Researchers focus on six categories of waste: failure of care delivery, failure of care coordination, overtreatment or low-value care, pricing failure, fraud and abuse, and administrative complexity.
Waste accounts for about 25% of U.S. healthcare spending, new research indicates.
No other country spends more on healthcare than the United States, with the gross domestic product share of healthcare spending estimated at nearly 18% and rising. Earlier research on U.S. healthcare spending has estimated that waste accounts for about 30% of the spending total.
Reducing wasteful spending is a promising avenue to curb annual increases in the country's healthcare spending, according to the co-authors of the new research, which was published today in the Journal of the American Medical Association. "Implementation of effective measures to eliminate waste represents an opportunity reduce the continued increases in U.S. healthcare expenditures," the researchers wrote.
The researchers examined data from 54 published reports. They tallied waste in six categories identified in 2010 by the Institute of medicine (IOM): failure of care delivery, failure of care coordination, overtreatment or low-value care, pricing failure, fraud and abuse, and administrative complexity. Pricing failure includes medication pricing, payer-based health services pricing, and laboratory-based and ambulatory pricing.
In 2019, total U.S. healthcare spending is projected at $3.82 trillion.
The JAMA researchers generated several key data points:
Annual wasteful spending on healthcare is estimated from $760 billion to $935 billion.
Interventions to reduce waste in the six IOM categories would result in annual savings from $191 billion to $282 billion.
The annual cost of wasteful spending from administrative complexity accounts for the highest category of waste, estimated at $265.6 billion.
The annual cost of waste from pricing failure is estimated from $230.7 billion to $240.5 billion.
The annual cost of waste from failure of care delivery is estimated from $102.4 billion to $165.7 billion.
The annual cost of waste from overtreatment or low-value care is estimated from $75.7 billion to $101.2 billion.
The annual cost of waste from fraud and abuse is estimated from $58.5 billion to $83.9 billion.
The annual cost of waste from failure of care coordination is estimated from $27.2 billion to $78.2 billion.
The impact of likely interventions to reduce wasteful spending are significant but limited, the researchers wrote.
"The best available evidence about the cost savings of interventions targeting waste, when scaled nationally, account for only approximately 25% of total wasteful spending. These findings highlight the challenges inherent in rapidly changing the course of a health system that accounts for more than $3.8 trillion in annual spending, 17.8% of the nation's GDP."
Assessing the data
The highest amount of wasteful spending was associated with the administrative complexity category. The development and adoption of value-based payment models has the most potential to impact this category of wasteful spending, the researchers wrote.
"In value-based models, in particular those in which clinicians take on financial risk for the total cost of care of the populations they serve, many of the administrative tools used by payers to reduce waste (such as prior authorization) can be discontinued or delegated to the clinicians, reducing complexity for clinicians and aligning incentives for them to reduce waste and improve value in their clinical decision-making."
Reducing spending the second-highest wasteful category—pricing failure—poses daunting challenges because of the rising prices of pharmaceuticals, the researchers wrote. "New high-cost specialty drugs, which will soon exceed 50% of pharmaceutical spending, are raising new questions about how to maintain affordability. This topic has thus received considerable attention from policy makers, and numerous proposals are currently under consideration."
The researchers say strategies to ease cost pressure in pharmaceuticals include increasing market competition, importing drugs from countries with lower medication prices, and reforming price transparency.
The big picture view
An editorial accompanying the new research says the findings are a significant contribution to the ongoing effort to rein in the country's healthcare spending.
"At a time when the United States is once again mired in a great debate about the future of its healthcare system, the data reported in the article … should become part of the national discussion. It would be nearly impossible for all waste to be eliminated in any healthcare system, just as it is impossible to know the true cost of any change in the delivery and financing of healthcare without understanding possible savings, and recognizing that there is complexity in knowing the savings," the editorial says.
Concentrating on wasteful spending is crucial, the editorial says. "While no single solution will solve the continuous increases in U.S. healthcare spending, identifying, reducing, and eliminating waste are important and appropriate places to start."
Researchers have found that the percentage of women in internal medicine specialties has decreased over the past two decades, which is likely contributing to the physician wage gender gap.
From 1991 to 2016, the percentage of women in internal medicine increased, but the percentage of women in subspecialty fellowships fell, recent research shows. The percentage of women enrolled in cardiovascular disease fellowships was particularly low.
An increasing number of women have been enrolling in medical schools, with women accounting for 50.7% of enrollees in 2017. However, female physicians have lagged behind their male counterparts in compensation.
The lead author of the recent research, which was published in the Journal of the American Medical Association, told HealthLeaders that the growing underrepresentation of women in internal medicine subspecialties is contributing to the compensation gap.
"The fewer women we have in the more highly reimbursed specialties of medicine, the wider the gender wage gap in medicine will be," said Mary Norine Walsh, MD, MACC, medical director of Heart Failure and Cardiac Transplantation at St. Vincent Heart Center in Indianapolis.
Walsh and her co-authors generated several key data points:
From 1991 to 2016, the percentage of female internal medicine residents increased from 30.2% to 43.2%.
In 1991, 33.3% of internal medicine subspecialty residents were women and 66.7% were men.
In 2016, 23.6% of internal medicine subspecialty residents were women and 76.4% were men.
The researchers examined data for nine subspecialties. Women represented 21.3% of cardiovascular disease fellows—the lowest representation of women in the nine subspecialties.
Women were most highly represented in geriatric medicine, at 76.9%.
"Between 1991 and 2016, although the percentage of women in internal medicine residencies increased, the percentage of women in subspecialty fellowships decreased," Walsh and her co-authors wrote.
Interpreting the data
Female and male physicians have significantly different views of careers in cardiology, the co-authors wrote.
"A survey of internal medicine residents about their professional preferences, their perceptions of cardiology, and how these attitudes combine to inform career choices showed substantial sex differences. More women than men reported never considering cardiology, and women had different perceptions of cardiology than men. Women cardiologists are more likely than men to experience sex and parenting discrimination, be single, not have children, and report less satisfaction in family life, though overall career satisfaction remains high for both men and women," they wrote.
Differing career goals between women and men could be influencing the choice of specialty between the genders, Walsh told HealthLeaders. "When asked, women internal medicine residents have assigned a greater importance to long-term patient relationships and family time than to financial considerations."
A lack of female role models in cardiology could be contributing to underrepresentation of women in the field, she said. "Because of the fewer numbers of female cardiologists, female trainees aren't always exposed to female cardiologist role models during their training."
At MD Anderson Cancer Center, patient and family advisors are involved in a wide range of activities, including safety, process improvement, research grants, expansion of the organization's call center, and policy development.
The University of Texas MD Anderson Cancer Center is committed to involving patients and family members in a range of decision-making at the Houston-based organization.
After decades of providing directive care to patients, most health systems, hospitals, and physician practices across the country are trying to provide patient-centered care. Research has shown that patient-centered care is associated with several positive outcomes for patients, including better recovery from discomfort and concern, better emotional health, and fewer diagnostic tests and referrals.
Randal Weber, MD, chief patient experience officer at MD Anderson, says the organization's Patient and Family Advisor Program represents a leap forward in the organization's efforts to provide patient-centered care.
"If you are really committed to patient-centered care, you need input from your patients to change culture. Many institutions are provider-centered. The patient advisors are the best people to inform us about where we have opportunities to change our culture and make it more patient-centered and improve patient experience," he says.
MD Anderson launched its Patient and Family Advisor Program in 2014 with 20 founding members. Patients and family members who participate in the program are considered unpaid employees, and they receive extensive training in areas including patient confidentiality such as Health Insurance Portability and Accountability Act (HIPAA) compliance.
"They are fully vetted with HIPAA and everything else a regular employee receives training for, but they are not paid. They can sit on a range of committees such as process improvement and safety committees, and they can be privy to confidential information," says Elizabeth Garcia, RN, MPA, associate vice president of patient experience at MD Anderson.
The Patient and Family Advisor Program was almost immediately successful, and demand for advisor participation in institutional committees and research efforts soon outstripped the supply of advisors, says Kathleen Denton, PhD, MEd, director of patient experience at MD Anderson. "After a year and a half, we expanded the program, and we now have 80 advisors. We still have monthly meetings, but we also place patient and family advisors on institutional committees. They participate in focus groups. We send them electronic surveys."
Scope of involvement
The patient and family advisors have been involved in dozens of initiatives, policy decisions, and research projects, including:
The advisors played an active role in developing MD Anderson's "Stop the Line" safety policy. Stop the Line gives staff, patients, and family members the ability to call for a pause whenever patient safety is in doubt. "We have had patients and family members say, 'stop the line,' when they were about to go into a diagnostic imaging test because they didn't think it was what the doctor ordered. Patients and family members are part of our healthcare team and can stop any procedure or process for safety concerns," Garcia says.
Advisors sit on process improvement and quality improvement committees. For example, the advisors flagged the need to improve the functionality of call buttons in patient rooms. "We put a quality check in place for all our call bells throughout the institution. Now, every time we admit a new patient, the call bell gets checked," Garcia says.
The advisors played an essential role in convincing MD Anderson's leadership to expand the organization's call center, Garcia says. "We extended our call center hours to cover weekends and holidays as well as evenings. We are also adding clinical services to the call center. We could have never gotten funding for our 24/7 call center without our patient advisors saying it was a need."
The advisors requested better follow-up with patients after they are discharged from inpatient care. "In August, we launched a team that calls every patient when they go home. They ask whether the patient got home OK, how they are feeling, and whether they have their meds and their equipment. It's a mental thing—it shows that the institution cares enough to call the patient at home," says Ronnie Pace, a breast cancer survivor who is a founding member and former co-chair of the Patient and Family Advisor Program.
Patient and family advisors were instrumental in improving parking at MD Anderson's main campus by urging adoption of a computerized red, green, and blue light parking system for guiding patients to parking spots similar to parking systems used at airports. "Because the suggestion came from the patients, that really gave the parking director the voice with the administration to get that in place. We also have a new kiosk that can tell patients exactly where their car is parked and how to get there," Denton says.
The advisors have also helped MD Anderson researchers write grant applications.
Recruiting patient and family advisors
Patients and family members are eager to serve in the advisor program, says Pace. "The word got out that this council was the real deal, and that the institution wanted to know how we felt and how we thought about certain situations," he says.
There is a rigorous selection process for patients and family members who want to serve in the advisor program.
New members are recruited annually in July. There is an extensive recruitment outreach effort, which includes applications through My Chart and paper applications that are distributed at learning centers, the patient experience office, and the patient and family relaxation area. MD Anderson's internal communications team also advertises the advisor openings to patients and staff members.
There are three primary selection criteria to serve in the Patient and Family Advisor Program: disease-site representation, diverse representation from all populations, and experience with MD Anderson services. "If we have two candidates who are both breast cancer patients, but one has used chaplaincy, supportive care, and a variety of services, we will lean toward the more experienced candidate. We have a steering committee that makes the selections," Denton says.
The advisor selection process includes a 30-minute, on-site interview.
"You need be very careful to choose people who are in it for the right reasons. We have applicants who are going through the grieving process, and sometimes they have not worked through those issues. We want our advisors to understand that they are giving back. This is not a support group. This is about giving back to the organization and making things better for future patients and family members," Garcia says.
New advisors need to be prepared to work on meaningful projects, Pace says. "There is plenty of work to do for patient advisors who want to come in and do the job. There is no lack of opportunity. Our meetings are held once per month, and they're full of activity from start to finish."
MD Anderson's Patient and Family Advisor Program was the focus of a featured presentation at this summer's HealthLeaders Innovation Exchange in California. 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 will be considered. To inquire about the HealthLeaders Exchange program, email us at exchange@healthleadersmedia.com.
Photo credit: Pictured above: Janice Finder, RN, MSN, MD Anderson Cancer Center's director of patient experience for clinical support, makes a point at this summer's HealthLeaders Innovation Exchange in California. (Photo: David Hartig)
Researchers document improvement in physician burnout from 2014 to 2017, but they find clinicians are at significantly higher risk than other members of the U.S. workforce.
Over the past seven years, there have been several nationwide efforts to address physician burnout, which has been linked to physician involvement in patient safety incidents, unprofessionalism, and lower patient satisfaction. The efforts to curb physician burnout have included American Medical Association conferences and initiatives to create online resources.
The co-authors of the recent research, which was published in Mayo Clinic Proceedings, say improvement in physician burnout and work-life integration is promising, but more progress is needed.
"The current prevalence of burnout among U.S. physicians appears to be lower than in 2014 and near 2011 levels. This trend is encouraging and suggests improvement is possible despite the numerous contributing factors and complexity of the problem. Although the improvement is good news, symptoms of burnout remain a pervasive problem, and its prevalence among physicians continues to be markedly higher than in the general U.S. working population," the researchers wrote.
Physician burnout by the numbers
The researchers have assessed the prevalence of physician burnout in 2011, 2014, and 2017. The primary metrics used in the assessments are the emotional exhaustion and depersonalization measures of the Maslach Burnout Inventory.
The researchers generated several key data points:
In 2017, 43.9% of physicians reported at least one symptom of burnout. This prevalence of burnout is significantly lower than the 54.4% level reported in 2014 and on par with the 45.5% level reported in 2011.
In 2017, 42.7% of physicians reported satisfaction with work-life integration. This prevalence of work-life integration satisfaction is better than the 40.9% level reported in 2014 but worse than the 48.5% level reported in 2011.
In 2017, physicians were more likely to be at risk for burnout compared to other U.S. workers (odds ratio 1.39). Physicians were also less likely to be satisfied with work-life integration compared to other U.S. workers (odds ratio 0.77).
From 2011 to 2017, there has been a steady increase in the percentage of physicians screening positive for depression: 38.2% in 2011, 39.8% in 2014, and 41.7% in 2017.
"Burnout and satisfaction with work-life integration among U.S. physicians improved between 2014 and 2017, with burnout currently near 2011 levels. Physicians remain at increased risk for burnout relative to workers in other fields. … Although the change in burnout is favorable, symptoms of depression among physicians have continued to worsen," the researchers wrote.
Possible causes of physician burnout reduction
The researchers say there are four likely factors that contributed to the lower level of burnout reported in 2017 compared to 2014.
1. Outlier year: In 2014, physicians faced several challenging working conditions, including hospital and physician group consolidation, new regulations, and heightened administrative burdens such as increasing demands to feed data into electronic medical record systems.
2. Attrition: There may have been fewer burned out physicians in 2017 because distressed physicians left the workforce or decreased their clinical effort.
3. Rising to the challenge: National healthcare organizations have launched several initiatives to ease physician burnout, including the Accreditation Council for Graduate Medical Education, American College of Physicians, American Medical Association, and Association of American Medical Colleges.
4. Fixing problems: Health systems, hospitals, and physician practices have taken actions to improve the practice environment such as boosting team-based care, implementing documentation assistance, and designing more efficient workflows. "These and other efforts to improve physician well-being have proven to be efficacious and should be recognized as potential contributors to the favorable trend," the researchers wrote.
Prescription for change
The researchers say future work to reduce physician burnout and increase satisfaction with work-life integration should be viewed as "an ongoing journey."
"A coordinated, systems-based approach at both the national and organizational levels that addresses the underlying drivers is the key to making progress. Evidence indicates that both individual- and organization-focused interventions are effective and indeed complementary. A formal program to assess, design, coordinate, and lead efforts to reduce the occupational risk for burnout and cultivate professional well-being can help accelerate progress at the organization level," the researchers wrote.
The new screening tool features a collaborative approach to designing screening processes, creating conditions for screening, identifying care team members to conduct screening, and documenting social needs.
The American Hospital Association has developed a 4-part tool to help healthcare providers screen patients for social determinants of health (SDOH).
Social needs such as housing and food security can have a crucial effect on patient health. By making direct investments in initiatives designed to address SDOHs and working with community partners, healthcare organizations can help patients achieve positive health outcomes in ways beyond the traditional provision of medical services.
The American Hospital Association's screening tool for SDOHs has four elements:
1. Collaborative approach to designing the screening process
A collaborative approach to designing social needs screening features healthcare providers, patients, and community stakeholders.
Including clinicians in the design process boosts their commitment to the questions and the screening process. Patients can play an essential role in the design process because they can provide insights into developing screening questions and guidance for how questions should be asked. Community stakeholders can play a pivotal role in the design process because they have intimate knowledge about their communities.
2. Conditions and settings for screening
When conducting SDOH screening during a patient encounter, location, mode of communication, and point of contact are significant considerations.
For hospital patients, screening can be conducted in office space, an exam room, or electronically from patients' homes with follow-up during an office visit. Modes of communication include paper questionnaires, electronic surveys, and in-depth conversations. Point of contact can be before, during, or after a patient encounter.
Determining the best location, mode of communication, and point of contact for SDOH screening varies depending on the healthcare organization and the community it serves, Priya Bathija, JD, MHSA, vice president of The Value Initiative at the American Hospital Association, told HealthLeaders.
"It really takes partnering with providers, patients, and community stakeholders, within and outside of hospital walls, to identify the logistics behind a social needs screen, whether it's the location, mode of communication or the point person conducting the screen. Additionally, partnering with patients allows hospitals and health systems to understand how well they respond to the screening. Some may feel uncomfortable in hospital settings and some in physician practices. These partnerships will help inform what will work best for a specific hospital and community," she said.
3. Identifying care team members to conduct screening
Although physicians are well-suited to conduct SDOH screening because they can identify social needs as well as clinical needs linked to SDOHs, other care team members can be qualified to play the screener role. Possible non-physician screeners include community health workers, medical assistants, nurses, patient navigators, and social workers.
"Equipping care teams with proper tools, training, and resources will build capacity within an individual to understand a person's social needs and increase opportunity for better engagement with patients," Bathija said.
For example, she said the Women-Inspired Neighborhood Network at the Henry Ford Health System in Detroit utilizes community health workers to build relationships with pregnant women and to be the point of contact throughout a mother's pregnancy. "By building this relationship, community health workers are able to assess the needs of mothers at every stage," Bathija said.
4. Documenting social needs
The results of SDOH screening should be routinely documented in medical records so the results can be included in a patient's treatment plan. The screening results also should be accessible to the patient's entire care team.
Hospitals can use ICD-10-CM Z codes to document factors influencing health status, Bathija said. "Some examples of existing Z codes for social determinants of health are codes to identify problems related to education and literacy, employment, housing such as homelessness, lack of adequate food or water, and occupational exposure to risk factors such as dust, radiation, or toxic agents."
Using Z codes has several benefits, she said. "For example, by documenting this information, hospitals can track the social determinants most impacting their patients. At the individual level, once someone has shared their information and the care team has determined there is a social need, they can address that need for specific patients. They can make the right referrals to address an individual patient's needs."
Bathija said other benefits of using Z codes include aggregating social needs data across patients to determine where hospitals should focus their efforts, using the data to align services and programs with the needs of hospital patients, and examining the data to help identify the best care team members to address social needs.
New research indicates that increases in minority students who are applying to and enrolled in medical school are not keeping pace with increases in minority populations nationwide.
Despite a decade-long effort to racially and ethnically diversify medical school graduates to reflect the diversity of the general population, underrepresentation of minority groups in medical schools remains problematic, new research shows.
Earlier research has demonstrated that demographic representation in the physician workforce has multiple benefits, including better healthcare access for underserved populations, better cultural effectiveness among physicians, and better medical research and innovation for all populations.
In 2009, the Liaison Committee on Medical Education created accreditation guidelines mandating medical schools to develop programs or partnerships that would open up medical education to more students with diverse backgrounds.
A co-author of the new research, which was published in the Journal of the American Medical Association, told HealthLeaders that boosting physician diversity is beneficial at the patient bedside and at healthcare organizations more broadly.
"Oftentimes, we talk about diversity at the frontlines of healthcare because we want to make sure that we have diverse providers engaged with diverse patients because it will mitigate interpersonal bias or individual biases. The truth of the matter is that we need a diverse medical workforce not just at the frontlines but also among those generating the science of tomorrow and generating the systems in which we deliver care," said Jaya Aysola, MD, MPH, an assistant professor of medicine at the University of Pennsylvania's Perelman School of Medicine and executive director of the Penn Medicine Center for Health Equity Advancement.
Medical school diversity by the numbers
Aysola and her JAMA co-authors examined data from 2002 to 2017. The primary metric was representation quotient (RQ), which is a ratio that shows the proportion of a particular subgroup among the total population of medical school applicants or enrollees relative to the proportion of that subgroup in the U.S. population. An RQ greater than 1 indicates overrepresentation. An RQ less than 1 indicates underrepresentation.
The researchers generated several key data points:
The main finding is that the overall numbers and proportions of black, Hispanic, and American Indian or Alaska Native (AIAN) medical school enrollees increased from 2002 to 2017, but the increases did not keep pace with increases of these minorities in the general population.
For minority medical school applicants from 2013 to 2017, Hispanic female applicants were the only minority group that showed a statistically significant increase in representation, with RQ rising from 0.29 to 0.34. For the same time period, the RQ for Hispanic male applicants was relatively constant at 0.28.
For medical school enrollees from 2012 to 2017, there were no significant RQ increases or decreases for any racial or ethnic group. For example, the RQ for male and female Hispanic graduates was relatively constant at about 0.30.
"Black, Hispanic, and AIAN students remain underrepresented among medical school matriculants compared with the U.S. population. This underrepresentation has not changed significantly since the institution of the Liaison Committee of Medical Education diversity accreditation guidelines in 2009. This study's findings suggest a need for both the development and the evaluation of more robust policies and programs to create a physician workforce that is demographically representative of the U.S. population," Aysola and her co-authors wrote.
Addressing underrepresentation
Aysola told HealthLeaders that the underrepresentation problem cannot be solved by just focusing on societal factors such as educational disparities early in life.
"When we consider the pipeline in isolation as the only contributing factor, we are ignoring the system inequities that also play a big role in underrepresentation. I'm interested in what is intrinsic to the system that makes a difference in who is selected to attend our medical schools. What are the systematic biases that exist that prevent professional diversity?" she said.
One policy change that could make a difference at medical schools is already in place at many commercial businesses, Aysola said. "We want to test the priming technique, where you can prime interviewers and selection committees to consider their biases before an interview and after an interview, then determine whether biases are playing a role."
"For example, after you are done conducting an applicant interview, the interviewer considers whether there is anything about the applicant that they see in themselves. Is there anything in the applicant's CV that resonates with the interviewer? You are encouraging interviewers to screen themselves for their own personal biases, so they become more self-aware."
AbleTo Medical Director David Whitehouse shares the potential and best practices for providing behavioral health services through telemedicine.
David Whitehouse MD, MBA, the new medical director at AbleTo, a provider of virtual behavioral health services, says telemedicine is a 'particularly good fit' for behavioral health.
Telemedicine is one of the most significant growth areas in healthcare around the world. Last year, the value of the global telemedicine market was estimated at more than $38 billion, and the market is expected to be valued at $130 billion by 2025. With a high degree of anonymity and convenience, telemedicine has gained significant traction in the provision of behavioral health services.
Whitehouse was recently picked to serve as the medical director at New York–based AbleTo Inc. He earned his medical degree from Dartmouth College's Geisel School of Medicine. His professional background includes serving as chief medical officer for Aliso Viejo, California–based UST Global and working as CMO for strategy and innovation for Optum Behavioral Health Solutions.
HealthLeaders spoke with Whitehouse recently to get his perspectives on the potential of telepsychiatry and best practices for telepsychiatry visits. Following is a lightly edited transcript of that conversation.
HL: Why is telemedicine a good fit for providing behavioral health services?
Whitehouse: It is an especially good fit.
When the Internet was getting started, an observation that was made quickly was that among social groups and chat groups the largest number of users were people who had behavioral health issues. What they loved about the Internet was the anonymity. The other thing the Internet provides is a treatment process that can be less demanding in terms of time and energy commitment.
For example, let's take a mother with postpartum depression. Part of the stresses for her are not sleeping at night and dealing with a crying child. If you tell her that she must find baby-sitting arrangements to see a therapist on a weekly basis, you are just going to add to her stress. The ability to make treatment available conveniently to her in her home or some other private place at moments when she can best use it is incredible.
In rural situations, you have the same ability and can overcome shortages of child psychiatry, shortages of opioid addiction treatment—not just medication but also ongoing therapy. All of these services can be provided through telemedicine to people privately and conveniently.
Another thing is that stigma is a huge issue. People have been reluctant to get treatment because they do not want to be seen going into an office. People don't want to be seen going into the employee assistance program office at work because it will be presumed that they have a drinking problem or a marital problem or something else is going wrong in their life.
There is shame in admitting that your emotional life is not totally under your control. If we can do anything to reduce that stigma and tell people that seeking help when they are emotionally challenged is acceptable, it would go a long way toward helping people.
HL: Give an example where technology is driving change in the mental health field.
Whitehouse: In more serious mental illness, there are new technologies that monitor people's movements and activities. For serious and chronic conditions such as schizophrenia and psychotic depression, people become reclusive and cut themselves off from the world. Now, we can do things like use cell phones to monitor social interactions, monitor affective tone, and monitor movement. With this technology, we can have a better sense of how these people are doing.
HL: What are the best practices for conducting behavioral health visits through telemedicine?
Whitehouse: Good telepsychiatry generally should start with an excellent screening process to choose patients who are most likely to benefit from telemedicine. That first screening session is probably one of the most important things that we do.
There are some cases that should not be handled in telemedicine—certain personality disorders have a high degree of intensity in emotional and behavioral interactions. For these patients, the day-to-day flareups are not handled well at a distance.
There also is a different skill related to the way you appear when you conduct a telehealth session. Whether it is just voice-to-voice or a telehealth presence, therapists must present themselves professionally. Probably even more so than a medical doctor, a therapist is part of the therapy—the eye contact they have on the screen, the way they look interested in the patient, how they dress, how their office looks—all these factors create an ambience in which you are creating a sense of safety for the patient. It can be unconscious to the therapist, and it can be unconscious to the patient, but its power is dramatic.
HL: How are AbleTo's telemedicine visits financed?
Whitehouse: The model at AbleTo is primarily geared to health plans and insurance companies. Our telehealth visits are generally considered a payable service. In most cases, we work with patients who pay with their behavioral health insurance benefit.
In commercial insurance, there usually is a copay. Behaviorally, we like the copay because psychologically, when you make something tremendously convenient for people, you want people to have an interest in the therapy themselves. The copay is an indicator that the patient is willing to make an investment in themselves.
HL: Is it particularly challenging when you are working as a telepsychiatry provider and you have a patient who slips into crisis?
Whitehouse: There are two considerations.
One, in the screening process, you want to determine who is a high-risk patient and who is not. If a patient has a history of past suicide events or a history of psychosis, they are not going to be a good candidate for telepsychiatry. They should be handled by a team of people who can be much more readily available.
Two, everyone with a behavioral health issue can experience a crisis, and every telehealth service should have a capability that is available 24/7 for both the intake team as well as therapists out in the field.
What happens when someone has a crisis is there needs to be a way over the computer, or text message, or over the phone that you can alert someone in the organization that the patient is in crisis. The one thing you don't want to do is get off the phone or break the human contact in any way. You then start to assess the crisis; and if you are the therapist in the field, you hand over the patient to the professional crisis team, whether it's over the phone or over the computer. Then the situation is exactly the same as if the patient was connected to the national suicide hotline.
Basically, a crisis worker is trained to perform a series of protocols that will first assess and try to de-escalate the situation. Often, when psychiatric patients are in crisis, the one thing they are most afraid of is loss of autonomy. You try to maximize their autonomy and try to find out what resources are available. Is there someone else in the house? Can you get a close friend on the phone?
If someone is suicidal and they have a gun, you are going to keep them on the line, and you will generally have a text-messaging capability to text a colleague. You will text that colleague and get them to contact the crisis team in the local community. Every telehealth crisis team should have the numbers for local resources. The local crisis teams deal with these situations often, and they can determine who should go out to the patient—whether it is a mental health crisis team or the police in a highly escalated situation.
You need to have not only a series of protocols in place and access to a crisis intervention system, but you also need to make sure that every provider who is engaged internally and every provider who is engaged externally is fully aware of the crisis services and trained in how to use them. That's one of the things that we take seriously at AbleTo.
Most hospitals and physician practices do not screen for all five of the social determinants of health featured in the federal Accountable Health Communities model.
Most healthcare organizations are not screening for the primary social determinants of health, recent research shows.
Social determinants of health (SDOH) such as housing, food security, and transportation can have a pivotal impact on the physical and mental health of patients. By making direct investments in initiatives designed to address SDOHs and working with community partners, healthcare organizations can improve patient health in profound ways beyond the traditional provision of medical services.
"The association of patients' social needs, such as food insecurity, housing instability, utility needs, transportation needs, and experience with interpersonal violence, with health outcomes and costs is increasingly recognized by the medical community, and an increasing amount of evidence documents that physician- and hospital-led interventions addressing patients' social needs can produce improved health outcomes and less costly medical care," wrote the co-authors of the recent research, which was published in the Journal of the American Medical Association.
Prevalence of SDOH screening
The researchers examined data from more than 2,000 physician practices and more than 700 hospitals.
The primary focus of the research was the prevalence of screening for the five social needs highlighted in the Centers for Medicare & Medicaid Services (CMS) Accountable Health Communities model: food insecurity, housing instability, utility needs, transportation needs, and experience of interpersonal violence.
The research generated several key data points:
24.4% of hospitals and 15.6% of physician practices reported screening for all five SDOHs
8.0% of hospitals and 33.3% of physician practices reported no screening for SDOHs
The most commonly screened SDOH was interpersonal violence, at 75.0% of hospitals and 56.4% of physician practices
The least commonly screened SDOH was utility needs, at 35.5% of hospitals and 23.1% of physician practices
At physician practices, the highest rates of screening for all five SDOHs were at federally qualified health centers (29.7%), Medicaid accountable care organizations (21.8%), bundled payment participants (21.4%), and primary care improvement model participants (19.6%)
Among hospitals, the highest rate of screening for all five SDOHs was conducted at academic medical centers (49.5%)
"This study’s findings suggest that most U.S. physician practices and hospitals do not report screening patients for key social needs, and it appears that practices serving more economically disadvantaged populations report screening at higher rates," the researchers wrote.
Interpreting the data
Availability of resources is the most likely explanation for why hospitals are more likely to screen for SDOHs than physician practices, the researchers speculated. "Hospitals may have more resources, including staffing, financial, and technological, as well as more processes, protocols, and standardization in care delivery."
Regulatory considerations are another likely factor driving higher screening rates at hospitals, the researchers wrote. "Hospitals may also be more likely to screen patients for transportation and housing needs as part of their discharge processes because they are subject to federal regulations on patient safety as part of their certification from CMS."
Lack of financial resources was reported as a major barrier to screening at both physician practices and hospitals. At physician practices that conducted no SDOH screening, 51% reported lack of financial resources as a major barrier. At hospitals that conducted no screening, 60% reported lack of financial resources as a major barrier.
Increased financial support will likely be needed to increase screening for SDOHs at hospitals and physician practices, the researchers wrote.
"Payers could allow physicians and hospitals to bill for evidence-based programs, such as FoodRx, that have been shown effective at addressing needs and improving outcomes. The CMS could consider expanding care management billing to include managing care for patients who are both at risk or have clinically complex conditions in addition to social needs."
Researchers have associated metabolic surgery with lower risk for all-cause mortality, coronary artery events, cerebrovascular events, heart failure, nephropathy, and atrial fibrillation.
Metabolic surgery in patients with obesity and type 2 diabetes results in significantly lower risk of major adverse cardiovascular events, recent research indicates.
From 2015 to 2016, 39.8% of Americans over age 20 were obese, according to the Centers for Disease Control and Prevention (CDC). For the same time period, 20.6% of adolescents were obese, the CDC says. In 2008, the estimated annual medical cost of obesity was $147 billion.
The stakes are high for people with obesity and type 2 diabetes, according to the co-authors of the recent research, which was published in the Journal of the American Medical Association. "In patients with obesity and type 2 diabetes, weight and glycemic goals are difficult to achieve through usual care including lifestyle modifications and pharmacotherapy. In patients with obesity and diabetes, cardiovascular disease is the major cause of morbidity and mortality," they wrote.
Cardiovascular impact of metabolic surgery by the numbers
The recent research features data collected from more than 13,000 patients—2,287 patients who underwent metabolic surgery and 11,435 patients in a control group that did not have surgery. The primary focus was the incidence of six major adverse events: all-cause mortality, coronary artery events, cerebrovascular events, heart failure, nephropathy, and atrial fibrillation.
30.8% of patients in the metabolic surgery group experienced major adverse events after their operations compared to 47.7% in the nonsurgical control group
All-cause mortality occurred in 10.0% of patients in the metabolic surgery group compared to 17.8% in the nonsurgical group
After following patients for eight years, mean body weight was reduced by 29.1 kg in the surgery group and 8.7 kg in the nonsurgical group
Utilization of noninsulin diabetes medications, insulin, hypertensive medications, lipid-lowering therapies, and aspirin were significantly lower for the surgery group compared to the nonsurgical group
Complications after metabolic surgery were relatively low, including bleeding requiring transfusion in 3.0% of patients, pulmonary adverse events in 2.5% of patients, venous thromboembolism in 1.0% of patients, cardiac events in 0.7% of patients, and renal failure requiring dialysis in 0.2% of patients
"All six prespecified outcomes were significantly lower in the surgery group, including all-cause mortality, coronary disease events, cerebrovascular events, heart failure, atrial fibrillation, and nephropathy," the JAMA researchers wrote.
Interpreting the research
The research team speculated that substantial and sustained weight loss after metabolic surgery led to a lower prevalence of major adverse cardiovascular events. "It's the most obvious conclusion," one co-author told HealthLeaders.
"You do metabolic surgery, and people lose a lot of weight. We know obesity is associated with cardiovascular risk enhancement from increased cholesterol, increased blood pressure, and higher incidence of diabetes. So, if you make the obesity better, it stands to reason that you would expect rates of cardiovascular disease to go down," said Steven Nissen, MD, professor of medicine, Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland.
The magnitude of the cardiovascular benefits of metabolic surgery was unexpected, he said.
"This is a huge treatment effect. It was possible that the adverse cardiovascular prognosis from obesity would be largely irreversible. In other words, once people were obese, you would have a hard time reversing their cardiovascular event rate. That was not what we saw. There was a 39% reduction in six component adverse cardiovascular events and a 41% decreased risk of all-cause mortality. Those are really large effects," Nissen said.
Despite the eye-popping results, it is unreasonable to expect that metabolic surgery alone can end the country's obesity epidemic, he said.
"There are tens of millions of people in America who have severe obesity, and we cannot do surgery in all of them. Last year, about 250,000 people underwent bariatric surgery. Studies like ours will increase the number of people who are offered the operation. … It is a therapy that can be utilized in more people, but it is not going to completely fix the obesity epidemic because it just is not practical to do the operation in everybody who is obese."
More research is needed to confirm the JAMA study's findings, Nissen said.
"We recognize there are limitations of our study. It is an observational study, not a randomized controlled trial. We think that our findings make it imperative that we do a large randomized controlled trial, and we are working on securing the necessary funding to do that. We need to nail down for certain what these benefits are and what the risks are in a randomized controlled trial."
The initiative is designed to improve care for the 46 million Americans over age 65—a population that is growing by 10,000 people daily. The primary focus of the initiative is promoting evidence-based care for this vulnerable population.
"What's drawn health professionals to the Age-Friendly Health Systems movement is that it offers an organizing framework of evidence-based care that can be practiced reliably. And it all starts with knowing and acting on what matters to the older adult," IHI Senior Director Leslie Pelton said in a prepared statement.
Four-component framework
The IHI initiative, which was launched in early 2017, features the 4Ms:
1. What matters to the patient: With a potentially dramatic impact on medical decisions, determining what matters to patients may be the most momentous of the 4Ms, Kedar Mate, chief innovation and education officer at Boston-based IHI, told HealthLeaders earlier this year. "Improving medical decision-making is a key element of attaining value. Of all the interventions, the first M—what matters—gets you to high value as defined by the patient. It gets you to services that offer value in the patient's eyes."
2.Medication: Managing medications is crucial for achieving therapeutic benefits and avoiding adverse drug reactions, which cause harm and costly complications. Annual costs in the United States associated with adverse drug reactions have been estimated at $30 billion, according to a December 2013 article in the Journal of Pharmacology & Pharmacotherapeutics.
3. Mentation: Addressing delirium in the inpatient setting generates significant mentation benefits, Mate said. "Delirium is extremely common among older adults in inpatient settings, and it is extremely costly both on the human cost side with complication rates and lengths of stay, and the financial side. Length of stay is often 20% to 30% longer with delirium."
4. Mobility: Maintaining mobility also generates clinical and financial benefits, he said. "The data on functional impairment is stark. If you have a patient with one or two chronic conditions, then you add on functional impairment, the cost of care roughly doubles. Functional impairment is a big impediment in older adults' lives in achieving what matters to them, and it costs us a ton of money as a society."
Gaining recognition
Last week, IHI recognized 162 hospitals and physician practices for their Age-Friendly Health Systems initiative adoption efforts.
Eighty-five of the healthcare organizations were designated as "Age-Friendly Health Systems—Committed to Care Excellence" for reporting the number of older adults reached with the 4Ms over at least a three-month period. The remaining 77 organizations were recognized as "Age-Friendly Health Systems Participants" for showing commitment to put the 4Ms into practice and submitting their plans for IHI review.
