Researchers call for early warning system to improve the care of cancer inpatients.
Several factors are associated with clinical deterioration of hospitalized cancer patients, with implications for patient monitoring, allocation of care resources, testing, and early warning systems, recent research shows.
Hospitalization is a leading contributor to cancer-related healthcare spending. Hospitalizations for cancer involve longer length of stay and higher costs than inpatient care for other conditions.
The recent research published in Journal of Oncology Practice was based on data collected from more than 21,000 hospital admissions at Barnes-Jewish Hospital in St. Louis. Clinical deterioration of cancer patients was defined as a composite of oncology ward death and intensive care unit transfers.
The research features several key data points:
Clinical deterioration of cancer patients was relatively common, at 9.2% of admissions
6.4% of cancer patients admitted to the hospital experienced at least one ICU transfer
2.7% of cancer patients admitted to the hospital died in an oncology ward
Factors associated with clinical deterioration included age, comorbidities, illness severity, emergency admission, bacteremia, and administration of antimicrobials and transfusions
The relatively high rate of clinical deterioration among cancer patients calls for an increased focus on high-risk patients, the researchers wrote. "Our findings suggest that inpatients with active cancer are at increased risk for clinical deterioration. This risk is particularly important, because prior work has shown that patients with cancer who develop critical illness may have worse outcomes than patients without cancer whose health deteriorates similarly."
Identifying cancer patients who are at high risk of clinical deterioration can generate significant care benefits, the researchers wrote. "Identification of patients on the wards before deterioration may offer the opportunity for interventions aimed to prevent ICU transfer, cardiopulmonary arrest, and death. Early intervention has been associated with improved short-term and long-term outcomes among patients with cancer whose health is deteriorating."
Early warning system
Cancer inpatients at high risk for clinical deterioration should be targeted for enhanced monitoring such as telemetry and differential vital sign monitoring, the lead author of the research told HealthLeaders. There are three reasons to establish early warning systems to monitor the health status of cancer inpatients, said Patrick Lyons, MD, a fellow in the Division of Pulmonary and Critical Care Medicine at Washington University School of Medicine, St. Louis, Missouri.
"First, their higher baseline risk means a well-performing early warning system would generate fewer false positive results, which are known to be harmful. Second, some literature suggests that subjective triage of oncology patients is uniquely challenging, so an objective risk prediction score might be able to help with triage. Finally, certain groups oncology patients—especially those with hematologic malignancies and recipients of stem cell transplants—commonly experience reversible deterioration, like sepsis, and ultimately recover good functional status. This suggests that some aspects of their critical illness might be modifiable if caught earlier," he said.
Lyons and his research colleagues are in the process of developing an early warning system for cancer inpatients, he said. "We are working to create an oncology early warning system and intend to test its performance, issues related to implementation and workflow integration, and ultimately patient outcomes. So, I am hopeful that our work will help develop a broad field of inquiry into how best to deliver inpatient care to such an important patient population."
Top areas where AI can have a significant effect on primary care include risk prevention and intervention, population health management, and device integration.
Artificial intelligence (AI) is poised to have a transformative impact on primary care, a recent journal article says.
AI technology is starting to be applied across the healthcare sector, including digital clinical decision support tools and natural language processing. With more than 500 million patient visits annually, primary care is a prime area for AI to have a revolutionary effect on healthcare.
"Primary care is where the power, opportunity, and future of AI are most likely to be realized in the broadest and most ambitious scale," the authors of the recent article in Journal of General Internal Medicine (JGIM) wrote.
The journal article identifies 10 primary care areas where AI is either already generating benefits or expected to gain traction.
1. Risk prevention and intervention: Potentially preventable medical conditions account for $1 in every $10 of hospital spending, so millions of hospital stays and billions of dollars in care costs could be avoided with better risk prediction and interventions in the primary care setting. For example, Phoenix-based Banner Health is using BaseHealth AI technology to predict risk for 42 health conditions to reduce emergency room and hospital utilization through primary care interventions.
2. Population health management: AI has the potential to identify and close care gaps as well as to improve healthcare providers' performance in quality payment programs such as those established under the Medicare Access and CHIP Reauthorization Act of 2015. For example, IBM and Siemens have established a partnership to develop new population health tools for primary care clinicians using Watson Health AI technology.
3. Medical advice and triage: "AI doctors" can offer medical advice to patients who have common symptoms, which opens up primary care access for more complex cases. Examples of companies that have developed this AI technology include Babylon Health and HealthTap Inc. The JGIM article authors caution that AI doctors should not be deployed to supplant primary care physicians. "Rather than AI replacing real providers for some conditions, we believe that AI support can be integrated into team-based care models that make it easier for primary care physicians to manage a patient panel," they wrote.
4. Risk-adjusted paneling and resourcing: By setting panel sizes according to patient complexity, risk-adjusted paneling can help primary care physicians see patients in an efficient manner, which can boost patient satisfaction and curb physician burnout. For example, University of California-San Francisco is using electronic health record (EHR) data on healthcare utilization to train algorithms that assess primary care panel sizes.
5. Device integration: Nearly a quarter of Americans have wearable devices that collect health data such as vital signs, but this voluminous data is often unwieldy and incompatible with healthcare provider EHRs. AI technology such as Apple's HealthKit has the potential to tame this cumbersome treasure trove of wearable-device data.
6. Digital health coaching: Treatment of chronic illnesses account for most of healthcare spending in the United States, with the cost of care for diabetics alone estimated at more than $300 billion annually. Companies that have developed digital health coaching tools for diabetes, hypertension, and obesity include Glooko, Lark Health, Livongo Health, Omada Health Inc., and Virta Health Corp.
7. Chart review and documentation: EHR clinical documentation is a major factor in physician burnout, causing as much as $140 billion in annual lost physician time. Automatic speech recognition technology is being used at healthcare organizations including Pittsburgh-based UPMC, which has partnered with Microsoft to develop AI-powered digital scribes that can monitor patient-physician conversations and produce clinical notes.
8. Diagnostics: AI algorithms have made inroads for diagnosing several diseases, including skin cancer, breast cancer, colorectal cancer, brain cancer, and cardiac arrhythmias. When deployed in areas of the country that have shortages of medical specialists, these diagnostic technologies have the potential to expand the services provided by primary care physicians. For example, Iowa City-based University of Iowa Health Care is using IDx-DR to detect diabetic retinopathy.
9. Clinical decision-making: Several EHR companies such as industry leaders Epic and Cerner are adding AI to workflows to provide clinicians with digital clinical decision support tools. For example, Nashville-based HCA Healthcare has deployed an EHR-based clinical decision support tool called Sepsis Prediction and Optimization of Therapy (SPOT) that can detect sepsis about 18 hours earlier than the best clinicians.
10. Practice management: AI can automate repetitive clerical tasks that create administrative burdens at primary care practices For example, Olive uses AI technology to automate several clerical tasks, including insurance claims, prior authorizations, billing, and data reporting.
Keys to AI success in healthcare
Successful AI initiatives in primary care augment rather than subvert the physician-patient relationship, the lead author of the JGIM article told HealthLeaders.
"The key is to never lose sight of the patient-provider relationship as the single most important ingredient that makes everything else in healthcare possible," said Steven Lin, MD, vice chief and technology innovation medical director at Stanford Family Medicine, and executive director, Stanford Medical Scribe Fellowship, Division of Primary Care and Population Health, Stanford University School of Medicine, in Palo Alto, California.
"Technology like AI can help strengthen that relationship if it serves to free up providers' cognitive and emotional capacity to connect with their patients, such as relieving them of the burden of clinical documentation or supporting clinical decision-making to reduce decision fatigue," he said.
It is also crucial for healthcare organizations to try to ensure that primary care patients accept AI innovations, Lin said.
"Patients need to trust that AI is not replacing part of their care, and that they are still being cared for by human providers who know them and care deeply about them. AI should be introduced as an additional member of their care team, not replacing anyone already on it. AI should be invisible or in the background, helping human providers become more efficient and giving them more capacity for face-to-face time."
To remain financially viable, all health systems must generate a positive operating margin to reinvest in their organization, which can pose challenges to nonprofits from a mission perspective.
"There is natural tension with being a nonprofit and being able to maintain the organizational vitality to further our mission," says CFO Rob McMurray, MBA, CPA, of Wilmington, Delaware-based Christiana Care Health System.
While operating margin targets are in a "constant state of flux" depending on the capital needs of any given year, Christiana Care must generate a positive margin year to year, McMurray says.
"We know that we want to maintain a margin that will provide us with the resources to continue to invest in our infrastructure to deliver optimal services. And we need to continue to invest and develop the people who will lead us in our strategic aims as well as continue to invest in innovative tools and strategic partnerships. It requires a certain margin to do those things," he says.
The necessity to post a positive operating margin can be a hard sell to board members who are laser-focused on nonprofit status, McMurray says. However, Christiana Care's board recognizes the importance of both fulfilling the nonprofit mission and business needs. "We spend a lot of time educating the board and ensuring that we have a board with the proper level of sophistication to understand how our business strategies support our mission. It's critical."
Mary Ann Freas, senior vice president and CFO of Southwest General Health Center in Middleburg Heights, Ohio, says the financial reality of operating a hospital "muddies the water" at nonprofit organizations.
"I'm the CFO. I'm always worried about making sure we have the resources available to stay viable, to make sure we have a steady workforce, to have the ability to reinvest, and to do all the things that are necessary to maintain ourselves in perpetuity. I know that means my revenues must exceed my expenses."
"It gets fuzzy and it gets confusing trying to explain this to caregivers if I'm asking to cut their budget, or to live with the same budget they had last year. Reimbursement is not growing; if anything, it's flat or declining from year to year, so we have to become more efficient. Sometimes, it's a hard equation to articulate," she says.
Depending on patient volume, which varies from year to year, Freas says Southwest General sets an operating margin target from 2.5% to 4.0%. Meeting those targets can lead to hard choices and pointed conversations.
"Sometimes, I challenge some of the resources that clinical leaders want to bring on board. We can't be everything to everybody. There's more clarity in the for-profit world. They can say, ‘This is our business, and this is how we're going to do it.'"
Three strategies have helped Southwest General generate positive operating margins, says Freas.
First, Southwest General has a large outpatient footprint, including ambulatory facilities in Middleburg and Strongsville, Ohio, that feature physician offices and outpatient services. "That strategy has allowed Southwest to grow its outpatient revenues to a level that is nearly two-thirds of the total," she says.
Second, Freas says Southwest General's employed physician group has contributed to the organization's financial success. Third, Southwest General has made steady investments in new services such as hyperbaric wound care and outpatient physical medicine, she says.
Banking on growth
Growth has always been important at for-profit health systems because investors demand it, but growth has become equally essential at nonprofit health systems in recent years, says Paul Keckley, managing editor of The Keckley Report in Washington, D.C., and former executive director of the Center for Health Solutions at New York–based Deloitte.
"Even in a community where you are the only game in town, the declining reimbursement rates for your core services require you to find new sources of revenue to create any kind of operating margin," Keckley says.
While nonprofit and for-profit hospitals are engaged in the same fundamental activity—patient care—tax status leads to divergent approaches to strategy and governance.
Tax status is one of the most significant defining characteristics of U.S. hospitals. There are more than 5,200 nonfederal, short-term general, and other special hospitals in the country, according to the American Hospital Association. Nearly 3,000 of these hospitals are nonprofits, more than 1,300 are for-profits, and almost 1,000 are state and local government organizations.
"With the caveat that there is a wide range of nonprofits and the investor-owned hospitals vary from company to company, I have been involved in strategic planning for both, and there are substantial differences. You can't overstate the significance of the difference," says Paul Keckley, PhD, managing editor of The Keckley Report in Washington, D.C., and former executive director of the Center for Health Solutions at New York-based Deloitte.
HealthLeaders talked to several executives and representatives of nonprofit and for-profit healthcare organizations to learn about the three primary differences in strategy and governance between nonprofit and for-profit hospitals: relationships with the communities they serve, the level of leanness in their operating models, and the time horizon of their strategic plans.
1. Community-driven approach
Southwest General Health Center, which features a 350-bed nonprofit hospital in Middleburg Heights, Ohio, is literally rooted in the local communities it serves.
Six communities founded Southwest General in 1920 after a post–World War I flu epidemic, says Mary Ann Freas, senior vice president and CFO. "The residents had seen many of their neighbors die while they were being transported to the nearest Cleveland hospital."
The six communities raised $100,000 in 10 days and built a 32-bed hospital.
"Ever since, we have been invested in serving our local communities. It is reflected in our governance, and it is reflected in our strategic plan as well. You can have for-profits that move in and out of communities on the perception of whether the communities need them or not. At Southwest General, there is a specific governance structure in place to make sure that's never going to happen," Freas says.
Southwest General has two governing boards—a 34-member health system board and a 24-member health center board that focuses on the organization's hospital. Four trustees drawn from each of the six taxing districts dominate the health system board, which also appoints half of the members on the health center board. In each of the six communities, local delegates appoint three out of four of the health system board trustees that represent their city or town.
In addition to the 24 health system board trustees drawn from the taxing districts, there are eight at-large board members drawn from the local communities, the past president of the medical staff, and one medical staff physician.
"These board members are truly local. They may be local business leaders, school district superintendents, the local college president, and people … who have been involved heavily in fundraising for their local school system," Freas says.
The delegates are community leaders who play a vital role in keeping Southwest General a locally focused organization, she says. "Fifty-one percent of them have to approve any change to the code of regulations, and they only meet once a year. So, for them to be educated in terms of why we would want to make a change would be a challenge. It has been attempted—some minor things have gone through. But to put forth a wholesale change to our governance structure would be a very big undertaking."
The community-based governance has had an impact on the kind of services that Southwest General provides, Freas says.
"This structure preserves the community's interest in having their care local. If we have patients who need quaternary care, they are transferred to University Hospitals in Cleveland, with whom we have a partnership. But we have two surgical robots, we do open heart surgery, and we have radiation therapy. We have the full gamut of services, and we can provide a high level of care here in the community," she says.
In contrast, for-profit health system boards tend to be a blend of investor representatives and community leaders.
At Nashville-based HCA Healthcare Inc., a for-profit health system with more than 180 hospitals, the chairman of the board is Thomas F. Frist III, founder and managing principal of Frist Capital LLC, a Nashville investment firm.
Other members of the HCA board include Nancy-Ann DeParle, a partner at New York-based Consonance Capital Partners, a private equity firm that invests in healthcare companies. Charles O. Holliday Jr., chairman of Royal Dutch Shell PLC, which is headquartered in The Hague, the Netherlands, is also on the board.
Truman Medical Centers, a safety-net healthcare organization based in Kansas City, Missouri, is firmly linked to the communities it serves, says CFO Allen Johnson, CPA.
"We are more community-driven than a for-profit model, which is more driven by the ability to derive financial benefits to shareholders. Because we are more community-driven, our strategic plan is more oriented to community-based programs," he says.
For example, Truman Medical Centers has been entering into community partnerships to expand its primary care footprint. "We opened a new clinic that is connected to a community-based YMCA, and we are going to invest in another clinic with the YMCA," Johnson says.
In addition to local imperatives to be community-oriented, the Internal Revenue Service requires nonprofits to have a local focus in their strategic planning, Freas says.
"We are required to develop a community needs assessment, and we reference that assessment in our strategic plan. We have a whole section in that strategic plan centered on partnerships. This is to develop partnerships with other community entities—schools, businesses, and the taxing-district communities. We work together to target needs that have been identified in the assessment," she says.
2. For-profits' lean advantage
In the current era of declining or flat-leveled reimbursement from major payers such as Medicare, lean operating models are a distinct strategic advantage at for-profit healthcare organizations, says the leader of the investor-owned hospitals' national trade association.
"There is no question that the financial and revenue cycle aspects of the investor-owned sector hospitals is their sweet spot. They do a wonderful job in a complex environment. The companies we represent have generally found the balance between centralizing much of the paperwork for groups of hospitals, as well as making sure that the right kind of collection information and other tools are used at their individual hospitals. It has been an advantage for us," says Charles N. "Chip" Kahn III, president and CEO of the Washington, D.C.–based Federation of American Hospitals.
Cost-consciousness is a hallmark of for-profit health systems, Keckley says. "If you have a lower cost structure in this environment, it's an advantage. Period. And that tends to be an advantage that the investor-owned health systems have. In most markets, they operate cheaper."
One cost-conscious strategy pursued at for-profits is to shy away from offering tertiary and quaternary care in many markets, Keckley says.
"In some markets, you will find that the investor-owned hospitals have clinical programs like neonatal intensive care units, organ transplants, and burn units, but it's rare. That's because those programs tend to have operating losses. So, the cost structure at the investor-owned hospitals is typically lower because they tend to operate efficiently, they tend to buy in bulk with group purchasing muscle, and they don't do everything that many of the not-for-profits of the same or bigger size do," he says.
For example, Dallas-based Steward Health Care has adopted a community hospital-focused strategy in Massachusetts, essentially ceding tertiary and quaternary care to nonprofit competitors such as Boston-based Partners HealthCare, which features Massachusetts General Hospital as well as Brigham & Women's Hospital.
"There are four big payers in Massachusetts, and you have five big academic medical centers that were fighting among themselves. So, Steward had an interesting strategy," Keckley says.
There are examples of for-profits that buck this trend, Kahn says.
"Every market is different. Tenet has the Detroit Medical Center. HCA Healthcare has hospitals in Dallas that provide tertiary care. Beyond those Dallas hospitals, HCA Healthcare has a strategy across its hospitals to become the largest provider of graduate medical education in the country. This year, HCA has 4,000 residents," he says.
3. Short-term vs. long-term outlook
Compared to nonprofit health systems, for-profit organizations tend to have less tolerance for member hospitals that struggle financially, Keckley says.
"What's clear about the investor-owned world is they are in the asset management business, and when they can no longer generate a return on an asset, they will change. They will dispose of the asset, they will sell the company, or they will find another line of business. In the not-for-profit world, making bold changes is harder," he says.
Nonprofit health systems have more of a long-term strategic approach to struggling hospitals, says CFO Rob McMurray, MBA, CPA, at Wilmington, Delaware-based Christiana Care Health System.
"In a for-profit business, there is a greater focus on shorter- or nearer-term profitability. Whereas, in a not-for-profit organization, there is a greater focus on the long-term organizational vitality of the health system that is serving the community. As a result, the not-for-profit organizations are going to be more likely to accept short-term losses, with the understanding that there are going to be long-term positive benefits to the community," he says.
The long-term view prevalent at nonprofit health systems also applies to investment strategies, McMurray says.
"The nonprofit healthcare organizations are more likely to invest into the community that they serve, with a longer-term and more nontraditional view of return on investment," he says. "A nonprofit healthcare organization is more likely to invest money into programs that may not provide a return in the near term and, in the long term, ultimately provide a return that is aligned with the mission of the organization."
For example, Christiana Care recently made a $1 million commitment to the REACH Riverside Development Corporation, which is working to invigorate a struggling neighborhood in the health system's core service area.
"It's a local, nonprofit, community-based organization in one of the most impoverished neighborhoods of Wilmington, Delaware, which is the primary community that we serve. This group is supported by a combination of nonprofit, government, and community organizations. It is designed to address the needs of the local neighborhood, and it is led through a high level of community engagement. Our contribution will help provide REACH with the resources necessary to meet the needs of this neighborhood," McMurray says.
The investment in REACH reflects Christiana Care's commitment to the communities that the health system serves, he says. "Nonprofits have a different focus. We are focused on our community. A for-profit organization can address a community-based mission, but there's just a different focus involved."
Physicians in primary care specialties experienced a relatively high 4.91% increase in median compensation, survey data shows.
In 2018, physician compensation increased significantly and physician productivity rose slightly, according to an American Medical Group Association survey.
The AMGA has been conducting the compensation and productivity survey since 1986. The survey is designed to help medical groups evaluate and compare physician compensation and productivity levels as well as gauge trends. The compensation data can help medical groups make compensation-related decisions.
Median overall physician compensation in 2018 increased 2.92%, compared to a 0.89% increase in 2017. Physician productivity increased 0.29%, compared to a 1.63% decrease in 2017.
“The 2019 survey shows that physician compensation in 2018 rebounded from a stagnant 2017. While productivity also increased, it did not increase enough to surpass the decline we saw in last year's survey, meaning productivity still has not risen since 2016," AMGA Consulting President Fred Horton, MHA, said in a prepared statement.
The survey data, which was collected from 272 medical groups that employ more than 117,000 providers, includes several key data points:
Median compensation for primary care specialties rose 4.91% in 2018, compared to a 0.76% increase in 2017.
Compensation for primary care physician assistants rose 2.50%.
Compensation for primary care nurse practitioners rose 2.92%.
Overall median compensation for other medical specialties increased 3.39%.
Five of the highest specialties for mean compensation were orthopedic surgery, $591,245; gastroenterology, $527,998; general cardiology, $519,964; diagnostic radiology (MD non-interventional) $482,599; and urology, $469,755.
Five of the lowest specialties for mean compensation were urgent care, 283,787; internal medicine hospitalists, $293,252; neurology, $310,518; general obstetrics/gynecology, $340,388; and emergency medicine, $363,201.
To set physician base salaries, 93% of survey respondents said they relied on market salary data.
The use of work RVUs remained the dominant measure of productivity determining pay, at 79% of survey respondents. A work relative value unit is a non-monetary unit of measure that indicates the professional value of services provided by a clinician.
Other than productivity, the top five components of determining compensation were patient satisfaction, clinical quality and outcomes, citizenship, patient access measures, and care coordination.
Interpreting the data
The increase in overall compensation could have been an effort to offset the low compensation increase in 2017, Horton told HealthLeaders.
"Yearly compensation increases are approximate to standard 'cost of living' adjustments for physicians, so we expect to see them occur every year. In 2017, providers only saw an increase of 0.89%, which is well below the 2% to 3% we had seen in years prior. The 2.9% increase in 2018 is within the 'normal' range, albeit at the upper end. It may be that organizations in 2018 were attempting to compensate providers for a stagnant compensation increase in 2017," he said.
Supply-and-demand economics drove 2018 compensation higher for primary care specialties, Horton said. "The healthcare industry is currently experiencing a shortage of primary care physicians, so the demand for primary care is driving higher compensation."
The aging physician population is a major contributing factor to low productivity in recent years, he said. "In 2018, our survey showed there were more physicians over the age of 55 and nearing retirement than ever before in the history of this survey. Physicians at the beginning of their careers tend not to produce as much as those at the end of their career."
Three other factors likely contributed to low productivity in 2018, Horton said. "Employers are placing more of an emphasis on addressing burnout and lifestyle issues, which contributes to lower production. Physician assistants, nurse practitioners, and some other non-physician providers are starting to take on their own panel of patients, lessening the need for physician involvement. Burdensome electronic health record use is another factor contributing to productivity inhibition."
The 2018 data and information collected this year indicate trends for 2019 compensation and productivity, he said. "Thus far, we have seen no signs that indicate compensation will go above or below the 2% to 3% increase we typically see. We also do not expect to see significant increases in productivity, given ongoing retirements."
Residents report that the impacts of being bullied include feeling depressed and burned out.
Bullying of medical residents is a significant concern, new research shows.
Widespread burnout among clinicians and other medical staff has raised alarm about the mental health of healthcare professionals. Recent research indicates that nearly half of physicians are experiencing burnout symptoms, and a study published last October found that burnout increases the odds of physician involvement in patient safety incidents, unprofessionalism, and lower patient satisfaction.
New research published by the Journal of the American Medical Association includes a dire warning from the article's authors: "Bullying during medical education can have negative consequences that range from the well-being of the trainees to compromised patient care."
The JAMA research is based on data collected from the Internal Medicine In-Training Examination, a self-assessment exam administered annually to internal medicine residents by the American College of Physicians. In 2016, the examination included a brief survey on bullying during residency training, and the JAMA researchers analyzed data from more than 21,000 trainees who participated in the survey.
In the survey, bullying was defined as harassment on more than one occasion by someone in a position of greater power.
The JAMA research features several key data points:
13.6% of the survey respondents reported being subjected to bullying since the beginning of their residency training
Verbal harassment was the most common form of bullying reported (80%), followed by the "other" category (25%), physical harassment (5.3%), and sexual harassment (3.6%)
The most common impacts of bullying were feeling burned out (57%), diminished professional performance (39%), and depression (27%)
Four resident characteristics were associated with those trainees who reported being bullied: having a native language other than English, high postgraduate year level, being an international medical graduate, and posting a relatively low rating for the Internal Medicine In-Training Examination
A broader definition of bullying would have resulted in higher levels of reported bullying, the researchers wrote. "The bullying estimates in this study most likely represent an underestimate of mistreatment because less consequential hassling or microaggressions by superiors and harassment by those of equal or less power would not have been counted."
Interpreting the findings
Discrimination is a likely factor in the bullying of medical residents, the lead author of the research told HealthLeaders.
"Our research supports previous studies that note that international medical graduates are more likely to be bullied than those graduating from U.S. medical schools. A perhaps related observation is the independent association between reported native language and perceived bullying, which may in part be due to bias and stereotyping," said Manasa Ayyala, MD, an assistant professor of medicine in the Department of Medicine at Rutgers New Jersey Medical School in Newark.
It is unclear whether bullying during residency sets the stage for burnout and depression later in physicians' careers, she said. "Additional research is needed regarding longer-term sequelae experienced by residents who perceived bullying and reported burnout and depression as consequences. However, it is definitely concerning that such significant consequences starting in residency could affect one's future career."
Although further research is necessary, medical educators should step up efforts to curb bullying of medical residents, Ayyala said.
"To start addressing bullying, educational leaders and training program directors need to be aware that bullying is a significant problem in medical education and work toward creating effective reporting structures where trainees feel empowered to report bullying. Further research is also needed to effectively inform strategies and programs that will aim to reduce bullying of medical trainees."
The CMO of Cardinal Analytx shares the keys to addressing chronic illnesses, investing in social determinants of health, and reducing healthcare costs.
Chris DeRienzo, MD, wants to bend the trajectory of human diseases in a positive direction to improve lives and contain the country's unsustainable increasing healthcare costs.
As the American population ages with the maturation of the baby boomer generation, the prevalence of chronic conditions is expected to swell and exert upward pressure on healthcare spending, which is already approaching a burdensome one-fifth of the country's gross domestic product.
DeRienzo is the chief medical officer at Cardinal Analytx Solutions in Palo Alto, California, and an adjunct professor at the Stanford Medicine Clinical Excellence Research Center in Stanford, California. Cardinal Analytx is applying artificial intelligence to improve healthcare outcomes while containing costs.
The author of the book Tiny Medicine: One Doctor's Biggest Lessons From His Smallest Patients, DeRienzo specialized in neonatology after graduating from Duke University School of Medicine. Prior to joining Cardinal Analytx, he served in two roles at Asheville, North Carolina–based Mission Health: system chief quality officer, and chief patient safety officer and vice president.
HealthLeaders spoke with DeRienzo recently to get his perspectives on treating chronic illness, cost containment, and healthcare reform. Following is a lightly edited transcript of that conversation.
HL: Why did you pick neonatology as your specialty?
DeRienzo:NICU was at first a hard choice but ultimately an easy choice. I started med school thinking I was going into adult cardiology. But as med school evolved and I went through different rotations, I struggled with caring for adult patients, especially those with preventable conditions. I looked for an area where I could work with patients who were as early in their condition as possible, so I went into pediatrics.
NICU stood out to me because you basically own anything that happens to the child. All of the harm that can occur in the NICU is potentially preventable.
HL: How can healthcare organizations improve the treatment and management of chronic illnesses?
DeRienzo: There are two parts to the equation.
The first is to identify the trajectory of disease as early as possible and try to arrest its downward spiral. For example, with someone showing early signs of kidney disease, the No. 1 area of focus is getting the healthcare system to do a better job of servicing them and connecting the person with a matched intervention that gives the best possible chance at fundamentally changing their trajectory.
You also have to acknowledge that there are many folks who have already progressed in their disease states—whether it's COPD, heart failure, or another condition. Sometimes, their progression is not reversible. For those patients, we need to focus at the minimum on maintaining the condition as it is for as long as possible.
In my current role, I look across health plan claims, and I have seen folks with a variety of COPD. Despite having significant chronic obstructive pulmonary disease, there are some folks who are consistent with their medication regimen, they have stopped smoking, they are seeing a pulmonologist once per year, they are engaged with primary care, and they are doing spirometry testing—that kind of care coordination with someone who has a chronic condition can maximally help them live their best possible life.
HL: Give an example of an area where there can be a relatively quick ROI for social determinants of health initiatives?
DeRienzo: Transportation is really important, especially for the Medicaid population, which often relies on public transportation. When I ran my own clinic as a resident, transportation was one of the primary drivers of patients and their parents not being able to come to appointments. Certainly, there is an ROI for transportation.
Once you get into things like housing, it gets to be more challenging. It has to be under the right risk-sharing or revenue model that allows those investments to drive improvements in health, reduce healthcare utilization, and be sustainable for everyone involved.
HL: At this summer's HealthLeaders Innovation Exchange, you discussed the concept of "newly high-cost patients." Why is it important to effectively manage those kinds of patients?
DeRienzo: One of the reasons why I joined Cardinal Analytx is that when I looked at the universe of managing cost in healthcare, it had previously been divided in half. There were many people who were generally well and generally low-cost. There were other people who were generally not well and generally high-cost. The thought process was that the people who were generally well did not need much engagement, and that the people who were already high-acuity and high-cost required the most interventions that we could give them.
The problem with conceptualizing people in those two halves is that some people rise in cost, then revert to the mean. And some people who look well are about to fall off a health cliff.
The concept of the rising risk of the newly high-cost patient is new, but it is just as real as the patients who rise in cost then revert to the mean.
With an AI-enabled solution to find those newly high-cost folks, we can try to understand why they are going to fall off a health cliff and why their health costs are going to rise. Then we need to connect them with an intervention that can change their trajectory. If we can do that, we are not only changing people's lives but also dramatically changing the financial sustainability of managing population health.
For example, you can have someone with COPD who has generated $4,000 worth of healthcare costs this year, then rises to more than $30,000 in costs next year. If we can connect with that person, understand what is going on in his or her life, and see that they have had COPD and have been to the urgent care twice, we can intervene. We can get them on a consistent medication regimen. We can engage them with primary care. And we can connect the person with interventions that we know work.
Instead of rising to $30,000 in costs next year, maybe the patient will only go up to $5,000, or even go down to $2,000. If we can replicate that process over and over across our country's population, we would have a huge bend in the healthcare cost curve in the short-term that would compound year over year.
The Innovation Exchange is one of six healthcare thought-leadership and networking events that HealthLeaders holds annually. While the events are invitation-only, qualified healthcare executives, director-level and above, will be considered. To inquire about the HealthLeaders Exchange program, email us at exchange@healthleadersmedia.com.
Photo credit: Pictured above: Chris DeRienzo, MD, CMO at Palo Alto, California–based Cardinal Analytx Solutions and an adjunct professor at Stanford University, makes a point at this summer's HealthLeaders Innovation Exchange. (Photo: David Hartig)
J. Mario Molina, MD, former chief executive of Molina Healthcare, has been picked to lead the new medical school in Claremont, California.
The Claremont, California-based Keck Graduate Institute (KGI) has selected the former president and CEO of Molina Healthcare to serve as the first dean of the KGI School of Medicine.
One of the top missions of the new medical school is to address the shortage of primary care physicians in Southern California. Nationwide, there is expected to be a shortage of 122,000 physicians by 2032, the Association of American Medical Colleges reported earlier this year.
KGI announced the selection of J. Mario Molina, MD, as the founding dean of the KGI School of Medicine today. Molina was reportedly forced to resign as president and CEO of Long Beach, California-based Molina Healthcare in December 2017 after the health plan posted disappointing financial results.
Molina is the son of C. David Molina, the late founder of Molina Healthcare. He became president and CEO of Molina Healthcare in 1996. He earned his medical degree from the University of Southern California, then completed an internship and residency in internal medicine at Johns Hopkins Hospital in Baltimore.
Molina told HealthLeaders that there is a pressing need to open a new medical school in California.
"Many physicians will retire in the next decade just as the wave of baby boomers drives the demand for physician services ever higher. The truth is, the pipeline of physicians coming out of medical schools has not kept up with the growth of the population or the demand for medical care. California will be especially hard hit. About one-third of physicians in California are over the age of 60, so as they retire California will need to replace them. We know that 70 percent of physicians who receive their education in California stay here," Molina said.
"Accreditation is an arduous process—we will approach it respectfully. In the first two years, the key activities focus on fundraising, making key personnel hires, curriculum development, and building community partnerships. Once we receive initial applicant status, we will work hard to advance to candidate status, and then continue working to satisfy requirements until we are accredited," he said.
The KGI School of Medicine will seek to build partnerships and strong working relationships with nearby institutions of higher learning, Molina said.
"We want to make use of the existing resources of the Claremont schools. Keck Graduate Institute contributes world-class science and technology, as well as a School of Pharmacy and Health Sciences, while Claremont Graduate University already brings economics, healthcare policy, public health, and a renowned business school. Finally, Harvey Mudd College is one of the finest engineering schools in the nation," he said.
The new medical school will capitalize on geographic and demographic advantages, Molina said.
"Claremont is located somewhat in the middle of Los Angeles, San Bernardino, and Riverside counties, a metropolitan area of over 17 million people, second only to New York in population. California is home to more Latinos and Asians than any other state. We have a large and diverse population to draw from. The campus itself has new buildings and plenty of room to grow," he said.
Approaches to medical education
The KGI School of Medicine will take several approaches to medical education that should distinguish the institution from other medical colleges, Molina said.
"Today, medicine is delivered by teams of healthcare professionals, and physicians need to learn how to work in teams. Teamwork is something that KGI is already skilled at teaching. We want to flip the classroom around, producing fewer lectures and more work in small groups. Our students will work together in teams to solve problems—similar to how they will function when they enter practice," he said.
The new medical school's curriculum will acknowledge the significance of social determinants of health, Molina said. "The old model of healthcare focused on disease. We now understand that social and cultural factors are just as important in establishing good health. A new curriculum needs to incorporate this knowledge so that physicians have a better understanding of their patients and the challenges that they face in maintaining health."
Graduates will be able to apply the latest advances in science at the bedside, he said. "Our graduates will have the skills to pursue the practical application of new scientific information and technology and apply them to patient care."
The new medical school also will teach students about the business and economics of healthcare, Molina said. "Medical schools rarely include anything about the business of medicine in the curriculum. Modern physicians need to understand the economics of healthcare and the role they can play in either driving up costs or making healthcare more affordable."
New England Journal of Medicine editorial, articles, and interactive feature spotlight intersection between global warming and healthcare.
In an editorial, three articles, and an interactive feature that includes the impact of climate change on a dozen medical specialties, the New England Journal of Medicine has declared the Earth's ailing atmosphere a "major public health emergency."
At least 97% of actively publishing climate scientists believe the planet's atmosphere is warming and human activity is a primary driver of the process. In addition to healthcare impacts such as air pollution, climate change has been linked to several existential threats to human populations, including sea level rise, extreme weather events, insect-borne diseases, and drought.
"The stark reality is that high levels of greenhouse gases caused by the combustion of fossil fuels—and the resulting rise in temperature and sea levels and intensification of extreme weather—are having profound consequences for human health and health systems," the NEJM editorial says.
The negative effects of climate change on health and healthcare organizations—including damage to public health infrastructure such as flooding, heat-related illnesses, increased pollen fueling allergies and exacerbating asthma, disrupted supply chains, and rising insect-borne diseases—demand a response from the healthcare sector, the editorial says.
"We, as a medical community, have the responsibility and the opportunity to mobilize the urgent, large-scale climate action required to protect health—as well as the ingenuity to develop novel and bold interventions to avert the most catastrophic outcomes."
The three articles NEJM published last week explore climate-sensitive disease, easing of regulations at the Environmental Protection Agency, and air pollution's impact on mortality.
"CKDu was first described in El Salvador in the 1990s, when unusually large numbers of agricultural workers began dying from irreversible renal failure. It quickly became evident that the phenomenon was pervasive among innumerable agricultural communities in hot, humid regions of Central America. CKDu's presence is now potentially global, with similar disease patterns observed in North America, South America, the Middle East, Africa, and India," Sorensen and Garcia-Trabanino say.
Although several factors may contribute to CKDu, heat exposure is a primary driver of the disease, they say. "What we do know for certain is that CKDu is related to heat exposure and dehydration, although exposure to agrochemicals, heavy metals, and infectious agents, as well as genetic factors and risk factors related to poverty, malnutrition, and other social determinants of health may also contribute."
The increasing reported cases of CKDu in areas of the world that have experienced relatively high temperatures in recent decades shows an ominous link between global warming and illness, Sorensen and Garcia-Trabanino say.
"We may have now reached a physiological limit, in terms of heat exposure, at which acclimatization and behavioral modifications can no longer overcome the biologic stressors of unsafe working conditions and environmental exposures in these hot spot communities. We are now living in an era when climate change is no longer a distant, existential threat. It is happening now, and it is affecting human health in profound ways."
"We can demand that proposed climate policies come with a credible accounting of their health effects. We can prioritize research evaluating the health effects of carbon-reduction strategies. We can discuss climate action in ways that make it personal, telling stories about the people we see in our clinics, hospital beds, and emergency departments whose health has been compromised by climate change, in an effort to educate and influence the media, decision makers, and parents," McCarthy and Berstein say.
The EPA has eliminated or weakened air pollution regulations on several fronts, including fuel-efficiency standards for cars, greenhouse gases such as methane, and mercury emissions.
"Burning fossil fuels generates roughly 80% of our country's carbon pollution and the bulk of other air pollutants known to cause or exacerbate a host of ailments, including everything from chronic obstructive pulmonary disease, myocardial infarction, and stroke to lung cancer, type 2 diabetes, pneumonia, and possibly even dementia," McCarthy and Berstein say.
3. Air pollution and mortality
In "Ambient Particulate Air Pollution and Daily Mortality in 652 Cities," Cong Liu, MS, et al., found a positive association between increases in particulate matter (PM) pollution and all-cause, cardiovascular, and respiratory mortality. PM is generated in combustion such as power plant operations or formed through atmospheric chemical transformation.
The key findings of the research focused on two classes of PM pollution: PM with an aerodynamic diameter of 10 μm or less (PM10) and fine PM with an aerodynamic diameter of 2.5 μm or less (PM2.5).
An increase of 10 ug per cubic meter of PM10 concentration was linked to a 0.44% increase in daily all-cause mortality, 0.36% increase in daily cardiovascular mortality, and 0.47% increase in daily respiratory mortality
An increase of 10 ug per cubic meter of PM2.5 concentration was linked to a 0.68% increase in daily all-cause mortality, 0.55% increase in daily cardiovascular mortality, and 0.74% increase in daily respiratory mortality
The stronger association between PM2.5 exposure and mortality may be because this class of PM has more small particles that can absorb toxic materials in the air and lodge deep in the lungs, Liu and his coauthors wrote.
The data, which was collected from 1986 to 2015, shows a correlation between PM pollution and mortality, they wrote. "Our multi-country time-series analysis provides evidence on positive associations between short-term exposure to PM10 and PM2.5 and daily all-cause, cardiovascular, and respiratory mortality. This study indicated independent associations of PM10 and PM2.5 concentrations with daily mortality after adjustment for gaseous pollutants."
Practice transformation networks engage 9,800 physicians who serve 5.9 million patients in The Golden State.
In California, state leaders, healthcare organizations, and business groups have reported significant benefits from a federally funded clinical practice initiative, including $345 million in cost avoidance.
Under the Centers for Medicare & Medicaid Services' Transforming Clinical Practice Initiative, grants totaling more than $52 million were awarded to three practice transformation networks in California over the past four years. The primary goals of the federal initiative are to increase the value of U.S. healthcare through improved quality and reduced costs across the country.
In addition to the $345 million in cost avoidance, the initiative has generated impressive results in California:
67,000 avoided emergency room visits
57,000 avoided hospitalizations
750,000 patients have achieved improved health outcomes—including 26,000 diabetics improving HbA1c control—or benefited from improved processes of care such as treatment with enhanced clinical guidelines
Transformation network trio
With support from the federal funding, Golden State healthcare stakeholders formed three practice transformation networks, with 9,800 physicians serving 5.9 million patients.
1. Pacific Business Group on Health's Practice Transformation Initiative: In partnership with the Integrated Healthcare Association and the Center for Care Innovations, PBGH formed the Practice Transformation Initiative, which features 1,900 clinical practices. About 90% of the practices are primary care clinics with one or two clinicians.
The Practice Transformation Initiative includes a train-the-trainer model to promote peer-driven technical assistance and a practice coaching model to develop technical skills. In the practice coaching model, practices hire facilitators or reassign existing staff to lead training efforts in areas such as quality improvement and change management.
2. Southwest Pediatric Practice Transformation Network:CHOC Children's Hospital and Rady Children's Hospital-San Diego engaged more than 200 clinical practices in Orange and San Diego counties that serve about 1.2 million children. The children's hospital effort focuses on a common operational framework, performance improvement strategies, and evidence-based best practices.
The Southwest Pediatric Practice Transformation Network targets 14 quality and utilization metrics for six common pediatric conditions: acne, acute gastroenteritis, bronchiolitis, asthma, community-acquired pneumonia, and headache. Clinical guidelines for the conditions were disseminated to pediatric clinics, including building the guidelines into the electronic medical record systems of large physician groups. New decision support tools and standard order sets also were established at clinics.
Coding best-practice training was provided for pediatric office visits such as encounter submissions, office workflows, and clinical documentation improvements.
3. Los Angeles Practice Transformation Network:L.A. Care Health Plan led an effort to help Los Angeles County clinicians improve care for diabetes and depression, transform practices, and lower costs.
L.A. Care's Los Angeles Practice Transformation Network provides onsite and remote assistance to support treatment of patients at high risk for hospitalization, facilitate transitions to community-based care settings after acute hospitalizations, promote medication reconciliation, and boost medication management. Improvements achieved include a 79% boost in suicide risk assessment for children.
Payer player
Several factors contributed to the positive impacts of the Los Angeles Practice Transformation Network efforts, L.A. Care CEO John Baackes told HealthLeaders:
Community partnerships closed the loop on community referrals and enabled warm handoffs to organizations that help patients address social factors that impact health such as food security, transportation, and housing.
Robust utilization of healthcare information technology tools improved the validity and integrity of data exchanges and risk stratification, including near real-time notifications.
Fostering a culture of quality improvement such as improved staff engagement clearly defined and assigned care team responsibilities, which helped drive improvements in patient health.
Disease-specific care was promoted through patient education and chronic disease self-management training such as the Diabetes Empowerment Education Program.
Cost avoidance was significant, he said. "We saw reduced utilization in all types of admissions for patients diagnosed with diabetes, depression, or both. That includes inpatient admissions, emergency room visits, and 30-day readmissions. We had 45,000 avoided emergency room visits and 19,000 avoided hospital admissions. That resulted in $136 million in savings."
There were several components that contributed to reduced emergency room visits, Baackes said.
"We can attribute the reduction in ER utilization and the associated cost savings to better patient engagement with primary care, risk stratification, improved care coordination, integration of physical and mental health within the medical home, and value-based payment programs. Specifically, we saw increased provider adherence to evidence-based care guidelines for both preventive care and chronic disease management."
Healthcare IT tools such as integrated population health management solutions and admission, discharge and transfer (ADT) messages also helped reduce ER visits and hospitalizations, he said. "These tools helped to drive improved patient outreach and delivery of appropriate care services. We were able to identify so-called frequent flyers, those members who had repeated readmissions. That led to targeted care management delivery and reduced admissions."
