Last year, 5,492 adults were treated at Intermountain Health's Behavioral Health Access Centers.
Intermountain Health has improved access to services for mental health patients by opening 24/7 outpatient centers.
With a nationwide shortage of psychiatrists, access is one of the biggest challenges in behavioral health. More than half of U.S. adults with mental illness do not receive treatment, according to Mental Health America.
Intermountain has opened Behavioral Health Access Centers at three hospitals in Utah. "Prior to the access centers, the only place someone in a mental health crisis would go to was the emergency department. The ED was the gateway for behavioral health screenings and determining whether someone needed to be admitted to a behavioral health unit or discharged," Clint Thurgood, crisis services director at Intermountain, told HealthLeaders.
The Behavioral Health Access Centers are an alternative to the ED for mental health patients who are not at risk of harming themselves or others, he says. "The access centers are built in close proximity to the EDs. When patients come to the ED, the triage nurse in the ED asks a couple of questions related to their immediate safety and whether they are at risk of harming themselves, which would constitute a medical emergency. If the patient does not have a medical emergency, they are physically escorted to the access center to be triaged and registered similar to the procedure in the ED."
The access centers are staffed with a psychiatrist during the day, along with several other psychiatric care providers, Thurgood says. "We have crisis workers who could be a mental health social worker or licensed family therapist. We also have psychiatric nurses and psychiatric technicians. The access centers are designed to ensure that the patients who are in need of psychiatric care are meeting with the right providers at the right time."
With the access centers in place, mental health patients in crisis do not have to go to the ED, he says. "Patients do not need to go to the ED to be screened. As we have seen at our three locations, more and more people are self-presenting to the access centers, which have community-facing doors. So, the public can access them. The police can access them if they have patients who are appropriate to be seen in the access center. We are open for walk-ins."
The access centers have reduced the number of mental health patients seeking care in the EDs at the three hospitals as well as decreased the number of these patients who are admitted to the hospitals, Thurgood says. "One of the successes we have seen with the access centers is that at our EDs about 55% of all adults who come to our hospitals needing a psychiatric crisis evaluation end up being admitted to the hospital. But for patients who are seen at the access centers, the rate of admission goes from 55% down to 39%. More patients can successfully discharge to home."
Last year, 5,492 adults were treated in the three access centers.
Patients receive a thorough evaluation in the access centers, he says. "There are psychiatric consults provided by the psychiatrists. Crisis evaluation consults are provided the crisis workers. There are standardized screening tools such as the Columbia Suicide Severity Rating Scale to determine a patient's suicidality."
The access centers are a lower cost setting for treating mental health patients than EDs, Thurgood says. "Over the past five years at the hospitals with access centers, about 80% of adults with mental health crises have been seen in the access centers rather than the ED. We know that the most expensive place to receive care is the ED. So, by shifting the volume of patients away from the ED to the access centers, costs are much lower for Intermountain as well as the cost impact on the patients. It is about a third to a quarter of the cost to receive care in an access center compared to an ED."
Patients seen in the access centers receive a care plan and are connected to outpatient services in the community, he says. "By coming to the access center, patients as needed can stay in the access center for as many as 23 hours of observation. This gives us time to assess their needs and to connect them with formal and informal resources to create a care plan, including a plan for discharge from the hospital and a follow-up plan in the community."
Patients who are prescribed medication by access center psychiatrists are targeted for follow-up care, Thurgood says. "There is a concern about starting a patient on medication if they do not have follow-up care. So, a key component of the access centers is having case management workers who can connect with the patient following their discharge from the access center to make sure they have ongoing care. So, if the psychiatrist starts a patient on a medication at the access center, a case manager needs to call them the next day and say, 'Let's set you up with an outpatient provider who can continue monitoring you, so you have somewhere to go for the next seven to 14 days.'"
The new chief medical officer of OU Health faces challenges including access to care, workforce shortages, and financial sustainability.
Editor's note: This article appears in the June 2023 edition of HealthLeaders magazine.
The first chief medical officer of OU Health plans to focus on quality and safety, medical informatics, data analytics, patient experience, digital health, population health, and process improvement.
Carolyn Kloek, MD, was recently named as the inaugural CMO of the Oklahoma City, Oklahoma-based health system. She previously served as senior vice president of clinical strategy and integration at OU Health. Her other leadership positions include serving as vice chair of quality and innovation at Dean McGee Eye Institute.
HealthLeaders recently talked with Kloek about a range of topics, including defining the CMO role at OU Health, achieving high-quality care, and driving innovation at OU Health. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: You are the inaugural CMO at OU Health. What are the primary ways you plan to define the role?
Carolyn Kloek: It is a tremendous opportunity, and I am thrilled to be able to work with teams across OU Health.
As the CMO, I see myself as a leader to drive change and improvements in our performance in many different areas. I also think that healthcare is a team sport, and I will be leaning into teamwork, supporting our teams in their efforts to drive improvement in our patient outcomes.
The scope of work under the office of the CMO has several areas that we are actively building out, which includes quality and safety, medical informatics, data analytics, patient experience, digital health, population health, and process improvement. There are tremendous synergies between all of these areas, and I will be working hard to set up teams within each area, then matrixing those teams so we can drive performance improvement.
HL: What do anticipate will be your biggest challenges in serving as CMO of OU Health?
Kloek: There are some overarching themes of challenges that we face at OU Health. One is our access to care, particularly in Oklahoma, which is a state that is largely rural. Access to care is an issue that we need to tackle. It is on OU Health and healthcare professionals in general to aid in the development of strategies to improve access for patients in the rural parts of the state and to ensure that we are delivering equitable care to all patients seeking care at OU Health.
Another challenge we are facing is in our workforce shortages. Our providers, nursing staff, and other key pieces of the healthcare workforce are stretched thin. We depend heavily on these valuable, highly skilled professionals to create access and to deliver high-quality care. We need to continue to do everything we can to support members of our healthcare workforce and get creative in the ways that we design and deliver care at OU Health.
Financial sustainability is another challenge that we and many other healthcare organizations are facing. At this point in time coming out of the coronavirus pandemic and as the state's only academic health system, it is critical that we remain strong financially while we concurrently provide top-notch clinical care to meet the most complex medical needs in the state and fulfill our academic mission as well.
HL: You were vice chair of quality and innovation at the Dean McGee Eye Institute. What are the primary keys to success in achieving high-quality care?
Kloek: One of the important principles is the commitment to strong leadership in delivering high-quality patient care. It is on leaders to work with their teams to establish a culture of quality and safety, to set clear goals, and to provide the necessary resources and support to care teams.
Tied with leadership is a culture of continuous quality improvement—creating a continuous cycle and driving to always improve in our healthcare settings.
We need a data-driven approach to improvement. Performance needs to be measured—you can only manage what you measure. Data becomes the tip of the spear to help us identify the areas in which we are underperforming. Then we need to ask ourselves, why, and what can we do to improve performance? On the flip side, we can also use data to tell us where we are doing well, then try to scale that across the organization.
Collaboration and teamwork are also important to performance improvement in a health system, which is a complicated ecosystem.
HL: How can OU Health drive innovation?
Kloek: As the only academic health system in Oklahoma, OU Health is very well positioned to drive innovation. We have the unique aspect of having the tripartite mission—the alignment of clinical care, education, and research. We can innovate in each of those areas. By innovating in those areas, each one feeds and builds on the other areas and makes those areas stronger. You get into a virtuous cycle that drives innovation in each of the three domains.
Carolyn Kloek, MD, chief medical officer of OU Health. Photo courtesy of OU Health.
HL: What are the key elements of patient safety?
Kloek: For health systems to drive safety, there needs to be a preoccupation with the delivery of safe care across the board. There needs to be a hardwiring of safety within all elements of the organization. You need to look at areas where you are underperforming and understand the safety areas you need to be tackling in order to improve. Similarly, you need to look at areas where you are doing well—find out the safe practices that you are proud of and want to scale across the organization.
An important element of patient safety is capturing the voice and input of our frontline caregivers. They are often the best positioned to identify practices that are enhancing patient safety as well as any areas where we could be improving.
HL: You have a clinical background in internal medicine and ophthalmology. How has this clinical background helped you serve in physician leadership roles?
Kloek: Having had diversity of training both in internal medicine during my internship and ophthalmology is incredibly helpful. It has given me perspective on many different sites of service in a health system—in the inpatient setting, ambulatory care, operating rooms, and ambulatory surgery centers. I have worked as a clinician delivering care in all of these settings, and that diversity of experience has been helpful in leadership positions.
HL: What advice can you offer to other female physicians who may be interested in administrative leadership roles?
Kloek: The first piece of advice is to believe in yourself. You need to have confidence in yourself and believe that you can achieve in whatever area you are striving to grow and lead.
It is helpful to develop leadership skills, and that comes from proactively developing leadership skills. There are formal paths to doing that through leadership courses specifically tailored to physicians, and you need to pair that with leadership experience in the clinical setting. Gaining leadership experience in the clinical setting often does not start big. It can be asking yourself, "What can I help fix? What can I help address to make this environment better for my patients and for my colleagues?" You need to roll up your sleeves. With on-the-ground leadership experience, opportunities will start to come as you have wins in different areas.
Another piece of advice is to build a network of support and mentorship. When I look at the mentors I have had along the way, they have been able to give me coaching, give me advice, open up opportunities, and help me to this day as I continue to grow as a leader.
The last piece of advice is to embrace diversity and inclusivity in all forms. We all are strengthened by seeking the input of a diversity of people—people with different thoughts and different backgrounds.
The immediate release of test results without counseling from a clinician is controversial.
The vast majority of patients want to receive test results online even if their healthcare provider has not reviewed the test results, according to a new research article.
In April 2021, a federal rule went into effect requiring immediate electronic availability of medical test results upon request by patients and care partners. Providing patients access to their medical records has been proposed as a way to strengthen patient-clinician relationships. However, the immediate release of test results without counseling from a clinician is controversial.
The new research article, which was published by JAMA Network Open, features survey data collected from more than 8,000 adult patients and care partners who had gotten test results through an online patient portal from April 5, 2021, to April 4, 2022.
The survey was conducted at four academic medical centers: University of California, Davis Health; University of Colorado Anschutz Medical Center; University of Texas Southwestern Medical Center; and Vanderbilt University Medical Center.
The study features several key data points:
95.7% of all survey respondents wanted to receive test results immediately through the online patient portal, even if the results had not been reviewed by a healthcare provider
95.3% of survey respondents who received abnormal test results reported that they wanted to continue to receive test results immediately through the online patient portal
Most survey respondents (57.3%) reported their test results were normal
7.5% of survey respondents reported that receiving test results before they were contacted by a healthcare provider increased worry
Increased worry was more common among survey respondents who received an abnormal test result (16.5%) than among survey respondents who received a normal test result (5.0%)
"In this multisite survey study of patient attitudes and preferences toward receiving immediately released test results via a patient portal, most respondents preferred to receive test results via the patient portal despite viewing results prior to discussion with a health care professional. This preference persisted among patients with nonnormal results," the study's co-authors wrote.
Interpreting the data
Balancing patient worry with immediate access to test results is a key issue, study co-author Liz Salmi, communications and patient initiatives director of OpenNotes at Beth Israel Deaconess Medical Center, said in a prepared statement. "As healthcare systems continue to navigate this new era of health information transparency, balancing patients' expectation of immediate access to their information with the need to manage increased worry is important. Additional research is necessary to better understand the nuance of worry from receiving abnormal test results, especially as it relates to revealing information about a newly diagnosed condition such as Huntington's disease or cancer."
There are apparently positive factors to receiving test results immediately even when the results are abnormal, the study's co-authors wrote. "We found that 95.3% of participants who received abnormal test results would like to continue to receive immediately released results through the portal. This finding suggests that there may be benefits to receiving abnormal results online, such as allowing patients to choose where and with whom to view such results."
Most survey respondents (92.3%) reported receiving precounseling about their test results, but there was no association found between precounseling and lower levels of worry. The study's co-authors wrote that there can be several approaches to precounseling.
"Precounseling strategies might encompass both technical and social-technical approaches, including in-person anticipatory guidance, improved asynchronous communication, and portal-based educational materials. Other strategies include optimizing existing patient portal interfaces to give users control over their notification preferences related to sensitive or abnormal results or timing the release of test results during working hours. Additional research is necessary to further investigate the efficacy of strategies to mitigate emotional distress."
Given the impact of the coronavirus pandemic and the decline in emergency medicine training applicants, a predicted oversupply of emergency medicine physicians is likely overstated.
The number of emergency medicine training program applicants dropped 26% this year, falling from a high of 3,734 in 2021 to 2,765 in 2023, according to the National Resident Matching Program.
The steep decline in applicants to emergency medicine training programs comes as emergency departments nationwide emerge from a harrowing experience of chaotic emergency rooms during the coronavirus pandemic. Prior to this year's plunge in applicants, there was an expectation that there would be an oversupply of emergency physicians, with 8,000 more than needed by 2030, according to a 2021 report.
The plunge in applicants is disturbing, says Christopher Kang, MD, president of the American College of Emergency Physicians and a practicing emergency medicine physician. "It is concerning but it is not necessarily surprising. No specialty likes to see a drop in trainees, but if you look at both the short-term and long-term factors involved, we were anticipating that this would likely happen, although not at this degree."
Multiple factors likely contributed to the sharp decrease in emergency medicine training program applicants, he says:
"One factor is we knew there was a decline in applicants last year; however, when you look back at the past five or 10 years, emergency medicine was one of the more popular specialties and the number of training applicants increased. However, as many specialties have experienced, somewhere along the way when you try to meet training demand, you have to start more training programs. At this point, a mismatch has occurred."
"Second, when people want to go into this specialty, they have certain perceptions. Then when they experience the specialty, they start to see whether it is for them. In this regard, there are two factors at play. One is some of their expectations of what they were looking for in a career changed after they experienced it. Second is when young doctors see what emergency physicians have done over the past three years of the coronavirus pandemic, it has been challenging for those in the profession. When young doctors see that, despite the noble mission, emergency medicine is not what they want for a career."
"Third, young doctors have seen outwardly—not just in the emergency department itself but also in the media—rising frustrations among patients and a rise in workplace violence. They know it is difficult to see patients in a timely fashion, and they all probably have family members or friends who have experienced delays in care that have not met their immediate acute healthcare needs."
"Fourth, there are always specialties that become more popular; and somewhere along the way, those who are helping young doctors look for a career to match their expectations and skillsets may say, 'Emergency medicine is going to be a challenging environment, is this really what you want to do?' For those who may be on the fence, they may have another specialty they were interested in, and they decide to try that instead."
Given the impact of the pandemic and the decline in emergency medicine training applicants, the predicted oversupply of emergency medicine physicians in the 2021 report needs to be revised downward, Kang said. "Largely due to the pandemic, the attrition rate has increased. So, we have tried to review the numbers, and our best estimate now is that if the attrition rate increased by 2% or 3%, if the number of training applicants decreased, and if the number of residency slots changed, the number of excess emergency medicine physicians is going to be half of what was forecasted."
Emergency medicine is a noble profession that can continue to attract young doctors, he said. "Those who are called to the base of our profession, which is to serve anybody at any time regardless of their background, their situation, or their needs, want to be the quintessential doctor. Emergency medicine physicians are there to help the patient whatever their needs are. Young doctors who want to serve those patients as well as their communities are at the heart of emergency medicine."
The physician gender pay gap eased from 28% in 2021 to 26% in 2022.
After increasing 3.8% in 2021, the average pay for doctors last year decreased 2.4%, according to Doximity survey data released today.
More than 80% of doctors are members of Doximity, a digital platform for U.S. medical professionals. The annual physician compensation report released today is based on survey data collected from more than 31,000 full-time physicians in 2022.
The Doximity report features several key findings:
Doximity found a significant gender pay gap among physicians, with male doctors earning $110,000 more than their female counterparts. This represents a 26% gender pay gap in 2022, compared to a gender pay gap of 28% in 2021.
Physician compensation growth in metropolitan areas decreased in 2022. In 2021, the top 10 metropolitan areas for physician compensation growth experienced growth rates of at least 6%. In 2022, Oklahoma City, Oklahoma, was the only metropolitan area with a physician compensation growth rate above 6%.
Emergency medicine led all specialties in compensation growth (6.2%) followed by pediatric infectious disease (4.9%) and pediatric rheumatology (4.2%).
Charlotte, North Carolina ($430,890), St. Louis, Missouri ($426,370), and Oklahoma City, Oklahoma ($425,096) were the metropolitan areas with the highest average compensation.
Washington, DC ($342,139), Baltimore, Maryland ($346,260) and Boston, Massachusetts ($347,553) were the metropolitan areas with the lowest average compensation.
The specialties with the highest average annual compensation tended to be surgical and procedural specialties treating adults. The top three specialties by average annual compensation were neurosurgery ($788,313), thoracic surgery ($706,775), and orthopedic surgery ($624,043).
The specialties with the lowest average annual compensation tended to be pediatric and primary care specialties. The bottom three specialties by average annual compensation were pediatric endocrinology ($218,266), pediatric infectious disease ($221,126), and pediatric rheumatology ($226,186).
Most physicians have either accepted lower compensation for more autonomy or better work-life balance (35%) or would consider lower compensation for more autonomy or better work-life balance (36%).
Interpreting the data
Compared to 2021, physician compensation growth was low in 2022, the Doximity report says. "In 2021, there was an increase in compensation across all specialties. However, in 2022, compensation was stagnant or down across many specialties, contributing to the overall decline observed across the industry. Emergency medicine physicians reported the highest increase in compensation in 2022, a likely result of the continued demand for emergency healthcare services."
Several factors likely contributed to the decline in average compensation in 2022, Amit Phull, MD, senior vice president and medical director of Doximity, told HealthLeaders. "What we have found is that the reimbursement mix is changing over time. In addition, physicians have been negotiating down their compensation in return for better control over their work-life balance and greater autonomy. In addition, physicians have been taking on more hybrid careers. All of this has come together to result in a slight decline in compensation."
He had mixed views on the long-term prospects for the physician gender pay gap. "The optimist in me would like to think that over time the gender pay gap will close. There was a slight reduction that we found year-over-year from 2021 to 2022. The cynic in me would focus more on the fact that despite that slight reduction, the pay gap itself is still quite substantive. The last time we looked at rolling out the pay gap across a career, it netted out to a couple of a million dollars in compensation over the course of a clinical career."
Providing female physicians with compensation data could help reduce the gender pay gap, Phull said. "Part of why we do a physician compensation report is we view it as a service for our members. For the female cohort of Doximity members, if they are made aware of the pay gap, they might be empowered to be better advocates for themselves. I am cautiously optimistic that the gender pay gap can be reduced."
Autonomy and work-life balance have clearly become important factors for physicians, he said. "Physicians are people, too. So, autonomy and work-life balance are generally important, and given the events that have transpired over the past few years, autonomy and work-life balance have been amplified even further. That reality that we lived through during the pandemic is an accelerant on a trend that already existed in the healthcare space. Over the course of the last generation of physicians, the ability to manage your own practice has changed substantively. … This is just the beginning of more interest in life-work balance. We have begun to see signs of overwork and burnout present themselves more consistently."
Mental health conditions have come to the forefront in the United States for all age groups.
Addressing mental health needs is a primary aspect of healthcare in the post-COVID world, the new chief medical officer of MSU Health Care says.
Michael Weiner, DO, MSM, was named the new CMO of MSU Health Care, in East Lansing, Michigan, last month. Prior to joining MSU Health Care, he served as CMO for Maximus, a public company that contracts with government agencies to make them more accessible and affordable. He was previously chief medical information officer at IBM, where he led the healthcare solution teams in infrastructure, analytics, consumer engagement, and cognitive computing. Previously, as both CMO and CMIO for the U.S. Department of Defense, his office was responsible for a significant enhancement to the Veterans Affairs electronic medical record.
HealthLeaders recently spoke with Weiner about a range of topics, including clinical challenges now that the crisis phase of the coronavirus pandemic has passed, electronic medical records, and physician leadership. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: Now that the crisis phase of the pandemic has passed, what are the primary clinical challenges that health systems are facing?
Michael Weiner: The tsunami that is coming our way post-COVID revolves around the mental health needs of the populations that we serve. People are going to start reaching out for the mental health support that they have come to realize that they need, whether that be loneliness, depression, or anxiety. These topics have all come to the forefront of care in America today across all age groups.
Post-COVID, we are going to have a focus on mental health. We are fortunate to have an amazing mental health department at MSU Health Care that we look forward to relying on to support this burgeoning population of patients who have increased mental health and behavioral health needs.
HL: What do you anticipate will be your biggest challenges in serving as CMO of MSU Health Care?
Weiner: The challenges for the CMO at Michigan State University are the same challenges that are affecting medicine in 2023 across the nation. There are increasing patient needs, decreasing provider resources, technology is being added to the mix, there is more and more provider burnout, and we are all living in a post-COVID world.
On the patient side, we are seeing an increased need for mental health services and an aging population. We are seeing shrinking resources to support those populations and are layering more technology into the provider workflows that is increasing burnout even further.
HL: How can a CMO rise to these challenges?
Weiner: We need to address these challenges one-by-one. There is nothing we can do about the changing demographics of aging populations that come with more diabetes, more obesity, more hypertension, and more mental health needs. We just need to understand that these patients are coming, and we need to support them. We may not have control over this challenge, but we do have control over what we can do and offer to the populations that have entrusted their care to us. We can make sure we have the right tools, the right people, and the right teams to support them.
We need to get to the root causes of burnout for our providers and our support staff. Like anything else in the world, burnout is a complex mix of factors. We were already looking at provider burnout pre-COVID, then COVID caused even higher degrees of provider burnout, and we lost providers throughout the pandemic. So, our goal is to build the pool of providers back up. We are actively recruiting providers to come and join our team. Our goal is to make MSU Health Care the place to work in America.
HL: How will your experience serving as CMIO at IBM help you in your new role at MSU Health Care?
Weiner: Burnout is tied to many of the new technologies that have been given to our providers. If you look at the core of that, there is an electronic health record that was mandated years ago, and many providers are skeptical that EHRs were created with them in mind.
What I was able to learn at IBM is that there are many new technologies emerging in support of better patient care, better quality care, and increasing access to care. If we go back to the concerns about providers, how do we make the electronic health record experience better for our providers and staff? We cannot forget our nurses and medical assistants who are all interacting with the same technology and have had many of the same frustrations. We need to concentrate on technology to make that experience better.
We have learned there are things we can put into the system such as voice recognition technology integrated with our electronic health record to improve the workflow of seeing a patient. Right now, our job is to listen to the providers, hear what they are asking for, and begin to deliver to improve their experience. If we can take good care of our staff, that allows our staff to take amazing care of our patients.
Michael Weiner, DO, MSM, chief medical officer of MSU Health Care. Photo courtesy of MSU Health Care.
HL: How will your experience enhancing the EHR at Veterans Affairs help you in your new role at MSU Health Care?
Weiner: While working at the Department of Defense and working with the VA, I had the opportunity to serve large populations of providers—thousands of providers. After a while, you begin to realize the challenges for providers are common regardless of where they are practicing care. Whether a provider is working at the VA or an academic medical center, the challenges are largely the same.
I have been able to take lessons learned at the VA and bring them to this incredible academic medical center. With this experience, I am hoping to achieve progress more quickly.
The one thing we worked on at the VA and are hoping to bring here is optimization, which becomes a life-long journey in whatever electronic health record you are using. The electronic health records are typically developed with teams of experts and users of the system—we call them "super users" who are high-end users. We want to be able to take the lessons that the electronic health record vendors have built into their systems and bring those across to our own providers, so they can be more efficient, optimize the way the system is used, be able to document more quickly, spend more time with patients, and get home at a reasonable time.
HL: Is there anything specific that can be done to electronic health records to make them more user friendly for clinicians?
Weiner: You must aim for optimization of the electronic health record. For example, when I see a patient, if I have to click 40 times to get from the beginning of the patient encounter to the end of the patient encounter, is there a more optimal way to do that? Is there a way to get through in 20 clicks? Is there a way for me to be able to dictate into the blocks I need to fill out to make it more efficient for me?
One solution is advanced optimization training, which is having elbow-to-elbow experts working with the physicians as they see patients to improve their workflow within the electronic health record. There are also technologies that can make the experience better for clinicians and patients. We have adopted patient-supportive technology to make it easier to sign in, to make it easier to give medical history, and to avoid filling out pages of forms when you see a doctor. You can also bring in additional support such as scribes to help do the input work. We are looking at optimizing the electronic health record to improve retention and to make us a more attractive employer.
HL: You have a clinical background in internal medicine. How will this clinical background help you serve as CMO of MSU Health Care?
Weiner: I believe that primary care is the basis of care for a population. I am a primary care physician, and being able to support patients holistically in their journey through the healthcare system is invaluable in helping to elevate the health of an entire population.
Serving as a primary care physician helps me serve as CMO. It gives me an understanding of the care of a population and an understanding of my primary care colleagues who provide care to patients who seek care at Michigan State University. It also has involved years of interacting with specialty care providers who also support our patients. So, I know the primary care side and have worked with specialty care providers for two decades, and this will help me bring us together as a tightly knit team.
HL: What are the primary keys to success in physician leadership?
Weiner: At the nd of the day, providers have three requests of their leadership.
Number one, they want to be listened to. They want someone to hear them. Providers do incredible work taking care of complex populations, and they have asks. Since I began working here, no one has asked for anything unreasonable given our collective goal of delivering better care.
Number two, they want to be supported. How do we offer them the support that they are asking for?
Number three, they want to work with someone who is also seeing patients. In my role, I am working with patients with a full clinic schedule.
Those three things make for a good physician leader at a health system, particularly a good CMO.
Hopper Health is serving neurodivergent patients in California and New York.
A new healthcare company has launched a digital-first primary care platform to serve neurodivergent adults.
One in five U.S. adults is neurodivergent, with a range of conditions such as autism, attention-deficit/hyperactivity disorder (ADHD), obsessive compulsive disorder, and Tourette syndrome. These adults can struggle in healthcare settings; for example, dense paperwork can overwhelm them and bright lights can lead to anxiety.
Brooklyn, New York-based Hopper Health is serving neurodivergent adults in California and New York. Hopper CEO and founder Katya Siddall-Cipolla told HealthLeaders that she was inspired to create the company from personal experience.
"I am an autistic and ADHD person myself, and I also have Crohn's disease, which is a lifelong chronic illness, and I have spent the past 20 years of my adult life not getting medical care that understands people like me. Whether it is not understanding my sensory needs in a medical environment or communicating differently the way that I might explain or experience pain, I have gotten care that sometimes was not the right care or sometimes was delayed by many years. … For me, the inspiration for Hopper is I do not want my daughter's generation to go through the things that my generation has had to go through to get to some semblance of health," she said.
Siddall-Cipolla said there are two primary elements to providing quality care for neurodivergent adults.
"One is clinicians understanding the population, being very curious, being collaborative with patients, and understanding that they must take time and energy to deeply understand what is going on because if they operate at the surface level, oftentimes they might miss cues that neurodivergent people are sending that are important from a diagnostic perspective. The other piece that is incredibly important is the peer support component. Many neurodivergent folks like myself struggle with executive functioning—things like planning, task follow-through, and following steps in a certain order. So, the red tape of healthcare such as insurance, specialist visits, and who is in network and out of network is so challenging that oftentimes people like me will just avoid care and shut down. The peer navigation component is designed to be the support system for health for the individual patient," she said.
Clinicians selected to cater to neurodivergent adults
Hopper clinicians offer culturally competent care, Siddall-Cipolla said. "One thing we have done is we want to be neurodivergent-affirming, which means we need to understand the experience of neurodivergent people. We need to be thoughtful of sensory needs, information processing, and communication differences. In addition, all of our providers go through a training process for people of color as well as LGBTQ and transgender issues so that they have a broader perspective on inclusion. Unfortunately, there are a lot of neurodivergent folks who are multiply marginalized, and they have the least access to care and tend to have the lowest success rates finding clinicians who can understand them."
Hopper offers contextual primary care, she said. "Context is the patient's environment and experience—it is what is happening with them. We are saying that we are meeting people where they are instead of expecting them to come to where we are. We are wanting to understand all of the context around a person's experience, so that we can accommodate them appropriately in a healthcare setting, versus saying, 'This is how you must show up. This is how you must access care. This is our process.'"
Peer navigators
Peer navigators are a key aspect of Hopper, Siddall-Cipolla said. "Our navigators have been through health challenges. Our navigators have dealt with the mental health system. Our navigators live challenges every day, and they also have the additional education around the healthcare ecosystem as well as how all the parts and pieces fit together at a level that most patients do not have."
The navigators can help neurodivergent patients with tactical healthcare challenges such as prior authorization for medication as well as other issues, she said. "They can also help with things like asking for accommodations at work, or things like getting an MRI. For patients who have never had an MRI, our navigators can tell the patients about accommodations they can reasonably ask for at the imaging center. Navigators can call ahead and have conversations with office staff for other types of visits to make sure our patients are understood even before they walk in the door. They do advocacy work on top of the navigation component."
Visit length and financial model
At Hopper, telehealth visits are usually longer than typical primary care visits, Siddall-Cipolla said. "Our first 'welcome' visit with each patient is a full hour with their primary care provider. Prior to that full hour, patients have an opportunity to connect with their navigator, talk through some of their challenges, and give more context. So, by the time the patient sits down with the clinician, the clinician has a ton of contextual information about the patient's life, and the clinician has time to ask questions. … A typical urgent care visit is anywhere from 20 to 30 minutes, depending on the issues. There is time with the patient and time for good charting and documentation as well as follow-up."
For now, Hopper is operating with a direct-to-consumer financial model, with patients joining monthly or annually. The monthly fee is $99. Hopper hopes to establish relationships with payers soon, she said. "The near-term goal is to be in a capitated model with payers. We want to offer true value-based care and take on risk for managing our patients' conditions."
Overdoses, particularly involving opioids, are a national crisis, according to the Centers for Disease Control and Prevention (CDC). There were an estimated 107,622 drug overdose deaths in 2021, an increase of nearly 15% from 2020.
The ability to provide buprenorphine for opioid withdrawal in emergency departments is a gigantic leap forward in substance use disorder care, says Natasha Kolb, MD, emergency medicine program medical director at Presbyterian Medical Group.
"Historically, when we would see patients in the emergency department in opioid withdrawal, we would give them medications to try to cover up the symptoms of withdrawal and they were suboptimal. You would give a patient something for nausea and it would help a little bit, but nothing we gave them helped with the craving for opioids. Now, while a patient is in the ED and in crisis, we can start them on a medication that not only treats the symptoms of withdrawal but also treats the craving for opioids. So, they leave the ED feeling normal and they are more likely to follow through on appointments to get continued prescriptions for buprenorphine or make it to an inpatient treatment center or outpatient care. The success rates went way up to keep people in treatment," she says.
Providing naloxone for opioid overdose
In addition to providing buprenorphine in PHS emergency departments, the health system is dispensing naloxone to patients as well as family members in EDs, Kolb says. "What we do when a patient is in the ED and has suffered a near-death experience because they have overdosed on an opioid, we actually put a Narcan atomizer in their hand or the hand of a family member. We say they have something that can save their life if there is another overdose, and they walk out of the ED with that life-saving medication. It is part of their ER visit, they do not have to pay for it, and they do not have to go to a pharmacy to fill a prescription."
Filling a prescription for naloxone at a pharmacy can be daunting, she says. "It can be difficult to fill a prescription for naloxone. If you go to the pharmacy to fill the prescription, the cost is $90 with insurance."
Interdisciplinary approach
PHS emergency departments are providing evidence-based treatment for opiate and alcohol use disorder through an interdisciplinary workgroup that includes peer support specialists, pharmacists, informaticists, addiction specialists, and emergency medicine clinicians, Kolb says.
The peer support specialists are crucial, she says. "We have peer support specialists—many of them were formerly addicted to substances themselves and are in recovery. So, they are the perfect people to connect with patients, and they work in our EDs. They get a list of patients who have checked in with certain acute complaints such as withdrawal, then they talk with the patients; and if we initiate treatment, they will circle back with the patient within 24 hours to see how the patient is doing. They help patients with the next step to get treatment in an inpatient or outpatient setting. They also come to our interdisciplinary meetings on substance use disorder."
The pharmacists are also key members of the interdisciplinary team for substance use disorders, Kolb says. "Pharmacy has also been critical in coming to these meetings, too. They talk about stocking naloxone, so we have it in our drug cabinets to dispense. They make sure we have the right formulations of buprenorphine—is it going to be a pill or is it going to be the dissolvable strips?"
Opioid stewardship
PHS emergency departments practice opioid stewardship to reduce addiction to opiates, she says.
"We have worked on making our order sets to take providers to non-opioid pain management strategies first, then work down to opioids as the last option. It's not that we never use opioids—if there is a bone sticking out of a patient's leg, you are probably going to have to use morphine for that patient. But we try to start at the safest and easiest modalities first. So, you start at the top of the order set with old-school therapies such as ice or a heat pad, then you might go to topicals such as patches with lidocaine for someone with back pain. Then you move to non-opioid medications such as acetaminophen and ibuprofen. Opioids are used as the last resort."
PHS hospitals are also using technology to promote opioid stewardship, Kolb says. "If a provider writes a prescription for a patient to go home with an opiate, our electronic medical record is integrated with our Prescription Monitoring Drug Program system. So, when a provider wants to write a prescription, you get a pop up with a link to the patient's prescription history. If there is any indication that the patient is not using opioids in a safe manner, the provider gets that information before the prescription is written."
CommonSpirit Health has launched several efforts that target cardiovascular care in maternal health.
CommonSpirit Health is stepping up efforts to address cardiovascular disease in maternal health.
In several reports, the United States has the highest maternal mortality rate compared to other developed countries—a report from The Commonwealth Fund found the United States had the worst maternal mortality rate compared to 10 other developed countries. According to a Centers for Disease Control and Prevention (CDC) report, the U.S. maternal mortality rate rose from 20.1 deaths per 100,000 live births in 2019 to 23.8 in 2020. The CDC report highlighted a racial disparity, with the maternal mortality rate for Black women at 55.3 deaths per 100,000 live births, which was nearly three times higher than the rate for White women.
A new report from the CDC shows that the U.S. maternal mortality rate rose 40% from 2020 to 2021.
Addressing cardiovascular disease during pregnancy is crucial to reducing maternal mortality, says Rachel Bond, MD, system director of women's heart health at CommonSpirit. "Cardiovascular death, which is the leading cause of death during pregnancy, is preventable 80% of the time. A lot of that has to do with us communicating with each other and diagnosing these conditions early."
CommonSpirit has established a Maternal Heart Council to educate patients and clinicians about cardiovascular health during and after pregnancy as well as to provide guidance and protocols, she says. "We are getting guidance from both cardiologists who specialize in high-risk pregnancies as well as cardiologists from subspecialty services. So, in the event that we need interventional cardiologists, advanced heart failure cardiologists, or cardiologists who come from other specialties such as electrophysiology where we may have an abnormal heart rhythm, they are incorporated within the Maternal Heart Council. We work collaboratively with the primary obstetrician as well as the maternal fetal medicine provider, who is a high-risk obstetrician."
The Maternal Heart Council is led by physicians and includes advanced practice providers, nurses, and hospital administrators, Bond says. "We all work collaboratively, and the council meets monthly. In addition to the council, on the outskirts of the council, clinicians and nurses meet regularly to actively discuss the day-to-day management of individual patients. So, the council is a broader umbrella, where we are creating guidance on protocols and educational materials that we give to both patients and clinicians. Outside the scope of the council, we as clinicians are meeting regularly and discussing these patients."
Targeting preeclampsia
CommonSpirit has also developed quality improvement toolkits to address preeclampsia, she says. "We know that preeclampsia is an independent risk factor for cardiac disease, which may occur during a pregnancy but can also occur decades after a pregnancy. This is why we like to target preeclampsia because it is a common adverse pregnancy outcome that we are seeing and rates of it are increasing. A lot of that has to do with the fact that women are having children later in life, and we know that anyone who has a baby past the age of 35 is at a slightly higher risk of having preeclampsia. The other reason we are focusing on preeclampsia is that many of these moms are coming into pregnancies with many common risk factors for high blood pressure outside the scope of pregnancy, and preeclampsia impacts blood pressure."
The health system is providing education about preeclampsia, Bond says. "The way from a quality improvement perspective we have been able to tackle preeclampsia is by providing education not only to the patients but also to the clinical staff. The way we have been able to do this successfully for the patients is we have created a 'passport.' That passport goes over signs and symptoms of how preeclampsia may present. It also goes over the common risk factors. In addition, it goes over how to track your blood pressure during pregnancy and after pregnancy. One thing many people do not realize is that when it comes to preeclampsia, it can occur in the post-partum period, usually upto six weeks post-partum."
Providing preeclampsia education to clinicians is pivotal, she says. "The first group of clinicians preeclampsia patients are seeing when they come to the hospital are emergency physicians. So, there is a large value in educating our emergency room providers. One of the questions we have them ask is, 'When was your last pregnancy?' If your last pregnancy was within a year, and you are coming in with signs and symptoms that are concerning for a cardiac condition, it could be related to that pregnancy. We have come a long way in providing education to our emergency medicine providers; and, similarly, we have provided education to our inpatient internal medicine providers—our hospitalists. It is important to highlight that this education is not just in the inpatient setting, it is also in the ambulatory setting. That is where this education has been targeting our obstetricians."
Standardizing care and protocols
Standardizing care and protocols for maternal health is essential, Bond says. "Data has shown that standardizing care and standardizing protocols can ensure that all of our patients are receiving the same level of care. More importantly, standardizing care and standardizing protocols can ensure that patients have access to the most current research and best practices."
Standardizing care and protocols helps address disparities in maternal health, she says. "It is important to highlight the fact that we have a maternal health crisis in the United States, and we know that this crisis disproportionately is affecting women of color and women who come from lower socioeconomic status. Unfortunately, one driver of this situation is there is implicit bias. So, if we remove the potential for implicit bias by standardizing care and creating protocols that are available for anybody regardless of race, ethnicity, or socioeconomic status, our hope is that we will be able to make a change and decrease poor outcomes."
Virtual care for rural patients
To help reach patients who struggle with healthcare access, CommonSpirit is providing virtual care for rural patients, Bond says. "We are targeting rural areas for telemedicine because we know those areas are where we have the majority of maternal care deserts. A maternal care desert is where you have limitations in obstetric care. Not only do they have limitations in obstetric care, but they also have limitations in specialty care such as cardiologists who focus on high-risk pregnancies."
Using telemedicine for patients in rural areas is good for patients and clinicians, she says. "It has been phenomenal because it allows us to reach the patient, it is convenient for the patient, and it can be convenient for clinicians. Through these visits, patients can access all levels of care that they may not already have available in their communities. More importantly, we can work with physicians who are more local to the patient to try to provide them guidance and co-manage patients."
At Pfizer, a global approach to supply chain is crucial, one of the company's senior vice presidents says.
In the U.S. pharmaceutical sector, supply chain resiliency is not achieved through concentrating all manufacturing capabilities in the country, a top Pfizer executive said yesterday during a webcast held by The Brookings Institution.
Supply chain resiliency has been a hot topic during the coronavirus pandemic. Shortages of medical supplies and medications such as personal protective equipment have sparked debate on whether more medical products should be produced domestically.
Pfizer's capacity to produce an unprecedented supply of COVID-19 vaccine in a short period of time was the result of a global supply chain, not just investments in the United States and Europe, said Tanya Alcorn, senior vice president as well as biotech and sterile injectables operations lead at Pfizer.
"In order to make those vaccines, we needed hundreds of materials from more than 80 suppliers that were located in about 20 different countries. That is why the idea of onshoring may make us feel better, but it is not the answer. Having agreements that incentivize governments to play together in a fair way to allow for trust and free movement of goods is the way you get to resiliency, not trying to bring everything into one country because one country cannot solve it all," she said.
Pfizer achieves risk mitigation and supply chain resilience through several methods, Alcorn said.
"As a manufacturing organization, we are constantly assessing risk and resiliency. We are assessing risk whether it is war as we have seen in Ukraine or natural disasters. So, we think about risk in a lot of different ways, and we are constantly looking at ways to mitigate risk. We do it through scale, through redundancy of suppliers, through inventory management, and not relying on one supplier in one country. We diversify our supply chain. For us, diversification is key as well as building a trust relationship with suppliers and encouraging governments to allow the free flow of materials," she said.
When it comes to the COVID-19 vaccine, building production facilities in developing countries would not have solved those countries' vaccine access challenges, Alcorn said. "What we have learned through our experience working with developing nations is putting a plant in the country is not the answer. It may make us feel better, but it is not the answer. We have found that one of the primary barriers is infrastructure. So, the infrastructure that surrounds the storage, distribution, and administration of vaccines was more of the barrier."
In some developing countries, Pfizer used drone technology to address the vaccine access challenge, she said. "We created a packaging that allowed our vaccine to be drone shipped and dropped into villages. That is how we expanded access. It was successful versus if we built a plant in the country, which would not have solved the fundamental access problem."
At Pfizer, a global approach to supply chain is crucial, Alcorn said. "Pfizer is all about giving access to as many patients as possible to our medicines and vaccines. The way that we do that is through trust, partnership, and scale. Not one country can do it alone. You need many countries and many partners. You need the private sector and governments all playing nicely together."