Operating room black boxes collect video and audio of the OR staff as well as images of the surgical field.
Black boxes not only help ensure airliner safety, but they are now used to ensure the quality and safety in Northwell Health operating rooms.
In February 2019, the Manhattan-based health system became the first in the nation to deploy OR Black Box, technology developed at Surgical Safety Technologies in Toronto, Canada. At Northwell, OR Black Box has been used to examine adverse events in granular detail, to assess teaching in ORs, and to look for improvement opportunities.
Northwell is piloting the black box technology with laparoscopic urologic and colon surgical teams at Long Island Jewish Medical Center, says Mark Jarrett, MD, MBA, senior vice president, chief quality officer, and deputy chief medical officer at the health system. "It takes several inputs from the room—the physiology, audio from microphones, video of the staff, and the digital image from the scope to make certain that the gradings of the surgical technique and the teaching going on are analyzed."
OR Black Box is designed to record laparoscopic procedures, which is why urologic and colon procedures were chosen to pilot the technology, he says. "We wanted laparoscopic surgery because it depends on the digital feed from the camera of the actual surgery."
Northwell also picked urologic and colon surgical teams to be the first ORs with the black box technology because there were eager physician champions willing to pioneer the initiative, Jarrett says. "It required a physician champion with a team in the OR that would feel comfortable doing this."
The OR Black Box computer packages the scope video with video and audio collected from the OR staff as well as physiology data collected from the patient such as heart rate, pulse, blood pressure, and oxygen level. Then all the time-synched data is sent electronically to Surgical Safety Technologies for analysis.
"It pays for all of us to do the analysis centrally—it leads to more reliability and validity. By doing the analysis centrally, we can also share information between hospitals. For example, if Northwell does 150 urology cases and five other medical centers do 150 urology cases each, we can have 900 cases analyzed. That will give us better information in terms of things that happen frequently and infrequently. Maybe there is a near miss that happens once every 300 cases," Jarrett says.
The cost of the black box equipment is $100,000 per OR.
How Northwell uses black box technology in operating rooms
At Northwell, all black box data collected in an OR is de-identified, he says.
"It's the team approach that we look at. Everything is de-identified. The cameras blur out the faces of the OR team members. The purpose is to look for system issues—not individual people issues. That was important because one of the fears of people was having Big Brother watching over them. We are not looking to get anyone in trouble. What we are looking for is system issues that we can correct to protect the patients. It's about taking a proactive approach based on the data."
De-identifying the data also protects patient privacy, Jarrett says.
Taking a team approach for analysis of OR Black Box data is a key element of capitalizing on the new technology for OR performance improvement, he says.
"Outcomes are not totally dependent on the surgeon. They are also dependent on the interplay between all the nurses in the room, the anesthesiologist, the problems that occur no matter how good the surgeon is, and how those problems are addressed. All those things can be looked at because the technology uses digital algorithms much like a black box in a plane."
Northwell is also generating surgical technique and teaching gains from the black box technology, Jarrett says.
"When we do the analysis of the video for technique, we can give scores for it and we can show what happened. We can use this information at conferences to show how a surgeon approached a problem and achieved a great outcome. So, you can use this information for teaching. For residents who rotate into a service for four months, you can see whether there is improvement in performance or not to assess the quality of the teaching program."
And the black box technology is well-suited to analyzing adverse events, he says.
"Adverse outcomes can occur even when nobody does anything wrong—it can be the anatomy of the patient. However, when we analyze the surgery, we can ask whether there was any way to anticipate the anatomy was different than expected and how the situation was addressed. Was it addressed in a timely fashion? Did the surgeon communicate that there was a problem and what was needed to address it? Was all the right equipment in the room?"
Jarrett says "it's too early in the game" to measure the impact of OR Black Box at Northwell, but the pilot program is focusing on an area for improvement—distractions. "There are a lot of distractions in the OR. Not all of them are bad, but there are more distractions than we realized, which is one of the reasons we are studying their impact."
A major distraction identified in analyzing the black box data is people leaving and entering the OR, he says.
"Some people go out of the room for breaks, some people go out of the room to get special equipment, but the question is do we need to have that happening all the time? We may want to limit people going in and out of the OR, and the black box technology can tell us whether that kind of a rule makes a difference. We want to base decisions about our protocols on real data rather than assumptions."
Adapting to black box technology
The OR teams that have worked with OR Black Box have acclimated to the technology, Jarrett says. "Now that we have been doing this for a year, the first team performs like it doesn't even know the black box is there. They turn it on at the beginning of a case, turn it off at the end of a case, and work as if it wasn't even there. They get used to it."
Northwell is considering whether to install the black box technology at more hospitals in the health system, and several other U.S. health systems are contracting for OR Black Box with Surgical Safety Technologies this year, he says.
CareMore Health's care management program in Tennessee has multidisciplinary care teams with community health workers, primary care providers, and social workers.
A care management program in Tennessee for high-need, high-cost Medicaid patients reduces healthcare service spending and healthcare utilization, research published this month indicates.
"Superutilizer" patients account for a disproportionate share of healthcare spending in the United States, with earlier research finding that 5% of the country's population accounts for 50% of annual healthcare expenditures. A study published last month by New England Journal of Medicine stirred controversy about care management programs for superutilizer patients—finding that the Camden Coalition of Healthcare Providers "hotspotting" program did not reduce hospital readmissions.
The research published this month, which appears in American Journal of Managed Care, features a care management program for Medicaid patients conducted by CareMore Health in Memphis, Tennessee. The lead author of the CareMore research told HealthLeaders that the NEJM study is a reminder that there is no silver bullet for hotspotting, but he said care management for complex patients should continue.
"The results from our evaluation of CareMore’s complex care management program suggest that carefully designed and targeted programs can improve care and reduce spending for high-need, high-cost patients. Hopefully, this results in a more optimistic view on the potential of hotspotting, and spurs continued work to develop care models that better serve our most complex patients," said Brian Powers, MD, MBA, director of population health strategy and analytics at CareMore.
CareMore research data
The CareMore care management program was staffed with a multidisciplinary team including a community health worker, a social worker, and a primary care provider.
The community health worker conducted patient accompaniment, activation, engagement, and outreach. The social worker conducted counseling and brief interventions for patients with behavioral health needs and coordinated referrals to social service agencies and other medical providers. The PCP conducted comprehensive care for acute and chronic conditions as well as coordination with specialists and inpatient clinicians.
The CareMore research examined data collected from nearly 200 Medicaid patients, with 71 assigned to the care management program and 127 assigned to usual care over a year-long period. The research includes several key data points:
Compared to patients receiving usual care, care management program patients had significantly lower total medical expenditures ($7,732 lower per member per year)
Care management program patients had 3.46 fewer inpatient bed days per member per year
Care management program patients had 1.35 fewer specialist visits per member per year
"A complex care management program reduced spending and inpatient utilization among high-need, high-cost Medicaid patients. Patients randomized to complex care management had [total medical expenditures] that were 37% lower than those randomized to usual care, an absolute reduction of $7,732 per patient per year. This spending reduction appeared to be driven primarily by decreases in inpatient utilization—bed days were reduced by 59% and admissions by 44%," Powers and his co-authors wrote.
Keys to care management success
Powers told HealthLeaders that CareMore's hotspotting program has four essential elements.
Target the right patients: CareMore's care management program used predictive models, claims data, clinical criteria, and clinician judgment to identify "rising risk" populations and those most likely to benefit from complex care management, rather than focusing on historical "superutilizers" whose care needs and spending often regress to the mean.
Incorporate non-traditional healthcare staff such as community health workers: CareMore's hotspotting program underscored the important role that community-based, non-medical team members play in engaging patients, building trust, and better understanding and managing the non-medical drivers of poor outcomes. For example, the community health worker served as an engagement specialist, creating a safe and welcoming environment for patients and utilizing their training to increase patient motivation and activation. The community health worker also functioned as the engaged family member that many patients lacked.
Integrate within the clinical team: The care management program was built into an existing medical home model. This removed barriers for collaboration and coordination between the community health worker, social worker, and primary care physician. It also allowed the care team to simultaneously address the medical and non-medical drivers of poor outcomes, rather than approaching each in a siloed fashion.
Focus on the most impactable drivers of poor outcomes: The hotspotting program tailored complex care management to the needs of individual patients rather than using a one-size-fits-all approach. For each patient, the care team identified and prioritized patients' unique drivers of poor health and high costs, with a focus on the drivers that mattered most to the patient and those that could be addressed over the course of weeks and months. This was essential for improving efficacy and efficiency.
A new study finds that female and minority medical students face significantly higher rates of mistreatment compared to male and white students.
Women, racial and ethnic minorities, and sexual minorities bear a disproportionate share of medical student mistreatment, new research shows.
In medical school, mistreatment of students includes a range of actions such as assault, discrimination, sexual harassment, and verbal abuse. Mistreatment has been linked to several negative consequences, including alcohol abuse, burnout, depression, and medical student attrition.
The new research, published today in JAMA Internal Medicine, suggests that mistreatment of women, racial and ethnic minorities, and sexual minorities in medical school impacts not only the quality of education but also efforts to boost diversity among physicians. "This differential burden of mistreatment may have substantial implications for the medical school learning environment and the diversity of the physician workforce," the research co-authors wrote.
The research is based on data collected from the 2016 and 2017 Association of American Medical Colleges Graduation Questionnaire. The AAMC Graduation Questionnaire is administered annually to all 140 accredited allopathic medical schools in the country.
The researchers analyzed 27,500 graduation questionnaires, which represents 72.1% of medical school graduates in 2016 and 2017. More than one-third of survey respondents reported experiencing at least one type of mistreatment. The most common form of mistreatment was public humiliation, which was reported by 21.1% of survey respondents.
Student mistreatment data
The JAMA Internal Medicine study generated several key data points.
1. Mistreatment by sex:
More female students reported at least one episode of mistreatment compared to male students (40.9% vs. 25.2%)
More female students reported public humiliation compared to male students (22.9% vs. 19.5%)
More female students reported unwanted sexual advances compared to male students (6.8% vs. 1.3%)
More female students reported a higher rate of gender-based discrimination compared to male students (28.2% vs. 9.4%), including being denied training opportunities and receiving lower evaluations
2. Mistreatment by race or ethnicity:
Among white students, 24.0% reported experiencing mistreatment. Reported rates of mistreatment were higher for Asian (31.9%), underrepresented minority (38.0%), and multiracial (32.9%) students.
Among white students, 3.8% reported discrimination based on race or ethnicity. Reported discrimination rates were higher for Asian (15.7%), underrepresented minority (23.3%), and multiracial (11.8%) students.
Among white students, 0.7% reported receiving low evaluations because of race or ethnicity. Reported rates of low evaluations because of race or ethnicity were higher for Asians (5.0%), underrepresented minorities (9.6%), and multiracial (3.4%) students.
3. Mistreatment by sexual orientation:
Nearly twice as many lesbian, gay, or bi-sexual (LGB) students reported an episode of mistreatment compared to heterosexual students (43.5% vs. 23.6%)
More LGB students reported being publicly humiliated than heterosexual students (27.1% vs. 20.7%)
More LGB students reported being subjected to unwanted sexual advances than heterosexual students (7.7% vs. 3.7%)
More LGB students reported discrimination based on sexual orientation than heterosexual students (23.1% vs. 1.0%)
More LGB students reported receiving lower evaluations based on sexual orientation than heterosexual students (4.0% vs. 0.3%)
Data interpretations and implications
The study's data reveals trends in the mistreatment of medical school students, the co-authors wrote. "The major findings of our national study include not only a high prevalence of medical student mistreatment but also differences in the prevalence of mistreatment by student sex, race/ethnicity, and sexual orientation," they wrote.
The data also demonstrate that several inappropriate behaviors are common in medical school, the co-authors wrote.
"These reported behaviors include, but are not limited to, unwanted sexual advances (6.8% of female students and 7.7% of LGB students), lower evaluations secondary to bias and discrimination (6.8% of female students and 9.6% of underrepresented minority students), and being subjected to sexist or bigoted comments (24.3% of female students, 18.9% of underrepresented minority students, and 21.8% of LGB students)."
The data indicate several disturbing implications, they wrote.
"The differential treatment reported by medical students in this study suggests a noninclusive learning environment, which could have profound implications for the well-being and academic success of students. … Another concerning negative experience reported by students was missed opportunities or lower grades because of discrimination. These experiences may have incremental consequences as trainees advance through their medical careers."
Medical schools can take actions to combat mistreatment of students, the co-authors wrote. "Potential interventions include implicit bias and bystander intervention training, better protections for individuals who have been subjected to and report instances of bias and discrimination, and greater transparency in policies for reporting and remediating instances of bias and discrimination."
New research findings are a step forward in understanding the harms and benefits of screening for dementia in the primary care setting.
Screening for Alzheimer disease and related dementias (ADRDs) in the primary care setting does not harm patients as measured by prevalence of depression and anxiety, recent research shows.
Primary care clinicians provide the most care to older adults, and at least half of primary care patients afflicted with ADRDs are never diagnosed with the conditions. For patients who do receive an ADRD diagnosis, the determination is often made two to five years after the onset of symptoms, which limits the benefits of early detection such as reducing family burden.
The recent research, which was published in the Journal of the American Geriatrics Society, examined data collected from 4,005 primary care patients over age 65. Half of the patients were screened for ADRDs and the other half served as a "no screen" control group.
"This is the first randomized controlled trial to evaluate the benefits and harms of population screening for ADRD among asymptomatic patients attending primary care. Our trial demonstrated no harm from screening, as measured by depressive and anxiety symptoms," the research co-authors wrote.
Research data
To assess harm to patients, prevalence of depression was measured with the Patient Health Questionnaire-9 (PHQ-9) and prevalence of anxiety was measured with the Generalized Anxiety Disorder seven-item scale (GAD-7). Assessment of benefits to patients included data collected for health-related quality of life (HRQOL).
The assessments generated several key data points:
At baseline for the ADRD screened group and the control group, the scores for the PHQ-9 and GAD-7 assessments were similar.
At one month, six months, and 12 months for the ADRD screened group and the control group, the mean scores for the PHQ-9 and GAD-7 assessments remained similar.
At baseline for the ADRD screened group and the control group, the mean HRQOL score was similar.
At 12 months for the ADRD screened group and the control group, the mean HRQOL score remained similar.
"We were unable to detect a difference in HRQOL for screening for ADRD among older adults. We found no harm from screening measured by symptoms of depression or anxiety," the researchers wrote.
Interpreting the data
The research is a significant contribution to the debate over whether ADRD screening should be standard practice in the primary care setting, the lead author of the study told HealthLeaders.
"The results from this study are some of the first to show that screening for dementia does not increase harm for patients, as measured by an increase in depression or anxiety. They get us a step closer to determining if screening for dementia should be part of routine care for older adults," said Nicole Fowler, PhD, an assistant professor of medicine at Indiana University School of Medicine in Indianapolis, and a research scientist at the Regenstrief Institute in Indianapolis.
Fowler said her research team is examining whether other harms may be linked to ADRD screening in the primary care setting. "For example, how does early detection of dementia via screening impact the older adults' family members who might be in a position to be a caregiver?"
More research is also required to determine the benefits of ADRD screening, she said. "This study measured benefits of screening using measures of health-related quality of life, healthcare utilization, and creation of new advance care plans. We did not find benefits among these measures. But the caveat is that only 66% of the people who screened positive sought follow-up testing to determine if they had ADRD, and if so, received collaborative care."
Future research on the benefits of ADRD screening need to account for essential actions after screening, Fowler said. "To truly determine benefit of screening, we need to ensure that screening is coupled with appropriate diagnostic follow-up and care for the patients and family."
A recent New England Journal of Medicine study is "not an indictment against all care management and care coordination programs," Camden Coalition's CEO says.
Despite the recent publication of a research article that generated disappointing results about its care management program for "superutilizer" patients, the Camden Coalition of Healthcare Providers is continuing its commitment to serve a complex patient population.
The Camden Coalition's "hotspotting" program targets complex patients with comorbidities and social needs. These kinds of superutilizer patients account for a disproportionate share of healthcare spending in the United States, with earlier research finding that 5% of the country's population accounts for 50% of annual healthcare expenditures. Programs such as the Camden Coalition's care management initiative are designed to help reduce these healthcare costs.
The recent research, which was published in the New England Journal of Medicine, assessed the hospital readmissions impact of the Camden Coalition's hotspotting program from 2014 to 2017.
The randomized, controlled trial featured 800 patients split evenly between participants in the Camden Coalition's care management intervention and a control group receiving usual care. The study found that the 180-day readmission rate for the intervention group was 62.3% compared to a 61.7% rate for the control group.
The Camden Coalition's care management intervention focuses on the 90-day period after hospital discharge. The program is staffed by a multidisciplinary team that includes community health workers, health coaches, registered nurses, and social workers. The team conducts several interventions such as connecting patients with social services, medication management, self-care coaching, and coordinating follow-up care.
Camden Coalition of Healthcare Providers CEO Kathleen Noonan, JD, recently spoke with HealthLeaders about the Camden, New Jersey–based organization's perspectives on the NEJM study. The following is a lightly edited transcript of that conversation.
HealthLeaders: What is your reaction to the NEJM study's finding that your hotspotting program had no effect on hospital readmissions?
Noonan: It's clear to us that there is still a lot to learn in this area. We don't think that there is a clear-cut solution for how to reduce utilization and costs for this very complex population. And because our healthcare and social service systems are siloed—and accessing services from either is complicated and difficult—we found that accessing the services that our population needed was difficult even with a skilled team.
We were dealing with issues of poverty, racism, and disinvestment that were front-and-center for our patients. Sometimes, these issues were even more front-and-center than the health issue that brought them into the hospital. So, the healthcare intervention that was trying to connect patients to social services within a 90-day time period was not sufficient.
You have to remember that this study was done between 2014 and 2017. If you did an Internet search of the phrase social determinants of health during that period, you would see it far less often than you would see it in the past couple of years. The changes that have occurred since 2017 have built up the ecosystem that is trying to connect health and social services.
HL: What lessons have you learned from the NEJM study?
Noonan: Our main lessons are that extreme hospital and emergency room over-utilization is driven by the patient's complexity and the inability of any one system to manage that complexity. What we are doing now is working with others across the country who are also trying to build new care models that can respond to the needs of complex patients.
We also are trying to figure out how to catch patients earlier. There is a lot of terrific work being done in predictive modeling and how to find complex patients earlier.
While we didn't reduce readmissions in the study, we did see an increase in SNAP participation in the intervention group, which is a promising outcome since food insecurity is a key social determinant—something we see in Camden over and over again. Many of our local hospital partners are responding to this need, with the development of food pantries, food prescriptions that are connecting patients to nutritionists, and other supports.
HL: Is Camden Coalition going to re-evaluate its hotspotting program?
Noonan: Before, during, and after the study, we have been learning about the patients and adjusting the hotspotting model. The authors of the study recognized that they knew that the Camden Coalition was going to modify certain parts of the intervention, so the examination of the intervention looked at the average effect of the program.
One thing we did two years into the study was to create a housing program called Housing First. We knew that it is difficult for us to help a patient when there is homelessness or severe housing instability. That's one change we made.
Another change we made that we were not able to get off the ground during the study period was the creation of a medical-legal partnership. For many of our patients, we found they faced difficulties because of civil cases or barriers to benefits that we needed legal help to resolve. We are now partnered with Rutgers Law School, and we have two lawyers who work with the care team. This has helped us to quickly deal with legal issues that our care team did not have the expertise to address.
We have also worked locally to support the development of medication-assisted treatment. We've worked at the state level with partners to waive prior authorization for medication-assisted treatment.
We are trying to look at the whole system around these patients and to work at the levels of care intervention, healthcare providers, and policy to make changes that can respond to some of the barriers identified during the study.
HL: How much more work do you have to do to perfect a care management model for complex patients?
Noonan: Now that the study's data has been published, we are continuing to analyze the data in partnership with the Abdul Latif Jameel Poverty Action Lab at MIT and Rutgers University, so we can understand more about sub-populations and promising trends. We are going to use that analysis to guide us through the demographics—and the health and social history—of this population to target patients better.
There was a broad population that was included in the study, from 18 to 80 years old. So, we are trying to understand different trends for different parts of the population.
HL: What advice can you offer to other healthcare providers that have launched hotspotting programs?
Noonan: The study's results make a significant contribution to the field. But it is important to consider what the results do not say. The results are not an indictment against all care management and care coordination programs.
Other studies have shown positive results, but the populations for those studies were older and predominantly Medicare populations. The NEJM study noted that our patients had much higher levels of complexity at baseline. We don't want other healthcare providers to think that the core elements of care management have been proven ineffective. That's not the case.
Angela Shippy shares her perspectives on quality improvement and C-suite leadership skills.
Angela Shippy, MD, is eager to apply her clinical and administrative experience in an expanded role at Memorial Hermann health system.
For the past five years, Shippy has served at the chief quality officer at the Houston-based health system. She has been promoted to senior vice president, chief medical officer, and chief quality officer.
Prior to joining Memorial Hermann, she was HCA Healthcare's Gulf Coast Division chief medical officer. Before working at HCA, Shippy was vice president of medical affairs at St. Luke's Episcopal Hospital, an affiliate of Houston-based Texas Medical Center, where she also practiced as a hospitalist.
Shippy recently shared her perspectives on the CMO and chief quality officer roles with HealthLeaders. The following is a lightly edited transcript of that conversation.
HealthLeaders: How will your experience as chief quality officer help you in your new role as CMO?
Shippy: There are a couple of different ways. First, as a chief quality officer you interact with everyone, you collaborate on projects, and you help to prioritize. We have strategic initiatives that are ongoing, so it helps me to continue to make connections on those initiatives.
Second, quality is involved in everything we do—particularly providing care to patients. The same could be said of the chief medical officer role. There are opportunities to be involved in multiple different aspects of the clinical care that we deliver.
HL: Give one or two examples of quality initiatives that you led as chief quality officer.
Shippy: Over the past six years, one of the key changes at Memorial Hermann from a quality standpoint is we went from an emphasis on process measures to outcome measures. Early on in value-based purchasing, the emphasis was on whether you were doing particular interventions. For example, you could check the box for heart failure if you gave an ACE inhibitor or did an echocardiogram.
Where we have been evolving over the past six years is to actual outcomes. So, if you are doing all of the processes properly, you should see outcomes such as decreased readmissions or decreased mortality. We have been working toward hardwiring processes, so we know the outcomes are good for patients and patients are able to take care of themselves outside of our acute interventions.
We also have been working outside of clinical areas to make sure that we have quality improvement methodology for operational areas. We have been identifying waste, we have been standardizing processes, and we have been sustaining changes once we have made them. We have been taking principles we use in clinical areas and helping operational colleagues and departments use those principles for their improvement.
HL: What aspects of your career best prepared you to work in C-suite roles?
Shippy: As a resident, I used to moonlight in the emergency department quite a bit. One of the hardest things to do there is to call one of your colleagues to admit a patient. So, very early on, I learned to completely assess a patient, to conduct all the testing that was needed, and to be able to succinctly present that patient to colleagues so they could understand the necessity to admit the patient. That teaches you how to put information together and put it in a format that other people can understand.
As a practicing hospitalist, I had the opportunity to interact with every member of the medical staff and every specialty. When you are taking care of patients who come through the ED, some are very ill, and you have to tap into your colleagues at all times of the day. So, you understand how the hospital works at 8 a.m., 8 p.m., and 2 a.m. You learn about the staff outside of the clinical staff that you have to deal with to make sure the patients get the care that they need. Having those interactions gives you a unique perspective on how to activate people and get things done.
HL: What are the essential leadership skills to be a successful CMO?
Shippy: To be a successful CMO, you have to understand that clinical skills and that background initially led you on the journey to get to the C-suite; but, ultimately, you need to have the ability to lead, collaborate, and inspire across multiple disciplines and across the entire organization.
In healthcare, you also must understand that caring for the patient is a team sport and the same can be said for administrative roles. You are never doing the work alone—it is a group of people coming together to provide the best outcomes or the best results.
The opportunity to be a chief medical officer is truly an honor for anyone who started their career as a practicing physician. It is an opportunity to take your clinical skills and combine them with what your organization wants to do from an operational standpoint to deliver the best possible care for patients.
In the largest-ever study of Medicare sepsis data, the increased rate of beneficiaries hospitalized with sepsis is nearly double the increased rate of enrollment in Medicare.
The largest sepsis study every conducted with Medicare data found a 40% increase in the rate of Medicare beneficiaries hospitalized with the deadly infection from 2012 to 2018.
Sepsis is diagnosed in at least 1.7 million adults annually in the United States, according to the Centers for Disease Control and Prevention. About 270,000 Americans die from sepsis every year, and 1 in 3 patients who die in hospitals are diagnosed with sepsis, the CDC says.
The new study was conducted by researchers from the U.S. Department of Health and Human Services. The journal of Critical Care Medicine has published the research in three articles:
"We were astonished by the study's results. To save lives in public health emergencies, we must solve sepsis. The findings of this study have implications not only for patient care, particularly after patients are discharged, but also for investments by industry, non-government organizations, and government agencies," Rick Bright, PhD, a study co-author, DHHS deputy assistant secretary for preparedness and response, and director of the Biomedical Advanced Research and Development Authority, said in a prepared statement.
Research data
The study features several key data points:
From 2012 to 2018, the annual number of fee-for-service Medicare beneficiaries with an inpatient hospital admission and a sepsis diagnosis increased from 811,644 to 1,136,889.
During the study period, the total annual cost of inpatient hospital admissions among fee-for-service Medicare beneficiaries increased from $17.8 billion to $22.4 billion.
The total annual cost of skilled nursing facility (SNF) care for fee-for-service Medicare beneficiaries in the 90 days after a hospital inpatient discharge with a sepsis diagnosis increased from $3.9 billion to $5.6 billion.
For Medicare Advantage beneficiaries with a sepsis diagnosis, the total annual cost of inpatient admissions and SNF care increased from $6.0 billion to $13.4 billion.
The total annual cost for fee-for-service Medicare and Medicare Advantage beneficiaries with an inpatient admission for sepsis and SNF admission increased from $27.7 billion to $41.5 billion.
The study includes a conservative forecast for sepsis care costs in 2019 for all Medicare beneficiaries and private payer patients. Last year, the cost of sepsis care for inpatient admissions and SNF admissions for these patients was estimated at more than $62 billion.
The 6-month mortality rate among fee-for-service Medicare beneficiaries with an inpatient hospital admission was about 60% for septic shock (the most serious form of sepsis) and 36% for severe sepsis.
The 40% increase in the rate of Medicare beneficiaries hospitalized with sepsis from 2012 to 2018 cannot be accounted for fully by increased Medicare enrollment, which rose 22% during the study period.
Interpreting the data
The total cost of sepsis care is significantly higher than earlier estimates, according to the DHHS study.
A highly cited study published in 2016 estimated the cost of all acute hospital inpatient care for sepsis in 2013 was $23.7 billion. The DHHS study was limited to Medicare beneficiaries, who accounted for 61.5% of the patients in the 2016 study. So, the earlier study estimated the total cost for inpatient care among Medicare beneficiaries at about $15 billion.
"We observe that the projected 2019 cost of inpatient sepsis care alone (not including SNF) for Medicare FFS beneficiaries alone (not including Medicare Advantage) is $23.5 billion," the DHHS study co-authors wrote.
The study provides new insights for the cost of sepsis care and the public health response necessary to address sepsis, they wrote.
"We now know the actual national expenditures for sepsis to far exceed widely cited contemporary estimates. The question is 'exceed by how much?' Answering this question requires new public-private partnerships that harmonize definitions of sepsis, that facilitate internal analyses and preparation of comparable summary data, and above all that promote the sharing of those summary data into the public space. Only when we understand the burdens, the trajectories, the predispositions, and the costs of sepsis can the nation fairly and prudently allocate the resources necessary to solve sepsis."
Sepsis is a significant burden on Medicare beneficiaries, their families, and the Medicare program, the DHHS study co-authors wrote.
"The human and economic burdens of sepsis experienced by Medicare beneficiaries continue to grow. Although there are improvements in mortality and in cost-per-case throughout a pragmatic hierarchy of sepsis severity, the year-over-year growth of the beneficiary population, the year-over-year increase in the total number of sepsis deaths, and the year-over-year increase in the total cost of sepsis care highlight the need to understand how beneficiaries become septic, their clinical courses once septic, and how sepsis survivors fare following discharge from the acute care hospital," they wrote.
Prevention and early detection of sepsis are critically important, the study co-authors wrote.
"Those strategies, which likely will require innovation in public health as well as improving individual immunoinflammatory health, are among the most promising strategies toward protecting populations and saving lives. Once sepsis is established, improving the immediate postsepsis trajectory—either by actions during the inpatient hospitalization or by actions during and after transfer to a facility offering prolonged care—appears to be an essential step toward value-based transformation of sepsis care."
Cost containment is a common theme of most trends that are expected to affect medical practices over the next 10 years.
The Medical Group Management Association (MGMA) has identified six trends that are likely to have a major impact on medical practices over the next decade.
MGMA, which is based in Englewood, Colorado, has about 55,000 members nationwide. The new trends report was produced by the organization's government affairs staff.
Cost containment is a common theme in most of the trends, Anders Gilberg, MGA, senior vice president of government affairs at MGMA, told HealthLeaders.
"The Medicare and Social Security trust funds are being quickly depleted. Short of full entitlement reform, which is fraught with political consequences, policymakers will look toward leveraging new technology and data and focusing on prevention as necessary first steps at bending the cost curve in healthcare. Medical groups are well positioned to take advantage of this trend," he said.
1. Ambulatory care ascendency: Changes in government and payer policies are expected to generate gains for medical practices relative to hospital-based care settings. For example, the federal government is likely to end payment differentials for outpatient settings that currently favor hospital-based sites.
"Clinical innovation and technological developments will continue to expand the types of services that can be performed in non-facility settings. With greater transparency, no one will be willing to pay the current mark-up on facility-based ambulatory care. The balance of power will shift toward group practices as payers realign incentives and facilities struggle with greater overhead and fixed costs," the MGMA trends report says.
2. Emphasis shifts from treatment to prevention: For decades, medical care has focused more on treatment than prevention. Several factors are promoting prevention in this decade, including telemedicine, chronic care management, and new payment models that do not put a premium on face-to-face patient visits.
"Data are beginning to show that services like chronic care management not only improve patient outcomes but save money in the long run. Expect to see greater alignment between reimbursement policy and preventative care, including non-traditional services like telemedicine. Primary care specialties will be obvious beneficiaries of this shift toward prevention," the trends report says.
3. The data decade: Data collection such as the widespread adoption of electronic medical records was a dominant data trend of the last decade. Efforts to harness data such as establishing interoperability, creating electronic decision-making tools, and applying data to precision medicine are likely to dominate the next decade.
"With effective population-based analytics, data will help practices with financial modeling and allow for more risk-based contracting or participation in advanced alternative payment models (APMs). As Medicare and commercial payers shift risk to physicians, group practices should prepare to monitor patient costs, measure outcomes, and improve population health," the trends report says.
4. Medicare Advantage edge: Regardless of healthcare reform efforts in the next decade, Medicare Advantage is likely to continue to expand. In the last decade, Medicare Advantage enrollment nearly doubled.
"The growing Medicare Advantage market could present new challenges and complexities for group practices stemming from non-standardized payment and administrative policies. It will also shift more power in the hands of private plans and exacerbate some of the most frustrating policy issues of the day, such as the increased use of prior authorization," the trends report says.
5. Twists and turns in the value journey: The slow pace of the federal government's efforts to develop value-based care payment models is likely to continue, the trends report says. "Medicare's Innovation Center is 10 years old yet has been frustratingly slow in producing new APMs, and results from existing models have been mixed. The lag in APM development has left most physicians participating in the Merit-based Incentive Payment System (MIPS), where resources and time spent on reporting have outweighed small bonuses."
There is more hope for speedier adoption of value-based care payment models among commercial payers, the trends report says. "Private payers … have greater opportunity to pilot innovation. Through data sharing and analytics, technological tools, infrastructure support, and less bureaucracy, the private sector will be better positioned than the government to facilitate value-based payment reform over the next decade."
6. Price transparency: Lawmakers have already proposed to increase hospital price transparency and medical practices are likely to face pressure to reveal charges and negotiated service rates.
The push for price transparency involves several challenges, the trends report says. "Anti-trust and anti-competitive concerns will continue. Posting prices may seem like a quick fix but getting to the true upfront cost for patients will prove difficult. Ultimately, health plans are in the best position to inform patients about their coverage and out-of-pocket costs, and lawmakers will hold plans' feet to the fire alongside providers."
An intellectual giant played a large role in shaping the career of Neel Shah, MD, MPP.
Shah is making his mark in Boston, where he is an obstetrician-gynecologist at Beth Israel Deaconess Medical Center, an assistant professor at Harvard Medical School, director of the Delivery Decisions Initiative at Ariadne Labs, and board chair of Costs of Care. He is a self-described health systems scientist—a calling that started when he studied neuroscience at Brown University in Rhode Island.
"My interest in neuroscience came from following a person. When I was in college, there was a professor named Leon Cooper who was my advisor. He won the Nobel Prize in Physics in 1972 for the theory of superconductivity at a relatively young age, then [he] moved on. He decided he was going to study the brain, and he came up with a bunch of theories about the brain that revolutionized the field," Shah says.
"Professor Cooper was an audacious thinker. For every young person, there is someone who believes a better world is possible, and he was that person for me. He was a mentor who taught me to think about systems because the brain is a complex system."
Healthcare reform advocate
Shah cofounded Costs of Care—a nongovernmental organization dedicated to providing better healthcare at lower cost—a decade ago.
"When we started, Costs of Care was focused on transparency. Abraham Verghese has a wonderful quote: 'If you are ordering off a menu with no prices, it's easy to get the filet mignon every time.' We wanted to put prices on the healthcare menu because there were brand-new clinicians clicking on a mouse who were spending tens of thousands of dollars without even knowing it," he says.
"Now, we have moved beyond transparency, which is important, but there are multiple failures at the point of care that are preventing people from accessing affordable, safe, dignified care. We can't tell people what services cost. We often don't tell patients whether a service is worthwhile to begin with. Then, when services are worthwhile and expensive, we are not deploying all of the resources to make sure that patients can comply with our recommendations."
Pursuing innovation
At Ariadne Labs—a joint healthcare innovation center of the Harvard T.H. Chan School of Public Health and Brigham and Women's Hospital, Shah has played a leadership role in the Team Birth Project. The initiative seeks to revolutionize the relationship between pregnant women, their families, and their healthcare teams to boost childbirth outcomes.
"The Team Birth Project is a large-scale experiment across the country that is trying to get clinicians and families on the same page to achieve more appropriate, safer, and more affordable care," he says.
Shah says even though he has always been "a little bit of a generalist," he gravitated toward the field of OB-GYN. He says that as he's spent more time in the field, it's become more personal for him. "I have a family of my own, and one of the things I have realized is that the period when you are growing your family from pregnancy to parenting an infant is a universal period of vulnerability. There are a lot of opportunities to make our systems of support and care better."
Perspectives on healthcare
Following are highlights from a conversation between Shah and HealthLeaders where he shares his perspectives on obstetrics-gynecology, value-based care, medical entrepreneurship, and health systems science.
"In childbirth, the main way we think about quality is the absence of injury. The absence of injury is good, but most women have goals beyond escaping unscathed from the process. Survival is the floor of what they are expecting and what they deserve. If we are going to design a better system, we should be aiming for the ceiling, but we haven't figured out what that looks like."
"Nobody goes to medical school thinking about GDP, but Americans have the least affordable healthcare compared to a half century ago. So, for the longest time of taking care of people, the ethic in U.S. medicine has been thoroughness rather than appropriateness. Thoroughness is a good goal, but appropriateness is a better goal."
"In the quest for thoroughness, 50 years ago there were only a handful of causes of chest pain; now, there are thousands. You literally cannot test for all of them—it's not efficient, it costs people a lot of money, and it can even be harmful to over-test. So, that's why appropriateness is important. We must find out how to deliver healthcare affordably for every American."
"The best models are the ones that put a contingency on payment over and above having simply provided a service. Any of those models are better than testing for something, drawing blood, or poking you with a sharp object, then billing for it irrespective of the outcome. That clearly is a crazy system. There is no other sector of the economy or other industry where that would be OK. There's no other area that tolerates the kind of paternalism or opacity that behavior requires."
"The mission of Ariadne Labs is trying to figure out how we can drive improvements at scale in healthcare. It's kind of the opposite of Costs of Care in some ways. Costs of Care is focused on catalytic, breakthrough innovations. Ariadne Labs is based on the recognition that the dominant cause of suffering in the world is not necessarily lack of knowledge—it's lack of execution. It's about fixing execution failures in a way that works in multiple settings across the world."
"It's 100% entrepreneurship in my mind because there's a vision, a commitment to realize that vision, and there's an ROI that is not necessarily cold, hard cash. It's more about making an impact. It's the same mindset and the same process as entrepreneurship. The things I invent are not widgets or artificial intelligence—the Team Birth Project has a totally analog whiteboard as a key tool. You write with a dry-erase marker, but it is fundamentally changing the way people experience care."
Pictured above: Neel Shah, MD, MPP, is an obstetrician-gynecologist at Beth Israel Deaconess Medical Center; assistant professor at Harvard Medical School; director of delivery decisions initiative at Ariadne Labs; and board chair of Costs of Care. (Photo credit: Jason Grow/Getty Images.)
Since 1997, CVS Health and its subsidiary Aetna have invested more than $1 billion in affordable housing and other social needs.
Woonsocket, Rhode Island-based CVS Health invested $67 million in affordable housing last year and plans to invest $75 million in affordable housing this year, the company announced today.
Housing is considered as one of the leading social determinants of health (SDOH), along with other social needs such as transportation and food security. By making direct investments in initiatives designed to address SDOH and working with community partners, healthcare organizations can help their patients in profound ways beyond the traditional provision of medical services.
Last year, CVS Health supported affordable housing projects in 24 cities in California, Georgia, Hawaii, New Hampshire, Oregon and Texas, creating more than 2,200 affordable homes often with support services, the company reported. This year, CVS Health's plans to invest in affordable housing include $25 million in Ohio.
"Providing affordable housing options to people who are facing significant challenges can be their first step on a path to better health. However, we understand that more support is often needed—that is why we work with community organizations to provide access to services such as independent living skills, cooking and nutrition, financial literacy, health information classes, resident outreach and engagement, client-centered treatment plans, and social support," Karen Lynch, executive vice president of CVS Health and president of the company's Aetna Business Unit, said in a prepared statement.
CVS Health and healthcare insurer Aetna merged in 2018. Since 1997, CVS Health and Aetna have invested more than $1 billion in affordable housing and other social needs. The two-decade effort has supported the construction or renovation of more than 93,000 affordable rental units, the company reported.
Affordable housing investments in The Golden State
California has been a primary focus of CVS Health's and Aetna's affordable housing efforts, Kristen Miranda, California market president for Aetna, said in a prepared statement.
"We have made more than $160 million of affordable housing investments in California over the past 20 years, including nearly $50 million in the past two years alone. These investments are helping to address the unique needs of residents in California, helping to improve health at both the individual and community level," Miranda said.
The investments in California affordable housing include four recent projects, the company reported:
This month, CVS Health is working in partnership with CREA LLC to close an $8.1 million deal to finance development of 85 affordable housing units. The project is in collaboration with East LA Community Corporation and New Directions for Veterans.
On Feb. 14, there will be a grand opening of Sequoia Commons in Goshen, California. The 66-unit low-income community received funding from CVS Health, the California Department of Housing and Community Development, the Federal Home Loan Bank of San Francisco, Red Stone Equity Partners and Pacific Western Bank.
In December 2019, CVS closed on a $25 million commitment to an investment fund that will build or rehabilitate more than 500 affordable housing units in five California cities.
In November 2019, there was a grand opening of Bishop Street Studios in San Luis Obispo, California. The 33 permanent supportive housing units were established through the renovation of an abandoned orphanage and were funded by CVS Health, the Transitions-Mental Health Association, and the Housing Authority of San Luis Obispo. The affordable housing units are for individuals with mental health issues.
