There are several considerations for both physicians and administrators, including notice periods and how to initiate retirement discussions.
Healthcare organizations should create a positive culture and effective processes for physician retirements, according to a recent survey report published by Alpharetta, Georgia-based Jackson Physician Search.
Physician retirements pose multiple challenges, the survey report says: by next year, about one-third of physicians will be over 65 and nearing retirement; and open positions impact patient satisfaction, staff morale, and revenue. For example, a hospital can lose about $150,000 in revenue per month when a specialist retires and is not replaced.
Physicians and healthcare organization administrators should work cooperatively to manage retirement transitions, the survey report says. "Differences remain on length of notice and whose responsibility it is to bring up retirement, but when handled respectfully and conducted in a non-discriminatory way, both parties can find the ideal way to transition the retirement with proper planning and processes."
The survey report, which features data collected from more than 550 physicians and 100 administrators, has several key findings:
For physicians, lifestyle was identified as the most important factor in retirement decisions, with lifestyle cited by 44% of physicians surveyed. Financial stability was the next most important factor, cited by 23% of physicians. Other factors included burnout and frustration with the "current state of medicine."
Most physicians (80%) said it was their responsibility to broach the topic of retirement, but only 52% said they were comfortable discussing retirement.
Only 37% of administrators said it was their responsibility to broach the topic of retirement, but 74% said they were comfortable discussing retirement.
Physicians and administrators were at odds over the ideal notice period for retirement. The largest percentage of physicians (40%) expressing a notice preference said six months or less was appropriate, and 34% said no notice of retirement was required. Nearly 50% of administrators said notice of retirement should ideally be one to three years.
Physicians and administrators also had widely varying views on post-retirement employment. Nearly 40% of administrators said they expected retiring physicians to stop practicing entirely, but only 17% of physicians said they planned to leave practice entirely. More than a quarter of physicians said they would work full-time or part-time after retirement at another healthcare organization, or they would pursue other employment opportunities such as locum tenens work or telemedicine.
Initiating retirement conversations: Physicians
For physicians, there are three primary considerations when broaching the topic of retirement with healthcare organization administrators, Tony Stajduhar, president, Jackson Physician Search, told HealthLeaders.
1. Coping with uncertainty: It is OK to discuss retirement even if you don't have a set date. Because recruiting a physician is difficult and takes time, approach the topic early prior to having a firm date. This will give administration the time it needs to identify the right candidate to try and fill your role and fulfill your legacy.
2. It never hurts to ask: Present your ideal scenario to the administration—they may be willing to work with you because your services are highly valued. There may even be an option to shift from full-time practice to part-time if desired.
3. Make retirement mutually beneficial: Approach the topic as a win-win, whether you want to transition slowly or fully retire. You want both parties to have mutual understanding.
There are also three primary considerations when administrators broach the topic of a physician's retirement, Stajduhar said.
1. Retirement is not a taboo topic: Work in close coordination with your human resources department to make sure physicians know they work in a safe environment and that they will not be fired or let go early for bringing up the topic of retirement.
2.Be flexible: Knowing what physicians really want while winding down their career is important. The more flexibility you can offer, the longer the physician will stay, ideally full-time but possibly even part-time for the long-term. Offering employment options potentially avoids the need for expensive locum tenens coverage.
3. Establish guidelines: Work with your HR department to have a retirement policy in writing or as part of hospital bylaws, and make sure the policy is communicated in writing.
Ongoing recruitment
The survey report recommends that administrators consider having an ongoing process for physician recruitment. For administrators, there are three best practices for ongoing recruitment, Stajduhar said.
1. Be knowledgeable about recruitment timelines: Some specialties are more difficult to recruit than others. Know how long it has taken you in the past and work backward from there. To serve patient needs, a little extra capacity is always better than a vacancy.
2. Have a strong recruitment partner: If a retirement is unexpected and it is crucial to fill the position quickly, explore the option of working with an established recruitment firm. They often have access to a larger pool of resources and experienced consultants to provide expert advice.
3.Time is not on your side: The longer you wait to actively start your search, the longer you will have a vacancy. Residents and fellows are very time sensitive and usually interview in the fall. Sometimes, residents and fellows interview as early as the spring of the previous year for a start date the following summer—almost 18 months out.
A new report identifies diagnostic errors as the top patient safety risk in ambulatory care settings.
A watchdog group has identified the top four risks for patient safety at ambulatory care settings, according to a new report.
Ambulatory care facilities such as physician offices and outpatient clinics are the most widely used settings in U.S. healthcare, according to the ECRI Institute PSO report published last week. Ambulatory care settings provide a wide range of services to patients such as consultation, diagnosis, and interventions.
"As healthcare delivery shifts from hospitals to ambulatory care settings, it can be challenging to coordinate care among various clinicians, systems, and facilities, raising the potential for errors that put patients at risk. Reducing and eliminating adverse events in an outpatient environment will require an unprecedented commitment to collaboration and coordination," Marcus Schabacker, MD, PhD, president and CEO of the ECRI Institute, said in a prepared statement.
The watchdog group is based in Plymouth Meeting, Pennsylvania.
According to the ECRI Institute PSO (patient safety organization) report, the top four risks for patient safety at ambulatory care settings are diagnostic testing errors, medication events, falls, and security incidents.
ECRI Institute PSO examined more than 4,300 ambulatory care patient safety events from December 2017 to November 2018. Diagnostic testing errors accounted for the most events (47%), followed by medication safety events (27%). Highlights of the findings and recommendations are below.
1. Diagnostic testing errors
Patients can experience several negative impacts from diagnostic testing errors such as missed or delayed diagnoses, delayed interventions, and duplication of services. According to the ECRI Institute PSO report, the most common diagnostic testing errors involved laboratory tests (69%), followed by imaging tests (21%).
The report's recommendations to curb diagnostic testing errors include the following:
Establish decision support tools to help clinicians order appropriate tests
Establish processes for communicating test results such as a chain of command that includes a reporting provision when the clinician who ordered a test is absent
Establish standard operating procedures in writing for specimen, collection, preparation, and delivery
2. Medication events
Medication safety events are a leading cause of malpractice claims in ambulatory care. In a Coverys analysis of more than 10,000 closed malpractice claims, medication errors were the fourth most common cause of medical professional liability claims, and 42% of the errors occurred in an ambulatory setting.
In the ECRI Institute PSO analysis, the most common medication safety event (67%) involved "wrong" errors such as wrong patient or wrong drug, followed by monitoring errors (16%). "Such events can occur during any stage of the medication process and are rarely the fault of one person; rather, as with most adverse events, they result from a series of failures within a system," the ECRI Institute PSO report says.
The report's recommendations to reduce medication errors include the following:
Identify priority areas for medication safety improvement such as medication-event reporting and medication safety education
Establish standardized policies and procedures that feature best practices for each phase of the medication management process
Establish and communicating management processes for high-alert medications such as chemotherapy drugs, including storage and administration
3. Patient falls
Patient falls accounted for 14% of the events in the ECRI Institute PSO analysis, with most falls occurring in the physician practice setting.
"Falls are often preventable occurrences that can lead to patient injury, cause hospitalizations, and significantly increase healthcare costs. Falls occurring in hospitalized patients are a major source of risk for acute and long-term care providers. In ambulatory care, screening for the risk of falls is an important component of preventing falls whether in the office setting, at home, or elsewhere," the report says.
The report's recommendations to decrease falls include the following:
Screen patients for falls during every visit, when there is a change in medical condition, and after a fall
Train staff to identify fall risks during a range of patient interactions such as welcoming and conducting medical assessments
In the electronic medical record, flag prescriptions of medications that have a fall risk when the drug is ordered and during medication reconciliation
4. Security incidents
About three-quarters of U.S. workplace assaults occur in healthcare settings, according to a federal Occupational Safety and Health Administration report. Most of the security events examined in the ECRI Institute PSO analysis involved verbal threats or disruptive behavior by patients or patient visitors.
"Unfortunately, security and safety issues, such as workplace violence, are common in healthcare, including ambulatory care settings. Although most episodes of disruptive behavior or violent acts are perpetrated by patients, some are perpetrated by family members of patients, other visitors, employees, or ill-meaning trespassers," the ECRI Institute PSO report says.
The report's recommendations to address security incidents include the following:
Establish a well-resourced workplace violence prevention program
On at least an annual basis, conducting an all-hazards risk assessment that includes patient risks, environmental risks, and operational risks that gauge the potential for violence
On at least a monthly basis, have security and safety surveillance rounds
In the New Orleans area, LCMC Health is making strides toward value-based care by taking a population health services organization approach to its new clinically integrated network.
A New Orleans–based health system has crafted a new clinically integrated network (CIN) as a population health services organization.
One of the major challenges in healthcare is managing the shift from the traditional fee-for-service model for delivery of medical services to value-based models. The primary goal of these efforts is to replace fee-for-service contracts with payers with value-based contracts such as shared savings arrangements that include financial rewards for reducing cost of care.
LCMC Health formally launched the New Orleans health system's new population health services organization CIN in January 2018 in a business relationship with St. Louis–based Lumeris. There are five essential elements in the initiative, says Meg Vitter Greene, MHA, vice president of population health and network development at LCMC Health.
"What is unique about building a population health services organization is that it is a commitment to building out the five components that Lumeris identifies as being part of a PHSO: governance and leadership, physician engagement, payer strategy, care delivery, and technology and analytics. Many clinically integrated networks may do one or two of those well, but they do not focus on all five. Without building all five and making sure that they all have adequate attention, I don't think you can be successful," Vitter Greene says.
Population health services organization CIN by the numbers
LCMC Health's population health services organization CIN, which is called LCMC Healthcare Partners, enjoyed a measure of success in its first year, generating $3.6 million in gains from value-based contracts based on quality metric performance and shared savings in 2018, she says. About $1.5 million of the total was shared savings.
"We had success in both categories. For the quality metric dollars, we receive them throughout the course of the calendar year. For shared savings, we have an annual evaluation as to whether we have reduced the cost of care. In 2018, we earned shared savings with Medicare Advantage payers, and we earned quality metric dollars across all types of payers, including Medicare, Medicaid, and commercial insurance," Vitter Greene says.
The LCMC Healthcare Partners network features all five of LCMC Health's hospitals: a safety-net academic medical center, a children's hospital, and three community hospitals. There are nearly 900 physicians in the network—about 270 primary care physicians split evenly between adult care and pediatric care along with about 600 specialty clinicians.
In January 2018, LCMC Healthcare Partners launched with about 65,000 lives managed in value-based contracts, and that figure could be as high as 90,000 by the end of this year, she says. "For now, about 70% of our patients are still in the fee-for-service world."
Vitter Greene shared some of the highlights of LCMC Healthcare Partners' five-part strategy.
1. Governance and leadership
The first big step in developing LCMC Healthcare Partners was educating the health system's senior leadership about the benefits of increasing efforts to shift from fee-for-service to value-based care, she says.
"Without that commitment, embarking on a long-term strategy like this just won't work. So, there was a lot of time and energy educating our leadership on the value of providing population health across our patient base and educating leaders about the movement to value-based care. We educated people about why this was better for our patients and physicians, why it would improve the quality of the care we provide, and why it would reduce the overall cost of healthcare."
The health system's senior clinical leaders were convinced that a value-based approach to population health would garner significant benefits, Vitter Greene says. "We have physician leaders and quality leaders throughout the organization who are focused on preventative medicine and focused on keeping patients healthy instead of waiting to treat them until they are sick. They are interested in improving the overall health of our patient population."
2. Physician engagement
LCMC Healthcare Partners has several physician engagement initiatives, including educational sessions at physician practices and large physician groups that are part of the network, along with identifying physician champions at employed and community physician practices, she says.
A significant component of the physician engagement effort is a "pod structure" to reach individual physicians in the network, Vitter Greene says.
"We have associate medical directors working over groups of practices who share information about performance and care gap closures with physician champions at the practice level. Then those physician champions get information down to the individual physician level. We think the pod structure will encourage physician engagement and healthy competition among our physicians to perform well in value-based contracts and take great care of their patients."
3. Payer strategy
LCMC Health has a diverse payer mix, including many patients covered through Medicaid who receive services at the health system's safety-net academic medical center and the children's hospital. As a result, LCMC Healthcare Partners' payer strategy involves seeking value-based contracts with a range of payers, she says.
"To build a clinically integrated network that can support all of our hospitals, we have to have an all-payer, all-population network. Oftentimes, clinically integrated networks will focus on Medicare such as a Medicare accountable care organization—managing one specific population well. We can't do that because the mission at LCMC Health is to take care of all patients. It's an ambitious goal, but we believe that we can build an all-payer, all-population model."
LCMC Healthcare Partners is striving to establish value-based contracts with as many payers as possible, which has impacted the network's managed care strategy, Vitter Greene says. "We are focused on a managed care strategy that straddles across Medicare Advantage, traditional Medicare, commercial payers, and Medicaid."
4. Care delivery
The health system's diverse population and payer mix has implications for care delivery such as case management, she says.
"We have our own case managers, but we need them to be diverse. We can't just have case managers who have experience in doing adult case management—we need case managers who have experience with behavioral health issues and experience in pediatrics. So, we're always looking to make sure we are being as thoughtful as possible in building out a case management team that can take care of the diverse population we serve."
5. Technology and analytics
Harnessing data is an essential function at LCMC Healthcare Partners, Vitter Greene says.
"We've been able to take claims data from all of the payers that we work with and marry it with data from our electronic medical record that we have at LCMC Health. Then we put all of that information in one population health tool, which analyzes and risk stratifies our patient population so we can prioritize patients for outreach. Through that identification of patients for outreach, our case managers can execute on their workflows."
The Leapfrog Group's surveys collected data from more than 300 ambulatory surgery centers and more than 1,100 hospital outpatient departments.
For the first time, The Leapfrog Group has collected patient safety and quality information about ambulatory surgery centers (ASCs) and hospital outpatient departments (HOPDs).
Leapfrog has been collecting patient safety and quality data about hospital inpatient facilities for years. With more than 60% of surgical procedures now possible to perform at ASCs and HOPDs, the Washington, DC-based watchdog organization decided to expand collection of data to these same-day surgery settings.
The data was reported recently in a report based on two surveys. A new survey collected data this year from 321 ASCs. In an expanded Leapfrog Hospital Survey, data was collected this year from 1,141 HOPDs. "Both surveys were developed with guidance from national experts and include standardized, evidence-based measures of care specific to places that perform ambulatory and outpatient procedures," the report says.
The surveys generated several key data points, including the following:
Life support: All ASCs and HOPDs reported having a board-certified clinician for advanced cardiovascular life support present while adult patients undergo procedures and recovery. However, fewer of the facilities reported always having a board-certified clinician present for pediatric advanced life support: 89% of ASCs and 96% of HOPDs. "This displays a potential gap in ability to perform life-saving actions if complications arise for pediatric patients," the report says.
Surgery board certification: Leapfrog found that 1 in 3 same-day surgery facilities do not have 100% board-certification among surgical professionals.
Anesthesia board certification: Nearly 30% of ASCs reported that not all providers administering anesthesia are board certified. Nearly 20% of HOPDs reported that not all providers administering anesthesia are board certified. "Though 71% of ASCs and 83% of HOPDs report that all individuals who administer anesthesia are board-certified, there is still significant room for improvement," the report says.
Surgery consent materials: Relatively few ASCs and HOPDs provided surgery consent materials to patients before the day of surgery. Consent materials were provided to patients at least three days prior to surgery at 17% of ASCs and 21% of HOPDs. Consent materials were provided to patients one to three days prior to surgery at 14% of ASCs and 21% of HOPDs. Consent materials were provided to patients the same day as surgery at 65% of ASCs and 49% of HOPDs. "Providing consent materials prior to the day of the procedure gives patients the opportunity to adequately consider the risks involved," the report says.
Anesthesia consent materials: ASCs and HOPDs reported similar data for provision of anesthesia consent materials to patients. Anesthesia consent materials were provided to patients at least three days prior to surgery at 8% of ASCs and 10% of HOPDs. Consent materials were provided to patients one to three days prior to surgery at 8% of ASCs and 12% of HOPDs. Consent materials were provided to patients the same day as surgery at 80% of ASCs and 71% of HOPDs.
Antimicrobial stewardship: Only 18% of ASCs reported they had adopted antimicrobial stewardship programs. "ASCs are encouraged to adopt a program to promote the appropriate use of antimicrobials (including antibiotics), which can in turn improve patient outcomes, reduce microbial resistance, and ultimately decrease the spread of infections," the report says. Although data was not available for HOPDs, 93% of acute care hospitals have reported having antimicrobial stewardship programs.
Interpreting the data
Erica Mobley, director of operations at The Leapfrog Group, told HealthLeaders that the survey result on antimicrobial stewardship at ASCs was "certainly a concern."
"Antibiotic and antimicrobial use in ASCs is different from that administered in other healthcare environments, which is why Leapfrog chose to include this safety protocol on its survey. Many resources and toolkits have been developed to help ASCs with implementing an antimicrobial stewardship program, and we are confident this number will grow in the future," she said.
The findings that 11% of ASCs and 4% of HOPDs do not always have a clinician present who is certified to provide advanced life support for pediatric patients is also concerning, Mobley said. "If unexpected complications arise, these facilities may not be well-equipped to care for pediatric patients. ... Parents should inquire about the availability of clinicians certified in pediatric advanced life support prior to scheduling a procedure for their child."
When selecting an ASC or HOPD for a surgical procedure, patients should consider the presence of board-certified clinicians performing procedures and administering anesthesia, she said.
"Board certification is a voluntary process separate from licensure. Medical professionals who pursue it demonstrate a desire to grow their skillset to keep pace with the latest advancements in their specialty. Consumers considering their options for surgery should inquire whether the healthcare team consists of board-certified individuals to inform their decision of where they seek treatment. In some cases, the absence of board-certified clinicians may mean that experts who have the skillset to treat true complications are not present in the facility."
CMS Administrator Seema Verma vows to take 'aggressive actions.'
The Centers for Medicare & Medicaid Services (CMS) have announced a five-part strategy to combat fraud, waste, and abuse in the Medicare program.
About 25% of U.S. healthcare spending is wasteful, according to a recent article published in the Journal of the American Medical Association. The JAMA researchers focused 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.
Administrative complexity accounted for the largest amount of estimated annual wasteful spending at $265.6 billion. Medicare has drawn criticism for decades over administrative complexity.
In a blog post published last week, CMS Administrator Seema Verma outlined the agency's five-part "program integrity strategy."
"CMS defines program integrity very simply: 'pay it right.' Program integrity must focus on paying the right amount, to legitimate providers, for covered, reasonable and necessary services provided to eligible beneficiaries while taking aggressive actions to eliminate fraud, waste and abuse," Verma wrote.
The five approaches to improve program integrity are stopping bad actors, preventing fraud, mitigating emerging programmatic risks, reducing provider burden, and leveraging new technology. Highlights of the strategies are below.
1. Stopping bad actors
Verma says several agencies are actively involved in identifying Medicare fraud and referring cases to law enforcement, including CMS, the Office of the Inspector General, the Department of Justice, and Unified Program Integrity Contractors. "We work with law enforcement agencies to identify and take action on those who defraud the Medicare program," she wrote.
For example, she says "healthcare fraud takedowns" in recent months targeting orthotic braces and genetic testing saved Medicare $3.3 billion dollars.
2. Preventing fraud
As opposed to Medicare's "pay and chase" model of combatting fraud in the past, CMS is developing approaches to prevent fraud, waste, abuse before claims are paid, Verma wrote.
"After we identify bad actors and their schemes, we make system changes to avoid similar fraudulent activities in the future. CMS' oversight, audit, and investigative activities allow us to analyze data to identify potential problem areas. We then work with our law enforcement partners to develop policies, regulations, and processes to prevent vulnerabilities from being exploited before claims are paid."
For example, CMS took measures to prevent fraud during the recent effort to send new Medicare cards to beneficiaries, she wrote.
"CMS implemented an enhanced address validation process to verify beneficiaries' identities and addresses against multiple information sources. This ensured that we mailed new Medicare cards to the right person at the right address. We reviewed over 61 million cards for address accuracy, which we estimate saved billions of dollars in fraudulent claim payments."
3. Mitigating emerging programmatic risks
As Medicare shifts from the program's traditional fee-for-service payment model to value-based payment models, CMS is committed to developing safeguards to ensure the integrity of the new reimbursement processes, Verma wrote.
"New payment models have been very beneficial but also have the potential to cause new challenges in identifying improper payments, beneficiary safety issues, and other program integrity concerns. CMS is continuing to explore ways to identify and reduce program integrity risks related to value-based payment programs by looking to experts in the healthcare community for lessons learned and best practices."
4. Reducing provider burden
While CMS steps up efforts to combat fraud, abuse, and waste, the agency is mindful that it should not create inappropriate time and cost burdens on healthcare providers, Verma says.
"To that end, we have increased efforts to educate providers in CMS program rules and regulations and remedy onerous processes to assist rather than punish providers who make good faith claim errors. That's the purpose of our Targeted Probe and Educate (TPE) program and our efforts to streamline our recovery audit processes. It's vital to separate providers who make clerical errors from truly nefarious actors."
Through the TPE program from October 2017 to February 2019, she says CMS provided one-on-one education for 20,000 healthcare providers and medical goods suppliers to decrease honest mistakes. "As a result, approximately 80% of those providers and suppliers were released from further review," she wrote.
5. Deploying new technology
CMS is committed to deploying new technology to boost the efficiency of fraud, waste, and abuse reduction efforts, Verma wrote.
"Today, the Medicare fee-for-service program relies on clinician reviewers—human beings—to review the medical records associated with items and services billed to Medicare. Providers also have to send us copies of medical records, which is time-intensive and burdensome. That is why we only review less than 1% of medical records. Looking forward, CMS is seeking new, innovative strategies and technologies, perhaps involving artificial intelligence and/or machine learning, which are more cost effective and less burdensome to both providers, suppliers and the Medicare program."
For example, CMS is hoping to upgrade the agency's Fraud Prevention System and case management systems, she wrote. "While these systems have helped us to obtain a positive return on investment, we believe that by adopting cutting edge technology—such as AI and machine learning tools—we can achieve greater savings for taxpayers and allow us to review more claims."
Comments on the CMS Center for Program Integrity initiative can be submitted electronically via email at ProgramIntegrityRFI@cms.hhs.gov. Documents should be submitted in PDF format.
A new clinician burnout report from the National Academy of Medicine includes six recommendations to address the problem.
The National Academy of Medicine has released an extensive report on how the country can respond to burnout in the medical professions, with the president of the organization calling burnout an epidemic in need of urgent action.
Research indicates that about half of physicians nationwide are experiencing burnout symptoms, and a study published in October 2018 found burnout increases the odds of physician involvement in patient safety incidents, unprofessionalism, and lower patient satisfaction. Burnout has also been linked to negative financial effects at physician practices and other healthcare organizations.
The new report was unveiled Wednesday at an event held in Washington, DC. Victor Dzau, MD, president of the National Academy of Medicine, made a passionate call to action.
"Our nation is facing an epidemic of clinician burnout. Over the past several years, the medical community has recognized an alarming crisis of physician burnout and suicide, although the public remains largely unaware of it. So, it is in the interest of ensuring quality patient care and well-being of our clinicians that today's report is released to shine the spotlight on the crisis and recommend solutions to prevent it," he said.
Burnout is widespread throughout the medical community, Dzau said.
"The epidemic of burnout affects both those in training as well as those in practice. Over 50% of physicians and 45% to 60% of medical students and residents have symptoms of burnout. Furthermore, physician rates of depression or suicidal ideation remain very high—as high as 40%. This issue is not unique to physicians. There are high prevalence rates of symptoms of post traumatic stress disorder and emotional exhaustion among nurses and many other health professionals."
Burnout among healthcare workers has significant implications for patient care and society at large, he said.
"Burnout has been linked to self-reported errors, patient dissatisfaction, a reduced ability to express empathy, increased familial problems, stress-related illnesses, automobile accidents, and substance abuse. Clinician burnout also is a threat to the quality of patient care."
The new report was crafted by the National Academy of Medicine's Committee on Systems Approaches to Improve Patient Care by Supporting Clinician Well-Being. To address burnout among healthcare professionals, the report makes six recommendations, which are highlighted below.
1. Foster positive work environments
Healthcare settings should be transformed in ways that prevent and reduce burnout, support professional well-being, and promote quality care.
For example, senior leaders of healthcare organizations should be committed to monitoring and improving the clinical work environment. "Specifically, governing boards should hold organizational leaders accountable for creating and maintaining a positive and healthy work environment," the report says.
2. Promote positive learning environments
Medical education and training should be improved to create learning environments that prevent and reduce burnout as well as promote professional well-being.
For example, learning environments should support quality patient care with a collegial approach to learning. "Enhance the ability of learners to contribute meaningfully to patient care while learning, and implement strategies that build relationships among and between learners, faculty, and other health professionals with the intent to build social support and interprofessional practice," the report says.
3. Decrease administrative burden
Actions should be taken to address the negative side effects of laws, regulations, policies, and standards set by government agencies, professional associations, and accrediting organizations.
For example, resources should be allocated to assess the impact of laws, regulations, policies and standards. "Formal assessment should be conducted both prior to and following implementation in order to evaluate how the requirements affect clinician workload and whether they are redundant or conflict with other requirements. Regulations, policies, and standards should then be modified accordingly," the report says.
4. Develop technology solutions
Health information technologies should be redesigned and improved in ways that help clinicians to provide high-quality care.
For example, health information technology enhancements should focus on improvements that support clinicians and other healthcare professionals. "Health IT vendors and healthcare organizations should design and configure systems to improve the clinical work environment, including attention to cognitive load and workflows that reduce the demand of clinical documentation and automate non-essential tasks," the report says.
5. Support clinicians and trainees
Efforts should be made to decrease prejudice against healthcare professionals who experience burnout and to tear down barriers to receiving support and services to address burnout.
For example, barriers to receiving burnout support and services in training settings should be identified and brought down. "Health professions educational institutions, healthcare organizations, and affiliated training sites should identify and address those aspects of the learning environment, institutional culture, infrastructure and resources, and policies that prevent or discourage access to professional and personal support programs for individual learners and clinicians," the report says.
6. Promote research
Funding should be allocated to support research of clinician professional well-being.
For example, federal agencies such as the Agency for Healthcare Research and Quality, the National Institute for Occupational Safety and Health, and the Health Resources and Services Administration should lead efforts to research burnout and burnout interventions. Federal agencies should work in public–private partnerships with a range of stakeholders, including professional associations, foundations, payers, healthcare organizations, and professional liability insurers.
"Organizations need to be willing to test, learn, and share in order to accelerate the pace of change," the report says.
Paul King has served in leadership roles at some of the country's premier healthcare organizations, including Mayo Clinic and the University of Michigan.
After serving in leadership positions for more than three decades, the new top executive at Stanford Children's Health has a wealth of insight to share about management principles and pediatric care.
In January, Paul King, MHA, was named president and CEO of Stanford Children's Health and Lucile Packard Children's Hospital in Palo Alto, California. He started his career at Mayo Clinic, including working as the operations manager at the Mayo Clinic facility in Scottsdale, Arizona, when it was opened in 1987.
King has worked in pediatric medicine administration since 1996, when he joined Children's Hospital Los Angeles as president and CEO of the organization's Pediatric Management Group. He worked at CHLA for 18 years. Before joining the chief executive leadership team at Stanford Medicine, King led the University of Michigan's C.S. Mott Children's Hospital and Von Voigtlander Women's Hospital as executive director.
HealthLeaders recently spoke with King to find out about his perspectives on pediatric medicine and healthcare leadership. Following is a lightly edited transcript of that conversation.
HL: Why have you devoted the bulk of your career to pediatric healthcare?
King: The ability to have an impact on a child's life is pretty intoxicating.
From a fundraising standpoint, whenever we have an opportunity to meet with some of our supporters, the most powerful moments are when we can bring out a former patient who has an extraordinary story to tell with some sort of health condition. Then there's a tearful moment, when they introduce their family. They bring out their babies and their children. You see the full circle of life—we were able to intervene in a meaningful way to change their lives to the point where they have a family of their own.
Another attractive part of pediatric medicine is the sharing of knowledge. Compared to adult care, there are higher rates of cure and faster rates of improvement in pediatric medicine. In the pediatric space, we tend to share with each other. When we find something that works—we share that broadly with everyone.
HL: What is the most daunting challenge in pediatric medicine?
King: When we think about kids, they are a small portion of the national spend on healthcare. And when you are talking about pediatric care, you are often talking about Medicaid. We all agree healthcare needs to be reformed. The challenge for us in children's healthcare is to make sure that as healthcare is reformed it is done in a way that does not harm kids.
At most children's hospitals, close to half of their patients have their bills paid for by government programs—primarily Medicaid. So, the top 20 children's hospitals such as Stanford have a significant part of their budget supported by the government. Here at Stanford, about 40% of our budget is supported by California's version of Medicaid: Medi-Cal.
So, when you think about the best children's hospitals in the country, they are good because of the fundamental supporting structure that is provided by the government. That is not exactly intuitive when you think about the Medicaid program—most people tend to think about that program as being for poor kids. But it provides an infrastructure that supports all kids. We think that is a message that resonates whenever we get in front of our legislators—the unraveling of the public safety net can lead to the unraveling of the entire healthcare system.
HL: What is an emerging area of pediatric healthcare that you find most exciting?
King: One area where Stanford Medicine would like to carve a niche and make us more distinctive is precision medicine. We can look at a patient's genome and figure out a specific disease such as cancer and how we can customize an intervention or a care plan that is unique to the patient's genetic makeup. A traditional medication may be effective for a high percentage of patients across a population, but it may not be effective for specific individuals.
For example, with precision medicine you can create an intestine in a test tube, then provide medications and interventions to that organoid rather than having to put the patient through treatment directly. We think that precision health is the future of medicine, particularly as more and more organizations learn about genetics. That's an area for children's health that is very exciting.
HL: What is a primary area that needs to be addressed to improve maternal mortality?
King: The good news is that here at Stanford some of our staff members and researchers have been leaders in this space. Also, California has been bucking the trend that has been seen nationally. While maternal mortality rates have gone up nationally, California has been reducing maternal mortality rates.
One question is why the doctors at Mayo or Stanford are better than doctors elsewhere. It's not that they are better—it's that practice makes perfect. Most of the better health centers have higher volumes, so they are used to seeing complications and they can recognize them more easily.
One of the factors to improving maternal mortality is making sure the data generated from high volumes of activity is shared broadly, and we need to engage as many partners in that improvement process as possible. You get better performance by sharing your results with others. Then, when those other centers share their results, it becomes a virtuous cycle.
HL: What advice do you offer to emerging healthcare leaders?
King: I have been very blessed to have been recruited to every job I have had in 35 years in the healthcare field. The main factor that contributed to my good fortune was my willingness to be curious, and my willingness to pursue opportunities that may not have appealed to me right out of the gate.
It's also important to surround yourself and expose yourself to people who are different than you. When you think about diversity, equity, and inclusion, you can't limit yourself to the workplace. You should be thinking about these areas more broadly—this kind of education doesn't just happen in the classroom or the workplace. It's about how you live your life.
HL:Why is exposure to diversity so important for healthcare leaders?
King: For example, there is the inequity in the issue of maternal mortality for African Americans. When you think about the healthcare access barriers for the different populations in this country to get prenatal care, there are social determinants such as economics and culture impacting the kind of experience that a patient will have when they come in for care. They will ask unique questions of their care providers, and there will be different power differentials created when they are interacting with their care providers—these will be different with different patient populations.
The more experience you have with a diverse group of colleagues, the more you will learn that people don't look at the same issues in the same way. Men and women are different. There are different cultures. Diversity is more than skin deep. It's diversity of thought and diversity of economic background. All of those things bring a richness of experience to solving problems that a singular way of thinking just does not provide.
At the end of life, clinicians should engage their patients in conversations about care plans that include addressing the cost of care, researchers say.
Patients with terminal cancer are not recommended to receive intensive medical services at the end of life, but more than half are receiving these services, a recently published journal article says.
In the last year of life, patients experience a disproportionate share of medical spending. Although much of this spending is associated with the costs of serious illness, clinicians can often predict when costly intensive medical services have low value for patients at the end of life.
Spending on intensive medical services at the end of life can have an adverse financial impact on patients and their families, according to the co-authors of the recent journal article, which was published in the Journal of the American Medical Association.
"Given the low income of many elderly patients in the United States, the financial consequences of medically intensive services may be substantial. Costs of medically intensive services at the end of life, including patient financial consequences, should be considered by both physicians and families," the co-authors wrote.
The researchers examined data for more than 48,000 patients over the age of 65 who died as the result of a solid tumor. The study generated several key data points:
Despite recommendations from the National Academy of Medicine and the American Society of Clinical Oncology against intensive services at the end of life for this class of patients, 58.9% of them received intensive services in the last month of life
Patients who received no intensive services in the last month of life generated $7,660 in mean health system costs
Patients who received one or more intensive services in the last month of life generated $23,612 in mean health system costs
Patients who received no intensive services in the last month of life generated $133 in mean expected beneficiary costs
Patients who received one or more intensive services in the last month of life generated $1,257 in mean expected beneficiary costs
An intensive care unit stay was the most expensive intensive service at more than $20,000 in health system costs per patient and more than $1,100 in expected beneficiary costs
Chemotherapy was the least expensive intensive service at more than $2,900 in health system costs per patient and more than $800 in expected beneficiary costs
Patients and their clinicians should engage in shared decision-making about intensive medical services at the end of life, the JAMA researchers wrote.
"Ideally, patient-clinician decisions to pursue medically intensive services should involve discussions of the likelihood of benefit, risks, and side effects, including potential financial consequences, of these interventions. The present study provides reference cost estimates that may help inform those discussions."
The out-of-pocket costs of intensive services at the end of life are significant, they wrote.
"The present analysis indicates that patients experience approximately $1,250 out-of-pocket health costs in the last month of life due to medically intensive services. To place this number in context, the median annual household income of a Medicare beneficiary in 2014, the last year of this analysis, was $24,150, or $2,013 a month. Using these figures, expected beneficiary spending on medical services that have a low likelihood of helping them and could harm them may represent 62% of the household income of the typical Medicare enrollee in the last month of his life."
Avoiding questionable intensive medical services
In comments provided to HealthLeaders via email, two of the study's co-authors said intensive services at the end of life are often ill-advised.
"We found that most older cancer patients do indeed get intensive services at the end of life, even though experts recommend avoiding them. Other studies have shown that when asked, many patients prefer to avoid them as well," said Risha Gidwani-Marszowski, DrPH, a health economist at VA Palo Alto Health Care System in Menlo Park, California, and Steven Asch, MD, MPH, professor of medicine, Division of Primary Care and Population Health, Stanford University, Stanford, California.
"One guiding principal recommended by many specialty groups is having the discussions earlier in the course of the eventually fatal disease. This maximizes the chances of matching the course of care with the patients' preferences," they said.
When discussing end-of-life care with patients, the financial element should be part of the conversation, Gidwani-Marszowski and Asch said.
"Honest and early discussion with the patient about the medical risks and benefits of intensive care—and even an exploration of financial copays and burdens—can help patients make the best decisions. Other researchers have found that such discussions usually reduce patients' desires for intensive care. For patients with advanced cancer whose primary concern is longevity, still other researchers have found that less intensive palliative care that includes such discussion does not reduce life expectancy."
The National Academies of Sciences, Engineering, and Medicine has published a detailed report on implementing efforts to address the social needs of patients.
Healthcare providers can address social determinants of health through five approaches—awareness, adjustment, assistance, alignment, and advocacy, according to a report from the National Academies of Sciences, Engineering, and Medicine.
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 help their patients in profound ways beyond the traditional provision of medical services.
"The consistent and compelling evidence concerning how social determinants shape health has led to a growing recognition throughout the healthcare sector that improvements in overall health metrics are likely to depend—at least in part—on attention being paid to these social determinants," the National Academies report says.
The report outlines the "5As" strategies that healthcare organizations can implement to address SDOHs in the communities they serve. The strategies were developed by the National Academies' Committee on Integrating Social Needs Care into the Delivery of Healthcare to Improve the Nation's Health, Board on Health Care Services, Health and Medicine Division.
1. Awareness
The committee says awareness should focus on identifying the social risks and assets of specific patients and populations of patients.
"On the clinical side, patients visiting healthcare organizations are increasingly being asked to answer social risk screening questions in the context of their care and care planning. In some places, screening is incentivized by payers. As part of the MassHealth Medicaid program, for instance, Massachusetts accountable care organizations now include social screening as a measure of care quality," the report says.
2. Adjustment
Instead of addressing social needs directly, healthcare organizations can pursue a strategy that focuses on adjusting clinical care to address social determinants of health.
"Many examples of adjustment strategies were identified in the literature, including the delivery of language- and literacy-concordant services; smaller doctor-patient panel sizes for cases with socially complex needs (e.g., teams caring for homeless patients in the U.S. Department of Veterans Affairs health system have panel sizes smaller than the size of other VA care teams); offering open-access scheduling or evening and weekend clinic access; and providing telehealth services, especially in rural areas," the report says.
3. Assistance
Healthcare organizations can pursue strategies to connect patients with social needs to government and community resources.
"The literature contains descriptions of a variety of assistance activities that have been undertaken by health systems and communities. These assistance activities vary in intensity, from lighter touch (one-time provision of resources, information, or referrals) to longer and more intensive interventions that attempt to assess and address patient-prioritized social needs more comprehensively," the report says.
Intensive interventions include relationship building, comprehensive biopsychosocial needs assessments, care planning, motivational interviewing, and long-term community-based supports.
4. Alignment
Healthcare providers can pursue an alignment strategy that assesses the social care assets in the community, organizes those assets to promote teamwork across organizations, and invests in assets to impact health outcomes.
"The committee defined alignment activities to include those undertaken by healthcare systems to understand existing social care assets in the community, organize them in such a way as to encourage synergy among the various activities, and invest in and deploy them to prevent emerging social needs and improve health outcomes," the report says.
5. Advocacy
Healthcare providers can form alliances with social care organizations to advocate for policies that promote the creation and distribution of assets or resources to address social determinants of health. For example, healthcare organizations can call for policy changes to overhaul transportation services in a community.
"In both the alignment and advocacy categories, healthcare organizations leverage their political, social, and economic capital within a community or local environment to encourage and enable healthcare and social care organizations to partner and pool resources, such as services and information, to achieve greater net benefit from the healthcare and social care services available in the community," the report says.
Implementing the five strategies
Assessing the level of existing social needs activities should be a starting point for healthcare organizations that want to address social determinants of health, the chairperson of the National Academies committee told HealthLeaders.
One of the first steps healthcare organizations can take is identifying activities they may already have underway that fit the 5As, then expand or enhance those activities through greater commitment from leadership, investment of resources into supporting infrastructure, and strengthening of engagement with patients and community stakeholders, said Kirsten Bibbins-Domingo, PhD, MD, MAS, professor and chair, Department of Epidemiology and Biostatistics, UCSF School of Medicine, University of California, San Francisco.
"Healthcare organizations may not have activities in all of the 5As and should use this framework to develop strategies that will work within their local context. In all cases, it is critical to be aware that addressing health-related social needs of their patients is essential to achieving goals of high quality and high-value care," she said.
"Partnerships are crucial," Bibbins-Domingo said.
"Activities in the clinical setting should be designed and implemented in a way that engages patients, community partners, frontline staff, social care workers, and clinicians in planning and evaluation, as well as in incorporating the preferences of patients and communities. Establishing linkages and communication pathways between healthcare and social service providers is critical, including personal care aides, home care aides, and others who provide care and support for seriously ill and disabled patients."
The number of physician assistants who received certification reached its highest annual mark in 2018.
Growth in the number of physician assistants is robust, according to the latest statistical profile published by the National Commission on Certification of Physician Assistants (NCCPA).
Physician assistant participation in clinical care teams is widely viewed as part of the solution to the country's physician shortage. By 2032, the physician shortage is expected to grow to about 122,000 doctors, according to the Association of American Medical Colleges. The U.S. Bureau of Labor Statistics projects 31% growth in the PA profession from 2018 to 2028, which the federal agency characterizes as "much faster than average" compared to other occupations.
The 9,287 physician assistants who received NCCPA certification in 2018 is the largest number of PAs ever certified in a single year, the NCCPA statistical profile published this month says. More than 160,000 PAs have received NCCPA certification since 1975.
The statistical profile, which features data from 2018, includes many key data points:
24% of PAs certified in 2018 are working in primary care
The median annual salary for PAs certified in 2018 is $95,000
Mirroring gender wage gaps among other clinicians, the mean salary for male PAs was $99,450 compared to $94,986 for female PAs
Nearly two-thirds of PAs certified in 2018 have a total educational debt of more than $100,000
The 2018 cohort of certified PAs is the youngest since NCCPA began issuing certifications in 1975: 72.5% were under 30, and 23.4% were 30 to 39 years old
59.0% of PAs certified in 2018 have accepted a clinical position as a physician assistant, and 74.4% of these clinicians received at least two PA job offers
85.6% of PAs certified in 2018 identified their ethnicity as white
Interpreting the data
Dawn Morton-Rias, EdD, PA-C, president and CEO of the NCCPA, told HealthLeaders that the relatively high number of recently certified PAs who have chosen to work in primary care is beneficial for U.S. healthcare.
"The number (24%) of recently certified PAs who have accepted a job working in primary care—family medicine, general internal medicine, and general pediatrics—is encouraging. This represents an increase in year over year comparison. We know from an American Association of Medical Colleges study that America is projected to have a shortage of primary care physicians as high as 55,200 by 2032," she said.
Morton-Rias said it was rewarding to learn that 71.9% of recently certified PAs who have accepted a position indicated that they did not face any challenges when searching for a job.
"When I entered this profession, it was still relatively new, and there wasn't always a certainty that those who studied to become a physician assistant would be able to find employment, nor did we know what the future was for the profession. To see that a majority of recently certified PAs are having no trouble finding employment—and also that 67% of them were offered employment incentive—is a positive indicator that employers not only see the value of certified PAs, but that they are willing to do what is necessary to bring them onboard," she said.
Recently certified PAs have shown a significant propensity to work in areas of the country that desperately need clinical professionals, Morton-Rias said. "We also see from the report that 43.6% of recently certified PAs who have accepted a position in a health professional shortage area—or a medically underserved area—are doing so because they prefer to work in this setting."
Room for improvement
Despite 2018 generating the most diverse cohort of PAs since NCCPA began publishing the statistical profile in 2013, more diversity is needed in the physician assistant ranks, Morton-Rias said.
"America is becoming more diverse, and so are patients. As the physician shortage worsens, PAs are increasingly finding themselves working in socioeconomically depressed and isolated communities that would benefit most from a more diverse selection of providers. Studies have shown that minority patients report higher rates of satisfaction when they receive care from minority providers, and that when providers share the same racial and cultural background as their patients, it can even lead to improved patient outcomes," she said.
The gender wage gap among PAs has worsened slightly in recent years, Morton-Rias says. "While the median salary for recently certified male and female PAs who have accepted a position has [been about $95,000] from 2016 to 2018, the disparities between the average salaries of recently certified male and female PAs who have accepted a position continues to grow."
The statistical profiles for 2016, 2017, and 2018 detail the wage gender gap:
In 2016, the average salary for recently certified male PAs who accepted a position was $95,244, while the average salary for recently certified females PAs who accepted a position was $91,132, for a difference of $4,112.
In 2017, the average salary for recently certified male PAs who accepted a position was $97,592, while the average salary for recently certified female PAs who accepted a position was $93,386, for a difference of $4,206.
In 2018, the average salary for recently certified male PAs who accepted a position was $99,450, while the average salary for recently certified female PAs who accepted a position was $94,486, for a difference of $4,464.
"When we think about delivery of healthcare, patients aren't going to receive more services or better care because of the gender of their provider. Providers must receive equal pay for equal work, and healthcare employers have a real opportunity to lead on this issue by making wage parity between male and female providers a reality," Morton-Rias said.
