The coronavirus pandemic has worsened healthcare workforce woes that were already plaguing healthcare workers before the public health emergency.
The American Hospital Association (AHA) says there is a three-pronged approach to current healthcare workforce challenges—addressing well-being, supporting behavioral health, and preventing workplace violence.
Healthcare worker burnout has reached crisis proportions during the coronavirus pandemic and workforce shortages are widespread among nurses, physicians, and other clinical roles across the country. The health and the sustainability of the healthcare workforce are in jeopardy.
The AHA recently released Part 1 of a three-part series of reports on the strained healthcare workforce. The first installment is titled "supporting the team," and it focuses on addressing well-being, supporting behavioral health, and preventing workplace violence.
The pandemic has driven the healthcare workforce in an alarming direction, says Elisa Arespacochaga, MBA, vice president of clinical affairs and workforce at AHA.
"At its core, healthcare is people providing care for people. We need a talented, engaged, and diverse workforce to be able to do that effectively. Unfortunately, the healthcare field just like other fields across the country is facing mounting workforce challenges, including some critical staffing shortages that could jeopardize access to care. Some of these challenges come from longer term trends such as the demographic shifts of having fewer young people and more people who are on Medicare. The bottom line is the pandemic exacerbated the problems and took a toll on the healthcare workforce," she says.
The pandemic has worsened burnout, Arespacochaga says. "We knew before the pandemic that the impact of burnout was not only taking a toll on the physical and mental health of our workforce, but also was contributing to challenges related to patient outcomes, people leaving the workforce, and recruiting. Over the past two years, COVID has just amplified all of these challenges."
The pandemic has increased the need for behavioral health services for healthcare workers, she says. "COVID-19 has been a huge emotional and physical strain for our healthcare workforce. Our healthcare workers are incredibly resilient, but the ongoing impact of the pandemic has taken a toll on their ability to recover and to be resilient."
The pandemic has also increased workplace violence incidents, Arespacochaga says. "We knew before the pandemic that healthcare workers were among the highest rates of injuries from workplace violence. We are there to care for people in their most extreme circumstances, and sometimes there is violence. However, the pandemic has made workplace violence worse. We have seen a marked increase in violence against hospital employees, and it does not seem to be slowing down."
Supporting healthcare workers
The new AHA report includes initiatives and strategies associated with the organization's three approaches to supporting the healthcare workforce.
Addressing well-being
Dealing with burnout requires a cultural shift, not just a checklist of tasks to complete
Planning to engage key stakeholders in well-being initiatives should include front-line and core managers
When there are gaps in resources, prioritize needs and seize on opportunities to launch pilot initiatives
Address self-care through training during onboarding and continuing education programs
Supporting behavioral health
Seek to have a culture of psychological safety where healthcare workers feel safe to speak out and seek treatment for mental health or substance use disorders
Share stories about mental health or substance use disorders—try to normalize mental illness
Integrate physical and behavioral health services, which has been shown to boost employee satisfaction
Prevent workplace violence
There should be an assigned leader who fosters workplace safety initiatives
There should be accountability protocols for all leaders and those protocols should be shared with the staff
Reporting of workplace violence should be encouraged, with a zero-tolerance organizational expectation about violent behavior
Create an interdisciplinary threat assessment team to identify opportunities to mitigate threats
Conduct ongoing education and training programs, including simulation training
Allcove centers provide a range of services to young people, including mental health screening, short-term therapy, primary care, and addiction treatment.
In California, Stanford Children's Health is helping to open allcove centers, which is a new model for prevention, early detection, and treatment of mental illness in young people.
Millions of American children and young adults experience mental health conditions, and access to care is a challenge. In 2020, 13.01% of Americans aged 12 to 17 reported experiencing a major depressive episode in the previous year, according to Mental Health America. The mental health of high school students has deteriorated during the coronavirus pandemic, with 37% of students reporting they experienced poor mental health in 2021, according to the Centers for Disease Control and Prevention.
The status of mental health for children and young adults is raising alarm, says Steven Adelsheim, MD, director of the Stanford Center for Youth Mental Health and Wellbeing.
"Prior to the pandemic, we were already facing a crisis in terms of access and support for children's mental health issues. There were increasing rates of youth suicide and struggles to have access to care in terms of enough qualified providers to meet the needs of young people. With the pandemic, the challenges have increased, including the growing number of young people needing mental health support. We have higher rates of anxiety, higher rates of depression, and more young people coming into emergency rooms for suicidal ideation and suicide attempts," he says.
Adelsheim and his colleagues at the Stanford Center are playing a leading role in the creation of allcove centers across California. With support from Santa Clara County Behavioral Health Services, two allcove centers opened in Santa Clara County in June 2020. There are plans to open five more allcove centers, with as many as three opening by the end of this year.
The allcove model
Allcove centers are designed to play an important role in the behavioral health continuum of care for young people, Adelsheim says. "We have seen a lot of national attention on school mental health services. The allcove centers become the community place for young people 12 to 25 to come in and get early care. So, we are trying to create a public mental health continuum of early support from school mental health to allcove centers to even early psychosis programs that have grown exponentially across the country since the federal government made the investment through the federal 10% set-aside for early psychosis programs."
Mental health services available at allcove centers include screening and short-term therapy, he says.
"Generally, it is a short-term therapy model, so staff help young people feel comfortable if they are having a breakup in a relationship, or sexual orientation questions, or bullying, or some other type of challenge. They do not have to wait until things become severe. Most of the time, we see young people and families accessing mental health services through emergency rooms at times of crisis. The idea with the allcove centers is they are places that are comfortable enough for young people to come in for an early mental health visit with a licensed therapist and be able to access short-term support. Family therapy is available. Group services are available."
If young people need a higher level of mental health care, allcove center staff can connect them with other behavioral health providers.
Other services provided at allcove centers include primary care, education and employment support, addiction treatment, and peer support, Adelsheim says. "We are looking at a range of supports for young people. Some services support building resiliency and wellness. Other services provide mental health support. We also have integrated support with primary care clinicians who can provide sexual health services for young people as well as general medical services. In addition, we have peer support services. Every young person who comes in to an allcove center is met by a peer support specialist—someone who is close to their age who may have a lived experience with a mental health issue. The peer support specialist can help a young person learn about the services that are available at the allcove center."
Allcove centers have been designed and developed by young people for young people, he says. "Each allcove center has an active youth advisory group that is involved in decisions about the services that are provided. The youth advisory group is involved in the hiring of the staff."
The physical characteristics of allcove centers are designed to create a welcoming environment for young people, Adelsheim says.
"They all have a space called The Cove, which is a warm and welcoming place for young people where they can be together and be able to interact with each other in a comfortable way. One of the ideas is to be able to come in for a moment of pause. Young people can be alone, without really being alone. … The colors and the design are set up to create a level of comfort for young people in terms of the space itself. We try to create a space that is not as clinical as one might see in a typical mental health clinic. There are areas for young people to do creative things and snacks are available. There are art supplies available."
Launching allcove centers
At this stage of the allcove center initiative, the facilities have relied on a range of financial support, he says.
"We are working with the state of California on funding models to be able to provide Medicaid as well as commercial insurance support for the centers. We are doing that work through a partnership with the state Mental Health Services Oversight & Accountability Commission. The centers that opened in Santa Clara County started with some funding from California's millionaire tax for mental health. Santa Clara County also used some of their innovation funds for their two centers. In addition to the state pilot funds, communities are also pulling together other funds from their own mental health services. We are also working with managed care networks to talk about how we can build in the capacity for early and upfront support. There is also some foundation support. The goal is to create a financial model that will allow for broader sustainability over time."
There have been discussions to open allcove centers in other states, Adelsheim says. "They can connect with us through our website, allcove.org. We have information available to share with communities that are interested in rolling out this model. We have a technical support team whose role is helping interested communities think about what it would take to start a model like this. Opening a center often begins with developing a youth advisory group because the youth voice is important to developing services and to helping communities pull together the service delivery partners."
For financially distressed rural hospitals, affiliation with other hospitals was linked to a lower risk of closure compared to being independent, researchers found.
For financially distressed rural hospitals, affiliations with other hospitals lower the risk of closure; but for financially stable rural hospitals, affiliations with other hospitals increase the risk of closure, a new research article found.
Several factors have made rural hospitals more exposed to financial distress than urban hospitals, the new research article says. Compared to urban hospitals, rural hospitals struggle to attract and retain clinicians. Rural hospitals face higher fixed costs than urban hospitals because of lower patient volumes. Compared to patients at urban hospitals, patients at rural hospitals are more likely to be uninsured or covered by public insurance.
The new research article, which was published by JAMA Health Forum, examines data collected from 2,237 rural hospitals from 2007 to 2019. The study compared closure risk for independent hospitals, hospitals that were already affiliated with other hospitals in 2007, and hospitals that became affiliated after 2007.
The study has several key data points.
140 (6.3%) of the rural hospitals closed by 2019
The number of rural hospitals that were independent decreased dramatically over the study period, falling from 68.9% in 2007 to 47.0% in 2019
For financially distressed rural hospitals in 2007, affiliation was linked to a lower risk of closure compared to being independent (adjusted hazard ratio 0.49)
For financially stable rural hospitals in 2007, affiliation was linked to a higher risk of closure compared to being independent (adjusted hazard ratio 2.36)
For financially stable rural hospitals in 2007, for-profit ownership was linked to a high risk of closure (adjusted hazard ratio 4.08)
On average, affiliated hospitals had more beds than independent hospitals
Hospitals that were already affiliated in 2007 were more likely than independent hospitals to have maternal and neonatal care (71.7% versus 61.1%)
Hospitals that were already affiliated in 2007 or became affiliated after 2007 were more likely than independent hospitals to have mental and/or substance use disorder (MSUD) treatment and surgical care (80% versus 74%)
Overall, the percentage of rural hospitals in financial distress increased from 25.0% in 2007 to 30.2% in 2019
"The results of this cohort study suggest that affiliations may be associated with lower risk of closure for some rural hospitals in financial distress. However, among initially financially stable hospitals, an increased risk of closure for hospitals associated with affiliation and proprietary ownership raises concerns about the association of affiliation with closures in some circumstances," the study's co-authors wrote.
Interpreting the data
Rural hospitals experienced significant changes from 2007 to 2019, the study's co-authors wrote. "Approximately 6% of rural hospitals that were open in 2007 have now closed. Affiliations and financial distress have increased substantially, whereas market shares have declined. Downsizing was observed across the board in terms of decreases in number of beds and total volume of inpatient stays. During the study period, rural hospitals decreased maternal and neonatal, MSUD, and surgical inpatient services."
Some rural hospital closures may have been business decisions that were not aligned with community needs, the study's co-authors wrote. "Notably, hospitals that became affiliated during the study period had a higher rate of financial distress at the end of the study period, as well as a greater reduction in total inpatient volume and market share than independent hospitals, suggesting that these hospitals may have not performed well even after joining a system or merging with another hospital. Additionally, private for-profit ownership was associated with closure among financially stable hospitals."
Some financially distressed affiliated rural hospitals may have reduced risk of closure because affiliation provides access to more resources, the study's co-authors wrote. "Among financially distressed hospitals, affiliations were associated with a lower risk of closure compared with being independent. This finding did not hold in the subanalysis of hospitals that were independent in 2007, suggesting the protective association may have been associated with mature affiliations (i.e., hospitals already affiliated in 2007)."
Clinician compensation growth and productivity from 2020 to 2021 are comparable to levels seen before the coronavirus pandemic, according to AMGA data.
The coronavirus pandemic had significant impacts on clinician compensation and productivity in 2020. Patient service volumes decreased, with some clinicians furloughed and declines in office visits and elective surgeries.
The AMGA 2022 Medical Group Compensation and Productivity Survey is based on data collected from 383 medical groups that employ 183,000 clinicians. The survey features several key data points.
Median clinician compensation increased 3.7% from 2020 to 2021, compared to a 0.1% increase from 2019 to 2020
Compensation per work unit (wRVU) fell in 2021—clinicians were compensated 11.0% less for each individual unit of work in 2021 than they were in 2020
Productivity increased sharply—median total wRVUs increased by 18.3% from 2020 to 2021, compared to a 10.2% decrease from 2019 to 2020
The compensation increase indicates compensation growth is nearing pre-pandemic levels, Fred Horton, MHA, president of AMGA Consulting, told HealthLeaders. "You could say that should make up for two years of compensation, but there were guarantees put in place for 2019 to 2020 and productivity has not come all the way back. We are approaching the pre-pandemic compensation levels with the 3.7% rate of compensation escalation."
The 3.7% compensation increase from 2020 to 2021 compares favorably to compensation growth before the pandemic, he said. "On an annual basis, we normally see compensation increases of 1.7% to 3.0%. So, we are seeing a larger increase."
The increase in productivity offset the decrease compensation per wRVU, Horton said. "Based upon where productivity came in, it more than made up for the reduced compensation per work RVU. It made up for it in aggregate at an increase of 3.7% in compensation. So, even though we have a decreased compensation per work RVU, we have more than enough units in the marketplace to offset that decrease and still produce on average a 3.7% compensation increase for providers."
Two factors drove the 18.3% increase in median total wRVUs from 2020 to 2021, he said. "The first piece is a return of approximately 90% of the 10.2% decrease in median total work RVUs from 2019 to 2020. So, we almost returned to the productivity that we saw before the pandemic. The second piece, which is about 8% to 9% of the 10.2% decrease in median total work RVUs from 2019 to 2020, represents new values that were assigned to the evaluation and management (E&M) codes on an RVU basis. The RVU values went up for all of the E&M codes—the Centers for Medicare & Medicaid Services changed the RVU values on the E&M codes in 2021."
AMGA expects compensation and productivity to stabilize in 2022, Horton said. "Overall, we should be able to see more stable metrics—whether it is compensation, compensation per work RVU, or productivity. One of the things we have seen historically is that productivity tends to be relatively flat. We have seen large changes mainly because the coding weights changed. There should be the same underlying visit volume as we get back to pre-pandemic levels. I do not anticipate that there are going to be significant increases in productivity going forward."
Chief medical officers and chief nursing officers recently participated in a HealthLeaders virtual roundtable that focused on healthcare workforce issues.
The CMO/CNO panel at the HealthLeaders Healthcare Workforce of the Future virtual roundtable tackled a range of issues, including worker retention, adjusting care models, and using telehealth to address workforce shortages.
Workforce shortages have become a pressing issue for the clinical operations at health systems, hospitals, and physician practices across the country. The HealthLeaders Healthcare Workforce of the Future virtual roundtable was designed to focus largely on solutions to workforce shortage problems.
Strong leadership is essential to promote worker retention at healthcare organizations, panelists said.
"When you talk about retaining workers, you must have strong leadership in place. We need to develop local leaders and have a good succession plan for top leadership. When you have a good practice environment and clinicians feel empowered to come to work and do their job, that starts at the top of the organization," said Crystal Beckford, MHA, chief nursing officer and vice president of patient care services at Luminis Health's Doctors Community Medical Center in Lanham, Maryland.
"Leadership is crucial. There is a saying, 'People do not leave jobs—they leave managers,'" said Greg Kasper, MD, MBA, vice president of medical affairs-metro region at Toledo, Ohio-based ProMedica.
Employee engagement fosters worker retention, he said. "To succeed in retention, you need to engage the frontline staff. Often times, it is as simple as asking them, 'What do you want? What are you looking for?' Obviously, pay is usually an answer, but that is difficult right now with the financial constraints that healthcare organizations are under. Retention should be more than just pay, and engagement and purpose are very effective keys. Brainstorming solutions in open houses can go a long way to retain staff."
Avoiding rigid schedules is an effective retention strategy, Beckford said. "To retain workers, you must be flexible. Whether it is eight hours, six hours, or four hours, we must have flexibility in our work schedules and flexibility in our programs. If someone only wants to work over the summer, we need to have flexible workforce programs that make that possible. We need to support staff in the way they want to work, so they see your organization as the preferred place to work."
To retain workers, healthcare organizations need to be sensitive to the values of different generations of workers—Baby Boomers, Generation X, and Millennials—said Deana Sievert, DNP, MS, chief nursing officer at The Ohio State University Wexner Medical Center in Columbus, Ohio. "One of my colleagues on the East Coast came up with a great idea—getting a generational mentor. Get a Millennial mentor. Get a Generation X mentor. Talk with them and find out what you could be doing differently to meet the needs of the generations. While core things such as pay are generally the same for generations, you can do little things for each one of the generations and meet them where they are."
Adjusting care models
One way to address workforce shortages in the inpatient setting is to change care models to ease pressure on nursing and physician staffing, panelists said.
"We know we need to be careful with our nurse-to-patient ratios. But one of the things that we have the opportunity to explore is related to infusing some of our other disciplines into the inpatient care teams. For example, we know that in our current practice we have tried hard to increase mobility for our patients. One of the best people for mobility care are our physical therapists and the physical therapy assistants. So, we are looking to change the model not just for nurses and physicians but also looking at other disciplines and infusing them into the inpatient care models," Sievert said.
Adjusting care models can be tied to having clinical staff work at the highest point of their licensure, she said. "When we talk about getting nurses to work at the highest point of their licensure, off-loading some responsibilities to some of our other disciplines is a very good strategy. We haven't always been good at that, and we haven't always been wise at allowing more people into the inpatient space as an every-moment partner. They have been transactional—they come in and they perform their care, then they leave the unit. We have to think differently about how we use other disciplines and incorporate them into our inpatient care team."
In adjusting care models in the inpatient setting, leaders need to adopt unconventional approaches, Beckford said. "We are going to have to think about care models in a way that is totally different from how we have thought about them in the past. The physical therapists are there, the occupational therapists are there, the respiratory therapists are there. But we are experiencing a worker shortage across the board. So, we must look more at roles that do not exist today or have been tried on a smaller scale. For example, we are looking at nurse extenders for documentation—that could definitely save nurses time and a non-nurse could help with that."
Telehealth solutions
Telehealth offers opportunities to address workforce shortages, panelists said.
"We are all struggling with workforce shortages, and in the rural areas it is particularly tough. You cannot recruit physicians to work in rural areas. It is hard to find ICU nurses to work in rural areas. We need to leverage our relationships between rural hospitals and hospitals in urban areas with telehealth. Using telehealth in this way is not limited to physicians. You can do it with nursing and respiratory therapy, for example," Sievert said.
Respiratory therapy is a great example where telehealth can address workforce shortages, Kasper said. "Any time you have that kind of role that requires an experienced, highly skilled individual, you can apply telehealth as a solution. We were looking at respiratory therapy in a remote ICU during COVID surges—with a goal of managing an ICU patient remotely from our tertiary and quaternary referral centers. You need a lot of ancillary skills to evaluate the patient locally, but much of the care can be done remotely. We were using telestroke monitors to remotely and accurately evaluate patients. As long as the patient had appropriate lines and monitors in place, they were able to be managed remotely in many situations."
Telehealth can be a vital workforce resource even in urban areas, said Jeanette Nazarian, MD, vice president of medical affairs and chief medical officer at Howard County General Hospital, which is part of Baltimore-based Johns Hopkins Medicine. "My hospital is in a very populated county close to two large quaternary health systems in Baltimore, and we still struggle to get some of the specialty services. The irony of COVID is, as horrible as the pandemic has been, it forced people to move into virtual realms in ways that we would have never been able to persuade people was acceptable in the past."
Using telehealth has allowed Howard County General Hospital to offer several specialty services, she said. "We have telehealth for ophthalmology. We have telehealth for rheumatology because the rheumatologists do not come to the hospital anymore. The most important area where we are using telehealth because it was a crisis is for pediatric psychiatrists—we did not have any available in the hospital. There are a whole bunch of pediatric psychiatrists at Hopkins, so we started doing virtual visits with the pediatric psychiatrists. We worried that parents would be in an uproar that their kids were not seeing a doctor in person, but they did not care. They just wanted their kid seen."
Telehealth is also cost-effective, Nazarian said. "We have tried to use telehealth in areas where we have low volumes and paying someone to provide that coverage is exorbitant and does not make sense."
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At Bon Secours Mercy Health, clinicians serve on Clinical Transformation Committees and Physician Resource Optimization teams.
The supply chain subsidiary of Cincinnati-based Bon Secours Mercy Health has two formal ways for clinicians to participate in the supply chain function.
At health systems and hospitals, supply chain departments play a gatekeeper role in the acquisition of medical devices and supplies, particularly for new products. Physicians and nurses can play formal or informal roles in this decision-making.
At Bon Secours Mercy Health, the supply chain function is administered by a wholly owned subsidiary, Advantus Health Partners. Clinicians from the health system play two formal supply chain roles: Clinical Transformation Committees and Physician Resource Optimization (PRO) teams.
Clinical Transformation Committees
These committees meet to make supply chain decisions for specific specialties, says Jimmy Chung, MD, MBA, chief medical officer of Advantus Health Partners.
"These committees have voting members who are clinicians from each of our hospitals as well as operational leaders such as operating room directors and cath lab directors. These committees make decisions at a group setting at the system or ministry level. This is work that a lot of health systems would like to achieve because at many health systems decisions are made at the hospital level. If you have a health system that has 10 to 20 hospitals, you can imagine 10 to 20 different processes, and supply chain trying to listen to all of them. In terms of strategy, that situation is very difficult," he says.
Clinical Transformation Committee attendees can be as many as 200 people to participate in discussions, but the voting members are generally the key leaders and clinicians from the hospitals, which is usually less than 30 people. "We have created centralized Clinical Transformation Committees at the ministry level that make decisions where there is opportunity for standardization and reduction of unnecessary variation. This brings the best value for our patients," Chung says.
Physician Resource Optimization teams
PRO teams function under the clinical operational leadership at Bon Secours Mercy Health, Chung says.
"The function of the PRO teams is to look at specific initiatives that may be heavily influenced by the way physicians practice. They deal with physician preference items—these items are generally high-priced products such as orthopedic implants. The spend for these items can be in the tens of millions of dollars for an organization our size. The challenge with physician preference items is that there are many vendors in the industry; and with a health system such as ours with 50 hospitals, each hospital and its surgeons all like to do things their way. You end up with 30 or 40 different contracts with different vendors. That leads to a lot of waste, a lot of unnecessary variation, and potential safety issues," he says.
PRO teams, which are relatively new at Bon Secours Mercy Health, are ad hoc groups of clinicians, Chung says. So far, there have been several PRO teams in the cardiac area, there is one PRO team for orthopedic work, and one PRO team created for the spine category. A PRO team is being formed for vascular work. "They are mostly designed to be ad hoc, but they can continue to do initiatives as they come up in the same category or the same specialty," Chung says.
Typically, a PRO team will have eight to 10 physicians, he says. "They are generally meant to reflect each of our hospital markets."
PRO teams can be used to reduce the number of vendors for products such as implants, Chung says. "We may go to a PRO team with a situation in orthopedics where we are working with 40 vendors; but based on our use pattern, market shares, and clinical quality research, we think that we can reduce the number of vendors to five or six. We present this scenario to the PRO team physicians, who analyze the data. If they approve the move, we have a process for that standardization activity. If there are any specific clinical needs that are not met, the PRO team will let us know so that we can then get any outlier products."
Selecting physicians to play supply chain roles
The clinicians who serve on the PRO teams and the Clinical Transformation Committees tend to be physician leaders, Chung says.
"In general, the PRO teams have physicians who can serve as leaders and content experts. These physicians tend to have leadership responsibilities. They can be held accountable for initiatives at their local level. In the Clinical Transformation Committees, we have looked for physician leaders. We look for physicians who may not have the highest volume for a product but are aligned with the direction where we would like to go to provide the highest value to our patients. These physicians tend to be well known in the hospital markets—they are validated by the market chief clinical officers," he says.
Ideally, physicians who work in these supply chain roles have business savvy, but other qualities are also important, Chung says.
"We would love to have all physicians who work with the supply chain to have an understanding of how health systems work and how the business of healthcare works. But we can't ask for that. Every physician does not have those skillsets. We look for physicians who are open-minded and are open to the idea of teamwork. We look for physicians who are engaged and dynamic. We look for physicians who are willing to work with peers to work toward improvement in healthcare quality and value," he says.
Researchers find that 98% of emergency medicine residents are working in urban areas of the country.
Emergency medicine residents are disproportionately located in urban areas of the country, which is contributing to an emergency physician "desert" in rural America, a new research articlesays.
Earlier research on clinically active emergency physicians found that the number of emergency physicians increased by more than 9,000 from 2008 to 2020. However, 92% of emergency physicians were located in urban areas, with only 6% located in large rural areas and 2% located in small rural areas.
The new research article, which was published by Annals of Emergency Medicine, identified emergency medicine residents in the 2020 American Medical Association (AMA) Physician Masterfile and compared 2020 to 2008 data. The researchers also compared the number of Accreditation Council for Graduate Medical Education-accredited emergency medicine residency programs from 2013 versus 2020.
There were nearly 7,000 emergency medicine residents in the 2020 AMA data set. The overwhelming majority of the emergency medicine residents (98%) were located in urban areas, with 6,850 of the clinicians in urban areas, 114 in large rural areas, and 23 in small rural areas.
The number of residency programs increased significantly, from 160 in 2013 to 265 in 2020. However, the new residency programs were disproportionately added in states that already had a high number of programs.
In California, the number of residency programs increased from 14 to 22
In Florida, the number of residency programs increased from 5 to 19
In Michigan, the number of residency programs increased from 11 to 25
In New York, the number of residency programs increased from 21 to 31
In Ohio, the number of residency programs increased from 9 to 18
In Pennsylvania, the number of residency programs increased from 12 to 21
Several, mostly rural, states had no emergency medicine residency programs in 2013 or 2020: Alaska, Hawaii, Idaho, Montana, North Dakota, South Dakota, and Wyoming.
"The number of emergency medicine residency programs has increased; most new programs were added to the states that already had emergency medicine residency programs. There is an emergency physician 'desert' in the rural United States, lacking both residents and residency training programs," the co-authors of the new research article wrote.
Telehealth could help address the shortage of emergency medicine physicians in rural areas, the co-authors wrote. "One potential means of bringing emergency physician care to these rural areas without necessarily bringing the emergency physicians there could be an expansion of telehealth infrastructure and increased uptake of telehealth in the rural areas where emergency physician care is most needed."
Having emergency medicine residents work in rural areas is an attractive option to relying on telehealth, they wrote. "Increased emphasis on and availability of rural rotations for emergency medicine residents could alternatively provide residents exposure to clinical sites not routinely encountered in their training and increase the rate of graduating emergency physician residents relocating to these environments. Ultimately, if we are not increasing the opportunities for residents to practice in rural, more resource-limited environments, it is likely that many will be unprepared for the unique challenges of working in these environments and subsequently more unwilling to take more jobs in rural areas."
The internal medicine specialist society urges renewed effort to shift from volume-based physician payment to value-based payment models.
The American College of Physicians (ACP) has proposed a seven-part set of reforms to link physician payment to value and equity rather than volume of services.
Policymakers and lawmakers have been seeking to replace fee-for-service reimbursement in healthcare with value-based payment models since passage of the Patient Protection and Affordable Care Act in 2010. Despite more than a decade of effort, a recent study found that physician payment remains overwhelmingly based on service volume rather than service value.
ACP consists of internal medicine specialists and subspecialists. With more than 160,000 members in several countries, ACP is the largest medical-specialty society in the world.
This week, ACP published the organization's seven-part set of physician payment reforms in a position paper in Annals of Internal Medicine. Physician payment models dominated by fee-for-service approaches do not promote value or equity in U.S. healthcare, the position paper says. "Socioeconomic factors remain one of the most clinically significant contributors to health outcomes in this country, yet the current fee-for-service payment structure incentivizes volume and does not address such factors. The American College of Physicians proposes specific policy recommendations on reforming payment programs, including those designed to treat underserved patient populations, to better address value in healthcare, and achieve greater equity."
The position paper says there is a need to design "smarter" healthcare payment models. "The approach of building a healthcare system that is smarter about how dollars are spent to make people healthier must shift to one with a clear intention of decreasing health inequities and addressing social drivers of health."
The position paper urges more meaningful efforts to create value-based payment models. "Policy leaders and the clinical community must work together to make progress toward equity using value-based payment. For more than a decade, policy goals have highlighted the need to achieve greater equity, yet the fact remains that execution of these policies continues to lag. Now is the time to set a national intention to build on that experience and support implementation and assessment of payment approaches to advance health equity and overcome social drivers and other disparities that lead to poorer health outcomes."
Position one
ACP calls on Medicare and other payers to craft population-based, prospective payment models for primary and comprehensive care. These payment models should promote access to care and address healthcare disparities and inequities that are related to personal characteristics and/or social drivers of health. New payment models should be designed to improve care for underserved patient populations.
Position two
Research should be conducted to measure the cost of caring for patients who are impacted by healthcare disparities and inequities based on personal characteristics and/or social drivers of health. In value-based payment models, performance and cost measures should be adjusted for risk, health status, and social drivers of health. Performance and cost data should be used to improve the value of primary and comprehensive care.
Position three
Medicare law should be modified to establish a way to calculate savings from increased investment and payments for primary care and preventive healthcare services (Part B) that reduce emergency room visits and hospitalizations (Part A). These savings should be reinvested in primary and preventive care as well as social and public health services. Investment in primary care should not be based only on short-term cost savings because primary care improves population health, and some savings are generated over several years.
Position four
The federal secretary of health and human services should reform the Medicare Quality Payment Program to ensure the program addresses inequity, healthcare disparities, and social drivers of health. New policies and financial approaches should encourage physician practices to adopt value-based payment models.
Position five
Delivery and payment systems should support clinicians and healthcare facilities in offering care to patients when and where they need it in a range of modalities, including in-person visits and telehealth. This approach to care is particularly important for patients experiencing healthcare disparities and inequities based on personal characteristics and/or social drivers of health. These delivery and payment systems should not add administrative burdens on clinicians or inappropriately question clinician judgment.
Position six
Money should be allocated for the development of health information technology systems and communication capabilities such as broadband so that delivery and payment reforms address the needs of all patient populations. These capabilities should help patients who are experiencing healthcare disparities and inequities linked to personal characteristics and/or social drivers of health. Policies fostering these capabilities should not unintentionally redistribute resources away from at-risk patients or create incentives to avoid at-risk patients.
Position seven
Healthcare stakeholders including policymakers, payers, health systems, private-sector investors, and philanthropic organizations should develop financing mechanisms other than direct payment to clinicians such as grants to address inequities, healthcare disparities, and social drivers of health.
The new top doctor at Atlantic Health System views mentoring as one of her favorite job responsibilities.
Every member of a health system has a responsibility to promote quality care, the new chief clinical officer of Atlantic Health System says.
Suja Mathew, MD, was hired recently to serve as executive vice president and chief clinical officer of the Morristown, New Jersey-based health system. Before joining Atlantic, she was the chair of medicine for the Cook County Health and Hospitals System in Cook County, Illinois.
HealthLeaders recently talked with Mathew about a range of issues, including quality care, patient access, research and academic programs, and mentoring. The following is a transcript of that discussion, which has been edited for brevity and clarity.
HealthLeaders: As chief clinical officer, how can you promote quality care?
Suja Mathew: Every individual in this organization must promote quality care. That applies to every clinical individual and every non-clinical individual. We all need to be committed to providing quality care.
Having said that, as chief clinical officer, our quality and patient safety programs roll up to me, so I have direct accountability. We have a long history of being recognized as a high-quality provider of patient care and a safe provider of patient care. I will be looking at our programs—always looking to see where we can improve. My goal is to be better. We are great now and we are going to be better. As our environment continues to shift and as challenges in our industry continue to affect us, we will be looking for opportunities to improve.
HL: How are you going to approach improving patient access to Atlantic's network of care?
Mathew: The key is to ensure no matter where a patient or family member enters the Atlantic Health System that individual will have access to the very best care that we offer should they need it. My goal is to make sure that we continue to look at what our patients and our communities need in place where they are and to match that up with the resources that we have in local communities.
I also want to create clear routes where patients can, if needed, access our secondary and tertiary services. So, when they need to stay healthy, we want to achieve that locally; but when they need a higher level of care, they will be able to access all of the resources that we have at Atlantic.
HL: How are you going to approach elevating the health system's research and academic programs?
Mathew: Clinical work and academic programs are symbiotic. We provide outstanding clinical care at Atlantic, and that is exactly the type of system where you want to educate learners. That is also the type of system where you want to conduct research. These areas fuel each other.
We are already providing excellent clinical care, we are already doing meaningful research particularly in clinical trials, and we are already doing impactful medical education. We are going to try to continue to build the connections between each of those three pieces of work so that our research and our clinical trials elevate the clinical services that we can provide to our patients. We want our educational programs to elevate the clinical interaction that we have with our patients. We want the great clinical work that we are doing to be fully leveraged to educate our learners and clinicians of tomorrow.
HL: How did serving as chair of medicine for the Cook County Health and Hospital System prepare you for the role as chief clinical officer at Atlantic?
Mathew: I was at Cook County Health and Hospital System for 22 years. I grew up professionally in that system. In my last role there, which was as chair of medicine, I oversaw delivery of internal medicine and oversaw education and research activities throughout the department. So, that range of work is similar to what I am doing at Atlantic as chief clinical officer; however, the scope of what I do at Atlantic is larger.
Cook County was a wonderful place for me to be for so long. It is a public health system that does great work but does so within a very challenging environment. Learning as a clinician in that environment and learning how to lead in that environment has prepared me for working at Atlantic. I learned how to hone my creativity and my ingenuity while working in an under-resourced environment. I will bring that skillset to Atlantic.
HL: What are the key elements of promoting career sustainability and professional satisfaction among physicians?
Mathew: There are three pillars of professional satisfaction for physicians. First is ensuring a long and sustainable career in medicine. I would break that down to looking at the system within which we practice medicine—we need to ensure that the system promotes high-level activity. Everyone on the care team should be working at the top of their license. So, physicians should be involved in activities that are designed to fully utilize their skillset and knowledge base.
The second element of sustainable professional satisfaction is to look at the individual's resilience. By and large, the clinical workforce has highly resilient people. We have gone through many years of training and preparation for this work. We are strong. Still, we need to make sure we are allowing our clinicians to invest in themselves. We must support their time away from work.
The third element of creating sustainable professional satisfaction is to look at our leadership. The leadership under which clinicians practice is very impactful in the level of professional satisfaction that they feel. Leaders must have the right qualities—their communication skills must be optimal, they need to be able to motivate the folks who report up to them, and they need to provide an environment that promotes career growth.
HL: What are the primary elements of serving as a mentor to residents and faculty members?
Mathew: This is one of my favorite things to do. I served as a program director and medical educator for most of my career. As a medical educator, what you do as a course director or a program director is you have direct contact with a lot of learners. As the chair of medicine, I had direct contact not only with learners but also with faculty and young leaders. I delight in the opportunity to be part of people's success stories.
There are formal programs that can facilitate mentoring. But at the end of the day, it takes individuals who will be generous with their time to invest in learners and younger colleagues. For us as leaders, it is often a matter of a little bit of our time and energy for a significant payoff. I have been the recipient of strong mentoring over the years as well as sponsorship, both of which have propelled my career in ways that I could not have imagined. I feel it is a responsibility to pay that back, but it is also a great joy to be a mentor.
Researchers have compared Medicare Part D generic drug pricing with pricing at the Mark Cuban Cost Plus Drug Company.
The Medicare program could realize significant generic prescription drug cost savings if it could match the prices of the Mark Cuban Cost Plus Drug Company (MCCPDC) direct-to-consumer model, a new research article shows.
Nationwide spending on prescription drugs has increased sharply in recent decades, increasing from $30 billion in 1980 to $335 billion in 2018. In 2019, the United States spent more than $1,000 per capita on prescription drugs, a spending level higher than other high-income countries.
The new research article, which was published today by Annals of Internal Medicine, is based on an analysis of 109 generic drugs sold by MCCPDC in February 2022. The researchers found comparable Medicare Part D plan pricing for 89 of the generic drugs, and they calculated pricing differences for the maximum (90 count) and minimum (30 count) quantities available.
The research article features several key data points.
The estimated annual Medicare spending on the 89 targeted generic drugs was $9.6 billion.
If Medicare purchased generic drugs at the maximum quantities available from MCCPDC, the program could have saved $3.6 billion on 77 of the 89 generic drugs. This represented a 37% cost savings.
If Medicare purchased generic drugs at the minimum quantities available from MCCPDC, the program could have saved $1.7 billion on 42 of the 89 generic drugs. This represented an 18% cost savings.
The drug with the highest cost savings was esomeprazole at $293 million in savings.
"Our findings suggest that Medicare is overpaying for many generic drugs, which is consistent with findings that Medicare overspent on 43% of generic prescriptions in 2018 relative to Costco member prices," the research article's co-authors wrote.
In the United States, the system used to purchase generic drugs is not cost-effective, the research article's co-authors wrote. "Generic drug competition is a major source of prescription drug savings in the United States, but the lower prices from a direct-to-consumer model highlight inefficiencies in the existing generic pharmaceutical distribution and reimbursement system, which includes wholesalers, pharmacy benefit managers, pharmacies, and insurers. By one estimate, this supply chain retains 64% of every dollar spent on generic drugs."
The research article's co-authors offer a prescription for improving the cost-effectiveness of U.S. generic drug spending. "Although direct-to-consumer private companies like MCCPDC may offer savings for some patients on select drugs, policy reforms that improve price transparency, increase competition for high-cost generic drugs, prevent annual price increases, and limit pharmacy and distribution costs could increase affordability of essential generic medicines for all Americans."
