The hospital association says it is focusing advocacy on workplace violence, Medicare residency slots, the nursing shortage, and workforce diversity.
Strengthening the healthcare workforce is one of the top priorities of the American Hospital Association's advocacy agenda for 2023.
Health systems and hospitals are facing workforce shortages across the full spectrum of their employees. In addition to a well-recognized shortage of nurses nationwide, health systems and hospitals are struggling to fill openings among physicians, technicians, and other job positions.
The American Hospital Association recently released the organization's 2023 advocacy agenda. In addition to strengthening the healthcare workforce, the AHA is targeting three other areas: ensuring access to care and providing financial relief; advancing quality, equity, and transformation; and enacting regulatory and administrative relief.
A pair of AHA executives spoke with HealthLeaders today about the organization's focus on strengthening the healthcare workforce. "Workforce is the Number One concern for hospitals across the country," says Priscilla Ross, executive director of executive branch relations and senior director of federal relations.
Addressing workplace violence
She says addressing workplace violence and intimidation is a key focal point for the AHA.
"Over the past few years and during the coronavirus pandemic, we have seen a sharp increase in the number of violent incidents at hospitals, particularly physical attacks on staff. It is demoralizing. It harms the quality of care because providers must spend time focusing on deflecting attacks and recovering from attacks, rather than focusing on patient care. It has become a big issue across the board. It is something we hear about from our hospitals on a consistent basis," she says.
Workplace violence and intimidation is taking a heavy toll on staff members, Ross says. "In addition to being demoralizing, workplace violence makes staff fearful of dealing with patients. It is causing stress, burnout, and prompting staff to decide they do not want to practice in a hospital setting anymore."
Increasing Medicare residency slots
The AHA is also focusing on increasing the number of residency slots eligible for Medicare funding to address physician shortages, she says.
"We have seen estimates that the physician shortage is going to reach 124,000 physicians within the next 10 years. That is going to jeopardize access to care in communities across our nation. The Medicare Graduate Medical Education program was created at Medicare's inception in 1965 to ensure that Medicare beneficiaries had access to providers. Congress decided that the Medicare program would play a role in funding graduate medical education. Unfortunately, back in the Balanced Budget Act of 1997, Congress decided to freeze the number of Medicare-funded residency slots to about 90,000 slots," Ross says.
The AHA has supported federal legislation that has been bipartisan and bicameral for several years that would add a significant number of Medicare-funded residency slots to the program, she says. "The most recent bill in the last Congress was the bipartisan Resident Physician Shortage Reduction Act, which would have added 14,000 new residency slots over seven years. We need to have additional funding so that communities can have an adequate number of physicians."
Tackling the nursing shortage
The AHA also plans to support measures that would help address the nursing shortage, says Akin Demehin, senior director of quality and patient safety. "The nursing shortage did not happen overnight. There have been structural shifts and demographic shifts in the nursing workforce. Prior to the COVID-19 pandemic, about half of nurses were age 50 and over, and about 30% were age 60 and over. So, just from that perspective, there was a need to replace the portion of the nursing workforce that was approaching retirement age. The pandemic served as a profound accelerant, with nurses facing wave after wave of COVID patients, experiencing increased incidences of violence, and many readying for the next phase of their lives in retirement."
Several efforts can increase the nursing workforce, he says. "The first is investing in faculty for training nurses. Nursing faculty are in significant shortage, so much so that about 80,000 applicants to nursing schools who were qualified to attend nursing school had to be turned away, in large part because there were not enough faculty to train them. We have supported legislation to help address the faculty shortage—the Future Advancement of Academic Nursing Act.
There are also short-term actions targeting regulation that could bolster the nursing workforce, Demehin says.
"We need to look critically at the range of regulations that affect nursing workload and increase burden without necessarily adding value in terms of quality of care. There were some flexibilities granted during the pandemic's public health emergency that were very helpful for the nursing workforce. For example, we would like to see changes to the discharge planning requirements that are administratively intense but are not necessarily leading to the better transitions in care that were the original intent. Another example is doing away with Medicare requirements around advanced practice nurses that are more restrictive than state laws—that could be a step forward in encouraging flexibility in the nursing workforce," he says.
Boosting healthcare worker diversity
The AHA is also planning to support efforts to increase diversity in the healthcare workforce.
Ross says the AHA has been supporting federal legislation that would boost diversity in the physician workforce.
"In the last Congress, there was a part of the Build Back Better Act called Pathways to Practice that established 1,000 new fully funded medical school scholarships for medical school or post-baccalaureate studies for people who came from disadvantaged backgrounds, rural areas, were the first in their families to attend college, or graduates of historically black colleges and universities. In addition to tuition, Pathways to Practice provided a stipend for students. It would have taken great strides toward increasing diversity for those who find pursuing a medical career out of reach. It passed in the House, but it did not make it through the Senate," she says.
The AHA is supporting work at the local level to promote diversity throughout the healthcare workforce, Demehin says. "What we hear from AHA members about their diversity work above and beyond the physician workforce is that the work takes place at the local level through partnerships with local schools and colleges to create linkages for those who are considering health professions as a career. Members are reaching out in intentional ways to diverse communities to encourage them to work in the healthcare field. Ultimately, improving diversity can help us take better care of the communities that we serve."
Education and communication are essential when healthcare providers address vaccine hesitancy for vaccine-preventable diseases.
At the national level, vaccination rates for vaccine-preventable diseases are stable, but healthcare providers need to address vaccine hesitancy at the local level, an infectious disease expert says.
Last year's polio outbreak in New York and a spike in measles cases in 2019 are recent examples of alarming flare ups of vaccine-preventable diseases in the United States. As of Jan. 4, about 81% of the U.S. population had received at least one dose of a COVID-19 vaccine, with about 69% of the population fully vaccinated.
While national vaccination rates for vaccine-preventable diseases such as measles are relatively high and stable, healthcare providers need to be on guard for vaccination lapses at the local level, says Susan Koletar, MD, a practicing physician and director of the Division of Infectious Diseases at The Ohio State Wexner Medical Center in Columbus, Ohio.
"Some of it is education and hesitancy among populations who have themselves benefited from vaccines. Vaccination rates are stable, but the world is small. You can get on a plane and be anywhere in less than 24 hours and be exposed to a range of diseases. The question is, why are vaccines not more broadly utilized? We don't talk enough to our patients about vaccines—that's not just doctors, it is also nurses and pharmacists. Something as important as vaccines requires some time and explanation and understanding of what drives people's behavior to get vaccinated or not," she says.
Social determinants of health are a key factor in local lapses of vaccinations, Koletar says. "We must pay attention to the social determinants of health. If you look at the vaccine surveys, while vaccination rates are pretty stable, there are clearly groups of people who are less economically advantaged or minority populations where the numbers are not as good. …. At the foundation, social determinants of health and vaccination intersect at access to healthcare and pharmacies. Do people have the means to have access to good healthcare? When you think about vaccines, you can walk into any Walgreens and get several vaccines, and you can get the COVID vaccine at several locations, but if you do not have the economic means or transportation to get to those places, that impacts vaccine uptake."
Addressing vaccine hesitancy
In addition to education, communication between healthcare providers and their patients is crucial to address vaccine hesitancy, she says. "With the communication, it needs to be a two-way street. We need to talk with our patients and find out what they know about diseases and what they know about the consequences of not getting vaccinated. We also need to dispel myths such as getting the flu from flu vaccination. Communication is key because healthcare providers need to understand what patients think and what drives their behavior on vaccination. Do they think they are going to get a disease from a vaccination? Do they think there is a nefarious plot to inject chips with vaccines, which was misinformation during the COVID pandemic. Are they worried that their children will be at risk for autism? So, you need honest conversation and to try to understand what people's concerns are. It takes time to deliver good healthcare, and we need to take time to communicate."
Effective communication is essential when patients have been misinformed about vaccinations, Koletar says. "You must ask patients what they think they know, what they have heard, and what their sources are. You must start with the basics. Where did you hear your information? You need to be nonjudgmental—did you get your information from respected authorities or respected community members? We have learned a lot about providing information during the COVID pandemic. Did you get your information from Tony Fauci or did you pick it up on Facebook?"
When dealing with vaccine hesitancy, healthcare providers must be honest with their patients, she says. "I am honest about what we know and what we do not know. That was critically important during the pandemic. There were a lot of questions that we did not know the answers to. One of those questions was about long-term side effects from the COVID vaccines, which we did not know. We could not tell patients what was going to happen in 10 years because the vaccines were new. Sometimes, that is comforting, but often it is not comforting. However, there is value in honesty."
Healthcare providers cannot force their patients to get vaccinated, and the best approach to encouraging vaccination is shared decision-making, Koletar says. "You must realize that you cannot always talk your patients into getting vaccinated. You give the best information you can and the best evidence of what the outcomes will be, then make the decision together. Shared decision-making is critical in the delivery of healthcare. You cannot hold someone down and give them a vaccine—all you can do is give your best advice."
The supply chain leader of Allegheny Health Network says it is important to manage expectations at this stage of the coronavirus pandemic.
At Allegheny Health Network (AHN), the top supply challenges include supply resiliency and inflation, the health system's senior vice president of supply chain says.
Alan Wilde, MBA, has been senior vice president of supply chain at AHN since June 2019. Previously, he served as interim senior vice president of supply chain at WellStar Health System, vice president of enterprise facilities management and supply chain at BayCare Health System, and vice president of supply chain at University Hospitals.
Wilde recently talked with HealthLeaders about a range of issues, including supply chain challenges at AHN, AHN's group purchasing organization, and involving clinicians in supply chain decision-making. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: What are the primary challenges of serving as the top supply chain officer at AHN?
Alan Wilde: Right now, it is about supply resiliency. Getting out of COVID, goods and labor for doing the things we need to do for the health system are key factors. We have had several inconsistencies in the supply chain during the coronavirus pandemic—we are trying to get out of that. Inflation is a challenge—a lot of our suppliers are saying they needed to raise wages for their labor that produces supplies for us. We have had pointed responses to them—we are not seeing increases in reimbursement from commercial insurance carriers as well as Medicare and Medicaid. So, we have no where to go.
Also, internally, I have been trying to manage expectations. There is a general feeling that COVID is over or significantly reduced. There is an expectation that we can get back to doing the things we were doing before the pandemic. I need to manage those expectations.
HL: What are the primary inconsistencies you have been experiencing in the supply chain?
Wilde: We are still on allocation for some supplies such as needles, syringes, and several plastic products. It is starting to fall off, but not as quickly as we would hope. We have made some switches to other suppliers because of the incumbents' inability to deliver for us. Some of our suppliers left us high and dry, so we have had some conversations about not going back to them.
HL: How is supply chain managed at AHN?
Wilde: We manage supply chain centrally. I have a corporate supply chain function. Within that is sourcing, procurement, our own warehouse and distribution function, our own pharmacy warehouse, and I have a group that does clinical integration—they help us work with physicians on product decisions and when we are going out to bid. The clinical integration team also helps us with standardization efforts and converting from one product to another. Our clinical integration team is our secret sauce—I have been able to hire some former sales reps, and they are adept at talking with physicians. They nurture relationships.
HL: How does your group purchasing organization function?
Wilde: We are a member of Vizient, so we use Vizient for most of our commodity items. For the physician preference items, we have created a local and regional GPO called Provider PPI. We have contracts for all of the different parts of the body. We also market those contracts to members in Delaware, Pennsylvania, and West Virginia. We have about 80 hospitals that are utilizing our contracts.
HL: How big of a challenge is it to have 80 hospitals utilizing your contracts?
Wilde: It is challenging. Most of our contracts are dual source or multi-source. And we are basically an a la carte kind of GPO. You can sign up for the orthopedic contract, you can sign up for shoulder implants—you do not have to sign up for pacemakers and defibrillators. You can pick and choose the contracts you sign up for. The challenge is whether we have the two or three orthopedic vendors on contract that hits the mix of another hospital. The other hospital may be a heavy user of Smith & Nephew, but we do not have Smith & Nephew on our contract.
Where there is a fit, we have seen a lot of traction. We have delivered a lot of savings to our members.
Alan Wilde, MBA, senior vice president of supply chain at Allegheny Health Network. Photo courtesy of Allegheny Health Network.
HL: What were the primary supply chain challenges AHN faced during the coronavirus pandemic?
Wilde: It was mainly about supply availability. There was not a lot of slack in the supply chain. There were a lot of just-in-time inventory practices. We were lucky that we had our own warehouse, which gave us about 20 days of buffer. That gave us an ability to go out and find new sources for products.
The other challenge we had was making decisions quickly. Traditionally, you would get samples of supplies and have your clinicians look at them. We would be told, "It's available. Buy it now or it is going to be gone in the next hour." So, we ended up having to take some leaps of faith with our clinicians.
There was a lot of fraud going on, which we got adept at figuring out. We had some suppliers who would take certifications from the Food and Drug Administration and slap them on their products—they would be certifications for another manufacturer. We ended up reaching out to law enforcement such as the FBI and educated them about some of the things that were going on.
HL: How did you rise to that fraud challenge?
Wilde: Before we would buy from a previously unknown supplier, we would ask for certifications. Then we used some tools—we would go to the FDA website and put in a manufacturer's number, and it would tell you where a product was manufactured, and we would compare that to what the supplier was telling us. If they did not match up, we had a pretty good idea that they were fraudulent.
I had some colleagues at other places and heard horror stories. It was a crisis. We started our day at 7 or 8 a.m. and ended at 7 p.m. It was just calling anybody and everybody. We were calling multiple suppliers for gloves and other supplies that we would have never thought of calling before.
We were lucky. There were a couple of times when I got worried that we were going to run out of supplies within a couple of days. But we were able to find those supplies quickly.
HL: How do you involve clinicians in supply chain decision-making?
Wilde: We will look at a category and benchmark it. We may get information from dealers about physician preference items. We will then engage our physicians in deciding how we are going to do a request for proposal. Are we using three vendors? Can we go down to two vendors? If we are using two vendors, can we go down to one? Are there other things in a category that we need to look at? For the physician preference items, beyond implants, is there instrumentation or other things that we can try to leverage?
Once we get buy-in from physicians, we will send out the bids. We will get the bids back. We will then share the results of those bids with the clinicians. We go through a process to reach the best decision. In some cases, we may include some of the physicians in the negotiation strategies, which can be helpful.
The clinical integration team is heavily involved in bid scenarios. Before we go out to bid, I may have them reach out to physicians and ask how their incumbent vendors are working out. They may ask physicians whether there is a new technology that needs to be incorporated in the bidding process.
HL: What are the primary keys to success in supply chain management?
Wilde: You need to always be open to change. You need to be open to new ideas. I have learned from vendors. I have learned from people in other industries.
You also need to look for opportunities to automate. How can you automate day-to-day activities that are routine and do not add a lot of value? You want to be able to take those people and have them do what I call knowledge work. I would rather be paying people for their brains than their ability to do data entry or other mundane tasks.
Another key to success is keeping your stakeholders involved. Whether that is clinicians, finance people, or operations people, you need to be thinking about keeping them involved.
You also need to be cognizant of the cost of doing change. We may save $100,000 with a change, but it may cost $200,000 to make the change.
There are two other things to consider from a finance perspective. You need to help your accounts payable department and manage the bills. You need to make sure that records are accurate and bills are getting paid on time, so you are not getting put on credit hold or shipping hold. You also need to look at your accruals—your purchase order accruals, your receiving accruals, and invoice accruals. You need to make sure those are accurate because you have a responsibility to make sure the financials of the organization are correct.
The chief medical officer of Allegheny Health Network shares predictions for 2023.
This year, financial pressures on health systems, hospitals, and physician practices will spur innovation, according to the chief medical officer of Allegheny Health Network (AHN).
Donald Whiting, MD, is CMO of AHN; president of the health system's physician organization, Allegheny Clinic; and chair of the AHN Neuroscience Institute. HealthLeaders recently talked with him about a range of issues, including predictions for clinical care in 2023, the challenges of being the top clinical leader at AHN, and physician engagement.
The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: What are your predictions for clinical care in 2023?
Donald Whiting: The financial troubles of 2022 made all providers decide what they needed to do to realign their footprints and realign how they work because the cost of doing business was not going to go down anytime soon with inflation. So, this year, all providers need to reinvent themselves in some way, whether it is consolidating the footprint, going more to virtual care than bricks-and-mortar offices, or changing the services they offer. I also expect a surge in consolidation of providers.
HL: What are the primary challenges of serving as CMO of AHN?
Whiting: The chief medical officer of any organization is the clinical voice of that institution. Over the past several years, there have been many challenges—there's been COVID, the weak finances of providers, and inflation. Helping to bring a clinical sensibility to the issues in healthcare has been a challenge. You need to get all of the providers to understand the issues and be part of the solution.
At AHN, I am concerned about common issues related to quality of care and maintaining access. But for us in particular, we are also part of a large payer, so I look at opportunities to evolve healthcare from taking care of sick people to figuring out how we can keep them healthier. That creates opportunities for us to look at things in a different way than many healthcare providers.
HL: What are some of those opportunities?
Whiting: With us, because we are a provider with a large payer in the same area, we can look at sites of service changes, where we can do better care that is more efficient for the patient. That is not necessarily something that a provider alone would do.
We look at longitudinal care of a patient over time. So, if we can keep patients healthier, then that creates cost savings overall in the healthcare system. We also are focused on providing value-based care.
Donald Whiting, MD, chief medical officer of Allegheny Health Network. Photo courtesy of Allegheny Health Network.
HL: You are also president of AHN's physician organization, Allegheny Clinic. What are the challenges of leading a large physician organization?
Whiting: First of all, managing any physician organization revolves around having standards—standards of behavior, standards of care, and standards of practice. So, maintaining the standards is part of the job, but there is also recruiting good talent and being part of the medical staff development and growth of the provider organization.
HL: What are the primary elements of physician engagement?
Whiting: Physician engagement comes from physicians believing in the mission of your organization. You need to have transparency about the organization's plans and physicians' roles in those plans. Physicians need to understand how they fit into the organization and what their contributions can be. Then, you need to appreciate physicians for what they do.
HL: How do you make sure physicians feel appreciated?
Whiting: We have a couple of ways of doing that. We have core values for the organization, and we conduct core values surveys. Those surveys ask physicians whether they feel appreciated by the people they work with, whether they have friends at work, and whether they get frequent updates on how they are doing. We act on the results of those surveys.
We also have wellness surveys and a robust set of workstreams around improving wellness and feeling appreciated at work.
HL: You are also chair of the AHN Neuroscience Institute. How do you balance your responsibilities as CMO, president of Allegheny Clinic, and chair of the institute?
Whiting: The short answer is I have a strong team that I work with in each of those areas. They help me balance my responsibilities. There is a lot of overlap in each of those roles. For example, being chair of the Neuroscience Institute gives me more on-the-ground information than if I was just the leader of the physician organization—I can give much more direct input on how things are going by being involved in the institute. In the chief medical officer role, it also gives me input and insight into what is going on at the hospital floor level and in the operating rooms. So, my roles are complementary in terms of sources of information.
HL: Are there any commonalities in these teams? How are you being supported?
Whiting: There are commonalities. In the institute, I have a dyad partner who is a service line vice president. As head of the physician organization, all of the service line vice presidents report to me, so I have ground-level information about what the service line vice presidents are dealing with, including trials and tribulations that I can help address. As CMO, I work with the president and the chief operating officer of the entire organization—between me as the CMO and the COO, we are in a dyad relationship that oversees the entire structure of clinical operations.
HL: What are your primary clinical challenges now that the crisis phase of the coronavirus pandemic has passed?
Whiting: Staffing is a big challenge. The people that left during the Great Resignation are not coming back. In our area, hospitals and ambulatory settings are not fully staffed, but the patient volume is coming back. The worry is that if we do not get relief for the people who are doing the work, more people are going to get burned out.
We are doing things to address workforce shortages. For example, on the nursing floors, we are piloting a half virtual, half in-person model, where somebody is at home doing part of the work and somebody is on the floor doing the hands-on work. This creates a pool of people you normally would not have been able to recruit, such as nurses who retired early but have good skill sets.
HL: What kinds of workforce shortages are you experiencing at AHN?
Whiting: It is across the board—we could use more of everything. We need CT techs, nurse's aides, medical assistants, nurses, and pharmacy techs. We need people in almost every area.
HL: What are the primary efforts you have in place to address workforce shortages?
Whiting: We are going upstream—we are working with high schools, community colleges, and trade schools. We are trying to get to people earlier. We are doing exploration visits such as bringing in high school and college students to shadow staff members to see what our jobs are like. We are providing scholarships to students if they commit to us when they are done with their studies. We are providing flexibility in our nursing schedules—someone can work just on weekends if they want that schedule, or work just four hours or eight hours if they are working somewhere else.
We are also working on retention. There has been lot of base salary increases to retain the people we have. There have been retention bonuses in certain areas. We try to care for employees as if they were family—we want them to feel as though they are cared for. We want to be a place where people want to work because we are a place that cares about their people.
A new healthcare report from The Commonwealth Fund finds that the United States does not compare favorably to other high-income countries.
Despite spending more on healthcare than other high-income countries, the United States lags peer countries in several measures of healthcare performance, according to a new report from The Commonwealth Fund.
The new report mirrors the findings of a 2020 report from The Commonwealth Fund. The 2020 report found that the United States spent nearly twice as much on healthcare as the average level of spending at Organisation for Economic Co-operation and Development (OECD) countries and had the lowest life expectancy and highest suicide rates among 11 OECD countries.
The new report, which was published today, compares U.S. healthcare to healthcare in Australia, Canada, France, Germany, Japan, the Netherlands, New Zealand, Norway, South Korea, Sweden, Switzerland, and the United Kingdom. The report also compares U.S. healthcare to average performance for the 38 high-income OECD countries for which data are available.
In 2021, the United States spent 17.8% of its gross domestic product on healthcare, which was nearly twice the level of spending of the average OECD country, according to the new report.
In the new report, the United States compared unfavorably with other OECD countries on several measures:
In 2021, 8.6% of Americans were uninsured, and the United States was the only high-income country with a substantial segment of the population with no form of health insurance.
In 2020, U.S. life expectancy at birth was 77 years, which was three years lower than the OECD average.
In 2020, the United States had the highest avoidable mortality rate among all of the countries in The Commonwealth Fund's analysis. Avoidable mortality is defined as deaths that are preventable and treatable through public health measures and primary prevention such as exercise.
In 2020, the U.S. infant mortality rate was 5.4 deaths per 1,000 live births, which was the highest rate among all the countries in the analysis.
In 2020, there were nearly 24 maternal deaths for every 100,000 live births in the United States, which was more than three times the rate in most of the other high-income countries.
The United States had the third-highest suicide rate among OECD countries.
The United States had far more deaths from physical assault including gun violence, with 7.4 deaths per 100,000 people compared to the OECD average of 2.7.
The United States has an obesity rate nearly two times higher than the OECD average.
In 2020, nearly one-third of U.S. adults reported being diagnosed with two or more chronic conditions in survey data. In other OECD countries, no more than a quarter of residents reported being diagnosed with two or more chronic conditions.
More Americans have died from the coronavirus than residents in other OECD countries.
Americans visit a doctor less than the OECD average, with four visits per American per year.
The United States has fewer hospital beds than most other OECD countries, with 2.8 hospital beds per 1,000 population compared to the OECD average of 4.3 hospital beds.
The United States has one of the lowest COVID-19 vaccination rates compared to other high-income countries.
Addressing U.S. shortcomings
The new report calls on the United States to boost the availability of affordable healthcare services. "While the United States spends more on healthcare than any other high-income country, the nation often performs worse on measures of health and healthcare. For the U.S., a first step to improvement is ensuring that everyone has access to affordable care. Not only is the U.S. the only country we studied that does not have universal health coverage, but its health system can seem designed to discourage people from using services," the report's co-authors wrote.
The new report says the United States can take three additional steps to generate better healthcare outcomes from healthcare spending:
Implementation of the Inflation Reduction Act, which reduces the cost of some drugs and caps out-of-pocket costs for older Americans.
Cost containment: "Other countries have achieved better health outcomes while spending much less on healthcare overall. In the U.S., high prices for health services continue to be the primary driver of this elevated spending," the report's co-authors wrote.
Improved prevention and management of chronic conditions: "Critical to this is developing the capacity to offer comprehensive, continuous, well-coordinated care. Decades of underinvestment, along with an inadequate supply of healthcare providers, have limited many Americans' access to effective primary care," the report's co-authors wrote.
Trinity Health operates its urgent care clinics in joint ventures with Premier Health.
Trinity Health is committed to urgent care growth, according to Daniel Roth, executive vice president and chief clinical officer at the Livonia, Michigan-based health system.
"Urgent care will continue to grow. One of the interesting things to be mindful of is that everybody is growing urgent care, which is creating a more competitive environment. That is why it is important for us to make urgent care easy for people and integrated with our delivery system. Another thing that is going to change in urgent care is that as we meet people's needs, there may be new services that we offer in the urgent care setting that are not delivered in the urgent care setting today," he says.
At Trinity Health, urgent care centers are a key access point and integral part of the health system, Roth says. "For us, it is about whole-person care and being available and accessible to patients. Our vision for urgent care is as an important access point, so people can get care when they want it, where they want it, but in an integrated way. So, urgent care is important for us because it is an accessible point for care when people have urgent issues, and it ties into the rest of our care delivery model including primary care as well as if people need additional care after they have been at an urgent care center such as specialty care."
Urgent care has been fully integrated with the health system, he says. "We want urgent care to be a seamless part of the care journey for patients. We want it to be there when people have an urgent issue, so they can get care when they want it. But urgent care is seamless when patients get follow-up care. If a patient has a fracture and needs follow-up care, we can provide that care. We make it easy for people to continue their care journey. It is important that we integrate a patient's clinical information across the continuum of care. We know the patient if they show up in an urgent care center and they came from one of our primary care practices, or if they end up in one of our hospitals after an urgent care visit."
Urgent care is also a way to lower costs for patients, Roth says. "Urgent care is also good for patients because it is at a lower cost than going to the emergency room. It allows us to partner with patients to lower their out-of-pocket expenses."
Urgent care has grown to be a significant care setting at Trinity Health, he says. "It has evolved a lot, and it will continue to evolve. It has grown to become a much more prominent part of our health system. Whereas in the past we may have relied on the emergency room as a point of access, more and more care is being delivered in an urgent care setting. That is what people want, and we are meeting people's needs. Another way urgent care has evolved at Trinity Health is as we grow our presence in primary care, urgent care has become an integrated partner with primary care."
Trinity Health operates its urgent care centers in joint ventures with Baton Rouge, Louisiana-based Premier Health. "We were looking for somebody who had demonstrated expertise in running high-quality, easy to access urgent care centers on a wide geographic footprint. We did not have that level of expertise within Trinity Health—there are unique skills involved in running urgent care centers. First, Premier Health has broad experience working with health systems and working as health system partners. Second, they have the same shared vision and history as we have around service and mission. Third, they have a focus on quality—we were impressed by their focus on quality of care and quality of service," Roth says.
Redlands Community Hospital has been offering inpatient behavioral health services since the mid-1980s.
Citing financial constraints and relatively low utilization rates, Redlands Community Hospital in California is closing its Behavioral Health Inpatient Adult Unit.
Financing is one of the top challenges for hospitals' behavioral health services. Primary strategies to address inadequate reimbursement of behavioral health services are subsidization and seeking grant funding.
Redlands has been offering inpatient behavioral health services since the mid-1980s. The Behavioral Health Inpatient Adult Unit, which features 18 locked adult beds, is set to close on Feb. 1. The closure will affect 27 staff members.
The hospital will continue to offer outpatient behavioral health services, including a partial hospitalization program.
The decision to close the Behavioral Health Inpatient Adult Unit was not taken lightly, James Holmes, Redlands president and CEO, told HealthLeaders. "Our decision to close the unit comes after a comprehensive review, including the assessment of multiple factors such as the cost of uncompensated care and a decline in patient volume."
Redlands is committed to continuing to offer outpatient behavioral health services, he said. "The inpatient and outpatient services have distinct purposes. Once a patient's mental health is stabilized, outpatient services can further assist the patient in their symptom management and treatment goals at a lower level of care with the goal of community integration. Our outpatient care programs help individuals get the services they need, while reducing the likelihood of hospitalization. Across the board, both culturally and medically, outpatient care is often the preferred method of care by patients and their families. We are committed to continuing to provide access to outpatient behavioral health services."
Redlands does not expect the closure of the inpatient unit to have a significant impact on mental health services in the region, Holmes said. "The Redlands Community Hospital inpatient volume has been down. Additionally, the Inland Empire has other behavioral health service providers that have larger capacity and specialize in a broader range of services. Redlands Community Hospital has informed these facilities of its closure to ensure a smooth transition."
Three hospitals in the region have larger inpatient behavioral health programs: Loma Linda Medical Center with 87 beds, Arrowhead Regional Medical Center with 90 beds, and the Community Hospital of San Bernardino with 99 beds.
Finances and related challenges were key factors in the decision to close the inpatient behavioral health unit, Holmes said. "Nationally and locally, hospitals and health systems have experienced financial challenges since the coronavirus pandemic began and Redlands Community Hospital is not immune. Like most industries, we have experienced staffing issues, supply chain disruptions, inflation, and the rising cost of doing business. The cost for uncompensated care is another factor in this challenging equation as we absorb additional costs post-pandemic."
Closing the inpatient behavioral health unit is in the best interest of the hospital and the communities it serves, he said. "Just as we did during the pandemic, by coming together, we are able to innovate and create initiatives that serve the greater good. We need to remain strong so we can keep individuals healthy and be there for our communities that depend on our services."
Redlands employs 1,700 staff members and about 300 physicians work at the hospital. The facility has an annual budget of $350 million.
The federal government buys a wide range of medical supplies, including hospital beds, surgical instruments, defibrillators, bandages, needles, and syringes.
The federal government spent more than $8.2 billion on medical supplies in fiscal year 2021, according to the Health Industry Distributors Association (HIDA).
The federal spending figure is one of the findings in HIDA's first-ever Federal Procurement Market Report. HIDA examined medical products within the North American Industry Classification System codes that showed federal government purchases. Among a wide range of products, these purchases included supplies such as hospital beds, surgical instruments, defibrillators, bandages, needles, and syringes.
Public-private partnerships are important in supply chain operations, Linda Rouse O'Neill, vice president of supply chain policy and executive branch relations at HIDA, told HealthLeaders. "The COVID-19 pandemic proved that the public and private sectors have complementary roles to play in supply chain operations. The private sector has expertise in the manufacture and distribution of medical products across the entire continuum of care. The public sector has greater resources and access to information to respond effectively to a pandemic. Private companies and government agencies must work together to ensure the seamless functioning of the medical supply chain."
HIDA represents the healthcare distribution network, which links global healthcare supply manufacturers and local care providers. HIDA members operate more than 500 distribution centers that bring critical products, supplies, and services to more than 560,000 healthcare settings across the country including hospitals and physician practices.
HIDA's Federal Procurement Market Report includes several key findings:
Compared to fiscal year 2020, federal government medical supply purchases decreased 38% in fiscal year 2021, but spending was well above pre-pandemic levels.
Nearly all of the federal government medical supply purchases (98%) were made by four departments: Department of Defense, Department of Health and Human Services, Department of Homeland Security, and Department of Veterans Affairs.
In fiscal year 2021, $2.4 billion in federal contracts for medical supplies were awarded to small businesses.
In fiscal year 2021, $1.35 billion in federal government medical supply contracts were awarded to diverse small businesses.
Interpreting the data
Regarding the drop in federal government medical supply purchases from fiscal year 2020 to fiscal year 2021, federal purchases related to the pandemic have followed a boom and bust cycle tied to public health priorities, a HIDA spokesperson told HealthLeaders. "The Administration for Strategic Preparedness and Response, which manages the Strategic National Stockpile, went from approximately $4.5 billion in purchases in FY 2020 to approximately $842 million in FY 2021. This accounts for approximately $3.7 billion of the approximately $4.9 billion federal government purchasing difference between FY 2020 and FY 2021."
The agency concentration of federal government medical supply purchases is not surprising, the spokesperson said. "With a total spend of $8.2 billion in contracts to healthcare distributors and manufacturers in 2021, the federal government is a major purchaser of medical supplies. It makes sense for the overwhelming majority of federal purchases in the medical supply chain to be made by agencies tasked with preparedness (Department of Homeland Security), agencies with significant patient needs (Department of Defense and Department of Veterans Affairs), or both (Department of Health and Human Services)."
Federal incentives for small businesses provide opportunities for many small and independent distributors and manufacturers in the medical supply chain, the spokesperson said. "Such support for all businesses—from national to local—diversifies the source of medical supplies, building resilience and capacity in the event of future surges in demand."
The level of federal purchases from diverse small businesses is substantial, the spokesperson said. "This reflects a significant federal strategic commitment to provide equitable access to purchasing and contracting opportunities for diverse businesses. Supplier diversity is an important goal for both the public and the private sectors. It promotes innovation, identifies new sources of talent, and rewards experience."
Mass General Brigham strives to not only be the best in the Boston market but also exceptional in the national and international markets.
The biggest clinical challenge at Mass General Brigham is coping with patient volumes in the inpatient and emergency department settings, says Chief Medical Officer Thomas Sequist, MD, MPH.
Sequist was announced as the health system's CMO in February 2022. He has been with the health system since 1999, when he started his residency at Brigham and Women's Hospital. He still practices as a primary care physician at the hospital, and before taking on the CMO role, Sequist served as chief patient experience and equity officer at Mass General Brigham.
Sequist recently talked with HealthLeaders about a range of issues, including the top clinical challenges at the health system, predictions for clinical care in 2023, and equity challenges at the health system. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: What are the primary challenges of serving as CMO of Mass General Brigham?
Thomas Sequist: The challenges of being CMO at Mass General Brigham reflect the broader challenges that we are experiencing across the health system. We have significant capacity challenges—the volume of patients who need care is substantial, and we are continuing to deal with the ebbs and flows of the COVID pandemic and the strain that creates.
HL: Tell me more about your capacity constraints.
Sequist: It is having enough beds in the hospitals for the patients who need to be hospitalized and having enough room in the emergency departments to take care of patients without long waits.
One of the drivers of the capacity challenges we are facing is the coronavirus pandemic—we are treating and managing those patients, whether it is in the emergency departments or the hospital setting, which creates a challenge in the inpatient setting.
Another capacity challenge is the process of admitting patients, caring for them, and discharging them in a timely way. When we are not able to manage the length of stay, we end up with not enough beds freed up for our new patients who need care.
Thomas Sequist, MD, MPH, chief medical officer of Mass General Brigham. Photo courtesy of Mass General Brigham.
HL: Mass General Brigham is in a competitive healthcare market. What are the clinical challenges of working in such a market?
Sequist: At Mass General Brigham, we are always striving to be the best—to be the top performer not just in the local market but also the national and international market. We consider ourselves to be world leaders, not just leaders in the Boston area. With that context, we are trying to lead in many important areas such as research and innovation as factors to drive our patient care. Another area is caring for the patients who are sickest and most complex. We are always developing new care programs at our academic medical centers to care for the patients with the most complicated care concerns.
Then I would move to a different area, which is how do we provide care for the larger population that has less-complex care needs but significant care needs. That is where we engage our entire integrated delivery system from the academic medical centers to the community hospitals and the ambulatory settings to provide comprehensive care. Across the country, that is a challenge as we move to more and more integrated delivery systems. How do you design those systems such that you can meet the most-complex care needs and at the same time deliver on population-based needs such as primary care?
HL: Do you have any predictions for clinical care in 2023?
Sequist: The biggest thing that is going to happen for the healthcare system in 2023 is learning how to meet the needs of all our patients—from the most complex to the most generic—while doing that in the context of what we have learned from the pandemic. We need to avoid having a foot in two canoes, where we are managing COVID patients separately from managing the rest of our patients. We will be learning how to treat both sets of patients in a more integrated fashion.
HL: You previously served as the patient experience officer for Mass General Brigham. What are the keys to success in patient experience?
Sequist: Patient experience and equity are linked to each other and hard to pull apart. We must acknowledge that we have to meet the patient where they are; and in order to that, we have to truly understand who our patients are, and we have to be engaged not only in delivering their care clinically but also understanding who they are as a person. This is how you develop a successful patient experience strategy. Then equity comes into play. What that ultimately will mean is that we need to avoid saying that our gold standard is treating everybody the same. Our gold standard must be assuring the same outcomes for everybody, which is often going to mean treating people differently based on what they need.
HL: What are the primary equity challenges at your organization?
Sequist: Our equity challenges are much like those at other health systems. I frame it in two ways. One, we continue to have a primary strategy of being united against racism. That is a monumental challenge, and it is not a problem that we will solve over the next year or several years. This is a problem that has a long history, and it is going to take us a long time to make progress.
Secondly, another core challenge that we have is that many of the equity concerns outside of the healthcare system relate to social risk factors that our patients have. They relate to factors such as housing stability, food insecurity, and economic stability, which are the strongest predictors of health outcomes. As a health system, we must figure out how we fit into the patchwork of the public health system as well as the broader society in terms of social risk factors contributing to health.
HL: How do you rise to that second challenge?
Sequist: We rise to that challenge by ensuring that equity is one of our core strategies and one of our core priorities. That is something that we have committed to across Mass General Brigham, and it allows everyone to focus on equity and anti-racism throughout our organization. It also allows us to weave and embed those concepts into everything that we are doing across our organization. So, we have a foundation that everyone understands—one of our core priorities is equity across every facet of what we do. Then we layer on top of that a core set of focused priorities within the space of equity and anti-racism.
HL: Give me an example of that core set of priorities.
Sequist: In the ambulatory setting, one of those focused priorities is hypertension control. We have had a data-driven approach to figure out the areas we are going to focus on, and when you look at the data, a primary source of excess mortality and morbidity among Black and Hispanic patients in the Boston area is cardiovascular disease. One of the leading risk factors for cardiovascular disease is poorly controlled hypertension. We know that among Black and Hispanic patients the rates of achieving good control of blood pressure are lower in those populations compared to White populations.
We have developed many work streams across our delivery system all with the focus on enabling better blood pressure control. We are developing electronic tools that are multilingual for our patients with hypertension, ensuring that they have home-based tools to manage their hypertension such as electronic blood pressure cuffs, creating a workforce of digital navigators who help our patients understand Internet-based tools for managing their blood pressure, and creating a workforce of community health workers who can help our patients deal with access to care and other social risk factors such as food insecurity.
We are setting specific blood pressure goals and creating an accountability infrastructure within our leadership team and among our clinicians to achieve those goals.
Researchers gauged PTSD and subthreshold PTSD levels among emergency department and emergency medical service workers.
In a recently published studyconducted during the coronavirus pandemic, 5.5% of healthcare workers met criteria for probable posttraumatic stress disorder (PTSD) and 55.3% experienced subthreshold PTSD symptoms (PTSS).
The pandemic has been associated with higher levels of burnout among healthcare workers. The pandemic has increased the risk of healthcare workers developing PTSD.
The recent study, which was published in the Journal of Psychiatric Research, is based on survey data collected from 852 healthcare workers from January 2021 to February 2021. The survey participants were recruited from emergency departments affiliated with the University of Pittsburgh Medical Center and emergency medical service agencies in several states, including Maryland, New Hampshire, New York, Ohio, Virginia, and West Virginia.
The study features several key findings:
Nursing and patient support services workers were less likely to be in the no symptoms group and more likely to be in the subthreshold PTSS group compared to ambulance and transport services workers.
Physicians and mid-level providers reported fewer physical health symptoms than any other job category.
Nursing and patient support services workers reported more sleep problems than all other job categories.
Survey participants who fell into the subthreshold PTSS group and the probable PTSD group were more likely to report health impairment than survey participants who fell into the no PTSS group.
The adjusted likelihood of having physical symptoms was 1.87 times more likely in the subthreshold PTSS group and 3.38 times more likely in the probable PTSD group than the no PTSS group.
The adjusted likelihood of having sleep problems was 1.36 times more likely in the subthreshold PTSS group and 1.96 times more likely in the probable PTSD group than the no PTSS group.
The three most common health impacts reported by members of the probable PTSD group were relatively common in the subthreshold PTSS group: 93.6% of PTSD group reported sleep problems and 69.4% of the PTSS group reported sleep problems, 74.5% of the PTSD group reported constant fatigue and 37.1% of the PTSS group reported constant fatigue, and 72.3% of the PTSD group reported weight change and 46.3% of the PTSS group reported weight change.
"The present investigation demonstrates the prevalence and significance of subthreshold PTSS in [healthcare workers] responding to the COVID-19 pandemic. Furthermore, it demonstrates that to promote [healthcare workers'] mental health, subthreshold PTSS must be accounted for and incorporated into the intervention approaches employed in this population," the study's co-authors wrote.
Healthcare workers who experience subthreshold PTSD symptoms are afflicted with significant health conditions, Bryce Hruska, PhD, assistant professor of public health in the Falk College at Syracuse University, said in a prepared statement. "Even though they weren't reporting symptoms indicative of a clinical diagnosis of PTSD, these workers were still feeling its effects."
As the pandemic ebbs and flows, healthcare workers remain at elevated risk of PTSD and PTSS, he said. "While the world tries to move on from the pandemic, our healthcare workers continue to face a significant mental health risk with every surge in cases, as is happening now."
Thomas Sequist, MD, MPH, chief medical officer of Mass General Brigham. Photo courtesy of Mass General Brigham.