Top executives from across the country are set to participate in a special HealthLeaders leadership summit next month in Atlanta.
Staffing shortages are the primary challenge as health systems emerge from the crisis phase of the coronavirus pandemic, says Eric Eskioglu, MD, MBA, executive vice president and chief medical and scientific officer at Novant Health.
Eskioglu is one of more than a dozen healthcare executives set to participate in The Way Forward, a HealthLeaders leadership summit scheduled for next month at the Loews Atlanta Hotel in Georgia. Eskioglu will serve on a clinical care panel, and there will be panels for CEOs, chief financial officers, and chief information officers.
The focus of The Way Forward will be on sharing of plans, thoughts, strategies, and impressions of the future of the industry. HealthLeaders coverage of the leadership summit includes a Q&A interview of each panelist. The transcript of Eskioglu's interview below has been edited for clarity and brevity.
HealthLeaders: Now that the crisis phase of the coronavirus pandemic has passed, what are the primary clinical challenges that you are facing?
Eric Eskioglu: Staffing is the biggest challenge. Everybody knows about the nursing challenge in healthcare, but we are facing challenges beyond nursing—it's spread into respiratory therapists, phlebotomists, medical assistants, as well as physicians and other healthcare workers. So, the whole environment has been completely disrupted.
Part of the problem is generational. The millennials and increasingly the Gen-Z generation are looking for a different variety of experiences. They do not want to be tied down to a place for more than a year or two. So, there is a pattern of contract labor, travel nursing, and other travel professionals that seems to fit their lifestyle.
HL: How are you addressing these workforce shortages?
Eskioglu: For the next two to three years, for every 10 healthcare workers we used to employ, we are probably going to employ five, contract out traveling healthcare workers for about three, and have the other two automated.
I have been a big proponent of artificial intelligence and natural language processing. We have got to get to the point where we automate a lot of the mundane things that the nurses and the physicians do. Once AI takes over in areas such as documentation, what is left are tasks that require human intelligence that helps us through judgment, which AI cannot do yet. If you ask nurses, they just want to have meaningful work—they do not want to have work that is mindless.
We are trying to make work more meaningful, get rid of hunting and gathering, and eliminate as much of the documentation burden as we can. We want healthcare workers to come to us to work not only because we offer good compensation and good benefits but also because they love the work that they are doing. That is how we are going to differentiate ourselves from everybody else.
HL: Now that the crisis phase of the pandemic has passed, what are your primary COVID-19 challenges?
Eskioglu: The pandemic phase has passed, and we are now in the endemic phase, which means this disease is going to be with us for years to come. Over the past six to nine months, it has been like Whac-A-Mole. We had a wave of delta variant cases at the beginning of the year, then the first omicron variant spiked up, then the second omicron variant spiked up. I do not know whether the next stage of the endemic is going to be a huge spike, with lots of hospitalizations, or whether it is going to be more of a drawn-out spike with less hospitalizations.
We are prepared for all of the scenarios because we have to be prepared—we do not have a choice. But I am hopeful that the new boosters targeted at omicron will be effective.
There also are other infections that we need to address. We have done an incredible job managing monkeypox—we have been able to limit the spread of that disease unlike what we could not do for COVID. We are also going into our flu season, so we are facing a triple threat in the coming months. We feel confident that we can rise to these challenges.
HL: In the next year, in what areas would you like to launch clinical initiatives?
Eskioglu: We are going to have more mental health issues as a country. If you look at national and international events, whether it is the national discourse, the war in Ukraine, inflation, or the recession that might be upon us, a lot more people are going to have mental health issues and there is going to be exacerbation of people who have pre-existing mental health issues. We are going to have more depression and anxiety.
We are focusing on how to address mental health needs better through initiatives such as telemedicine. We are having a lot of touch points with our mental health patients.
Over the next year, we are also going to be focusing on our AI initiatives—that is where we are going to change healthcare in the long run.
HL: Give me an example of where you see AI making a difference at Novant in the next year.
Radiology is a good example. On a busy ER night, you could have as many as 50 images pile up on the radiologist, and everything in the ER is STAT. The problem is that the queuing system is so old-fashioned that you face a logistics challenge. Often, it is first come, first served. That makes it difficult to find the image that might be the ticking time bomb. If radiology images pile up on a radiologist, the first 49 images could be normal and not require an intervention, but the 50th image could be a ticking time bomb with a brain bleed, and it could take 30 minutes to get to it.
We are developing a radiology AI module that collects images from the source and using machine learning it automatically updates the queue to put abnormal findings at the top of the radiologist's queue. It puts the most emergent images at the top of the queue with a differential diagnosis. One of the benefits has been that the radiologists are less anxious—particularly on busy nights—because they do not have to worry about ticking time bombs. It has helped reduce physician burnout and anxiety.
HL: Do you have any other insights on the way forward now that the crisis phase of the pandemic has passed?
Eskioglu: There is going to be more disruption led by Microsoft, Amazon, Apple, Google, Oracle, CVS, and Walmart. Amazon CEO Andy Jassy has said that healthcare needs to be reinvented. There are altruistic motivations behind that statement, but it is also financial—Amazon is a very large, publicly held company that has a for-profit mentality.
I expect the tech companies to make more forays into healthcare, and the feeding frenzy has started. Amazon has bought One Medical, which is a huge primary care group. CVS has bought Signify Health, which is a home health group with lots of physicians.
The tech companies are trying to establish their own niches. Microsoft has taken the role of creating an ecosystem that can nurture and support the healthcare system—provider systems like Novant and other healthcare organizations. Apple wants to be the company of choice for wearable devices.
Amazon is probably the company that is disrupting the most—they are not only disrupting in a big way but also trying to transform and innovate. Amazon is seeking to establish itself in the most lucrative parts of healthcare such as ambulatory care and pharmacy.
Oracle is trying to be the software of choice. They want to be the data repository of choice for healthcare data.
CVS is well ahead of Walgreens because they have bought Aetna, and they are getting into the provider space by buying Signify Health.
Walmart is another disruptor to watch. In all of their neighborhood clinics, they are implementing EPIC, which is the electronic health record that most health systems use. They have also announced a collaboration with UnitedHealth.
All of this disruption does not have to be a negative development for providers like Novant. It is time to think outside of the box. You have seen megamergers happen such as with my competitor Advocate, Aurora, and Atrium. I would not be surprised to see companies such as Amazon, Apple, or Google take a minority interest in health systems to get people on our boards and learn from the inside-out, rather than from the outside-in.
A new report identifies best practices in several areas, including accounts receivable, earnings, expenses, and patient access.
A new report from MGMA highlights the best practices of successful medical groups.
The MGMA assigns Better Performer status based on metrics including compensation and production, cost and revenue, and practice operations. The new report is based on information collected from 4,098 organizations, with 1,129 identified as Better Performers—a 36% increase compared to organizations that earned the Better Performer designation in 2021.
Better Performers excel in accounts receivable, the report says. "Across the board, Better Performer practices collect more A/R in the first 30 days compared to all practices, with the biggest difference (nearly 9%) occurring in primary care collections made in the first 30 days. Primary care Better Performers also had the biggest difference in outstanding A/R in the 120+ days bucket."
Michelle Mattingly, director of data solutions at MGMA, told HealthLeaders that there were three primary commonalities among Better Performers that excelled in accounts receivable.
An emphasis on collecting accounts receivable in the first 30 days of billing, leaving less dollars to be collected in the past due buckets such as 120+ days in accounts receivable
Use of a claim scrubbing tool to catch clerical and coding errors
Running monthly accounts receivable and separate out insurance and patient balances by service date
There were three primary commonalities among Better Performers that succeeded in posting high earnings, Mattingly says.
Better Performers will often show slightly higher total operating cost per full-time equivalent physician
Investments in areas such as staff, medical supplies, building occupancy, and equipment typically help produce greater revenue in Better Performer organizations
Better Performers follow the adage that you have to spend money to make money
With pandemic-related constraints such as higher labor expenses, Better Performers posted lower expenses compared to their counterparts. Two factors were primarily responsible for driving down expenses at Better Performers, Mattingly says.
In some cases, attrition helped practices avoid steep rises in labor expenses
Practices experiencing staffing shortages did not have staff to pay, so they saved on an expense they would have had otherwise
Staffing shortages have put a strain on patient access such as creating longer appointment wait times. There were four primary commonalities among Better Performers that were able to hold the line or improve patient access, Mattingly says.
Better Performers had a higher percentage of same-day appointments
The third next available appointment for new patients was up to four days sooner at Better Performers compared to other practices
New patients were asked to fill out electronic forms prior to their visit
Denver Health's chief medical officer says the program is specifically designed to provide support for healthcare workers.
Denver Health has implemented the Resilience in Stressful Events (RISE) program to help boost the well-being of the health system's healthcare workers, Chief Medical Officer Connie Savor Price, MD, MBA, said during the recent HealthLeaders CMO Exchange.
Stress and burnout are common in the healthcare industry. Healthcare worker burnout has reached alarming proportions during the coronavirus pandemic, a healthcare worker well-being expert has told HealthLeaders. Prior to the coronavirus pandemic, healthcare worker burnout rates on average ranged from 30% to 50%, says Bernadette Melnyk, PhD, APRN-CNP, chief wellness officer of The Ohio State University and dean of the university's College of Nursing. Now, burnout rates range from 40% to 70%, she said.
RISE was developed by Johns Hopkins Medicine specifically to help healthcare workers, Price says. "The concept of RISE is geared toward the specific needs of healthcare providers and what they face in some of the difficulties of being healthcare providers. Healthcare providers are involved in adverse patient events and medical errors, and bearing witness to those can result in emotional or even physical distress."
RISE programming is designed to play a supportive role for healthcare workers, she says. "RISE is basically a service to empathize, listen, validate, and normalize. It facilitates a connection to other providers and resources if that connection is needed. It is available 24/7 and there is strict confidentiality. RISE is not counseling. It is not a problem-solving service. It does not provide psychotherapy or any kind of psychiatric care. It is a support service, with listening and connections to other resources."
Denver Health has launched seven RISE initiatives:
24/7 RISE Line (303-436-RISE): This phone-based service provides 24/7 access to emotional support and psychological first-aid, including a handoff to well-being resources.
Department or team-specific RISE group support: Group support opportunities are available virtually or in-person. Any leader can activate a group support request by emailing dhrise@dhha.org or by calling the 24/7 RISE Line for urgent requests.
RISE Up Staff Support Center: This is a dedicated space staffed by RISE peer responders that provides staff with a place for self-care, reflection, emotional support, and access to resources, snacks, and beverages. The support center has been open seven days a week from 10:30 a.m. to 8 p.m.
Inter-disciplinary virtual RISE group support: These group support opportunities are offered on a weekly basis for various themes of distress and specific affinity groups such as the Black Affinity Group.
Peer Assault Care Team: PACT offers immediate, confidential, and voluntary support for staff after an assault in the workplace. A PACT response can be initiated by any staff member or leader by calling the 24/7 RISE Line and requesting the PACT responder on-call.
RISE outreach: RISE peer responders are available to provide outreach to staff to introduce RISE services and assess needs. The peer responders also provide emotional support, psychological first-aid, and connections to resources. Requests for deployment of outreach services can be made via email at dhrise@dhha.org or by calling the 24/7 RISE Line.
RISE 2 You: This mobile service can be requested to come to a department or clinic. RISE peer responders and other resources are available by requesting a visit via email at dhrise@dhha.org.
Stress in healthcare settings
There are multiple sources of stress among healthcare workers, Price says.
"I am at a Level 1 trauma center and public health hospital, and our provider staff frequently witness distressing events. The problem of being a 'second victim' is you also often feel personally responsible for the outcome. Sometimes, you feel that you should have been able to do more—you question whether you did everything you could have done. So, there are special needs among healthcare providers. There are also factors that we are seeing in the workplace such as an increase in violence. There are ethical dilemmas and moral distress—there are patients who can't access the healthcare they need because they do not have the right insurance. There are tragic events—there is a lot of stress in healthcare teams," she says.
At Denver Health, three dozen themes of distress were identified through RISE from July 5 to Aug. 1 this year, including grief and loss, death of patients and colleagues, physical and mental exhaustion, conflict with co-workers, staffing shortages, isolation and loneliness, and desire to quit.
The president of the American Medical Association calls for "urgent action" to improve physician well-being.
The physician burnout level and other measures of physician distress have increased dramatically during the coronavirus pandemic, a new research article has found.
The researchers led by Tait Shanafelt, MD, chief wellness officer at Stanford Medicine, have measured physician burnout every three years since 2011. After measuring physician burnout in 2020, the researchers decided to measure the impact of the ongoing pandemic, conducting a survey from Dec. 9, 2021, to Jan. 24, 2022.
The findings of 2021 survey are troubling, with 62.8% of physicians reporting at least one symptom of burnout compared with 38.2% in 2020.
Yesterday, Jack Resneck Jr., MD, president of the American Medical Association, said the new findings are alarming.
"While the worst days of the COVID-19 pandemic are hopefully behind us, there is an urgent need to attend to physicians who put everything into our nation's response to COVID-19, too often at the expense of their own well-being. The sober findings from the new research demand urgent action as outlined in the AMA's Recovery Plan for America's Physicians, which focuses on supporting physicians, removing obstacles and burdens that interfere with patient care, and prioritizing physician well-being as essential requirements to achieving national health goals," he said in a prepared statement.
The new research article, which was published this week by Mayo Clinic Proceedings, features information collected from more than 2,400 physicians. In addition to the finding on increased physician burnout, the study includes several key data points.
Mean emotional exhaustion scores among physicians increased 38.6% from 2020 to 2021
Mean depersonalization scores increased 60.7% from 2020 to 2021
Satisfaction with work-life integration decreased from 46.1% in 2020 to 30.2% in 2021
The proportion of physicians with a favorable professional fulfillment score decreased from 40.0% in 2020 to 22.4% in 2021
The proportion of physicians who reported they would choose to become a physician again if they could reconsider their career choice decreased from 72.2% in 2020 to 57.1% in 2021
In a multivariable analysis of the 2021 data, being a woman (odds ratio 2.02), long work hours per week (odds ratio 1.02 for each additional hour), and practicing emergency medicine (odds ratio 4.59), family medicine (odds ratio 1.57), and general pediatrics (odds ratio 2.44) were linked to higher levels of burnout
In a multivariable analysis of the 2021 data for work-life integration factors, being a woman (odds ratio 0.59) and long work hours per week (odds ratio 0.94 for each additional hour) were linked to lower odds of satisfaction with work-life balance
The data indicates a significant increase in physician distress between the 2020 and 2021 surveys, the research article's co-authors wrote. "The results show a large increase in mean emotional exhaustion and mean depersonalization scores, as well as the proportion of physicians with symptoms of burnout compared to both fall of 2020 and all prior assessment timepoints over the last decade. Mean scores for emotional exhaustion were 39% higher relative to the 2020 survey while mean depersonalization [scores] were 61% higher. The prevalence of burnout increased roughly 25% over the 12-month interval between the end of 2020 and the end of 2021. Satisfaction with [work-life integration] also declined over this interval."
Interpreting the data
The pandemic has had a disproportionately negative impact on female physicians, the study found. In a multivariable analysis that adjusted for personal characteristics such as age and professional characteristics such as practice setting, the odds ratio for burnout among female physicians compared to male physicians was 2.02 in 2021 compared to 1.27 in 2020. "These data suggests the long-documented increased risk for burnout and work-life conflict in women physicians has been exacerbated by the COVID-19 pandemic," the study's co-authors wrote.
The impact of the pandemic on physicians has broader ramifications for the entire healthcare system, the study's co-authors wrote. "The collective effect on the US physician workforce appears to be profound. Given the association of physician burnout with quality of care, medical errors, reductions in clinical work effort, turnover, departure from practice, and healthcare costs, these findings also have potentially critical implications for the US healthcare delivery system."
Rising to the challenge
Although the pandemic has prompted many healthcare organizations to acknowledge the essential role that their workforce has in providing high-quality and safe care, efforts to promote physician well-being are often inadequate, the study's co-authors wrote.
"While sincere, many of these organizations have focused on providing resources for individuals in distress, such as psychological first aid, peer support, mental health care, and counseling. These organizations will benefit from embracing a more expansive and holistic approach to prevent occupational distress rather than simply perpetually reacting to it by providing support to distressed clinicians. Such approaches require organizational commitment as well as dedicated leadership and include comprehensive and sustained approaches to reduce administrative burden, enhance team-based care, address inefficiency in the practice environment, and establish staffing models consistent with new models of care delivery."
Joshua Lenchus' leadership style is to seek consensus and to try to ensure that everyone's voice is heard.
Broward Health has elevated Joshua Lenchus, DO, from interim chief medical officer to chief medical officer.
In September 2018, Lenchus joined the Fort Lauderdale, Florida-based health system as chief medical officer of Broward Health Medical Center. He was named as the health system's interim chief medical officer in July 2021.
Before joining Broward Health, he served as chief of staff and as an internal medicine/hospitalist at Jackson Memorial Hospital in Miami. He was also associate program director for the University of Miami Jackson Internal Medicine Residency Program.
HealthLeaders recently spoke with Lenchus about becoming the permanent chief medical officer at Broward Health and a range of issues, including physician engagement, patient safety, and quality improvement. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: What are the primary elements of physician engagement?
Joshua Lenchus: Physician engagement is predicated on credibility, networking, and relationships. To engage folks as a fellow physician, you need to build those foundational elements to be successful. This helps us in problem solving, appropriate communication, and timely responses.
The office of chief medical officer is responsible chiefly for problem solving. So, on a day-to-day basis, we have people who bring up issues and we must understand the mindset of the individuals that bring up the issues. That level of understanding is predicated on networking and relationship building.
HL: What are your goals for patient safety at Broward Health?
Lenchus: Our patient safety goals at Broward Health are similar to other healthcare organizations across the nation. We are trying to create the safest environment in which patient care can be provided. There are always opportunities for improvement through identifying issues that preclude us from achieving a 100% patient-safe environment. Once those issues are identified, we put them through a root cause analysis to try to identify system-based solutions to mitigating future events from happening. We are always looking at providing the safest care that we can to our patients, who entrust us to do so.
HL: Are there particular safety issues that you are personally interested in?
Lenchus: I have a predilection for the more clinical patient safety goals such as prevention of infections. I have a background as a pharmacist, so medication safety is a personal and professional interest of mine. Of course, all patient safety issues are equally important, and we focus on all of them.
HL: What are your goals for quality improvement at Broward Health?
Lenchus: Similarly to patient safety, we obviously want to provide the best quality to the patients that we care for. We are doing a good job on that path. We have a graduate medical education program at two of our four hospitals. Involving residents in education necessitates keeping up on the transformation of medical practice throughout the health system, which only emboldens us to continue to take steps in a positive direction by providing high-quality care.
We recognize that standardization has its limits—each patient is an individual—but to the extent that we can standardize the care that we provide in an evidence-based manner is a primary goal in quality improvement.
HL: What is your vision for the role of the CMO at Broward Health?
Lenchus: My goal is to collate best practices, not just across our institution but also among other institutions with whom I have relationships, in an effort to apply best practices at Broward Health. I realize that not everything that works at another site may work at Broward; but to the extent that we can bring transformation here, my job is to navigate and spearhead transformation along with the medical staff, nursing leaders, and administrators to move the health system forward.
As the highest-ranking clinician in the organization, it also is my job to ensure that clinical practice is front-and-center in everything that we do. That means that the care of the patient takes precedence over everything else. The health system has been a part of the community for nearly a century, and the patient has always been at the heart of what we do. I see my job as furthering that mission to provide the high-quality care that our community should expect when they come to see a Broward Health physician or when they come to seek care at a Broward Health facility.
HL: How do you view the CMO as a member of the C-suite team?
Lenchus: At finance meetings, operational meetings, and strategic meetings, it is my job to keep the clinician within that conversation. So, when we have conversations of a nonclinical nature, it is important to have a clinical voice in the room because, sometimes, we may want to make a move financially or operationally that discounts the role that the clinical workforce has in the organization. Frankly, the workforce that we have at Broward Health is largely clinical, so it would be a grave omission for the CMO's voice not to be heard. I carry the torch for the clinical folks—doctors, nurses, therapists, and support staff who work in the health system.
HL: How do you see your role as CMO as the coronavirus pandemic continues?
Lenchus: I work with a host of specialists and representatives of diverse departments. From the outset of the pandemic, we have developed several task forces for different aspects of our preparedness and interventions. With medications, there are specialists in infectious disease, pharmacy, nursing, and the emergency room that we work with to gain experience and insight. If we are talking about masking, testing, vaccines, and the host of other facets in our response to the coronavirus pandemic, we have created task forces to leverage talent so that you can hear a multitude of perspectives and interests to come to a palatable solution in trying to move the institution in the right direction. My role is to work closely with these specialists and task forces.
HL: How would you characterize your leadership style?
Lenchus: I have had the pleasure over my years in medicine of working with incredibly talented and knowledgeable people. My leadership style has always been to try to recognize the talent in the room and leverage folks for their strengths. When I must manage a situation, I try to engage the people who are going to be affected downstream. Even if I create a solution in draft form, I want to give people something to build upon. I try to engage people, so they have ownership over whatever solution we are going to implement.
I do not rule by executive fiat—I operate more on a consensus method. In management, as any leader will tell you, you cannot appease everyone at all times. However, the objective is to ensure that everyone's voice is heard, and everyone is at the table to provide their unique perspective. It would be incredibly presumptuous of me to think that I have all of the answers. That is why I try to include as many people as possible in change management.
Concordance between telehealth diagnoses and in-person visit diagnoses was lowest when in-person visit diagnoses involved physical examination, neurological testing, or pathology.
There is a significant level of agreement between telemedicine diagnoses and in-person outpatient visit diagnoses, a recent research article found.
In the early phase of the coronavirus pandemic, telehealth utilization increased exponentially—one published estimate pegged the increase in utilization in April 2020 at 20-fold. A concern associated with this increase in telehealth utilization is the accuracy of telemedicine diagnoses compared to in-person visits.
The recent research article, which was published by JAMA Network Open, examines data collected from more than 2,000 Mayo Clinic patients who had telehealth diagnoses followed by an in-person visit diagnosis for the same clinical concern in the same specialty within 90 days.
The study generated several key data points:
Overall, the telehealth diagnosis matched the in-person visit diagnosis in 86.9% of cases.
For ICD-10 conditions, diagnostic agreement between telehealth visits and in-person visits ranged from 64.7% for diseases of the ear and mastoid process to 96.8% for neoplasms.
In non-primary care specialties, diagnostic agreement between telehealth visits and in-person visits ranged from 77.3% for otorhinolaryngology to 96.0% for psychiatry.
Diagnostic agreement between telehealth visits and in-person visits was significantly higher for specialty care compared to primary care (88.4% versus 81.3%).
When an in-person visit diagnosis could be established through clinician opinion only, there was a high level of agreement with diagnoses made in telehealth visits.
When an in-person visit diagnosis required confirmatory pathology, a physical examination, or neurological testing, there was a lower level of agreement with diagnoses made in telehealth visits.
Among the 313 (13.1% of the total) cases where there was not agreement between the telehealth diagnosis and the in-person visit diagnosis, 166 cases had the potential for morbidity and 36 of those cases had actual morbidity.
Among the 313 cases where there was not agreement between the telehealth diagnosis and the in-person visit diagnosis, 30 had the potential for mortality and 3 of those cases had actual mortality.
Telehealth diagnoses often should be paired with in-person visit diagnoses, the study's co-authors wrote. "These findings suggest that video telemedicine visits to home may be good adjuncts to in-person care. Primary care video telemedicine programs designed to accommodate new patients or new presenting clinical problems may benefit from a lowered threshold for timely in-person direct follow-up in patients suspected to have diseases typically confirmed by physical examination, neurological testing, or pathology."
Interpreting the data
The level of agreement between telehealth diagnoses and in-person visit diagnoses appears to be dependent on how the diagnoses are confirmed, the study's co-authors wrote.
"In diagnoses confirmed through clinician opinion, such as many psychiatric diagnoses, there was a significantly greater concordance between video telemedicine diagnosis and in-person diagnosis. In diagnoses necessitating confirmation through traditional physical examination, neurological testing, and pathology—such as many otological and dermatological diagnoses—there was a significantly decreased concordance between video telemedicine and in-person diagnoses," they wrote.
A primary result of the study was the difference in diagnosis agreement between specialty care versus primary care, the researchers wrote.
"One of the most salient findings in our study was the discrepancy between video telemedicine diagnostic concordance with in-person visits in specialty care (higher concordance) and primary care (lower concordance) clinical settings. This finding was further emphasized by our individual analyses of cases that resulted in morbidity and mortality. There were some cases identified in our primary-care telemedicine program that resulted in morbidity and mortality that might have been mitigated by an initial in-person visit, an observation that was not mirrored in specialty practices," they wrote.
Longer wait times for physician appointments in metropolitan areas indicate that demand for physicians is exceeding supply.
The time it takes for patients to schedule a new physician appointment in 15 metropolitan areas has increased significantly, according to a recent survey report.
Physician appointment wait times reflect the supply and demand for physician services. The survey's reported increase in physician appointment wait times in four out of five specialties suggests that there is a shortage of physicians.
The survey was conducted by AMN Healthcare and the company's physician search division, Merritt Hawkins. The survey features data collected from more than 1,000 physician practices in 15 metropolitan areas: Atlanta, Boston, Dallas, Denver, Detroit, Houston, Los Angeles, Miami, Minneapolis, New York, Philadelphia, Portland, Oregon, San Diego, Seattle, and Washington, D.C. The survey was conducted from March to May 2022.
The survey sought to simulate someone new to a community trying to schedule a nonemergent appointment over the phone or online. The survey focused on five specialties: cardiology, dermatology, family medicine, obstetrics-gynecology, and orthopedic surgery.
The survey has several key findings:
Since the survey was conducted in 2017 and 2004, average physician appointment wait times have increase substantially. In 2022, the average wait time for a physician appointment across the five specialties is 26.0 days, an 8% increase compared to the 2017 survey and 24% increase compared to the 2004 survey.
In 2022, the average wait time to see a cardiologist is 26.6 days, which is a 26% increase compared to 2017. Average wait times to see a cardiologist range from 49 days in Portland to 13 days in Dallas.
In 2022, the average wait time to see a dermatologist is 34.5 days, which is a 7% increase compared to 2017. The average wait times to see a dermatologist range from 72 days in Minneapolis to nine days in Philadelphia.
In 2022, the average wait time to see a family medicine physician is 20.6 days, which is a decrease of 30% compared to 2017. The average wait times to see a family medicine physician range from 44 days in Portland to eight days in Washington, D.C.
In 2022, the average wait time to see an obstetrician-gynecologist is 31.4 days, which is a 19% increase compared to 2017. The average wait times to see an obstetrician-gynecologist range from 59 days in Philadelphia to 19 days in New York.
In 2022, the average wait time to see an orthopedic surgeon is 16.9 days, which is a 48% increase compared to 2017. The average wait times to see an orthopedic surgeon range from 55 days in San Diego to five days in Washington, D.C.
Portland (45.6 days) has the highest average physician appointment wait time across all five of the specialties.
New York (17.4 days) has the lowest average physician appointment wait time across all five of the specialties.
Interpreting the data
The data indicate that there is an ongoing physician shortage, Merritt Hawkins President Tom Florence told HealthLeaders.
"Simply stated, demand for physicians continues to exceed supply. Even though at its height COVID-19 temporarily suppressed demand for physicians, the underlying factors driving the physician shortage never went away. These include an aging population, widespread ill-health, an aging physician workforce, and a limited supply of newly trained physicians. The pandemic actually added accelerant to the physician access problem by creating patient backlogs and by exacerbating physician burnout and attrition. We are emerging from COVID-19 with the same key challenge we faced prior to the pandemic—a chronic shortage of physicians. The practical effect for patients is longer wait times to see a doctor," he says.
Average physician appointment wait times are even higher in rural areas of the country, Florence says. "The top metro areas we surveyed have some of the highest ratios of physicians per population in the country, yet physician appointment wait times even here can be extended and are growing. In smaller communities, wait times can be 50% or more longer. That is provided patients can find the type of specialist they need, which often is not the case. Long physician appointment wait times in major cities clearly are a troubling sign for rural communities."
Change in the healthcare provider market are linked to the decrease in wait times to see a family medicine physician, he says. "Over the last several years a new front door has opened up in healthcare. More patients are accessing primary care through urgent care centers, retail clinics, and telehealth, all venues that often are staffed with a growing number of nurse practitioners and physician assistants. That makes it less challenging to see a family physician, though it can still be difficult."
The variation in physician appointment wait times between metropolitan areas is not surprising, Florence says. "The number and type of physicians per specialty can vary in large metro areas, as can disease incidence, patient demographics, physician practice patterns, and rates of insurance coverage. These are complex medical service areas and some variation within them is to be expected."
A landmark study examines the economic burden and lives lost due to mental health inequities.
Mental health inequities cost billions of dollars and thousands of lives annually, according to a new report.
Indigenous populations such as Native Americans and minority groups such as African Americans experience mental health inequities that limit access to care. These inequities result in poor clinical outcomes such as suicide.
The new report was produced by the Satcher Health Leadership Institute at the Atlanta-based Morehouse School of Medicine, with support from Otsuka America Pharmaceutical Inc. The researchers examined data from 2016 to 2020.
The report features two key data points:
From 2016 to 2020, 116,722 members of indigenous populations and racial and ethic minority groups experienced premature mental and behavioral health-related deaths.
From 2016 to 2020, the costs associated with premature mental and behavioral health-related deaths among indigenous populations and racial and ethnic groups linked to mental illness, substance abuse, and suicide were $278 billion.
The new report is unique, according to the study's executive summary. "Previous studies have attempted to highlight how health disparities affect economic and lifespan outcomes for indigenous populations and racial and ethnic minoritized groups, but none have specifically analyzed the economic burden of mental and behavioral health inequities. This first-of-its-kind report is designed to inform all stakeholders on the ramifications of a chronically underfunded and siloed system of mental health care, with a particular focus on underserved and under-represented communities."
The full report, which has not been published yet, calls for actions and solutions on three fronts:
Long-term investments in mental and behavioral health, including solutions that advance mental health equity
Development of socio-culturally crafted approaches to mental and behavioral health services
Tackling the social and political determinants of health inequities
Interpreting the data
The report represents a call-to-action, Daniel Dawes, JD, director of the Satcher Health Leadership Institute, told HealthLeaders. "We must do something about mental health inequities. This is a first step in helping our policymakers and our political influencers to have a better understanding of this issue that has eluded us for decades in America. It took me 15 years to finally get an organization that was aligned with our vision and our research agenda to say, 'Yes, this is worthy of studying and reporting out.' We appreciate the efforts that Otsuka America Pharmaceutical have helped us to finally get this work done."
Payers have a key role to play in addressing mental health inequities, he says. "Insurance coverage is a major systemic issue that we have been trying to address, and the lack of health insurance is often flagged as one of the most statistically significant determinants of depression, low educational attainment, and poor self-rated health."
Several factors drive mental health inequities among indigenous populations and minority groups, Dawes says. "The fact that we have not addressed stigma and cultural beliefs about psychiatric issues as we should has posed significant barriers to mental health care among communities of color. Then you tie that to the rural geographic variations that we have seen, and these communities report that more than two-thirds of their communities have no psychiatrists, no psychologists, and no behavioral health professionals. These disparities are even worse when you break them out by race and ethnicity."
The economic cost of mental health inequities is deeply rooted, he says.
"The economic burden of behavioral health conditions is even greater for mentally unwell persons who are representative of indigenous populations or racial and ethnic minority groups. This is due to a hindered ability to participate in economic activities such as employment, workforce training, and educational opportunities. They are exacerbated by having historically disadvantaged socio-economic status because of their indigenous, racial, or ethnic status. From an economic standpoint, the structural barriers in accessing care, the cultural differences to pursuing behavioral health care, the biased delivery of behavioral health care, as well as the social and political determinants of health including insurance status all perpetuate systemic inequities."
Addressing mental health inequities would result in significant cost savings, Dawes says. "We could save billions of dollars in this country if access to behavioral health services was more equitable. Health equity will not be achieved unless there is adequate coverage and payment for behavioral health services among all public and private insurance programs. Whether it is Medicaid, Medicare, or commercial payers, there needs to be enforcement of mental health parity. We need better enforcement of the parity law to cover mental health services in line with physical health services."
Thousands of live could be saved if mental health inequities were mitigated, he says. "We found during the period from 2016 to 2020 that nearly 117,000 people of color lost their lives prematurely due to behavioral health conditions, and the inability to access the treatments, interventions, and the services that they needed. We could save lives if we could rectify and repair the structures of behavioral health and if we were to do a better job building and repairing the behavioral health infrastructure."
At Bon Secours Mercy Health, a peer support program is a key component of healthcare worker well-being efforts.
A program that features peer support is helping healthcare workers at Bon Secours Mercy Health address behavioral health issues.
Healthcare worker burnout has reached alarming proportions during the coronavirus pandemic, a healthcare worker well-being expert has told HealthLeaders. Prior to the coronavirus pandemic, healthcare worker burnout rates on average ranged from 30% to 50%, says Bernadette Melnyk, PhD, APRN-CNP, chief wellness officer of The Ohio State University and dean of the university's College of Nursing. Now, burnout rates range from 40% to 70%, she said.
In 2021, 71% of Bon Secours Mercy Health providers reported experiencing COVID-19 distress.
In May 2020, the Cincinnati-based health system launched Caring4Colleagues in response to the pandemic and the toll it was taking on healthcare providers and their families. The program features peer support, which in the beginning focused on clinicians, says W. Carson Felkel II, MD, system medical director for behavioral health.
"It started out with flyers in the physician lounges. It was a grassroots initiation effort. The beauty of the early version of the program was the simplicity. The flyer had many cellphone numbers on it. When people are in crisis, they reach out and often feel shame and guilt. They want a person to talk to and they want to feel heard. So, they would call one of our cellphones, and we would begin to have a conversation and continue to follow up with them over time," he said.
The peer support effort has grown to include all of the health system's associates, Felkel says. "To date, we have done 430 of these peer support pairings among physicians, advanced practice clinicians, nurses, and other associates."
Peer support volunteers not only engage struggling healthcare workers in a deep conversation but also help connect them with behavioral health services, he says. "What we have been finding from COVID and the workplace in general is associates need to have easy access to a colleague—a peer—who can navigate the complex mental health world and get them to the right resource at the right time."
The peer support volunteers receive training from health system professionals, Felkel says.
"We have a robust team of psychiatrists, psychologists, therapists, nurses, chaplains, and other specialists who train volunteers to have conversations with their colleagues. The volunteers are in the trenches alongside our associates, and that is why peer support works. It's not like just having a behavioral health team applying mental health. We are colleagues talking with colleagues. Within the training, we train individuals to have deep conversations using a trauma-informed approach and motivational interviewing," he says.
The engagement of top health system leaders has boosted the Caring4Colleagues program, Felkel says.
"One of the successes of this program has been our extraordinary leadership within Bon Secours Mercy Health supporting the effort. Whenever you do associate well-being efforts, it is usually top-down, meaning that it comes from upper leadership, and that is exactly what has happened with the Caring4Colleagues program. Leaders have talked about the program in many meetings, and they have utilized the program—it is not just physicians, advanced practice providers, and nurses who have been struggling, it's all of us, including leaders. So, leaders have modeled the use of the program themselves and talk about the success and share it with others. That creates trust in these conversations," he says.
Caring4Colleagues serves as a bridge to the health system's employee assistance program (EAP), Felkel says. "The beauty of Caring4Colleagues is that we provide the transition from a crucial conversation to the therapists within the EAP program. We grew EAP services within our ministry for physicians from 6.8% to 9.7%. With Caring4Colleagues, we were able to get almost 1 in 10 physicians into an EAP therapist, and that is not common in healthcare."
Reaching out to healthcare workers
The Caring4Colleagues program also includes "empathy rounding."
"Rounding is essential to our ministry because it creates visibility, trust, and relationships. We have many types of rounding that go on daily. We have leaders rounding, but more recently, we have started empathy rounding with chaplains and therapists rounding on units to provide visibility and immediate care when necessary. The beauty of our Caring4Colleagues program is that we can support empathy rounding when there is a crisis or the identification of someone who is struggling. We can immediately surround them with multidisciplinary care," Felkel says.
Empathy rounding is a way to be proactive with healthcare workers, he says. "In empathy rounding, we are visible and present. We must be intentional about being present with our colleagues. Several times a month, the chaplains and therapists are available on the units just to check in."
Getting help
At Bon Secours Mercy Health, healthcare workers in crisis have a support system in place to navigate behavioral health services, Felkel says. "It is as easy as calling one of our Caring4Colleagues cellphones, so we can have a conversation and walk alongside them. We can listen to what they are going through."
The health system is helping healthcare workers with a multidisciplinary approach, he says. "To address mental health needs, it takes a coordinated health system effort, and we have great leader engagement around this effort. For example, we have a great provider network within our benefit plan, we have excellent EAP benefits such as six free counseling sessions, we have leader rounding, we have well-being committees, we have chaplains and therapists rounding, and all of this must be tied together through a trusted peer program."
Two federal payment programs that give financial support to rural hospitals are set to expire on Oct. 1.
The Federation of American Hospitals (FAH) is urging Congress to reauthorize two federal programs that provide financial assistance to rural hospitals.
Rural hospitals face multiple financial challenges, including low patient volumes and relatively high numbers of Medicare, Medicaid, and uninsured individuals in their patient populations. Over the past decade, more than 130 rural hospitals have closed and more than 30% of rural hospitals are at risk of closing, according to the Center for Healthcare Quality and Payment Reform.
Two Medicare payment programs that provide financial support to rural hospitals—the Medicare-Dependent Hospital (MDH) program and the Low-Volume Hospital (LVH) program—are set to expire on Oct. 1. Last week, FAH President and CEO Charles N. Kahn III sent a letter to Congressional leaders imploring them to reauthorize the MDH and LVH programs.
"Rural hospitals traditionally serve patient populations that are older, lower income, uninsured and more likely to rely on Medicare and Medicaid when compared to the national average and to their urban counterparts. This challenging patient demographic means rural hospitals have a high volume of Medicare-dependent patients, and a lower volume of total patients overall. The MDH and LVH Medicare payment programs provide eligible rural hospitals with the financial stability and support they need to prevent closures and ensure continued access to care in rural communities," Kahn wrote.
Citing rising inflation and supply chain challenges, he wrote that rural hospitals are facing "unprecedented times" and financial pressure. "The nation's healthcare workforce shortage, in particular, is having a devastating, disproportionate impact on rural hospitals. Long-documented recruitment challenges have been exacerbated by an aging healthcare workforce, burnout, price gouging by traveling nurse staffing agencies, competing higher wages in larger cities, and a slowing of visas granted to foreign healthcare workers—all factors that are contributing to higher average payrolls and strained resources."
Dire consequences
Many rural hospitals are desperate for federal assistance, Jonathan Jagoda, MPP, senior vice president of legislative affairs at FAH, told HealthLeaders. "When you look at the role that rural hospitals play in their communities, you are often talking about the sole comprehensive provider for patients within many miles—sometimes hundreds of miles. It is critical that those facilities remain open and that services remain available to their patients. Even before the coronavirus pandemic, we saw the struggles that rural hospitals faced across the nation. They were cutting services lines, and many were being forced into closure. It is the community that suffers when service lines are cut or hospitals close."
If the MDH and LVH programs are not reauthorized, the consequences for rural hospital would be severe, he said. "If these programs are not reauthorized, the risk of rural hospitals closing is significant. Obviously, it depends on the hospital and the extent to which they utilize these programs to offset costs. Every rural hospital would not close, but you would see difficult decisions having to be made, whether that is eliminating services or hospital closures in the worst-case scenario. These programs help keep the doors open at rural hospitals. I would be very worried if the MDH and LVH programs were not renewed."
Congressional support
The MDH and LVH programs have bipartisan support in Congress. Last month, U.S. Rep. Terri Sewell (D-Alabama) and U.S. Rep. Carol Miller (R-West Virginia) introduced H.R. 8747, the Assistance for Rural Community Hospitals (ARCH) Act. The bill would reauthorize the MDH and LVH programs for five years.
The FAH, which represents more than 1,000 for-profit health systems and hospitals across the country, supports the ARCH Act.
Federal lawmakers know the stakes for reauthorization are high, Jagoda said. "They know they have to do it on a bipartisan basis. Leadership and the committees of jurisdiction have indicated support for these programs. They want to ensure that rural hospitals have the resources they need. So, we are fighting tooth and nail to ensure reauthorization comes by October 1 to make sure there is no gap in funding for rural hospitals."
