In a survey conducted in 2020, 23.4% of physicians reported that they had experienced mistreatment in the prior year.
A survey of physicians found that a significant proportion of the clinicians had experienced mistreatment in the prior year, with patients and visitors the most common source of abuse, a new research article says.
Mistreatment of healthcare staff including workplace violence has become a pressing national issue. In March, American Hospital Association President and CEO Richard Pollack wrote a letter to Merrick Garland urging the U.S. attorney general to back legislation to protect healthcare workers from assault and intimidation. "For medical professionals, being assaulted or intimidated can no longer be tolerated as 'part of the job.' This unacceptable situation demands a federal response," Pollack wrote.
The new research article, which was published by JAMA Network Open, reports the results of a survey of nearly 1,400 physicians conducted from September to October 2020. The study features several key data points.
23.4% of physicians reported that they had experienced mistreatment in the prior year
Patients and visitors were the most common perpetrators of mistreatment, with 16.6% of physicians reporting mistreatment by patients and visitors
Other physicians were the second most common perpetrators of mistreatment, with 7.1% of survey respondents reporting mistreatment by physicians
Female physicians were more than twice as likely to report mistreatment than male physicians (31% versus 15%)
The most common forms of mistreatment were verbal abuse (reported by 21.5% of physicians), sexual harassment (5.4%), and physical intimidation or abuse (5.2%)
On a scale of 1 to 10, experiencing any type of workplace mistreatment was linked to a 1.13-point increase in burnout
On a scale of 1 to 10, experiencing any type of mistreatment was linked to a 0.99-point drop in professional fulfillment
Lower perception that protective workplace systems were in place was linked to higher levels of burnout and lower levels of professional fulfillment
Workplace mistreatment was linked to 129% higher odds of moderate or greater intent to leave employment within two years
"This survey study found that mistreatment was common among physicians, varied by gender, and was associated with occupational distress. Patients and visitors were the most frequent source, and perceptions of protective workplace systems were associated with better occupational well-being. These findings suggest that healthcare organizations should prioritize reducing workplace mistreatment," the study's co-authors wrote.
Interpreting the data
The lead author of the research article told HealthLeaders that it was unsurprising that patients and visitors were the most common source of mistreatment.
"Mistreatment of healthcare workers has been described for decades, but it appears to be growing much more widespread and more severe. On one level it makes sense—we are all experiencing an extraordinary confluence of stressors: the pandemic, of course, but also accelerating epidemics of mental illness and opioid use disorders; financial insecurity; erosion of public trust and politicization of science and healthcare; and race- and gender-based trauma, to name a few recent stressors," said Susannah Rowe, MD, MPH, an ophthalmologist at Boston Medical Center, and chair of the Wellness and Professional Vitality Council at Boston University Medical Group.
New tools are required to address healthcare worker mistreatment by patients and visitors, she said. "Organizations have traditionally relied on Human Resources to address employee mistreatment by other employees, a strategy that is both appropriate and essential given the incidence of mistreatment by coworkers and supervisors. Addressing mistreatment by patients and visitors requires a different approach and would most likely succeed through broad collaboration among those working in patient experience, patient advocacy, health equity, public safety, and workforce well-being. Local and federal policy level interventions could also be needed as healthcare institutions may not be able to do this without additional support."
The study highlighted the importance of perceiving that there are systems in place to ensure healthcare workers are treated with dignity and respect, Rowe said. "Supporting a culture of bystanders represents one promising strategy, especially when managers know how to respond effectively to bystander action. Ensuring that workers can discuss and report mistreatment without repercussions (for example via anonymous reporting systems and confidential resources) will, at the very least, help organizations diagnose where problems lie."
Another emerging strategy relies on promoting positive actions—initiatives that actively affirm people's dignity may be even more powerful than preventing mistreatment alone, she said. "Some examples include fostering inclusive language in the workplace, equitable hiring and promotion practices, education about counteracting unconscious biases, and upstander training. Providing ways for feedback, input, and ideas may also help, allowing for consistent assessments and changes to institutional policies and practices that truly prevent harm and keep workers safe."
The findings of the inspector general study are similar to Medicare data reported in 2010.
Medicare patients experience harm in hospitals at a relatively high rate and the harm costs the federal program hundreds of millions of dollars per month, according to a new report from the U.S. Department of Health and Human Services Office of Inspector General (OIG).
In 2010, OIG published the first report on Medicare patient harm in hospitals, finding that 27% of patients experienced harm in October 2008. These harm events cost Medicare and patients an estimated $324 million in reimbursement, coinsurance, and deductible payments. Nearly half of the harm events were deemed preventable.
The new report is based on a review of medical records for a random sample of 770 Medicare patients who were discharged from hospitals in October 2018. Patients experience two kinds of harm. "Adverse events" resulted in longer hospital stays, permanent harm, life-saving intervention, or death. "Temporary harm events" resulted in interventions, but they did not cause lasting harm, prolong hospital stays, or require life-sustaining measures.
The report features several key findings.
In October 2018, 25% of Medicare patients experienced adverse events (12% of patients) or temporary harm events (13% of patients).
Reviews by physicians found that 43% of the harm events could have been avoided with better care.
The most common harm events were linked to medication (43%), followed by patient care such as pressure injuries (23%), procedures and surgeries (22%), and infections (11%).
Among patients who experienced a harm event, 23% required treatment that resulted in additional Medicare costs. These costs were variable and there was a small sample of patients, so OIG was not able to estimate the costs with precision. The costs of patient harm events in October 2018 range from $347 million to $1.2 billion.
The Centers for Medicare & Medicaid Services (CMS) have two programs that reduce reimbursement to hospitals for some hospital-acquired conditions (HACs): the HAC Reduction Program and the Deficit Reduction Act HAC list. For the harm events that the OIG found, only 5% were on the HAC Reduction Program list and only 2% were on the Deficit Reduction Act HAC list.
In comparing the first OIG report in 2010 with the new report, there has been little change in harm events for hospitalized Medicare patients, the new report says. "Our findings suggest that patient harm events continue to be widespread among Medicare patients in hospitals since the publication of our 2010 report, with an estimated 27% of Medicare patients experiencing harm in 2008 and an estimated 25% of Medicare patients experiencing harm in 2018. … When comparing the results, we did not detect a statistically significant difference in the rates of patient harm, severity of harm events, or preventability of harm events over time."
Recommendations to improve safety
The new report issues seven recommendations to improve safety for hospitalized patients.
Three recommendations are made to CMS: "(1) update and broaden its lists of [hospital-acquired conditions] to capture common, preventable, and high-cost harm events; (2) explore expanding the use of patient safety metrics in pilots and demonstrations for healthcare payment and service delivery, as appropriate; and (3) develop and release interpretive guidance to surveyors for assessing hospital compliance with requirements to track and monitor patient harm."
Four recommendations are made to the Agency for Healthcare Research and Quality: "(1) with support from HHS leadership, coordinate agency efforts to update agency-specific Quality Strategic Plans; (2) optimize use of the Quality and Safety Review System, including assessing the feasibility of automating data capture for national measurement and to facilitate local use; (3) develop an effective model to disseminate information on national clinical practice guidelines or best practices to improve patient safety; and (4) continue efforts to identify and develop new strategies to prevent common patient harm events in hospitals."
Researchers surveyed patients about their experiences with care transitions from hospitals and skilled nursing facilities to home.
A survey of more than 1,000 patients found inconsistencies in care transition processes from hospitals and skilled nursing facilities to home, including social determinants of health challenges and racial disparities, a new research article shows.
Boosting the quality and value of care can be achieved by improving patient experiences and outcomes while limiting costs. One strategy for achieving this goal at hospitals and skilled nursing facilities is to improve the care transition process, which includes education, medication reconciliation, follow-up appointments and telephone calls, and supportive care in the home.
The new research article, which was published by JAMA Network Open, is based on survey data collected from 1,257 patients discharged from hospitals or skilled nursing facilities (SNFs). Seventeen hospitals and six SNFs in Michigan participated in the study.
The study features several key findings.
11.4% of patients said they did not receive a telephone number to call for care-related questions after hospital or SNF discharge
Compared to White patients and patients of other races, more Black patients did not receive a telephone number to call with care-related questions
21.4% of patients said they did not receive a follow-up phone call
Among patients who did receive at least one follow-up phone call, 89.9% said the calls were helpful or very helpful
1.9% of patients said they did not receive prescribed medical equipment in the home
Compared to White patients and patients of other races, more Black patients did not receive prescribed medical equipment in the home
20.8% of patients said they had at least one social determinants of health (SDOH) challenge
The four most common patient SDOH challenges were inability to afford aspects of care such as prescriptions and physical therapy (7.6% of patients), lack of transportation for health-related activities such as physician appointments and grocery shopping (6.0%), inability to afford medical visits and copayments (5.6%), and lacking help at home to care for themselves
Lack of transportation decreased the odds of completing a follow-up appointment by nearly 70%
Patients who said they had at least one SDOH challenge were more likely to have no follow-up appointment than patients who said they did not have SDOH challenges
63.3% of patients said they had seen a physician for follow-up and another 28.1% said they had an appointment scheduled
Compared to White patients and patients of other races, Black patients were less likely to see a physician for follow-up or have an appointment scheduled
"These findings suggest that health systems should recognize that care transition processes are variable, patients experience substantial social determinants of health issues, and potential racial disparities exist in postdischarge follow-up with physicians," the study's co-authors wrote.
Interpreting the data
The data shows inconsistency in follow-up phone calls, the study's co-authors wrote. "Overall, these findings show that most patients receive postdischarge follow-up telephone calls and find them valuable, but 21% of patients do not receive a telephone call, indicating inconsistencies in care transition processes."
The data shows there are disparities impacting Black patients, the study's co-authors wrote. "We also found that 1 in 10 patients reported not receiving a telephone number to call regarding their care after discharge, with a higher proportion of Black patients not receiving a telephone number to call. In addition, Black patients reported not receiving prescribed equipment more often than White patients, and these gaps persisted even after adjustment for demographic variables. … Black patients reported fewer scheduled or completed follow-ups with physicians compared with White patients and patients of other races."
SDOH play a significant role in care transitions, the study's co-authors wrote. "One in 5 patients surveyed … reported SDOH concerns, such as the inability to afford prescriptions, medical care, doctor appointments, and basic needs; transportation issues; and having adequate assistance at home. Although the healthcare industry is aware of the important role SDOH plays in patient health, awareness has not translated into improvement. In a 2019 survey of Michigan seniors, 34.7% noted their reason for not seeing a physician for follow-up was because they could not afford to, another 18.1% did not because of lack of insurance coverage, and 22.1% did not because of lack of transportation."
The data points to several areas for enhancement, the study's co-authors wrote. "There are still multiple opportunities for improvement, including (1) providing reliable, systematic care transition processes for all (follow-up telephone calls, numbers for patients to call, and delivered home medical equipment); (2) addressing patient SDOH, such as transportation; (3) scheduling and helping patients attend follow-up appointments; and (4) recognizing and reducing racial disparities in care. This information on patient challenges during the transition of care process could help hospitals and physicians tailor future care transition interventions to be specific to their patients' needs."
An orthopedic ambulatory surgery center executive says an easing in the upward trajectory of ASC growth is unlikely.
The coronavirus pandemic has accelerated the growth of ambulatory surgery centers (ASCs) and growth is likely to continue for the foreseeable future, an ASC expert says.
The first ASC in the United States opened in 1970 and explosive growth happened through the late 1980s and into the 1990s, according to the Ambulatory Surgery Center Association (ASCA). ASC growth as been steady over the past two decades, with more than 5,800 ASCs performing an estimated 30 million procedures in 2020, the ASCA says.
"ASC growth has continued in the United States, and particularly for orthopedics, the number of ASCs is growing, and the number of cases shifting from main hospitals to ASCs continues to grow. We have seen this trend in recent years; but with the coronavirus pandemic, we have seen ASC growth accelerate over the past two years," says Alexander Sah, MD, co-director of the Institute for Joint Restoration and Research in Fremont, California.
Several factors are driving ASC growth, he says. "We see that there is an increasing movement of cases from the main hospitals into ASCs, mainly for increased safety for patients, profitability, removing costs from the health system, and better patient outcomes. Many surgeries that used to be thought to only be done in a main hospital can be done safely in a surgery center, which can be beneficial for physicians, health systems, and patients."
Sah says ASC growth is strong in his field. "Particularly in orthopedics such as elective hip and knee replacements, there has been a major shift, where it has been projected that by 2030 more than 50% of joint replacements would be performed in ASCs. That trend has likely been accelerated by the pandemic."
ASC growth is likely to continue for years, he says. "ASC growth will continue. I do not know when it will plateau—one would assume that at some point it will plateau because the number of ASCs would saturate the market, or the number of patients appropriate for ASCs would plateau. But we are not near that point yet."
ASC benefits
ASCs benefit healthcare providers, patients, and payers, Sah says.
"For healthcare providers, ASCs are an opportunity to have more control over how things are done. In a main hospital, you have many resources at your disposal, but you also have the challenges of emergency cases as well as operating rooms that have a wide scope of procedures that they perform. In an ASC, there is an opportunity to fine-tune skills and develop very specific programs. For example, you can develop an orthopedic-specific ASC or another facility that has a narrow focus of care. In that way, you can have areas of excellence. You can have centers that focus only on hip and knee replacement. Those centers can fine-tune their protocols and processes so that patients can have more efficient and predictable surgeries and outcomes."
For patients, there are benefits in avoiding main hospitals, he says. "For elective surgeries, such as joint replacement, many patients do not want to go to a main hospital. They do not want to be in a building where there are ill people—they want to avoid infection risk or other complications. By avoiding exposures to potential risks in the main hospitals, patients can achieve better outcomes."
An example of superior care for patients in ASCs is MicroPort Orthopedics' comprehensive pathway for patients, which looks at the entire episode of care for patients having elective joint replacement so that they can have the best preoperative experience and preparation, the best surgical experience, and the best recovery over the first 90 days after a procedure, Sah says.
"This program has virtual joint classes, engagement with patients throughout their episode of care, and good communication with surgeons. These surgeries are done in an ambulatory surgery setting with rapid discharges, where patients get to go home the same day, they do not have to sleep in a hospital, they can recover in the comfort of their own home, and there are ways to have patients tightly connected with their surgeons, thereby having better outcomes, quicker recoveries, and a more satisfactory experience," he says.
Compared to procedures done in main hospitals, ASCs have reduced costs, which benefits payers, Sah says.
"With the growth of ASCs, the amount of dollars that are saved by the healthcare system are in the realm of billions. When cases and surgeries move to ASCs, billions of dollars are saved by the healthcare system because procedures can be done more efficiently outside of the main hospitals. For payers, ASCs save money. There is less waste and less cost because ASCs can be more efficient in how they deliver their care. Both Medicare and commercial payers can save money by having cases shifted from the main hospitals to ASCs," he says.
Best practices for operating an ASC
There are two primary considerations when a health system or hospital operates an ASC, Sah says.
"The most important thing in opening an ASC is looking at what procedures are done and what the surgeons are capable of. A lot of the confusion for surgeons about ASCs is they think just because you do the same surgery under a different roof called an ASC, you will automatically have better outcomes and save money. You must have surgeons who are able to do surgery in an efficient way. They must be able to do surgery in a predictable fashion," he says.
The only way to make an ASC profitable is to be efficient, Sah says. "For example, if an elective joint replacement should only take an hour, if some cases it takes two hours and others take 40 minutes. The variability can make it challenging for the ASC to produce a consistent product. So, surgeons need to be capable, and they need to have the proper protocols in place. That means there needs to be buy-in from the anesthesia team, the recovery nurse team, and the physical therapy team. A successful ASC is more than just what happens in the operating room—it's everything that is involved surrounding a surgery."
The watchdog group also released a report that shows patient experience in the inpatient setting has declined significantly during the coronavirus pandemic.
The Leapfrog Group conducted an analysis of 2,844 U.S. hospitals, and one-third of the facilities earned an "A" grade for patient safety.
Patient safety has been a pressing issue in healthcare since 1999, with the publication of the landmark reportTo Err Is Human: Building a Safer Health System. Despite two decades of attention, estimates of annual patient deaths due to medical errors have risen steadily to as many as 440,000 lives, a figure that was reported in the Journal of Patient Safety in 2013.
Today, The Leapfrog Group released its latest grades for hospital patient safety. The analysis utilizes more than 30 measures, including the PSI 90 Patient Safety and Adverse Events composite, which features 10 component measures.
The Leapfrog Group was founded in 2000 by large employers and other purchasers of healthcare. The nonprofit group publishes reports on hospital patient safety in the fall and the spring.
The distribution of letter grades for the hospitals in the spring report is as follows:
A…33%
B…24%
C…36%
D…7%
F…Less than 1%
The Top 10 states by percentage of "A" grade hospitals are as follows:
1. North Carolina (59.8% of hospitals with an "A" grade)
2. Virginia (59.2%)
3. Utah (55.6%)
4. Colorado (55.3%)
5. Michigan (50.6%)
6. Idaho (tied at 50.0% of hospitals with an "A" grade)
6. Massachusetts (tied at 50.0% of hospitals with an "A" grade)
6. Hawaii (tied at 50.0% of hospitals with an "A" grade)
9. Oregon (47.1%)
10. Pennsylvania (45.9%)
Four states and the District of Columbia had no hospitals with an "A" grade: North Dakota, West Virginia, and Wyoming.
Seventeen hospitals received an "F" grade:
Shoals Hospital, Muscle Shoals, Alabama
Barstow Community Hospital, Barstow, California
Henry Mayo Newhall Hospital, Valencia, California
Pacifica Hospital of the Valley, Sun Valley, California
Pioneers Memorial Hospital, Brawley, California
San Joaquin General Hospital, French Camp, California
Howard University Hospital, Washington, District of Columbia
Halifax Health Medical Center - Port Orange, Port Orange, Florida
Vista Medical Center East, Waukegan, Illinois
Southwest Medical Center, Liberal, Kansas
Byrd Regional Hospital, Leesville, Louisiana
Jennings American Legion Hospital, Jennings, Louisiana
Granville Medical Center, Oxford, North Carolina
Great Plains Regional Medical Center, Elk City, Oklahoma
Baylor Scott & White Medical Center—McKinney, McKinney, Texas
CAMC General Hospital, Charleston, West Virginia
CAMC Teays Valley Hospital, Hurricane, West Virginia
Effects of the coronavirus pandemic
The pandemic has had a grave impact on hospital safety, for both patients and health workers, Leah Binder, MA, MGA, president and CEO of The Leapfrog Group, told HealthLeaders.
"As a recent New England Journal of Medicinearticle authored by Centers for Disease Control and Prevention as well as Centers for Medicare & Medicaid Services leadership found, the stress of the pandemic—from burnout to shortages—has reversed years of patient safety progress, most notably regards to healthcare-acquired infections and patient experience. Comparing the fall 2021 and spring 2022 rounds, we saw that three infection measures—central line-associated bloodstream infection, catheter-associated urinary tract infection, and methicillin-resistant Staphylococcus aureus—worsened by a statistically significant amount. The pandemic has revealed that we must build a more resilient culture of safety," she said.
Hospitals need to take action to get patient safety back on track, Binder said. "Hospital leadership and boards must make patient safety a top priority. They need to be transparent and hold themselves accountable for progress. That means hospitals need to recommit to the patient safety basics—proper hand washing, infection prevention, communication, and medication safety to name a few—and fortify safety culture from the top down. An aggressive approach to patient safety can help reduce burnout, which is directly associated with staffing shortages."
State of patient experience
In addition to the hospital safety grades report, The Leapfrog Group also released today a report on adult patient experience in the inpatient setting. The watchdog group analyzed data collected in the Hospital Consumer Assessment of Healthcare Providers and System (HCAHPS) survey.
The patient experience report includes three key findings:
During the pandemic, patient experience in the inpatient setting has declined significantly in nearly all measures
Patient experience in the care transitions metric remains the least favorable measure and declined significantly during the pandemic
Declining metrics of patient experience are associated with patient safety indicators, which indicates the pandemic has had a negative effect on hospital patient safety
Patient experience in the inpatient setting has declined across the board during the pandemic, Binder said. "This is deeply disturbing. Research has shown that hospitals that score higher on these patient experience measures tend to have better safety outcomes. For example, effective patient communication with nurses and doctors can prevent errors like medication mix-ups or misdiagnoses. Hospitals with better staff communication ratings have been shown to also have lower rates of hospital-acquired conditions. Additionally, if a patient is in pain, experiencing new symptoms, or cannot reach the bathroom, it is critical that staff respond quickly."
The largest difference comparing adult patient experience in hospitals pre-pandemic and mid-pandemic is in "responsiveness of hospital staff," which experienced a 3.7-point HCAHPS score decrease. Hospitals and patients can act to address this problem, she said.
"There are several ways hospitals can improve, but the first step they need to take is ensuring appropriate staffing levels. When hospitals don't have enough nurses, for example, patients might face greater risk of harm. Additionally, patient safety is a team sport—patients and hospitals will need to work together on this. While hospitals work to ensure appropriate staffing and care, patients, families, caregivers, and loved ones also play an important role. Patients should be encouraged to bring a caregiver along to act as a second set of eyes and ears. Hospitals should engage patients in every aspect of care, and the Agency for Healthcare Research and Quality, among others, offer extensive resources that hospital staff can utilize."
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."
