For nine common maternal morbidities in 2019, medical costs were estimated at more than $18 billion and nonmedical costs were estimated at more than $13 billion.
In 2019, the estimated costs associated with maternal morbidity for U.S. births from conception through the child's firth birthday were $32.3 billion, a new study found.
The United States is experiencing a maternal health crisis. In 2019, the United States lagged other developed countries in maternal mortality ratio, with 20 maternal deaths per 100,000 live births.
The new study, which was published today by The Commonwealth Fund, examined the medical and nonmedical costs associated with nine maternal morbidities: amniotic fluid embolism, cardiac arrest, gestational diabetes mellitus, hemorrhage, hypertensive disorders, maternal mental health conditions, renal disease, sepsis, and venous thromboembolism.
Medical costs include treatment and hospitalization of mothers and their infants. Nonmedical costs include productivity loss and use of social services, such as the Supplemental Nutrition Assistance Program; Special Supplemental Nutrition Program for Women, Infants, and Children; Medicaid; and Temporary Assistance for Needy Families.
The research features several key data points for 2019 from conception to the child's fifth birthday.
Medical costs for the nine maternal morbidities were estimated at $18.723 billion
Nonmedical costs for the nine maternal morbidities were estimated at $13.576 billion.
Total costs for the nine maternal morbidities were estimated at $32.3 billion.
The costs associated with child outcomes were estimated at $24.0 billion.
The costs associated with maternal outcomes were estimated at $8.3 billion.
The healthcare system accounted for 58% of maternal morbidity costs.
Employers, public social services programs, and other nonmedical entities accounted for 42% of maternal morbidity costs, including losses in productivity ($6.6 billion) and costs linked to behavioral and developmental disorders in children ($6.5 billion).
In a prepared statement, the lead study author said maternal morbidity has a widespread impact on society.
"We show that the costs of maternal morbidity affect not only birthing people and their families but also all of us. Our findings highlight the need for more societal investments in maternal health, an area where the United States performs poorly in comparison to other developed nations, despite having the resources to prevent morbidity and mortality," said So O'Neil, a senior researcher and director at Mathematica.
Interpreting the data
The study's co-authors say that the costs associated with maternal morbidity are likely much higher than they have estimated.
"Our model estimated that nine common maternal morbidity conditions associated with births in a given year (2019) cost society $32.3 billion from the beginning of pregnancy through five years postpartum. The lack of comprehensive data for other conditions suggests that maternal morbidity has the potential to exact a much higher toll on society than what we have found, rivaling that of expensive chronic conditions like diabetes, whose costs run into the hundreds of billions of dollars," they wrote.
In addition, the availability of data also likely underestimates the costs associated with maternal morbidity in the study, the co-authors wrote.
"Of the costs documented, medical costs made up the majority (58%). This preponderance of medical costs is likely driven by the relative availability of hospital discharge data compared with other cost information. The focus of these costs on the delivery period also implies our estimates might further miss costs associated with later and longer-term physical and mental health consequences of maternal morbidity for birthing people and their children, including consequences for subsequent pregnancies," they wrote.
Nonmedical costs are also likely underestimated, the co-authors wrote.
"Nonmedical costs accounted for the other 42 percent of total costs, which mainly stemmed from maternal mental health conditions—the maternal morbidity for which we had the most complete information on outcomes and costs. While the literature contained fewer documented nonmedical costs for the eight remaining maternal conditions in this model, studies of other health conditions have found that nonmedical costs attributable to lost earnings, productivity loss, and other indirect costs can account for more than half of overall costs. Additional information on nonmedical costs related to maternal morbidity could raise our estimate of nonmedical and total costs," they wrote.
The co-authors conclude that addressing maternal morbidity must be a healthcare system priority. "The cost of maternal morbidity has significant implications for delivery system leaders and policymakers. System failures that result in today's severe maternal morbidity can result in tomorrow's maternal death, which makes preventing morbidity even more critical to addressing the U.S. maternal health crisis," they wrote.
The Mountain View, California-based health system helped develop one of the first electronic medical record systems.
As El Camino Health marks the health system's 60th year of operating in the Bay Area of California, the health system is celebrating its history of innovation.
Innovation has been a hallmark of the healthcare sector for more than a century. Innovation has driven advancements in a range of medical areas, including medical technology, surgical techniques, and patient experience.
It is critical for health systems and hospitals to be innovative, says Deb Muro, chief information officer at El Camino Health, which features two acute care hospitals.
"You are not going to be able to survive, thrive, and grow if you are not innovating. We all know that healthcare does not provide the best experience for patients—we know that we must innovate to get better. We have opportunities to do things better, and the only way to do that is to do things differently. Innovation is the way that we can make that happen," she says.
El Camino has a lengthy innovation track record:
In the late 1960s, El Camino Health collaborated with Lockheed Martin to develop a computerized physician order entry system. The system was implemented in the early 1970s and became the precursor to one of the first electronic health records.
El Camino Health participated in the development of MitraClip, a medical device that uses a catheter-based approach to repair the mitral valve in a beating heart. MitraClip has revolutionized therapy for mitral regurgitation and received Food and Drug Administration approval in 2013.
In 2014, El Camino Health was one of first hospitals in California to perform a new, minimally invasive aortic valve procedure using the Medtronic CoreValve System.
In 2019, El Camino Health's interventional pulmonology program was the first in the world to perform a robotic lung nodule biopsy commercially. Since then, El Camino's Ganesh Krishna, MD, has published findings showing that the use of robotic-assisted technology leads to more accurate diagnoses and more successful removal of hard-to-reach lung nodules.
In 2019, El Camino Health became the first hospital in California to perform bronchoscopic lung volume reduction, a minimally invasive procedure for severe chronic obstructive pulmonary disease.
One of El Camino Health's newest innovations gives patients the ability to communicate with the health system that they are on their way to the emergency department, Muro says.
"First of all, the patient can go on our website to see how long it will take for them to be seen in the ED. Then the patient, at that moment, can communicate that they are coming, along with a brief description of what is happening with them so we can be prepared when they arrive. We are in our infancy with this initiative, but there is so much that we can do with being able to be predictive. In other words, we do not only want to know what is going to be happening in this moment, we want to know what is going to happen in an hour, four hours, or 24 for hours in the future," she says.
'We have innovation in our DNA'
El Camino Health is committed to innovation as an organization, says CEO Dan Woods. "It is part of the culture of being in Silicon Valley. The people who live in this area have a mindset of new ideas and being innovative. So, innovation is fostered and nurtured within the community and the people who work at El Camino."
Innovation is deeply rooted at El Camino Health, Muro says. "We have innovation in our DNA. We love innovation. We take care of Google patients. We take care of Apple patients. We take care of high-tech industry patients. Innovation helps us to deliver great care and to differentiate us in the community."
There are several factors involved in promoting an innovative culture at health systems and hospitals, Woods and Muro say.
"You cannot be afraid to lead. Sometimes, hospital folks have a tendency to follow. You also need to heed the perspective of the consumer. We as healthcare leaders have a tendency to look at our problems through our own lens and through our own operations, as opposed to looking at our problems from the consumer perspective. You should not try to boil the ocean. Sometimes, hospitals and inventors feel they have to solve moon shots. You need to just try to move the dial one notch. That movement of one notch can start additional waves of innovation, like a pebble into a pond. In promoting innovation, you need to identify a problem or a friction," Woods says.
Fostering an innovative culture at a health system or hospital requires linking innovation to the goals of the organization and having a keen awareness of the market, Muro says.
"You need to place those goals front and center, then you need to determine how you can move the dial to achieve your goals. You need to think about doing things in different ways. Some of it is educating ourselves and going out into the market to see what opportunities are out there. We partner with startups. We partner with our technology vendors to see where they are going," she says.
Achieving innovation at a small health system or standalone hospital
When it comes to innovation, El Camino Health has several characteristics that have enabled the organization to succeed despite its relatively small size, Woods says.
"There is a high willingness to embrace change, which is related to accepting new ideas. There is a willingness to accept failure and to learn from failure. Finally, part of the reason I came to El Camino is because it is a smaller organization that is nimble. I wanted to use that nimbleness to our advantage. We can get things done much faster than larger organizations. We have tech companies that have come to us because we respond with a 'yes' or 'no' much faster than any of the large academic medical centers in California," he says.
Muro offered advice for other small health systems or standalone hospitals that want to aggressively pursue innovations.
"In a small organization, it is critical that you run the business well. Sometimes, the margins are tight, so you want to make sure that innovation helps financially, helps to drive growth, helps with quality, or helps improve the patient experience. If you can achieve those goals, it is an easier road," Muro says.
The study found that if all hospitals operated as efficiently as the most cost-efficient hospitals, the Medicare program would save $8 billion annually.
A new analysis by the Lown Institute lists the 10 most cost-efficient hospitals in the country.
Healthcare accounts for a significant share of the U.S. economy, according to statistics published by the Centers for Medicare & Medicaid Services. In 2019, national health expenditure grew 4.6% to $3.8 trillion, or $11,582 per American. In 2019, national health expenditure accounted for 17.7% of the country's gross domestic product.
The Lown Institute analyzed data from more than 3,000 hospitals. The study examined how much Medicare was billed and compared that figure to 30- and 90-day mortality rates.
For hospitals with average 30-day mortality rates, per-patient Medicare costs ranged from $9,000 to $27,000. The study found that if all hospitals operated as efficiently as the most cost-efficient hospitals, the Medicare program would save $8 billion annually.
The 10 most cost-efficient health systems and hospitals were as follows:
1. Pinnacle Hospital, Crown Point, Indiana
2. Saint Mary’s Regional Medical Center, Reno, Nevada
3. Mercy Medical Center Dubuque, Dubuque, Iowa
4. Encino Hospital Medical Center, Encino, California
5. Park Ridge Health, Hendersonville, North Carolina
6. Oroville Hospital, Oroville, California
7. Saint Michael’s Medical Center, Newark, New Jersey
8. UnityPoint Health-Meriter, Madison, Wisconsin
9. East Liverpool City Hospital, East Liverpool, Ohio
10. Maple Grove Hospital, Maple Grove, Minnesota
The study proves that hospitals can provide cost-efficient care with good outcomes, Vikas Saini, MD, president of the Lown Institute, said in a prepared statement. "If we want to keep costs low for the Medicare program and provide quality care for the 60 million Americans who depend on it, hospitals must be as efficient as possible. The best hospitals prove that you can save Medicare dollars and deliver great patient outcomes at the same time."
The study analyzed Medicare claims data for patients hospitalized from 2016 to 2018. Mortality rate and cost data was adjusted based on patient risk. Hospitals with the lowest mortality rates and lowest costs generated the best cost-efficiency scores.
Although clinician comfort with technology impacts the success rate of video visits, patient characteristics such as advanced patient age loom large.
Patient characteristics including older age and ethnicity are associated with the successful completion of video telemedicine visits, a new research article says.
Telemedicine visits have increased exponentially during the coronavirus pandemic. Challenges associated with access to telemedicine services such availability of broadband service for patients have raised concerns about equity.
The new research article, which was published by JAMA Network Open, examines the results of a quality improvement study of more than 130,000 scheduled video visits at an academic health system between March 1 and Dec. 31, 2020. Video visits were considered a success if the service was completed. Video visits were considered a failure if they were converted to a telephone visit.
The study generated several key data points.
90% of video visits were successful and 10% were converted to telephone visits
Lower clinician comfort with technology was associated with conversion to telephone visits (odds ratio 0.15)
Advanced patient age (66 to 80 years old) was associated with conversion to telephone visits (odds ratio 0.28)
Lower patient socioeconomic status including low access to high-speed Internet was associated with conversion to telephone visits (odds ratio 0.85)
Patient ethnic and racial minority status was associated with conversion to telephone visits (for Black and African American patients, the odds ratio was 0.75)
Relatively high patient income ($75,001 to $213,000) was associated with successful video visits (odds ratio 1.18)
Patient use of a tablet or laptop was associated with successful video visits (odds ratio 1.41)
"As policy makers consider expanding telehealth coverage and hospital systems focus on investments, consideration of patient support, equity, and friction [such as access to smartphones, computers, and quality Internet connections] should guide decisions. In particular, this quality improvement study suggests that underserved patients may become disproportionately vulnerable by cuts in coverage for telephone-based services," the research article's co-authors wrote.
Interpreting the data
Patient characteristics were the primary variable determining whether a video visit was successful or a failure, the research article's co-authors wrote.
"Clinicians were associated with some variability as a part of the equation, especially those working remotely, with poor network or with Wi-Fi network dropped connections, or those learning how to manage new equipment and workflows. However, this study showed that most of the variability in successful or failed video visits was associated with patient characteristics versus clinician characteristics, particularly regarding sociodemographic characteristics and age," they wrote.
Sociodemographic characteristics of patients such as Internet connectivity and technology literacy are essential to the success of a video visit, the co-authors wrote.
"Internet connection with sufficient bandwidth to facilitate a video visit is often a hurdle for various populations. One-fourth of rural households do not have access to broadband Internet; the digital divide is also present in urban communities, emphasizing the necessity of more inclusive Internet access. Video communication yields higher patient understanding and satisfaction compared with only telephone communication," they wrote.
Several factors may contribute to older patients converting video visits to telephone visits, and this group can benefit from telemedicine visits, the co-authors wrote.
"Older individuals may face more technology barriers, may have visual or movement disorders that make computing more difficult (especially on smaller devices), or may simply be more casual users of the Internet. Despite those assumptions, individuals who are older likely have a higher need for virtual care associated with transportation challenges to and from appointments or other impairments or chronic ailments that make leaving the house difficult," they wrote.
There is a learning curve that impacts the success or failure of video visits, the co-authors wrote.
"As patients and clinicians in the study population became more comfortable with technology, distinct learning curves were found in both user categories. The existence of a learning curve suggests that there are modifiable telemedicine program components, such as technical support or training, that may reduce video visit failures. Previous studies have shown that effective clinician training in telemedicine increases clinician confidence not only in using medical technology but in educating patients in how to have a successful video visit," they wrote.
The research article has important implications for policy makers and healthcare providers, the co-authors wrote.
"A future focus for policy makers should consider inclusion of telephonic services as a form of reimbursable telemedicine. Permanent expansion of low-cost or free broadband Internet for at-risk populations is also critical. For healthcare systems, it will be imperative to improve the ease of use of telemedicine as well as to provide support for patients to access such services," they wrote.
Jeff Ciaramita says being an effective chief physician executive starts with listening and being present.
The new chief physician executive of the Mercy health system's Mercy Clinic says it is essential in his new role to serve as an effective intermediary between clinicians and the health system.
Jeff Ciaramita, MD, was promoted to senior vice president and chief physician executive of Mercy Clinic in October. Mercy Clinic is a large medical group with more than 4,000 providers. The Mercy health system is based in Chesterfield, Missouri, and operates more than 40 hospitals in Arkansas, Kansas, Missouri, and Oklahoma.
Ciaramita first joined Mercy in 2008 as a noninvasive cardiologist and director of cardiovascular education. He served as section chief of cardiology at Mercy Clinic St. Louis for more than five years, then became president of Mercy Clinic South in 2017. In 2019, he became president of Mercy Clinic St. Louis.
HealthLeaders recently talked with Ciaramita about his new role. The following is a lightly edited transcript of that conversation.
HealthLeaders:How can a chief physician executive serve as an effective intermediary between clinicians and their health system?
Jeff Ciaramita: At the minimum, this is one of the most critical parts of my role.
Number One, a chief physician executive can serve as an intermediary by understanding what is going on at the local level. You need to be present and to ask the questions that need to be asked.
Secondly, it is also my role to understand the overall strategy of the ministry. Our primary strategy is to keep our patients at the center of everything. If our clinicians and their teams do not understand that underlying strategy, there is no way that they will be able to understand or accept the things that we need to do to evolve, or to get them the supports that they need to deliver care in their practices.
Lastly, from a strategy perspective within Mercy, most of our strategies to deliver superior clinical care come from our clinicians. So, it is very important for us to identify early on who can help guide us in the next generation of leadership and to look at ways to innovate and to transform healthcare. I need to find ways to collaboratively use my greater than 4,000 providers and their expertise to deliver care for the health system.
HL: What are the keys to success for a chief physician executive?
Ciaramita: First, it all starts with listening and being present. You need to listen to providers. You also need to understand the workforce, which includes physicians, advanced practice providers, and the staff who support them. You need to be willing to sit down and listen to what they have to say rather than tell them how healthcare should work.
Close behind is leading innovation. Healthcare has always been evolving and the rate of evolution today is probably faster than it has ever been, so you must be willing to fail. Part of innovation is failing along the way. In healthcare, physicians have been historically driven by evidence-based medicine and first do no harm. The training of physicians today completely goes against innovation and the willingness to fail.
HL: What are the primary elements of physician engagement at a large medical group?
Ciaramita: You must be present. COVID throws a wrench into that, but engagement is only possible when you are locally present and meet with the people who are responsible for delivering the care.
The second phase of engagement comes when you not only listen up front but also provide support. Listening will only get you so far—understanding how you need to support your physicians is important. You must follow up with support.
Lastly, with every large medical group, including Mercy Clinic, engagement comes down to the practice level. The Mercy health system likes to say we have one care model, and we have many operating and clinical standards that we know can deliver high quality care. But the reality is that engagement in a large medical group comes down to the relationships and collaboration with our practice managers. The focus is individual locations and making sure that despite a singular care model that they are still being heard and understood.
HL: How can a chief physician executive help to address provider burnout?
Ciaramita: Burnout is present unequivocally and unquestionably in physicians, advanced practice practitioners, and our other staff members. Until everybody in the health system acknowledges that, we will not be successful in addressing it.
I need to truly understand what leads to dissatisfaction from a provider's perspective. Burnout could be the result of working too many hours, but it could also be the result of ongoing non-employment issues, lack of support, or performing unwanted job duties. For example, a provider might think they went to medical school to operate on patients, but they spend a significant amount of their day writing notes and charting in the electronic health record, which they never wanted to do.
I need to understand the factors that lead to provider dissatisfaction, then find the tools that can minimize those distractions or sources of dissatisfaction. We will never find that out unless we address burnout individually with every single provider in our ministry.
HL: Are there examples of what you would like to do to address burnout as a chief physician executive?
Ciaramita: I would like to expand programs and minimize the stigma of burnout. I would also like to change the perception of the term burnout—we must realize that the possibility for burnout is going to exist for every single physician. Burnout is a universalizing term to say, "There are areas of my job as a care provider that I absolutely love, and there are other areas that I struggle with." I want to help find the tools for those areas that people struggle with or those areas that create dissatisfaction to allow providers to practice at the top of their license and be able to focus on areas that they enjoy.
I also want to encourage flexibility. In healthcare, taking care of the overall health of a community is not an 8 a.m. to 5 p.m. job. So, our approach to our providers might be creating opportunities for them to deliver healthcare in nontraditional manners and nontraditional hours. From a provider's standpoint, that creates another opportunity for us to be able to deliver care in ways that provide more joy and can address burnout individually.
Nine communities across the country received resources, coaching, and technical assistance from experts to test best methods to promote wellness and equity.
Nemours Children's Health has led an effort to develop a five-part toolkit to help community organizations advance health equity.
Health equity has emerged as a pressing issue in U.S. healthcare during the coronavirus pandemic. In particular, there have been COVID-19 health disparities for many racial and ethnic groups that have been at higher risk of getting sick and experienced relatively high mortality rates.
Jacksonville, Florida-based Nemours Children's Health worked with nine communities across the country to develop its five-part health equity toolkit. The communities were Bridgeport, Connecticut, Flathead County, Montana, Guilford County, North Carolina, Los Angeles, Paterson, New Jersey, Philadelphia, Sarasota, Florida, Ventura County, California, and Washington, DC.
1. Community organizations need to establish a common definition and understanding of equity.
Communities seeking to address equity must bring together multiple sectors such as healthcare, schools, and housing to achieve their goals, says Allison Gertel-Rosenberg, MS, vice president of national prevention and practice at Nemours Children's Health.
"When groups come together and agrees on a shared definition of equity, what they are really trying to get to is their North Star. It allows groups to coalesce better around strategy, around thinking who has the capacity and expertise to lead different components of an initiative, and around how the work and the leadership is going to spread across the groups. This way, all the groups can focus on what they do best; and, at the same time, they can focus on what they do best to get to the same goal," she says.
2. Community organizations need to heed the voices of real-world experts through governance and decision-making structures that solicit the perspectives of the community members whom the effort seeks to serve. Community members who participate in this process should be compensated for their expertise.
Enlisting community members to participate in equity efforts elevates the role of end users, Gertel-Rosenberg says. "If you think about other industries, a tech company would not develop a new phone without asking consumers what they wanted to do with the phone."
When communities create and design systems to tackle equity goals, initiatives should seize on the opportunity to ask community members what they want to happen, she says. "We can ask about what is not working. We can ask about what capacities and assets they have as a community that we can build on. Then we can take those answers and combine them with the expertise of people who do this work as their job to come up with the best strategies and best opportunities that will work in the community."
Community members should be compensated for their participation, Gertel-Rosenberg says. "Compensation is important. When we ask a community member who feels strongly about equity to take time away from their family or their job, we need to compensate them for their expertise."
3. Community organizations need to enact data-sharing and data-driven resource allocation to identify groups experiencing inequities as well as carry out community-led mitigation strategies.
She says data related to equity challenges is collected at several sources, including health systems, schools, social programs, and community organizations. "It would be great if we could take these data sets and combine them to start to draw a picture of what is happening in the communities that we are serving. The ability that data sharing presents to us is getting enough data to not only look at overarching data about a community but also start to disaggregate data to see where there are opportunities to address disparities and the inequities that are driving those disparities."
"For example, if we look at rates of food insecurity in a community, what the average looks like could be hiding significant disparities between different parts of the population that could be based on race, ethnicity, or geography. When we start to put that data together and disaggregate the data, we can look at solutions that target at-risk populations and start to raise them up," Gertel-Rosenberg says.
4. Community organizations should conduct "equity impact reviews" to assess the results and potential unintended consequences of current and proposed practices, policies, and strategies, which should be revised as needed.
Equity impact reviews are a tool in a community's equity toolbox, she says. "In the broadest way, equity impact reviews allow a community to break down what is happening with an initiative and what the intended or unintended consequences might be not only for the population as a whole but also for different parts of the population."
Equity impact reviews unify equity efforts, Gertel-Rosenberg says. "If we have communities that are using equity impact reviews, they are sharing data, they are ensuring the voice of the community is at the table, and they are having a shared language. By having equity impact reviews, communities can shape the best strategies that are going to address their shared goals."
5. Community organizations need to embed equity-promoting workflows into daily operations.
Embedding equity-promoting workflows into daily operations elevates equity efforts, she says.
"When we start to embed equity into our daily workflows, we ensure that we are talking about equity at every meeting. We ensure that we are asking questions about disaggregated data and the impact on different parts of the population at every meeting. We need to ask questions about equity and ensure that when we consider a new strategy or a new goal, we ask the same questions about the data, about how the community voices are integrated, and about the impact on different sub-populations. It is not enough to set a strategy or a goal and leave it."
About 90% of survey respondents report that regulatory burdens have increased over the past year.
The coronavirus pandemic has increased the regulatory burdens on medical practices, according to a new survey report from the Medical Group Management Association (MGMA).
Regulatory burden has been a top concern at medical practices for years. The "Annual Regulatory Burden Report" published this week by the MGMA highlights the pain points medical practices are feeling this year.
The survey report has responses from executives representing more than 400 group practices. More than 80% of the survey respondents work at independent practices.
The survey report features several key findings.
91% of survey respondents said the overall regulatory burden on their medical practice over the past year has increased
When asked which regulatory issue was very or extremely burdensome, the Top 3 issues were prior authorization (88% of survey respondents), COVID-19 workplace mandates (71%), and Medicare quality payment programs (71%)
92% of survey respondents said healthcare consolidation such as acquisitions of physician practices by health systems and hospitals is increasing
72% of survey respondents said consolidation is having a negative overall impact on the U.S. healthcare system
75% of survey respondents said regulatory requirements are a significant driver of healthcare consolidation
79% of survey respondents said the move toward value-based payments for Medicare and Medicaid patients has increased the regulatory burden on their practices
70% of survey respondents said the move toward value-based payments for Medicare and Medicaid patients has not improved the quality of care
70% of survey respondents said the move toward paying physicians based on value has not been successful so far
93% of survey respondents said the positive payment adjustments of Medicare's Merit-based Incentive Payment System (MIPS) do not cover the costs of time and resources spent preparing for and reporting under the program
80% of survey respondents said that Medicare does not offer an Advanced Alternative Payment Model that is clinically relevant to their practices
Interpreting the data
The pandemic has worsened the regulatory burdens on medical groups, says Anders Gilberg, MGA, senior vice president of government affairs at MGMA.
"Particularly early in the pandemic, it impacted the revenue of medical groups significantly. There was a drop of about 50% across the board in revenues in the early months of the pandemic. Revenue has bounced back but there was a shock to the system at medical groups. So early in the pandemic, it created a situation where the regulatory burden was still high, but practices were forced to furlough staff and lay off staff because they simply did not have patients coming in for visits. This put a strain on practices to keep up with regulatory burdens," he says.
This year, vaccine mandates have created new staffing shortages at medical groups, Gilberg says.
"There are still underlying staffing issues, but we are finding ramifications in 2021 from state mandates and vaccine mandates affecting practices. This is especially true in states where there is hesitancy about getting the coronavirus vaccine. Practices that are attempting to implement vaccine mandates are losing staff. On the administrative side, employees in some of the lower paying positions such as billing are making the choice to leave healthcare—they can find similar jobs outside of healthcare that do not have vaccine mandates. In addition, there is a large percentage of nurses who have been reluctant to get vaccinated, so practices have been losing staff on the clinical side as well."
The latest wave of staffing shortages is heightening regulatory burdens, he says.
"When you do not have administrative staff or clinical staff to process bills or to take care of patients, we are hearing frustration about the growing regulatory burden coupled with not having enough staff members to report quality measures, which practices do not feel are relevant. There are not enough staff members to sit on the phone with payers to administer prior authorizations. There is a confluence of events where the regulatory burden continues to grow, while the resources that medical groups have are shrinking. That is putting an incredible strain on medical groups."
Prior authorization is the most costly and time consuming regulatory burden at medical practices, Gilberg says. "When practices do not have the clinical staff to administer prior authorizations or when physicians are pulled out of direct patient care to authorize care, it creates significant strain on the practice in terms of time, resources, and finances. When you cannot be productive as a physician because you are on the phone with payers, it stresses a practice."
Many prior authorizations are unnecessary burdens, he says. "There are many services that require prior authorizations that are routinely approved, yet you still must jump through the hoops to get these services approved. That creates an unnecessary burden. There are also medical groups that are in value-based payment arrangements, where they are held accountable for cost and quality. In those arrangements, practices are already doing what they can to address the underlying issues that prior authorization also seeks to address."
Regulatory burdens are a significant factor in healthcare consolidation such as the acquisition of medical groups by health systems, hospitals, and other larger organizations, Gilberg says. "Especially in an environment where we have had a shock from the pandemic, which has affected the finances of independent practices as well as the staffing of independent practices, medical practices do not have the finances or the staffing to deal with growing regulatory burdens. As a result, the physicians who own independent practices think about getting someone else to deal with the regulatory burden."
Many medical groups feel trapped in the MIPS program, he says. "MIPS is a quality reporting program that was largely meant to be a bridge as Medicare and the Center for Medicare and Medicaid Innovation created new opportunities for physician to avail themselves of Alternative Payment Models. What we have seen is that many practices are stuck in the MIPS program. In our new survey report, most practices do not find that many of the Alternative Payment Models that are in the Medicare program are clinically relevant to their practices."
More Alternative Payment Models should be launched, Gilberg says. "We are looking for more Alternative Payment Models so we can move more practices out of the MIPS program. We need more Alternative Payment Models so we can create a win-win for value-based care. Many of our practices are optimistic about value-based care, and they would be interested in participating if there were programs that could help them both financially and clinically. But many practices do not have that opportunity. That's why the MIPS program rises to the top of our regulatory burden survey."
Spectrum Health had well-being initiatives in place before the coronavirus pandemic and has launched more efforts during the pandemic.
Grand Rapids, Michigan-based Spectrum Health is one of 44 healthcare organizations nationwide to be recognized by the American Medical Association's Joy in Medicine Health System Recognition Program.
Healthcare worker burnout and well-being have been top concerns during the coronavirus pandemic. The Joy in Medicine Health System Recognition Program is designed to recognize health systems that are committed to improving physician satisfaction and decreasing burnout.
Spectrum Health has had a longstanding commitment to healthcare worker well-being, says Kristin Jacob, MD, medical director of the health system's Office of Physician and APP Fulfillment.
"Even before the pandemic, Spectrum Health was committed to focusing on work-related stress and reduction of burnout. The health system promoted a call to action to improve the well-being of our frontline caregivers, and part of that call to action is submitting an organizational commitment statement to the National Academy of Medicine, which states our dedication to reducing clinician burnout and improving well-being," she says.
The Joy in Medicine Health System Recognition Program provides accountability for well-being efforts at Spectrum Health, Jacob says. "We are continuing to collaborate with other organizations across the country that are doing work to reduce burnout and sharing best practices. The AMA Joy in Medicine Health System Recognition Program provides another layer of accountability for our organization to focus on measuring well-being, building leadership development, promoting teamwork, and measuring work done outside of working hours, which is a huge driver of burnout."
Addressing burnout and wellbeing
At Spectrum Health, the Office of Physician and APP Fulfillment was established in 2019 to initially focus on physicians and advance practice providers. "The reason for targeting this population first was twofold. First, we know that our physicians and APPs are at the highest risk for burnout, suicidal ideation, and a negative impact on patient care due to these factors. Second, we recognized that we needed to start somewhere," Jacob says.
Spectrum Health has been measuring well-being with a validated tool for several years, she says. "We use the Mayo Clinic Well-Being Index to measure the wellbeing of our physicians and APPs. This is crucial to be able to understand where we are and to create reports based on factors such as specialty, gender, age, and ethnicity to develop targeted interventions."
The pandemic has been taking a toll on healthcare workers at Spectrum Health, she says.
"We have seen a significant increase in the distress of our physicians and APPs over the past year as measured by our validated tool and our engagement surveys. We have seen similar increases in distress among our nurses and other team members. This aligns with the trends we are seeing across the country and puts data behind the toll that the pandemic has taken on us. When we think about the drivers of this distress, we are grappling with extreme staffing shortages that are leading to extraordinary workloads. Michigan is also experiencing, arguably, our worst COVID-19 surge, where most of the rest of the country has been turning the corner."
The Office of Physician and APP Fulfillment launched a well-being program called Med+Up before the pandemic, Jacob says. "Med+Up gathers small groups of physicians and APPs together to have monthly facilitated discussions about meaning in work. These gatherings are intended to be a relaxed setting outside of work to facilitate discussions. This is a best practice that has data behind it showing improvement in meaning in work and reduction of burnout. There are about 100 physicians and APPs who are participating in this program."
Spectrum Health also has employee benefit programs that are designed to boost well-being and reduce burnout, Jacob says.
"From a benefits standpoint, we have a robust healthy lifestyles program that promotes a healthy lifestyle, emotional health, and mental health. The healthy lifestyles program has a strong relationship with our employee assistance program, which can provide in-the-moment support as well as appointments. The employee assistance program is a vital component in supporting our team members. An additional benefit is we partner with Headspace, which is a mindfulness app with data behind it for reducing stress. Headspace was established as a benefit in early 2020 for all Spectrum Health employees."
The health system is committed to suicide prevention among patients and healthcare workers, she says. "We have a zero-suicide initiative that is for our patients, but we also have strong education and processes for team member suicide prevention. We have continued to improve education, awareness, and training around those efforts."
Spectrum Health has launched several initiatives during the pandemic to address healthcare worker well-being and burnout, Jacob says.
"First and foremost, during the pandemic, we have been addressing the basic needs of our workforce. Early in the pandemic, this effort included securing personal protective equipment. We have provided additional benefits to support backup childcare, compassionate paid time off, and support for unexpected time off. There have also been generous wage increases. With the support of many leaders, we have initiated widespread delivery of meals, snacks, water, and free coffee through our nutrition services. We also have wellbeing navigators who are rounding to check on people, see what they need, and connect them with resources. We have placed wellness carts in 150 of our highest acuity spaces that include wellness-related items and tangible resources," she says.
During a COVID-19 patient surge last November and December, Spectrum Health enlisted volunteers to pack more than 3,000 COVID support snack boxes that were delivered throughout the health system's clinical care units, Jacob says. "That effort has evolved, and we are doing targeted funding for our leaders so that they can support the basic needs of their teams and other creative ways to deliver meals to make sure that staff members can eat on their busy shifts."
The health system has been focusing on emotional support during the pandemic, she says. "We have had an extensive rollout of many support groups that we have launched for our caretakers over the past year. We also have had a lot of resources and education around psychological safety and secondary trauma. We recently launched a peer support program, which offers one-on-one peer support for colleagues to process difficult events and chronic stress as well as connect team members to resources."
Resources related to well-being at the health system include the employee assistance program as well as a critical incident stress management team and spiritual care team, Jacob says. "We also partner with Priority Health, which has a platform called myStrength that offers content related to mental health support online. Priority Health also provides access to a phone line so that staff members can seek mental health support outside of the employee assistance program."
Hopeful for the future
Despite the challenges posed by the pandemic, Jacob says she has a positive view about healthcare worker well-being. "The long-term prospects are optimistic. There are silver linings of the pandemic, including the way that the pandemic has brought attention and urgency about mental health awareness. In addition, the pandemic has brought attention and urgency to holistically care for the caregivers of our patients."
The pandemic could be a turning point in efforts to boost healthcare worker well-being, she says. "This may just be the pressure that we need to realign our values in healthcare and realize that human capital is our most crucial resource. There is still much work to do, but I am encouraged by our local leaders and their authentic desire to care for our team members. The conversation that is occurring at the national level is also encouraging—it is putting pressure at a high level to think about what regulatory agencies are doing to put standards of care in place that protect healthcare workers."
Clinical decision support tools help clinicians to have up-to-date information about medical conditions.
An effective clinical decision support tool is available at the point of care, is as current as possible, and is accurate, a chief medical information officer says.
Medical knowledge advances rapidly, with a plethora of new studies published daily. Clinical decision support tools can help clinicians stay up to date with the constant changes of information about diagnoses and treatments.
A good clinical decision support tool has three primary characteristics, says Jon Michael Vore, DO, chief medical information officer Southern New Hampshire Health. The Nashua, New Hampshire-based health system features a medical center and a network of more than 400 clinicians.
First, a clinical decision support tool must be easily accessible to clinicians at the point of care, he says. "You want clinical decision support at the point of care when you are taking care of a patient. If you are going to have a clinical decision support tool, it needs to be at your fingertips. If you have to go into a completely separate system or leave the room, it detracts from being able to use a tool. A clinical decision support tool should be directly integrated into your workflow."
Second, a clinical decision support tool must be as current as possible, Vore says. "A good clinical decision support tool should be up to date and peer reviewed. If you are sharing information with a patient, you want to make sure that you have the most up-to-date recommendations in regards to whatever you are talking about."
Third, a clinical decision support tool must be accurate, he says. "A good clinical decision support tool is trustworthy. You need to be able to trust the information that the tool is providing. These days, patients are doing their homework and they are checking up on you. When they leave the office, they are not absolutely assuming that the provider has given them 100% correct information. Many times, they are going home and following up and doing their own review and seeing if the information their clinician has provided is accurate."
Clinical decision support tool in practice
Southern New Hampshire Health has clinical decision support in the health system's electronic medical record as well as Wolters Kluwer's UpToDate clinical decision support tool.
"We have the Epic electronic medical record system. There are a lot of clinical decision support tools in Epic, where you get best practice advisories. You get medication and allergy interactions as well," Vore says.
At the health system, UpToDate is integrated into Epic, he says. "As we are doing our documentation or seeing patients, we have a hyperlink directly in Epic that will automatically log a provider into UpToDate and allow them to do a search for medical conditions. This allows providers to have a clinical decision support tool at their fingertips. Providers do not need to go to another Web browser or type in a URL. Having UpToDate integrated into our electronic medical record makes it quick and easy for clinicians to access information they need to verify their treatment or even review information with the patient in the exam room."
Using clinical decision support tools to address misinformation
A good clinical decision support tool can help clinicians to educate misinformed patients, Vore says. "If you know you have a trustworthy source of information that has the most up-to-date recommendations and the most up-to-date information from studies, that arms clinicians to have sometimes difficult conversations with patients. These days, patients will go to the Internet, go to blog sites, and go to social media such as Facebook. They often do not go to the most evidence-based resources to look for information."
A good clinical decision support tool will approach areas where there is information that needs to be debunked, he says. "Many times, these tools will present information in a way that can be easily transferred to the patients. That may or may not change the outcome with the patient, but the best that clinicians can do is provide them with the most up-to-date information and recommendations to help them move in an appropriate direction for their overall health."
Administrative spending accounts for about a quarter of total U.S. healthcare spending, report says.
Three kinds of interventions could reduce administrative spending in healthcare by $265 billion annually, a new report says.
According to the new report, which was published this week by McKinsey & Company, total U.S. healthcare spending in 2019 was $3.8 trillion, with administrative spending pegged at $950 billion. "The goal is not to reduce administrative spending to zero but rather to gain the highest value for each administrative dollar spent without sacrificing quality or access," the report says.
More than a quarter of administrative spending could be eliminated through three kinds of interventions, the report says.
"Within" interventions are cost-cutting measures that can be made by individual organizations. Within interventions could achieve about $175 billion in annual savings, which represents about 18% of total administrative spending. Examples of within interventions include automation of repetitive back-office work such as human resources and finance.
"Between" interventions are cost-cutting measures that can be made through agreement and collaboration between organizations. Between interventions could achieve about $35 billion in annual savings, which represents about 4% of total administrative spending. Examples of between interventions include creating payer-provider communications platforms that provide unified messaging to patients.
"Seismic" interventions are cost-cutting measures that can be made with broad and structural agreements and changes throughout the U.S. healthcare system. Seismic interventions could achieve about $105 billion in annual savings, which represents about 11% of total administrative spending. Seismic interventions such as new technology platforms and changes in payment design are often based on partnerships between the public and private sectors to coordinate incentives for change.
"Many seismic interventions address the same sources of spending as the within and between ones but take the savings a step further. Accounting for this overlap, we estimate total savings across all three types of interventions at about $265 billion, or 28% of total administrative spending," the report says.
Some organizations have already achieved cost-cutting through within and between interventions, the report says. The keys to success in these efforts include four factors, the report says: "prioritizing administrative simplification as a strategic initiative; committing to transformational change versus incremental steps; engaging the broader partnership ecosystem on the right capabilities and investments; and disproportionally allocating resources, such as capital and talent, to the underlying drivers of productivity."
Seismic interventions are more challenging to achieve than within and between interventions because they are opportunities for change related to a lack of motivation to innovate at the organizational level, the report says. Three stakeholders can drive seismic interventions, the report says.
"Government could set the framework in which other organizations operate. Federal and state bodies can set guardrails for payers, hospitals, and physician groups."
"Investors can prove ideas with pilots. They might create public-private partnerships to test interventions within a state and then scale up success stories nationally."
"Third parties, such as foundations and bipartisan groups, can conduct objective fact gathering and analyses. An arbiter of facts can galvanize action."
The conditions are ripe to tackle administrative spending, co-authors of the report wrote in article published by the Journal of the American Medical Association.
"Economic downturn often leads to health system change. With COVID-19 creating enormous disruption to the healthcare system, a known opportunity to capture more than a quarter-trillion dollars in the next few years without compromising the U.S. healthcare system’s ability to deliver care could be quite attractive. The sooner healthcare administration is simplified, the easier it will be for all to engage the U.S. health care system," the wrote.