A new analysis examines cost changes for diseases tracked in the federal Bureau of Labor Statistics' Disease Based Price Indexes.
The average cost of treating disease in the United States increased 60% from 1999 to 2022, according to a new report by HealthCare.com.
The United States spends more on healthcare services than any other country. In 2022, national health expenditures are expected to increase at 4.6%, driven in part by higher healthcare prices linked to inflation in the economy, according to a recent analysis by the Centers for Medicare & Medicaid Services. Healthcare spending is expected to total $4.5 trillion this year, the CMS analysis found.
The new report is based on an analysis of the federal Bureau of Labor Statistics' Disease Based Price Indexes. The federal data tracks the costs to treat 115 diseases.
The new report has several key data points.
The average cost of treating disease increased 1.6 times from 1999 to 2022
Intestinal infections experienced the largest treatment cost increase, rising 4.3 times from 1999 to 2022
After intestinal infections, the two diseases that experienced the largest treatment cost increases were tonsillitis (4.19 times increase) and diseases of the mouth excluding dental (4.16 times increase)
Diabetes with complications experienced the largest treatment cost decrease, falling to 0.2 in 2022 compared to a base treatment cost of 1 in 1999
After diabetes with complications, the two diseases that experienced the largest treatment cost decreases were heart attack (0.39 times decrease) and arterial blood clot (0.52 times decrease)
For disease categories, "symptoms; signs; and ill-defined conditions" experienced the largest treatment cost increase, rising 2.4 times from 1999 to 2022
For disease categories, cancer experienced the largest treatment cost decrease, falling to 0.9 times what it cost to treat in 1999
Interpreting the data
The causes of increasing cost for treating disease include three factors, says Dan Grunebaum, MS, a data journalist at HealthCare.com. "Inflation in the cost of goods and services needed to treat a disease is one factor that can lead to an increase in treatment cost. Another factor is that treatments can become more intensive due to rising disease severity, and thus more costly. A third factor is that the medical coding of diseases can change over time, making them appear more costly to treat in the index.
Similar factors contribute to decreasing cost for treating disease, he says. "The cost of goods and services needed to treat a disease can go down. For example, a drug can go generic and drop in price. Alternatively, treatments can become less intensive due lower disease severity. Another factor is technological advances in treatment leading to cost declines. Finally, changes in coding diseases can make treatment cheaper. For example, a milder level of diabetes that was previously coded as 'diabetes' is recoded as 'diabetes with complications,' making 'diabetes with complications' effectively more costly to treat."
The data on diseases that experienced the biggest increases in treatment cost reflect three trends, Grunebaum says.
"One of the main trends seen in diseases that increased the most in treatment cost is increasing severity of the disease. In the index, intestinal infections, including common bugs like E. coli, saw the most growth in treatment cost, rising 4.3 times by 2022 against the base of 1 in 1999. Bureau of Labor Statistics economist Brett Matsumoto told us, 'This is consistent with more severe infections becoming relatively more common. For intestinal infections, the increase in utilization appears to be driven by an increase in inpatient hospitalizations and emergency room visits.'"
"Consistent with the large rise in cost of treating intestinal infections is the fact that three out of five diseases to see the greatest percent growth are conditions of the digestive system."
"Looked at by disease category, infectious and parasitic diseases show the fourth largest growth in cost. It is possible that the rise of antibiotic resistant bacteria is partly behind the increase in severity and cost of treating infections."
The data on diseases that experienced the biggest decreases in treatment cost reflect three trends, Grunebaum says.
"Technological advances leading to treatments being performed in less intensive settings, such as outpatient instead of inpatient, is one trend behind large decreases in treatment costs."
"The substitution of cheaper generics for expensive drugs is another trend."
"Finally, better preventive care is an important trend lowering treatment costs for some diseases. Two out of the five diseases to see the most decrease in treatment costs are circulatory illnesses. Harvard health economist David Cutler notes in the [report] that, 'The number of people having heart attacks and strokes is way down. Part of that is because we have much better preventive care. That's a huge factor in medical care: the ability to prevent and treat cardiovascular events. And that's having a huge effect on spending.'"
The incidence of behavioral health conditions is increasing and patients with behavioral health conditions have relatively high medical costs.
Healthcare payers that can improve treatment of behavioral health conditions will generate a competitive advantage and reduce the risk associated with political solutions, according to a new Moody's Investors Service report.
Patients with behavioral health conditions have higher medical costs than patients without behavioral health conditions. In the United States, the number of people with behavioral health conditions has been increasing in recent years, with the incidence of behavioral health conditions rising sharply during the coronavirus pandemic.
"The steady rise in behavioral health diagnoses, and the corresponding increase in medical costs, underscores U.S. health insurers' need to augment and improve the integration of behavioral health services within the full range of their offerings. Those companies that are successfully able to manage behavioral health, and contain medical costs, can also reduce the likelihood that the industry will face political solutions to address this problem[, which come with associated risk]," the Moody's report says.
Behavioral health conditions increase medical costs and healthcare payers have been responding to the challenge, the Moody's report says. "Average annual medical costs for those with behavioral health conditions are 3.5x higher than for those without such conditions, according to one study. In response, the health insurance industry has been devoting more resources to identifying and treating behavioral health conditions in a more coordinated manner than in the past, while also better using digital capabilities such as telehealth for treatment and diagnosis."
Earlier research found that behavioral health conditions have been increasing in the U.S. population in recent years. For example, from 2010 to 2018, the number of adults with major depressive disorder jumped 12.9% to 17.5 million. During this period, the overall cost of major depressive disorder skyrocketed 37.9%, rising from $236.6 billion to $326.2 billion.
"According to the National Health Interview Survey, covering January – June of 2019, 11% of adults reported symptoms of anxiety disorder and/or depressive disorder. That number increased to 41.1% by January 2021. This reflects many factors including isolation, job loss, and deaths of close friends and relatives. For children, the pandemic has been especially tough. In October 2021, The American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, and the Children's Hospital Association, citing the pandemic, declared a national emergency in children's mental health," the report says.
One strategy healthcare payers have pursued to respond to the increased incidence of behavioral health conditions and associated hikes in medical costs is the acquisition of specialist companies, the Moody's report says.
"In 2020, Anthem Inc. (Baa2 stable) acquired Beacon Health Options Holdco Inc., the largest behavioral health organization in the U.S., thereby improving its ability to manage behavioral problems of its members. Also in 2020, UnitedHealth Group acquired AbleTo, which uses advanced analytics to identify individuals with unmet behavioral health needs and provide cognitive based therapy. And in 2021 Centene Corporation (Ba1 stable) acquired Magellan, a leading behavioral health company. In each of these cases, the companies will generate third-party revenue and earnings, but a key consideration in each acquisition is the ability to better identify and treat behavioral health issues and generate better outcomes and, thereby, reduce medical costs," the report says.
The hospital launched its Maternal Wellness Program in August 2020 and expanded the initiative after six months.
Yale New Haven Hospital has successfully launched a clinical program to address the mental health needs of new mothers.
After childbirth, new mothers can experience a range of mental health conditions, says Maria Raffia, LCSW, a clinical social worker at Yale New Haven Hospital's Maternal Wellness program.
"There's something called the Baby Blues, which happens around two days to two weeks after a woman delivers. That impacts about 60% to 80% of women. It's due to an influx of hormones. If the mood disorder lasts longer than two weeks, that's when we see postpartum depression and postpartum anxiety, which are the main conditions we see among our moms. We also work with moms who experience postpartum obsessive-compulsive disorder," she says.
The hospital launched the Maternal Wellness Program in August 2020, with one location, but demand for services quickly led to an expansion of the initiative, says Maria Mackeil, MSN, DNP, director of women's specialties at Yale New Haven Hospital. "We originally started with just one social worker, who was trained to do therapy sessions. Within six months, we realized that we had grown beyond our capacity, so we added a second social worker and two additional sites. The social workers are at different sites on different days of the week."
Service volume is one of the key performance metrics for the Maternal Wellness Program, Mackeil says. "Volume … gives us information about whether we have capacity. When we reach capacity, we have to look at the potential for expansion of the program, which happened right after launching the program a year and half ago."
In the first six months of the program, there were 500 visits with new moms and family members, Mackeil says. From September 2020 to September 2021, the clinical social workers conducted more than 1,300 visits that affected more than 130 families, she says.
Meeting an unmet need
Yale New Haven Hospital decided to launch the Maternal Wellness Program based on feedback from obstetricians in the hospital's market, Mackeil says.
"When this program was established, it came out of a driving need that was made clear to us by our community providers. Our obstetrics providers saw a need for their patients that they were not able to meet. They saw women who had mood disorders and there was no place to refer them to. There was limited access to care, and that was our primary driver for creating this program. We listen to our community providers very closely because they clearly know what their patients need the most," she says.
A range of services are offered to new moms and their families, Mackeil says. "The Maternal Wellness Program offers services to treat our mom's mood disorders through psychotherapy, screening, psychoeducation, individual therapy, couples' therapy, and risk assessments. We also work with their obstetrics providers for coordination of care."
Screening is a key service to assess patients and gauge their progress, Raffia says. "We use the Edinburgh Postnatal Depression Scale, which is something that we do at intake and every three to four sessions. This scale looks at how moms are doing over time."
Providing access to services is a primary goal of the Maternal Wellness Program, Mackeil says. "The program is open to all women, who can self-refer, which is wonderful. One of the things that we pride ourselves on is improving access to care for our moms and families. That is why we offer the program at three locations, and we have telehealth options for moms who have trouble with access to transportation."
The coronavirus pandemic was part of the impetus to establish telehealth services at the program, Mackeil says. "We opened when COVID was hitting a peak, and that required us to be creative in establishing the telemedicine aspect of seeing patients. While we realize that telemedicine is not ideal—we want to see our patients face-to-face—it fills a need to make sure our patients have access to care."
Rising to challenges
The Maternal Wellness Program has faced several challenges since it was launched, Mackeil and Raffia say.
"There are challenges in launching in any program. For us, we had never had a program like this at Yale New Haven Hospital, so we had challenges along the way. We had to figure out the best way to build the program. We knew that we were going to have patients—planning treatment was the easy piece. The harder piece was the logistics around the program—the funding, the development of education for social workers, and the structure," Mackeil says.
The primary source of revenue for the program is service reimbursement from Medicaid and commercial insurers. "The program is financed through the hospital, and we bill for services," Mackeil says.
Stigma is a major challenge, Raffia says. "A big barrier is the stigma around postpartum depression and anxiety. Many moms feel that this should be a happy time, but they are having feelings that are not usual to them, and that is hard. We try to normalize mood disorders when our moms come in. We also have social workers in some of our community clinics, and they work with us in normalizing mood disorders and talking about it more often."
Community outreach is an ongoing challenge, Mackeil says. "We have been trying to get information out to obstetrics providers in the community to make sure that everyone is aware of the services and to see what their needs are."
It is also necessary to conduct community outreach with patients, Raffia says. "Another barrier is moms not knowing about the options for care. We are trying to address that through community outreach."
Last year, Providence launched or expanded several telehealth services, and service volumes surged.
As long as there is a payment model, telehealth utilization will be robust at health systems, hospitals, and physician practices, the chief medical technology officer at Providence health system says.
The Centers for Medicare & Medicaid Services (CMS) expanded reimbursement for telehealth services at the start of the coronavirus pandemic. The expanded reimbursement, which is set to continue during the pandemic's Public Health Emergency, has fueled an unprecedented level of growth in telehealth services.
At Providence, telehealth has flourished since the beginning of the pandemic, according to the Renton, Washington-based health system's Telehealth Annual Reportfor 2021. Since the start of the pandemic in March 2020 through 2021, Providence's COVID-19 home monitoring reached nearly 30,000 patients and ambulatory virtual visits surpassed 3 million encounters.
Providence operates more than 50 hospitals in seven states: Alaska, California, Montana, New Mexico, Oregon, Texas, and Washington.
After a significant drop-off in the beginning of 2021, video visits at Providence stabilized at about 100,000 encounters per month last year. Chief Medical Technology Officer Todd Czartoski, MD, expects that level of utilization to continue this year.
"In 2022, we are right around 100,000 encounters per month. In January, we were at nearly 200,000 because there was another surge of COVID. But since then, it has come back to around 100,000 and has stayed consistent at that level. My expectation for the remainder of 2022 is that video visits will stay around 100,000 per month. The main driver that is facilitating that level of utilization is the Public Health Emergency. The biggest predictor of what will happen with volume over the long-term is what will happen with CMS reimbursement. As long as the payment model is there, video visits at Providence will hover around 100,000 per month," he says.
The country's healthcare system would benefit from making the expanded CMS telehealth reimbursement permanent, Czartoski says. "Right now, we know the Public Health Emergency will extend until the middle of July, and we believe it will extend until the end of the year. Hopefully, they will put something permanent in place."
Telehealth growth at Providence in 2021
Providence launched or expanded several telehealth programs in 2021, according to the Telehealth Annual Report.
Providence Hospital at Home launched in July 2021. The hospital at home program includes a technology-enabled virtual MD and RN command center.
The health system's Behavioral Health Concierge program, which provides counseling services to employees and their family members at Providence and several large companies, experienced explosive growth in 2021. Behavioral Health Concierge's virtual visits grew 167% and the number of the program's licensed clinical social workers doubled to 17. At the end of 2021, the program served 500,000 lives.
Tele-EEG services were expanded through a partnership that features Cerribell EEG technology.
The health system's telepsychiatry program, which provides virtual behavioral health expertise to emergency departments and inpatient units, added Harbor Regional Medical Center in Aberdeen, Washington. The program now serves 34 hospitals in Alaska, California, Oregon, and Washington.
Providence's TeleHospitalist program, which primarily supports hospitals with nighttime telehospitalist services, continued to expand. In 2020, TeleHospitalist providers were enlisted to cover Providence Covid Home Monitoring alongside nurses. In 2021, telehospitalists started serving as command center physicians for the Providence Hospital at Home program.
The Providence TeleStroke program added 16 sites across five states.
Several new telehealth services launched in 2021, including TeleTransplant at Providence St. Joseph Hospital Orange, TeleVascular Surgery Consults in Spokane, Washington, and TeleOncology visits and patient support groups in several regions.
Two factors loom large in future telehealth growth at Providence and nationally, Czartoski says.
"It is tied to the payment model. Growth of telehealth depends on how long the Public Health Emergency stays in place or CMS acts to make reimbursement for telehealth permanent. That will predict how broadly you will see utilization in the United States. The second factor is risk. If we are moving from Medicare fee-for-service to Medicare Advantage, that will be another driver of telehealth utilization as we see more commercial, value-based contracts," he says.
Embracing remote patient monitoring
Providence is planning to expand its use of remote patient monitoring (RPM), and the health system is looking for an RPM platform partner, Czartoski says.
"We have had great success with our COVID home monitoring program—more than 30,000 patients have been monitored. Going forward, our RPM efforts depend on the use case. The platform of choice has to have flexibility. Sometimes, you need Bluetooth connectivity, which tends to be more expensive for medical grade equipment. Sometimes, you just need something that the patient can self-serve such as checking their oxygen level with a pulse oximeter and self-reporting. The current rules around CMS reimbursement require RPM to be automated, not self-reported by a patient. So, for that type of a requirement, you need Bluetooth connectivity," he says.
The move from fee-for-service reimbursement to value-based care is a driver of RPM utilization, Czartoski says. "As we are taking care of populations of people—particularly those who have diseases that can exacerbate such as congestive heart failure and require vigilance over a long period of time—it makes a whole lot of sense to be monitoring at home and keeping people safe, so they do not end up in the emergency department."
Providence has a vision for RPM, but the ultimate mix of services is uncertain, he says. "Our primary focus, at least initially, will be on a handful of diseases such as congestive heart failure, chronic obstructive pulmonary disease, and diabetes. That's where our plans are now, but the ultimate platform we choose will have to be flexible as our needs change going forward. We have hospital at home now, but we expect to expand that to other low-acuity conditions that we will monitor in the home. A platform that is scalable and flexible is important to us."
The health system employs physicians as supply chain medical directors and nurses as value analysis nurses.
Physicians and nurses play a formal role in supply chain at Yale New Haven Health.
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.
Lorraine Lee, MHA, is senior vice president of clinical operations at Yale New Haven Health, and she formalized the role of physicians and nurses in supply chain at the New Haven, Connecticut-based health system. "I have been responsible for supply chain for four years. When I got there, there was no infrastructure within supply chain to have doctors and nurses be part of the department. That's something we started right away," she says.
Physicians and nurses play key roles in the health system's supply chain department, Lee says. "I have a medical director and an associate medical director who are doctors and work for the supply chain department. I also employ nurses, many of whom have worked in operating rooms, critical care, and the emergency department. Those are usually the types of physicians and nurses we like to have involved in supply chain because they are used to devices and using medical supplies—they have worked in procedural areas or surgery."
The medical directors have backgrounds in emergency medicine and anesthesiology.
Lee says she looks for communication skills, authenticity, and transparency for doctors to fill the medical director roles. "They need to be someone who can be approachable by the physicians they have to deal with. They are often the ones who are trying to figure out whether a device or medical supply is the right one to have, so they have to ask questions and be approachable. They have to be able to talk with all levels of physician staff, from training physicians all the way up to chairmen of departments. They need to be able to understand where the requesting physician is coming from."
The eight nurses who work in the supply chain department as value analysis nurses all have extensive clinical experience, she says. "Most of my nurses have worked as nurses for 15 to 20 years at the bedside. So, they have seen it all. They know how to use medical supplies and devices. They understand procedures. The more we can hire nurses with that kind of background the better because a surgical nurse, an emergency department nurse, or a nurse who has worked in the diagnostic cath lab can understand supplies."
Doctors and nurses play formal role in supply chain decisions
The medical directors and value analysis nurses work collectively as a team, Lee says.
"They review our formulary of medical supplies. Due to supply chain backorders, they look at things that we cannot get in, which happens as many as hundreds of times a day. They find out what we can use instead, what is safe for the patients, and what is good for the caregivers to use. They do a lot of backorder management or outage management for supplies. They also review all new requests. So, if a new surgeon joins our health system and wants to use a new device or a new supply that we do not have on our formulary, they review the request. They review for safety profile, for how well it works in other places, and other information they can get about it."
After new requests have been reviewed, they are submitted to a physician forum—the Clinical Governance Committee—that meets monthly to decide whether requests for new devices and supplies are approved, she says.
"The Clinical Governance Committee is a group of physicians from across our health system in all of the specialties. They congregate once a month, and supply chain manages the agenda and recommendations for new things to be added to the formulary. We make presentations to this group of physicians for a vote. For new products, there are several considerations at this meeting. For example, is it a new and enhanced supply that will help our patients or is it just like the supply that we have and does not offer any advantage?"
Doctors and nurses generate benefits in supply chain roles
Having physicians and nurses working in formal supply chain roles establishes credibility for the department, Lee says. "The biggest win is that we consider ourselves to be a clinically integrated supply chain. The broader view is that supply chain is not making decisions about supplies and devices based on cost alone. We are bringing in the right devices or supplies for patient care. People believe in that because we have physicians and nurses helping to make the decisions."
Physicians and nurses have backgrounds that help them perform admirably in supply chain departments, she says. "Physicians and nurses are vastly experienced in reading medical literature and understanding the pros and cons of a new therapy or a new device. So, they are able to look at decisions with a medical eye and use evidence-based medicine in their review of products."
Physicians and nurses can also play a role in staff development, Lee says. "They can teach—they teach members of my staff who are not clinical. We have people who work in contracting or on the procurement staff who tend to not have a clinician background, and it is beneficial for them to learn from physicians and nurses."
The pandemic has worsened the life expectancy gap between the United States and other high-income countries, researchers find.
Compared to 21 peer countries, the United States experienced a large decrease in life expectancy from 2019 to 2020, and life expectancy dipped sharply for Hispanic and Black U.S. populations, a new research article indicates.
In 2020, there were more deaths from COVID-19 in the United States than any other country, and Americans had relatively high COVID-19 mortality rates. Before the pandemic, the United States had one of the lowest life expectancy rates among high-income countries.
The new research article, which was published by JAMA Network Open, examined data for three racial and ethnic groups that account for most of the total U.S. population: Hispanic, non-Hispanic Black, and non-Hispanic White. The 21 peer countries in the study were Austria, Belgium, Canada, Denmark, England and Wales, Finland, France, Germany, Israel, Italy, Netherlands, New Zealand, Northern Ireland, Norway, Portugal, Scotland, South Korea, Spain, Sweden, Switzerland, and Taiwan.
The study generated several key data points.
From 2019 to 2020, life expectancy in the United States fell by a median of 1.87 years, from 78.86 years to 76.99 years.
The Hispanic (3.70-year decrease) and non-Hispanic Black (3.22-year decrease) U.S. populations experienced significantly larger decreases in life expectancy than the non-Hispanic White U.S. population (1.38-year decrease).
Hispanic men (4.31-year decrease) and non-Hispanic Black men (3.54-year decrease) had the largest drops in life expectancy in the United States, compared to a 1.53-year decrease among non-Hispanic White men.
In the 21 peer countries, life expectancy fell by a mean of 0.58 years.
In 2020, the mean life expectancy in the peer countries was 4.51 years higher than U.S. life expectancy (81.50 years versus 76.99 years).
In the 21 peer countries, Spain experienced the largest decrease in life expectancy, falling 1.43 years. There were increases in life expectancy in New Zealand, South Korea, and Taiwan.
"The large and highly racialized decreases in U.S. life expectancy underscore the growing U.S. health disadvantage relative to peer countries and the need for policies that prioritize health and equity," the research article's co-authors wrote.
Assessing decrease in U.S. life expectancy
Stagnation and decreases in U.S. life expectancy since 2010 are due to multiple factors, the research article's co-authors wrote. There has been increasing mortality rates among young and middle-aged adults from causes including drug overdoses, cardiometabolic diseases such as diabetes, and other chronic illnesses.
Compared to peer countries, there are several systemic factors that contribute to the "U.S. health disadvantage," the research article's co-authors wrote.
The United States ranks low on social and economic conditions such as education, poverty, and affordable housing
The United States ranks low on health-promoting environments and infrastructure such as walkability and access to healthy food
The United States ranks low on social well-being such as racial segregation and social isolation
The United States ranks low on healthcare access and health insurance
"In contrast to policies adopted by its peers, U.S. social welfare spending is less equitable and less beneficial to children and families. The United States also lacks universal healthcare and provides weaker protections for public health and safety," the research article's co-authors wrote.
The systemic shortcomings in the United States made the country susceptible to high mortality rates during the coronavirus pandemic, the research article's co-authors wrote.
"These preexisting conditions, combined with mismanagement of federal, state, and local pandemic responses and factional public resistance to practices to prevent viral transmission, drove U.S. death rates above those experienced by other countries. The excess deaths included not only those attributed to COVID-19 but also non-COVID deaths associated with social and economic disruptions of the pandemic, along with inadequate or delayed care of acute emergencies and chronic illnesses and behavioral health crises that fueled a record increase in fatal drug overdoses," they wrote.
During the pandemic, conditions were ripe for a large decrease in life expectancy among Hispanic and non-Hispanic Black Americans, the research article's co-authors wrote.
"The large decreases in life expectancy among Hispanic and Black populations reflect their higher risk of hospitalization and death from COVID-19 and vulnerability to conditions causing non-COVID deaths. The racialized health inequities that were conspicuous in 2020 have existed for generations, the products of systemic racism, segregation, and exclusionary policies. Historic and current conditions have systematically blocked racial and ethnic minority groups from access to healthcare, social and economic mobility, and environmental conditions that determine health and life expectancy," they wrote.
Healthcare worker burnout was a top concern for health systems, hospitals, and physician practices before the coronavirus pandemic, and it has reached crisis proportions during the public health emergency.
Prior to the pandemic, burnout rates averaged in the range of 30% to 50%; now, average burnout rates range from 40% to 70%, a healthcare worker well-being expert recently told HealthLeaders.
At Bon Secours Mercy Health, physician burnout has increased during the pandemic, says Herbert Schumm, MD, vice president, and medical director of education and physician engagement at the Cincinnati-based health system.
"We do a physician engagement survey every fall, and through that we have our baseline burnout numbers for both our physicians and our advanced practice providers. We are pretty much in line with the national trends. When we compare early in the pandemic with last fall, year-over-year, we were up about 17 percentage points, which is consistent with national levels that are up about 21 percentage points," he says.
Awareness of healthcare worker burnout has increased dramatically, Schumm says.
"There are some practical reasons for this change. In particular, we have Lorna Breen, a physician who died of suicide at the beginning of the pandemic and received national attention. That raised awareness. Also, folks realize that healthcare professionals overall—nurses, respiratory therapists, physicians, and others—are experiencing burnout. Awareness is higher than it's ever been. When we look at some of the legislative work that is going on across the country, it is supportive of our healthcare professionals. It is also boosting mental health support for them," he says.
Tackling physician burnout
Bon Secours Mercy Health had several physician burnout interventions in place before the pandemic, including three programs, Schumm says.
Wellness: The health system has an employee wellness program that allows clinicians to make sure they are receiving healthcare and closing care gaps. The employee wellness program also offers the Life Matters program, which provides free counseling to employees and their family members, plus "convenience services," he says. "If you have a quick question about finances or a legal question, or you have a flat tire on the way to work, you can call them, and they take care of it."
Coaching: Bon Secours Mercy Health offers coaching to clinicians, Schumm says. "Some physicians might say, 'I don't need a counselor, but I am struggling with time management or struggling with closing my charts.' We offer life coaching—physicians can choose whatever coach they want."
Treatment: The health system makes sure clinicians have access to physician health programs in their states, he says. "Physician health programs are programs that help with substance use and behavioral health. They also help protect a physician while they are getting treatment. These programs provide treatment, it is confidential, and as long as physicians comply with the treatment, they can protect their license. We reached out to all of these programs in our states to make sure 1) that these programs were available to our physicians, and 2) make sure that our health benefits cover the service for our physicians. We make sure physicians have coverage for both treatment and for any short-term disability."
Bon Secours Mercy Health also has interventions to boost physician resilience, Schumm says.
"Within our Life Matters program and Be Well program, we have several options that clinicians can take advantage of. One example is Joyages, which is an app that can be used in real-time and on-demand, individually or as a team," he says.
"Another example is our employee wellness program has different activities that you can do with others on your team. You can do a challenge with others in your office that involves activities such as exercise or diet—something that can engage your whole team," he says.
The health system has a strong ethics program to support clinicians and foster resilience, Schumm says. "We often talk about moral distress as a factor in burnout. We have full-time ethicists who are available to discuss difficult cases and to give support to clinicians immediately. It helps to support clinicians and whatever needs they have in real-time."
Bon Secours Mercy Health has launched two clinician burnout programs during the pandemic, he says.
Psychiatric support: "About two months into the pandemic, a couple of our psychiatrists called me and said, 'What can we do to help our colleagues?' They got several psychiatrists together and offered to provide support 24/7 to any of their colleagues—simply a cellphone call away. There were 10 psychiatrists who made themselves available. They have had 300 physicians and advanced practice providers call them. Some just needed someone to talk to, some needed therapy," Schumm says.
Extending free counseling services: "We were able to provide free counseling for all of our associates and their family members. Early in the pandemic, we were able to extend this service to all of our physicians and advanced practice providers who were not our employees but worked in our hospitals. They were without mental health and supportive services."
The Coalition for Physician Well-Being has been a good partner for Bon Secours Mercy Health in addressing physician burnout, Schumm says. "They have a great program so you can measure your organization against about 50 standards to see how you are doing in supporting your physicians. During the pandemic, we were able to receive their Medicus Integra Award, which is a milestone. But more importantly, The Coalition for Physician Well-Being gave us standards for measuring ourselves and an opportunity to find out what we needed to work on more. We found out things that we were doing well that we had not recognized. For us, it helped us to pull our team together."
Gauging the state of healthcare worker burnout
Schumm says healthcare organizations are in a fragile state regarding burnout.
"To use a sports analogy, we are approaching the end of game and some players are injured. Everybody is tired. Some players are ready to go on—others are not. We need to give each other a little bit of grace. We are also in a society that is divisive and not open to conversation. To get past this point, we need to be able to talk with each other. There needs to be psychological safety, where we can have open conversations. We are in a fragile state, but we are also in a hopeful state. People are looking forward to not being in the pandemic. I was on a recent call with a chief clinical officer, and he said, 'Herb, we have zero COVID patients today.' It was a relief that we had gotten to that point for a day. That brings hope that we can push forward," he says.
Schumm is hopeful about physician burnout at Bon Secours Mercy Health.
"I am optimistic because I can see how we have been able to invest in resources to help our clinicians. I also see a profound interest in the mental health of our physicians among our senior leaders. Top executives don't only want to know the state of burnout—they want to know what they can do. They want to know what is meaningful and how to approach it. I am optimistic because people are engaged and are looking at what we can do to support each other," he says.
New York hospitals must report sepsis-related data to the state Department of Health.
The establishment of mandatory sepsis protocols at all hospitals in New York State is estimated to have saved more than 16,000 lives between 2015 and 2019, according to the New York State Department of Health.
Sepsis develops in response to infection, and it can lead to tissue damage, organ failure, and death. Sepsis is the leading cause of in-hospital death in the United States. More than 1.7 million Americans are diagnosed with sepsis annually.
The mandatory sepsis protocols in New York were implemented in 2013 following the death of a 12-year-old boy from Queens, Rory Staunton, who succumbed to undiagnosed and untreated sepsis in a New York City hospital in 2012. The regulations requiring the sepsis protocols are known as Rory's Regulations.
Other states should follow New York's lead, says Jeffrey Hammond, deputy director of communications at the New York State Department of Health. "States should identify subject matter experts, hospitals, and physicians who can work collaboratively with the state to provide input and feedback on the program. Sepsis protocols should be evidence-based, including training of professional staff to implement the protocols and a mechanism for data collection and analysis."
The mandatory sepsis protocols are intended to improve rapid identification and treatment of sepsis. Rory's Regulations have five primary requirements for hospitals to adopt sepsis protocols.
There must be a process for screening and early recognition of patients with sepsis, severe sepsis, and septic shock.
There must be a process to identify and document patients for treatment with protocols for severe sepsis and septic shock.
There must be treatment guidelines, including early administration of antibiotics.
There must be training for healthcare providers to quickly recognize and treat sepsis in adults and children.
There must be reporting of sepsis-related data to the New York State Department of Health. The data is used to develop and evaluate risk-adjusted mortality rates.
The number of lives saved by Rory's Regulations was estimated by comparing the observed severe sepsis in-hospital deaths between Jan. 1, 2015, and Dec. 31, 2019, to the expected number of deaths among severe sepsis cases during the same timeframe, Hammond says.
"The expected number of in-hospital deaths was calculated by projecting the unadjusted severe sepsis in-hospital mortality rate observed in 2014 to all subsequent years' cases and the number of observed deaths was then subtracted from this figure to determine the estimate of lives saved. The analysis of adults and children shows an estimated 16,011 New York State lives saved from 2015 to the end of 2019, which is the most current year of validated data available," he says.
The mandatory sepsis protocols must be evidence-based, Hammond says. "Each hospital develops their own protocols based on accepted standards of care and then updates their protocols based on clinical evidence."
Implementing the protocols is an ongoing process, he says. "Hospitals should have internal review processes that use data to monitor their achievements, identify areas for improvement, and modify their protocols and procedures as needed to ensure performance targets are met."
A new study examines trends in physician practice consolidation and physician employment.
The coronavirus pandemic has accelerated trends in physician practice consolidation and increased the number of employed physicians at health systems, hospitals, and corporate entities, a new study found.
The purchase of independent physician practices by health systems, hospitals, and corporate entities has been going on for several years, as have the increasing number of employed physicians at health systems, hospitals, and corporate entities.
The new study was commissioned by the Physicians Advocacy Institute and conducted by Avalere Health. The Physicians Advocacy Institute is a non-profit organization that supports physician practices through advocacy, research, and educational tools for physicians. The primary source of data for the report was the IQVIA OneKey database.
In the report, corporate entities include health insurers, private equity firms, and umbrella corporate entities that own multiple physician practices. Physician practices are considered independent if they do not have a corporate parent.
The pandemic has had a profound impact on physician practice ownership and physician employment, Kelly Kenney, JD, CEO of the Physicians Advocacy Institute (PAI) said in a prepared statement. "COVID-19 drove physicians to leave private practice for employment at an even more rapid pace than we've seen in recent years, and these trends continued to accelerate in 2021. This study underscores the fact that physicians across the nation are facing severe burnout and strain. The pressures of the pandemic forced many independent physicians to make difficult decisions to sell their practices to hospitals, health insurers, or other corporate entities."
The consolidation trends raise concerns about the patient-physician relationship and the clinical autonomy of physicians, she said. "Regardless of practice ownership, it is important to preserve the patient-physician relationship and maintain physicians' clinical autonomy. PAI supports policies that promote these principles and allow physician-owned practices to compete with corporate and hospital-owned entities."
The study covers a three-year period from January 2019 to January 2022. The research features several key findings.
The number of physicians employed by hospitals or corporate entities rose steadily from 2019 to 2021, from 375,400 in January 2019 to 484,100 in January 2022. There was an 8.8% increase in the growth rate of physicians employed by hospitals or corporate entities during the pandemic, including rising from 404,100 in July 2020 to 484,100 in January 2022.
There was a sharp increase in the number of physicians employed by hospitals and health systems after the start of the pandemic, rising from 290,200 in July 2020 to 341,200 in January 2022.
There was a sharp increase in the number of physicians employed by corporate entities after the start of the pandemic, rising from 110,900 in July 2020 to 142,900 in January 2022.
The percentage of physicians employed by hospitals, health systems, and corporate entities rose significantly during the three-year study period, from 62.2% in January 2019 to 73.9% in January 2022. In other words, nearly 3 of 4 physicians are now employed by hospitals, health systems, and corporate entities.
There was a steady increase in the percentage of physicians employed by hospitals and health systems during the three-year study period, from 46.9% in January 2019 to 52.2% in January 2022.
There was a sharp increase in the percentage of physicians employed by corporate entities during the three-year study period, from 15.3% in January 2019 to 21.8% in January 2022.
There was a sharp increase in the number of physician practices owned by hospitals, health systems, or corporate entities, rising from 99,100 in January 2019 to 135,300 in January 2022. This represented a 36% increase. Most of this growth occurred after the start of the pandemic.
The number of hospital-owned physician practices increased 8% over the three-year study period, from 61,900 practices to 66,700 practices. Most of this growth occurred after the start of the pandemic.
The number of physician practices owned by corporate entities increased 84% during the three-year study period, from 37,200 in January 2019 to 68,500 in January 2022. Most of this growth occurred after the start of the pandemic.
By the end of the three-year study period, more than half of physician practices were owned by hospitals, health systems, or corporate entities, rising from 38.8% in January 2019 to 53.6% in January 2022. Most of this growth occurred after the start of the pandemic.
There was a modest but steady increase in the percentage of physician practices owned by hospitals during the three-year study period, from 24.3% in January 2019 to 26.4% in January 2022.
There was an 86% increase in the percentage of corporate entity-owned physician practices during the three-year study period, from 14.6% to 27.2%. Most of this increase occurred after the start of the pandemic.
The federal agency says Saint James School of Medicine lured medical students with deceptive marketing practices.
Citing deceptive marketing practices and violations of credit law, the Federal Trade Commission (FTC) has levied a $1.2 million penalty against a for-profit medical school in the Caribbean that is based in Illinois.
Saint James School of Medicine (SJSM) operates two Caribbean campuses: one in Anguilla and one in St. Vincent. The medical school also does business as Human Resource Development Services Inc. (HRDS), which has headquarters in Park Ridge, Illinois. A complaint filed recently in U.S. District Court names HRDS and Delta Financial Solutions Inc., which is affiliated with HRDS and shares the same headquarters, as "corporate defendants." Kaushik Guha, MBA, executive vice president of operations at HRDS, was also named as a defendant.
The $1.2 million penalty will go toward refunds and debt cancellation for students harmed by deceptive marketing, the FTC reported in a prepared statement.
The complaint features three primary allegations, the FTC prepared statement says:
The defendants misrepresented the pass rate of SJSM students on a key medical exam: "They lured consumers with false guarantees of student success at passing a critical medical school standardized test, the United States Medical Licensing Examination Step 1 Exam. In their sales calls, presentations, and marketing materials, the defendants falsely claimed that the first time USMLE Step 1 pass rate for Saint James students was very high. For example, the defendants distributed a brochure at their open houses that stated: '96.77% FIRST TIME USMLE STEP 1 PASS RATE.' … Since 2017, only 35% of Saint James students who have completed the necessary coursework to take the USMLE Step 1 exam passed the test."
The defendants misrepresented the residency match rate of SJSM students: "The defendants touted Saint James students' residency match rates and advertised the Saint James educational opportunities as 'the same' as American medical schools. For example, their telemarketers were instructed to tell consumers the match rate for Saint James students is 85-95%. … The defendants have also stated on their website that the residency match rate for Saint James students was 83%; in reality, the match rate for Saint James students is lower than touted, and lower than that reported by U.S. medical schools. Since 2018, the defendants' average match rate has been 63%.
The defendants used illegal credit contracts: "The defendants also marketed financing for tuition and living expenses used for attending their classes. The financing contracts contained language attempting to waive consumers' rights under federal law and omit legally mandated disclosures. Specifically, the defendants failed to provide a Holder Rule notice in their credit agreements, which requires that any seller that receives the proceeds of a purchase money loan include, in the underlying credit contract, a specific notice informing the consumer of their right to assert claims against any holder of the credit contract. The defendants also failed to provide a [Credit Practices Rule] disclosure in their credit agreements, which requires creditors to inform cosigners of their liability prior to obligating the cosigner, in a separate document using specific language."
Medical school's response to penalty
HRDS felt compelled to settle the case, Guha said in a prepared statement.
"We have chosen to settle with the FTC over its allegations that disclosures on our website and in Delta's loan agreements were insufficient. While we strongly disagree with the FTC's approach to this matter, we did not want a lengthy legal process to distract from our mission of providing a quality medical education at an affordable cost. However, we have added additional language and clarifications any time the USMLE pass rate and placement rates are mentioned. We are committed to being an industry leader for transparency and accountability and hope that our efforts will lead to lasting change throughout the for-profit education industry," he said.
Guha said SJSM provides value to students, many of whom who otherwise could not afford a medical education.
"Saint James School of Medicine will continue to provide a high-quality medical education at a tremendous value, opening the door to a medical career to students who would otherwise find it impossible to become a doctor. Over 600 of our alumni are serving as licensed physicians in communities across the United States and Canada. Many are working to bridge the health equity gap in underserved areas in North America," he said.
Tuition at SJSM is relatively affordable, according to the FTC complaint. "Defendants charge consumers tuition ranging from about $6,650 to $9,859 per trimester (depending on campus and course study). Between 2016 and 2020, Defendants have had approximately 1,300 students enrolled in their schools each year."
Saint James has an ethnically diverse student population, which includes many U.S. citizens, the FTC complaint says. "Defendants market enrollment at their Caribbean medical schools primarily to consumers from the United States; they state that 68.64% of the student body are American citizens. SJSM brochures provide a demographic breakdown of the student body and state that 60% of SJSM students are African American, Asian, or Hispanic or Latino."
