There are still COVID-19 patients in hospitals and staff are still contracting the virus, so coronavirus remains a top healthcare issue.
Now that COVID-19 has reached an endemic phase, one of the biggest challenges facing healthcare organizations is keeping communities focused on containing the virus, says Janet Tomcavage, MS, executive vice president and chief nurse executive at Geisinger Health.
Tomcavage is one of more than a dozen healthcare executives set to participate in The Way Forward, a HealthLeaders leadership summit scheduled for next week at the Loews Atlanta Hotel in Georgia. Tomcavage will serve on a clinical care panel, and there will be panels for CEOs, chief financial officers, and chief information officers.
The focus of The Way Forward will be on sharing of plans, thoughts, strategies, and impressions of the future of the healthcare industry. HealthLeaders coverage of the leadership summit includes a Q&A interview of each panelist. The transcript of Tomcavages's interview below has been edited for clarity and brevity.
HealthLeaders: Now that the crisis phase of the coronavirus pandemic has passed, what are the primary clinical challenges that you are facing?
Janet Tomcavage: The biggest obstacle is staffing. It is a clinical challenge because we have had to close beds because we do not have enough staff.
The other concerning challenge is an experience gap. We are seeing fewer experienced nurses staying at the bedside. So, you have less nurses with at least 10 years at the bedside alongside young, inexperienced nurses who are precepting even less-experienced graduate nurses. Instead of having a new graduate paired with an experienced nurse who has been here 10, 15, or 20 years, now you are pairing a graduate nurse with a nurse who has only been here for three years if you are lucky. You do not have that wealth of knowledge that comes with experience. It is a big concern for me.
HL: How are you addressing workforce shortages?
Tomcavage: We have traveling nurses because we can have nurse vacancy rates on our medical-surgical units of 40% to 50%. So, we have leveraged premium labor in the form of travelers.
We started our own internal traveling nurse program to try to offer nurses higher payment rates to travel within our organization. We had a goal to hire 100 internal traveling nurses this year, and we are at 70, so we have made good progress. We have nine hospitals in our system, and we require our internal traveling nurses to work a 12-week rotation. We allow a break of 30 days in between rotations because travelers do not have to sign back up earlier than that traditionally. They get compensation for travel along with lodging if they must travel more than 60 miles one way.
We have opened up our staffing model for flex and per diem nurse roles because one of the things we heard from our staff is they wanted flexibility in the staffing model. We are allowing many more nurses to flex, which means they do not have set hours. The challenge with this situation is you are at the mercy of nurses signing up for shifts.
We have offered recruitment loans to new graduates and retention bonuses to nurses to stay with us. In the opposite of exit interviews, we are conducting "stay interviews" so we can understand what would keep people with us. We are looking at other retention strategies with benefits, the ability to work into a day-shift job, or reduced work on the weekends. The problem is you must have adequate staffing to do those things.
The big challenge is on medical-surgical units. New graduates want to work in specialty areas. So, we are trying to figure out how to entice people to work on medical-surgical units, but we are still looking for solutions.
HL: Now that we are in a new phase of the pandemic, what are your primary COVID-19 challenges?
Tomcavage: We still have about 100 patients with COVID in the hospitals, so we are not past the pandemic. We still have staff who contract COVID, so we are still dealing with that.
A main COVID challenge is we still have a lot of patients who have long-haul COVID. We also are seeing the effect of people who stopped receiving care during the pandemic who are now coming to the hospital with higher acuity in their conditions.
The primary COVID challenge is continuing to keep the communities focused on the virus. People need to get their boosters and take precautions because COVID is still out there. We need to stay diligent about community spread of COVID.
HL: In the next year, in what areas would you like to launch nursing initiatives?
Tomcavage: We have plans to kick off a virtual nursing model. This could be a fit for some of the nurses who have left the bedside because of the physical demands of inpatient work such as lifting patients and being on your feet through a 12-hour shift. We want to see whether we can engage experienced nurses to provide mentoring and to do admissions and discharges virtually. We are looking at a virtual model to help address the experience gap. We are looking at a pilot to get a virtual nursing model rolling.
A second area we are working on is team-based nursing. We want to convert from a primary nurse model to a team-based model. That team may be an LPN, an RN, and a nursing assistant, or it may be two RNs working together. The goal is to care for a group of patients versus a primary nurse with five patients. We are also looking at non-licensed nursing roles in team-based care.
We are also looking at how we can increase the market for nursing. We are working with local schools—both high school and colleges—to see how we can get better-prepared nurse graduates coming out of school. We want nurse graduates to be working at the top of their license sooner.
The last area is behavioral health and safety. There are patients who come into the hospital with suicidal ideation and violent behaviors. We want to care for these patients. State and federal guidelines call for one-on-one care or patient companion roles, which has impacted the nursing team because we must pull nurses from the team to sit in a patient's room. We are looking at whether technology such as video monitors can help in this area.
HL: Do you have any other insights on the way forward now that the crisis phase of the pandemic has passed?
Tomcavage: We need to think about the impact on emotional well-being that the pandemic has had on care teams. Whether it be at the physician level, the nurse level, or the nurse assistant level, it is a concern. We have got to continue to work on resiliency programs for our staff because this is not something you recover from overnight. They have worked extremely hard for almost three years. They have seen more loss of lives in the past two-and-a-half years than they have probably seen in their entire career. They have seen loved ones die. They have seen staff pass away.
Another area we need to think about is the significant increase in violent behavior in the healthcare setting. Patients and family members are verbally abusive and physically abusive. Every day, a nurse is being verbally or physically assaulted in our hospitals. We track all of the events. Thank goodness, the number of serious physical events is not that big, but the number of serious events is increasing.
Healthcare organizations need to look at ways to improve security and safety for our staff. Geisinger has done a lot of that work. For example, we have introduced emergency buttons, so if any staff member is in a room and a patient is getting out of hand or a family member is being inappropriate, we can touch a button and immediately it sounds at the nursing station and at our security office. Somebody comes to the room immediately. Sometimes, you can diffuse the situation quickly.
Workplace violence could make our staffing shortages worse. People are going to leave because they do not want to tolerate this behavior.
Physician burnout and turnover at physician practices has increased, according to a new survey.
Jackson Physician Search presented the findings of a survey of physicians and practice administrators on burnout and related issues at this week's Medical Group Management Association (MGMA) conference in Boston.
Physician burnout was already a pressing issue before the coronavirus pandemic. A recently published research article found that physicians reporting at least one symptom of burnout rose from 38.2% in 2020 to 62.8% in 2021.
The new survey was commissioned by Jackson Physician Search and MGMA. The survey was conducted in August, and 354 physician practice administrators and 66 physicians participated.
The survey features several key data points:
The percentage of physicians reporting they are experiencing burnout rose from 61% in 2021 to 65% in 2022
Administrators' estimate of burnout among their physicians also increased from 68% in 2021 to 73% in 2022
When asked to gauge how much their burnout levels changed from 2021 to 2022, 35% of physicians reported there was a significant increase and 40% reported burnout had increased somewhat
Physicians were more likely than administrators to say the administration's handling of their practices was the source of burnout rather than the nature of the physicians' work
Physicians and administrators shared perceptions on physician engagement, with both reporting physician engagement at 7.7 on a scale of 1 to 10
Physician satisfaction with their employers was an average of 6.4 on a scale of 1 to 10
51% of physicians reported considering leaving their practice for a different job in healthcare
41% of physicians reported considering leaving the practice of medicine entirely
36% of physicians reported that they had considered early retirement
When asked what they wanted most in their practices to increase work satisfaction, physicians reported that they wanted two-way communication with management for the second year in a row
The survey report's co-authors wrote that administrators need to make intentional efforts to retain physicians.
"Awareness alone will not prevent physicians from exiting the profession in the coming years; it will require empathy and organizational efforts to restore professional relationships that make high-quality care delivery a sustainable reality, producing healthier outcomes and margins in the process. Like most issues in medical practices across the country, physician stress and burnout can be tackled when positive, two-way communication between physicians and administrative leaders is in place to reach understandings around the significant challenges everyone faces within the organization," they wrote.
Interpreting the data
Jackson Physician Search President Tony Stajduhar presented the new survey during the MGMA conference. He said the survey reveals important trends now that the crisis phase of the pandemic has passed. "When we talk about the post-pandemic period, a few things emerge from the new survey. Administrators are acknowledging worsening levels of burnout in physicians. Physicians often perceive not enough is being done to mitigate burnout. So, the two-way communication is the thing that physicians believe is missing the most and the thing they desire the most."
Physician burnout has reached alarming levels, he said. "Physician burnout and the long-term cumulative stress and depersonalization that doctors experience continues to threaten the entire industry. Burnout is prompting more physicians to leave their jobs and, in some cases, the profession."
The shift from physicians working in independent practices to physicians working as employees has had some negative consequences, Stajduhar said.
"There is a sense of moral injury as well as detachment from the management. One factor that is important is more physicians are working as employees than ever. It has become rare to see independent contractor situations as we did 15 years ago. Our business flipped on a dime after Obamacare. So, now we see physicians who are engaged in employment and often they do not feel like physicians anymore. They do not feel they have the power to practice medicine in the way they want to. They feel they are being inhibited to do the things that need to be done. And it is killing them. Physicians are feeling more like an employee than a healer."
Physician turnover is a concern at physician practices, he said. "Right now, half of U.S. physicians are saying they are going to make a move to another practice. The turnover is getting greater and greater. The number of physicians making a move previously was 6%, or more than 50,000 physicians changing jobs annually. Now, it has gone up to 7%. It could potentially go up another percentage point. An increase of 1% does not sound like a lot, but when the turnover number has been at 6% for many years, the numbers are increasingly alarming."
A growing physician shortage is also an issue for physician practices, Stajduhar said.
"It is a reality that we have an aging population and the need for healthcare is going to keep growing. We do not have any additional residency programs that are being built—certainly not enough to meet the demand for new physicians. We could be 150,000 physicians short in the next 10 years. So, this is a major problem that practices are running into. … It gets harder every day to recruit physicians, whether it is temporary staffing or permanent positions. It is great for physician staffing companies—my company will be stable for a long time because there are physicians constantly moving. But it is not the best thing for the country. It is not the best thing for your patients. It is not the best thing for your practices."
Physician practices should have formal physician retention programs to help address staffing concerns, he said. "We must come up with some solutions on how to retain physicians. There is no single way to do it. There are a lot of things you can do. You can get creative. If you have a chief medical officer within your group, you can get them involved with a line to the administration and a dotted line to the physicians. You must have open lines of communication and find out what your physicians need. It is going to take a good plan and gathering data on what is important to your physicians."
New studies show increased boarding of patients in emergency departments and more patients leaving emergency rooms without being seen.
Hospital emergency departments have been under severe strain during the coronavirus pandemic, according to a pair of new research articles.
The new studies examine boarding of patients in emergency departments before they are moved to inpatient beds and patients who left without being seen (LWBS), the latter presumably because of ED crowding and long wait times. The Joint Commission has deemed extended boarding of patients in the ED as a patient safety risk, with boarding recommended not to exceed four hours. Relatively high LWBS rates can have significant negative consequences for patients if they are deferring care for acute conditions.
Both studies were published by JAMA Network Open.
The ED boarding study is based on hospital measures data collected through a voluntary peer benchmarking service offered by Epic Systems Corporation—the leading electronic medical record company in the country. Measures were collected on a monthly basis from January 2020 to December 2021. The study features three key data points:
Hospital inpatient bed occupancy rates had a threshold association with boarding time. When occupancy rates were higher than 85%, ED boarding was higher than The Join Commissions four-hour standard for 88.9% off hospital-months.
For hospital-months with occupancy rates higher than 85%, the median ED boarding time was 6.58 hours versus 2.42 hours during other hospital-months.
For all hospitals, the median ED boarding time was 2.00 hours in January 2020, 1.58 hours in April 2020, and 3.42 hours in December 2021.
The ED boarding study's findings indicate strains on EDs before the pandemic likely worsened during the pandemic, the study's co-authors wrote. "We found that hospital occupancy greater than 85% was associated with increased ED boarding beyond the 4-hour standard. Throughout 2020 and 2021, ED boarding increased even when hospital occupancy did not increase above January 2020 levels. The harms associated with ED boarding and crowding, long-standing before the pandemic, may have been further entrenched."
Left without being seen study
The LWBS study is also based on hospital measures data collected through a voluntary peer benchmarking service offered by Epic Systems Corporation. The measures were collected on a monthly basis from 2017 to 2021.
The LWBS study includes two key findings:
Median rates for hospital LWBS increased significantly from 1.1% in 2017 to 2.1% at the end of 2021.
Among the worst performing hospitals, the LWBS rates for ED patients increased from 4.3% in the beginning of 2017, to 4.4% in January 2020, to 10.0% at the end of 2021.
LWBS at EDs is troubling, the study's co-authors wrote. "Access to emergency care cannot be considered universal until all patients presenting to EDs receive high-quality treatment for time-sensitive conditions. Given contributing system constraints, LWBS should be viewed as a failure to offer equitable access to acute care."
Lead author's perspectives
The lead author of both studies, Alexander Janke, MD, MHS, says the research indicates the pandemic has compromised a crucial part of the U.S. healthcare system. "Emergency departments are the levees on acute care demands in the U.S. While once there were decompression periods in even the busiest EDs, what we are seeing here, as others are seeing in Canada and the U.K., demonstrates that the levees have broken," he said in a prepared statement.
The studies show long-standing problems at EDs have worsened during the pandemic, Janke said. "Boarding and overcrowding in EDs have been a growing issue for over 30 years. Incredible work has been done in the emergency medicine community to make our care better, more accurate, and nimbler using limited resources. But without more space and staff in the hospital, and downstream in skilled nursing facilities and across community settings, this crisis will continue."
The health system recently added its 12th participating hospital to the TeleEmergency service and plans to add another hospital soon.
Dartmouth Health is expanding its TeleEmergency service for hospitals in Northern New England.
Dartmouth Health launched its TeleEmergency service in 2016. The health system recently added Grace Cottage Family Health and Hospital in Townshend, Vermont, to the service, bringing the total number of participating hospitals to 12. Littleton Regional Hospital in Littleton, New Hampshire, is expected to be added to the service this fall.
The TeleEmergency service is organized with a hub at Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire. The hub operates 24/7 with an emergency medicine physician and nurse on duty.
The hub has four stations that are essentially identical, says Kevin Curtis, MD, MS, medical director of Dartmouth Health Connected Care. The stations are hardwired with direct lines to all 12 of our participating hospitals' emergency departments. It does not require a cart and it does not require a transfer center. They call us directly, and we are instantly in the room by high-fidelity, live, interactive audio-visual technology."
Participating hospitals have telehealth technology in emergency department rooms, he says. "Each hospital has emergency department rooms that have monitors in a corner of the room, a computer below the monitor, and a camera that we can operate from the hub. The camera has zoom capability as well as pan-tilt. There is a microphone hanging from the ceiling of the room that can pick up audio from throughout the room. There is a button on the wall that anyone on the local team can press for a direct line to our hub."
There is a simple procedure for TeleEmergency calls, Curtis says. "If they want any help from us, a hospital staff member hits the button; and we answer the phone in the hub; we say, 'TeleEmergency, how can we help?' If it is Grace Cottage Hospital, for example, they will say, 'This is Grace Cottage Hospital. We would like some TeleEmergency help in Room 4.' Once we hear that, we call them up on live, interactive audio-visual technology, and we are 'in the room.' We think of ourselves as a doctor and a nurse who are walking into the room just like we were in the emergency department, and saying, 'How can we help?' We work collaboratively with the bedside team from that point forward."
Benefits for participating hospitals
The TeleEmergency service can help participating hospitals in several ways, Curtis says. "EDs are unpredictable in terms of volumes of patients, severity of patients, and complexity of patients. There can be sudden surges of patients. And the smaller the hospital, the less deep your staff bench is when a surge occurs. We have a system that can help the bedside team when there is a significant trauma, critically ill patient, or multiple patients at the same time—the kinds of situations where you would love to have an extra doctor and nurse."
The TeleEmergency service supplements the onsite bedside team, he says. "We can join the bedside team on demand whenever they want; and if we can be in the background as part of the team, the bedside team can spend more time focusing on patient care. Ultimately, our service may allow the patient to stay local and get their care at the local hospital."
The TeleEmergency nurse can help resuscitate a patient, Curtis says. "The ways in which we help include having our TeleEmergency nurse having oversight of a patient resuscitation in cardiac arrest. So, the bedside team is working on the resuscitation while we are overseeing the care—we can zoom in on the cardiac monitor. We can keep track of when it is time for the next medication or to stop CPR or start CPR. We can do all of that easily from afar."
The TeleEmergency team can facilitate a patient transfer if necessary, he says. "If despite us working together, the patient needs to be transferred elsewhere, we will help make that happen both by transport such as putting a DHART helicopter in the air or coordinating admission to the Dartmouth-Hitchcock Medical Center ICU or another facility. We can make all of that happen so that the bedside team can focus on the patient."
TeleEmergency financial model
The TeleEmergency service is financed by participating hospitals and Dartmouth Health, Curtis says. "The TeleEmergency service is first and foremost a mission-driven service not a revenue-generating service. Although each site that participates pays an annual fee to be part of the program, those fees do not offset the expense of having a 24/7 doctor and nurse in the hub. The TeleEmergency service and all of our Connected Care services are mission-driven from the health system to deliver outstanding services to the region regardless of where our patients are—we want to help patients and communities."
Dartmouth Health is committed to subsidizing the TeleEmergency service, he says. "The health system outlays money each year to continue this service because we are committed to the service and the benefit to patients."
The health system has also invested staff in the TeleEmergency service, Curtis says. "There is also a human investment—you need people to work in the hub. We are at the point now where we have physicians and nurses who enjoy doing the work. There are others who are interested in doing this work."
A decade-long process to secure the safety and security of the pharmaceutical supply chain is nearing the finish line.
The pharmaceutical supply chain is gearing up for the final deadline of the Drug Supply Chain Security Act (DSCSA).
The DSCSA is a federal law passed in 2013. On Nov. 27, 2023, pharmaceutical supply chain entities such as manufacturers, distributors, and pharmacies will be required to provide serialized data in transaction information when a product changes ownership such as a sale from a manufacturer to a distributor.
To discuss the DSCSA and the 2023 deadline, HealthLeaders recently spoke with Elizabeth Gallenagh, JD, general counsel and senior vice president of supply chain integrity at the Arlington, Virginia-based Healthcare Distribution Alliance(HDA). The following transcript of that conversation has been lightly edited for brevity and clarity.
HealthLeaders: What is serialized data?
Elizabeth Gallenagh: Serialized data in this context means that the supply chain will have information related to transactions—sales of pharmaceutical products from supply chain partner to supply chain partner. This data will be at a finite level. Right now, we have serialized product at the manufacturer level, which is uniquely identifiable. We also have data exchange of transaction information that is being passed along, but that information is at the lot level. In 2023, the information will be unit-level data tied to a serial number for each product.
For example, now, we are passing transaction information statements and history that is not necessarily tied to a specific serial number. After the deadline, that serialized number will be incorporated into the data.
HL: What are the central purposes of the DSCSA?
Gallenagh: The overarching purpose was to protect the U.S. domestic supply chain for prescription drugs and to make sure that bad actors and counterfeit products were kept out. As part of those purposes, the goal was to put a framework in place so that if there was a bad actor or counterfeit product that entered the supply chain, that would be stopped and there would be a trail to enable prosecutions and find the source of bad products. For example, if a counterfeit was detected at a wholesaler, there are provisions in place in the law for identifying and investigating suspect or illegitimate product.
There is also a requirement for all trading partners engaged in the U.S. supply chain to be only dealing with authorized trading partners. So, the onus is on each entity—manufactures, wholesalers, third-party logistics providers [such as UPS], and pharmacies—to ensure that they are checking to make sure that their trading partners are properly licensed or registered with the Food and Drug Administration in the case of manufacturers.
Safety and security were the main goals, but another goal was uniformity. Before 2013, safety and security were tackled at the state level, and it got to the point where we had a 50-state patchwork of laws, particularly for wholesalers and the licensure area. It became clear it would not benefit the entire supply chain if California had one track-and-trace law, and Florida had another, and Virginia had a different approach, for example.
HL: What are the key elements of the 2023 deadline?
Gallenagh: First and foremost is the unit-level data exchange—what we call unit-level tracing capability. Right now, because DSCSA is a phased-in law over 10 years, many pieces of tracing capabilities are already in place. We already have serialization. We already have data exchange for each transaction. What we do not have is serialized data exchange, which requires many connections and interoperability across the supply chain. We also do not have a lot of engagement at the pharmacy level—they have the authorized trader requirement, and they also must be able to provide information when they are returning a product to a wholesaler. But pharmacies are facing more robust requirements. Hopefully, the entire supply chain will come full circle, and everyone will achieve the serialized-data level.
HL: What are the primary challenges of meeting the 2023 deadline?
Gallenagh: There are many challenges. The primary challenge is probably the connectivity piece—making sure that every trading partner can connect and exchange data with every other trading partner that they do business with. There are other factors that are related to connectivity and data exchange such as data quality and bar code quality. A product could be serialized and there could be systems in place at all trading partners, but there might be errors in capturing the bar code on the product, or there may be readability issues.
The other big challenge is that there is another component of the law related to uniform licensure for wholesalers and third-party logistics providers, and that has not been finalized by the FDA. There is a lot of work to be done in this area. The goal is to streamline what the states are doing and how enforcement across the states is working. In this area, there is a gap of knowledge in the supply chain about knowing what to expect on inspections and licensure. There is also a knowledge gap on the powers of the state boards of pharmacy and departments of health as well as how their interactions are going to work with FDA.
Another challenge for the 2023 deadline is a lack of understanding and engagement among the pharmacy community. There is a lot of concern that there is a gap in understanding on the part of some of the pharmacy customers of what they need to do, how they need to do it, and their level of engagement. The health system pharmacies and the large pharmacy chains have been engaged—many of them have been working on their own projects and testing. The bigger concern is the small, independent pharmacies, which may not have adequate resources and may be depending on their trading partners to help them.
HL: What are the main capabilities that pharmaceutical distributors should have in place before the 2023 deadline?
Gallenagh: We are hoping that many pharmaceutical distributors have capabilities in place already because of the ramp up over the past decade. They are going to need to have a mechanism to ensure that their suppliers and customers are authorized trading partners—whether they have staff or a system to check licensing. They are going to need to be able to receive and distribute serialized product. They are going to need to be able to receive and share serialized data, so they need to have connections established with their trading partners. They are going to need to have processes in place for identifying and investigating suspect and illegitimate product as well as be able to engage with their supply chain partners and FDA or the states on those investigations.
Many pharmaceutical distributors are testing now or trying to ramp up to get into compliance well before the 2023 deadline, but this is something that does not work with just one entity or just one segment of the supply chain. DSCSA was designed to be interactive, so all parties must do their part in order for interoperability to work.
The HDA will be holding its 2022 Traceability Seminar from Oct. 12 to Oct. 14 in Washington, D.C. The event will include discussions about the 2023 DSCSA deadline.
Researchers examined payments to male and female physicians from the 15 highest-grossing U.S. medical supply companies.
A new research article has found that male physicians are paid significantly more by medical supply companies than their female counterparts.
Several studies have found a salary gap between male and female physicians. Medical companies spend more than $30 billion annually for advertising and promotion, with most of the money directed at physicians.
The new research article, which was published by JAMA Surgery, features data from the Open Payments Database for female and male physicians who received the most payments from the 15 highest-grossing U.S. medical supply companies from January 2013 to January 2019. The companies selected for the analysis were Abbott Laboratories; Baxter International Inc.; Becton, Dickinson and Company; Boston Scientific Corporation; Cardinal Health Inc.; Edwards Life Sciences Corporation; Fresenius Medical Care AG & Company KGaA; Medtronic PLC; Novartis International AG; Olympus Corporation; Siemens Healthineers AG; Smith & Nephew PLC; Stryker Corporation; Terumo Corporation; and Zimmer Biomet Holdings Inc.
The research article has several key data points:
Among the 1,050 payments examined, 96.9% of the five highest earners were men and 3.1% were women.
Over the study period, female physicians were paid a mean of $41,320, and male physicians were paid a mean of $1,226,377.
From 2013 to 2019, the payment gap between female and male physicians jumped from $54,343 to $166,778.
For all academic ranks, male physicians received higher median payments than female physicians. For example, male physician professors received median payments of $129,499 compared to $19,559 for female physician professors.
Male physicians received higher median payments across all specialties. The largest payment gap was in orthopedic surgery, where male physicians received median payments of $1,752,573 compared to $24,387 for female physicians.
Even in the female-dominated obstetrics and gynecology specialty, male physicians received higher payments than female physicians. The median payment for male obstetricians and gynecologists was $87,596 compared to $31,166 for female physicians.
"This study found that male physicians received significantly higher payments from the highest-grossing medical industry companies compared with female physicians. This disparity persisted across all medical specialties and academic ranks. The healthcare industry gender payment gap continued to increase from 2013 to 2019, with a wider compensation gap in 2019," the study's co-authors wrote.
Interpreting the data
The medical company payment gap was dramatic, the study's co-authors wrote. "We found that in the 15 highest-grossing medical industry companies from 2013 to 2019, there was a median 3-fold increase in the compensation of highest-earning men compared with the highest-earning women. Only 3.1% of women were within the 5 overall highest compensated physicians."
Payments to male physicians were higher than payments to female in all specialties—even female-dominated specialties, the study's co-authors wrote.
"We looked at all medical fields, including but not limited to surgery, radiology, pathology, dermatology, internal medicine, and obstetrics and gynecology and found that men earned significantly more than women regardless of their medical specialty. Obstetrics and gynecology is a female-dominated specialty of which women [comprise] more than 60% of all physicians. Our study showed that 52 of the physicians receiving industry payments were from obstetrics and gynecology: 31 women and 21 men. Despite a higher female-to-male ratio, male obstetricians and gynecologists received 3 times the amount of payment compensation from industry," they wrote.
Top healthcare executives from across the country are set to participate in a special HealthLeaders leadership summit this month in Atlanta.
Staffing shortages and slippage in some clinical areas such as quality are primary challenges as Providence emerges from the coronavirus pandemic, says Hoda Asmar, MD, MBA, executive vice president and system CMO at the health system.
Asmar is one of more than a dozen healthcare executives set to participate in The Way Forward, a HealthLeaders leadership summit scheduled for this month at the Loews Atlanta Hotel in Georgia. Asmar will serve on a clinical care panel, and there will be panels for CEOs, chief financial officers, and chief information officers.
The focus of The Way Forward will be on sharing of plans, thoughts, strategies, and impressions of the future of the healthcare industry. HealthLeaders coverage of the leadership summit includes a Q&A interview of each panelist. The transcript of Asmar's interview below has been edited for clarity and brevity.
HealthLeaders: Now that the crisis phase of the pandemic has passed, what are the primary clinical challenges you are facing at Providence?
Hoda Asmar: The challenges are multifaceted, but one of the main things we are facing is workforce-related challenges. Do we have enough staff? Do have enough people wanting to relocate or to take new roles? We have a shortage of licensed professionals, and we need more flexibility in the work schedule. What is happening with the workforce shortage is we are asking the same people to take on more and more shifts. There are also workforce concerns around burnout and the well-being of the staff who are on the frontline.
A second challenge for us that is related to the pandemic is a slippage in some of the clinical measures such as quality. So, Providence is focused on going back to the march toward top quartile and top decile clinical performance and being able to regain some of the performance that was lost during the pandemic.
HL: Give an example of where you have experienced slippage in quality.
Asmar: An example is managing sepsis. We are focused on managing sepsis, which is a diagnosis that carries with it high morbidity and mortality. Before the pandemic, our sepsis performance was better than expected—we had bent the curve significantly to better than expected on metrics related to sepsis management. During the pandemic, we lost some of that ground. Now, we are focused on getting back to better than expected.
HL: How are you addressing workforce shortages?
Asmar: We have a senior team that is focusing on workforce shortages, including our chief nursing officer.
We are taking a multifaceted approach. We are looking at the principle of functioning at the top of license—we are looking at people's roles and functions and trying to reduce the tasks that someone with a high-level license does not need to do. We are also looking at the schedule and offering our workforce more options in flexibility, types of shifts, and the shifts they work.
We are piloting a virtual nursing program at Covenant Medical Center in Texas. On one nursing unit, we are supporting the in-person nursing team with a virtual nursing team for tasks that do not need to be done directly in-person. This pilot will be ongoing for 90 days, and we hope the virtual nurse model will support frontline nurses.
For the virtual nursing program, we had the nursing staff at the hospital sit down with the hospital's senior leaders. They went through every task that is being done to separate the tasks that have to be done in-person with tasks that can be done virtually. The tele-nurse checks with the patients on any tasks that can be done virtually. Examples of virtual tasks include checking on the patient verbally, tasks related to documentation, and tasks in the electronic medical record.
HL: In this new phase of the pandemic, what are your primary COVID-19 challenges?
Asmar: Now that we are in the endemic phase of COVID-19, there are a couple of things we are focusing on. We need to remind people that for us to remain in the post-pandemic phase, we still must take infection precautions. We also are hoping that the vaccines will become like the flu with annual vaccinations. We want people to stay alert about COVID-19.
The good news is we are seeing less acute patients and less inpatients, but we must remember that COVID-19 is still here. It is in an endemic phase, and we still must practice certain precautions and certain measures such as vaccination to be able to continue to protect our patients, our staff, and our communities. We must make sure that we do not go back to the first and second waves of COVID-19 and the negative impact we had with morbidity and mortality. We do not want to go back to the height of inpatients that we had with COVID-19.
HL: In the next year, in what areas would you like to launch clinical initiatives?
Asmar: We are in the middle of preparing for our 2023 priorities. We will continue to be focused on safety measures such as reducing mortality for sepsis as well as hospital-acquired infections and complications, including central line- and catheter-associated infections. We are also going to be focusing on falls, particularly falls with injuries. These are the clinical initiatives we are focusing on in terms of quality and safety.
Another area we are going to focus on is supporting our caregivers including our physicians in terms of resiliency, well-being, and mental health. In the past two years, staff on the frontlines have taken on a lot.
HL: Can you give some examples of initiatives you are going to be launching related to the resiliency and well-being of your staff?
Asmar: We launched in 2022 and we will enhance in 2023 an initiative that we call No One Cares Alone. We trained more than 10,000 caregivers basically to support each other. Through this intervention just in 2022, we have identified 300 caregivers who have had signs of depression and even suicidal ideation, and we were able to support them.
In behavioral health, we have taken a telehealth approach and have been providing training and raising awareness for staff well-being. We have been measuring success based on the number of caregivers who access services, surveys on well-being and resiliency, and specific measures such as when we identify someone who may have early signs of depression or burnout. We measure the response to the interventions.
The health system has created a community care program that includes mobile units and neighborhood-based Community Care Centers.
Sentara Healthcare has launched a community care program to provide neighborhood-level access to services for people who are on Medicaid or are uninsured or underinsured.
A primary focus of Sentara Community Care is to help patients address social determinants of health such as housing, food security, and transportation, which have a pivotal impact on the physical and mental health of patients.
So far, Sentara Community Care has launched a mobile unit and two facilities:
Sentara Mobile Care: This bus is serving the Hampton Roads, Virginia, area to work with individuals who struggle with lack of transportation and time constraints. The mobile unit sets up at community events and offers scheduled services at multiple locations, including Queen Street Baptist Church in Norfolk, Ivy Baptist Church in Newport News, and the Center for Global Diplomacy in Virginia Beach.
Sentara Community Care Center—Union Mission: Sentara has opened a Community Care Center at Union Mission, which is a homeless residential program in Norfolk. The care center offers both on-site and virtual care services as well as care navigation and health improvement programs.
Sentara Community Care Center—Berkley/South Norfolk: This care center is located at an affordable housing apartment complex, and it serves one of Norfolk's most medically underserved neighborhoods. The care center provides traditional medical services such as primary care as well as on-site social services and wellness resources.
Sentara Community Care is designed to meet basic medical care needs as well as social service support, says Jordan Asher, MD, executive vice president and chief physician executive of the Norfolk-based health system. "Our integrated healthcare delivery model will provide comprehensive primary care, behavioral health, and social support services. Specific services vary by location and are designed to meet the individual needs of the community."
A range of services are available through Sentara Community Care, including the following:
Food and nutrition security assistance
Cooking and health education services
Healthcare navigation
Substance use resources
Education and career training
Transportation assistance
Housing assistance
Domestic and community violence assistance
Financial literacy services
The health system plans to launch another mobile unit in Harrisonburg, Virginia by the end of the year, Asher says. "Then we have eight different Community Care Center locations on the drawing board slated through 2023 and as many as eight more sites in 2024," he says.
Addressing 'dis-eases of life'
Asher says it is critical to address social determinants of health, which he calls "dis-eases of life."
"We believe that by being out in the communities where the needs are greatest and helping to address social determinants of health—or the dis-eases of life—we can medically care for individuals even better. To truly drive measurable change and advance health equity in the communities we serve, we must focus on addressing the root factors that greatly influence a person's health and well-being beyond the care that we deliver inside of our medical facilities," he says.
Sentara Community Care is based on the belief that dealing with social determinants of health is essential to achieving positive clinical care outcomes, Asher says.
"Sentara Community Care builds on our existing efforts and commitment to address social determinants of health, especially in those who are most vulnerable and have the greatest need. Social determinants of health, such as housing, financial literacy, food insecurity, and transportation needs, directly impact 80% of a person's health and well-being—factors that occur outside the walls of medical offices and facilities. We are focused on treating these dis-eases of life before treating medical diseases."
Targeting community care
Sentara is using data to target neighborhoods for community care services, Asher says. "We spent a lot of time over the past year engaging our communities. We got data points from the grassroots level, including community leaders and faith-based ministers and pastors. So, we came at this from a voice-of-the-customer perspective. We also came at it from a market perspective, meaning, what does the market need by the definition of what data shows us such as geographic information system data, gaps in care for Medicaid lives, and gaps in care for the uninsured?"
Sentara combined geographic information system and insurance data with data collected from communities, he says. "We married that data with qualitative and quantitative data that we got from the communities. That has made a huge difference in where we go and what services we bring to those areas, which might be different from place to place. Most importantly, we are building trust and community commitment because they were part of the data collection to begin with."
Financing community care
Sentara is financing the health system's community care program itself, Asher says. "We are financing the community care program because we believe that a healthier community is better for the overall community. As a not-for-profit, we are a community asset, and the community care program is part of how we are going to fulfill our community role."
Serving the uninsured is part of the financing challenge, he says. "We are an integrated delivery network, so we have an insurance arm. When people come in and they are uninsured, we are working on getting them insurance, and we can do that because we have an insurance arm. That's one of the big social determinants—not having insurance or a way to fund your healthcare needs when you need to fund them."
Community Care Center staff offer uninsured patients affordable options, Asher says. "A lot of these people qualify for services that they don't know they qualify for, and they need someone to help them through the process. So, we can sign up people for Medicaid, and we are able to work with them from an Affordable Care Act standpoint on the individual insurance market depending on their income level. Virginia is a Medicaid expansion state, so enrolling people in Medicaid is one of our major focal points. At our Community Care Centers, we have staff there to help patients get what they qualify for."
IHI is offering two ways for healthcare organizations to participate in its Pursuing Equity initiative.
With sponsorship funding, the Institute for Healthcare Improvement (IHI) is launching a new iteration of the organization's Pursuing Equity initiative.
Health equity has emerged as a pressing issue in U.S. healthcare during the coronavirus pandemic. In particular, there have been COVID-19 health disparities for many racial and ethnic groups that have been at higher risk of getting sick and experiencing relatively high mortality rates.
IHI created the Pursuing Equity initiative in 2017 to help health systems address healthcare disparities that are systematic, avoidable, and unjust. The Pursuing Equity initiative is based on a framework with five key components for healthcare organizations:
Establish health equity as a strategic priority
Design structures and processes to bolster health equity work
Develop strategies to address determinants of health that healthcare organizations can impact directly
Reduce institutional racism within the organization
Form partnerships with community organizations to improve health and equity
Genentech, which is a subsidiary of the Roche Group, has provided funding that will allow dozens of healthcare organizations to participate in the Pursuing Equity initiative at no cost from January 2023 to June 2024. IHI is offering two opportunities for healthcare organizations to participate in Pursuing Equity:
Learning Network: 40 teams will develop the infrastructure needed at health systems to advance health equity and racial justice at their organizations and communities
Action Community: 10 teams will use quality improvement tools to make measurable positive changes in clinical health equity disparities
Action Community applications are open through Oct. 21 and Learning Network applications are open through Nov. 1. Details about submitting applications, expectations for participating organizations, and IHI support are available online.
Working with IHI on equity
HealthPartners has been working with IHI on equity issues for many years, says Beth Averbeck, MD, senior medical director for primary care at the Bloomington, Minnesota-based health system. "We were one of the Pursuing Perfection grantees two decades ago and equity was one of the aims. So, we have had a number of different collaborations with IHI. Because of the work we have done already, Pursuing Equity has been an opportunity to focus on an area that is important to both organizations."
Participating in Pursuing Equity was helpful during the pandemic, she says. "Some of the concepts that we learned in the Pursuing Equity initiative helped us in the COVID-19 vaccine work that we did. Given some of the distrust that we anticipated, there were potential disparities in COVID vaccination. So, we applied some of the Pursuing Equity principles to how we could be nimble and try things to close equity gaps."
Pursuing Equity complements ongoing equity work at HealthPartners, says Nance McClure, JD, chief operating officer at the health system. "For Pursuing Equity, what we have tried to do is to make sure that the team we have working in the initiative with IHI is directly connected to work that we have in our annual plan. Pursuing Equity has been an accelerant for work that we have in our annual plan. We have not been creating new and different work. In that way, we have not made specific investments in Pursuing Equity."
McClure offered advice for other health systems that are planning to participate in the Pursuing Equity initiative. "You need to make sure there is a solid link between people participating in the Pursuing Equity initiative and the work that is going on in the organization so that it does not become siloed and work that is competing for resources. It must be part of the mainstream work of the organization. … It also helps to keep the team small. Some organizations will have a team of 10 or 15 people, but it is often more productive to have a small team that is accountable for working on the team and incorporating their work with what is happening in the organization."
The Baltimore-based health system has provided more than 1.5 million telehealth visits since the beginning of the coronavirus pandemic.
Johns Hopkins Medicine has surpassed 1.5 million telehealth visits, and the health system expects virtual medicine visits to maintain a brisk pace over the next two years.
At most health systems, hospitals, and physician practices, telehealth visits have increased exponentially since the beginning of the pandemic. New regulations adopted during the pandemic boosted the ability of healthcare providers to offer telehealth visits; and as long as those regulations remain in place, the volume of telemedicine visits is expected to be significant.
Telehealth visits at Johns Hopkins Medicine have leveled off since the early phase of the pandemic, but the volume of visits is expected to be robust over the next two years, says Helen Hughes, MD, MPH, medical director of the Office of Telemedicine at the health system.
"Over the past six months, we have reached a steady state of about 30,000 to 35,000 outpatient telemedicine visits per month across Johns Hopkins Medicine. That is about 15% of our outpatient volume. If we assume no major regulatory restrictions in the near future, we think this is the level of telemedicine our providers want to offer, and our patients want to receive. This is about 400,000 telemedicine visits per year," she says.
Hughes says three types of investments were required to support the increase in telehealth visits at Johns Hopkins Medicine: technical, operational, and training.
"From a technical standpoint, our Office of Telemedicine as well as our Johns Hopkins IT infrastructure quickly spread technical tools that we had prior to the pandemic. We used those tools in the spring of 2020, but we realized that some of those tools were not effective for our patients and providers. For example, we adopted a new video platform in August of 2020, which we continue to improve based on provider and patient feedback."
"From an operational standpoint, it was amazing to see our clinics on the frontline need to pivot and incorporate this type of care into caring for their patients, who they also saw in-person. Our Office of Telemedicine needed to work with all of our operational teams that support outpatient care, including scheduling services, interpretation services, and our frontline clinical support staff to make sure patients were having a seamless telemedicine care experience. All of this was new at the beginning of the pandemic, but we adjusted to integrating telemedicine into the continuum of our usual outpatient care operations."
"From the training standpoint, telemedicine was new to many staff members two-and-a-half years ago, and we needed to conduct a lot of training. Our Office of Telemedicine partnered with several of our training teams both on the clinical side and the education side to make sure our providers and staff knew how to use the technical tools in a way to provide high-quality care."
Clinicians had several options for telehealth training, Hughes says.
"We had training tip sheets, videos, and electronic learning modules, which covered both the technical and the clinical basics. We also partnered with many of the educational leaders—our educational leaders in primary care, our educational leaders in the pediatrics residency training program, our educational leaders in the medical school, and our educational leaders in specialties such as neurology. We wanted to make sure clinicians in their various content areas were trained to use telemedicine as a clinically appropriate tool. It has been multifaceted, from basic education such as how you get on a visit and how you act professionally during a visit to how you use this tool for a neurological exam or a gastrointestinal exam at a distance," she says.
Telehealth adoption by clinicians
About 60% of Johns Hopkins Medicine clinicians have conducted at least one telemedicine visit since March 2020. In April 2021, the health system surveyed its clinicians to understand how they wanted to use telemedicine in the future and how they had used telemedicine during the pandemic, Hughes says. "We found that there were some overall trends in what types of specialists wanted to do more telemedicine in the future—after the acute part of the pandemic. Providers in specialties that are less in-person, less physical exam-dependent or less in-person procedural-dependent such as psychiatry, nutrition, and genetics were more likely to want to do more telemedicine in the future."
When the survey data was examined by specialty, the health system found there was a wide variety in how much individual providers wanted to do telemedicine, she says. "In almost every specialty, we saw a range from providers who wanted to do 100% telemedicine to providers who wanted to do 0% telemedicine in the future, which indicated that there are some specialties where telemedicine works very well, but within each specialty there are early adopters who have loved using this tool and want to do it more in the future. Then there are providers who are hesitant about telemedicine and want to go back to the in-person visits they were doing before the pandemic."
The survey data indicated that female clinicians and providers who had fewer than 15 years in clinical practice tended to want to do more telemedicine, Hughes says.
