A data analytics capability added this year helps the payer target health plan members for social needs support.
UnitedHealthcare has added a data analytics capability to the payer's social determinants of health efforts.
Social determinants of health factors such as food security and housing play a pivotal role in the health of individuals and populations. A landmark 2016 study published by the American Journal of Preventive Medicine found that socioeconomic factors, health behaviors, and the physical environment account for determining more than 80% of health outcomes, with clinical care accounting for only 16% of health outcomes.
Minnetonka, Minnesota-based UnitedHealthcare has been working to address social determinants of health for two decades, and the payer's new data analytics capability is bolstering the effort, says Chief Consumer Officer, Rebecca Madsen, MBA. "We have had a longstanding focus on social determinants of health. Since 2000, we have contributed more than $1 billion to 4,600 communities for such things as housing and access to care. We have been at this for a long time, but this capability became more robust in the second quarter of this year with the addition of a data analytics program."
Focusing on social determinants of health is a priority at UnitedHealthcare, she says. "Our mission is to help members lead healthier lives. Today and historically, we know that social determinants are a substantial part of overall health. In our mission to help members lead healthier lives, we want to make sure that we are not only looking at the clinical aspect but also the entire individual. We want to enhance their experience—providing them with the support that they need as well as being a true partner and advocate."
The payer has a three-pronged approach to addressing social determinants of health, Madsen says.
1. Data analytics: "We worked with the American Medical Association to develop 23 new ICD-10 codes. These ICD-10 codes more precisely diagnose social determinants of health. So, if you are in a doctor's office and they see that you have needs such as food security or housing, that can be flagged with an ICD-10 code. We pull together claims data and use predictive analytics focused on these ICD-10 codes to proactively identify on both the individual and community level who is most likely to need support. By leveraging this data, we can generate a health risk score that leads to a next-best action that is put into a dashboard. That dashboard is personalized and ranked by value, so we can use the data to have more informed conversations with an individual when we have interactions with them," she says.
2. Active listening: "We specifically train our advocates to encourage them to listen to what the health plan member says. We call them 'trigger words.' For example, if someone calls in to our advocate call center for a provider search, and they say, 'I'm hungry. I'm having trouble making ends meet,' the advocate is then aware that there may be a social determinant of health need," she says.
3. Social needs questionnaire: "The third approach is a questionnaire that we equip our advocates with to ensure that they are asking the right questions to identify social determinants of health needs," she says.
Health plan member engagement
UnitedHealthcare's call center advocates are on the frontline of the payer's social determinants of health efforts, Madsen says.
"We have a very robust dashboard for our advocates. We put a ton of information there—everything from clinical programs for health plan members, to the member's preferred name, to whether a prior authorization has been submitted and where it is in the process. We then put this information in a format that is easily accessible for the advocates. The predictive analytics model then creates a next-best action in the dashboard that the advocate can see. By having a greater understanding of the member, it enables the advocates to have a sensitive conversation with an individual," she says.
Call center advocates receive training that prepares them to have conversations with health plan members about social determinants of health, Madsen says. "The advocates are trained thoroughly in what we call 'compassion training.' We know how important it is for an advocate to have a human connection and be able to demonstrate empathy. We hire for those characteristics, and we train people in those characteristics."
Connecting health plan members with social services
UnitedHealthcare has developed a curated database to connect members with social services, Madsen says.
"If someone has food insecurity, or isolation, or financial stress, we can look in the curated database and plug a health plan member into low- or no-cost community-based resources. This database has more than 500,000 community resources across the country. For example, if a member says they are housing insecure, our advocates can then pull up an agency or community-based organization that can support that individual," she says.
Measuring the impact and return on investment
The primary metric for UnitedHealthcare's social determinants of health work and its return on investment is how many members accept offers of social support, Madsen says.
"The goal here is to support our consumers and to make sure that we are giving them the care and support that they need. This was not necessarily started to generate a return on investment because it is the right thing to do. But we have seen that 50% of the people we offer support to accept the offer. So, in the long run, we believe that this work will lead to lower medical costs," she says.
UnitedHealthcare's social determinants of health work has an impact on total cost of care, Madsen says. "When we look at total cost of care, we do that holistically and the social determinants of health work is one part of that effort. It is not linear—we cannot say that this program ties to an exact dollar amount. We want to make sure that we are doing the right thing; but when we look at total cost of care, our social determinants of health work is evaluated as part of total cost of care."
A Florida-based spine surgeon has patented an augmented reality system that allows surgeons to display operating room screens on glasses.
A spine surgeon at AdventHealth has developed an augmented reality system to boost the efficiency and outcomes of spine surgery.
Augmented reality systems have been developed for operating rooms and other healthcare settings. For example, Google Glass has been adopted for several healthcare applications.
Chetan Patel, MD, medical director for spine surgery at the AdventHealth Neuroscience Institute has patented the iSight augmented reality system, and it has been used for spine surgery at the Altamonte Springs, Florida-based health system.
"The goal of iSight is to take any screen in the operating room regardless of what technology it is on and bring it to the surgeon within the surgical field. The way this system works is that we have a box that attaches to whatever it is you want to see. The box will be different depending on what technology you are using. The box takes information, digitizes the information if it has to, then encrypts and compresses the information. The surgeon wears glasses to see the information on the screen. The glasses are a controller, which gets a wireless signal that is decrypted so the surgeon can see the information on the screen," he says.
The iSight system is designed to address three problems during spine surgery, Patel says.
"The first problem is we have to look back and forth away from the patient to the screen to do our job. The second problem is the ideal place to put a screen is in front of the surgeon; but in surgery, my assistant is in front of me. Usually, the screens are between 20 and 30 inches, and they are off to the side. The screens are also quite a distance away to maintain sterility. It's difficult because I have to twist my neck to see the screen. The third problem is that errors can occur because you are looking at the screen and you are not able to look at the patient at the same time," he says.
The iSight system can display critical information from several screens in the operating room, Patel says.
"For screw placement, we are looking at the screen that allows us to accurately place the screw. For other procedures, there is other types of displayed data. For example, in tumor surgery the information that I care about is the pre-operative MRI and the CT scan that shows me where the tumor is located. So, that is the image that I would choose to display. If there is a herniated disc and I am just removing part of it, I would want the X-ray displayed. If I am taking pressure off the spinal cord from arthritis or bone spurs, blood pressure is critical. If the blood pressure gets too high, there is too much bleeding. If the blood pressure gets too low, the spinal cord can be in danger. So, in those cases, I want to see the anesthesia monitor," he says.
Boosting efficiency and outcomes
The iSight system increases surgery efficiency because the surgeon does not have to look back and forth between display screens and the patient, Patel says. "I have done a prospective study to see what happens when I don't use iSight versus when I do use iSight. For example, when placing a screw, there is about 10 minutes of time saved. That's less anesthesia time, less blood loss, and it is just easier and more comfortable for the surgeon."
Surgeons do not need to climb a steep learning curve to use iSight, he says. "With iSight, you can deliver a better result from Day One. The result is better than what you can deliver in the operating room today without having to learn anything new because this system is simple. All you have to do is plug in power, put on the glasses, and click on what you want to view."
Reducing the time of a spine surgery procedure is likely to improve clinical outcomes, Patel says. "Boosting outcomes is related to the time saving from iSight. With the reduction in the time to do a surgery, it results in a better outcome because there is less anesthetic, less blood loss, and improved accuracy. All of that leads to better outcomes."
Learning opportunity
The iSight system can record surgical procedures, creating a learning opportunity for surgeons and operating room staff, he says.
"If you look at elite athletes, they usually record themselves and analyze what they are doing to get better. But in surgery, we do not typically do that, partly because we do not have an easy way to record a surgery. With iSight, you can record operations. What I have found is that the improvement in time did not just come from me. It also came from my operating team. We watched our surgeries and looked for opportunities to do it better. So, there is the opportunity to share the footage with others, then teach and learn."
Potential for new applications
The iSight system has the potential to improve any medical procedure that involves a clinician looking back and forth from the patient to a screen, Patel says.
"This is just the tip of the iceberg. Once we have the opportunity to launch iSight outside of spine surgery, I can imagine the implications. Any surgeon who must look at a screen can benefit from this technology. For example, you can think of orthopedic surgery in general. Orthopedic surgeons fix fractures while looking at a screen. They are having to do the same thing—looking at the patient, looking at a screen, then having to put a screw in place. Using iSight completely eliminates looking back and forth."
The iSight system also has potential outside of orthopedic surgery, he says. "I am excited about what iSight can do for other specialties and getting it in the hands of others to see what benefits we can gain for physicians in other fields. That is the next immediate stage."
CMO of Denver Health spotlights five of the major challenges in U.S. healthcare.
This week in Kohler, Wisconsin, a group of clinical leaders is focusing on some of the top issues in healthcare during the HealthLeaders Chief Medical Officer Exchange.
The coronavirus pandemic has been one of the most disruptive periods in U.S. healthcare in generations. The pandemic has exposed longstanding challenges such as health equity and created new challenges such as securing adequate supplies of personal protective equipment (PPE).
HealthLeaders Chief Medical Officer Exchange member Connie Savor Price, MD, CMO of Denver-based Denver Health, conducted a presentation that focused on five healthcare challenges linked to the pandemic and healthcare in general.
1. Labor shortages and burnout
The coronavirus pandemic has compounded labor shortages in healthcare with a heightened level of burnout, Savor Price says.
"Burnout is affecting everyone in healthcare, including physicians, advanced practice professionals, and our nursing colleagues. They are all experiencing this issue. Many are leaving the profession—in statistics that I have seen, 30% of healthcare workers are considering leaving the profession. And those who have stayed are having a hard time—60% of healthcare workers have reported a mental health impact from COVID-19," she says.
2. Long-term impact of COVID-19
COVID-19 will persist for many years, says Savor Price, who is an infectious disease specialist. "COVID will stay. We have to start thinking about how we can live with COVID-19. It is going to become endemic in our viral respiratory testing, and it will become endemic among our patients and our healthcare staff. So, we have to determine how we are going to be living with it."
The pandemic is going to have far-reaching impacts on healthcare, she says.
"What we are going to see is that some of the protocols that we have put in place for infection prevention will continue. There will be universal masking around patient care—I think that is here to stay. We have more respect for infectious diseases—particularly emerging infectious diseases. It is very much like what we experienced after the start of the AIDS epidemic, where we now routinely use gloves for drawing blood. That was not always the case before AIDS. Now, we will routinely see use of more PPE such as medical masks for patient care and tightened visitor policies."
3. The changing role of the hospital
The pandemic has had a profound impact on the role of hospitals in communities across the country, Savor Price says. "During the coronavirus pandemic, the hospitals have taken on a lot of public health functions. Our hospital systems have been giving vaccines. Our hospital systems have been providing testing. Public health agencies have been doing some of this work; but in our community, testing did not go well. It had to be done by institutions that could process a specimen and report the results."
Hospitals are also likely to play a greater role in disaster preparedness, she says. "We are seeing federal funding for disaster preparedness that used to go to public health departments going directly to health systems."
4. Adoption of new technologies
One major healthcare issue that predates the pandemic that still looms large is adoption of costly technologies, Savor Price says. Technology adoption comes with the need to develop new competencies in the healthcare workforce, she says. "We have to think about the implications for credentialing and privileging, and make sure staff have the competencies to use the equipment that you have."
Healthcare organizations must focus on making technology sustainable, Savor Price says. "Unfortunately, many of the new technological tools have not increased our efficiency. So, we need to find innovations that truly reduce costs, and that is going to be especially true with the labor shortages and the burnout. We need to be able to extend our providers further using new technologies."
5. Future of value-based reimbursement
Despite many years of effort to shift healthcare financing from the fee-for-service model to value-based models, the future of value-based care remains questionable, Savor Price says. "We have been hearing about value-based reimbursement for years. The adoption of it has been slow. I think the slow adoption is because it is so hard to measure and pin down value. It is hard to determine which metrics should be rewarded."
Adoption of value-based care has been modest at best in The Centennial State, she says. "In Colorado, we have a low rate of value-based reimbursement, and we are largely still fee-for-service. We have not seen value-based reimbursement take off."
Since adopting a 'Bold Goals' initiative in 2005, the California-based health system has posted several gains, including reduced infections and lower sepsis mortality.
The Fountain Valley, California-based MemorialCare health system has made significant progress in decreasing patient harm.
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 have risen steadily to as many as 440,000 lives, a figure that was reported in the Journal of Patient Safety in 2013.
MemorialCare has been focused on reducing patient harm significantly since 2005, says Helen Macfie, PharmD, chief transformation officer of the health system. "In 2005, we created what we called 'Bold Goals.' We have been looking at making significant reductions in patient harm—heading toward zero."
Since the Bold Goals initiative began, MemorialCare has posted impressive patient safety gains:
84% reduction in "harm across the board," which includes preventable harms such as infections, blood clots, pressure injuries, and falls in the hospital setting
10% lower readmissions
50% fewer infections
71% more patients surviving sepsis
"You need to think about bold goals. You do not aim low and settle for good enough. To me, a bold goal is at least a 50% reduction on your way to zero. Every year, you should make your goals stronger," Macfie says. "Our board of directors monitor them as well as our executive teams. Our medical staff monitor them, then they cascade out to our nursing staff. We have leadership rounds to go out and talk with the staff and the doctors to look at their accomplishments. We celebrate what is going well, then we ask about what we can do better."
Reducing hospital readmissions
At MemorialCare, there have been three primary areas where the health system has succeeded in decreasing readmissions, Macfie says.
"First, you need to make sure there is a safe discharge from the hospital to begin with. If the patient is prepared well for care in the home or another setting, the patient is less likely to be readmitted. The patient or caregiver needs to understand the discharging clinician's orders. So, discharge education is critical," she says.
"Second, you need to follow-up with patients after they have gone home. We do post-discharge phone calls, and we are introducing more extensive outreach to patients' smartphones," she says.
"Third, we have eased access to questions getting answered. We have a navigation center that we created before the coronavirus pandemic, which provides 24/7 advice lines with nurses who can answer questions. We can help patients decide whether they should see their primary care physician, go to urgent care, or come to the emergency room," she says.
Reducing infections
MemorialCare has made progress in limiting hospital-acquired infections such as catheter-associated urinary tract infection (CAUTI), Macfie says.
"When these catheters are inserted, they can become infected. The first way to limit CAUTI is to have strict criteria for when catheters are inserted. The second way to limit CAUTI is to make sure the catheter is inserted no longer than necessary—we conduct rounding and perform checklists to make sure catheters are only in place as long as necessary. Then we have a care bundle that lowers the risk of the catheter getting infected such as placement of the urine bag—if the bag is above the patient, you can get back flow," she says.
Hand hygiene is a key element of limiting hospital-acquired infections, Macfie says. "We want pristine hand hygiene before and after when care is delivered. Hands are a major source of infection."
MemorialCare staff have achieved a high degree of hand hygiene compliance, she says. "We are typically at 97% to 99%. Most healthcare organizations are at about 75%. We use hand washing or a gel. We have broad education. We have 'secret shoppers' who monitor compliance, and we have data from audits."
Technology is also playing a role in limiting hospital-acquired infections, Macfie says. "We have UV-light robots that irradiate a room, so once a patient is discharged, we can not only do a deep cleaning of their room but also irradiate the room to kill microorganisms. We have a little army of UV-light robots that cleans patient rooms, bathrooms, and operating rooms."
No single approach can succeed in reducing infections, she says. "Limiting infections takes all of these things—it's called whole system thinking. You attack the problem from many angles."
Sepsis survival
Lowering sepsis mortality rates also takes a broad approach, Macfie says.
"There are national guidelines called Surviving Sepsis, and we have a best practice team for sepsis that is made up of physicians who work in our emergency departments, medical floors, and ICUs, along with nurses, pharmacists, and other staff members who treat sepsis patients. We have developed best practices—we have order sets and prompts that go into our electronic health record. Then we have protocols that are like a Code Blue for sepsis. We identify a sepsis patient, then we do all the things we need to do to provide timely care. For example, providing fluids and antibiotics early is crucial," she says.
Community outreach efforts have also helped reduce sepsis mortality rates at MemorialCare, Macfie says. "We have been doing outreach in the community to raise awareness about sepsis. It is like a stroke—the longer you wait to get care, the worse the outcomes. If a sepsis patient does not seek care, it can get worse fast. When our navigation center directs a sepsis patient to the emergency department, it can reduce unnecessary mortality."
Highlighting areas for improvement
MemorialCare uses "visibility boards" to keep the organization focused on limiting patient harm, Macfie says.
"We have created visibility board slides that have data that show the progression of data over time. The visibility boards also have the key activities that we have put in place and what we are working on next. We use PowerPoint slides because they are easy to create," she says.
For example, MemorialCare has a visibility board for Cesarean section (C-section) rates, Macfie says.
"We have a visibility board for C-section rates that shows the rates coming down on one side of the board, and we slice the data by race and ethnicity to see if there are any differences. This board also has our plans to address differences by race and ethnicity. Anybody can present that visibility board to a governance body, medical staff, or our leadership teams. Having these visibility boards helps drive culture and the relentless pursuit of reliability and zero harm. The visibility boards also promote conversation."
Female emergency residents are more likely to experience most forms of workplace mistreatment compared to their male counterparts.
Workplace mistreatment is relatively common among emergency medicine (EM) residents and the mistreatment is associated with suicidal thoughts, a new research article says.
Earlier research has shown that workplace mistreatment—discrimination, abuse, and harassment—is linked to several negative consequences such as feelings of marginalization, decreased job performance, increased stress, job dissatisfaction, and turnover. Workplace discrimination has been associated with health problems, including anxiety, depression, and cardiovascular disease.
The new research article, which was published by JAMA Network Open, is based on survey data collected from more than 7,000 EM residents enrolled in residencies accredited by the Accreditation Council for Graduate Medical Education. The 35-item survey was conducted in February 2020. Male residents (4,768) outnumbered female residents (2,698) in the survey study.
The research article features several key data points.
45.1% of survey respondents reported experiencing workplace mistreatment in the most recent academic year
The most common source of mistreatment was patients and patient family members—among the survey respondents, 1,234 reported gender discrimination, 867 reported racial discrimination, 723 reported sexual harassment, and 282 reported physical abuse by patients or patient family members
Gender discrimination was reported by 2,104 survey respondents, with more women (1,635) reporting this form of mistreatment than men (407)
Racial discrimination was reported by 1,284 survey respondents, including 371 White residents and 907 residents from other racial and ethnic groups
220 survey respondents reported discrimination based on sexual orientation or gender identity
1,047 survey respondents reported sexual harassment, with more women (721) reporting this form of mistreatment than men (294)
Verbal or emotional abuse was reported by 2,069 survey respondents, including 32.2% of female residents and 27.0% of male residents
331 survey respondents reported physical abuse
178 (2.5%) survey respondents reported having suicidal thoughts, with the incidence rate split evenly by gender
The prevalence of suicidal thoughts was relatively high for residents who identified as LGBTQ+ (odds ratio 2.04)
Divorced or widowed residents had a higher probability (odds ratio 3.36) of reporting suicidal thoughts than residents who were married or in a relationship
Experiencing mistreatment at least a few times per month was associated with a relatively high probability of having suicidal thoughts (odds ratio 5.83)
"In this survey study, EM residents reported commonly experiencing workplace mistreatment, and experiences of mistreatment were associated with suicidality. Identifying and promoting best practices to minimize workplace mistreatment during residency may help optimize the professional career experience and improve the personal and professional well-being of physicians throughout their lives," the research article's co-authors wrote.
Interpreting the data
The researchers identified segments of the EM resident population who are most likely to experience workplace mistreatment. "In this comprehensive survey study, mistreatment of EM residents based on gender, race/ethnicity, and sexual orientation was more common among women, residents from racial/ethnic minority populations, and residents identifying as LGBTQ+, respectively. Discrimination based on pregnancy and childcare status was also more common among women than among men," the co-authors wrote.
Female EM residents carry a heavier burden of most workplace mistreatment compared to their male counterparts, the co-authors wrote. "Women reported higher levels of nearly all forms of mistreatment compared with men, with most of the reported gender-based mistreatment originating from patients and their families. The second most likely source of gender-based mistreatment was nurses and staff."
The research provides insight into physician suicide, the co-authors wrote. "In this study, there was a significant association between the reported frequency of mistreatment and suicidal thoughts. After adjusting for mistreatment, women were less likely to report suicidal thoughts. The results suggest that the higher prevalence of mistreatment experienced by women in medicine may be one factor associated with the higher rates of suicide among female physicians."
Mistreatment interventions
Systemic interventions are a primary strategy to address workplace mistreatment, the co-authors wrote. "Leaders, peers, and other hospital colleagues may be bystanders, perhaps inadvertently, to workplace mistreatment. Healthcare systems, hospitals, and department and residency program leaders should consider training interventions to empower bystanders to intervene and to cultivate workplace norms that prohibit workplace mistreatment."
Boosting cultural competency is also likely to reduce workplace mistreatment, the co-authors wrote.
"An additional strategy is to provide cultural competency training to all emergency department staff with the goal of increasing collective knowledge about marginalized groups (women and individuals who are underrepresented in medicine or LGBTQ+) that are at increased risk of experiencing workplace mistreatment. This increase in knowledge and subsequent self-awareness may create a more open, safe, and supportive workplace for EM residents."
The trade association's survey report reflects the negative economic impact of the coronavirus pandemic on medical groups.
Physician compensation increased at a very modest rate in 2020, according to a survey report published by AMGA.
Physician compensation was impacted significantly last year by the coronavirus pandemic. Many physicians who had their compensation linked to productivity took a financial hit from the pandemic, with declines in patient office visits and other disruptions such as suspensions of elective surgery across the country.
The AMGA survey report is based on data collected from 398 medical groups representing about 190,000 clinicians. The survey report has several key data points.
Overall physician compensation increased 0.12% in 2020, down significantly from the 3.79% increase that AMGA reported for 2019.
Overall physician productivity decreased 10.17% in 2020, down dramatically from the 0.56% increase reported for 2019.
In primary care, 2020 median compensation for all specialties increased 0.40% and median productivity fell 10.63%. In 2019, median compensation increased 4.46% and median productivity increased 0.44%.
In medical specialties, 2020 median compensation for all specialties increased 0.39% and median productivity decreased 10.81%. In 2019, median compensation increased 3.52% and median productivity increased 0.9%.
In surgical specialties, 2020 median compensation decreased 0.84%.
Primary care nurse practitioner compensation increased 1.29%.
Primary care physician assistant compensation decreased 1.85%.
Orthopedic surgery posted the highest 2020 median specialty compensation at $631,900, followed by gastroenterology at $542,948, and general cardiology at $532,781.
General pediatrics and adolescent medicine posted the lowest 2020 median specialty compensation at $257,432.
For the 170 medical groups that indicated how base salary for physicians is determined, 90% reported that market salary data is the primary determinant.
The survey report reflects the impact of the coronavirus pandemic on physician compensation, according to an AMGA prepared statement. "Though the survey, conducted by AMGA Consulting, found very modest increases in compensation, there were significant decreases in productivity, which can be directly tied to the pandemic. The data reveals the devastating economic impact of COVID-19 on healthcare provider organizations and indicates that they may need to rethink their compensation models in order to remain resilient in the face of future disruptions."
In a prepared statement, AMGA Consulting President Fred Horton, MHA, said the trends in the survey report are associated with flat compensation and a stark decrease in service volume.
"Medical groups paid a steep price to retain their physician talent, even though productivity steeply declined. COVID-19 highlighted the need for medical groups and health systems to reconsider their compensation plans so that they rely less on obligatory annual pay increases and more on incentivizing productivity that rewards valuable outcomes. The shift to more value-based compensation models will help organizations become more resilient against future economic downturns," he said.
Kedar Mate, MD, decided to pursue a career in medicine after working with low-resource people in Haiti and Peru.
This article was published in the July/August edition of HealthLeaders magazine.
As the president and CEO of the Institute for Healthcare Improvement (IHI), Kedar Mate, MD, is the leader of one of the top healthcare reform organizations in the world.
IHI was founded in 1991. The nonprofit organization has been involved in a range of healthcare improvement initiatives, including patient and healthcare workforce safety, elder care, health equity, maternal and infant health, quality, and value-based care. In addition to working with U.S. healthcare organizations, IHI has worked on projects around the world, including Canada, England, Denmark, Sweden, Singapore, Latin America, New Zealand, Ghana, Malawi, South Africa, and the Middle East.
Mate received a degree in American history from Brown University in Providence, Rhode Island, and earned his medical degree at Harvard Medical School in Boston.
After graduating from Brown, Mate worked at Boston-based Partners in Health. He also worked at the World Health Organization and Brigham and Women's Hospital. Prior to being elevated to president and CEO at IHI, he was the organization's chief innovation and education officer. He recently told HealthLeaders that he was inspired to pursue a career in medicine while working for Partners in Health with HIV/AIDS patients in Haiti and drug-resistant tuberculosis patients in Peru.
"I joined Partners in Health and got a chance to work with an interdisciplinary group of doctors, economists, and anthropologists. I observed the work that the physicians did in direct care, and it struck me as very powerful, compelling, and different from the work of those in public health and economics. All of the disciplines were important to the kind of impacts that we were seeing, but it was the clinicians in their direct care and what they could do at the individual level that I found incredibly compelling," he says.
The career choice was in line with his upbringing. "Both of my parents are in the clinical arena. My dad is a pediatrician. My mom is a microbiologist—she works in a hospital laboratory," Mate says.
Following are the highlights of Mate's conversation with HealthLeaders.
"I love the fact that IHI does not view healthcare challenges as inevitable. It treats situations as solvable systems problems. I found that approach relevant whether I was in my practice environment or in sub-Saharan Africa working on a maternal and child health program. Regardless of the care setting, I found problems that were surfacing that were not just the pure clinical problems that were in front of us doing patient care—they were problems of the underlying system that was creating the clinical problems. Most people did not have the vocabulary for solving that systems problem, but IHI did."
"IHI had an approach that felt compelling, and that is what drew me to IHI and made me want to work for the organization, first internationally, then as leading the research and education team."
"The area that has been at the core for me is where health and social justice intersect. Today, that intersection is most evident in issues around health equity. There have been several examples in the work I have done, including the work that I did in Peru and Haiti with Partners in Health, and the work I did with IHI in sub-Saharan Africa."
"Equity was included in the definition of quality that the Institute of Medicine put forward in the late 1990s and early 2000s. But we still have a massive opportunity to bridge the equity chasm much as we have been trying to bridge the quality chasm for years."
"The big defect is to stop admiring the problem. We have had a lot of documentation of inequities and disparities in our systems for a long time. Not too long after we had To Err Is Human, we had Unequal Treatment in 2003. So, we have known these issues for a long time; but even today, we have more descriptive studies and analyses of what drives inequities and fewer intervention studies that talk about how to remediate inequities and close gaps."
"So, for me, the big opportunity that we have in the equity work is to actually tackle inequities."
"There is a big relationship between the inequities that we see and the safety challenges that we see. Some of the biggest opportunities in safety are also opportunities to remediate inequities or to close disparity gaps that we experience. A lot of the vulnerabilities of patients to injuries, infections, and readmissions are concentrated in the most vulnerable and under-resourced people in our communities—often in communities of color."
"We have a framework for change at IHI that has three components—will, ideas, and execution."
"For will, you must have the will and motivation to change. That will needs to exist at the senior leadership level such as the board of directors, but it also has to be driven in part by a sense that the status quo is untenable and that the future might be more attractive if you can chart a path to that future."
"You also need to have fundamentally better ideas for what the future can be—that is the second dimension. So, you must have will and motivation, but will is not enough without ideas to change your system from what it is today to what it should be tomorrow."
"The third area is execution. You need a disciplined approach to implementing change—whatever the change might be. The execution plan needs to be different based on the nature of the change. So, depending on the nature of the ideas and the will that is present, you might have a pilot program, or you might be ready to scale change widely. It takes different levels of execution depending on the will that is present and the belief you have in your ideas."
"Leadership is increasingly important as we tackle some of the big challenges that we have around equity, racism, and major social problems."
"Some of this work can be uncomfortable, and leaders should lean into that discomfort. There are some big challenges ahead, and they tend to be deeply rooted and systemic. These challenges will be uncomfortable and difficult to fix. You need to recognize that your biggest obstacles are people—the people who are voicing the most opposition to your change initiative are deeply passionate about what you are trying to change and have strong opinions because they are passionate about it, and you want to engage them in the process."
Photo: IHI President and CEO Kedar Mate, Julia Rendleman/Getty Images
Despite coronavirus pandemic disruptions, demand for physicians is high and physician compensation is growing, president of recruiting agency says.
The physician employment market is returning to pre-pandemic levels, a physician recruitment expert says.
Particularly in the spring of 2020, the coronavirus pandemic wreaked havoc on the physician employment market. Some physicians worked without pay and others were placed on furloughs.
"The demand for physicians went dormant in April and May 2020. Healthcare organizations started cutting back on their ability to do physician searches because they were losing money," says Tony Stajduhar, president of Alpharetta, Georgia-based Jackson Physician Search.
Now, demand for physicians is as strong as ever, he says.
"We started to see a change in the last quarter of 2020. There was a turnaround and our volume of hospitals recruiting started growing. Then in the first and second quarter of 2021, we had record months every single month in the history of our organization. Year-over-year in the first quarter of 2021, we were well over a 25% increase in volume. The demand for physicians had been pent up because healthcare organizations fell behind last year—they not only needed to catch up but also had a 2021 medical staff plan."
Stajduhar anticipates strong demand for physicians to continue throughout 2021. "Even with the coronavirus spikes that we are seeing, there were lessons learned in healthcare last year. You have got to keep your foot on the gas—you can't just 100% stop doing anything, including elective surgeries. You have got to figure out different ways to get creative," he says.
Physician compensation trends
Despite the upheavals of 2020, physician compensation has maintained a positive trajectory during the pandemic, Stajduhar says. "There were physicians who went unpaid last year. Physicians were on productivity contracts and having their compensation cut. But overall, physician salaries increased about 1.5%, according to Doximity."
As the pandemic drags on, physician compensation will likely continue to grow, he says.
"I anticipate that physician compensation is going to continue to rise during the pandemic. As physicians leave the field or retire early, the shortage of physicians is going to be even more exaggerated. As physician shortages continue to grow, this could turn into a free agency market because the competition between healthcare organizations needing physicians could lift restrictions and guidelines for hiring physicians. It is a market where the physicians should be able to demand what they want."
Whether or not physicians can negotiate significant salary increases, they should negotiate contracts with the pandemic in mind, Stajduhar says. "They should be negotiating for catastrophe clauses in their contracts. They need some protection financially because there were many physicians who took a major financial hit last year."
Moving away from the cities
Surveys conducted at Jackson Physician Search and other organizations have shown that some physicians are moving out of metropolitan areas for other locations.
"What we have been hearing from physicians is that they are trying to get out of some of the major metropolitan areas that have been hit hard by COVID-19. There is a perception that there are safer places to be located such as rural and suburban areas. Perception is driving a lot of this trend. Some physicians do not want to continue to live in metropolitan areas and put their families at risk," Stajduhar says.
Two other factors may be influencing the move away from metropolitan areas, he says.
"First, many physicians have loved ones who are hundreds of miles away or thousands of miles away, and things could happen to them in a heartbeat. So, physicians are looking to make a move to get closer to family. Second, some physicians may be looking for a slower pace of life. About 20% of the population lives in rural America, but only 10% of physicians work in rural America. So, there are opportunities for physicians to work in rural areas, make a very good living, and have a dramatically lower cost of living."
Recruiting advice for physicians and healthcare organizations
In the physician employment market, time is a crucial factor, Stajduhar says.
"From the physician perspective, they should be thinking ahead at least a year when trying to find the right position. If they think 18 to 24 months out, then they have more time to be selective. But once it gets to a year, the clock starts ticking and it gets louder every day. For healthcare organizations, they absolutely need to start recruiting early. They should start recruiting at least 12 months before they need to fill a position. In some cases, it can be hard to fill specialty positions and it can take two years."
Seeking perfection can be a mistake, he says. "I always tell physicians and healthcare organizations that if they can find 80% of what they are looking for that is probably as good of a match as you are going to find. For physicians, the key is judging the critical 80% of things that you must have for a good opportunity. For healthcare organizations, you must determine the 80% of things that you need in a physician."
Lastly, physicians and healthcare organizations should be open minded during the recruitment process, Stajduhar says.
"For physicians, they should be open about geography. Most people grow up in their town or one or two other places, they vacation in a couple of places, and that is what they think of in terms of locating for a job. They think about what is easy—they know a handful of locations and there is some comfort there. As someone who has recruited physicians across the country, I can say there are amazing places from coast to coast. Physicians just need to give a new location a chance. If the majority of what a physician needs is in a location, they should open their mind and take a look at it."
"For healthcare organizations, they should keep their minds open, too. They may want someone young who is going to stay for 30 or 40 years, but they can't build their recruiting program on that. If you find someone who is nearing the end of their career, they could still work for you for 10 years and make a huge difference in your practice. These are often physicians who are in your own backyard, and you do not have to work hard to recruit them."
A Boston-based hospital at home program added significant acute-care bed capacity during the city's first COVID-19 patient surge.
Hospital at home programs have the potential to add significant acute-care bed capacity during public health emergencies such as the coronavirus pandemic, a new research article shows.
Health systems and hospitals have been pushed to the brink during coronavirus patient surges across the country. Hospital at home programs can serve as a complementary strategy to open up traditional hospital beds to care for acutely ill patients.
The new research article, which was published by the Journal of General Internal Medicine, highlights the performance of the Brigham Health Home Hospital at Brigham and Women's Hospital program during the early phase of the pandemic. The study covers the period from March 15, 2020, to June 18, 2020, when the Boston area experienced its first COVID-19 patient surge.
The research article features several key data points.
Over the 95-day study period, the Brigham Health home hospital program cared for 65 acutely ill patients, which amounted to 419 bed-days.
During the study period, the home hospital program was staffed daily by one physician, one or two nurses, and one mobile integrated health paramedic.
Most (59%) home hospital patients were treated for infection followed by heart failure exacerbation (22%).
Most (65%) home hospital patients were discharged without services, 12.3% were readmitted within 30 days, and 13.8% presented to the emergency department within 30 days.
Over the 95-day study period, a field hospital established in Boston cared for 394 patients. The field hospital was staffed by 124 clinicians and 331 nurses. The cost of operating the field hospital was $29.8 million, which amounted to more than $75,000 per patient.
Interpreting the data
The lead author of the research article told HealthLeaders that the Brigham Health home hospital program made a significant contribution to acute-care capacity during the COVID-19 patient surge.
"During that first coronavirus surge in Boston, bed capacity was very challenging. Every single bed that we could get for patients who were seriously ill and needed to be in a hospital was a big deal. If you had told me that you could have created a model that could take five patients out of the hospital, I would have said, 'Let's look at that.' So, the fact that we were able to take care of 65 patients was impressive and impactful for the hospital, especially during those surge conditions," said David Levine, MD, MPH, MA, medical director for strategy and innovation at the home hospital program.
The cost of caring for patients in the home hospital program was a small fraction of the cost of caring for patients in the field hospital, he said.
"We did a randomized control trial that was published in Annals of Internal Medicine that showed that home hospital care costs about 38% less than traditional hospital care. Obviously, the cost of home hospital care is going to be way shy of the $75,000 per patient number at the field hospital. Typical hospital care costs about $15,000 per patient and home hospital care is about 38% less of that figure," Levine said.
Brigham Health's home hospital program should be viewed as a supplementary response to Boston's first COVID-19 patient surge, he said. "There was a different patient profile at the field hospital compared to home hospital. It is important to see home hospital as a complementary opportunity for hospital systems when thinking about responding to a pandemic. We should not get rid of field hospitals—but we need to think about complementary strategies for taking care of patients such as home hospital."
Future prospects for hospital at home programs
Levine has an expansive vision for the future of hospital at home programs.
"I am excited about the future of home hospital. If my vision comes true, hospital at home will be the way that we care for many acutely ill patients in the future and being in a traditional hospital bed will the exception as opposed to the rule. We are going to be able to expand home hospital with novel and creative care pathways and new technologies. We should be able to get this new care model to every person in the country irrespective of where they live and be able to get them the care that they need in their home," he said.
Reimbursement has been a major obstacle for hospital at home programs in the United States. That barrier was dramatically eased in November 2020, when the Centers for Medicare & Medicaid Services implemented the Acute Hospital Care At Home waiver. The waiver makes home hospital services eligible for Medicare fee-for-service reimbursement during the coronavirus public health emergency.
"It is exciting to look at the adoption curve since the CMS waiver. We went from about six programs to 145 programs in six months during a pandemic. It is a feat of early adoption," Levine said.
AdventHealth's new division chief clinical officer views seizing opportunities to improve facilities as a top priority.
Altamonte Springs, Florida-based AdventHealth has created a new chief clinical officer position for the health system's Central Florida Division.
Neil Finkler, MD, was recently named to fill the new post. A gynecologic oncologist by training, Finkler has previously served as chief medical officer of the AdventHealth Medical Group and chief medical officer of AdventHealth Orlando, which is the health system's quaternary hospital.
AdventHealth's Central Florida Division spans seven counties, and features more than 20 hospitals, 300 AdventHealth Medical Group physician practices, 35 urgent care centers, and 6,000 physicians and advanced practice providers.
HealthLeaders recently held a conversation with Finkler about the new chief clinical officer role, the challenges of overseeing a far-flung clinical enterprise, patient safety, and physician engagement. The following is a lightly edited transcript of that discussion.
HealthLeaders: Why did AdventHealth create this new chief clinical officer role?
Neil Finkler: This reflected the importance of making sure that we deliver on our service promises. Most notably, this new role is charged with making sure that we deliver the highest quality of safe and effective care throughout our facilities. We believe each of our facilities must function in unison. So, the care that you get at one facility should be identical to the care that you get at another facility, and we expect the outcomes to be similar.
We obviously understand that there are certain things that only the quaternary facility can do such as ECMO or transplants. But if you come in and you are treated for pneumonia, that treatment should look identical across our entire clinical spectrum.
In addition, we started to recognize that there was more than just the acute care side, which is where I have spent most of my career. We have a whole other aspect of our health system where most patients receive their care outside the walls of our hospitals. We have called that care "integrated health services." I also have oversight for the integrated health services world as well as the acute care world.
Healthleaders: What constitutes integrated health services at AdventHealth?
Finkler: The easiest way to think about integrated health services is everything that is outside the walls of the hospital. It includes physician offices, free-standing radiology and laboratory services, skilled nursing facilities, long-term acute care facilities, transition clinics, and infusion clinics.
HealthLeaders: What are the primary elements of this new chief clinical officer role?
Finkler: The most important thing for me to understand is the opportunities within each of our facilities. I particularly look at this from the standpoint of clinical excellence. Our division has several parameters that we use to assess clinical excellence. The three major ones are the Centers for Medicare & Medicaid Services five-star rating, the Leapfrog rating, as well as ranking in the top quartile of national mortality rates using the Premier Healthcare Database.
In addition, there are other parameters that we look at. We know that healthcare is constantly evolving, which means that the parameters and the metrics that we use are also changing. It is our job to make sure that we are on the spectrum of continuous improvement.
Regarding the CMS stars rating, AdventHealth Orlando, which includes the seven hospitals operating under the Orlando license in Orange, Osceola, and Seminole counties as well as AdventHealth Daytona Beach were recently awarded five stars. This is a great accomplishment, and it represents the skilled physicians and the collective effort it takes to bring excellence to the table. Only 13.5% of all hospitals are five-star ranked. These ratings are ranked with factors such as readmissions, mortality, safety of care, and patient satisfaction—all things that we believe that the communities that we serve should find important.
Within the Leapfrog reports, which give letter grades A through D, all AdventHealth hospitals in Seminole, Orange, Osceola, Valusia, and Lake counties have received an A grade for safety.
The world is changing, and every hospital and facility is also on this journey. So, the bar that you were able to meet this year for CMS star ratings or Leapfrog grades gets raised next year. Everybody needs to raise their game and these rankings give me the opportunity to look across my facilities and to see where we have opportunities to improve.
HealthLeaders: How are you focused on the issue of patient safety?
Finkler: We want to develop safe and reliable facilities across all avenues that our patients touch. We will know when we have reached success when we are all in a proactive system. We need to be able to identify future problems and be able to intervene now to prevent those future problems.
Improving safety involves empowering our entire workforce to speak up. I was trained in an era when the physician was the team. When I was trained, no one questioned what the physician had to say. That is not a safe environment.
We need to empower all members of the team to be able to speak up if they see something that does not look or sound right. Anybody on a team should be able to "stop the line." Even if you are the person who cleans the room, if you see something in that room that does not look right, you should be able to speak up. Everybody needs to understand the concerns of every member of the team. That is the way to achieve the safest possible environment.
HealthLeaders: What is your vision for leadership of AdventHealth's Central Florida Division?
Finkler: One of the advantages that I have is that our health system understands the importance of having chief medical officers at each one of the local facilities. These chief medical officers understand better than I do the issues in their local facility, and we communicate frequently. If there are any leadership issues, I can turn to my chief medical officers locally and we act as a dyad.
At the highest levels of this organization, the executive team realizes what the chief medical officers bring to the table. The chief medical officers understand that first and foremost we are a clinical organization that needs to deliver the highest quality care to the communities that we serve.
Given the fact that there is buy-in from every level of the organization, that is a great source of help for me. There has never been a time when the leadership has challenged or questioned what needs to get done to deliver high quality care. As a group, our physicians recognize that we are serious about what we are trying to do and that we are on a journey to become a top decile company because we want to be a leader in healthcare throughout the entire country. That is a journey that is going to take every one of us to make.
HealthLeaders: What are the key factors in physician engagement?
Finkler: The key factors are getting physicians to the table and having them be part of decisions. In general, physicians do not mind hearing "no." But when physicians hear a "no," they want to hear the why behind it.
I certainly believe in being completely transparent and putting physician leaders at the decision-making table. Several years ago, we started a group called the Catalyst. This is a group of physician leaders across our entire division, and there are now about 250 of them across our facilities. We have open discussions; we talk about the clinical goals that we want to attack in the next year. These physician leaders are part of the planning, development, and implementation of our strategies.
There is no better way to get physician buy-in than to have them be part of the plan. Part of including them in the plan is you must be completely transparent with your data.
You also need to celebrate wins. You start with easy wins because the easy wins will lead to more difficult wins. After a while, I will not need to lead the conversation. Physicians will come to me, they will recognize opportunities, and they will help us seize on opportunities.