Pharmaceutical company marketing to healthcare professionals accounted for the largest portion of spending, set at $20.3 billion in 2016.

Spending on healthcare industry marketing has increased sharply over the past two decades, rising from $17.7 billion in 1997 to $29.9 billion in 2016, research published this week shows.

In healthcare, marketing often raises ethical and professional concerns such as "detailing visits" by company marketing representatives to physician offices that can include gifts for doctors and staff.

Growth in spending on advertising mirrors expansion of medical services and therapies, the researchers wrote.

"Increased medical marketing reflects a convergence of scientific, economic, legal, and social forces. As more drugs and devices and medical advances convert once-fatal diseases into chronic illnesses and with renewed interest in prevention for some diseases, the marketing of tests, treatments, and services has expanded," they wrote.

The research published in Journal of the American Medical Association has several key findings.

• The steepest increase in marketing expenditures was in direct-to-consumer advertising, which increased from $2.1 billion in 1997 to $9.6 billion in 2016.
   
• Drug maker marketing to healthcare professionals accounted for the largest portion of spending, increasing from $15.6 billion in 1997 to $20.3 billion in 2016. The expenditures included $13.5 billion for free samples, $5.6 billion for prescriber detailing visits, and $979 million for direct payments to physicians such as speaking fees and meals.
   
• Advertising of health services rose from $542 million in 1997 to $2.89 billion in 2016. Health systems and hospitals accounted for the highest portion of direct-to-consumer health services advertising, with direct-to-consumer advertising expenditures for cancer centers rising from $18 million to $200 million.

"Although spending on DTC advertising for prescription drugs and health services increased the fastest, spending on pharmaceutical marketing to professionals consistently accounted for most promotional spending, despite efforts to limit industry entanglements," the researchers wrote.

Curbing unscrupulous marketing
 

The research article's supplement includes a list of recommendations to limit unscrupulous marketing techniques in the healthcare sector. For health services, three recommendations are proposed.

• Replicate the Food and Drug Administration's Bad Ad program to encourage clinicians and consumers to report misleading health service ads to the Federal Trade Commission and state attorneys general
   
• Have the Joint Commission conduct proactive review of hospital ads 
   
• Encourage health system and hospital marketing departments to take "truth in advertising" pledges and mandate submission of ads to a third-party reviewer for independent assessment prior to distribution

Several other recommendations directly involve health systems, hospitals, and physicians.

• Healthcare organizations should discourage physicians from accepting payment to prescribe advertised tests and require physicians identified through companies to tell patients how they are being paid
   
• At the state and healthcare organization level, restrictions or bans should be established on pharmaceutical company detailing visits and gifts to clinicians
   
• Health systems and hospitals should forbid faculty participation on pharmaceutical company speaker bureaus
   
• Public reporting of pharmaceutical industry payments to physician assistants, nurse practitioners, nurses, pharmacists and patient assistance charities—set to start in 2022—should be expedited.

Learn how one health system launched systematic initiatives to improve its quality and safety rankings and is pursuing a zero-harm environment.

Nearly two decades after the Institute of Medicine published its groundbreaking healthcare safety report "To Err Is Human," medical errors remain a leading cause of death in this country.

To rise to this challenge, hospitals from coast to coast are engaged in efforts to boost quality and safety such as initiatives aimed at hospital-acquired infections.

For one hospital in particular, a poor Leapfrog Hospital Safety Grade rating in 2014 became a launching pad for improved quality and safety.

"When we got a 'D' from Leapfrog, that was our wake-up call. We had done good patient safety work before, but it wasn't the fanatic level that we have now," says Leigh Hamby, MD, MHA, executive vice president and chief medical officer at Piedmont Healthcare, an integrated healthcare system with 11 hospitals and almost 100 physician and specialist offices throughout Atlanta and North Georgia.

Since launching systematic initiatives to improve quality and safety in 2014, the health system has posted gains.

• In November 2018, six of Piedmont's 11 hospitals received "A" grades in The Leapfrog Group's Fall 2018 Hospital Safety Grade ratings
   
• From July 2016 to June 2018, Piedmont reduced hospital-acquired infections 40%
   
• One Piedmont hospital has not reported a hospital-acquired infection for more than a year

Hamby says there are four ways Piedmont implemented better quality and safety at the healthcare organization and boosted its rankings.

1. Reallocate staff’s time and focus
 

One of the first quality and safety initiatives that Piedmont started was reforming quality and safety staff allocation. Hamby says about 80% of the staff's time was dedicated to surveillance such as chart reviews, rather than improvement projects.

He says the department, which has a staff of about 75, had to change.

"When I started looking at our hospitals and who was charged with quality and safety, they were not working on infections and other elements of the Leapfrog grades. When Leapfrog says hospital-acquired infections are important and people are working on something else, that told me we were working on the wrong things."

The department's functions were split into three branches: surveillance, analysis, and improvement. The improvement branch was divided into design and implementation segments.

"We took most of the folks doing the work—most of whom were clinicians reviewing charts—and put people on the design and implementation sides.

Our original resource allocation was about 80% looking for problems and maybe 20% trying to fix problems. We [have now] put it at 50-50," Hamby says.

2. Commit to a scientific approach
 

Piedmont's approach to clinical care is rooted in best scientific practices, Hamby says. "What we have done is to be fanatical about making sure every patient gets every component of the things we know scientifically they should be getting."

Central lines and other implantable devices are infection risks and hospitals can lower risk through a science-based approach to care, he says.

Hamby says the clinical team only inserts devices when needed and then removes them as soon as it is safe to do so. "You follow all of the procedures that science calls for while the devices are in to prevent an infection, and we measure  performance on a patient-by-patient and hour-by-hour basis."

To prompt clinicians and nurses about care steps, reminders have been built into Piedmont's EMR, Hamby says. "We are giving frontline caregivers real-time tools that help them remember the things they are supposed to do for the patient."

3. Standardize care into 'promise packages'
 

Piedmont has adopted an expanded approach to clinical care order sets that the health system calls promise packages. Catheter-associated urinary tract infection (CAUTI) is a prime example, Hamby says.

"The promise package is literally everything that you would do. For CAUTI, it's a policy, it's a training program, it's a documentation element in the EMR, and it's all the dashboards and reporting. You take all that up and call it a promise package," he says.

When new expanded order sets are rolled out, many members of the quality and safety staff are enlisted to assist in implementation, Hamby says. "We provide elbow-to-elbow support anywhere from seven to 14 days, depending on the complexity of the promise package. We get in the field and sort through the bugs in software or questions the nurses have."

After a 60-day trial period, effective promise packages become order sets for the entire health system and responsibility for order set compliance is shifted to hospital CEOs.

Compliance to promise packages and other order sets is crucial to quality and safety, Hamby says. "In the old days, we would be happy with 80% compliance," he says, but Piedmont found it needed to be within the  95%­–99% compliance range, especially because of medical departments such as the ICU with significant utilization of implanted devices.

Regular reporting of compliance rates can avert safety events, he says. "It gives you the ability to identify problems in the process measure before it becomes an outcome problem. If I've got 10 doctors doing colon surgery and I know who is not compliant to the order set, I can intervene before it leads to an infection."

4. Reach for zero harm
 

Piedmont embraced a zero-harm strategy as part of the fallout from the "D" Leapfrog grade in 2014, Hamby says.

"We look at our harm count every month. Our harm count is comprised of four components: hospital-acquired infections, serious safety events, hospital-acquired conditions, and patient safety indicators as described by AHRQ. Every month, we know how many harms we have, and we have programs to address them," he says.

Benchmarking has no value in the pursuit of zero harm, Hamby says.

"I don't care if we are the best in the country. If we're not at zero, we're not done. I think benchmarking is an excuse for when you can stop working on something. We're going to keep on working until we get to zero harm," he says.

Piedmont's goal is to attain zero harm by 2024, and Hamby says the 10-year time frame is realistic.

"Ten years is a long time, but this is a pretty complicated business. Sick patients, by their very nature, require lots of complicated treatment. Since the IOM report in 1999, as a nation, we have not gotten all that much better."

If health systems and hospitals can create high-reliability organizations, there should be significant economic and operational gains, he says.

"Let's just say we woke up tomorrow and no more harm ever happened. One of the things we would realize almost immediately is an increased capacity of the healthcare system to accommodate more people. We would reduce wait times for service," Hamby says.

Federal and state rules have enabled spending on nonmedical services that have health benefits such as food security.

Managed care organizations (MCOs) are on the leading edge of efforts to strike a better balance between health and social service expenditures, a recent article in JAMA says.

Evidence is mounting that countries with higher social services spending such as disability, unemployment, and housing have better population health outcomes. Among Organization for Economic Co-Operation and Development (OECD) countries, higher social services spending is associated with higher life expectancy, lower infant mortality, lower prevalence of chronic diseases, and lower all-cause mortality.

MCOs are taking a leading role in addressing social determinants of health, the JAMA article authors wrote.

"By expanding the scope of service delivery as part of managing population health risk, managed care companies can invest in services and supports that meet their members' health-related needs, benefit from reduced spending on medical care, and leverage business principles to justify resource reallocation," they wrote.

The Centers for Medicare & Medicaid Services (CMS) have enabled MCO expenditures for social services.

In 2016, CMS amended the Medicaid managed care rule to prompt Medicaid MCOs to help patients with nonmedical expenses that were considered crucial to achieving health outcomes and cutting costs.

Under the CMS Accountable Health Communities Initiative, many Medicaid MCOs assess patients' unmet social needs, including housing instability, food insecurity, utility needs, interpersonal violence, and transportation requirements.

An increasing number of states are requiring Medicaid MCOs to address social determinants of health as part of contractual agreements. In New York, The Empire State's Value Based Payment Roadmap requires MCOs to offer startup funds for partners in Value Based Payment agreements who are conducting social determinant of health interventions.

Berwick's perspective
 

MCOs cannot take on social determinants of health single-handedly.

"Even if all MCOs were appropriately incentivized to invest in upstream social services for their members, the sum of these investments would be insufficient to create the system for providing social services and blending them with medical services to optimally serve all U.S. residents," the JAMA article authors wrote.

Healthcare organizations must build partnerships to address social determinants of health in the communities they serve, Don Berwick, MD, former CMS administrator, told HealthLeaders at last month's IHI Forum.

"Cincinnati Children's Hospital Medical Center is working with dozens of organizations in the city with the shared goal of improving outcomes for 60,000 disadvantaged kids in Cincinnati. They are not trying to do it alone," he said.

Hospitals can also look for economic opportunities to engage distressed communities, Berwick said. "Hospitals account for about $750 billion of economic activity—employment, construction activity, and supply chain."

Opportunities to generate partners through economic activity include hiring from those communities, using construction firms from those communities, purchasing products in those communities, and investing in community infrastructure such as housing.

"We're going to spend the money anyway. Why don’t we spend it where we can work on progressive income redistribution and opportunities?" he said.

This year's expected developments include a new electronic recertification process for physician assistants.

This year will feature several significant trends and developments for physician assistants, says Dawn Morton-Rias, EdD, PA-C, president and CEO of the National Commission on Certification of Physician Assistants (NCCPA).

Physician assistants (PA) are widely viewed as part of the solution to the country's physician shortage. By 2030, the physician shortage is expected to grow to as many as 120,000 doctors, according to the Association of American Medical Colleges.

Physician assistants are a dynamic segment of the healthcare sector workforce, according to NCCPA statistics released in July 2018.

• From 2015 to 2017, the number of PAs grew more than 13%.
   
• The number of PAs per physician rose 23% from 2015 to 2017, increasing to 128 PAs per 1,000 physicians. Two of the highest PA-per-physician ratios were occupational medicine at 621 PAs per 1,000 physicians and orthopedic surgery at 537 PAs per 1,000 physicians.
   
• In 2017, the average salary of PAs was nearly $108,000.
   
• The ranks of PAs are filled with relatively young professionals. In 2017, 78.5% of physician assistants were under the age of 49.
   
• The family medicine and general practice area had the highest concentration of physician assistants (19.9%), followed by surgical subspecialties (18.5%).

Morton-Rias expects four trends and developments will significantly influence the physician assistant profession this year. 

1. Easing physician shortage
 

Physician assistants will continue to play a key role in easing the country's physician shortage, Morton-Rias says.

"Given the youth of the profession, the broad-based knowledge and skills of PAs, and the ability to provide services across all disciplines, PAs can ease physician shortages and improve access to care," she says.

The relatively young age of PAs—which averages about 38—and their propensity to stay in the profession is a bright spot in the healthcare workforce.

"The attrition rate is very low, and when we compare the PA profession to some of the other healthcare professions where the average age is in the 40s or 50s, there's a concern because you have a bolus that will be retiring out," Morton-Rias says.

The relative youth of PAs helps address the physician shortage in ways beyond actuarial considerations, she says. "The youth of the PA profession will help in increasing access to care. These are young, energetic folks who are entering the profession."

2. Modernizing certification exams
 

Starting this month, NCCPA will start offering electronic administration of the 10-year recertification exam for PAs, allowing PAs to take the exam on their phone, laptop, tablet, and desktop computers.

"This assessment that we are piloting is in keeping with the emerging trends in assessment and utilizing technology. In the PA profession, we have always relied on the testing methods where you sat in a test center after memorizing a lot of information," Morton-Rias says.

The electronic platform NCCPA has developed is the first major step toward modernizing certification exams at the accrediting organization, she says.

"In this assessment method, PAs can answer questions in real time, with about a minute to respond to a question. If they get the question right, they know right away, so it reaffirms their knowledge. If they get a question wrong, they are corrected right away, and they are given resources to improve their knowledge base."

Other primary facets of the new assessment method include completing 25 questions each quarter (there are a total of 100 questions and PAs have 11 weeks to complete each 25-question set). The questions cover a broad swath of core medical knowledge, and the assessment tool has the ability to allow test takers to delay answering questions that display images by switching from their phone or tablet to a device with a larger screen.

"This assessment utilizes technology and it provides real-time information in the same way people practice medicine today. Physicians are also starting to pilot this approach," Morton-Rias says.

3. Updating state PA legislation
 

Changes in the practice of medicine are prompting state lawmakers to reform the way PAs are regulated, Morton-Rias says.

"States are modernizing their legislation as it relates to PA practice because the healthcare industry has changed from PAs working for one doctor to more providers working in health systems. As this change has occurred, some of the states still have laws that are outdated and don't reflect the new flexibility."

She says the legislative changes include reforming scope of practice, supervision, and delegation of authority.

4. Expanding specialty care roles
 

PAs are shifting away from their roots in primary care to specialty care, Morton-Rias says. "Although the profession began with primary care and general medicine mostly in underserved areas, medicine has become highly specialized and the PA profession is becoming specialized as well."

She says as many as 70% of PAs are working in specialty practice, including surgical specialties such as orthopedics, neurosurgery, and cardiothoracic surgery.

The transition to specialty care presents a challenge to PAs, she says. "PAs are carrying two responsibilities. One is to maintain expertise in their current practice discipline; the other is maintaining core medical knowledge that is useful across all disciplines."

PAs are well-prepared to rise to the challenge, Morton-Rias says. "PAs have a very solid educational process and fount of knowledge that they develop through a rigorous educational training. It's a full-time immersion type of training, so PAs enter medicine with a deep knowledge base."