A physician involved in the move to seek union representation says the main reason for the effort is to gain influence on administrative decision-making.
Physicians and other healthcare workers at Bend, Oregon-based St. Charles Medical Group have filed for union representation from the American Federation of Teachers.
Union representation of physicians is relatively rare. Several factors are contributing to efforts to unionize physicians, including burnout, the growing physician as employee model, and desire among physicians to have a stronger voice in healthcare organization administration.
St. Charles Medical Group is affiliated with St. Charles Health System, which features four acute-care hospitals in central Oregon. In addition to physicians, the union effort at St. Charles Medical Group includes nurse practitioners, physician assistants, behavioral health clinicians, licensed clinical social workers, and other healthcare workers.
The American Federation of Teachers is a national union with 1.7 million members, including about 200,000 healthcare workers.
A physician involved in the move to seek union representation at St. Charles Medical Group says the primary impetus of the effort is to gain decision-making authority at the medical group and St. Charles Health System.
"It is mainly concern about bad administrative decisions. It has gone from bad decisions to frustration and concern about the healthcare that we are providing. The term union tends to make people think about things like pay and strikes, and that is not a major part of the discussion. It is concern about patient care," Lester Dixon, MD, an emergency room physician at St. Charles Medical Group, told HealthLeaders.
A recent event cemented the move to unionize, he said. "There is a group called the Medical Governance Board that is about 10 providers that St. Charles Health System has supported, theoretically. The Medical Governance Board is supposed to provide guidance in monthly meetings with the administration to help steer the St. Charles Health System and St. Charles Medical Group. About three months ago, when things were starting to get heated up regarding finances, the leader of the Medical Governance Board, Dr. Richard Freeman, did not show up to a meeting. The health system CEO and chief medical officer said they had fired him. Members of the Medical Governance Board said they should be part of that decision, and they were essentially told they had no power."
Forming a union will boost the voice of physicians and other healthcare workers, Dixon said. "The expectation is that if you have a union, the administration cannot make unilateral changes because there is a contract. A union gives you a guaranteed decision-making position that would be much more powerful than what we have had in the past."
Clinicians have also been frustrated by the health system administration's handling of COVID-19 patients, he said. "They closed the main hospital to everything except COVID patients, which completely eliminated elective surgery in the operating rooms of the main hospital. That put us behind on surgeries and affected patient care, when we had three other hospitals that could have absorbed some of the COVID patients."
Health system's response
Jeff Absalon, MD, chief physician executive at St. Charles Health System, responded to the union effort in a prepared statement.
"As always, we want to reassure our community that patient care is and will continue to be our top priority. We greatly value our employed providers and respect their right to take this step, although we'd far prefer to work directly with them in partnership while navigating these unprecedented times. We know many healthcare workers are frustrated and exhausted after the past two years of the COVID-19 pandemic. Our focus as individuals and a health system needs to be on healing and recovering from the pandemic and stabilizing our finances so that we can preserve and strengthen the vital healthcare services that we provide to our community," he said.
Other union benefits
Forming a union will benefit physicians and other healthcare workers in three areas beyond the ability to have more influence on administrative decisions, Dixon said.
"It will give us assurances that we can staff adequately. The administration has just announced that as part of their cost-cutting measures, they are going to go from two to one provider at some of the facilities. That is obviously not patient-focused."
"There has also been talk that compensation is going to be related to productivity in the clinics, where you will be required to see a certain number of patients per hour or per shift. There are huge concerns about how that is going to work, especially if the administration is cutting back other staffing."
"Forming the union will also open the accounting book. The administration has made a lot of claims—sometimes stepping on their own prior claims—about how money is being spent. By opening the accounting book, we should be able to make sure that financial claims are addressed directly."
A new study found that nearly three-quarters of primary care clinicians would prescribe antibiotics for bacteria in urine against established guidelines.
In a survey study of primary care clinicians, a majority of survey respondents said they would prescribe antibiotics for asymptomatic bacteriuria, which does not bode well for antibiotic stewardship, a new research article found.
Even if testing shows bacteria in a patient's urine, treating asymptomatic bacteriuria is against guidelines set by the Infectious Diseases Society of America. Prescribing antibiotics for asymptomatic bacteriuria can lead to negative outcomes, including the development of Clostridium difficile infection.
The new research article, which was published in JAMA Network Open, examines survey data collected from more than 500 primary care clinicians. The survey included a clinical scenario of asymptomatic bacteriuria: a 65-year-old man who reported foul-smelling urine but no pain or difficulty with urination.
The study includes several key data points:
Among 551 primary care clinicians surveyed, 71% said they would prescribe antibiotics in the asymptomatic bacteriuria scenario
Clinicians with a background in family medicine were more likely to prescribe antibiotics in the asymptomatic bacteriuria scenario (odds ratio 2.93)
Clinicians with a high score on the Medical Maximizer-Minimizer Scale, which indicated a tendency toward high utilization of medical services, were more likely to prescribe antibiotics in the asymptomatic bacteriuria scenario (odds ratio 2.06)
Resident physicians were less likely to prescribe antibiotics in the asymptomatic bacteriuria scenario (odds ratio 0.57)
Pacific Northwest clinicians were less likely to prescribe antibiotics in the asymptomatic bacteriuria scenario (odds ratio 0.49)
Survey respondents who would prescribe antibiotics in the asymptomatic bacteriuria scenario estimated a 90% likelihood of a urinary tract infection (UTI), and survey respondents who would not prescribe antibiotics estimated a 15% likelihood of a UTI
"The findings of this survey study suggest that most primary care clinicians prescribe inappropriate antibiotic treatment for asymptomatic bacteriuria in the absence of risk factors. This tendency is more pronounced among family medicine physicians and medical maximizers and is less common among resident physicians and clinicians in the U.S. Pacific Northwest. Clinician characteristics should be considered when designing antibiotic stewardship interventions," the study's co-authors wrote.
Interpreting the data
The findings related to the likelihood of a UTI probably indicate a knowledge gap, the study's co-authors wrote. "Overwhelmingly, clinicians who indicated they would prescribe antibiotics estimated that the patient had a high probability of having a UTI, although the case details did not support this diagnosis. We suspect that many clinicians in our sample were not aware of what constitutes UTI symptoms or were not aware that symptoms are required to substantiate a UTI diagnosis."
The study's findings indicate that resident physicians have less of a knowledge gap than attending physicians, many of whom do not have the benefit of better education about bacteriuria, the co-authors wrote. "Given that current residents were less likely than attending physicians to prescribe antibiotics, greater clarity in the recent literature on what constitutes a symptom and evolving graduate medical education on appropriate management of asymptomatic bacteriuria may mean that knowledge gaps will be less of an issue moving forward."
Regarding cultural impact, the study says a culture of high-value care in the Pacific Northwest likely led to better prescribing practices in that region of the country. The lead author of the study told HealthLeaders that fostering an effective antibiotic stewardship culture can be achieved while clinicians are training or early in their careers.
"Clinicians tend to model their behaviors on what they observe from their peers. One way to encourage the development of good habits would be to encourage trainees and early career clinicians to practice in different parts of the country or different settings, such as safety net hospitals or Veterans Affairs facilities. That way, clinicians are exposed to different ways to practice before bad habits can become too ingrained," said Jonathan Baghdadi, MD, PhD, an assistant professor in the Department of Epidemiology and Public Health at University of Maryland School of Medicine.
The survey data shows clinician attributes can impact their clinical decisions, study co-author Daniel Morgan, MD, MS, told HealthLeaders. "Our study demonstrates that doctors are human and not always rational. Human aspects like personality and culture can change how we treat patients," said Morgan, who is a professor of epidemiology and public health and medicine at University of Maryland School of Medicine.
The finding that clinicians who were medical maximizers were more inclined to prescribe antibiotics for asymptomatic bacteriuria was not surprising, Baghdadi said. "I suspect that inappropriate antibiotic prescribing for asymptomatic bacteriuria is driven by the common but potentially harmful attitude that doing more is better, even when doing more is not supported by evidence, known as 'action bias' or by others as the 'Yes, Prime Minister' effect. When facing a patient and not being sure what to do, many clinicians will opt to do something, even if it's not clear that doing that thing will be beneficial."
Antibiotic stewardship implications
"It is highly problematic that the majority of clinicians would give antibiotics when a patient is healthy, and antibiotics are unnecessary," Morgan said.
The study's findings are "shocking," Baghdadi said. "It is widely recognized that outpatient antibiotics for suspected urinary infections are commonly prescribed in situations not recommended by guidelines, using agents not recommended by guidelines, for durations not recommended by guidelines. The findings from our study are shocking because we present a case patient in which there is no ambiguity, and yet clinicians prescribed inappropriate antibiotics anyway."
For clinicians who face asymptomatic bacteriuria cases, clinical decision support is needed to encourage antibiotic stewardship, Baghdadi said. "Education alone is not the answer. Asymptomatic bacteriuria is poorly understood by clinicians, and efforts to improve awareness of who will benefit from antibiotics do not consistently or sustainably change behavior. To change antibiotic prescribing, solutions need to be hard-wired into electronic health systems that guide clinicians toward making the right choice."
After the first year of interventions at Emory Saint Joseph's Hospital, there was a 63% decrease in hospital-onset C. diff cases as compared to the two years prior.
Through a series of interventions since 2016, Emory Saint Joseph's Hospital in Atlanta has been able to significantly reduce hospital-onset Clostridioides difficile.
Clostridioides difficile (C. diff) is a bacterium that causes severe diarrhea and colitis, with nearly half a million infections in the United States annually, according to theCenters for Disease Control and Prevention. One in 11 patients over age 65 with a healthcare-associated C. diff infection die within one month, the CDC says.
Timing is crucial in determining whether a C. diff infection in the inpatient setting is categorized as a hospital-onset C. diff case. If a patient tests positive for C. diff in the first three days of a hospital admission, the case is categorized as community acquired. If a patient tests positive for C. diff after four days or more of a hospital admission, the case is categorized as hospital-onset C. diff. High rates of hospital-onset C. diff draw financial penalties from the Centers for Medicare & Medicaid Services.
Increasing the testing of patients for C. diff in the first three days of hospital admission was a key intervention at Emory Saint Joseph's Hospital, saysCherith Walter, RN, MSN, APRN, a clinical nurse specialist at the facility who led an interdisciplinary team formed in 2016 to tackle hospital-onset C. diff. "A lot of our hospital-onset C. diff cases were being erroneously categorized as hospital-onset infections because we were not testing in the first three days. So, we wanted to make sure we were accurately capturing and reporting community-acquired C. diff.”
The interdisciplinary C. diff reduction team had several stakeholders on the panel's roster.
As a clinical nurse specialist, Walter was chosen to lead the team because a major part of her role at the hospital is to improve outcomes for patients and the organization
Inpatient unit nurse champions helped with education efforts and the rollout of interventions
An infection preventionist brought C. diff expertise in areas such as diagnosis and testing
A physician champion and the hospital epidemiologist helped to make sure clinicians were engaged in C. diff interventions
A clinical microbiologist helped in areas such as setting testing criteria
An environmental services representative helped make changes in how patient rooms were cleaned
An antimicrobial stewardship pharmacist helped to make sure antibiotics were used appropriately and to reduce usage of fluoroquinolone antibiotics, which are a risk factor for the development of C. diff
The primary C. diff reduction interventions included a new testing protocol, enhanced environmental cleaning, antimicrobial stewardship, and education efforts. The ongoing initiative is detailed in a research article published recently by American Journal of Infection Control.
New testing protocol
The interdisciplinary team developed a "diarrhea decision tree algorithm" to increase the testing of patients for C. diff in the first three days of a hospital admission, Walter says. "In the first three days of a patient's admission, nurses have the autonomy to test any unformed stool for C. diff. They do not have to get a provider order. As soon as they recognize that a patient has an unformed stool, nurses can go ahead and put an order into the electronic medical record themselves and get the stool tested. At that time, the patient is placed on contact enteric isolation until we receive a negative result."
Contact enteric isolation includes requiring staff members to wear gloves and gowns in a patient's room. In addition, staff members must conduct hand hygiene with soap and water rather than hand sanitizer.
Increasing C. diff testing in the first three days of a patient's admission benefits the hospital and the patient, she says. "When we looked back at our hospital-onset C. diff cases and found that many of the cases that we were testing were in Day 4 and after, we identified that was one of our greatest opportunities—increasing testing during the community-acquired window in the first three days of an admission. We not only wanted to appropriately categorize cases as community onset but also wanted to get early diagnosis to improve patient outcomes and infection prevention. If a patient has C. diff, we want to get it diagnosed early, we want to get it treated early, and we want to get the patient in isolation to avoid the spread of infection to other patients and staff members."
Enhanced environmental cleaning
Environmental services workers made changes to how they cleaned patient rooms, Walter says. "For the enhanced environmental cleaning, we changed the type of sporicidal products that we were using. Previously, they were using a sporicidal disinfectant in the isolation rooms. In 2018, they moved to a more effective sporicidal disinfectant and started using that in all patient rooms regardless of isolation status. We became more proactive with our cleaning."
In patient rooms that were placed under contact enteric isolation for a C. diff infection, cleaning was intensified, she says. "For patients who were on C. diff isolation, at discharge we did a terminal cleaning with disinfectant and UV light disinfection. Any equipment was cleaned with bleach wipes."
Antimicrobial stewardship
Antimicrobial stewardship focused on reducing the use of fluoroquinolones, Walter says.
"They put protocols in place to make sure providers could not order fluoroquinolones as standalone orders—they had to order them as part of an order set and they had to use clinical decision support that was built in to the electronic medical record. We also added some Food and Drug Administration warnings that popped up in the electronic medical record. So, we made it more difficult for providers to order fluoroquinolones because they are associated with the development of C. diff. Fluoroquinolones are a risk factor for C. diff because they disrupt the gut flora."
C. diff education
The interdisciplinary team has introduced several educational initiatives for the hospital staff, she says.
"When the protocols first rolled out, our nurses were heavily involved in getting the protocols out to the inpatient units. We did educational emails, flyers, and huddles. We added new protocols to the orientation that we do for new hires. We designated a 'C. diff Day,' where we set up prizes and games in our cafeteria, and we had roving carts that went into all of the inpatient units to conduct quizzes and provide teaching opportunities for the nurses about C. diff and the new protocols."
Impact and lessons learned
The interventions have generated impressive results. After the first year, there was a 63% decrease in hospital-onset C. diff cases as compared to the two years prior. C. diff testing for appropriate patients within the first three days of hospital admission increased from 54% in 2014 to 81% in late 2019.
Walter has several suggestions for other hospitals seeking to decrease hospital-onset C. diff infections.
"First, I would recommend gathering an interdisciplinary team. We could not have done this work without the support and collaboration of each discipline working together because each discipline brought their own expertise and the ability to make sure that interventions were rolled out in their department. Our interdisciplinary team allowed us to do a robust project with multiple interventions. It is also important to focus on diagnostic stewardship and appropriate ordering as well as evidence-based interventions. Another thing that our team has done that is important is to continuously look for opportunities for improvement. Even after the submission of the American Journal of Infection Control manuscript, we continued to find opportunities for improvement."
Eight healthcare organizations are participating in a year-long program called the Advancing Equity Through Quality and Safety Peer Network.
A health equity initiative launched by the American Medical Association, Brigham & Women's Hospital, and The Joint Commission is designed to capitalize on peer learning at health systems and hospitals, the president of the AMA says.
Health equity has emerged as a pressing issue in U.S. healthcare during the coronavirus pandemic. In particular, there have been COVID-19 health disparities for many racial and ethnic groups that have been at higher risk of getting sick and experiencing relatively high mortality rates.
The Peer Network has lofty goals, says Gerald Harmon, MD, president of the AMA. "What we are trying to do is to eliminate as many of the inequities that we can in the current healthcare delivery system. We would like to embed this focus on improving health equity and lowering health disparities in the structural DNA of hospital operations and health system delivery. We want to improve the public discourse on health equity and make it a national priority."
The Peer Network will identify health equity interventions through a shared framework, he says. "This type of networking will generate actionable items. We are focusing on a framework of equity, quality, and safety. This framework was designed by the Institute for Healthcare Improvement and Brigham & Women's Hospital. The framework features a couple of things: the critical role of healthcare organizations when we address inequity by incorporating equity into the DNA of the operational, day-to-day, and everything we do, as well as promoting high-quality, safe, and equitable outcomes for every patient."
The eight early adopters of the Peer Network started their work by conducting a self-assessment, Harmon says. "The Peer Network participants provide a self-assessment outlining where they hope equity can be integrated into their current quality and safety practices. Each of the eight early adopters are going to have their own internal metrics and strategic plans. We are giving the early adopters a target outcome and letting them come up with initiatives on their own over a year."
Peer learning is an essential part of the initiative, he says. "We are going to have monthly calls for foundational learning and to facilitate the sharing of scalable solutions and opportunities. We also will have asynchronous meetings among the early adopters with subgroups to share what is happening at the institutions and to share metrics. I'm also hoping that the participants will be able to report on wins and scale them to the larger group."
The Peer Network will also develop health equity leaders, Harmon says. "Hopefully, what we will get is a pipeline of leaders who are capable of designing equitable healthcare systems going forward. We are going to have a learning pod of leaders who can find out what is available in their internal systems, then scale this out to other health systems and hospitals, which are desperately in need of improving equity within their own systems."
Getting to root causes
Harmon says he has had experience with delays in diagnostic testing that have impacted marginalized communities. "For example, we would order a CT scan or an X-ray that you could not get at the point of service—you had to get follow-up on it. Then there was a delay, which could happen for several reasons such as prior authorization or other insurance concerns, and there were issues with marginalized patients such as transportation or communication. These delays seemed to happen more often with marginalized communities."
The Peer Network is designed to get at the root causes of these kinds of health inequities, he says. "We need to find the root causes of these delays when they involve marginalized communities. Is it because of transportation? Is it because of communication? Is it because of health literacy? Whatever it is, these communities tend to have longer delays in diagnostic imaging, diagnosis, and reporting of laboratory results. When there are inherent delays, there can be inherent inequities."
The Peer Network is going to have to craft sophisticated solutions to health equity problems, Harmon says. "If this were easy, we would not have to have things such as the Peer Network. It is an incredibly complex situation. I have been dealing with inequities for 40 years and have tried to find workarounds such as electronic medical records and other ticklers, but when you are dealing with hundreds or thousands of patients, there are several opportunities for data to slip through the cracks. You do everything you can within your skillset to improve the interaction with the patient, but if we had an easy answer for equity challenges, we would have already applied it."
Researchers show that pulse oximetry, which is a gatekeeper in treatment decisions for COVID-19 patients, overestimates blood oxygen levels in people of color.
In a new study involving more than 7,000 COVID-19 patients, pulse oximeter devices overestimated blood oxygen levels in Asian, Black, and non-Black Hispanic patients, which could have affected their eligibility for treatment.
Pulse oximetry, which measures blood oxygen saturation levels based on blood pulse and the relative absorbance of two wavelengths of light, is used for triage and treatment decisions in the care of COVID-19 patients. Low blood oxygen saturation levels prompt interventions for COVID-19 patients.
Earlier research has shown that pulse oximetry overestimates blood oxygen saturation in people with skin of darker pigmentation compared to people with lighter pigmentation.
COVID-19 has had a disproportionate impact on people of color, including Black, Hispanic, American Indian, Alaskan Native, and Native Hawaiian and other Pacific Islander people, according to the Centers for Disease Control and Prevention.
The new study, which was published by JAMA Internal Medicine, examined data from five referral centers and community hospitals in the Johns Hopkins Health System.
The analysis included reviewing data from more than 1,200 COVID-19 patients who had their blood oxygen saturation levels measure by both pulse oximetry and arterial blood gas testing. That review showed pulse oximetry overestimated arterial oxygen saturation among Asian, Black, and non-Black Hispanic patients compared with White patients.
The analysis also included reviewing data from more than 6,500 other COVID-19 patients with pulse oximetry measurements, with predicted overestimation of arterial oxygen saturation levels for 1,900 patients associated with failure to identify many Black and non-Black Hispanic patients who were eligible to receive COVID-19 treatment.
The study includes two key data points.
When compared to White COVID-19 patients, pulse oximetry overestimated blood oxygen levels by 1.7% for Asian patients, 1.2% for Black patients, and 1.1% for non-Black Hispanic patients.
Compared to White COVID-19 patients, Black patients were 29% less likely to have their treatment eligibility recognized by pulse oximetry and non-Black Hispanic patients were 23% less likely to have their treatment eligibility recognized by pulse oximetry.
Bias in pulse oximetry could contribute to health disparity in care for COVID-19 and other respiratory conditions, the study's co-authors wrote. "We found statistically significant and persistent overestimation of arterial oxygen saturation by pulse oximetry among Asian, Black, and Hispanic patients compared with non-Hispanic White patients. Black and Hispanic patients were more likely to experience unrecognized and delayed recognition of eligibility to receive COVID-19 therapy. Differential inaccuracies in pulse oximetry should be examined as a potential explanation for disparities in COVID-19 outcomes and may have implications for the monitoring and treatment of other respiratory illnesses."
Pulse oximetry inaccuracy can impact treatment for COVID-19, particularly for people of color, study co-author Tianshi David Wu, MD, MHS, an assistant professor of medicine at Baylor College of Medicine, said in a prepared statement. "Because eligibility for many COVID-19 medications depends on oxygen levels, pulse oximeter tools have become de facto gatekeepers for how we treat patients with this condition. We've shown that biases in pulse oximeter accuracy can mean the difference between receiving a necessary medication and not—and, critically, we were able to quantify how much this disproportionately affects minority communities."
Compared to 21 other high-income countries, the United States has the highest per capital cancer care spending but has a cancer mortality rate higher than six countries.
In comparison to 21 other high-income countries, the United States spends more on cancer care but does not have the best cancer outcomes, a new research articleshows.
The United States spends more on healthcare than any other country. Despite the high level of U.S. healthcare spending, the country lags behind other high-income countries in several health outcomes such as maternal mortality.
The new research article, which was published by JAMA Health Forum, compares U.S. cancer care spending and mortality rates to 21 other countries in the Organisation for Economic Co-operation and Development in 2020. The study includes three key data points.
The median cancer mortality rate was 91.4 per 100 000 population. The U.S. cancer mortality rate (86.3 per 100 000) was higher than that of six other countries.
Median per capita spending for cancer care was $296. U.S. per capita spending for cancer care was $584, which was higher than any other country.
Smoking is a strong factor associated with cancer incidence, and the United States has a relatively low smoking rate. When adjusting for smoking rates, nine countries had lower cancer care spending and lower mortality rates than the United States.
"In this cross-sectional study of 22 high-income countries, cancer care spending was not associated with age-standardized cancer mortality rates. Although the U.S. spent more on cancer care than any other country, this expenditure was not associated with substantially lower cancer mortality rates. Understanding how other countries achieve lower cancer mortality rates at a fraction of U.S. spending may prove useful to future researchers, clinicians, and policy makers seeking to best serve their populations," the research article's co-authors wrote.
The study's findings provide more evidence that the United States does not generate high value from the country's high health care spending, co-author Elizabeth Bradley, president of Vassar College and a professor of science, technology, and society, said in a prepared statement. "The pattern of spending more and getting less is well-documented in the U.S. healthcare system; now we see it in cancer care, too. Other countries and systems have much to teach the U.S. if we could be open to change."
Factors driving U.S. cancer care spending
Several factors account for why U.S. cancer care spending is higher than that found in other countries, according to the research article.
The United States spends more than other countries on cancer drugs
The prices of U.S. cancer drugs are relatively high, particularly for new drugs
The U.S. Food and Drug Administration grants earlier and wider access to new drugs compared with other countries' regulatory agencies
U.S. cancer care includes interventions for low-risk tumors such as early-stage prostate cancer, which is unlikely to cause harm if left untreated
End-of-life care in the United States is relatively intensive compared to other countries, with one study finding that U.S. cancer patients are admitted to intensive care units at twice the rate found for cancer patients in six other developed countries
Clinicians and patients are being encouraged to use the "in between" care offered in the health system's hospital at home and post-acute care at home programs.
Michigan Medicine is pursuing two primary pathways to offer home-based medical care.
Healthcare organizations are reimagining how they provide care to patients, increasingly looking beyond the walls of hospitals and other facilities to find new ways to provide medical services. Home-based medical care such as hospital at home programs have shown promise in improving clinical outcomes and reducing cost of care.
Michigan Medicine and the University of Michigan have a strategic initiative called Care at Home, says Grace Jenq, MD, associate chief clinical officer for post-acute care at Michigan Medicine and a clinical associate professor at University of Michigan Medical School.
Jenq says there are two key pathways in the Care at Home initiative—a hospital at home program called Hospital Care at Home and a post-acute care program called Completion at Home.
"With Hospital Care at Home, we take patients from the emergency department and enroll them directly into Hospital Care at Home. They go from the emergency department straight home, and we bring the nursing, the doctors, the medications, and the technology to monitor vital signs to the patient's home, so, they avoid admission to the hospital. We also have within Hospital Care at Home a way to get patients out of a hospital bed a little bit earlier. These patients get into the hospital, cool down a little bit, but they still need acute care—whether it is IV medication, IV fluids, nursing, or doctors to check their labs. We will transfer them to their home, then take care of them through the Hospital Care at Home program," she says.
Completion at Home is a program designed for high-risk patients after hospital discharge, Jenq says. "These are patients who are discharged from the hospital, but our intent is to try to provide wrap-around services with visiting nurses, our house call program, and our technology for monitoring. We try to keep our attention on these patients after they have been discharged from the hospital, so they do not get readmitted or come back to the emergency department. It is like a glide path—we do not just discharge patients anymore who are at high risk for readmission, we provide a glide path."
Hospital Care at Home
Michigan Medicine started building the infrastructure for Hospital Care at Home in 2018, with Blue Cross Blue Shield serving as an essential payer partner. The coronavirus pandemic accelerated the program, with the Medicare Acute Hospital Care at Home waiver program providing a new reimbursement mechanism for Medicare patients.
Hospital Care at Home is designed for patients who need acute care services at a level below the 24-hour care provided in the hospital setting, Jenq says. "No. 1, the patient and family have to understand there is not 24-hour care at home. There is a nurse who comes out to the home twice a day. If the patient has an emergency, they can reach a doctor immediately and we can send a paramedic out to the home for urgent issues that can be addressed within 30 minutes. … Doctors also go out to the home—the first visit, which includes a physical, must be conducted in person. About 80% of doctor visits are in person and 20% are virtual. These visits are daily."
Patients are carefully screened for enrollment in the Hospital Care at Home program, she says. "The types of patients we look for are patients who do not want to be in the hospital, but they want to get high-level services such as IV medications if they need them. The kinds of conditions are wound infections, cellulitis, mild pneumonia that requires oxygen, congestive heart failure that requires diuretics, and urinary tract infection. So, it is bread-and-butter medicine that does not require 24-hour-a-day nursing and monitoring. They still need medications. They still need laboratory tests. They are still acute patients—this is not outpatient care where you manage your condition with a primary care provider and get medications from CVS."
Completion at Home
The Completion at Home program was launched in 2020, in part as a response to the coronavirus pandemic.
Completion at Home services are not as intensive as Hospital Care at Home services, Jenq says. "With Completion at Home, we will have the nursing come out to you at home every couple of days, and we have the technology so the patient can take vital signs. We also have a way for the patient to reach a nurse or a doctor immediately if there is an issue with medications or a worsening of symptoms. Our intent with this glide path with Completion at Home is to make sure the patient has necessary resources, so they do not come back to the hospital for readmission."
The Completion at Home program is basically three services bundled together, she says. "The nurses go out through Michigan Visiting Nurses. We have a patient monitoring kit, which includes a cellular tablet, blood pressure cuff, and daily symptoms survey. Then we have our house call program, which includes physicians and nurse practitioners who provide virtual and in-person visits to make sure the patients are OK."
Completion at Home patients do not need daily visits by a nurse or a doctor, Jenq says. "We have this program to provide wrap-around services after a patient gets discharged. In the first week after hospital discharge, a nurse will visit the patient about three times and a doctor will visit the patient about two times. We are making sure that these patients have what they need at home—they are eating and drinking well, they have the medications that they need, and they are improving."
For Completion at Home, 80% of doctor visits are virtual and 20% are in person, she says.
The Completion at Home program has generated positive results, she says. "We have had a 50% reduction in emergency department utilization and 50% reduction in readmissions for patients who have been on the Completion at Home pathway."
Culture change required
Growth of home-based medical services requires a cultural change for both clinicians and patients, Jenq says. "We are changing a culture. Doctors and patients usually think about care as you are either in the hospital or you are at home with no services. There is nothing in between. What we are trying to tell them is there is 'in between' care—we can provide hospital-level care in the home and generate good outcomes. We have to sell this to the public, and we have to sell this to our nurses and doctors."
Processes have been put in place to encourage clinicians to use home-based medical care, she says.
"We now have mechanisms within our electronic medical record that can flag patients who are in the right geography and right payer mix for home-based services. We have asked the care managers to work with the physicians on the hospital floors or the emergency department to screen patients for home-based services. Part of the process is educating the medical providers that these programs exist. We also provide feedback to physicians about how many patients could have been eligible for home-based care, and we ask why they did not refer patients or ask why they declined to refer patients for home-based care," Jenq says.
In some pain interventions, contrast media is used for imaging that visualizes the needle tip location for clinicians.
The temporary closure of a contrast media manufacturing facility in China for a COVID-19 lockdown is impacting some pain interventions, a pain medicine expert says.
The closure of the GE Healthcare facility in Shanghai, which makes iodine-based contrast media, is having a more widespread impact on radiology such as CT scans. The American College of Radiology has made several recommendations for imaging that requires iodinated contrast media.
The contrast media shortage is a concern in pain medicine, says David Dickerson, MD, chair of the American Society of Anesthesiologists Committee on Pain Medicine. He is also medical director of the Anesthesia Pain Services Department of Anesthesiology, Critical Care, & Pain Medicine at NorthShore University HealthSystem in Evanston, Illinois.
"In interventional pain care, we use contrast to visualize our needle tip location during procedures that are targeting inflamed or dysfunctional nerves, joints, or muscles. So, contrast is often used in spinal procedures to make sure that we are near the target that we want to be treating such as a nerve root before we deliver the medication. We want to make sure that our medicine goes to the right place and that the needle tip is not somewhere that can cause harm. Contrast is used with X-ray-guided procedures," Dickerson says.
The American Society of Regional Anesthesia and Pain Medicine has made several recommendations for pain interventions during the contrast shortage. One of the recommended alternatives to using contrast for pain interventions is using ultrasound, Dickerson says. "With ultrasound, you can visualize all of the soft tissue and you are able to see where your needle is in real-time. So, you can forgo using contrast with an ultrasound-guided approach."
Pain medicine specialists should not switch to gadolinium contrast for spinal procedures, he says. "We cannot switch from iodinated contrast to the gadolinium contrast used in MRI scans, which has not been affected by the contrast shortage. There have been cases of patients who have had injury from gadolinium getting into their spinal fluid during a spinal injection. Patients have lost consciousness, experienced confusion, and suffered neurologic injury."
Some procedures can be modified to use either approaches or drugs that do not require contrast as a part of the procedure, Dickerson says. "You might change your image guidance, or you might change your needle approach to be not in an area where blood vessels are located—you can use an alternative approach to get to the same target. That approach can avoid using contrast, and the efficacy or safety of the procedure is not compromised."
Epidural procedures
Contrast is required for one kind of epidural procedure, Dickerson says. "When doing something like a transforaminal epidural steroid injection, which is a nerve root injection for a herniated disc or disc bulge, there are a couple of different approaches to get steroid into the epidural space around the nerve root. One approach is to put the needle right next to the nerve root and introduce a small amount of medicine around the nerve root and the epidural space as well. That epidural is very targeted to the nerve root of interest, but it is also in a very vessel-rich area. So, contrast lets us know that we are in the right spot and that we don't need to move the needle tip a couple of millimeters to avoid putting the medicine into a wrong location."
He says two other epidural approaches achieve the same effect but do not require contrast: caudal or interlaminar epidurals. "Those approaches have us placing a needle tip or a tiny microcatheter that advances to the target and avoids being near blood vessels. That is one of the recommendations—if you do not have contrast available, consider using a caudal or interlaminar epidural, where you avoid the need for contrast."
Shortage expected to ease soon
There should be adequate supply of iodinated contrast soon, Dickerson says.
"The Shanghai facility that was shut down for a COVID lock down is back up and running. We have been told that by the end of June, we should have restoration of the supply chain. However, that assumes that there are no other hiccups. This is where we need to think about having redundancy in our supply chains."
Federal action may be required, he says. "We may need to work with members of Congress to ensure that we require the companies that import contrast have diversification of their supply chain. The companies that import iodinated contrast are exclusively bringing in the contrast from one facility in China. We could end up with geopolitical issues that affect that supply chain with very little room for flexibility or adapting outside of rationing."
A new study found female physicians and racial and ethnic minority physicians are at highest risk for mistreatment and discrimination by patients, families, and visitors.
Physicians who experience mistreatment and discriminatory behaviors by patients, families, and visitors have higher odds of burnout, a new research article says.
Physician burnout was a concern before the coronavirus pandemic, which has exacerbated the problem. Earlier research has linked physician burnout to negative personal and professional consequences.
The new research article, which was published by JAMA Network Open, is based on data collected from more than 6,500 physicians. The study has several key findings.
In the previous year, 29.4% of physicians had experienced racially or ethnically offensive comments by patients, families, or visitors. This mistreatment was more prevalent among female physicians (34.7%) than male physicians (26.0%).
In the previous year, 21.6% of physicians had a patient or family refuse to allow them to provide care because of the physician's personal attributes.
In the previous year, female physicians (odds ratio 2.33) and Black physicians (odds ratio 1.59) were more likely to report mistreatment or discrimination.
Offensive racial or ethnic comments by patients, families, or visitors in the previous year were experienced 55.8% of Black physicians and 55.4% of non-Hispanic Asian, Native Hawaiian, of Pacific Islander physicians. These experiences were reported by 22.0% of White physicians.
In the previous year, 28.7% of physicians reported offensive sexist remarks by patients, families, or visitors, with this mistreatment reported by more female physicians (51.0%) than male physicians (15.1%).
In the previous year 20.5% of physicians reported unwanted sexual advances by patients, families, or visitors, with this mistreatment reported by more female physicians (29.6%) than male physicians (15.0%).
At least once in the previous year, 14.8% of physicians reported physical harm by patients, families, or visitors. Physical harm was reported by 31.8% of non-Hispanic male physicians of two or more races, a rate more than twice that of other groups.
The researchers scored mistreatment on a scale from 0 (no mistreatment) to 3 or greater. Higher scores were associated with higher odds of burnout: score of 1 odds ratio 1.27, score of 2 odds ratio 1.70, score of 3 or greater odds ratio 2.20.
"In this study, mistreatment and discrimination by patients, families, and visitors were common, especially for female and racial and ethnic minority physicians, and associated with burnout. Efforts to mitigate physician burnout should include attention to patient and visitor conduct," the research article's co-authors wrote.
Compensation for most physician specialties saw modest increases between 2019 and 2021, according to new MGMA data.
It appears that medical practices are rebounding from the coronavirus pandemic, with most physician specialties reporting compensation levels that are the same or in excess of pre-pandemic levels, according to new data from MGMA.
The first year of the pandemic took a heavy financial toll on physician practices and physician compensation. An American Medical Association survey conducted from mid-July through August of 2020 found a 32% average drop in revenue at physician practices.
The 2022 MGMA Provider Compensation and Production report has data from more than 192,000 providers at more than 7,700 healthcare organizations. The report, which focuses on 2021, features several key data points.
Nonsurgical specialist physicians experienced the biggest percentage decline in median total compensation from 2019 to 2020. These physicians experienced a 3.12% increase in median total compensation in 2021, and a 1.79% increase over the 2019 compensation level.
Surgical specialist physicians experienced the second biggest percentage decline in median total compensation from 2019 to 2020. These physicians experienced nearly a 4% increase from 2020 to 2021, with median total compensation reaching $517,501.
In 2021, primary care physicians experienced compensation gains slightly below figures in 2020, with median total compensation reaching $286,525.
Work RVUs reflect clinician productivity while taking into account visit complexity. From 2020 to 2021, the average percentage increase in median wRVUs for all provider types was 14.3%. Advanced practice providers experienced the largest percentage gain at 16.58%.
The Top 3 specialties that posted total compensation gains from 2019 to 2021 were ophthalmology at 6.97%, general orthopedic surgery at 6.88%, and family medicine without obstetrics at 5.60%.
The Bottom 3 specialties that posted weak total compensation changes from 2019 to 2021 were neurological surgery at -0.23%, diagnostic radiology at -0.14%, and emergency medicine at 0.78%.
Interpreting the data
The 2021 data bodes well for 2022, Michelle Mattingly, senior manager of data solutions at MGMA, told HealthLeaders. "With the compensation and work RVU data from 2021 being at or greater than levels in 2019, there is a very strong case that the pandemic is less of a cause for concern as we look forward to 2022."
Physician productivity appears to have returned to pre-pandemic levels, she said.
"The work RVU growth in 2021 is reflective of the decrease in 2020 due to the pandemic. Work RVU volumes dropped by more than 10% in 2020. The volume in 2021 is in line with pre-pandemic levels. Surgical and nonsurgical specialty physician productivity is reported about the same as it was before the pandemic. Primary care physicians report a slight increase (1.16%) in productivity compared to 2019."
Regarding patient volume, MGMA examined data for total encounters, which reflect the number of direct provider-to-patient interactions regardless of setting, including telehealth visits. This data shows that the pandemic is still having a negative impact on physician practices, Mattingly said.
"Total encounters increased between 2020 and 2021, signaling that patients are more comfortable being seen than they were in the height of the pandemic. However, the total encounters data is still down from pre-pandemic levels in 2019. For example, primary care physicians had 2.69% more encounters in 2021 than 2020; however, the 2021 level was still 7.73% less than what it was in 2019. Likewise for surgical specialty physicians: encounters were 5.89% more in 2021 than 2020; however, the 2021 level was still 4.85% less than what it was in 2019," she said.
Compensation for most physician specialties saw modest increases between 2019 and 2021, according to the MGMA data. Mattingly said setting expectations for 2022 and beyond is difficult because there are several factors that could affect a practice's productivity and have a downstream effect on physician compensation. Three of those factors are as follows:
Short staffing: Many practices are struggling to maintain necessary staffing levels. Without the right number of staff, practices may not be able to handle higher patient volumes.
Inflation: As the cost of goods and services increases, some patients may struggle to keep up financially and put off care.
Physician Well-Being: Burnout was problematic before the pandemic, and there are indications that the pandemic may have added fuel to the fire. Without enough providers in the workforce, it may be difficult to keep up with the demand.
