As the number of long COVID cases grows, healthcare providers need to learn more about these patients.
Long COVID patients experience increased risk for several cardiovascular conditions in the year after coronavirus infection, a new research article found.
Long COVID, also known as post-COVID-19 condition (PCC), is defined as having new, returning, or ongoing health issues more than four weeks after an initial infection, according to the Centers for Disease Control and Prevention. Symptoms that lead to a diagnosis of long COVID include fatigue, cough, loss of taste or smell, shortness of breath, neurocognitive difficulties, and depression.
The new research article, which was published by JAMA Health Forum, features data collected from 13,435 long COVID adult patients and a control group of 26,870 adults without COVID-19. The data was drawn from national commercial insurance claims along with laboratory results and mortality data from the Social Security Administration's Death Master File and Datavant Flatiron data.
The research article has several key findings:
The long COVID patients experienced increased healthcare utilization for cardiac arrhythmias (relative risk 2.35).
The long COVID patients experienced increased healthcare utilization for pulmonary embolism (relative risk 3.64).
The long COVID patients experienced increased healthcare utilization for ischemic stroke (relative risk 2.17).
The long COVID patients experienced increased healthcare utilization for coronary artery disease (relative risk 1.78).
The long COVID patients experienced increased healthcare utilization for heart failure (relative risk 1.97).
The long COVID patients experienced increased healthcare utilization for chronic obstructive pulmonary disease (relative risk 1.94).
The long COVID patients experienced increased healthcare utilization for asthma (relative risk 1.95).
Risks for these conditions were higher for long COVID patients who were hospitalized during the acute phase of coronavirus infection compared to long COVID patients who were not hospitalized.
The long COVID patients also experienced increased mortality, with 2.8% of long COVID patients dying compared to 1.2% of individuals in the control group. This translated to an excess death rate of 16.4 per 1,000 individuals.
The long COVID patients in the study were at significantly higher risk for adverse outcomes in the year after initial infection, the research article's co-authors wrote. "This case-control study leveraged a large commercial insurance database and found increased rates of adverse outcomes over a 1-year period for a PCC cohort surviving the acute phase of illness. The results indicate a need for continued monitoring for at-risk individuals, particularly in the area of cardiovascular and pulmonary management."
Interpreting the data
Even for adults who are not hospitalized, long COVID patients are at risk for serious conditions and mortality, the study's co-authors wrote.
"Based on published literature, the most common symptoms experienced by individuals with PCC include fatigue, headache, and attention disorder. While these symptoms are concerning, results from this study also indicated a statistically significant increased risk for a range of cardiovascular conditions as well as mortality. While these risks were heightened for individuals who experienced a more severe acute episode of COVID-19 (ie, requiring hospitalization), it is essential to note that most individuals (72.5%) in the cohort did not experience hospitalization during the acute phase."
As the number of long COVID cases grows, healthcare providers need to learn more about these patients, the study's co-authors wrote. "Gaining additional insight into the risks and trajectory of the disease is essential for clinicians caring for these individuals, especially a need for primary prevention for individuals at higher risk. At a health-systems level, it is also necessary to develop resources and guidance for individuals at risk for serious complications."
The study has significant implications, they wrote. "From a health policy perspective, these results also indicate a meaningful effect on future healthcare utilization, and even potential implications for labor force participation. Gaining knowledge on the scope and trajectory of PCC is relevant for policy makers, given the recent guidance by the US Department of Health and Human Services that classifies 'long COVID' as a disability if it substantially limits major life activities."
Physicians need to be able to trust the people who are leading them, chief clinical officer says.
Transparency and creating an environment that promotes autonomy, mastery, and purpose are essential in physician engagement, the chief clinical officer of Mercy Health-Lima says.
Matthew Owens, MD, chief clinical officer of Mercy Health-Lima, is a practicing physician specializing in physical medicine and rehabilitation. Mercy Health-Lima, part of Bon Secours Mercy Health, is anchored by St. Rita's Medical Center in Lima, Ohio.
HealthLeaders recently talked with Owens about a range of issues, including physician engagement, quality improvement initiatives, and patient experience. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: You have oversight of Mercy Health Physicians-Lima. What are the keys to success in supervising a physician group?
Matthew Owens: Leading a large medical group is an honor I do not take lightly. There are many pressures that our physicians and our advanced practice clinicians face every day while they are delivering care.
Maintaining an engaged clinician workforce is probably the most critical factor in achieving success in care delivery. If I do not have a workforce that is engaged in the work they are doing each day, it is difficult to do the work that the medical group is required to do.
HL: What are the primary elements of physician engagement?
Owens: Physicians are a highly motivated, competitive, and self-driven group of people. Most will perform at a high level if they are provided with the environment to allow them to excel. One of the most critical elements to physician engagement is transparency in leadership. Physicians need to be able to trust the people who are leading them. I try to be highly transparent—sometimes to a fault. I want to allow our physicians to feel engaged with the plans of the organization.
Beyond transparency and thinking about factors that promote strong engagement, I often refer to three major principles that I picked up from a book called Drive by Daniel Pink. In that book, Pink says people intrinsically want to do things that matter, and there are three principles that are important to allow people to shine. You need to grant them autonomy, mastery, and purpose. When I am thinking about leading physicians, if I can be transparent, then constantly work to give physicians an environment that promotes autonomy, mastery, and purpose, I know that the physician colleagues that I lead will perform at a high level.
HL: What are the primary challenges of serving as a chief clinical officer?
Owens: As we emerge from the stressors of the pandemic, I am struck by the pace of change and the pressures to manage that change. So much of what we do feels different than pre-pandemic.
We have an evolving set of challenges in healthcare. There are workforce shortages. There are mobility challenges in the workforce. There are inflationary pressures. There are regulatory burdens. And, frankly, there is a lot of gamesmanship among our nation's insurance providers. Those are all factors that immediately come to mind that impact the daily delivery of care to those that we serve.
HL: How are you rising to these challenges?
Owens: We are having to think about doing things in a different way than we used to in the past. We look toward different strategies for staff recruitment—it is not just the recruitment of physicians, it is the recruitment of the care teams surrounding physicians. Candidates are looking for something a little bit different than before the pandemic, and if we do not adapt to that then we are going to see ourselves falling behind. Once they are here, we must figure out what the key elements are to retain that workforce.
Healthcare organizations in this country are in a difficult spot. The inflationary pressures are certainly apparent as in any industry, but unfortunately reimbursement changes are not keeping up with the inflationary pressures. So, we must be wise about our expenses—we must manage those expenses tightly.
Regarding regulatory burdens, there are a lot of new regulations being released on a regular basis, particularly during the pandemic. It has complicated our ability to be efficient with how we are using our workforce—we have a lot of pressures from various groups to try to live up to the standards they have set.
Matthew Owens, MD, chief clinical officer of Mercy Health-Lima. Photo courtesy of Bon Secours Mercy Health.
HL: What is Mercy Health-Lima doing to recruit and retain clinicians?
Owens: At Mercy Health-Lima, we are blessed to be leaders of a large, progressive regional referral center in a relatively rural area of Ohio. While that is not the setting that every physician seeks during a job search, we have a strong track record of retaining our physicians for a long time once they settle into practicing here. We are surrounded by several wonderful small cities and communities that are filled with wonderful people who seek our care, and that becomes endearing to our clinicians.
The landscape for recruitment is challenging right now. We know there is a physician shortage across the country. Our biggest sell is to convince clinicians to come and take a look at what we have to offer, to see how progressive our medical center is, then show them how nice it can be to live in our communities.
Regarding retention, we specifically work to ensure that our providers feel they have the tools needed to be successful. We also recognize the gravity of burnout and the emotional scar that the pandemic left on our care teams. We are healing together—we have developed a few methods of intervention that we hope provide members of our care teams a path to recovery. For example, we have a Life Matters platform that allows our providers to reach out if they have specific concerns related to mental health or burnout, or more broadly if they have specific life concerns and need help tracking down resources in the community.
We also have a program called Caring for Colleagues, where there are several of our physician colleagues across the ministry who have volunteered to provide their cell phone numbers so any care team member can call them at any hour of the day or night and receive counseling.
HL: What are the keys to success for quality improvement initiatives?
Owens: Transparency and communicating a clear "why" behind a quality improvement initiative are probably the most important factors to being successful. If I cannot communicate a compelling reason why a quality initiative should take priority in the minds of our care team members, it will certainly not gain traction.
HL: Give me an example of a quality initiative you have led.
Owens: As we emerged from the pandemic, we were finding that we had a high rate of catheter-associated urinary tract infections. That was partly related to long lengths of stay of COVID patients. We wanted to get those catheter-associated infections back under control. We brought together several physician and nursing leaders from across our healthcare market. We explained the "why" in a transparent way, and we asked them for action steps that would impact the hospitals that they lead. What was great as an outcome was getting buy-in right away, which helped us decrease those infections precipitously over the past six months.
HL: What are the keys to success in patient experience?
Owens: Our patients expect great care, and they are moved by how we make them feel. The soft skills of medicine such as body language and empathy are critical in every single patient interaction. As patients seek greater and greater awareness of their care plans, we must strive to keep them feeling like they are partners in their health.
The most basic thing is ensuring that our providers have the clinical skills and the knowledge base to be successful. That is the absolute baseline level that we would expect. The next level we would expect is the soft skills. I want a clinician in our market to walk into a room and not only make the patient feel they know what they are talking about but also make the patient feel like they are heard and they want to come back and see that provider again. That's how we convince our community that we are providing them a great patient experience. When patients leave feeling they have been heard and they have been truly cared for, and they leave thinking they want to come back, they go home and tell the rest of the community about that experience. Our providers also become more successful in attracting patients because of that experience.
So, we have programming that tries to teach soft skills to our providers. We try to go beyond the clinical knowledge base and make sure our providers are exposed to a curriculum that allows them to engage soft skills when they are interacting with patients.
The vast majority of healthcare executives surveyed said workforce will have a significantly negative or negative impact on growth strategies this year.
Workforce issues loom large for healthcare C-Suite executives, according to a new survey report from Guidehouse and the Healthcare Financial Management Association (HFMA).
Workforce shortages are widespread in the healthcare sector. In an annual survey published last month by the American College of Healthcare Executives, workforce challenges were the Number One concern of 2022.
The new survey report from Guidehouse and HFMA features data collected from 182 healthcare executives, 80% of whom were C-Suite leaders such as CEOs, CFOs, and COOs. The survey asked the executives five questions.
1. What impact is your workforce having on your 2023 growth strategy?
62% of survey respondents said the state of their workforce is expected to have a significantly negative impact on 2023 growth strategy
34% of survey respondents said the state of their workforce is expected to have a negative impact on 2023 growth strategy
Only 1% of survey respondents said the state of their workforce is expected to have a significantly positive impact on 2023 growth strategy
The workforce is a pivotal concern at healthcare organizations, the survey report says. "Labor is the root cause of delays in care delivery innovation. Clinician burnout, staff resignations, executive retirements, and equity issues now define many health system work environments. Fundamental changes in culture, work redesign, and workforce development are essential for providers to thrive in the new healthcare economy."
2. By how much do you project staffing to increase or decrease in the following areas?
55% of survey respondents expect staffing of advanced practitioners to increase by as much as 10%
34% of survey respondents expect staffing of advanced practitioners to increase by 10% or more
Behavioral and mental health providers:
45% of survey respondents expect staffing of behavioral and mental health providers to increase by as much as 10%
36% of survey respondents expect staffing of behavioral and mental health providers to increase by 10% or more
60% of survey respondents expect staffing of physicians to increase by as much as 10%
23% of survey respondents expect staffing of physicians to increase by 10% or more
47% of survey respondents expect staffing of nurses to increase by as much as 10%
31% of survey respondents expect staffing of nurses to increase by 10% or more
Contractors and travelers:
41% of survey respondents expect staffing of contractors and travelers to decrease by 10% or more
24% of survey respondents expect staffing of contractors and travelers to decrease by as much as 9%
19% of survey respondents expect staffing of contractors and travelers to increase by as much as 10%
15% of survey respondents expect staffing of contractors and travelers to increase by 10% or more
Healthcare organizations should not limit their primary recruitment strategies to physicians, the survey report says. "As organizations determine the best way to establish themselves as preferred providers, they may find they need fewer physicians to achieve these goals. Adding more behavioral health providers, social workers, and case managers to the team could help take pressure off overloaded medical professionals while giving patients the right support in the right setting, including in the home."
Health systems cannot continue to rely on contractors and travelers, Thomas Zenty III, a national adviser at Guidehouse, said in a prepared statement. "Health systems are struggling to afford the vast increase in the need for contractors and traveling clinicians. As their short-term contracts come to an end, leading organizations are finding attractive ways to keep these caregivers on full-time and integrate them into the business."
3. By how much do you project patient volumes to increase or decrease over the next 12 months?
54% of survey respondents expect outpatient volume to increase by as much as 10%
41% of survey respondents expect outpatient volume to increase by 10% or more
17% of survey respondents expect inpatient volume to decrease by 10% or more
24% of survey respondents expect inpatient volume to decrease by as much as 9%
35% of survey respondents expect inpatient volume to increase by as much as 10%
21% of survey respondents expect inpatient volume to increase by 10% or more
Patient volumes are an area of volatility for health systems as the country emerges from the coronavirus pandemic, Richard Bajner, Guidehouse partner and payer-provider leader, said in a prepared statement. "Most health systems are still experiencing volumes below pre-COVID levels, resulting in sizable market challenges. These shifts should inform strategic growth efforts that are focused on person-centered care, such as excellence in ambulatory services, to create sustainable business models that attract and retain patients while driving financial resiliency in an era of volatility."
4. What are your expectations for emergency department (ED) and elective procedure volumes?
55% of survey respondents expect ED volume to increase by as much as 10%
32% of survey respondents expect ED volume to increase by 10% or more
Elective procedure volume:
56% of survey respondents expect elective procedure volume to increase by as much as 10%
26% of survey respondents expect elective procedure volume to increase by 10% or more
The expectations for ED and elective procedure volumes are optimistic given market conditions, the survey report says. "Fundamental changes are contributing to unpredictability in the demand for emergency room visits, inpatient volume, ambulatory surgery procedures, outpatient visits, length of stay, case mix index, virtual care, and more. In turn, almost universally, hospitals and health systems are facing financial and operational instability like never before."
5. Please select the area your organization is projecting the greatest percentage budget increase in the next 12 months.
20% of survey respondents said digital engagement and virtual care
18% of survey respondents said revenue cycle automation
17% of survey respondents said investing in physician organizations
16% of survey respondents said managed services and outsourcing partners
13% of survey respondents said merging or acquiring strategic assets
10% of survey respondents said cybersecurity
5% of survey respondents said home care or hospital at home
Digital engagement, virtual care, and automation are top priorities for healthcare organizations, Zenty said. "With growth in labor and supply costs, many leaders are turning to purposeful artificial intelligence, automation, and digital care strategies to improve engagement and efficiency. Successful organizations are reevaluating their digital connectivity capabilities to ensure patients and caregivers know how to access and use patient portals, EHRs, and other technologies, as well as to streamline corporate and non-clinical services."
Mainly due to a shortage of primary care providers, millions of Americans do not have access to a usual source of primary care.
With more funding, Federally Qualified Health Centers would be well-suited to filling a gaping primary care gap, according to a recent report from the National Association of Community Health Centers (NACHC).
More than 100 million Americans do not have access to primary care, mainly due to a shortage of primary care providers in their community, the report says. The report deems these Americans as medically disenfranchised.
Federally Qualified Health Centers, also known as Community Health Centers, have a vital role to play in serving this medically disenfranchised population, Rachel Gonzales-Hanson, interim president and CEO of NACHC, said in a prepared statement. "The primary care gap is deepening in underserved communities across our nation, and Community Health Centers are vital to filling in those gaps by providing critical routine healthcare services. The COVID-19 pandemic only illuminated existing healthcare inequalities in the most vulnerable areas of our nation, making it crystal clear the important role of health centers."
The NACHC report highlights a national crisis, she said. "The Closing the Primary Care Gap report illustrates an unfortunate picture of medically underserved Americans with a disproportionately higher risk of harm from preventable diseases—and one-quarter of them are children. Expanding access to primary healthcare must be a national priority."
In addition to the findings that 100 million Americans do not have access to primary care and one-quarter of them are children, the report has several key findings:
Only 11% of the medically disenfranchised population is uninsured, which indicates that lacking access to primary care is not mainly related to insurance.
More than half of the medically disenfranchised population has an income below 200% of the Federal Poverty Level. These people may not be able to afford traveling long distances to access care.
Without community health centers, 15 million more people would likely not have access to primary care.
The number of medically disenfranchised people has doubled since 2014.
Investments are needed to reduce the medically disenfranchised population, the report says. "Access to primary care in medically disenfranchised communities can be improved through strategic investments, such as incentives for primary care practitioners to train and work in medically underserved communities and additional funding for Community Health Centers to expand their network of providers."
Addressing the shortage of primary care providers is crucial, the report says. "Gaps in primary care persist due to a nationwide primary care provider shortage that is driven by increased medical specialization and an uneven distribution of providers. Clinical trainees are pursuing increased specialization, which has led to a decline in the proportion of medical students and residents entering primary care. … Both primary care providers and specialists are more concentrated in highly populated urban areas that are home to higher-income, majority-insured populations. This pattern leaves fewer providers to care for rural communities that are more sparsely populated and may have a lower median household income. A variety of factors are also leading to consolidation, and clinic closures across the landscape of primary care practices are exacerbating the problem of unequal distribution."
More federal funding for Community Health Centers is needed to not only open more clinics but also to keep pace with inflation, the report says. "While the Community Health Center fund has increased by 14% since 2015, medical care inflation has risen by 25%, leading to a 9.3% decrease in federal health center funding in real terms."
Community Health Centers are geared toward providing services in underserved communities, the report says. "Health centers place an emphasis on culturally competent care and intentionally recruit providers who are underrepresented in the medical profession and those who reflect the cultural diversity of their community. This results in providers who represent the diverse racial, ethnic, and linguistic backgrounds of the communities they serve. Continued investments in these programs are necessary to sustainably grow the number of providers working in medically underserved communities and to strengthen the primary care workforce of the future."
Primary care is an essential component of the country's healthcare system, the report says. "Primary care providers can treat the common cold, ensure healthy childhood development, prevent future illness, manage chronic conditions, and connect patients to specialty services. Having a usual source of primary care is associated with decreased emergency department use and lower healthcare costs throughout the lifetime. On the other hand, a lack of access to primary care can weaken the public health response to future pandemics and could have dire consequences for patients, especially those facing compounding access barriers."
Community Health Centers should be part of the solution to the country's primary care crisis, the report says. "Health centers have a proven track record of filling primary care gaps in underserved communities, making them well-positioned to fill that need for the more than 100 million Americans who remain medically disenfranchised. The health center program has grown in the last five years to serve more patients and expand specialty services such as behavioral health, dental, and vision services in medically underserved communities. With sufficient resources, the health center program can expand into more underserved communities and continue to close the gap in primary care for America’s medically disenfranchised population."
The author of a new book expects the challenges facing healthcare before and during the coronavirus pandemic to persist for years.
Healthcare organizations should focus on four areas as they emerge from the coronavirus pandemic, the author of a new book says.
Healthcare organizations faced several challenges going into the pandemic, including the rise of consumerism and adoption of value-based payment models. The pandemic introduced new challenges such as widespread workforce shortages and severe financial problems.
Thomas Lee, MD, a primary care physician at Brigham and Women's Hospital in Boston and chief medical officer at Press Ganey, offers prescriptions for healthcare organizations in his new book, Healthcare's Path Forward. "The reason why I wanted to write this book is because we have been through a lot over the past few years, and I am hoping the pandemic will be winding down, but the fact of the matter is the stresses that became explicit the last few years are not going away in many ways. I wanted to come up with the path forward that we need to be pursuing in order to meet the challenges," he told HealthLeaders.
Drawing on the collective knowledge of colleagues inside and outside Press Ganey, Lee says there are a set of basic activities that healthcare leaders have to have in mind now that the crisis phase of the pandemic has passed. "One is building trust in the workforce. Second is building trust among patients. Third is developing a deeper and broader sense of patient safety. Fourth is understanding what consumerism really means—how do you build trust among people when they are not directly in front of you."
1. Building trust in the workforce
The first path forward is building trust in the workforce, Lee says.
"One definition of trust that I like is confidence that you are going to be treated fairly in circumstances you have not even thought of yet. We need everyone working in our healthcare organizations to feel that way about their organization. To do that, the organization and its leaders have to show that they understand what is important to the people working there, that they are authentic, and that they have a plan for making sure that the workers are taken care of. Those are the three key elements of trust building with the workforce," he says.
If healthcare workers trust their organization, it can promote pride and other positive factors, Lee says. "Data shows us that of course you have to pay people better, of course you have to try to do what you can to staff adequately, but the factor that is actually the main determinant of whether people in the workforce stay with your organization is the pride that they feel. It is the teamwork. It is the sense of inclusion. It is the culture. These are much more powerful determinants of whether people stay or go. This may sound like rhetoric, but it is supported by our data."
2. Building trust among patients
Patients want to know that their healthcare providers are well organized and efficient, Lee says. "Turning to patients, yes, patients do care about what their clinicians are like—are they showing empathy, are they coordinating with other clinicians, are they communicating well? But research from the past few years has shown that other things matter, too. The thing I would focus on is friction before the patient visit—chaos can shake patients' trust in the system. They want to know that their caregivers have their act together."
3. Developing a deeper and broader sense of patient safety
Attentiveness to patient safety is a crucial path in the way forward, he says. "Whether it is inpatient or outpatient, if patients see anything that shakes their confidence that things are excellent in terms of their safety, then they can't trust the whole system."
There needs to be a deeper sense of patient safety, Lee says.
"One of my favorite examples comes from the United Kingdom, where the nurses in one set of hospitals argued for switching to a disinfectant that did not smell like a disinfectant. After they switched, the patient experience declined, and there were increased complaints about cleanliness. That's because without the smell of the disinfectant, people did not feel safe. So, the thing that I emphasize is that we not only have to worry about keeping patients safe from physical harm but also keep them safe from emotional harm. We have to make them feel safe."
4. Understanding consumerism
For consumerism and people making choices, healthcare leaders must understand what builds trust among consumers, he says. "Managing what they see online, giving them lots of information such as comments and pictures, then giving them consistency by exporting those comments and pictures to third-party websites—it seems obvious that we are going to be moving in this direction, and some organizations are getting there faster than others."
Healthcare organizations need to revolutionize their customer service capabilities, Lee says. "Healthcare needs to go through what banking went through. Many of us can remember being agitated about whether we would get out of work in time to get to the bank to deposit a check. Now, there are digital interfaces to conduct banking. We need to get to the same place in healthcare, where consumers can get things done 24 hours a day, but we are not all going to get there at the same time, and organizations that get there faster are going to have advantages."
At Scripps Health, clinicians play an essential role in supply chain decision making.
Engaging clinicians is pivotal in healthcare supply chain such as value analysis and standardization initiatives, the top supply chain executive at Scripps Health says.
Cecile Hozouri, MBA, has been corporate vice president of supply chain at Scripps since 2010. She joined the San Diego-based health system as a supply chain manager in 2003.
HealthLeaders recently talked with Hozouri about a range of issues, including the keys to supply chain success, conducting value analysis for products, and enlisting clinicians in supply chain decision making. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: What are the primary elements of supply chain success?
Cecile Hozouri: First and foremost, you need an effective supply chain team. I have a very engaged team that helps solidify and support the supply chain across the organization and helps get changes done.
Another piece is a collaborative approach with clinicians. We are constantly connected with someone from the medical staff, the nursing teams, advanced practice nurses, or even our chief operating executives to have conversations about something we are thinking about doing.
At its best, supply chain is a vehicle for change. The Scripps executive team supports us in seeking change. All of our top executives are very supportive of moving forward with change. This is where the collaborative relationship with our clinicians is crucial. The only way we are going to achieve success with a change is if clinicians are doing it with us.
HL: What are the primary challenges of serving as corporate vice president of supply chain at Scripps?
Hozouri: For the past three years with the coronavirus pandemic, we have had significant challenges in the supply chain. That includes everything from raw materials, to specialty products, to the simplest plastic products such as syringes and basins. We have been able to tackle the most critical supply shortages by working directly with our nurses and clinicians who utilize these products and determine the best options for substitutions while their primary manufacturers are unable to produce the original products. It has been a challenging three years, and it continues to be challenging.
While we have managed those challenges with the supply disruptions and backorders, we are also combatting supply cost increases. We have had multiple conversations with our vendor partners to strategize what we can do together to offset those increases.
HL: How do you rise to the challenge of increased costs?
Hozouri: I have a very effective strategic sourcing team and contractual team that supports this piece. We have an integrated supply chain with our clinicians, which helps us manage costs. When it comes to cost increases, we are bringing those vendors to the table. When it comes to a physician-specific product, we make the physicians aware of what the cost increases look like, and they help us with that. They may choose another product.
HL: Do you work with a group purchasing organization?
Hozouri: We utilize a group purchasing organization called HealthTrust. They provide a wide variety of supply and service standardization opportunities for us. They have a full portfolio of commodity, service, and specialty product contracts that have been negotiated at great rates.
Cecile Hozouri, MBA, corporate vice president of supply chain, Scripps Health. Photo courtesy of Scripps Health.
HL: How do you conduct value analysis?
Hozouri: We have a clinical value analysis governance structure that is chaired by our physician leaders at Scripps. And within our own supply chain department, we have a clinical team that is made up of nurses with backgrounds in surgery, cardiac care, critical care, and med-surg. Our nurse team works closely with our service line leaders and connects with our nursing departments to review supply utilization data specific to their areas of expertise. Those reviews are centered on quality metrics and supply variation across our health system.
Our supply chain team also supports the clinical service lines in new product and technology requests, and they review how new requests may support our patient experience. Our collaboration with the clinical service lines is designed to choose the best products for the best patient outcomes at the best price possible.
HL: How is supply chain management organized at Scripps?
Hozouri: We have a very connected supply chain at Scripps. We have a corporate office function that has our contracting, procurement, and value analysis team. Then we have operations and logistics teams that work directly with our hospitals and clinics. Logistics supports all product and equipment needs for our standard processes such as ordering, receiving, and inventory management.
HL: How do you include clinicians in supply chain decision making?
Hozouri: Involving our clinicians is critical to our supply chain processes. On a daily basis, our logistics team or our nurses in value analysis work very closely with our service line physicians and nurses to address product disruptions. The physicians and the nurses review our recommended product substitutions if the manufacturers are unable to produce their usual products. We need their feedback to make sure that the substitutions can support patient care.
Clinicians also support us on cost-reduction initiatives, and clinicians review standardization efforts with our supply chain teams. For example, our emergency department clinicians came forward and asked about disposable devices that are used once and thrown away. We looked into that opportunity, and they were right—we were spending a lot of money on disposable products and there was a lot of waste. With their help and collaboration, we achieved more than $1 million in savings.
HL: How do you engage clinicians when there are supply disruptions?
Hozouri: We usually have physician leaders within the service lines that we connect with. We also have a physician executive at each one of our hospitals that provide other point persons for us to go to. Overall, when we are dealing with a supply disruption, we reach out to the physicians and nurses in that service line and talk with them about the backorders and the items we need to substitute. We pick up the phone. We send emails. We share product information. We send out substitute products that they can touch and feel to make sure things are OK to substitute.
HL: How do you convince clinicians to standardize supplies?
Hozouri: When we do standardization projects, we work with clinicians as a group. For example, when we come forward with standardization ideas in surgery, we bring those ideas to the surgeons as a group and see whether they are willing to take a look at changes. Getting the physicians to the table has not been a challenge for our supply chain team. We have been working very well together, and providing the necessary data to make decisions has been an effective way to get clinicians to the table.
A Hancock Regional Hospital executive says workforce shortages are going to be a long-term challenge in healthcare.
Now that the crisis phase of the coronavirus pandemic has passed, healthcare providers need to adapt to the "new normal," a hospital chief medical officer says.
Julia Compton, MD, recently succeeded Michael Fletcher, MD, as CMO of Hancock Regional Hospital in Greenfield, Indiana. Before taking on the CMO role, she served as president of the Hancock Physician Network, which employs about 100 clinicians. Her clinical background is in radiation oncology.
Compton recently talked with HealthLeaders about a range of topics, including physician leadership, physician engagement, and clinical care predictions for 2023. The following transcript of that conversation has been edited for brevity and clarity.
HealthLeaders: Now that the crisis phase of the pandemic has passed, what are the primary clinical challenges at Hancock Regional Hospital?
Julia Compton: The biggest challenge is making sure that we have enough staff to take care of patients.
The other big piece is that there is a new normal and we have to adapt. That's tough. We need to pivot because what patients want has changed with the pandemic. For health systems like ours, we must pivot to the need of the patient. Traditional medical models are not going to be what patients want going forward. We will see that patients want much more individualized care. They want time with their physician.
HL: What are the primary elements of this new normal in addition to patients wanting more individualized care and more time with their physicians?
Compton: It's learning to utilize artificial intelligence. Learning to utilize data that not only helps the physician but also helps the patient. It's looking around and saying, "Who has built some of this capacity better that can help with patient care?" Physicians have never wanted to spend their time in the electronic medical record, and that is where traditional medicine has gone. What we are going to see is a pivot away from that. There is going to be more face-to-face time with patients, which could mean using more direct primary care models and other new models of care. It also could involve addressing the social determinants of health to help physicians provide the type of care that patients need.
Julia Compton, MD, chief medical officer of Hancock Regional Hospital. Photo courtesy of Hancock Health.
HL: What are the primary challenges of serving as CMO of Hancock Regional Hospital?
Compton: The biggest challenge we are facing now is labor shortage and how that is impacting not only our hospital but also all hospitals in central Indiana. The labor shortage is tremendous. Like many hospitals, we have a lot of agency nursing supplementing our nurses. We are trying to create a new opportunity where travel nurses may want to remain and become a part of Hancock Health.
On the floors and ICUs, we are seeing that nurses are young. They are brand new. They are fresh out of school. A lot of them did not have clinical training because of COVID, so what the nurses are trained to do now is very different than traditional nurses prior to COVID. Nurses that would have been doing the lead in terms of training have retired. All of this has a massive ripple effect on our physicians and advanced practice providers in terms of influencing burnout and concerns about patient safety.
HL: Are you experiencing physician shortages?
Compton: Recruiting physicians has become difficult. We are finding our best recruitment is from friends of friends. Person-to-person relationships and recommendations are crucial. But what we are seeing is that there are just not a lot of physicians out there. For us, the need for hospitalists is high. The need for certain subspecialties such as gastroenterology is high. Those physicians are very difficult to recruit now.
HL: How are you rising to that physician recruitment challenge?
Compton: We are looking to our own doctors to contact friends or colleagues who they would want to invite to our hospital. We have started offering a recruitment bonus to doctors who have candidate recommendations. There is a recruitment bonus if a candidate interviews and a recruitment bonus if a candidate is hired.
In our physician recruitment, we are accentuating the positives of working at Hancock Regional Hospital. Our hospital is relatively unique in that it is in a suburb area near Indianapolis, meaning that we have a smaller state feel but you are 20 minutes from the big city. So, we are big enough to be interesting, innovative, and cutting-edge, but small enough for physicians to have an impact on the community.
HL: What are the key elements of physician engagement at Hancock Regional Hospital?
Compton: During the pandemic, our doctors united and became engaged on every level to move the organization forward, to have a cohesive plan, and to have an incredibly fast and innovative response to COVID.
We had a new meeting three times per week with our doctors from noon to 1 p.m., and there was a lot of idea sharing. More than 90% of our doctors were engaged in those calls. We created triage clinics. We created respiratory clinics. We stood up monoclonal antibody infusion centers. We created several surge protocols. That engagement piece has continued. We want to keep that momentum going.
Instead of having a call three times per week, we have a call monthly. We also have other avenues to keep our physicians engaged. For example, we are inviting physicians to participate in large strategy sessions. All physicians and advanced practice practitioners are invited. The meeting is held from 7 to 8:30 a.m. We delay the start of clinics until that meeting is over, which provides everybody with the opportunity to participate.
HL: What are the keys to success for physician leadership?
Compton: People assume that physicians are natural leaders, and they are natural leaders in their own offices. But when you ask a physician to go into physician leadership at a higher level in the organization such as outside their own service line, one of the biggest keys to success is that you can no longer think as an individual. Instead, if a decision is made or if we implement a new strategy, there will be a ripple effect that impacts many people, and the many must be considered.
As physicians, we are taught to focus on a problem and to immediately solve it, and there are a small number of outcomes from the solution. In physician leadership, when you start working at different levels of an organization, you realize there is rarely one answer to a problem. There are many pros and many cons with every decision, and you must think through those pieces.
In addition to moving from thinking as an individual to thinking about the many, physician leaders need to learn how to listen very well. Physicians are used to having the answer—we need to have the answer if we have a very sick patient. In physician leadership, you find that there are many answers and there are many incredible brains around the table. In physician leadership, you are not always going to be the one who has the answer.
HL: Do you have any clinical care predictions for 2023?
Compton: One thing will be living with a new normal of labor shortages. Many people have been hoping it would end, but I don't think it is going to end. It is something that we will all have to adapt to and figure out how to manage the workforce differently.
Innovation is my second prediction. We are already starting to see big players innovate in healthcare. It will be interesting to see what Amazon does after some of its recent purchases in the healthcare arena. I assume they will be able to do things well, including virtual medicine. The opportunity for us at the hospital level to innovate will become even more important in 2023 and going into 2024.
There is going to be considerable healthcare fatigue in 2023. During the pandemic, ambulatory clinicians had difficulties they had to deal with and that was also true on the inpatient side. So, each type of physician and each type of advanced practice practitioner has seen COVID through a different lens, and now clinicians are genuinely tired.
There is going to be an increased emphasis on mental health in 2023, not only adult mental health but also child mental health.
The last prediction I would make is that we are going to see an increase in cancer diagnoses and chronic disease diagnoses. Patients are becoming sicker, and a lot of that has to do with the annual wellness visits that so many people either put off or could not get scheduled during the pandemic. As people get back into cancer screening and annual wellness visits, we are going to see a sicker patient population not only from chronic disease but also with oncologic diagnoses.
Accenture consultants present a framework for addressing health equity that has three core areas that every healthcare organization can embrace.
A new report from Accenture provides guidance on how healthcare organizations can address health equity.
Health equity has emerged as a pressing issue in U.S. healthcare during the coronavirus pandemic. In particular, there have been COVID-19 health disparities for many racial and ethnic groups that have been at higher risk of getting sick and experiencing relatively high mortality rates.
Healthcare organizations have an obligation to address health equity, a co-author of the Accenture report told HealthLeaders. "First and foremost, it is a moral imperative. If we were able to reduce the disparity in infant mortality, we could save the lives of thousands of Black infants. This is a justice and a moral imperative," says Ankoor Shah, MD, principal director of consulting and health equity lead at Accenture.
Addressing health equity is also a good business practice, he says. "There is a business growth and sustainability opportunity as well by advancing health equity. There is an opportunity to increase revenue and decrease costs; and those who are addressing health equity and reinventing themselves now will be a market leader in the future."
There are five causes of health inequities, according to the report: implicit bias, fear and lack of trust, access barriers, uneven quality and experience, and racism in research and development of clinical practices.
The report presents a framework for addressing health equity that has three core areas that every healthcare organization can embrace.
1. Mitigate bias in data analytics and algorithms
Clinical algorithms play an essential role in the digital systems at healthcare organizations; they are intended to boost accuracy and efficiency, but they have the potential to worsen healthcare disparities, the report says. "The most cited example is the large commercial health decision algorithm that used healthcare costs as a proxy for health needs, which inappropriately led to Black and African American patients being labeled as 'healthier' than equally sick white patients. To advance health equity, data analytics and algorithms must be inclusive, fair, accountable, transparent, and easily explainable."
Data analytics and algorithms can improve care, but they come with risks for health equity, Shah says. "If datasets have biases in them, then we could expand disparities. What that means is we often have incomplete datasets. If we do not have a dataset that has the true demographics for race, ethnicity, and language, then we purchase a third-party dataset to fill in those gaps, we run the risk of having a poor baseline dataset that we are applying analytics to, which can lead us astray and cause disparities to widen further."
2. Design inclusive products and services
Health equity should be a prominent factor from the beginning of product and service design, the report says. "Inclusive design methods enable and draw on the full spectrum of human diversity and individual experiences to create solutions. This does not mean that a single product or solution meets every person's needs. Instead, it means designing different ways for people to receive the same access, experience, and outcomes while having a sense of belonging. Considering health equity at this stage encourages better practices, greater accessibility, and a more inclusive healthcare environment, which drives value for people and ecosystem participants."
Focusing on inclusion builds patient trust in healthcare organizations, Shah says. "In our report, we mention that there are 7 of 10 Black Americans who say they are treated unfairly by the healthcare system. So, how can we reimagine healthcare's delivery to have trust? That is through an inclusive mindset—it is through an inclusive lens for how we develop products and how we deliver services."
3. Create sustainable structural change
Structural change is essential to make long-term progress in addressing health equity, the report says. "Racism and implicit biases are embedded throughout the ecosystem. Addressing institutional policies such as inclusive hiring practices, the types of partnerships created, and how participants execute clinical treatment and tools will have far-reaching effects on the sustainability of the healthcare ecosystem. Additionally, engraining equity as a core tenant of participants' foundation will aid in normalizing these activities across the ecosystem."
Shah cites the example of a health plan that tied executive compensation and incentives to reducing racial health disparities among its members. "What this does is uses structures we have in place to tie strategy to execution—to tie financial rewards to actually delivering what your business is intended to deliver and tie to health equity. You are changing the whole organizational mindset and the mechanics within it to drive advancing health equity."
The researchers found variation in overall performance of for-profit and not-for-profit hospices, so they say decisions on selecting a hospice should be based on publicly available data.
Family caregivers say they have worse care experiences at for-profit hospices than at not-for-profit hospices, a new journal article found.
Earlier research has shown that for-profit hospices do not perform as well as not-for-profit hospices, with higher rates of hospitalizations and emergency department visits, as well as offering a narrower range of servicessuch as less nursing visits. The percentage of hospices that are for-profit has risen significantly over the past two decades, increasing from 30% in 2000 to 73% in 2020, according to the Medicare Payment Advisory Commission.
The new research article, which was published today by JAMA Internal Medicine, examines Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospice Survey data collected from 1,761 for-profit hospices and 906 not-for-profit hospices.
The CAHPS Hospice Survey includes eight measures of hospice care experiences by family caregivers: hospice team communication, getting timely care, treating family member with respect, getting emotional and religious support, getting help for symptoms, getting hospice care training, rating of hospice, and willingness to recommend a hospice. The CAHPS Hospice Survey also includes a summary measure, which is an average of a hospice's performance across the eight measures of hospice care experiences.
CAHPS Hospice Survey data was examined from April 2017 to March 2019.
The new research article includes four key findings:
For all measures, family caregivers reported worse care experiences at for-profit hospices than at not-for-profit hospices
For-profit hospice performance varied, with 31.1% of for-profit hospices scoring 3 or more points below the national hospice average of overall performance, and 21.9% scoring 3 or more points above the national average
Not-for-profit hospices scored better on overall performance, with 12.5% of not-for-profit hospices scoring 3 or more points below the national average, and 33.7% of not-for-profit hospices scoring 3 or more points above the national average
Family caregivers with patients who received care in for-profit state, regional, or national hospice chains reported the worst care experiences
"Family members and friends of patients receiving hospice care reported substantially worse care experiences in for-profit compared with not-for-profit hospices; however, there is important variation in quality among both types of hospices. Because both for-profit and not-for-profit hospices are represented among the highest-performing and lowest-performing hospices, reporting of quality results for individual hospices is critical. Publicly reported survey measure scores provide important information to guide selection of a hospice," the study's co-authors wrote.
Interpreting the data
The family caregiver survey data provides valuable information about hospices, the study's co-authors wrote. "Using national data, we find that caregivers report substantially poorer care experiences in for-profit hospices than in not-for-profit hospices, with caregivers of those in for-profit hospices nearly 5 percentage points less likely than those in not-for-profit hospices to definitely recommend their hospice."
Prior research and the new study raise serious concerns about for-profit hospices, the co-authors wrote. "In the hospice context, poor quality care has been associated with complicated family grief and poorer bereavement adjustment, so this quality gap, combined with the growing dominance of for-profit hospices, is of particular concern."
In comments to HealthLeaders, the study's lead author speculated about why caregivers report substantially poorer care experiences in for-profit hospices than in not-for-profit hospices.
"The difference in care experiences between for-profit and not-for-profit hospices is likely explained by a combination of things that for-profit hospices don't do as well, and things that not-for-profit hospices do especially well. For example, many for-profit hospices try to provide more cost-efficient care by using fewer and less skilled staff. This means that their hospice teams may be less responsive to telephone calls from patients and families, or less likely to visit patients when they need it most. In contrast, not-for-profit hospices, which have smaller profit margins than for-profit hospices, are more likely to provide services that help improve patients' quality of life but are not covered by hospice payments," said Rebecca Anhang Price, PhD, senior policy researcher at RAND Corporation.
She also speculated on why hospices in chains received the lowest care experience scores. "Chains may be particularly attentive to their profit margins, and as such, they may look to reduce the number and cost of staff, since staffing is the main expense for a hospice. But high-quality staff are key to a hospice's ability to provide high-quality care, so understaffing—in terms of either number of staff or the skills and training of that staff—can have negative effects on patient and family care experiences."
Lack of diversity in the healthcare workforce risks undermining trust and patient health, according to a report published by the Urban Institute. In the Urban Institute report, only 22.2% of Black adults reported being of the same race as their healthcare providers compared to 73.8% of White adults, and only 23.1% of Hispanic/Latinx adults reported racial, ethnic, and language concordance with their usual healthcare provider.
Racial, ethnic, and language concordance between clinicians and their patients makes a difference, says Veronica Mallett, MD, senior vice president at CommonSpirit. "There is data to support that concordant racial, ethnic, and language factors between physicians and patients matter. It matters because it improves health outcomes. It has been shown to overcome some of the social and economic drivers of health outcomes by creating trust and by allowing the patient to have care by someone who understands their language, culture, and lived experience."
CommonSpirit has committed more than $100 million over 10 years to support the More In Common Alliance. One of the goals of the partnership is to raise another $100 million through philanthropy, she says. "Part of the work I am responsible for leading is to find donors, high net-worth individuals, grants, foundations, and institutions to support this effort."
Philanthropy work so far includes three solicitations for "substantial dollars" and a $2 million grant that is supporting a family medicine residency program in California, Mallett says. "The grant is designed to support the startup costs of new primary care programs in the interest of addressing the looming workforce shortage and to train more primary care physicians in California."
Four primary "work streams" for the More In Common Alliance are graduate medical education, undergraduate medical education, culturally competent care, and research, she says. "The goal of the alliance is to affect and improve health equity by diversifying the healthcare workforce, and we are going to do that by doubling the class size at the Morehouse School of Medicine and creating five regional medical campuses in order to accommodate the increased need for students to have clinical exposure."
Morehouse currently has 125 medical school students.
The More In Common Alliance has identified three sites for regional medical campuses: Chattanooga, Tennessee, Lexington, Kentucky, and Seattle.
"In Chattanooga, our focus is on African American students. In Lexington, the focus is on rural students, both African American and Caucasian. For example, we know that Kentucky has slipped to 45th in the nation for overall health, and rural Kentuckians both Black and White experience worse health outcomes. Our goal is to recruit from that population, and we have partnered with Kentucky State University, which is a historically Black university, to have a robust applicant pool and to have some competitive matriculants that would come from Kentucky and return to Kentucky to serve as physicians," Mallett says.
In Seattle, the More In Common Alliance is targeting the African American population in Tacoma, Washington, as well as the Alaska Native and Pacific Islander populations, which are among the least represented groups in health professions, she says.
The More In Common Alliance is planning to establish two residency programs in Bakersfield, California, Mallet says. The first program at Bakersfield Memorial Hospital is slated to start July 2025. The second program at Mercy Hospitals of Bakersfield is expected to start in 2028 or 2029.
As part of the partnership, CommonSpirit will be providing training for culturally competent care to the health system's clinicians, Mallett says. "The plan is to train CommonSpirit clinicians on providing care through what is being referred to as a culturally humble lens. The idea is to listen to the patient and to understand what they feel is important to know about their culture. Clinicians need to ask, to listen, and to observe, which will impact the ability of the patient to form a trust relationship and be able to adhere to provider recommendations."
Progress has been made in the research work stream, she says. "The CommonSpirit Health Research Institute and the Morehouse School of Medicine are partnering to collaborate on at least two research projects a year focused on health inequities and approaches to eliminating inequities. The first research project is on birth equity. We are partnering on rolling out a birth equity toolkit across CommonSpirit and a project training community health workers and patient navigators to help reduce the inequity in maternal mortality and morbidity."
The More In Common Alliance is unique, Mallett says. "There has not been a partnership between a medical school and a health system with the investment of the size that CommonSpirit has made to increase diversity in the physician workforce. We want to remove excuses for why we cannot have a more diverse workforce. We hope that this will be a model for other health systems."