Prevea Health's CMO says the proposed 2.8% cut in the 2025 Physician Fee Schedule could force providers to reduce or even cut some services.
A proposed 2.8% cut in Medicare reimbursements for physicians could force healthcare executives to make some painful decisions, the CMO of Prevea Health says.
"Our revenue is tied to payer contracts, which may be signed a couple of years in advance," says Paul Pritchard, MD, senior vice president and CMO of the Green Bay, Wisconsin-based multispecialty medical group. "The Medicare cuts in addition to us not being able to adjust our revenue streams have a dramatic effect.”
“We have been seeing decreases in revenue while our expenses have been climbing," he adds.
The pay cut is contained in the proposed 2025 Physician Fee Schedule, which was released by the Centers for Medicare & Medicaid Services on July 10. It proposes reducing the conversion factor for Medicare reimbursement from $33.29 this year to $32.36 in 2025.
The conversion factor is the number of dollars assigned to a relative value unit (RVU), which is a key element of physician payment by Medicare.
If that pay cut is included in the final rule later this year, it would be the fifth consecutive year that Medicare reimbursements have been cut. According to the American Medical Association, Medicare reimbursements have been cut by 29% since 2021.
According to Pritchard, those cuts have forced Prevea Health, which employs about 500 physicians and advanced practice providers, to make some cuts of their own.
"We have taken some steps such as reduction of staff, which has been primarily non-patient-facing staff such as administrative employees," he says. "We have consolidated certain service lines, particularly specialists. We have not reduced the number of physicians, but we have closed some sites. For example, in Green Bay, orthopedics is now consolidated at one site."
Pritchard said the Medicare reimbursement cuts aren’t happening in a vacuum.
"We experienced a significant reduction in the workforce because of the coronavirus pandemic," he says. "That has created inflationary pressure because healthcare employers are trying to get the same people to work for them. We have seen wages escalate and benefits escalate. Then you couple that with inflationary pressure from supply chain issues."
Potential impact of reimbursement cut
If the reimbursement cut goes into effect, Pritchard said Prevea Health will have to take a hard look at whether to continue providing some services and maintaining some sites of care.
"We will do what any business would do," he says. "We will look at services that are not profitable, which leads to difficult decisions. There are certain things we have done as a physician-run organization because we felt it was right for the community and not because it was profitable."
One such reduction, he says, could come in care management, which Prevea Health established as a service in 2009. While most of the care managers are unfunded positions, the medical group has taken funds out of managed care agreements and risk-based contracts to run the program.
"If we have to consolidate a service line and take it out of our rural areas, so we can have economies of scale, we would reduce access for patients in rural areas," Pritchard says. "But we may have to do this from a business perspective. We may not be able to continue to operate a clinic site in rural Wisconsin that sees 10 patients a day if our revenue continues to get cut."
Broad implications of reimbursement cut
There is widespread unease about private equity getting involved in healthcare and the high volume of healthcare mergers and acquisitions. The continuing Medicare reimbursement cuts are a prime reason for these developments, according to Pritchard.
"As you see your revenue go down, you must start joining larger systems, so that you can get capital, or you have to start reaching out to private equity to get capital," he says.
And the reimbursement cut trend, he added, is unsustainable.
"If you don't know what your capital is going to be because your revenue streams are being cut on a continuing basis, you are going to be reluctant to improve your services," Pritchard says. "The unknown makes it difficult to plan for the future."
"This annual exercise where we must reach out to the federal government to prevent a decrease in reimbursement is déjà vu all over again," he adds. "We have to figure this out because it is not sustainable, and the way it is going, it is only going to get worse."
With financial support from the Patient-Centered Outcomes Research Institute, AdventHealth is tackling antibiotics use for acute respiratory infections.
AdventHealth is launching an initiative to improve antibiotic stewardship for pediatric patients in the outpatient setting.
Antibiotic stewardship has several benefits, including lowering cost of care, reducing medication side effects, and addressing antimicrobial resistance. For pediatric patients, most antibiotics are prescribed in the outpatient setting.
"What makes what we are doing unique is the focus on ambulatory care," says Jeffrey Kuhlman, MD, MPH, chief quality and safety officer at AdventHealth. "We have launched a program that is focused on patients such as a parent bringing a child in for an acute respiratory tract infection including sinus and throat. In the U.S. healthcare system, there is very little emphasis on antibiotic use in the ambulatory setting for pediatric patients."
The initiative is being supported in part by $2.5 million from the Patient-Centered Outcomes Research Institute (PCORI).
The effort is centered on three clinical care settings: Hundreds of AdventHealth doctor's offices such as pediatricians, family medicine doctors, and primary care physicians; AdventHealth's Centra Care urgent care centers, which have more than 60 locations; and 70 emergency departments, which for the purposes of this initiative are considered outpatient locations because most ED pediatric patients are not admitted to a hospital.
"We are working with three sets of providers: Family doctors, pediatricians, and primary care doctors; urgent care doctors, physician assistants, and nurse practitioners; and emergency medicine physicians," Kuhlman says.
A primary element of the initiative is addressing antibiotic use for acute respiratory infections, according to Kuhlman.
"Half of the time for those diagnoses, the illness is viral, which is not appropriate for antibiotics," Kulman says. "Half of the time it is bacterial, and you need to start with a narrow-spectrum antibiotic such as amoxicillin instead of a broad-spectrum antibiotic, which is like using a bazooka to kill a mosquito."
How the initiative works
Provider education is a key component of the initiative. PCORI funding will help AdventHealth to provide more organized and focused education for providers in all three outpatient settings, Kuhlman explains.
"We have online learning for providers through the AdventHealth Learning Network," Kuhlman says. "We have assembled a list of providers in our outpatient settings along with their medical directors. We will engage with the medical directors to encourage the providers to take advantage of our educational offerings."
The initiative is data driven, according to Kuhlman. Providers in all three outpatient settings will have access to dashboards that will have real-time data on the rate of prescribing antibiotics and the rate of prescribing narrow-spectrum versus broad-spectrum antibiotics.
"We have evidence-based literature from PCORI and Children's Hospital of Philadelphia that pediatric patients with an acute respiratory tract infection need antibiotics only half of the time," Kuhlman says. "The other half of the time, the illness is viral and not appropriate for antibiotics. A provider's prescribing patterns for antibiotics should follow that evidence."
Last year, AdventHealth providers gave antibiotics to two-thirds of pediatric patients with acute respiratory infections. With the new initiative, the goal is to decrease that rate to less than half, according to Kuhlman.
Last year, AdventHealth prescribed narrow-spectrum antibiotics for pediatric patients with acute respiratory infections about two-thirds of the time. Now, the goal is to increase that prescription rate to more than 90% of the time, Kulman explains.
"If providers use amoxicillin instead of a powerful antibiotic such as azithromycin, the outcomes are the same and there are fewer side effects," Kuhlman says. "In addition, the cost of care is significantly lower for the antibiotic."
In addition to provider education and data management, the initiative is improving the health system's electronic medical record, Epic. A highly skilled nurse is adjusting the order sets for pediatric patients with acute respiratory infections, according to Kuhlman.
"With these order sets, there are symptoms for acute respiratory tract infections in pediatric patients; the order sets remind clinicians about the differences between a viral infection versus a bacterial infection; and if clinicians go down the bacterial infection pathway, narrow-spectrum antibiotics are placed at the top of the treatment options," Kuhlman says. "We are making it easy for clinicians to do the right thing in the electronic medical record."
Why CMOs should be concerned
Initiatives such as AdventHealth's pediatric antibiotics stewardship program are in the CMO's wheelhouse, according to Kulman.
"CMOs basically have four jobs: professionalism, persuasion, performance, and patient safety," Kuhlman says. "If you think about pediatric antibiotic stewardship, it touches on all four of those areas."
In professionalism, part of integrity in being a clinician is doing the right thing. "Our initiative is helping clinicians to do the right thing," Kuhlman says.
In terms of persuasion, the initiative is designed to persuade clinicians to change their practice of medicine and improve antibiotics stewardship, according to Kuhlman.
For performance, the initiative is striving to improve clinicians' adherence to evidence-based guidelines. "Our initiative is changing the performance of clinicians," Kulman says.
In patient safety, clinicians should not expose pediatric patients with acute respiratory infections to harmful side effects," Kuhlman says. "We need to appropriately decide whether an antibiotic is necessary, then we need to pick the right antibiotic."
Telehealth expanded exponentially during the coronavirus pandemic, and telehealth visits remain high compared to pre-pandemic levels. Having 24/7 telehealth services is relatively rare, but this health system is working to change that.
Hackensack Meridian Health has launched HMH 24/7, a 24/7 virtual care service, in a partnership with K Health.
"K Health, which is providing the app for HMH 24/7, is now a part of our medical group," says Daniel Varga, MD, chief physician executive for Hackensack Meridian Health. "So, HMH 24/7 is the doctors that K Health convenes, and they are part of our employed medical group."
There are different approaches to patient engagement in the inpatient and outpatient settings.
Patient engagement as WellSpan Health includes a personal touch and digital tools, the chief physician executive of the health system says in a HealthLeaders podcast.
Patient engagement is an essential element of generating a positive patient experience. It also is crucial in involving patients in their care, which helps to achieve good clinical outcomes.
As part of the podcast, Anthony Aquilina, DO, executive vice president and chief physician executive at WellSpan, discusses patient engagement in the inpatient and outpatient settings.
Inpatient engagement
In the inpatient setting, patient engagement is pivotal to putting patients at ease, according to Aquilina.
"When you are a hospital patient, it can be one of the most anxiety-producing times of your life," he says. "You are there hoping and praying that the people who have your life in their hands are going to do the right thing for you."
The primary components of patient engagement in the inpatient setting are compassion and respect, and all members of the care team need to treat patients accordingly, Aquilina says.
"An inpatient can see as many as three or more people every hour they are laying in a hospital bed. Almost half of them are nurses, but there are also doctors," he says. "It is important that we focus on everybody who is encountering the patient and make sure they understand the basics about how to make the patient feel comfortable and to make sure the patient feels that the team is working together in their best interest."
A digital tool that the health system is using for patient engagement in the inpatient setting is called MyWellSpan Bedside, which is part of the MyChart experience in the Epic electronic medical record.
"MyWellSpan Bedside is an inpatient version of MyChart," Aquilina says. "It allows patients to engage and to be informed as well as to be empowered in their hospital-based care. They can see things such as upcoming tests, recent results, and other content about their care. It allows them to be digitally engaged."
The health system is also engaging patients through virtual nursing.
"The way this works is there is a nurse sitting in front of a monitor with the ability to view as many as six patients," Aquilina says. "His or her role is to supplement the care delivered by the bedside nurses. This nurse keeps an eye on the patient in the bed and communicates with them."
Virtual nursing allows early identification of potential risks such as falls, and it also improves patient education, transitions of care, and the discharge process, according to Aquilina.
"Virtual nurses can pop into a patient's room through a video feed and engage the patient as well as family members when they are visiting," he says.
Anthony Aquilina, DO, is executive vice president and chief physician executive at WellSpan Health. Photo courtesy of WellSpan Health.
Outpatient engagement
In the outpatient setting, patient engagement is more provider driven, so WellSpan has worked with physicians and advanced practice providers to mximize their patient engagement skills and focus on compassion and respect for all patients, Aquilina says.
The health system understands from the patient's viewpoint that their ambulatory care is not just a patient visit, according to Aquilina.
"It starts when a patient thinks about the need or desire to get care, then continues through the visit and the after care," he says. "We make sure that their instructions after a visit, follow-up after a visit, or tests after a visit are all coordinated."
In the outpatient setting, nurse navigators play an important role in patient engagement at WellSpan for both the pre-visit part of care and the after-visit part, according to Aquilina.
"For the pre-visit part of outpatient care, we started a program for nurse navigation that allows patients who have uncertainty about how to access care to talk with a real human being," he says. "The nurse navigator is trained to understand the patient's personalized needs and get them to the right place. The right place is not always an office visit. Sometimes, it could be a virtual visit. Sometimes, it is urgent care. Occasionally, it is an emergency room visit."
After outpatient visits, nurse navigators focus on patients with acute needs, according to Aquilina.
"For after-visit care, we are using our nurse navigators to make sure our highest risk patients are getting the care they need and the follow-up they need," he says.
Cleveland Clinic is the latest health system to appoint someone to oversee advanced practice providers (APP).
A growing number of health systems and hospitals have been creating APP executive positions, including Vanderbilt University Hospital, CommonSpirit Health, and Corewell Health. The new executive positions recognize the crucial role that APPs are playing in healthcare.
Add Cleveland Clinic to that list.
Cleveland Clinic has been using APPs, such as nurse practitioners and physician assistants for decades. Over the past 25 years, the number of APPs has grown significantly from about 400 to nearly 4,000.
The health system decided to create an executive position to improve the management of APPs at the health system, says Melissa Stoudmire, MSN, who became Cleveland Clinic’s first vice president of APPs in August.
"The organization identified the need to create a dedicated enterprise APP role to manage continued growth in APPs, maintain consistency in APP practice, and streamline the leadership structure," she says. "The health system wanted to give the APP group an executive presence."
The new position gives Cleveland Clinic an opportunity to enhance the health system's leadership model and bring APPs under one leadership structure, according to Stoudmire.
"I will be providing an executive leadership presence and providing direction for all APP teams," she says. "At the executive level, I will be helping to look at operations from a systems approach, look at strategy, and drive the metrics that are expected at Cleveland Clinic for high quality care, patient safety, and patient satisfaction. We will also be looking at the metric for APP productivity."
Melissa Stoudmire, MSN, is Cleveland Clinic’s first vice president of advanced practice providers.
The Role of APPs at Cleveland Clinic
"APPs are an integral part of multidisciplinary teams," Stoudmire says, noting they are a part of every service line at Cleveland Clinic. "The utilization depends on the service line. Ultimately, [they] work with physicians defined by state and national laws. We have APPs and physicians work to top of scope whenever possible."
For example, the Ohio Board of Nursing sets the scope of practice for advanced practice registered nurses (APRNs), which includes certified registered nurse anesthetists (CRNAs), certified nurse-midwives (CNMs), clinical nurse specialists (CNSs), and certified nurse practitioners (CNPs).
With direct supervision of a physician, a CRNA can administer anesthesia as well as perform pre-anesthetic preparation and evaluation, post-anesthesia care, and clinical support functions.
CNMs, CNSs, and CNPs are required to have a written standard care arrangement with a qualified collaborating physician.
In the inpatient setting, APPs participate in multidisciplinary rounds and other team-based functions, Stoudmire says. In the outpatient setting, she adds, either an APP or a physician can see a patient, based on either the service line or the patient’s symptoms.
"APPs play different roles in primary care practices vs. specialty practices," she says. "In primary care practices, APPs help physicians perform at top of license. In some specialty practices, patients have their first visit with a physician, with follow-up appointments managed by APPs. The roles of APPs are also determined by what providers are available. If a physician is not available, an APP can stand in for the physician."
Under some circumstances, Cleveland Clinic APPs lead care teams in collaboration with physicians, according to Stoudmire.
"In follow-up clinics, primary care clinics, and Cleveland Clinic Express Care, you may see more of an APP presence," she says. "But we always go back to the collaboration with a physician. So, while an APP may be the primary provider on a given day in a service line, [they] are always collaborating with physicians."
Nationally, APPs are playing an essential role on care teams, according to Stoudmire.
"We know that APPs improve access to care, and they help to expand the clinical services provided at a health system in multiple service lines," she says. "Nationally, there is a shortage of physicians in many specialties, and [they] can help bridge the gaps."
APP engagement at Cleveland Clinic
Cleveland Clinic has several methods for engaging APPs at the health system, according to Stoudmire.
"APPs sit on many committees throughout Cleveland Clinic alongside our physician colleagues," she says. "For example, [they] are non-voting members of our Medical Executive Council; [they] participate in peer review committees; and [they] serve on safety, quality, and patient experience committees."
Stoudmire says the health system gathers feedback from APPs through several surveys.
"In the APP group, we have an annual process to make sure that leaders are providing what our teams need and are asking for feedback to keep APPs engaged," she says.
Telehealth expanded exponentially during the coronavirus pandemic, and telehealth visits remain high compared to pre-pandemic levels. Having 24/7 telehealth services is relatively rare, but this health system is working to change that.
Hackensack Meridian Health has launched HMH 24/7, a 24/7 virtual care service, in a partnership with K Health.
"K Health, which is providing the app for HMH 24/7, is now a part of our medical group," says Daniel Varga, MD, chief physician executive for Hackensack Meridian Health. "So, HMH 24/7 is the doctors that K Health convenes, and they are part of our employed medical group."
The HMH 24/7 app includes an artificial intelligence component.
"We use an AI model in the app that allows a significant amount of information to be gleaned in a simple dialogue with the patient," Varga says. "You can use the app, get a chief complaint as well as get background and demographics from the patient, then the app populates a document for the physician."
Hackensack Meridian Health is expecting HMH 24/7 to provide "three tiers" of care for patients, according to Varga.
1. Virtual medical practice: The first tier is creating the virtual medical practice of Hackensack Meridian Health Medical Group. If needed, the health system will continue to do practice-specific telehealth visits. Moving forward, the health system will build around the HMH 24/7 platform. Anybody in the community can download the app and make an appointment to see a doctor through HMH 24/7, which is a pure virtual care model.
2. Bridge model: One of the biggest things that health systems and hospitals struggle with is emergency department discharge and readmission as well as hospital discharge and readmission. One of the obstacles to high performance in those areas is the ability to access a follow-up appointment quickly. With HMH 24/7, if there is an emergency department patient, and the ED physician would like the patient to have follow-up within 48 hours, the patient can download the HMH 24/7 app in the ED and make an appointment with HMH 24/7 before they leave the ED.
If there is a patient who has an established primary care physician, but it is going to take a week for the patient to see the PCP post-discharge, the health system can get the patient a bridge appointment by connecting them with HMH 24/7. When the patient gets in to see their PCP, the HMH 24/7 physician has documented the bridge appointment in the health system's electronic medical record. That way, the patient encounter with the HMH 24/7 physician is already in the patient workflow.
3. Wraparound services: The third tier is to build HMH 24/7 as a wraparound for the medical group that can provide 24/7 services to patients. A patient of a doctor who is a member of the Hackensack Meridian Health Medical Group can call the doctor and get connected to HMH 24/7. If the patient needs a doctor's visit, they can be immediately connected with a doctor through HMH 24/7, and the doctor can see the patient right then.
Benefits of HMH 24/7
Hackensack Meridian Health expects HMH 24/7 will improve transitions of care and limit readmissions, according to Varga.
"Where we hope HMH 24/7 will affect daily operations is particularly in transitions of care," Varga says. "When we are trying to get patients from the hospital to home or emergency department to home, HMH 24/7 can provide the appropriate medical oversight."
The around-the-clock access to care that HMH 24/7 will provide is a leap forward for Hackensack Meridian Health, Varga explains.
"We don't offer standard virtual visits after 4 p.m., and we don't offer standard virtual visits on weekends," Varga says.
Varga says HMH 24/7 should improve care for patients who visit Hackensack Meridian Health's emergency departments.
"For established patients, we are looking to provide bridge visits between the ED visits and when the patient can get in to see their primary care physician," Varga says. "For patients who do not have an established primary care physician with us, the HMH 24/7 practice can provide a primary care physician until the patients need someone to lay hands on them in an in-person visit. This enables us to provide continuity of care."
Varga provides three examples of how HMH 24/7 can connect patients to primary care through a seamless integration of virtual and in-person care.
First, there is the HMH 24/7 patient who is young and healthy and does not want to go in to get a complete physical with a primary care physician. At least 25% of New Jersey residents do not have a PCP. So, there are many patients for whom HMH 24/7 can act as the primary care doctor.
Second, for patients who already have a primary care physician through Hackensack Meridian Health, HMH 24/7 can be the after-hours and wraparound connection to their PCPs.
Third, for the patients who are discharged from the ED or the hospital, HMH 24/7 can connect those patients to a doctor then hand them off to a primary care physician.
Three of the hot topics at last week's HealthLeaders CMO Exchange were physician burnout, CMOs as liaisons, and the role of advanced practice providers.
Last week's HealthLeaders CMO Exchange focused on the top issues facing CMOs, chief clinical officers, and chief physician executives across the country.
HealthLeaders convened nearly two dozen CMOs, chief clinical officers, and chief physician executives from leading health systems and hospitals, including Yale New Haven Health, UW Health, OhioHealth, and RWJBarnabas Health. The event was held at the Hotel Effie Sandestin in Miramar Beach, Florida.
Physician burnout and wellness
Physician burnout was identified as one of the pressing issues facing CMOs.
"The top concerns for CMOs are maintaining the quality and safety of patient care delivery at our hospitals, while also maintaining physician integrity," says Seth Rosenbaum, MD, senior vice president and CMO of RWJBarnabas Health's Robert Wood Johnson University Hospital Hamilton. "As we know, burnout has become a concern as well as physician attrition and the rates of physicians leaving private practice."
"Physician engagement and physician burnout are high on the list of CMO concerns," says Candace Robinson, MD, CMO of Touro_LCMC Health. "I think there are ideas on how to address physician burnout, but no good clarity on what would be most effective at this point."
Physician burnout cannot be addressed in isolation from burnout in other healthcare workers, Robinson says.
"We need to have burnout programs that are for everyone, not just physicians, because we affect each other," Robinson says. "The nursing burnout is real—there is burnout across all of healthcare. COVID had a profound impact on burnout. Looking at the data from the American Medical Association, it looks like it is getting better, but it hasn't changed too much."
CMO's role as intermediary
CMOs play an essential role as the liaison between a healthcare organization's clinical staff and administrative leadership, Rosenbaum says.
"Traditionally, the CMO has been the liaison between the medical staff and the administration," Rosenbaum says. "The CMO has been the clinical person that understands both sides of care delivery. The CMO is supposed to help mediate differences between the administration, which sets policies and procedures, and the medical staff."
The intermediary role can be challenging, according to Rosenbaum.
"Sometimes, the medical staff says taking care of patients does not necessarily follow the policies and procedures that administration is establishing," Rosenbaum says. "The CMO must make both sides understand that in the interest of patient safety and patient care, both sides are working to the same goals. CMOs need to figure out a happy medium to get the job done and to make sure that we can provide the quality of care that our patients expect."
Working in a clinical role alongside their administrative duties can be helpful for CMOs to succeed as intermediaries, according to Robinson.
"I am not just sitting in a room during a meeting with clinical staff—I am working alongside them," Robinson says. "Many successful CMOs have at least a little dedicated clinical time, which is helpful in maintaining the connection between the administration and the frontline clinical team."
Role of advanced practice providers on care teams
APPs play a crucial role in today's practice of medicine, according to Rosenbaum.
"The physicians are overwhelmed with the volume of work in the timeframe allowed to do that work," Rosenbaum says. "They feel constantly pressured to see large numbers of patients in a short period of time. APPs can help mitigate that pressure."
APPs can perform clinical duties under the direction of physicians, according to Rosenbaum.
"We can have the ancillary support of qualified independently licensed practitioners such as APPs to assist physicians on clinical duties on a day-to-day basis," Rosenbaum says. "You must be able to find APPs who are able to do the work under the supervision of a physician."
APPs have an essential role to play but there are limitations, according to Rosenbaum.
"As long as everyone is on the same page, APPs will take on an expanding role in healthcare," Rosenbaum says. "We are seeing this across service lines, whether it is in the emergency department, the hospitalist medical service, or the outpatient arena."
Staffing realities make APPs crucial for care teams, according to Robinson.
"APPs are necessary to allow us to provide access to care for patients," Robinson says. "We just do not have enough physicians to take care of all of our patients."
The physician workforce is not going to be able to see enough patients without the help of APPs, according to Robinson.
"For example, if you have a large quantity of patients coming through an emergency room setting, the physicians need to be the ones taking care of the higher acuity patients, but APPs can be taking care of patients who have a lower acuity level and manage those patients, knowing physicians are there to answer any questions that arise," Robinson says.
Physicians should provide complex care, and APPs are qualified to help physicians manage patients who have complex conditions, according to Robinson.
"Given the way physicians are trained and the amount of clinical experience physicians gain during residencies, physicians should take care of the higher acuity patients. Those are the patients that physicians should be managing," Robinson says. "If an APP encounters a patient who is seriously ill, they can help manage that patient while knowing they have a physician who is available to help them with that management."
Most care teams should be physician-led, but there are circumstances where an APP can lead a care team, according to Robinson.
"It depends on what the team is leading. It depends on what type of initiative is involved," Robinson says. "The more medically complex initiatives probably need to be physician-led. In less complex initiatives, an APP can be an acceptable leader."
At Robert Wood Johnson University Hospital Hamilton, APPs play leadership roles in areas that do not require a high level of clinical expertise, according to Rosenbaum.
"We have our observational length of stay initiative, which has leadership roles for APPs," Rosenbaum says. "There are other initiatives that have hospitalist APPs and emergency department APPs leading on throughput issues, progress notes, and documentation."
The HealthLeaders Exchange is an exclusive, executive community for sharing ideas, solutions, and insights.
OU Health's chief physician executive offers advice on how healthcare providers can promote a positive patient experience.
The new chief physician executive of OU Health is focused on recruiting physicians, leading strategic clinical initiatives, and helping care teams to generate a positive patient experience.
On Sept. 6, Cameron Mantor, MD, MHA, was named as chief physician executive at OU Health and president of OU Health Partners, which is the health system's physician practice. He had been serving in the roles on an interim basis since January. His prior leadership experience at the health system includes serving as associate chief physician executive for physician practice at OU Health Partners and CMO for OU Health's hospitals.
Lifepoint Health’s CMO shares key insights into reducing unwarranted clinical variation through a clinician-centered, analytics-driven approach.
In today’s rapidly evolving healthcare landscape, reducing unwarranted clinical variation has become a top priority for hospital and health system leaders.
At the recent HealthLeaders CMO Exchange, executives discussed innovative strategies to tackle this issue, with Chris Frost, MD, senior vice president, chief medical officer, and chief quality officer of Lifepoint Health, at the forefront.
Lifepoint’s two-and-a-half-year initiative aims to standardize care, reduce waste, and elevate clinical quality by empowering clinicians and leveraging data-driven strategies.
"Our operational definition of unwarranted clinical variation is variation in healthcare delivery that cannot be explained on the basis of illness, medical need, or evidence-based medicine," Frost says.
Lifepoint has enlisted clinicians to reduce unwarranted clinical variation, according to Frost.
"Our approach is bottom-up as opposed to a top-down approach," he says. "We have a clinician-centered process that helps engage the doctors and advanced practice providers to create standards of care and provide consistent care."
Lifepoint has been deliberate about engaging clinicians early in the process to reduce unwarranted clinical variation, according to Frost.
"We acknowledged early on in our discussions with the doctors that we understood that this effort is not just about reducing costs," he says. "There was an element of reducing waste in healthcare delivery. Ultimately, this is about elevating the quality of care—this is not about robbing clinicians of autonomy."
The initiative has been driven by a four-pronged strategy:
Quality-focused process improvement
Leveraging analytics
Care standardization based on evidence-based medicine
Deliberate focus on change management
"Overall, we improve quality by using evidence-based medicine as the standard to provide the right care to the right patient at the right time," Frost says.
Change management has been an essential part of the initiative, according to Frost.
"We recognize that if this was as easy as adherence to order sets, we would not need change management," he says. "But there is the people side of change, which is distinct from the process side of change."
Change management in the unwarranted clinical variation reduction initiative has had several components, Frost explains.
Lifepoint assessed the cost of inaction and perpetuating the status quo.
The health system was deliberate about identifying outcome measures. For example, sepsis outcome measures were length of stay and mortality, and congestive heart failure outcome measures were length of stay and readmissions.
Lifepoint also identified process measures. For sepsis and congestive heart failure, order set compliance was a key process measure.
Process measures were viewed from a team-based care perspective. The health system did not just look at physicians and advanced practice providers, but also other team members such as nurses and lab technicians.
The health system adjusted the "choice architecture" for treating medical conditions. For example, when Lifepoint clinicians pull up the sepsis order set, there is a listing of the antibiotics alphabetically, but the health system made it easy to choose the ones that have the highest efficacy and are evidence-based for that particular condition.
To maximize the impact of the unwarranted clinical variation reduction initiative, Lifepoint focused on five areas: sepsis, congestive heart failure, length of stay, optimizing blood transfusion utilization, and reducing repetitive lab testing.
There are four takeaways from the initiative so far, according to Frost.
Unwarranted clinical variation reduction can decrease healthcare waste as well as improve quality.
You need to prioritize your areas of focus.
You need to settle on a strategic approach. In Lifepoint's case, the health system adopted a four-pronged approach.
Never underestimate the importance of change management as it relates to clinician engagement.
The HealthLeaders Exchange is an exclusive, executive community for sharing ideas, solutions, and insights.
Please join the community at our LinkedIn page. To inquire about attending a HealthLeaders Exchange event and becoming a member, email us at exchange@healthleadersmedia.com.
Engagement, leadership training, and building a sense of community are among the ways to limit burnout, HealthLeaders CMO Exchange members say.
Healthcare worker burnout was the primary topic of a roundtable discussion today at the HealthLeaders CMO Exchange.
Healthcare worker burnout was widespread before the coronavirus pandemic and spiked during the public health emergency. A study found that from September 2019 to January 2022, overall emotional exhaustion among healthcare workers increased from 31.8% of staff members to 40.4%.
CMOs are well-positioned to address burnout among staff members, says Gary Little, MD, MBA, a CMO at Atrium Health.
"The CMO and other physician executive leaders can lean in on burnout," he says. "The skill we bring and the expertise we bring is around identifying problems and putting teams together to find solutions. That is what we do—it is our superpower."
CMOs need to engage healthcare workers to help address burnout, several CMO Exchange members say.
"Medicine is about relationships," says Erik Summers, MD, CMO at Atrium Health Wake Forest Baptist. "We have to make time as CMOs to see our staff members. You have got to get out there. You may not solve their problems, but listening is therapeutic. Listening goes a long way toward addressing burnout. There's nothing like face-to-face communication."
Better communication addresses burnout, Little says.
"We communicate what is happening in the organization and why on a regular basis," he says. "We explain why decisions were made. We try to tie the complaints, issues, and concerns to an action or a solution, then communicate about it."
Recognition is one of the ways healthcare organizations can combat burnout, says Jared Muenzer, MD, MBA, chief physician executive at Phoenix Children's and chief operating officer of Phoenix Children's Medical Group.
"We got a lot of feedback from our providers that the marketing communications and celebrations were all about the institution, and not about the individual providers and physicians," he says. "Over the past two years, we have gone after celebrating our physicians and advanced practice providers. It's not a direct solution to burnout, but it has been a huge win."
Engagement is when a change is made and it impacts physicians, advanced practice providers, and other staff members, then they speak up about it, Little says.
"They may complain," Little says. "It is not always negative when doctors and APPs complain—that tells me they actually care."
Helplessness is a driver of burnout, and engagement can tackle the problem, says Bryana Andert, DO, medical director at New Ulm Medical Center.
"Things happen and staff members feel they are beyond their control. Learned helplessness feeds a victim mentality, which is where some of the burnout lies," she says. "You need to engage with your people better, so they can believe there is somebody who is going to stand up for them. They may not get every single thing they want, but at least there is a pathway to address helplessness."
Leadership training can help address physician burnout, says Chris Frost, MD, senior vice president, chief medical officer, and chief quality officer of Lifepoint Health.
"We have developed a physician leadership curriculum, which morphed as we were developing it to help address burnout," he says. "The curriculum now focuses on psychological safety, empathy, a culture of safety, and conflict resolution. If we can identify physician leaders, then equip them with this skill set, we can have a scalable approach for addressing burnout."
Limiting burnout can be achieved through removing "the pebble in the shoe" that can drive healthcare worker dissatisfaction, Andert says.
"For example, there was an operating room staff and the pebble in their shoe was they could not get the right-sized scrubs consistently when they showed up in the OR for their shift," she says. "The response was to make sure they could get the right-sized scrubs, which did not cost a lot of money or time. They took that pebble out of their shoe, and it was a step in the right direction."
A major driver for burnout is isolation, Andert says.
"Many years ago, physicians would go into the physicians' lounge and engage with each other. There was community and opportunities to have friends," she says. "We have to find ways to re-engage with each other and create ways to have a community of professionals. We have get-togethers once a month, where food is provided. We have a topic that spurs conversation."
