Experts from Duke University School of Law and Stanford University say physician unions can empower clinicians employed at health systems, hospitals, and other corporate entities.
Given consolidation in healthcare such as health systems acquiring independent physician practices, physicians are missing an opportunity to form unions to improve their status, a new opinion article in the Journal of the American Medical Association says.
Over the past decade, the percentage of independent practicing physicians has declined sharply. In 2012, physicians owned 60% of practices and 5.6% of physicians were employed directly by hospitals, the American Medical Association reported. In 2022, 52.1% of physicians were employed by health systems or hospitals, with another 21.8% employed by other corporate entities, for a total estimate of 74% of practicing physicians working as employees.
The healthcare consolidation trend can have a negative impact on physicians, the co-authors of the new opinion article wrote. "This rapid transformation has largely followed an aggressive strategy, put forward by hospital and corporate leadership, that seeks scale and exploits market power. However, it is also a strategy that is increasingly at odds with the interests of the physicians working in these organizations. The strategic differences are revealed in a variety of important policy differences, spanning from payer contracting strategies, compensation incentive structures, and service line prioritization."
While physician unions have been formed for decades, there are relatively few unionized physicians compared to employees in other industries. As of 2021, 7.9% of surgeons and 5.8% of other physicians had joined unions, according to Unionstats.com.
Physicians considering the formation of unions should have three primary considerations, the co-authors wrote.
1. Value of collective bargaining versus contracting individually for services: "If collective bargaining is seen as advantageous, physicians need to determine who the union represents: all physicians within a system or only those at a specific hospital? All physicians across specialties or only specific departments? This latter concern reflects the potential challenge when different clinicians have different compensation and governance interests within a single organization," the co-authors wrote.
2. Value of collective bargaining for salary: "For example, primary care physicians and specialist physicians may decide to join the same union and participate in joint negotiation with the hospital in a fee-for-service payment model, but they might prefer different unions when the financial interests of primary care physicians and specialist physicians diverge under a capitated payment model (this diversity of interest is reflected when nurses and other clinical staff join different unions or different bargaining units under the same union)," the co-authors wrote.
3. Value of unionization to shape hospital policies: "Collective bargaining can help address strategic issues that are of great interest to employees, such as in 2022 when nurses at Sutter Health went on strike over staffing shortages and access to adequate personal protective equipment. Policies related to the practice of medicine may benefit from explicit consideration through collective bargaining. Physicians and hospital managers might disagree over patient discharge policies, documentation standards, quality improvement programs, and requirements for after-visit services," the co-authors wrote.
Physician unions have limitations, the co-authors wrote. "They may not provide as much leverage for input into strategy as physician-led organizational structures such as physician-owned practices or other professional corporation models. For example, Kaiser Permanente Medical Groups are independent regional entities that negotiate with Kaiser health plans and hospitals. Further, unions are likely to expose differences in perspectives and incentives between rank and file physicians and their leaders (such as department chairs). This divergence of interests might further complicate the advocacy of physician interests into governance."
In addition, physician unions are unlikely to undo negative consequences of healthcare consolidation, the co-authors wrote. "Physician unions will be unable to convert the capital-intensive nature of health care systems into a meaningfully different economic enterprise. Those who question the sustainability and wisdom of these US healthcare giants are unlikely to find that unions can be used to curtail the deleterious effects of healthcare consolidation."
Novant Health physicians play formal supply chain roles in reducing clinical variation and managing the adoption of new products.
Physicians play formal and informal roles in supply chain at Winston-Salem, North Carolina-based Novant Health.
Formal supply chain roles for physicians include serving on value analysis teams and participating in quality assurance processes. Informal supply chain roles for physicians include alerting supply chain departments when products go out of stock and when there are problems with products.
At Novant, physicians serve on a pair of formal supply chain groups, says John Mann, MD, senior vice president of Novant Health Institutes, and president and chief operating officer of Novant Health Clemmons Medical Center in Clemmons, North Carolina.
"We have a Clinical Variation Reduction Team. The CVRT was established in 2012. That is a group that includes the supply chain team combined with physicians who represent most of our institutes—the clinical delivery side of the organization including some of our chief clinical officers. Together, we partner with the sourcing team around recurring contracts for products that we use in our acute facilities. That spans a wide variety of specialties, including orthopedics, vascular, cardiac, neurology—any specialty that uses a product in our hospitals can be involved in clinical variation," he says.
The physicians who serve on the CVRT provide clinical input and clinical guidance that is useful in negotiations with vendors, Mann says. "We have found that this relationship brings more power to the conversation. Historically, vendors have used physician relationships to influence hospital administration. We have turned the tables on them. Our sourcing team partners with physicians and they go to the vendor and say, 'This is what the physicians want for their patients. This is what we need for Novant Health.' We have turned the dynamic around, so the vendors cannot undermine the efforts of the health system to drive value and savings for our patients."
The health system also has a formal supply chain group that includes physicians to manage the adoption of new products, he says. "If a physician wants a new product, whether it is clinically better, drives better outcomes, or drives a competitive advantage, those decisions are done in collaboration between physicians and the sourcing team, so we are driving the conversation with the vendors. Having doctors involved ensures that we keep the patient front-and-center in all of our conversations, and it disarms the vendors. When vendors approach our sourcing team, they may say, 'A doctor wants this product.' But we are going to make that decision ourselves and draw value to the health system and our patients."
Physicians participate in supply chain beyond formal roles
Building relationships between the supply chain staff and physicians has educated the sourcing team, says Mark Welch, MHA, senior vice president of supply chain at Novant.
"The relationship between the supply chain team and physicians has evolved over the years. When we first started out, we focused on clinical variation to understand why we had clinical variation. What we found out was that having a relationship between supply chain and physicians to talk about those things has been more valuable than just addressing variation. Physicians have a scientific background, and most of them love to teach—they have taught my sourcing team many things about different procedures that we probably would have never known if we had not built a relationship," he says.
Both new physicians and physician leaders play informal roles in Novant's supply chain, Welch says. "When we recruit new physicians, part of the recruiting process is our physician leaders talk about supply chain and how we approach supply chain along with expectations for physicians to participate. At our institutes and service lines such as neurology, orthopedics, vascular, and surgical services, the leaders are involved in sourcing from Day 1 when they come onboard. We get them up to speed on where our contracts are, listen to any concerns they might have, and many times they bring a different perspective."
Novant physicians are often engaged to influence supply chain decisions, Mann says. "If we have a product that is in a three-year cycle and is coming up for renewal, we will engage with many physicians to gain their input. We want to know their experience with the product over the past three years. We may need to look at a change. It can be challenging to engage with dozens of physicians across the organization, but we have found that investment of time gives us a better result at the end of the process."
Certain qualities help physicians play formal or informal roles in supply chain, Welch says. "They must have curiosity. They need to be innovative. They need to be somebody who wants to learn the business side of healthcare. Physicians are curious about a lot of things, and as they get deeper into their careers, they get interested in where the money is going and where the money is coming from. Healthcare is complicated, but most physicians are intrigued by how it works."
The patient safety group has set two categories for its recommended practices— Organizational Leadership & Systems and the Diagnostic Process.
The Leapfrog Group has published a unique report with 29 recommended practices for hospitals to reduce diagnostic errors.
Diagnostic errors are one of the most common adverse events in U.S. hospitals. One study estimated that 249,900 harmful diagnostic errors occur annually in hospitals.
In 2021, Leapfrog convened a National Advisory Group of medical experts to evaluate diagnostic practices in hospitals and to develop the first-of-its-kind report to improve diagnostic safety—Recognizing Excellence in Diagnosis: Recommended Practices for Hospitals.
"Clinicians and hospital leaders tell us they know diagnostic errors are harming too many patients, but they are less clear on how to fix the problem," Leah Binder, Leapfrog's president and CEO, said in a prepared statement. "Thanks to the incredible leadership of the multi-stakeholder group Leapfrog has convened, hospitals now have clarity on the steps to take. The faster hospitals act, the more lives they can save."
Leapfrog, which is a nonprofit organization founded in 2000 to promote patient safety, identified 300 potential practices that hospitals could adopt to reduce diagnostic errors. The potential practices were pared down to a list of 29 recommended practices in two categories— Organizational Leadership & Systems and the Diagnostic Process. There are 16 recommendations in the Organizational Leadership & Systems category and 13 recommendations in the Diagnostic Process category.
"It is recommended that hospitals start by identifying a small set of practices that are most feasible and/or most impactful for them and begin there. Additional practices can be added to the initial set as time goes on," the Leapfrog report says.
The 13 recommendations in the Diagnostic Process category are as follows.
Train all staff members involved in the diagnostic process to collect accurate health information. Using evidence-based tools and strategies to collect health information from patients and family caregivers promotes timely and accurate diagnosis.
Hospitals should correct inaccurate diagnoses and data in the electronic health record. For example, the EHR should have a process to review and correct inaccurate diagnoses on "problem lists."
Hospitals should provide professional medical interpreters when patients and family caregivers have a preferred language that differs from their care team's language. These medical interpreters, who should be available 24/7, should help get accurate health information from the patient and communicate accurate information back to the patient.
Hospitals should provide access to radiology experts 24/7 to read and interpret urgent imaging studies as well as to consult on imaging test selection.
On at least a quarterly basis, hospitals should have a process for radiologists and pathologists to identify and review cases where a biopsy, cytology, or autopsy result does not match clinical and imaging impressions. There should be an interdisciplinary process to reconcile these discrepancies.
Hospitals should ensure that emergency departments have access to clinical expertise and technologies that support timely and accurate diagnosis of conditions that are often misdiagnosed and result in harm to patients.
Hospitals should provide knowledge resources to clinicians to help them improve their diagnoses when there is diagnostic uncertainty. Clinicians should be incentivized to use these resources.
Hospitals should train clinicians to recognize and minimize cognitive errors. For example, diagnostic performance can be improved through training on critical thinking as well as recognizing cognitive and affective bias.
Hospitals should implement and monitor adherence to evidence-based diagnostic guidelines such as guidelines for care in the emergency department.
Hospitals should have written policies for managing patient handoffs when there is diagnostic uncertainty such as transferring patients from the emergency department to an inpatient unit.
There should be a policy when patients are discharged from a hospital with an uncertain diagnosis or when potential diagnoses involve high-risk conditions. Discharge summary notes should include test results and test results that are pending. The patient and family caregivers should be given condition-specific instructions on troubling symptoms, when to return to the hospital, and how to get follow-up care.
If a patient is discharged with pending test results, hospitals should have a process in place to list the pending test results along with instructions on how to obtain the pending test results.
Hospitals should have a written policy to promote "closed-loop" communications. The policy should specify that test results and pending test results will be viewed by care team members and communicated to the patient in a timely manner.
Offering more behavioral health services in primary care practices would help address lack of access to care.
Eight of the country's leading physician organizations recently issued a call-to-action urging support for primary care practices to integrate behavioral health services into their operations.
The country is arguably experiencing a behavioral health crisis. There is a nationwide shortage of psychiatrists. In 2019, about 50 million Americans experienced a mental illness, but more than half of U.S. adults with mental illness do not receive treatment, according to Mental Health America (MHA). The coronavirus pandemic has exacerbated behavioral health problems, according to data from the MHA Online Screening Program. From January to September 2020, there was a 62% increase in people who took a depression screen compared to 2019 depression screening.
The eight physician organizations that made the behavioral health integration call-to-action are members of the Behavioral Health Integration Collaborative: the American Academy of Child and Adolescent Psychiatry, American Academy of Family Physicians, American Academy of Pediatrics, American College of Obstetricians and Gynecologists, American College of Physicians, American Medical Association, American Osteopathic Association, and American Psychiatric Association.
HealthLeaders recently talked with a co-author of the call-to-action, Gerald Harmon, MD, immediate past president of the American Medical Association and a practicing family medicine physician based in South Carolina. Harmon was asked to comment on the call-to-action's five solutions to accelerate widespread adoption of behavioral health integration by primary care practices. The following transcript of that conversation has been edited for brevity and clarity.
HealthLeaders: How can payers expand coverage and fair payment for all stakeholders utilizing behavioral health integration models?
Gerald Harmon: The reason we do not have established resources for behavioral health integration is we have not had coverage or compensation to invest in the resources. Primary care practices want to be able to invest in technology and employ nonphysician providers, consultants, social workers, and case managers to help take care of the behavioral health needs of our patients.
It is critical for payers to expand coverage and give us fair payment, so we can invest in behavioral health. I need the resources and cash flow, so I can spend the time addressing behavioral health issues and keep my doors open.
We have a law—the Mental Health Parity and Addiction Equity Act of 2008—but many payers do not appear to be complying with this parity law. They need to cover mental health and substance use disorders like they cover physical and surgical benefits. This is medical care—it may not be for physical services such as endoscopy but addressing behavioral health conditions saves money in the long run and gives help to patients who need it.
HL: What are the primary considerations for evaluating how and when to apply cost-sharing for integrated services?
Harmon: I understand that cost-sharing and patient responsibility for certain services may be beneficial to the system. Otherwise, folks might just say it is convenient for them to go to the emergency department and consume the highest-cost resource because that is where they could find it available. Cost-sharing such as deductibles can be efficient governors on unnecessary medical expenses; but if you have deterrents such as high deductibles or co-pays for behavioral health services, you can create disparities. If you have high rates of cost-sharing, economically disadvantaged patients can be deterred from having timely access to services. The more people with behavioral health issues put off access to treatment, diagnosis, and care, the worse their morbidity and overall physical health will be, which can cost the system and the patients more.
We need to make behavioral health services as accessible as possible. Often, people seeking mental health care need it urgently. We need to catch these conditions early before they become a more complicated and expensive process for the patient and the system.
HL: What kinds of provider training and technical support can support primary care practices seeking to adopt behavioral health integration?
Harmon: The reason I have had a lot of on-the-job learning about behavioral health in four decades of family medicine practice is I did not have a lot of formal training. I was family medicine certified, which means I understood the wellness concerns about anxiety disorder, depression, and other behavioral health issues—but I was not a psychiatrist or a behavioral health specialist. If I am going to integrate behavioral health into my practice, I am going to need some support. I need to be trained on best practices.
I need to know the best approaches and staffing models. I need to maintain relationships with other community partners such as the Mental Health Commission and clinics in my area where we have intermittently staffed psychiatrists. We need training beyond on-the-job training to effectively integrate behavioral health into our practices at the best cost and with the best fiscal model.
We also need to fix Medicare reimbursement for physicians to support technological investments. If I am going to use telehealth to gain access to a psychiatrist to help me make a diagnosis and manage medications because I don't have a psychiatrist in the local community, then I am going to have to invest in technology, and that is not cheap. To have adequate technician support, I need to know that my Medicare physician payment is adequate to be able to make an investment in my physician practice.
HL: Why is it important to minimize or eliminate utilization management for behavioral health integration services?
Harmon: An example is prior authorization, which is a barrier to patient care and an impediment to physician satisfaction. We have prior authorization for medications and all manner of referrals including behavioral health specialists.
Narrow networks are also a concern. For many patients, there may not be a behavioral health specialist in network for more than an hour drive.
It is important to eliminate utilization management barriers such as prior authorization for behavioral health for the same reason as not having access to behavioral health specialists. If you put in a barrier for me to gain access to the limited number of specialists I have in a narrow network, that is a recipe for disaster and an impediment to patient safety.
All of us as a society are going to pay a price when we don't address behavioral health issues. We are in the midst of a crisis with substance use disorder and opioid deaths. We need to minimize or eliminate any barriers to this kind of care.
HL: Why is it important to launch whole-person, employer-based behavioral health programs that destigmatize behavioral health?
Harmon: If we can get some employer-based treatment and employer-based diagnosis such as a social worker or especially trained nonphysician provider, we can get people care before they are unable to work or are taken out of the workplace for an extended period. We need to get people support as soon as they notice degradation in their behavior or their performance. If an employee is over-stressed and worried about their family or all manner of things, they need to be able to seek help without stigma.
There can be stigma with substance use disorder, depression, anxiety, or feelings of self-worth. We should not label patients and have them be unable to work because of stigma. We need to avoid patients getting a permanent bias against them.
We need to make whole-person diagnoses. A holistic-medicine approach does not mean just taking vitamins, eating well, and meditating. We need to recognize that your behavioral health state does have an impact on your physiological response. If you get a burst of adrenaline, you can get a burst of catecholamines and burst of chemicals from your midbrain, which can depress you, agitate you, increase your heart rate, raise your blood pressure, affect your cognitive ability—all of these things become a physical reality.
You would not be embarrassed to seek help if you had blood pressure trouble, or you were having chronic headaches. So, if you have concerns about your emotional health, you should not be deterred from seeking that care, and we as healthcare providers should not label patients with mental health issues with any kind of disparaging comments.
The patients featured in a new research article underwent Rous-en-Y gastric bypass or sleeve gastrectomy—two of the most common kinds of bariatric surgery.
Compared to the general U.S. population, adults who are not married and get weight-loss surgery are more than twice as likely to get married within five years, and adults who are married and get bariatric surgery are more than twice as likely to get divorced, a new research article found.
The primary motivations for bariatric surgery are weight loss and decreasing the risk of potentially deadly weight-related conditions such as heart disease, stroke, and high blood pressure, according to Mayo Clinic. However, preoperative patients have also reported having bariatric surgery for reasons related to romantic relationships such as improving intimacy and finding a life partner.
"Weight loss is generally the goal of bariatric surgery, but people have a variety of motivators for wanting to lose weight—for example, remission of Type 2 diabetes and improvement in joint pain," the lead author of the new research article, Wendy King, PhD, said in a prepared statement. "Patients have also described the desire for romantic partnership or improving relationships as important motivators. Before this study, we had no quantitative data in the U.S. on how marital status changes after bariatric surgery—are patients more likely to get married, divorced, find romantic stability?"
King is an associate professor in the Department of Epidemiology at the University of Pittsburgh Graduate School of Public Health.
The new research article, which was published by Annals of Surgery Open, is based on data collected from more than 1,400 U.S. adults who were enrolled in the National Institutes Health-funded Longitudinal Assessment of Bariatric Surgery-2 (LABS-2) study. The patients examined in the new research article underwent Rous-en-Y gastric bypass or sleeve gastrectomy—two of the most common kinds of bariatric surgery—from 2006 to 2009.
The new research article features several key data points.
The relationship status of most of the LABS-2 participants did not change in the five years they were followed after surgery, with 81% of married participants staying married and 70% of always-single participants staying single.
However, 18% of unmarried LABS-2 participants got married, compared to 7% of the general U.S. population during the same five-year time period; and 8% of the married participants got divorced, compared to 4% of the general U.S. population.
Cohabitating or being separated versus always single, younger age, having a college degree versus a high school education, lower body mass index, and lower Beck Depression Inventory score before surgery were associated with an increased likelihood of marriage after surgery.
Among LABS-2 participants who were not married before surgery, two of 16 pre- to postoperative changes evaluated in the new research article were associated with being married after surgery: improvement in physical health and an increase versus no change in household income.
Female sex, younger age, household income under $25,000 versus greater than or equal to $100,000, smoking, alcohol problems, and having sexual desire greater than once a week versus never were associated with an increased likelihood of separation or divorce after surgery.
Four pre- to postoperative changes were associated with being divorced or separated after surgery: greater weight loss, decrease versus no change in household income, starting psychiatric medication versus no preoperative or postoperative use, and increase versus no change in sexual desire.
"These estimates of change in marital status are higher than expected based on the percentage of U.S. adults who were married and the reported marriage and divorce rates from the same timeframe in the U.S. general adult population. Several preoperative predictors of marriage and of separation or divorce were identified, many of which have been identified in the general population. Greater weight loss was related to a higher chance of postoperative separation or divorce but not marriage," King and her co-authors wrote.
Interpreting the data
Lifestyle changes after surgery associated with weight loss likely contributed to higher rates of divorce and separation, King said. "This could indicate that a patient's changing lifestyle post-surgery put them out of sync with their spouse. It can be really hard when one spouse changes what they eat and how active they are, and desires more sexual activity, while the other doesn't. That can put significant strain on a marriage. It may be important for couples to consider this and have strategies to maintain their connection after surgery."
The new research article's findings about weight loss after bariatric surgery and its association with divorce were similar to the results of a Swedish study, King and her co-authors wrote. "The positive association between weight loss and divorce was also seen in the Swedish cohort and may reflect improved self-image and self-confidence that increase motivation or strength to leave an unhealthy marriage."
King and her co-authors offered other interpretations of the divorce data. "Additionally, partners of adults who undergo bariatric surgery may feel greater jealousy over their partner's weight loss and attractiveness or feel that they are no longer needed. Household income likely decreased as a function of the separation or divorce. Likewise, factors that prompted starting psychiatric medication may have stemmed from, rather than contributed to, separation or divorce."
King and her co-authors speculated on why an improvement in physical health and an increase in household income were associated with being married after weight-loss surgery. "Whereas improved physical functioning may have led to behaviors that increased the chance of marriage, household income likely increased as a function of marriage."
For primary care physicians, a capitation model risk adjusted for age and sex generates the smallest physician gender pay gap, researchers found.
For primary care physicians, the gender pay gap among clinicians varies by compensation model, a new research article found.
Earlier research has shown that male physicians receive higher compensation than female physicians, with one study estimating that male physicians earn an average adjusted gross income that is about $2 million higher than female physicians over a simulated 40-year career. Another study found that in productivity-based compensation models female physicians earn less compensation than male physicians because they spend more time with patients and conduct fewer patient visits.
The new research article, which was published by Annals of Internal Medicine, features data collected from 1,435 matched primary care physicians (PCPs)—881 male clinicians and 554 female clinicians. The study has several key data points.
Female PCPs conducted fewer patient visits than their male counterparts on an annual basis (1,210.3 versus 1,477.7)
Under a productivity-based fee-for-service compensation model, median estimated annual compensation was $285,397 for male physicians and $225,276 for female physicians, for a difference of $58,829
The gender pay gap was similar under a capitation model that was not risk adjusted, with a difference of $58,723
The gender pay gap was larger under a capitation model risk adjusted for age alone, with a difference of $74,695
The gender pay gap was largest under a capitation model risk adjusted for diagnosis-based scores alone, with a difference of $89,974
The gender pay gap was smallest under a capitation model risk adjusted for age and sex, with a difference of $36,631
"We observe a 21% gender wage gap between matched male and female PCPs in the same practices under productivity-based primary care payment that is similar under unadjusted capitation, larger under capitation risk-adjusted for age alone and for diagnosis-based risk scores, and smaller when accounting for patient age and sex," the study's co-authors wrote.
Interpreting the data
Female PCPs conducting fewer patient visits contributed to the gender pay gap under the productivity-based compensation model, the study's co-authors wrote. "We found that despite female PCPs likely working similar hours to or even more hours than their male counterparts, female PCPs received less compensation under productivity-based payment due to conducting fewer visits. These lower visit rates may be explained by female PCPs spending more time per visit, or being less likely to work with nurse practitioners or physician assistants billing under their [National Provider Identifiers], for example, when performing female preventive visits involving pelvic examinations."
This gender pay gap under unadjusted capitated payment was likely due to female physicians having smaller attributed patient panels, the study's co-authors wrote.
Capitation with diagnosis-based risk adjustment may exacerbate the gender pay gap, the study's co-authors wrote. "We found that male physicians' patients had higher mean diagnosis-based risk scores than those of female physicians (and although male patients of female PCPs had the highest [Hierarchical Condition Category] scores of any group, this was offset by female PCPs having majority female patients with lower HCC scores)."
Adoption of a capitation model risk adjusted for age and sex may be well-suited to primary care, the study's co-authors wrote. "Going forward, an alternative payment model such as age- and sex-adjusted capitation that minimizes the gender wage gap, or future models that more directly capture primary care effort, may be beneficial not only from an equity standpoint but also for retention of the increasingly female primary care workforce that is already disproportionately subject to burnout. Sustaining these workforce members may mitigate primary care capacity constraints and, in turn, support better health outcomes at lower cost."
The findings of a new research article could indicate significant improvements in patient safety.
In the past decade, the annual rates for in-hospital adverse events decreased for acute myocardial infarction, heart failure, pneumonia, major surgical procedures, and all other conditions, a new research article found.
Patient safety has been a pressing issue in healthcare since 1999, with the publication of the landmark reportTo Err Is Human: Building a Safer Health System. Despite two decades of attention, estimates of annual patient deaths due to medical errors rose steadily to as many as 440,000 lives, a figure that was reported in the Journal of Patient Safety in 2013.
The new research article, which was published in the Journal of the American Medical Association, is based on data collected from more than 244,000 adult patients hospitalized in 3,256 hospitals from 2010 to 2019. The study used data from the Medicare Patient Safety Monitoring System, which features 21 measures from four kinds of adverse events—adverse drug events, hospital-acquired infections, adverse events after a procedure, and general adverse events (hospital-acquired pressure ulcers and falls).
The study generated several key data points.
From 2010 to 2019, adverse events for acute myocardial infarction decreased from 218 to 139 per 1,000 hospital discharges
From 2010 to 2019, adverse events for heart failure decreased from 168 to 116 per 1,000 hospital discharges
From 2010 to 2019, adverse events for pneumonia decreased from 195 to 119 per 1,000 hospital discharges
From 2010 to 2019, adverse events for major surgical procedures decreased from 204 to 130 per 1,000 hospital discharges
From 2012 to 2019, adverse events for all other conditions were unchanged at 70 adverse events per 1,000 hospitals discharges
After adjustment for patient and hospital characteristics, there was a significant decrease in the relative risk of adverse events for all other conditions from 2012 to 2019
For acute myocardial infarction, heart failure, pneumonia, and major surgical procedures, overall observed in-hospital mortality declined from 4.6% in 2010 to 2.7% in 2019
For the all other conditions group, overall observed in-hospital mortality increased from 1.2% in 2012 to 2.2% in 2016, with the rate at 1.7% in 2019
"In the U.S. between 2010 and 2019, there was a significant decrease in the rates of adverse events abstracted from medical records for patients admitted for acute myocardial infarction, heart failure, pneumonia, and major surgical procedures, and there was a significant decrease in the adjusted rates of adverse events between 2012 and 2019 for all other conditions," the study's co-authors wrote.
Interpreting the data
Although the trends reported in the study do not definitely point to improvement in patient safety, the Medicare Patient Safety Monitoring System was designed to monitor adverse events, the study's co-authors wrote. Two other factors indicate the trends reflect an improvement in patient safety, they wrote. "The basis for the estimates is a highly structured and reproducible medical record abstraction process conducted at a central location by specialists in this work, and the definitions and measurement protocols were consistent over the study period."
The positive trends in adverse events are also consistent with major patient safety improvement initiatives launched during the study period such as the Partnership for Patients program as well as programs at the Centers for Medicare & Medicaid Services that target acute myocardial infarction, heart failure, and pneumonia, the study's co-authors wrote. Other factors could have improved patient safety, they wrote. "New technologies to support safety also were implemented along with new initiatives to increase person and family engagement in safety efforts. … Other factors such as spread of safer processes of care may also have played a role. Advances in care not directly attributable to patient safety efforts also may have contributed to the improvements (e.g., the widespread adoption of minimally invasive surgical techniques)."
The co-authors speculated on the cause of the only increase in adverse event rates reported in the study. "The only increase in adverse event rates was in the general adverse events domain for the all other conditions patient group in 2014 to 2019, and this finding may indicate a special need for new initiatives related to prevention of pressure ulcers and inpatient falls."
The co-authors also speculated about why there was a relatively low decrease in adverse events for the all other conditions category. "The lower overall rate of decline in adverse event rates in the all other conditions group, compared with the acute myocardial infarction, heart failure, pneumonia, and major surgical procedures groups, might be due to the quality improvement efforts targeted at the latter 4 conditions, whereas similar interventions did not occur for most of the conditions represented in the all other conditions group. Furthermore, the baseline adverse event rates were much lower in the all other conditions group, potentially leaving less opportunity to achieve improvement."
Jack Resneck Jr. shares the agenda for his American Medical Association presidency and prescriptions for some of the biggest challenges facing physicians.
A top priority for the new president of the American Medical Association is a recovery plan for the nation's physicians.
Jack Resneck Jr., MD, was recently inaugurated as the 177th president of the AMA. He is a practicing dermatologist in the San Francisco Bay Area and is the first dermatologist to serve as AMA president since 1925.
Resneck was elected to the AMA Board of Trustees in 2014, and he was board chair from 2018 to 2019. Before being elected to the AMA Board of Trustees, he served as chair of the AMA Council on Legislation and as a delegate to the AMA House of Delegates. Resneck has held several other leadership positions, including serving as the president of the California Society for Dermatology and Dermatologic Surgery.
HealthLeaders recently talked with Resneck about issues related to his AMA presidency, including his agenda, physicians and the coronavirus pandemic, and how physicians can address health equity. The following transcript of that conversation has been edited for brevity and clarity.
HealthLeaders: Physicians have been on the frontline of the pandemic for more than two years. What concerns should we have for physicians at this point in the pandemic?
Jack Resneck Jr.: First, I have never been prouder to be a physician as I look at my colleagues across the country and watch what they have endured and what they have done to support the country the past couple of years. They have put their lives on the line. Early in the pandemic, doctors were sleeping in their garages or tents to protect their families.
In terms of concerns, physicians have been holding together a health system that has been stretched too thin and tested by the pandemic. I have an enormous amount of concern about physician attrition and retirements. The AMA led a study that showed about one-in-five of physicians and about two-in-five of nurses intend to leave their professions in the next two years. On the physician side, we know that replacement costs are substantial. For organizations that employ physicians, the replacement costs are between $250,000 to $1 million per physician. The aggregate costs of physicians reducing their work time due to burnout alone is estimated to be $4.6 billion a year in the United States.
HL: What are the top agenda items for your AMA presidency?
Resneck: We have already talked about COVID stretching the healthcare system to the brink and furthering burnout among physicians. I feel strongly that our nation must renew its commitment to physicians and the patients they serve.
The Recovery Plan for America's Physicians has several points. One of them is addressing burnout and destigmatizing mental health issues for physicians. Another point is removing dysfunction from the healthcare system, which goes hand-in-hand with addressing burnout because dysfunction is a major driver of burnout. Prior authorization is a good example—it has grown out of control in the past few years. I have been a practicing physician for about two decades, and I remember a time when prior authorization was focused on a few expensive medications or tests. I now have to do prior authorizations for generic topical creams that have been around since the 1960s.
A third pillar of the Recovery Plan is stabilizing Medicare payments. We have seen two decades of nearly frozen payments as practice costs have gone up and inflation is now accelerating. Whether you are a large health system or a small physician practice, that is just unsustainable. In order for health systems and physicians to be able to invest in the future of healthcare, Medicare payments have to get fixed.
Fourth, the AMA is also focused on team-based care and making sure physicians are recognized for their expertise at the top of those teams. And fifth, we are focused on innovation and continuing to further telehealth and other innovations that help physicians move forward.
In terms of other top agenda items, I want to focus on a couple of other things. One is innovation more broadly. It has been a priority of mine for several years that when we have seen innovation go wrong in healthcare—such as lousy electronic health record products—it has been because physicians were not in the room in the early stages when the building blocks were being created. So now, with digital health and artificial intelligence, the AMA is working hard to bring physician values to the table.
Second, I want to keep politicians out of exam rooms. In reproductive health, transgender care, and other areas, we have seen states inserting politicians into the decision-making process that should be between doctors and patients.
Finally, I want to advance health equity. There are shameful inequities in our healthcare system for Black, Brown, Indigenous, and other marginalized patient populations.
HL: What can physicians do to address health equity?
Resneck: At the AMA, we created a Center for Health Equity a few years ago. In 2021, we released a plan to embed racial justice and advance health equity at the AMA and in healthcare. We are committed to eliminating longstanding health inequities and improving outcomes for historically marginalized populations.
There are many pieces to this work. One piece that is very important is reckoning with our own history at the AMA. We have been around for a long time and have done things in the past that have exacerbated inequities. Ultimately, addressing health equity is about embedding this work across the entirety of our organization, whether it's in how we think about chronic disease, whether it's thinking about medical education and having a pipeline of future physicians that looks like the patients we serve, whether it's in advocacy, litigation, or innovation. The effort needs to be on all fronts—it is not siloed work.
As physicians inside the AMA and nationally as a profession, we have an important role to play. This is part of our medical ethics and important to do for the patients we serve.
As individuals and groups, there are several steps physicians can take to address health equity. First is just being committed to doing the work. You must call it out and make it clear that this is something that you are committed to.
We have to have the education and training to shift our norms and practices. We need to be working in medical education to make sure we are producing physicians who are prepared to do this work. We must do the reading of the research so that we know the steps that we need to take.
Within our practices and organizations, we must analyze data to understand where inequities exist and are emerging. We need to develop a clear vision and goals within our practices and our communities. We need to do the work by launching targeted improvement efforts and measuring our progress as we go.
HL: How can healthcare organizations address physician burnout?
Resneck: We know that burnout can be reduced or even prevented with intentional organizational initiatives. The return on investment for organizations that address burnout can be substantial.
Since 2012, the AMA has been a leader in the national conversation on the physician burnout crisis. We have approached burnout in a data-driven way—both in terms of identifying what the problems are and what the solutions are.
Burnout manifests in individuals, but we think it originates in systems, and physicians cannot solve this crisis on their own. Addressing burnout requires a comprehensive strategy and investment to target barriers and burdens. Addressing burnout is not about yoga classes, dinners with leadership, and resiliency training, which are all lovely add-ons, but they are not at the core of what is going to solve burnout. If anything, they send the wrong message, which is the problem is with the physician as opposed to being with the system.
There are three things that systems must do to address burnout. First, measure burnout with validated tools such as the Mayo Clinic Well-Being Index and the Stanford Professional Fulfillment Index. Knowing where you are starting is important. Second, for healthcare organizations, addressing burnout must be an organizational value. It must be on the leadership dashboard and resourced. Third, the changes must be real. Physicians need real help with tasks that do not need to be done by physicians. For example, the in-basket in electronic medical records requires a team-based approach.
HL: What advice do you have to offer to new physicians entering the field?
Resneck: Given the challenges of the past two years, it would be easy for new physicians to be hesitant about the field. But I love my job—whether it is the part of my job that involves going into an exam room and working one-on-one with a patient or whether it is getting involved in policy and advocating on behalf of physicians.
I love what I do. So, I hope young physicians can be optimistic about the future that is ahead because we still have one of the coolest jobs possible. Physicians are incredibly lucky and privileged to do our work.
Survey data finds that 21% of healthcare workers experience childcare stress.
For healthcare workers, childcare stress during the coronavirus pandemic is associated with higher rates of burnout, intent to reduce work hours, and intent to leave jobs, a new research article says.
The pandemic has worsened preexisting childcare accessibility problems and disparities. Before the pandemic, the annual cost of full-time childcare for an infant was $21,700, which is more than one-quarter of an average hospital nurse's salary and more than two-thirds of an average nursing assistant's salary. Childcare is in short supply, with childcare desert designationsin three of five rural areas. In addition, it is difficult for healthcare workers to find care outside typical hourssuch as nights and weekends.
The new research article, which was published by JAMA Network Open, is based on survey data collected from 58,000 healthcare workers, including 15,700 physicians and 11,400 nurses. The study has several key data points.
Childcare stress (CSS) was reported in 21% of healthcare workers
CSS was more common in women than men (21.1% versus 17.9%)
Compared to healthcare workers without CCS, those with CCS had 115% greater odds of anxiety or depression
Compared to healthcare workers without CCS, those with CCS had 80% greater odds of burnout
High CCS was linked to 91% greater odds of intent to reduce work hours (ITR) and 28% greater odds of intent to leave jobs (ITL)
CCS was more common among racial and ethnic minority healthcare workers than White survey respondents
"The COVID-19 pandemic has had a myriad of effects on [healthcare workers] that put our workforce at risk. These data show an association between CCS and burnout, anxiety and depression, and ITL and ITR. Institutional interventions supporting childcare resources for [healthcare workers] may attenuate burnout, anxiety, depression, ITR, or ITL," the study's co-authors wrote.
Interpreting the data
Efforts to address CCS in healthcare workers should include interventions targeting racial and ethnic minority employees, the study's co-authors wrote. "Recovery based on racial equity needs to include collecting data, involving racial and ethnic minority communities in the process, and increasing access to childcare going forward. Without these efforts, individuals from minoritized groups will probably experience reduced participation in the workforce."
The study's findings also have important implications for female and male healthcare workers, the co-authors wrote. "Attending to CCS may help lower burnout rates for women, who historically have higher burnout rates than men. Given the increased burden women face at home, removing barriers for men in their participation in home duties is critical. Recognizing that men who are experiencing high CCS have strong odds of reporting anxiety and depression is important in discussing ways to support removing CCS burden from both male and female [healthcare workers]."
Childcare considerations should be a priority at healthcare organizations, the co-authors wrote. "We propose a more intentional approach in the health care workplace to assessing and addressing childcare concerns when worker assignments are made. Workplaces that can accommodate change on short notice, provide on-site care for ill children or on-site schools, and are aware of worker concerns about their children will be better positioned to show workers they are a caring environment, one that, we hope, workers would be more likely to remain with rather than leaving for shift work in other settings, a scenario that is currently occurring in large numbers."
Healthcare organizations should consider offering their own childcare services, they wrote. "Work-affiliated childcare reduces CCS and would be a reasonable strategy to mitigate the impact of childcare stress on ITL or ITR."
Merritt Hawkins, which is the largest physician search firm in the country, shows strong starting salaries and rising demand for physicians in latest annual report.
After being suppressed during the first year of the coronavirus pandemic, the job market and starting salaries for physicians appear to be rebounding, according to an annual report from AMN Healthcare and its physician search division, Merritt Hawkins.
Demand for physicians slumped in 2020, as health systems and hospitals suspended elective surgeries to accommodate COVID-19 surges and patients avoided healthcare settings because of fear of coronavirus infection. Downward pressure was exerted on physician compensation, and some physicians faced furloughs or reduction in working hours.
AMN Healthcare's newly released 2022Review of Physician and Advanced Practitioner Recruiting Incentives indicates the worst impacts of the pandemic on physician demand and compensation may be over. "Demand for physicians, and the salaries they are offered, have rebounded dramatically from the height of COVID-19," Tom Florence, president of physician permanent placement for AMN Healthcare, said in a prepared statement. "Virtually every hospital and large medical group in the country is looking to add physicians."
The 2022 Review is based on a representative sample of 2,695 permanent physician and advanced practitioner search engagements that AMN Healthcare and Merritt Hawkins had ongoing or conducted from April 1, 2022, to March 31, 2022. The report has several key findings.
Physician starting salaries show a rebound from the downward pressures of the first year of the pandemic, with the starting salaries of 14 physician specialties up year-over-year and only three down.
Orthopedic surgeons were offered the highest starting salary for physicians at $565,000.
Pediatricians were offered the lowest starting salary for physicians at $232,000.
Signing bonuses increased compared to the 2021 Review, with the average signing bonus for physicians rising from $29,656 to $31,000 and the average signing bonus for nurse practitioners (NPs) and physician assistants (PAs) rising from $7,233 to $9,000.
For the second year in a row, NPs were the most requested search engagement, which reflects a shift from physician office primary care delivery settings toward more convenient settings such as urgent care centers, retail clinics and telemedicine that employ advanced practitioners.
Nineteen percent of search engagements were for advanced practitioners such as NPs and PAs, which was up from 18% in the 2021 Review and 13% in the 2020 Review. This reflects higher demand for nonphysician clinicians.
Primary care physicians accounted for only 17% of search engagements, down from 18% in the 2021 Review and 20% in the 2020 Review. This reflects the shift from physician office primary care delivery settings toward more convenient settings.
Nearly two-thirds of search engagements were for physician specialists such as cardiologists, neurologists, and oncologists. This likely reflects the impact of an aging population that requires specialty care.
The combined categories of anesthesia providers (anesthesiologists and certified registered nurse anesthetists) accounted for the third highest requested search engagements. This indicates that the number of medical procedures requiring anesthesia, which declined in the first year of the pandemic, is rebounding.
Psychiatrists accounted for the fourth highest search engagements. This reflects the longtime shortage of behavioral health clinicians, which has been exacerbated by the pandemic.
Demand for telemedicine clinicians was strong, with 18% of radiology search engagements for teleradiologists and 15% of psychiatrist search engagements for telepsychiatrists.
Interpreting the data and trends
The increasing number of specialist search engagements relative to primary care physician search engagements represents a significant trend, Florence said. "The market has done a complete about-face. Several years ago, primary care physicians were the priority for most hospitals and medical groups. While many still seek them, the emphasis has shifted to specialists."
After slumping in the first year of the pandemic, demand for clinicians is surging, the 2022 Review says. "During the initial months of the pandemic, the number of search assignments Merritt Hawkins was engaged to conduct declined by 30% year-over-year. For the first time in over 33 years of providing physician search services, we saw a significant number of physicians laid off or furloughed, while some physicians were unable to find jobs coming out of residency. The contrast between then and the completion of our 2022Review could not be more pronounced. In the last quarter of 2021, Merritt Hawkins was retained to conduct more search engagements than in any other quarter in our history."
The number of physicians expected to leave the profession is alarming, the 2022 Review says. "The U.S. already faced a physician 'retirement cliff' before the pandemic, as close to 30% of active physicians are 60 years old or older. The fallout from COVID-19 is likely to accelerate physician retirements and otherwise drive exits from medicine as physicians become part of the 'Great Resignation' that has seen workers of all kinds leave their jobs."
Market disruptors such as retail clinics, insurance companies, and private investor groups are increasing demand for physicians and are likely to exacerbate physician workforce shortages, the 2022 Review says.
For example, CVS Health, which already has 1,500 Minute Clinics staffed mainly by NPs, is planning to open 1,500 HealthHubs that will shift from the episodic care provided at Minute Clinics to longitudinal care. "CVS has the stated aim of becoming the physician employer of choice, taking advantage of physician burnout and workplace disaffection to attract physicians seeking a more favorable practice model," the 2022 Review says.
