The American Medical Association has created or strengthen policies to promote public health and advocate for new laws and regulations.
The annual meeting of the American Medical Association's House of Delegates this week included the adoption of several new policies on issues ranging from medical education to gun violence.
The AMA's House of Delegates is the policy-making body of the organization, with physicians, residents, and medical students representing every state and medical specialty. Working through a democratic process, delegates reach a national physician consensus in areas including public health, science, ethics, and government.
The following are 10 new AMA policies adopted by the House of Delegates:
Children's mental health: The House of Delegates declared that children's mental health and barriers to mental healthcare access for children are in a state of national emergency that requires urgent attention. The new policy calls on the AMA to work with other stakeholders to increase the mental health workforce to address the limited access to mental health services for children.
Race and education: With the U.S. Supreme Court expected to rule on affirmative action this month, the House of Delegates declared that the consideration of race in undergraduate and medical school admissions is necessary to promote diversity in the physician workforce. "Efforts to do away with affirmative action undermine decades of progress in creating a diverse physician workforce and will reverse gains made in the battle against health disparities," AMA President Jesse Ehrenfeld, MD, MPH, said in a prepared statement.
Diversity, equity, and inclusion efforts at medical schools: The House of Delegates modified its Continued Support for Diversity in Medical Education policy to state that DEI efforts are essential in medical training. The delegates also voted to oppose any local, state, or federal actions that attempt to limit DEI initiatives, curriculum requirements, or medical education funding. "Diversity among healthcare professionals promotes better access to healthcare, improves healthcare quality for underserved populations, and helps physicians better meet the unique needs of each patient," the AMA said in a prepared statement.
Body mass index as a measure in medicine: The House of Delegates clarified how BMI should be used as a measure in medicine. The new policy is based on an AMA Council on Science and Public Health report that found BMI is an imperfect method of measuring body fat because it does not account for differences across racial and ethnic groups, genders, and age-span. The new policy directs physicians to use BMI in conjunction with other measures, including measurements of visceral fat, body adiposity index, body composition, relative fat mass, and waist circumference.
Overdose reversing medications: The House of Delegates voted to encourage states and communities to adopt legislation and policies to make overdose reversal medications accessible to staff, teachers, and students in educational settings. The House of Delegates also voted to support development of alternatives to naloxone to treat synthetic opioid-induced respiratory depression and overdose. Finally, the House of Delegates voted to increase the availability of naloxone and other safe and effective overdose reversal medications by supporting the availability, delivery, procession, and use of mail-order overdose reversal medications.
Firearm background checks and sales of multiple firearms: The AMA considers firearms violence as a public health crisis. The House of Delegates adopted a policy to advocate for federal and state regulations that prevent inheriting, gifting, or transferring ownership of firearms without adhering to requirements for background checks, waiting periods, and licensure requirements. The House of Delegates also voted to advocate for state and federal regulations to prevent the sale of multiple firearms to the same purchaser within five business days.
Extreme risk protection orders: Currently, more than 20 states allow law enforcement, family or household members, and/or intimate partners to ask courts to enact extreme risk protection orders (ERPOs) to temporarily remove firearms from high-risk individuals. The House of Delegates voted to support laws that include medical professionals as people who can ask a court to prevent an individual who is at risk of harm to themselves or others from purchasing or possessing firearms.
Social media and firearm violence: The House of Delegates voted to create a policy aimed at addressing social media posts that glorify firearm violence. "Under the new policy, the AMA will call on all social media sites to vigorously and aggressively remove posts that contain videos, photographs, and written online comments encouraging and glorifying the use of firearms," the AMA said in a prepared statement.
Medicinal psychedelics: The AMA is concerned about lawmakers in some states embracing the use of psychedelics or entactogenic agents such as psilocybin to treat psychiatric conditions. In response, the House of Delegates adopted a policy to advocate against the use of psychedelics or entactogenic agents except in uses that have received Food and Drug Administration approval or uses prescribed in approved investigational studies. The House of Delegates also voted to support more research into psychedelics or entactogenic agents with the scientific integrity and regulatory standards in place to evaluate other drug therapies.
Hazardous chemicals: In response to several recent train derailments that resulted in hazardous chemical spills, the House of Delegates voted to advocate for strengthening regulations for the transportation of hazardous materials. "Under the new policy, the AMA will advocate for regulations that prioritize public health and safety over cost. The new policy also supports efforts to hold companies responsible for chemical spills by making them liable for the healthcare costs incurred by individuals exposed to hazardous chemicals," the AMA said in a prepared statement.
Inpatients benefit from good communication with doctors and nurses, and they want to know the clinical staff is communicating and coordinating care.
In general, the primary elements of patient experience include healthcare access and treating patients as people rather than consumers, says David Williams, MD, chief clinical officer and senior vice president at UnityPoint Health.
Williams has been the top clinical executive at UnityPoint since May 2020. Prior to working in his current role, he was president and CEO of UnityPoint Clinic and UnityPoint at Home. Before joining UnityPoint more than two decades ago, his work experience included serving as regional medical director for Iowa Health Physicians.
HealthLeaders recently talked with Williams about a range of topics, including the primary challenges of serving as chief clinical officer at UnityPoint, home healthcare services, and how clinicians are involved in administrative leadership at UnityPoint. The following transcript of that conversation has been lightly edited for clarity and brevity.
HealthLeaders: What are the primary challenges of serving as chief clinical officer of UnityPoint?
David Williams: My mind goes right to COVID. We are more than three years into the pandemic, and it has taken a toll on our caregivers—doctors, nurses, and advanced practice providers. Specifically, you see COVID fatigue in the general public and in our workforce. It has led to significant workforce challenges. We have doctors and nurses who have been on the brink for a long time, and several are choosing to leave the profession.
In addition to the impact of COVID is workplace violence. I have been in healthcare for well over 25 years, and I have never experienced the incivility that we are seeing toward our caregivers. This puzzles me, and we are working to keep our team members safe.
HL: How are you rising to these challenges?
Williams: For the workforce challenges, I have to give credit to our chief nursing officer, Dr. D'Andre Carpenter, who is my dyad partner. We are looking at nursing workforce differently. We do not think the traditional nursing staffing model is going to come back. We do not think we are going to have enough staff for that model. So, we are developing a collaborative care model to have nurses work together to take care of populations of patients. We want to use our resources to the best of our ability.
We are using technology with both the nursing and physician workforce. One example is telehospitalists. During the pandemic and to the present time, I do not think we would have had enough hospitalists across our three states and nine regions to take adequate care of patients without telehospitalists. By using telehospitalists, we have been able to unlock resources particularly in some of our rural communities that we would not have been able to serve otherwise.
With workplace violence, we have taken a unified approach. We have three states and nine regions, and workplace safety has traditionally been handled at the local level. We now have a systemwide task force with clinical leaders as well as public safety leaders to come up with solutions. Some of it is limiting access points to our facilities. The other piece is training our staff with de-escalation training to recognize patients and family members who may be in an agitated state and de-escalate potentially violent situations. We are taking a multi-pronged approach.
HL: You previously served as president and CEO of UnityPoint at Home. For health systems, what are the main opportunities in home health care services?
Williams: Home health care is kind of a hidden gem. We spend a lot of time as health system leaders talking about our hospitals and clinics—we do not spend enough time talking about what we can do in the home. People define home health traditionally—they think of things like durable medical equipment and traditional home-based services.
What we have been able to do is expand the scope of home health. We have a suite of care-at-home services now, including hospital at home, palliative care at home, skilled nursing at home, and primary care at home. When you think about home health, patients want to be taken care of as close to home as possible. They are going to have the best care experience at home surrounded by loved ones, and it is also going to be a setting with the lowest cost of care.
We not only provide traditional home care services but also think about what else we can do in the home. That is where people want to be.
David Williams, MD, chief clinical officer and senior vice president at UnityPoint Health. Photo courtesy of UnityPoint Health.
HL: You have played a patient experience leadership role in the past. What are the keys to success in achieving a positive patient experience?
Williams: In our industry, there is a big debate about whether we should call people patients or consumers. I do not think either term works—we should call people as people. They want to be treated as people. They want us to treat them the way they treat their family members and loved ones.
Access is huge—we must focus on access. Virtual access is becoming crucial. For example, we are focusing on ways people can access us through their cellphones.
One example of boosting patient experience is at UnityPoint Clinic, where our front desk staff has been rebranded. We had a contract signing ceremony for all of them. Their new title is experience specialist, so they know the No. 1 thing we need them to do is to show people who come to our clinics how much they matter.
In the inpatient setting, the key to patient experience is communication—not just communication with nurses, not just communication with doctors. It is very easy for patients and family members to feel the difference between care on a weekday and care on a weekend. Showing them that our teams are talking and collaborating with each other is the key to patient experience in the inpatient setting.
HL: What are the main clinical care challenges in rural health?
Williams: Staffing problems are throughout the industry, but they are exacerbated in rural health. I live in the state of Iowa, and we also serve the states of Illinois and Wisconsin, and all three states are very rural. We have problems recruiting providers, particularly in obstetrics and behavioral health. We have problems with recruiting nursing staff. We have problems in recruiting for sub-specialties. We must do the best we can to stretch those resources.
We have a tendency to have one specialist such as an obstetrician in a small town in Iowa. What we are trying to do is at least provide them virtual groups because what tends to happen is you have one doctor in a specialty, and they are on call 365 days a year. They do not get a break. We try to team them up with doctors who might work a couple of towns away to form a virtual group to provide some coverage and collegiality. We have found this to be effective in extending careers in some of our small towns.
Telehealth is part of the answer to rising to rural health challenges. We have expanded sub-specialty care in rural areas via telehealth.
HL: How is UnityPoint staffing clinicians at rural hospitals?
Williams: In addition to forming virtual groups, we are utilizing to the best of our ability advanced practice providers in our rural hospitals. We also have several residencies at rural hospitals and that is key. If you can get young doctors in training to work in these communities, many of them fall in love with their towns. They decide they want to practice in a rural setting.
HL: How are clinicians involved in administrative leadership at UnityPoint?
Williams: We have a dyad leadership model throughout our organization in the clinic setting, the hospital setting, and the home care setting. We pair clinical leaders such as doctors, nurses, and advanced practice providers with operational leaders.
One thing we have done that is unique is we realized we needed additional training for our physician leaders. About 10 years ago, we started a physician leadership academy in partnership with the American Association for Physician Leadership. We bring in their faculty and train cohorts of our promising physician leaders. We have trained more than 100 doctors in this program, and I am one of them. I was in the first cohort. Some of these doctors go on to receive master's level training. Many of these doctors move into leadership roles throughout our institution. I am proud of how physicians are engaged directly in leadership at our health system.
Our hospitals have traditional medical executive committees and medical staff leadership. In UnityPoint Clinic, we have a group that is called the Physician Governance Council. It is a group of mainly physicians and some advanced practice providers in all of our regions that are our highest physician governance body. They are instrumental in not only clinical operations but also in strategy.
We also have physicians on the health system's board of directors and regional boards of directors. So, clinicians are involved in governance throughout our health system.
Researchers find younger, Black non-Hispanic, publicly insured, and male patients are at highest likelihood of being the subject of an electronic behavioral alert.
Patient behavioral alerts in electronic medical records designed to mitigate workplace violence may perpetuate systemic inequities, according to a recent research article.
In a poll funded by the American College of Emergency Physicians, two-thirds of emergency physicians and 70% of nurses said they had been physically assaulted at work in the prior year. Patients were perpetrators in 97% of the workplace violence incidences in the poll. The poll found hitting, spitting, and punching were the most common kinds of physical assaults.
The recent research article, which was published in Annals of Emergency Medicine, features data collected from nearly 3 million emergency department visits at 10 EDs from 2013 to 2022.
The study includes several key data points:
Out of the 2,932,870 ED visits, 6,775 (0.2%) generated electronic behavioral alerts for 789 patients
Out of the ED visits with electronic behavioral alerts, 5,945 (88%) were determined to have a safety concern involving 653 patient perpetrators
Among patients with safety-related electronic behavioral alerts, the median age was 44, 66% were men, and 37% were Black
In subsequent ED visits, patients with safety-related behavioral alerts had higher rates of discontinuance of care (7.8% versus 1.5% for patients with no alert) such as leaving without being seen
The most common incidents that prompted electronic behavior alerts were physical abuse (41%) or verbal abuse (36%)
Black non-Hispanic patients were more likely to be the subject of an electronic behavioral alert than White non-Hispanic patients (odds ratio 2.60)
Patients younger than 45 were more likely to be the subject of an electronic behavioral alert than patients 45 to 64 years old (odds ratio 1.41)
Male patients were more likely to be the subject of an electronic behavioral alert than female patients (odds ratio 2.09)
Publicly insured patients were more likely to be the subject of an electronic behavioral alert than commercially insured patients (Medicaid, odds ratio 6.18)
The data indicates electronic behavioral alerts may perpetuate bias against historically marginalized groups, the study's co-authors wrote. "In our analysis, younger, Black non-Hispanic, publicly insured, and male patients were at a higher risk of having an ED electronic behavioral alert. Although our study is not designed to reflect causality, electronic behavioral alerts may disproportionately affect care delivery and medical decisions for historically marginalized populations presenting to the ED, contribute to structural racism, and perpetuate systemic inequities."
Interpreting the data
ED clinicians may make biased decisions about agitated patients, the study's co-authors wrote.
"When agitation occurs, clinicians are required to rapidly diagnose potential causes and intervene to minimize any physical danger, apply verbal and behavioral techniques to deescalate behavior, and assess the need for any coercive measures such as physical restraints. … This combination of physical danger with a need for quick decision making may lead to reinforcement of biases during agitation events. Indeed, emergency clinicians have expressed frustration and negative attitudes toward individuals with substance use and mental illness, and racial and ethnic minorities are particularly vulnerable to negative outcomes in the ED," they wrote.
Electronic behavioral alerts may increase bias and discrimination, the study's co-authors wrote. "Electronic behavioral alerts with frequent notifications may only exacerbate biases given that we found their disproportionate application to sociodemographic minorities. Moreover, the fact that patients with electronic behavioral alerts have higher rates of care discontinuance suggests the possibility that these patients are treated differently or more quickly dismissed."
The data shows that workplace violence is a serious issue, but the best interventions to address specific patients are unclear, the study's co-authors wrote. "What remains unknown is what form and timing these interventions should have, which appropriately balance the risks to safety and mitigate propagating disparities. These interventions may take the form of focused meetings with patients outside of the acute encounter, auditing of electronic behavioral alert placement to ensure accuracy and fairness, continuing review to assess further need of the electronic behavioral alert as the risk of violence decreases, and removal of potentially biased or stigmatizing language."
Jack Resneck Jr., MD, spotlights the challenges and victories of his year-long presidency of the American Medical Association.
In the final speech of his American Medical Association presidency on Friday, Jack Resneck Jr., MD, offered his assessment of the U.S. healthcare system to the AMA House of Delegates.
Resneck, who is a practicing dermatologist based in San Francisco, gave a wide-ranging speech that included assailing prior authorization hurdles, criticizing the Medicare payment system, and shining light on threats to reproductive healthcare. He will be succeeded as AMA president this month by Jesse Ehrenfeld, MD, MPH, who is a Wisconsin-based anesthesiologist.
The AMA was founded in 1847. The physician-led organization convenes more than 190 state and specialty medical societies as well as other key stakeholders.
The following are highlights of Friday's speech:
"I'm sure some of the headlines about burnout stop you in your tracks—they certainly keep me up at night. One in five physicians plans to leave their practice within two years, while one in three are reducing their hours. Only 57 percent of doctors today would choose medicine again if they were just starting their careers."
"We never turn our backs on our patients because that's not who we are. And we carry that same stubborn resolve and tenacity into our advocacy work. That means fighting for the long overdue fixes to a broken Medicare payment system, and obnoxious prior auth abuses, even when policymakers have neglected the problems for decades. That means defending against scope expansions that put patients at risk, even when it requires gearing up again and again in state after state. That means confronting medical disinformation in the news and on social media, even when its growth feels overwhelming."
"No, I can't sugarcoat the very real threats. I’m still appalled by the Medicare cuts. What on Earth was Congress thinking? Practices are on the brink. Our workforce is at risk. Access to care stands in the balance. We absolutely must tie future Medicare payments to inflation, and we're readying a major national effort to finally achieve Congressional action."
"Shame on political leaders, fueling fear and sewing division by making enemies of public health officials, of transgender adolescents, of physicians doing anti-racism work, and of women making personal decisions about their pregnancies."
"I'm also deeply disappointed by our nation's lack of progress to address the public health crisis of gun violence. Preventable and needless homicides and suicides continue, and the political inaction is atrocious."
"You wouldn't know it from social media, but after some unfortunate detours, most patients are turning back to their trusted physicians for our insights and expertise about science and medicine."
"You wouldn't know it from 20 state legislatures racing to criminalize abortion and rob women of access to reproductive health care, but most people in this country support our policies and the fundamental rights of patients to make their own decisions about their health."
"You wouldn't know it from health insurers still bullying us with prior auth delays and denying care, but policymakers from both parties are onto these schemes, the momentum has shifted, and they’re not going to allow this nonsense anymore."
"In our country, and in our profession, we don't agree on everything, but we agree on enough things to pursue the shared things that we care about. Together. And let us not forget that those pursuits have generated some big and small wins tied to the AMA Recovery Plan for America's Physicians."
"Our Congressional advocacy played a key role in legislation to extend Medicare telehealth coverage."
"We have enormous privilege to do this work. We share a love for what we do—to help, to cure, to listen, to solve, to heal, to lead. And we have a responsibility to our patients and to the health of this nation. We are the keepers of an important tradition … a flame that must not be extinguished. Our profession is counting on us to get this right. Our patients are depending on us to continue this fight. We will not let them down."
The Making Primary Care Model will be tested in Colorado, Massachusetts, Minnesota, New Jersey, New Mexico, New York, North Carolina, and Washington.
The Centers for Medicare & Medicaid Services (CMS) has announced today a new primary care model that will be tested under the Center for Medicare and Medicaid Innovation in eight states.
Primary care is a fundamental building block of healthcare, including the management of chronic conditions. Access to high-quality primary care is associated with better health outcomes and health equity.
The Making Primary Care (MCP) Model will be tested in Colorado, Massachusetts, Minnesota, New Jersey, New Mexico, New York, North Carolina, and Washington. Primary care organizations in these states will be able to apply for participation in MCP this summer. The model is set to launch July 1, 2024, and it will run through Dec. 31, 2034.
According to CMS, the new primary care model has three goals:
Provide patients with primary care that is integrated, coordinated, person-centered, and accountable.
Establish a pathway for primary care organizations and practices to enter into value-based care payment arrangements. The focus will be on organizations and practices that are small, independent, rural, and safety net.
Improve care quality and health outcomes while reducing program expenditures.
MCP is designed to improve primary care for Medicare and Medicaid beneficiaries, CMS Administrator Chiquita Brooks-LaSure said in a prepared statement. "This model is one more pathway CMS is taking to improve access to care and quality of care, especially to those in rural areas and other underserved populations. This model focuses on improving care management and care coordination, equipping primary care clinicians with tools to form partnerships with health care specialists, and partnering with community-based organizations, which will help the people we serve with better managing their health conditions and reaching their health goals."
The new primary care model features three progressive tracks for primary care organizations and practices, according to the MCP webpage.
Track 1 focuses on building infrastructure. "Participants will begin to develop the foundation for implementing advanced primary care services such as risk-stratifying their population, reviewing data, building out workflows, identifying staff for chronic disease management, and conducting health-related social needs screening and referral. Payment for primary care will remain fee-for-service (FFS), while CMS provides additional financial support to help participants develop care transformation infrastructure and build advanced care delivery capabilities," the webpage says.
Track 2 focuses on implementing advanced primary care. "As participants progress to Track 2, they will build upon the Track 1 requirements by partnering with social service providers and specialists, implementing care management services, and systematically screening for behavioral health conditions. Payment for primary care will shift to a 50/50 blend of prospective, population-based payments and FFS payments. CMS will continue to provide additional financial support at a lower level than Track 1, as participants continue to build advanced care delivery capabilities," the webpage says.
Track 3 focuses on optimizing care and partnerships. "In Track 3, participants will expand upon the requirements of Tracks 1 and 2 by using quality improvement frameworks to optimize and improve workflows, address silos to improve care integration, develop social services and specialty care partnerships, and deepen connections to community resources. Payment for primary care will shift to fully prospective, population-based payment while CMS will continue to provide additional financial support, at a lower level than Track 2," the webpage says.
Mixed reviews of new model
Jack Resneck Jr., MD, president of the American Medical Association (AMA), praised MCP in a prepared statement.
"We're encouraged to see many of the AMA's recommendations featured in this model including a longer model test, a voluntary, progressive model that meets practices where they are and provides on-ramps for them to advance into prospective payment, and meaningful alignment with Medicaid. The longer test period of 10.5 years directly responds to AMA efforts calling for more transparency and stability to foster trust and encourage physician participation. The AMA strongly believes value-based care models are essential to the long-term wellbeing of the Medicare program and its ability to meet the needs of a diverse and aging population," he said.
The National Association of ACOs (NAACOS) criticized MCP in a prepared statement from President and CEO Clif Gaus, ScD. NAACOS supports investment in primary care, and the organization has proposed a new approach to paying for primary care in the Medicare Shared Savings Program, he said. "The approach we've offered would help CMS meet its stated goal of putting all beneficiaries in a relationship with a provider responsible for total cost of care and quality while increasing investment in primary care."
MCP is counter to these goals by excluding practices that participate in an ACO, he said. "While aspects of the new model are positive, practices should not be forced to choose between Making Care Primary and participating in an ACO. Within ACOs, primary care practices are the quarterback of care teams, but they must work with providers across the care continuum to achieve quality outcomes and cost savings. Working with ACOs has proven to be beneficial to primary care practices, and ACOs with practices concurrently participating in primary care models, such as Primary Care First or the Maryland Primary Care Program, are the most successful."
The survey polled clinical healthcare workers, healthcare administrative workers, and healthcare security personnel.
A recent survey found that 40% of healthcare workers had experienced workplace violence in the past two years.
Healthcare organizations carry a heavy workplace violence burden, with about three-quarters of U.S. workplace assaults occurring in healthcare settings, according to the Occupational Safety and Health Administration. Workplace violence is prevalent in emergency departments—78% of emergency physicians have reported being targets of workplace violence in the prior 12 months.
The recent survey, which was conducted by Premier Inc. and the Agency for Healthcare Research and Quality, features data collected from 672 clinical healthcare workers, healthcare administrative workers, and healthcare security personnel. The survey was conducted from Feb. 1 to April 14.
The survey includes several key data points:
Workplace violence is most common among nursing staff, and more than half of incidents involved combative patients as perpetrators
Most workplace violence incidents occurred when healthcare workers were explaining or enforcing an organizational policy, or when healthcare workers provided an update on a patient's condition to a patient or a patient's family members
For female survey respondents, 50% of workplace violence incidents involved emotional or verbal abuse and 50% of incidents involved physical or sexual abuse
For male survey respondents, 62% of workplace violence incidents involved physical abuse and 38% of incidents involved emotional or verbal abuse
Nearly two-thirds of survey respondents who experienced workplace violence identified themselves as bedside nurses
The majority (62%) of workplace violence perpetrators were men, 37% of perpetrators were women, and 1% of perpetrators were non-binary
Two-thirds of survey respondents reported that their workplace violence perpetrator was not noticeably or confirmed to be under the influence of drugs or alcohol
In workplace violence incidents involving combative patients: 62% of survey respondents reported being scratched, bit, and hit; 21% of survey respondents reported that the patient threw objects; 14% of survey respondents reported sexual abuse; and 1% of survey respondents reported being shot by a patient
In workplace violence incidents reported to law enforcements, 45% of survey respondents reported that law enforcement was responsive to physical or sexual violence incidents and 22% of survey respondents reported that law enforcement was responsive to verbal or emotional abuse incidents
Mental illness was cited as the top factor in workplace violence incidents by 27% of survey respondents
Drugs and alcohol were cited at the top factor in workplace violence incidents by 24% of survey respondents
Workplace violence in healthcare settings has several negative consequences, according to the survey report. "Healthcare workers experiencing workplace violence may suffer physical and psychological trauma. These acts of violence can also disrupt patient care when providers fear for their personal safety or are distracted by disruptive patients or family members. Having a strong prevention and mitigation strategy in place is critical in the prevention and reduction of incidents of workplace violence."
The survey report expresses support for the Safety from Violence for Healthcare Employees (SAVE) Act of 2023, which was introduced in the U.S. House of Representatives in April. "This legislation would give healthcare workers the same legal protections against assault and intimidation as aircraft and airport workers. It would also establish a federal grant program at the Department of Justice to augment hospitals' efforts to reduce violence by funding violence prevention training programs, coordination with state and local law enforcement, and physical plant improvements such as metal detectors and panic buttons."
The findings of the survey are significant, Soumi Saha, PharmD, JD, senior vice president of government affairs at Premier, told HealthLeaders.
"It's very concerning as violence in the healthcare setting continues to rise and, according to our survey, more than half of all respondents felt that these incidents had increased during their tenure. What is unique about Premier's survey is that we heard directly from healthcare employees regarding their experiences and the need for change moving forward to address burnout, retention, and recruitment. Furthermore, workplace violence incidents aren't considered a federal crime, which is why Premier continues to support bipartisan legislation like the SAVE Act to provide enhanced legal protections for healthcare workers," she said.
Healthcare workers and their organizations need to take a proactive approach to addressing workplace violence, Saha said. "According to the survey, more than half of the respondents dealt with a combative patient. We believe healthcare workers need to maintain open communication with their peers, teams, and leaders regarding access to workplace violence prevention programs, de-escalation training, and other resources that can help them stay safe while providing a calm and safe place of healing for all patients. The key is that addressing workplace violence requires a proactive approach that creates a safe space for workers to report incidents without fear."
In the wake of the coronavirus pandemic, healthcare organizations must be nimble in identifying needs and be able to pivot to meet those needs.
Now that the crisis phase of the pandemic has passed, health systems and hospitals need to focus on new staffing models and deploying technology, says Allan S. Philp Jr., MD, chief medical officer of Allegheny General Hospital (AGH) in Pittsburgh.
Philp has been CMO of AGH, which is a member of Allegheny Health Network (AHN), since June 2022. He has been chief quality officer of the AHN Surgical Institute since March 2020. His previous experience includes serving as a surgeon for the U.S. military.
HealthLeaders recently talked with Philp about a range of issues, including the primary elements of quality in surgery, how clinicians are involved in organizational administration at AGH, and the differences between military and civilian medicine. The following transcript of that conversation has been edited lightly for brevity and clarity.
HealthLeaders: What are the primary challenges of serving as CMO of Allegheny General Hospital?
Allan S. Philp Jr.: The challenges we have faced are similar to challenges at other hospitals. It has mostly been in regard to resources. Healthcare was a little bit challenging pre-pandemic, and it has become more challenging during the pandemic and post-pandemic largely because of staffing problems and supply chain problems.
One of the ways we have been fortunate is because we have a large network. We have been able to function as a network, which means we can shift resources. For example, we have an internal staffing team, so we can move staffing resources around to meet the needs and do not have to limit access for patients. At the end of the day, it is about getting people the care that they need.
The other piece is figuring out how to prioritize. At my level, that requires strong relationships with my colleagues. We cannot do everything all the time—nobody has the resources to do that, so we must have our priorities in the right order for patients to get care. Being able to work with my colleagues to think outside of the box on solutions to challenges is valuable.
HL: Now that the crisis phase of the coronavirus pandemic has passed, what are the primary clinical care challenges at Allegheny General Hospital?
Philp: The COVID pandemic made us realize that business as usual is no longer a successful model. It is no longer the best practice. We have to be more nimble than we used to be in terms of recognizing what the needs are and pivoting to be able to meet those needs. We need new models for staffing. We need to leverage technology and electronic medical records. Then, we cannot lose track of the fact that medicine is pushing forward every day.
When we look at the best treatment for a condition, if you settle for the best treatment when you trained, that is fine if you trained six months ago. It becomes less fine at three years, and it is not at all fine at 15 years. You must be scrutinizing the whole field all the time. You need to ask, "How can we do a procedure minimally invasively? How can we provide care in a way that has a faster recovery or lower risk?"
We have been fortunate that we have been able to stay on top of medical science during the pandemic and post-pandemic. For example, in the past year we have opened a hybrid operating room, which is like a combination of an interventional radiology suite and a conventional operating room. This allows us to do things like minimally invasive valve repairs and advanced vascular procedures.
Allan S. Philp Jr., MD, chief medical officer of Allegheny General Hospital. Photo courtesy of Allegheny Health Network.
HL: You serve as chief quality officer of the AHN Surgical Institute. What are the main elements of promoting quality in surgical care?
Philp: There are three parts to that. First, you must look critically at your outcomes. That means having meaningful data. There is a tendency for any healthcare provider to say, "We are working very hard. We are taking care of patients. I'm confident our care is fantastic." But if you do not look critically at your outcomes, you will not see opportunities to improve.
Second, once you have looked at your outcomes, you need to bring together the whole team to not only involve them in the solutions but also solicit the solutions from them. When you look at the people who are the boots on the ground, they have fantastic ideas about addressing challenges and figuring out which challenges to address.
The third piece is not living in a bubble. There is great healthcare being provided across the country, and reaching out to colleagues at other facilities is critical. Care should be agnostic of whatever the sign over the door says. We should be able to collectively determine best practices and find innovative ways to address challenges.
HL: How are clinicians involved in organizational administration at Allegheny General Hospital?
Philp: We are a clinician-led organization. There are a lot of places that give lip service to that, and not as many places that actually do it. For example, our president is a practicing hospitalist. I am active in our trauma care. Our chief nursing officer spends an enormous amount of time on the surgical and medical floors to understand what the needs are. So, we are provider driven, which is important because it keeps the patient and their family at the center of everything.
If you look at the way that changes are implemented, it flows through clinical committees. These are not just doctors. For example, our critical care committee that is involved in issues such as providing better respiratory care includes doctors, nurses, and respiratory therapists all working collaboratively—and you have senior people and more junior people so that you have input from all of those levels, and you can mentor the junior staff.
You also need to be realistic and savvy, with good business partners such as financial officers and operating officers. I am a capable trauma surgeon, but if we had to do a business plan for a $200 million addition to the hospital, we would need someone who lives in that world as well. The partnership between our clinical leaders, who are driving what the need is and what we need for our patients, and our operational leaders, who need to translate what we need to do to provide the best care for our community, allows us to draw up plans for providing world-class care.
HL: You have a clinical background in surgery. How has this clinical background helped prepare you to serve in leadership roles such as CMO?
Philp: It is helpful that I have been working in trauma specifically. If you look at the care of a trauma patient, it crosses a bunch of different areas of the hospital and different specialties. For example, we interact with emergency medical services, the emergency department, the blood bank, the operating room, and specialties such as orthopedics and neurosurgery. To be able to do that kind of work, you must have a collaborative approach. When I moved on to do the chief medical officer role, it was like trauma care on a larger scale.
HL: You led critical care teams in Afghanistan and Iraq for the U.S. military. What are the main differences between providing critical care in the military setting versus providing critical care in civilian hospitals?
Philp: The resources can be different. If you are at a military hospital, it is similar to being at a civilian hospital. On the other hand, if you are with a five-member military team and working out of backpacks, you have less resources. So, the resources vary from place to place and time to time in the military.
It has been valuable to have a military medicine background. The transition to the pandemic was easier for me. You are used to working with limited resources in the military, and applying those skills during the pandemic was helpful.
The Institute for Healthcare Improvement and the American Medical Association are co-leading the Rise to Health Coalition.
The recently launched Rise to Health Coalition is designed to move work on health equity from primarily documenting healthcare disparities to addressing healthcare disparities, the president and CEO of the Institute for Healthcare Improvement (IHI) says.
Health equity emerged as a pressing issue in U.S. healthcare during the coronavirus pandemic. In particular, there have been COVID-19 health disparities for many racial and ethnic groups that have been at higher risk of getting sick and experiencing relatively high mortality rates.
The Rise to Health Coalition is a nationwide initiative co-led by IHI and the American Medical Association. The Rise to Health Coalition has three primary goals, IHI President and CEO Kedar Mate, MD, told HealthLeaders.
"We are trying to build the capability for change. We are trying to create real results. And we are trying to change the story of health inequity in the country. Those are the three interlocking goals for the initiative—building the ability for our systems to change across many sub-sectors in healthcare, creating real results for real people, and by virtue of creating the capability for change and real results we are hoping to change the narrative around inequities in healthcare from a story of inaction and inevitability to a story of active change and preventing health inequity in the future," he says.
The Rise to Health Coalition includes a measurement committee, Mate says. "The measures essentially fall into several broad buckets. There are measures of access to care. There are measures of quality and safety. There are measures on the clinical side, which tend to bucket largely in cancer services, cardiovascular disease, and diabetes—for each of them there are efforts to create specific measurements and stratification guidance to help understand where disparities exist. There are also workforce measures around workforce diversity, workforce inclusion and belonging, and workforce turnover and burnout concerns that are prevalent at the moment."
Addressing systemic racism in healthcare is among the top objectives of the Rise to Health Coalition, he says. "Addressing systemic racism is an important question that we have built into the fabric of what we are trying to do. There is a lot of effort in Rise to Health to try to coproduce the goals of the initiative with agencies and community-based organizations that are responsible for trying to end systemic racism. Fundamentally, this focus is on trying to bring a racial justice lens to not just what we do but also how we understand the impact of the coalition."
The Rise to Health Coalition will also address inequities in patient care, Mate says. "Rise to Health builds on several initiatives that IHI and partner organizations have run for many years. We have been focusing on questions of where inequities arise in patient care and how we might go about resolving them. Fundamentally, Rise to Health like its antecedent initiatives builds on quality- and quality improvement-related methods. These efforts were originally designed to reduce variations in healthcare. Now, we are using quality and quality improvement methods to try to reduce inequities in specific care practices where we have found inequities."
Changing the health equity narrative
For many years, the narrative about health equity has reflected the belief that disparities and inequities are not changeable—that they are baked into the healthcare system, Mate says. "The belief is that if we are going to practice medicine, we are going to have some aspect of disparities. But as we start to improve cancer screening rates, or change stroke care outcomes, or improve maternal survival, we must be able to tell that story to demonstrate that these are not just things we document. In fact, we can tell stories about how we can change practices and change the story about inequity in healthcare."
Changing the health equity narrative could be the most significant impact of the Rise to Health Coalition, he says. "Yes, we will improve many different aspects of clinical care. Yes, we will change pharma discovery processes. Yes, we will modify many payment programs. All of these things are already in the works and are being done right now. But the bigger thing that we will hopefully accomplish is we will look back on this time and say, 'Until 2023, we had spent most of our time documenting the disparities in our healthcare system. But in 2023 and 2024, this was the time when the narrative shifted from documenting disparities to doing something about disparities.'"
Changing policy, payment, education, and standards
The Rise to Health Coalition will build on fundamental changes already occurring related to health equity, Mate says.
"I see government moving increasingly toward reducing race-based disparities—I see more effort to understanding where inequities are present in the healthcare system and more action to try to resolve those disparities. I see both public and private payers starting to configure incentive schemes as part of quality contracting to understand where disparities may be present in racial disparities, gender disparities, LGBTQ disparities, location-specific disparities, and income disparities. Payers are starting to pay differently for improvement in specific areas, which is going to be an important aspect of how addressing inequity attains long-term sustainability," he says.
Health equity is becoming a significant element in healthcare education, Mate says. "We have added to medical curricula and nursing curricula to understand implicit bias. We have started to understand where health equity education as well as anti-racism education has a role for us moving forward."
Health equity is also being incorporated in healthcare standards, he says. "The Joint Commission has started to accredit institutions based on equity standards. So, we are starting to see some standard-based change."
Clinics are particularly challenged in finding technical staff such as radiation therapy technologists and physicists.
More than 9 in 10 radiation oncologists report that their practices face clinical staff shortages, according to a new national survey from the American Society for Radiation Oncology (ASTRO).
Workforce shortages are widespread in the healthcare sector. Nursing shortages are being reported across the country, and the physician labor market is reportedly tighter than ever.
The new national survey on radiation oncology staffing shortages is based on data collected from 249 ASTRO members. The survey was conducted from March 24 to April 11. The survey has several key data points:
93% of radiation oncologists reported that their practices are facing shortages of clinical staff, including nurses, therapists, physicists, and dosimetrists
53% of radiational oncologists said the shortages are creating treatment delays for patients and 44% said the shortages are causing increased patient anxiety
On average, practice operating costs are up 23% compared to before the coronavirus pandemic, with 77% of radiation oncologists reporting that professional staffing is driving increased costs
Radiation oncologists reported that staffing shortages are forcing their practices to reduce support services, with 48% of the doctors saying they had reduced patient navigation services
Radiation oncology clinics are experiencing shortages of nurses, medical assistants, and front desk staff like other specialties, but the most acute shortages are in technical staff, says Constantine Mantz, MD, health policy council chair at ASTRO, chief policy officer at GenesisCare, and a practicing radiation oncologist at GenesisCare.
"We are struggling to employ permanent technical staff—particularly radiation therapy technologists, who are critical and irreplaceable to the process of delivering radiation therapy to cancer patients. We are observing an undersupply of graduating and certified technologists to meet the needs of the growing cancer patient populations in our markets. Also, more technologists appear to be taking on locum tenens work to earn more as temporary employees, further exacerbating the problem of finding stable technical staff needed for high-quality care," he says.
The pandemic has exacerbated longstanding shortages of technical staff at radiation oncology clinics, Mantz says. "The training programs have not been producing enough radiation technologists and physicists as the field demands. The coronavirus pandemic prompted retirements, changes in career plans, and other departures from the field. The workforce shortages have become much more acute. We are struggling with workforce in many markets, particularly smaller communities."
Radiation oncology clinics have tried to backfill their staffing needs through locum tenens hires brought on through temporary staffing agencies, he says. "That solution is very costly compared to having a permanent hire to do the work. Temporary staffing also compromises the quality of care because the continuity of care is disrupted when you have to bring in new staff on a temporary basis."
Responding to the shortages
Radiation oncology clinics are trying to boost the pipeline for technical staff, Mantz says. "We are trying to work through the training programs and schools that develop staff for our needs by sponsoring scholarships and providing internships in clinics to offer real-world experience. We are also providing stipends for education and other needs as a way of trying to retain people. The real answer is going to be expanding the training programs, which can be done through the accrediting bodies allowing an expansion of the number of sites that earn accreditation and certification to provide this type of education. At this point, that is the bottleneck."
Staff retention has become a top priority for radiation oncology clinics, he says. "The most effective approach is increasing compensation for the work to discourage our technical staff from looking for locum tenens work, which might pay more on a per week or per month basis. We try to elevate compensation for the staff, so they feel it is worth their while to stay."
However, increasing compensation is a challenge, Mantz says. "The problem with increasing compensation is that we face diminishing reimbursement for our services. Medicare payment has been on a consistent decline over the past 20 years for outpatient specialty care services such as radiation therapy. As margins shrink, it becomes increasingly difficult to compensate existing staff more, and it creates operational challenges that impact the bottomline."
Workforce prospects
About 80% of radiation oncologists surveyed reported that workforce shortages are worse than last year. Severe staffing shortages are likely to continue for the foreseeable future, Mantz says. "With the exception of premier cancer centers in urban centers, the rest of the country is going to face workforce shortages and difficulty meeting the demand for services. For the rest of this year, we will see continued pressure on clinics identifying and hiring much-need technical staff, and that is likely to play out for the next two or three years."
The staffing shortages are going to put pressure on providing services as the country's population ages, he says. "The problem is enhanced by the growing Medicare-aged population, which is the group of people that is most likely to develop cancers that we would treat with radiation therapy. The last Baby Boomer born in 1964 is going to be turning 65 years old in a few years. Between now and then, the population base of cancer patients is expected to grow commensurately with the Medicare population. We are going to encounter struggles over the rest of the decade to provide our clinics with sufficient qualified staff to render services."
Researchers examined four social needs screened at primary care practices: food insecurity, housing insecurity, transportation insecurity, and care coordination needs.
Significant resources would be required to address social needs and financing of interventions is mainly outside federal funding sources, according to a new research article.
Social needs such as housing, food security, and transportation can have a pivotal impact on the physical and mental health of patients. Unmet social needs are linked to health disparities, poor clinical outcomes, and health costs for several medical conditions.
The new research article, which was published by JAMA Internal Medicine, is based on data for patients who visited primary care practices. Four social needs were included in the analysis: food insecurity, housing insecurity, transportation insecurity, and care coordination needs. Primary care practices were divided into four categories: Federally Qualified Health Centers (FQHCs), non-FQHC practices in urban high-poverty areas, non-FQHC practices in rural high-poverty areas, and primary care practices in lower poverty areas.
The study features several key data points:
Among patients with food insecurity, 95.6% of people were eligible for a federal assistance program but only 70.2% were enrolled
Among patients with housing insecurity, 78.0% of people were eligible for a federal assistance program but only 24.0% were enrolled
Among patients with transportation insecurity, only 26.3% were eligible for a federal assistance program
Among patients with care coordination needs, only 5.7% were eligible for a federal assistance program
The cost of conducting evidence-based interventions for food insecurity, housing insecurity, transportation insecurity, and care coordination needs averaged $60 per member per month, with primary care practice screening and referral management accounting for $5 of the cost and federal funding available for $27 of the cost
Among patients who visited an FQHC, 31.9% were estimated to have food insecurity, 1.1% were estimated to have housing insecurity, 3.4% were estimated to have transportation insecurity, and 12.6% were estimated to have care coordination needs
Among patients who visited primary care practices in lower poverty areas, 4.3% were estimated to have food insecurity, 0.2% were estimated to have housing insecurity, 2.2% were estimated to have transportation insecurity, and 9.4% were estimated to have care coordination needs
The percentage of social needs costs paid by federal payers was 61.6% for food insecurity costs, 45.6% for housing insecurity costs, 27.8% for transportation insecurity costs, and 6.4% for care coordination costs
Federal financing is inadequate to cover most of the cost of social needs interventions, the study's co-authors wrote. "Food and housing interventions were limited by low enrollment among eligible people, whereas transportation and care coordination interventions were more limited by narrow eligibility criteria. Screening and referral management in primary care was a small expenditure relative to the cost of interventions to address social needs, and just under half of the costs of interventions were covered by existing federal funding mechanisms. These findings suggest that many resources are necessary to address social needs that fall largely outside of existing federal financing mechanisms."
Interpreting the data
More resources are needed to address social needs, the study's co-authors wrote. "We observed both low enrollment in existing programs, especially for food and housing interventions for which inadequate program capacity may limit participation of eligible people, and narrow eligibility criteria for existing transportation and care coordination interventions that excluded many in need. This suggests that major changes to the way social services are delivered in the U.S. may be needed if we are to respond appropriately to needs identified through healthcare-based screening."
Inadequate funding is a major barrier to addressing social needs, the study's co-authors wrote. "Our findings are consistent with national data on inadequate funding for housing or rental assistance. For example, among eligible households for the Section 8 Housing Choice Voucher Program, the nation's largest source of rental assistance, only 25% receive any rental assistance after an average wait time of approximately 2.5 years. Additionally, our findings suggest the total costs of social needs interventions are far beyond what is typically allocated to programs for addressing health-related social needs, and this is particularly true for practices serving the neediest patients."
Many primary care practices face challenges in addressing unmet social needs, the study's co-authors wrote. "The cost of screening and referral management may be high relative to capitated primary care payments to a practice. The highest needs and highest costs for overall social interventions were among populations attributed to both FQHC and non-FQHC practices in high-poverty areas. While disproportionate funding was available to populations seen at FQHCs, the populations seen at non-FQHC practices in high-poverty areas were found to have larger funding gaps in terms of the intervention costs not borne by existing federal funding mechanisms."
David Williams, MD, chief clinical officer and senior vice president at UnityPoint Health. Photo courtesy of UnityPoint Health.
