served as a member of the board of trustees at the Hyannis, Massachusetts-based health system. Agel has been a practicing obstetrician/gynecologist at Cape Cod Healthcare since 1999.
Healthleaders recently talked with Agel about a range of topics, including the challenges of serving as CMO at Cape Cod Healthcare, how to generate a positive patient experience in the hospital setting, and recruiting physicians in a tight labor market. The following transcript of that conversation has been lightly edited for clarity and brevity.
HealthLeaders: What are the primary challenges of serving as CMO of Cape Cod Healthcare?
William Agel: One challenge is navigating the competing priorities of managing a complex organization. As a practicing doctor, I understand that my No. 1 priority is the patient in front of me. My No. 2 priority is my practice. Those priorities can cause friction between me and other services or stakeholders such as nursing, case managers, or the friction that occurs between physicians trying to figure out how to take care of a patient.
As the CMO, my competing priorities are the community that I serve here on Cape Cod, the institution that I serve at Cape Cod Healthcare, the medical staff that I serve, and the individual doctors that I serve. The essence of being a good CMO is the ability to balance those priorities for the ultimate good of the patients, the community overall, and the doctors at the health system.
HL: How do you balance those responsibilities?
Agel: If you look at it from the perspective of what is right for the patients, the community, and the institution, it is easier to do the right thing. When I have two doctors who are disagreeing over who is going to take care of a patient, the most important thing is what is best for the patient. When we look at the situation in that framework, most people are going to do the right thing no matter what. It just takes a little bit of rebalancing of priorities. Sometimes, it is just a matter of making folks aware of the frictions and why they exist.
William Agel, MD, MPH, senior vice president and CMO at Cape Cod Healthcare. Photo courtesy of Cape Cod Healthcare.
HL: Cape Cod is a distinct region, and you have few direct competitors. What are the advantages of serving a distinct region with little competition?
Agel: Cape Cod is a distinct, beautiful, and unique place. It has unique problems and opportunities. The Cape Cod Canal represents a physical barrier to out-migration for our patients. With the Fourth of July holiday, if you try to get over the bridge, you can see just how much of a barrier that can be. So, we have an advantage over our competition in terms of market share, but that advantage comes with responsibilities. We can't just rely on our geographic isolation to protect our market share. We must do better by our patients. They are our neighbors. They are our friends. They are our relatives.
If someone chooses to battle the traffic to go up to Boston, which is our true competitor for care that could be provided here on Cape Cod, then we have failed our community.
HL: What are the primary elements of generating a positive patient experience in the hospital setting?
Agel: The most important aspect of patient experience is simply showing the patient and the family that I as a physician and we as a health system care about what happens to them. We need to provide care that respects their individual needs and puts our needs second. If we can work that way, a good patient experience follows.
All of the elements of the HCAHPS scores are important, but it comes down to whether we care about the people in front of us. If you look at the care we provide in that way, then all of the other HCAHPS scores fall into place. If I am truly showing to my patients that I care about what happens to them, and I am communicating with them and my nurses are communicating with them, they will know that they will get the care that they need.
HL: You have embraced a servant leadership style. In practice, what are the main elements of your servant leadership style?
Agel: Servant leadership is a good fit for healthcare. As a physician, my job for the past 30 years has been to serve my patients—offer them the information and therapies they need to live their best lives. As a chief medical officer, I try to follow that same path. My job is to give doctors the tools they need to help build a high-reliability organization. Sometimes, that is individual coaching for a physician with a behavior problem. Sometimes, it is looking at a case from a programmatic standpoint and translating that into something that my doctors can work with.
In the end for me, servant leadership is about identifying good people, preparing them to do the right thing, getting them the tools they need (not necessarily what they want) to do the right thing, then getting out of their way.
HL: By multiple accounts, the physician labor market is tighter than ever. How have you been managing physician recruitment?
Agel: The labor market is tight and getting tighter. Current predictions are that we will have a significant shortage of qualified doctors over the next 10 years. Shortages have been accelerated by retirements as a result of the coronavirus pandemic and provider fatigue. Administrative burdens have not helped.
At Cape Cod Healthcare, we have had success in both stopping the loss of providers and attracting young talent. In that regard, I can think of three major themes that have helped us.
No. 1, our president and CEO is dedicated to the health and well-being of our entire workforce, including our physicians. Over the past several years, we have made progress in decreasing the administrative burden on those physicians such as reducing in-box bloat, off-loading non-critical tasks, and optimizing our electronic medical record to make it more user friendly. Those efforts have paid off. Our doctors are happier in their work. The best recruiter we have for physicians is a happy incumbent physician.
The second theme is Cape Cod Healthcare is a place where an eager young doctor can practice at the top of their license. We do not have the luxury of having the ability to send someone down the road because their blood pressure is elevated. We must take care of the folks in front of us. For a young physician coming out of training, that is an attractive proposition. They have studied and trained hard to become extraordinary, good physicians. To give that away by becoming a physician in a city where they will be pigeon-holed into taking care of one particular type of patient is a downside. We offer an alternative to that type of care.
Finally, I can look outside my window and see the harbor and the beach. That is a pretty good recruiting tool.
We are an institution that cares about doctors and encourages doctors to practice their craft to the fullest. And they can practice in a place that is beautiful. It is a special combination.
HL: Cape Cod has a fluctuating seasonal population. Many more people are in the region during the summer. How do you serve this fluctuating population?
Agel: It is a balancing act. We go from about 225,000 people during the winter months to close to a million people on any given day during the summer. That presents significant infrastructure challenges. We need to maintain the infrastructure for serving a million people, but for most of the year we take care of significantly fewer people. We have learned to scale up and down. My colleagues are fantastic at flexibility in staffing and getting the right resources at the right time.
HL: Does this fluctuating population pose staffing challenges such as in emergency medicine?
Agel: Our providers in the emergency department are good at scaling up in the summertime. The emergency department is busy year-round; it just gets busier in the summer. Our emergency room physicians increase their hours and increase their availability during the summertime. They also have a group of doctors who work more during the summer and less during the winter, so they can scale up. We also scale up our nursing staff and support staff during the summer.
A recent Harris Poll conducted for the AAPA found 90% of patients believe physician associates are part of the solution for healthcare workforce shortages.
Physician associates (PAs) are part of the solution for workforce shortages in the healthcare sector, says Folusho Ogunfiditimi, DM, MPH, PA-C, president and chair of the Board of Directors at the American Academy of Physician Associates (AAPA).
Ogunfiditimi began his term as president of the AAPA this month. He currently works as administrator of practice management at Florida Health Care Plans. His prior experience includes serving as the associate administrator of the Detroit Medical Center Cardiovascular Institute.
HealthLeaders recently talked with Ogunfiditimi about a range of issues, including the priorities of his AAPA presidency and the ideal role for PAs on care teams. The following transcript of that conversation has been lightly edited for clarity and brevity.
HealthLeaders: What are the priorities for your AAPA presidency?
Folusho Ogunfiditimi: There are three main categories and a fourth that is not as critical. The three main categories are what I call the Three Ps.
The first P stands for patients and improving access for patient care. The ability of patients to get the care they need is critically important.
The second P stands for practice—the practice that PAs are actually working in. We need to improve outcomes, whether that is health outcomes or outcomes related to the value or productivity that PAs bring to practices. We need to be able to empower PAs as well as expand and grow their practices.
The third P stands for the profession as a whole. We need to modernize the laws around the profession. About 100 million people lack access to primary care. Only 47% of primary care needs are actually being met. So, some of the challenges that PAs have in terms of the current laws prevent us from boosting healthcare access for our patients. About 163 million people do not have access to mental health care. PAs need to be fully utilized to the extent of their training.
The fourth priority is looking at expanding the role of PAs as it relates to leadership, mentorship, and closing the equity gaps in healthcare. I want to focus on how we can mentor young PAs. So, I want to be looking at research and looking at leadership as well as looking at mechanisms to be able to effectively close health equity gaps.
HL: What is the ideal role for a PA on a care team?
Ogunfiditimi: We have talked a lot about optimal team practice—how PAs, physicians, and other healthcare providers work together to deliver care. That is the optimal role for PAs and being able to deliver services without the administrative burden that you see in terms of having constraints around them.
For example, when a PA is not legally tethered to a physician, the PA can be more flexible in the care they deliver. It would be easier to allow PAs to serve on care teams by expanding the role of PAs and making sure that PAs are able to practice to the top of their license and the top of their training. This will facilitate PAs to be able to serve in medically underserved communities, where we currently do not have enough physicians and in certain areas have no physicians. PAs are primed to provide care in those areas in states that allow them to practice autonomously.
So, the ideal role for PAs is to work on care teams with colleagues but to also have the ability to fully maximize their training and work autonomously.
HL: There are workforce shortages in healthcare nationwide, including shortages of physicians. How can PAs help to address workforce shortages?
Ogunfiditimi: PAs play a critical role in ensuring patients have access to high-quality care. A recent Harris Poll that was conducted for AAPA showed that 67% of patients who have seen a PA would trust a PA to serve as their primary care provider. The same poll showed that 92% of patients believe PAs should be allowed to provide care to the fullest extent of their education and training. The poll found 90% of patients believe PAs are part of the solution for our healthcare workforce shortages.
So, PAs play a critical role in ensuring that we can improve access to quality healthcare and improve on the disparities we see in healthcare. In most states, PAs are required to have supervision by a physician. Some states have gotten rid of that requirement, which is something we support.
Folusho Ogunfiditimi, DM, MPH, PA-C, president and chair of the Board of Directors at the American Academy of Physician Associates. Photo courtesy of the AAPA.
HL: You are administrator of practice management at Florida Health Care Plans. How did working as a PA help prepare you to serve in an administrative leadership role?
Ogunfiditimi: My training as a PA was critical to me being in a leadership role. The knowledge that I obtained at the bedside and as a clinical practitioner allowed me to be able to understand the challenges that patients have and be able to translate those challenges into potential solutions. You must be ingrained into the healthcare system to be able to make changes.
In being a PA, I had a wide variety of exposures working clinically with my patients but also sat on various committees. I realized that one of the ways I could continue to effect change is by growing in the leadership realm and impacting other providers. I am always going to be a PA at heart even though I work in administration now, and being a PA laid the foundation for where I am today.
HL: The American Medical Association has said that PAs should only practice medicine under the supervision of a physician. Are PAs capable of practicing independently of physicians?
Ogunfiditimi: The truth is that in modern healthcare there is no one including physicians who practice independently. We all practice collaboratively. PAs are fully trained in medicine, and they are fully capable of being able to practice medicine autonomously on healthcare teams. It is not a matter of whether someone wants to practice independently—there are no practitioners who practice independently. But PAs should be able to practice autonomously on healthcare teams—they should be able to practice with colleagues without restrictions so they can deliver the care they have been trained to deliver.
In states that do not require specific relationships between PAs and physicians, PAs practice in teams with physicians, and their scope of practice is determined at the practice level. Individual practices can determine how PAs work on those teams.
If a patient's condition falls outside of a PAs training, you want to be able to make sure that the PA can consult with other healthcare providers, whether they be physicians, advanced practice nurses, or other providers. Even in states where PAs are required to be supervised, physicians are rarely in the room when PAs are delivering medical services. PAs provide safe and effective care. According to our research with the Harris Poll, 95% of patients who have been treated by a PA felt valued by the PA. A study conducted in 2021 found that PAs provide the same or better care to patients as physicians at a lower cost.
So, there is evidence that shows PAs should be able to practice at the top of their license. They should be practicing autonomously—that is the only way we can be part of the solution for workforce shortages.
HL: Under what circumstances can PAs practice medicine autonomously?
Ogunfiditimi: Practicing medicine autonomously essentially means being able to eliminate some of the barriers to PAs practicing medicine. PAs can prescribe medications. PAs can diagnose conditions. PAs can treat conditions. PAs can work in all spectrums of medicine from surgery to primary care to multispecialty care. We need to allow PAs to work every day and to use their knowledge to deliver quality care without red tape or constraints such as direct supervision.
So, the opportunity to work autonomously means allowing PAs to be able to determine how they can work best at the practice level. They should be able to determine what their scope of comfort and training is as well as how they can maximize being able to offer medical services to patients, particularly in medically underserved communities, without the constraints of being tethered directly to a physician. We want to collaborate with our physician colleagues. We want to be part of healthcare teams. We want to be able to integrate with those teams and deliver care just as any other professional who has been trained to deliver that care.
Researchers find relatively high levels of burnout at hospitals designated as good places to work.
To address burnout, physicians and nurses prefer actions to boost nurse staffing, increase clinician control over workload, and improve work environments rather than wellness programs and resilience training, a new research article found.
Physician and nurse burnout was widespread before the coronavirus pandemic and spiked during the public health emergency. An earlier study found that from September 2019 to January 2022, overall emotional exhaustion among healthcare workers increased from 31.8% to 40.4%.
The new research article, which was published by JAMA Health Forum, is based on survey data collected from more than 15,000 nurses and more than 5,000 physicians at 60 Magnet-recognized hospitals in 2021. The Magnet Recognition Program designates hospitals as good places to work based on nursing excellence and healthcare quality.
The study features several key findings:
Burnout rates were 32% among physicians and 47% among nurses
12% of physicians and 26% of nurses rated patient safety unfavorably at their hospitals
28% of physicians and 54% of nurses said their hospitals had inadequate nurse staffing
20% of physicians and 34% of nurses said they had a poor work environment
42% of physicians and 46% of nurses lacked confidence in management
Less than 10% of physicians and nurses reported that their workplace was joyful
To improve mental health and well-being of clinicians, boosting nurse staffing was ranked as the top preferred intervention, with support of 87% of nurses and 45% of physicians
Other preferred interventions included taking breaks without interruptions, reducing time spent on documentation, improving the usability of electronic medical records, and control over scheduling
Popular management interventions such as clinician wellness champions, resilience training, and quiet places did not rank high with most physicians and nurses
23% of physicians said they would leave their hospital within a year possible
More than 40% of nurses said they would leave their hospital if possible
One-third of physicians and nurses said they had poor control over their workloads
A chaotic work environment was reported by 39% of physicians and 63% of nurses
The findings are notable given that the data was collected at hospitals designated as good places to work, the study's co-authors wrote. "This cross-sectional survey study of physicians and nurses practicing in U.S. Magnet hospitals found that hospitals characterized as having too few nurses and unfavorable work environments had higher rates of clinician burnout, turnover, and unfavorable patient safety ratings. Clinicians wanted action by management to address insufficient nurse staffing, insufficient clinician control over workload, and poor work environments; they were less interested in wellness programs and resilience training."
Interpreting the data
The research identified primary factors driving burnout, the study's co-authors wrote. "For physicians, whether they have control over their workload was shown to be of paramount importance regarding level of burnout. For nurses, the factors of greatest importance to burnout were sufficiency of nurse staffing and quality of the work environment."
There is a significant disconnect between clinicians and management at Magnet hospitals, the study's co-authors wrote. "Close to half of physicians and nurses were not confident that management would act to resolve problems that clinicians identify in patient care, and close to one-third of clinicians reported that their values were not well aligned with those of management. These are surprising findings in Magnet hospitals given that these issues may be even more pronounced in non-Magnet hospitals."
To boost their mental health and well-being, physicians and nurses preferred interventions aimed at improving their ability to provide effective care in a positive work environment, the study's co-authors wrote.
"Among their priority choices were improved nurse staffing (highly ranked by 45% of physicians and 87% of nurses) and improved work environments, including scheduled breaks without interruptions, not working unscheduled hours, more control over scheduling, and additional resources devoted to new-to-practice clinicians. Improving EHR usability and reducing emphasis on meeting external quality metrics were among the more highly ranked initiatives. Clinician wellness and resilience programs were ranked lowest, although they tended to be more commonly implemented than actions to improve clinicians' working conditions."
Medical groups are struggling to recruit and retain staff members such as medical assistants, a new report from the MGMA says.
Nursing positions posted an average 8.5% increase in median total compensation from 2021 to 2022, according to a new report from the Medical Group Management Association (MGMA).
There have been widespread nursing workforce shortages at health systems, hospitals, and physician practices in recent years. The increase in nursing compensation reported in the MGMA report likely reflects efforts to recruit and retain nurses at healthcare organizations.
The new report, "Management and Staff Compensation Data Report 2023," features data on more than 157,000 management and staff positions at more than 2,940 organizations. The MGMA represents about 15,000 group medical practices ranging from private medical practices to large health systems that employ more than 350,000 physicians.
The report has several key findings:
Median total compensation for all nursing positions has increased 19.37% since 2018
The five-year compensation trends for certified nursing assistants (27.67%) and medical assistants (23.06%) were even higher
From 2021 to 2022, median hourly compensation for medical assistants increased $2.14
From 2021 to 2022, median hourly compensation for registered nurses and triage nurses increased $5.80 and $5.70, respectively
From 2021 to 2022, there was significant compensation growth in all categories of management: executive management positions (8.99%), senior management positions (2.35%), general management positions (3.88%), and supervisors (4.52%)
Registered nurses with 21 or more years of experience earned about $27,500 more than nurses with five years or less experience
MGMA polls indicate that recruitment and retention of medical assistants and nurses are a top challenge at medical groups
Formal diversity programs at medical groups did not gain significant traction during the coronavirus pandemic
Interpreting the data
Despite lower inflation in the U.S. economy in 2023, staff compensation growth has continued an upward trend at medical groups, the report says. "Even as inflationary growth has lost steam in 2023, the increased labor expenses for medical group practices are continuing an upward path."
Workforce issues are a top concern at medical groups, the report says. "Staffing was easily ranked as the top challenge for medical group leaders in 2023 before the start of this year, and findings from this report and other MGMA research suggest the need for continued monitoring of labor market trends and efforts to boost recruitment and retention strategies for clinical and clerical support roles throughout provider organizations."
Although the coronavirus public health emergency is over, medical groups are facing several headwinds in 2023, the report says. "Medical group leaders face the ongoing pressure to handle growing patient demand for care in the face of historic difficulties in staffing medical practices and the financial squeeze of stagnating reimbursement and ballooning prices for supplies to operate their businesses effectively."
Medical assistants pose a significant staffing challenge, the report says. "It's no secret that hiring medical assistants (MAs) following The Great Resignation has been a challenge, affecting almost all practices, and that MAs have been among the toughest non-physician roles to hire in recent years, according to past MGMA Stat polls."
Medical groups are pursuing multiple strategies to recruit and retain nurses, the report says. "Beyond higher salaries, efforts throughout The Great Resignation to recruit and retain nurses have included taking burdens off staff through more patient self-service tools, updating job descriptions to better reflect the work to be done, and adding or expanding employee benefits."
From 2020 to 2021, nursing compensation growth was higher at hospital-owned medical groups than at physician-owned medical groups, which could have negative consequences at physician-owned medical groups, the report says. "In effect, the national nursing shortage and the high demand for professional nurses could easily result in a 'bidding war' among healthcare entities. For years, physician-owned practices were able to recruit and retain nurses with promises of a better working environment and regular scheduled hours. Unfortunately, if the pay differential continues to diverge, the 'deep pockets' of hospital systems may well overcome the attraction of working in a private practice."
MGMA data indicates there has been little change in adoption of formal diversity programs at medical groups in recent years, the report says.
"Two and a half years after major protests in most major American cities and the emergence of a staffing shortage across several roles within healthcare provider organizations, the focus on diversity appears virtually unchanged: A Feb. 21, 2023, MGMA Stat poll found that 34% of medical groups report having a formal diversity program, compared to 62% that do not and 4% that are considering one. These results show only a slight shift from a similar MGMA Stat poll from July 2021 that found 32% of medical practices had a formal diversity program at the time, with nearly two-thirds (64%) without and only 4% considering adding one."
Bruzzi has been CMO of both medical centers since February 2020. Her prior experience at Banner Health includes serving as a hospitalist and medical director of care coordination. Before joining Banner Health, she served as inpatient medical director and vice chair of family and community medicine at the University of Arizona.
HealthLeaders recently talked with Bruzzi about a range of issues, including her challenges as CMO, lessons learned from the coronavirus pandemic, and the main elements of physician experience. The following transcript of that conversation has been lightly edited for clarity and brevity.
HealthLeaders: What are the primary challenges of serving as CMO of Banner-University Medical Center Tucson and Banner-University Medical Center South?
Bethany Bruzzi: When you are supervising two facilities, especially ones that have different sizes and different complexities, it is a challenge to make sure that both facilities and the people within them feel like there is equally divided attention. In addition, they want to know that as a leader you are advocating for everybody and all of the needs of the different facilities. You need to be visible at both places, which is something that I continuously try to work on, so the teams feel supported at both the larger academic facility and the moderately sized community facility.
It is challenging with the business needs and trying to recognize that the individuals who have gone into healthcare have been more people-oriented. We must try to focus on improving the health of individuals in addition to the metrics that we are held to on a regular basis. I need to ensure that messages are passed down that are going to be meaningful for the bedside caregivers.
HL: How do you rise to the challenge of supervising clinical care at two facilities?
Bruzzi: In supervising two facilities, I have worked on trying to delegate to leaders at both facilities, so if I am not at one facility it is clear that there is representation of what I am trying to accomplish, and there are people the staff can go to, so they don't feel abandoned. No. 2, when I do connect with people at a particular facility, I let them know that even if I am not physically present, there are initiatives that I am working on and there are key points that are happening at the facility. So, there is a general awareness that I may not be physically at a facility, but I know what is going on, I know what the staff needs, I am going to be advocating for those needs, and I am grateful that the staff can keep the facility running in my absence.
Bethany Bruzzi, DO, MBA, chief medical officer of Banner-University Medical Center Tucson and Banner-University Medical Center South. Photo courtesy of Banner Health.
HL: You became CMO of both medical center campuses in February 2020, immediately before the onset of the coronavirus pandemic in the United States. What were your primary learnings from the pandemic experience at the medical centers?
Bruzzi: We had a lot of learnings through the pandemic. What kept us going the most and what I appreciated was being able to lean on the bedside teams. They problem solved. They were innovative. There was so much good that was created out of the teamwork as well as the ability to think fast about what we needed to do.
I also learned it was important to make decisions quickly. That is something that I feel comes naturally to me as long as I understand the details and can ask good questions. During the pandemic, I collected information, worked with bedside teams, and was able to say, "Here is a decision. We are going to make it and move forward. If we need to change something, then we will do that."
In addition, it was important for our teams to feel they were a priority and were protected. In the beginning of the pandemic with some limitations on personal protective equipment nationally, Banner Health did an excellent job of not only ensuring that PPE was available to our bedside teams but also fostering innovation and creativity. We were 3D printing. We were creating masks. We were reaching out to the community to try to come up with ideas. The physicians and the other healthcare workers knew that their safety was important.
HL: Part of your role is to improve physician experience. What are the key elements of a positive physician experience?
Bruzzi: No. 1, physicians want to feel respected. Including them in decision-making whenever possible is extremely important. No. 2, physicians went into healthcare to help people, so we must make sure that their daily work reflects why they went into practice. With all of the administrative duties and other things that come up that physicians have to deal with, the human connection with patients is what they truly desire. Physicians need to be able to sit with patients and connect with them and their families—that is what is meaningful. Promoting those opportunities on a day-to-day basis is important.
Another thing is what we call at Banner Health "the pebbles." The pebbles are little things that eat away at you. Especially when physicians are tired, we need to remove those pebbles. The electronic medical record is always a pain point, and we need to evolve how we use the electronic medical record.
HL: You have helped Banner-University Medical Center South achieve a high ranking for racial inclusivity by the Lown Institute. How has the medical center achieved this ranking?
Bruzzi: Banner-University Medical Center South has an extraordinary history. It was the county hospital. It is a half behavioral health and half medical hospital. It attracts special people to work there. Right now, we are in a space where there is a lot of light shown on diversity, equity, and inclusion. This is built within the roots of the south campus. It is in everyone's heart that every patient who comes in will be treated with respect, and we are going to treat them as if they were a part of our family. That persona of the campus has allowed us to be successful in the measures Lown Institute has been rating us on.
The special sauce of the south campus is that everyone looks at everyone equally, and they have common respect for not only each other but also all the patients who come to that campus.
HL: What role do physicians play in healthcare administration at the medical centers?
Bruzzi: At Banner Health, we have Advanced Leadership for Physicians or ALP. It is an eight-week pathway to get some experience with leadership. I went through ALP when I joined Banner Health. It is a structured way to include physicians in leadership.
We also have medical executive committees, and we have medical directors in almost every different department. That is one of my most meaningful jobs right now—I am creating a medical director council to bring our medical directors together and continue to advance their skills in administration and coaching. That is going to be critical for us moving forward.
Traditionally, physicians have taken a back seat when it comes to operational leadership. We do not learn a lot about business in medical school. We are not necessarily thinking about large-scale operations. But it has become our business to think about operations. That is something I enjoy teaching, and I hope to spark more interest as we progress.
HL: You have a clinical background in family medicine. How has this clinical background helped prepare you to serve in leadership roles such as CMO?
Bruzzi: As a family medicine physician or anyone in primary care, you are considered a jack of all trades. You know something about everything versus a specialist who knows the nitty gritty and details. The generalist mindset and ability to be able to take in information in multiple aspects of medicine is helpful. I know just enough that when I hear things, I can ask questions and learn about a topic to make informed decisions. A global thought process is ingrained when you work in primary care.
Minneapolis-based M Health Fairview has succeeded in achieving short wait times for mental health services.
With a national shortage of mental health professionals including psychiatrists, many health systems, hospitals, and physician practices have struggled to provide timely access to mental health services. In addition, there has been increased demand for mental health services across the country.
M Health Fairview is a partnership between the University of Minnesota, University of Minnesota Physicians, and Fairview Health Services. M Health Fairview's mental health and addiction service line employs 200 physicians, about 50 advanced practice registered nurses, about 60 PhD-level psychologists, and about 120 masters-prepared mental health-licensed clinicians.
There are two primary reasons why demand for mental health services has increased, says Lewis Zeidner, vice president of the mental health and addiction service line at M Health Fairview. "One significant reason is that there is reduced stigma and people are more receptive to accepting care. A second factor is that during the pandemic there was a drop in access to care—many people isolated and they did not receive care, so we are seeing a rebound in terms of demand that goes along with that decrease in access, increased symptomology during the time they were unable to get care, and more crisis levels of need for care."
M Health Fairview offers multiple settings for mental health services, including the following:
Hub sites: M Health Fairview has five hub sites in the Twin Cities region. Within a hub site, there is a suite of services that include psychotherapy, psychological testing, psychiatry, and addiction medicine. Some of the hub sites offer intensive outpatient programs.
Behavioral health integration: M Health Fairview offers mental health services at 16 primary care and specialty clinic locations. The organization has embedded masters- and doctoral-level psychotherapists in the primary care and specialty care clinics. They function to provide same-day access for mental health services. These are brief visits, brief interventions, and brief assessments with referrals to higher levels of care. They can help bridge patients until they get into a specialty referral.
Assessment center: M Health Fairview has an assessment center, which is used when a provider refers a patient and does not know what the patient needs or a patient does not know where to start. A patient can go to the assessment center and be seen by a masters-level mental health professional. Then the patient is directed to the right level of care. Access times for the assessment center are typically 24 to 48 hours.
Transition clinic: The transition clinic is designed specifically for people who have a need when there is a delay in access. The transition clinic can see patients on a same-day basis, and the clinic can see patients through the period when they are waiting to get into the care that they need. It is not a substitute for care, but it is a bridge for patients waiting for psychiatric care, medication management, as well as counseling and therapies.
Emergency Psychiatric Assessment, Treatment, and Healing unit: The EmPATH unit is relatively rare—there are about a dozen units across the country. The EmPath unit is designed to provide emergency mental health services without the drawbacks of a traditional emergency department, Zeidner says. "If you think about traditional emergency rooms, they are loud and structured with a lot of rules, and none of that is desirable for someone in a mental health crisis. The space we have created for the EmPATH unit is much more calming with appropriate lighting. Some people have equated the noise level to a library effect. In addition, the staff in the EmPATH unit are mental health professionals, as opposed to a traditional emergency department, where there are more generalists."
Rising to the staffing challenge
One of the reasons why M Health Fairview can achieve timely access to mental health services is through effective management of its mental health staff, says Chris Beamish, vice president of integrated and outpatient mental health and addiction services at M Health Fairview.
"We have a pipeline of trainees right out of graduate school and into our services. At any given time, we have about 45 openings across our service line, and we went from an average lead time of about 145 days to fill a position down to 60 days recently. Being able to hire learners and develop the next members of our workforce has helped us to create better access," he says.
In addition to the learner pipeline, M Health Fairview triages patients to clinicians with an appropriate level of license to ease the workload burden on psychiatrists, Zeidner says. "Historically, the model has been to send all patients to psychiatry; but, like everyone else, we have fewer psychiatrists than we wish we had. Not all of the work needs to be done by psychiatrists. So, we have begun to triage the work to the appropriate level of care, with an interdisciplinary team that allows us to use all levels of clinicians."
Embracing telehealth has boosted clinician retention, Beamish says. "There are a lot of employees who enjoy working from home and there is a high demand for telehealth. So, for many of our outpatient services, we have about an 80-20 mix of telehealth and onsite work. Staff may work one day onsite and four days working remotely from home."
Acknowledging the challenges mental health professionals face is also helpful for retention, Zeidner says. "The important piece to this is that the work is hard. If you do not acknowledge that the work is hard, then you wear people out. We do not have the level of burnout that other organizations have."
Brad Archer, MD, chief medical officer of Monument Health. Photo courtesy of Monument Health.
William Agel, MD, MPH, senior vice president and CMO at Cape Cod Healthcare. Photo courtesy of Cape Cod Healthcare.
Bethany Bruzzi, DO, MBA, chief medical officer of Banner-University Medical Center Tucson and Banner-University Medical Center South. Photo courtesy of Banner Health.