After more than a decade of relatively stable medical liability premiums, rates are increasing significantly, a new report from the American Medical Association says.
Over the past three years, there has been a surge in the percentage of medical liability premiums with year-to-year increases, a new report from the American Medical Association says.
The last time there was a spike in medical liability premiums year-to-year was in the early 2000s, according to the new report. Medical liability premiums were largely stable through 2018, the report says.
The new report is based on data collected from annual rate surveys conducted by the Medical Liability Monitor(MLM), including the latest annual rate survey from October 2021. The data features "manual" premiums, which do not reflect credits, debits, dividends, or other factors that may affect the actual premiums that physicians pay for coverage.
The increases in medical liability premiums from 2019 to 2021 have added to the financial strain that physicians have experienced during the coronavirus pandemic, Gerald Harmon, MD, president of the American Medical Association, said in a prepared statement. "The medical liability insurance cycle is in a period of increasing premiums, compounding the economic woes for medical practices that struggled during the past two years of the pandemic. The increase in premiums can force physicians to close their practices or drop vital services. This is detrimental to patients as higher medical costs can lead to reduced access to care."
The new report has several key data points.
Premium decreases have become more rare over time and are now less likely than premium increases. In 2012, the percentage of premiums that decreased was 25.7%. In 2021, only 6.5% of premiums decreased.
The percentage of premiums that increased spiked after 2018, when 13.7% of premiums increased. In 2019, 26.5% of premiums increased. In 2020, 31.1% of premiums increased, which was higher than any year since 2005.
The number of large premium increases has also risen. In 2018, 3.9% of all premiums increased by at least 10%. In 2019, 3.6% of all premiums increased by at least 10%. In 2021, 7.5% of all premiums increased by at least 10%.
Twelve states experienced double-digit premium increases in 2021. Illinois led all states with the largest proportion (58.9%) of premiums that increased 10% or more, followed by West Virginia (41.7%), Missouri (29.6%), Oregon (20%), South Carolina (16.7%), Idaho (11.1%), Kentucky (7.4%), Delaware (6.7%), Washington (6.7%), Michigan (5.4%), Texas (4.9%), and Georgia (3.7%). The size of the largest premium increase in these states ranged from 35.3% in Illinois to 10% in Idaho and Washington.
There were substantial geographic variations in premiums. For example, in 2021, manual premiums for general surgeons in Los Angeles County, California, were $41,775, compared to $215,649 for general surgeons in Miami-Dade County Florida.
There also were substantial premium variations by specialty. For example, in Nassau County, New York, premiums were $32,159 for internists, $146,353 for general surgeons and $165,824 for OB/GYNs.
Interpreting the data
The upward trend in premiums is not as severe as the last "hard market," according to the new report.
"The last hard market—also referred to as the liability 'crisis'—took place about 20 years ago, in the early 2000s. It was characterized by dramatic increases in premiums. In 2003 and 2004, respectively, 77.4% and 82.1% of premiums increased from their levels in the previous ears. Some general surgeons in Miami-Dade County, Florida, faced manual premiums that increased from $110,068 in 2000 to $277,241 in 2004," the report says.
However, premiums are trending toward a hard market, the report says. "In 2019 for the first time since the last hard market, the share of premiums that increased year-to-year went up significantly. Then in 2020, an even higher proportion increased, when 31.1% of premiums went up from the previous year. In fact, this was the highest proportion observed since 2005. Once again in 2021 and despite a small dip, almost 30% of premiums increased from the previous year—the highest proportion observed since 2006."
State data indicates a hard market is forming, the report says. "According to some actuaries, we were already in the early stages of a hard market in 2020, as insurers started raising premiums in response to deteriorating underwriting results, lower loss reserve margins, and lower returns on investment. Thus, it was expected that insurers would sustain or even push for higher premiums in 2021. The 2021 MLM data suggests that this is coming to fruition. Although large increases were concentrated in certain states, small increases in premiums were more widespread. In 2020, premium increases were observed in 33 states and in 2021, they were reported in 32 states. Twenty-four states saw increases in both of those years."
For now, the ultimate direction of the medical liability market remains to be seen, the report says. "It is not atypical for there to be hard and soft markets, for premiums to go up and down, as this is part of the insurance cycle. How severe and widespread the current hard market will become—how many premiums will increase, how high they will go and whether other states will follow suit in seeing their premiums go up—is still uncertain."
Staffing shortfalls were already a concern prior to the coronavirus pandemic, but they have reached crisis levels during the pandemic, according to ECRI.
ECRI released a report today on the Top 10 patient safety concerns of 2022.
ECRI is an independent, nonprofit organization dedicated to improving the safety, quality, and cost-effectiveness of care across all healthcare settings. The organization's annual Top 10 patient safety list is developed by multidisciplinary staff at ECRI and the organization's affiliate, the Institute for Safe Medication Practices (ISMP). Patient safety concerns are also validated by scientific literature as well as ECRI and ISMP data such as accident investigations and reported medication safety problems.
The Top 10 patient safety concerns of 2022 are as follows.
1. Workforce shortages: "Even before the COVID-19 pandemic, there was a persistent shortage of clinical and nonclinical staff across the continuum. Staffing shortages have continued to increase throughout the pandemic," the ECRI report says.
2. Healthcare worker mental health problems linked to COVID-19: "An often discussed but inadequately addressed collateral result of the COVID-19 pandemic is the toll it has taken on the mental health of healthcare workers. Healthcare professionals' mental health was already at crisis level before the COVID-19 pandemic; both physicians and nurses were at risk of burnout, emotional exhaustion, or depression prior to 2020. The pandemic has now forced a reckoning with healthcare workers' mental health needs," the report says.
3. Bias and racism in addressing patient safety: "Racial and ethnic disparities have been well documented in how they affect access to care and outcomes. What is less well publicized is that disparities can even affect how adverse events are reported and responded to. … Although patients from racial and ethnic minority groups are more likely to experience an adverse event while in the hospital, providers are significantly less likely to report harmful events for patients from minority groups than for white patients. In one study, the odds of reporting patient safety events in African American patients were only 0.65 times the odds of reporting in white patients," the report says.
4. Vaccine coverage gaps and errors: "The success of any vaccine relies on correct, widespread administration to appropriate populations. Vaccine gaps and errors may harm patients or provide inadequate protection against serious diseases," the report says. The most frequently reported vaccine errors include wrong vaccine, wrong dose, and expired vaccines.
5. Cognitive biases and diagnostic error: "Cognitive biases can result in misdiagnoses by skewing how clinicians gather and interpret evidence, take action, and evaluate decisions," the report says. For example, anchoring bias occurs when clinicians stick to an initial impression despite the development of conflicting evidence.
6. Nonventilator healthcare-associated pneumonia: "Pneumonia is the most common healthcare-associated infection in the United States and is linked to substantial morbidity and mortality. Despite the attention placed on ventilator-associated pneumonia, nonventilator healthcare-associated pneumonia (NVHAP) diagnoses in the United States make up 65% of the cases, compared with 35% associated with ventilators," the report says.
7. Human factors in operationalizing telehealth: "Overlooking human factors in the design, implementation, usability, and evaluation of telehealth systems may lead to a situation mirroring what happened during the widespread adoption of electronic health records (EHRs), which caused numerous issues for providers and patients alike, including: fractured adoption, interrupted workflows, user dissatisfaction, [and] complete system failure," the report says.
8. International supply chain disruptions: "The United States heavily relies on international manufacturers to produce medical equipment, drugs, and other healthcare supplies. While medical supply and drug shortages have long been a problem in healthcare, this issue has been exacerbated by international supply disruptions resulting from the COVID-19 pandemic and other recent natural disasters," the report says.
9. Products subject to emergency use authorization: "During emergencies, the U.S. Food & Drug Administration (FDA) can issue emergency use authorization (EUA) for drugs, devices, or biologics for serious diseases or conditions when no FDA-approved alternatives are available. However, FDA requires lower levels of evidence of safety and efficacy for EUA issuance than for FDA approval," the report says. Several EUAs have been issued during the coronavirus pandemic.
10. Telemetry monitoring: "Telemetry monitoring (TM) provides real-time measurements of monitored physiologic parameters from a distance. Technological breakdowns as well as breakdowns related to clinician response increase the risk of patient harm by the disruption in identification of critical and abnormal changes in a patient's health status," the report says. Common problems with telemetry monitoring include alarm fatigue, equipment not connected as ordered, patient connected to the wrong equipment, and equipment malfunctions.
The Association for Professionals in Infection Control and Epidemiology has published an expansive report on how the United States can be better prepared for the next pandemic.
Federal, state, and local policy makers have a lot of work to do to prepare the country for the next pandemic, the Association for Professionals in Infection Control and Epidemiology (APIC) says in a new report.
The United States was inadequately prepared to respond to the coronavirus pandemic such as insufficient supplies of personal protective equipment (PPE). The country leads the world in COVID-19 deaths, with 991,260 lives lost as of today, according to worldometer.
More than a dozen infection preventionists contributed content to the new report, which APIC 2022 President Linda Dickey, RN, MPH, said requires urgent attention. "APIC is issuing this call-to-action as we all recall the nightmare of extensive supply shortages and overworked healthcare workers. Especially troubling to APIC is how many preventable infections were transmitted inside hospitals during COVID because resilience was not built into our healthcare system," she said in a prepared statement.
Sizable investments will be necessary to prepare the country to respond effectively to the next pandemic, she said. "For the U.S. to create a safer, more resilient healthcare system, policymakers should make the substantial investments recommended by the hands-on infection prevention experts who had a unique vantage point as the pandemic overwhelmed hospitals, nursing homes and clinics nationwide."
The report makes 10 recommendations to improve pandemic preparedness in the United States.
1. Improve PPE
Congress should fund research at the National Institute for Occupational Safety and Health to develop a one-size-fits-all respiratory device that can be used in healthcare facilities during infectious disease emergencies.
Congress should fund research to replace some disposable PPE with PPE that is cleanable and reusable.
2. Promote the use of masks in response to infectious disease threats
Federal, state, and local officials should recommend that the general public use masks to combat respiratory viruses.
Congress should fund research to develop standards for masks for the general public and to determine the best types of masks for different types of infectious diseases.
Federal agencies should share mask research findings with the public to generate trust in mask use to prevent the spread of respiratory viruses.
3. Improve supply chain for PPE and disinfection supplies
Federal officials should develop better processes to manage, track, and rapidly distribute PPE during a public health emergency. This effort should include greater diversity in production locations.
Federal and state officials should anticipate high demand for essential supplies and be able to meet operational healthcare demand.
Federal officials should anticipate general-public demand for supplies such as cleaning materials to make sure essential supplies are available for healthcare workers and facilities.
Government officials should research when PPE can be decontaminated for reuse by healthcare workers.
4. Infection preventionists should play prominent roles during a pandemic
Federal officials should require that infection preventionists serve on healthcare facility incident command and emergency response teams.
Federal officials should require that infection preventionists play a role in determining policies and protocols related to disease transmission at healthcare facilities such as patient placement, workflow reviews, and patient isolation.
Federal officials should require that infection preventionists serve on teams that develop crisis standard of care protocols for PPE, anti-infective therapy, and vaccinations at healthcare facilities.
Federal officials should require that an infection preventionist participate in developing an infectious disease surveillance program for healthcare facilities.
Federal officials should require that an infection preventionist should oversee the analysis and reporting of pandemic surveillance program data for a healthcare facility.
5. Properly trained healthcare workers should staff high-risk settings
The Centers for Medicare & Medicaid Services (CMS) should require nursing homes to have at least one infection preventionist.
CMS should require additional nursing home staff to be trained in infection prevention and control (IPC) to establish surge capacity during an infectious disease outbreak.
CMS should require routine mandatory surveillance for healthcare-associated infections in nursing homes.
6. Promote infection prevention and control surge capacity
Congress should provide support to healthcare facilities to ensure they have enough infection preventionists during a pandemic.
Congress should provide support to healthcare facilities to make sure IPC and employee occupational health teams can do contact tracing, conduct employee exposure testing, and implement employee vaccination programs.
Congress should provide funding to address healthcare surges during a pandemic and avoid suspension of nonurgent medical procedures, which can lead to worse outcomes for individual patients and long-term public health problems.
7. Testing and contact tracing
Congress should make sure that healthcare facilities, public health agencies, primary care providers, and the public have access to testing.
Congress should fund contact tracing administered by public health agencies and healthcare facilities to limit the spread of disease during a pandemic.
8. Data sharing and interoperability for infection surveillance data
Congress should promote methods for rapid healthcare data collection and support the sharing of data between healthcare provider electronic health records, public health agencies, federal agencies, and the public. Data sharing and interoperability boosts testing, contact tracing, and other public health strategies to prevent the spread of disease.
9. Vaccine confidence
Congress should direct federal agencies to make efforts in public health education about the benefits and effectiveness of vaccines in preventing infectious diseases.
Congress should fund research and share strategies to address vaccine misinformation.
Policy makers should fund healthcare facility IPC and employee occupational health departments to tackle vaccine hesitancy among healthcare workers.
10. Pandemic preparedness workforce capacity and training
Congress should provide funding for healthcare facilities to have enough IPC capability to support patient safety during a pandemic and have enough infection preventionists during a pandemic.
Congress should fund "just-in-time" IPC education and training for healthcare workers and the broader workforce during a pandemic.
Congress should support academic pathways at universities for infection preventionists.
Congress should fund incentives such as loan repayment programs to encourage the next generation of healthcare professionals to become infection preventionists.
The health system has several programs specifically designed to address healthcare worker well-being.
Phoenix-based Banner Health has a multifaceted approach to addressing healthcare worker well-being.
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.
The pandemic is straining the Banner Health workforce, Chief Clinical Officer Marjorie Bessel, MD, says. "We have all had a shared experience over the past two years with the pandemic and the toll of trying to respond to a once-in-100-years pandemic has been very difficult on the entire organization, especially on those on the frontline. We are experiencing increased levels of burnout and we are also seeing effects in other metrics that we track, such as engagement in the workplace through our employee surveys, and turnover rates, which we are seeing at unprecedented levels."
Promoting healthcare worker well-being is essential during the pandemic, she says. "I am thankful for our healthcare heroes. It is my absolute pleasure to continue to advocate and make sure that we are supporting those who have been taking care of all of us during this pandemic. I am incredibly grateful for the work that they do, and I want to make sure that we help all of them who have been providing great care under stressful conditions for more than two years."
Layered approaches to well-being
Banner Health has three primary programs that are designed specifically to address healthcare worker well-being, Bessel says.
The Well-Being Collaborative is a health system-level program with initiatives for all Banner Health employees. The collaborative has a range of supportive offerings and activities from virtual online support to physical challenges. "The idea is to approach health holistically and to offer activities to everyone," she says.
The Cultivating Happiness in Medicine (CHIM) program is targeted at physicians and advanced practice providers. CHIM has been crafted on an evidence-based, holistic model with six themes, including leadership development, social community, and individual wellness. A multidisciplinary team runs the program.
"Our oversight team looks to make sure that we are balanced and that we are doing different types of activities in each one of the six themes. The oversight team is also attuned to the voice of our customer. So, periodically, we do deep listening tours where we have conversations with the individuals we are here to support. We ask questions and try to elicit the perceived needs of people, then we slot them into our model and include them in our action plans for each year. We try to do the right kind of activities that meet the ultimate goal of improving well-being," Bessel says.
Social community events are a popular aspect of CHIM, she says. "Despite us being in a pandemic, we had more than 50% of our employed physicians and advanced practice providers participate in social community events in 2021. In 2021, there were 696 events. We provide funding for the events; we ask for physicians and advanced practice providers to lead the events themselves," Bessel says.
The Wellness in Nursing (WIN) program targets nurse well-being. "WIN is set up much like CHIM, where there is a multidisciplinary team that is heavily populated with nursing leaders who oversee a multifaceted program to help support nurses. WIN was launched about two years ago. They also have done listening tours to have conversations with nurses to learn about the types of programs that are needed. There also is some crossover and collaboration between the CHIM and WIN efforts," she says.
Recent well-being initiatives
Last year, Banner Health launched a peer-support initiative for physicians and advanced practice providers.
"We have trained individuals who volunteer to provide peer support. These volunteers are available to other individuals who need somebody to talk with. It is not a professional level of counseling, but it is more formalized and one-on-one compared to the social community events that we organize. We have 20 volunteers who have been trained to provide peer support. They receive eight hours of training, and they periodically receive virtual refresher courses. They also commit to filling out ongoing surveys so that we can make sure that the program is working well," Bessel says.
Also last year, Banner Health started creating "recharge rooms" for all healthcare workers.
"The recharge rooms are not exactly like virtual reality, where you wear a headset. These recharge rooms use immersive reality, and it is voice activated. You go into the recharge room and say, 'Elsewhere.' In the room, you experience a multi-sensorial activity. On the walls there can be pristine nature scenes and there are customized music scores that play. As you continue through the experience, the lighting changes. Each one of these scenes last for about 15 minutes, but if you start a scene and you do not like it, you can say, 'Elsewhere,' and pick a different scene from the menu. Because it is multi-sensorial, there can be individualized aromatherapy added to the experience," she says.
Measuring well-being
Banner Health uses multiple metrics to measure healthcare worker well-being, Bessel says.
"We track physician and advanced practice provider turnover. Those statistics have gone up in 2021 compared to 2020. From 2018, to 2019, to 2020, we did make some progress on turnover. The turnover statistics are a reflection of all things that lead to turnover—early retirement, people leaving for different healthcare endeavors, and people leaving healthcare all together. In addition to turnover for physicians and advanced practice providers, we use the Maslach Burnout Inventory tool—we started using that in 2018. We also have our own internal employee survey, which has two metrics that we like to track. One is the percentage of employees who recommend Banner Health as a great place to work, the other is the percentage of employees who say they are actively engaged," she says.
In 2020, female Maryland physicians earned 50% less on average than male physicians, the survey found.
A significant gender pay gap in physician compensation is persisting in Maryland, a new survey report has found.
Earlier research has shown a pervasive gender pay gap in U.S. physician compensation. A study published in December showed that through a simulated 40-year career, male physicians earn an average adjusted gross income that is about $2 million higher than female physicians.
The new survey report was produced for MedChi—The Maryland State Medical Society—by Merritt Hawkins. The physician search and consulting firm is a company of AMN Healthcare. The survey features 2020 data collected from more than 500 Maryland physicians.
The new survey report includes four key data points on the gender pay gap.
In 2020, female Maryland physicians earned 50% less on average than male physicians. The average annual income for male physicians was $320,000 compared to $213,000 for female physicians.
In 2020, female Maryland primary care physicians earned 41.2% less in average pre-tax annual income than male primary care physicians. The average pre-tax annual income for male physicians was $262,542 compared to $172,542 for female physicians.
In 2020, female Maryland physicians in surgical, diagnostic, and other specialties earned 33.5% less in average annual income than male physicians. The average annual income for male specialist physicians was $350,625 compared to $250,115 for female specialist physicians.
The gender-based pay gap changed little compared to MedChi's survey of 2016 Maryland physician compensation. In 2016, female Maryland physicians earned 49.6% less than male physicians.
The new gender-based pay gap data is discouraging, MedChi CEO Gene Ransom, JD, said in a prepared statement. "The fact that significant gender-based income disparities persist among Maryland physicians is both disappointing and perplexing. We expected to see at least some closure of this gap, but it remains as wide as ever."
The factors driving the gender-based pay gap in Maryland are unclear, James Taylor, MBA, MA, group president and CEO of AMN Healthcare's Leadership Solutions division, said in a prepared statement. "We see little difference in the employment contracts of male and female physicians. Nevertheless, the data show that female Maryland physicians earn less than males, even when specialty, hours worked, practice status, and age are factored into the equation."
The Merritt Hawkins 2019 Survey of Women in Medicine queried female physicians about what they thought were the causes of the gender-based pay gap in medicine. Unconscious employer discrimination was identified as the primary cause, followed by less aggressive or adept negotiating skills among female physicians compared to male physicians.
Other survey results
The new survey report features several other primary findings.
The data indicates the coronavirus pandemic has had a negative impact on physician compensation. Compared to 2016 average income for all Maryland physicians, 2020 average income was down 7.7%.
In 2020, Maryland physician average pre-tax annual income varied by race and ethnicity. Asian American physicians reported income of $325,000, white physicians reported income of $268,000, and African American physicians reported income of $225,000.
In 2020, employed Maryland physicians earned 26% less than physicians in independent private practice. Employed physicians earned an average pre-tax annual income of $262,000 compared to $299,000 for physicians in independent private practice.
In 2020, Maryland physicians reported that telemedicine accounted for 15% of their pre-tax income.
Maryland physicians expected telemedicine's share of their income to fall to 11% in 2021.
Maryland physicians expect only a modest percentage of their income this year will come from value-based payments. They projected that 9% of their pre-tax income will be linked to quality measures such as patient satisfaction scores and adherence to treatment protocols.
In a surprising finding, 50.3% of Maryland physicians reported that they were not professionally impacted by the pandemic. But there were disruptions because of the virus: about 5% of physicians closed their practices, 4.3% joined another practice, 3.7% were furloughed, 3% found work in another field, 1.2% were laid off, and 1.2% retired.
Researchers examined Yelp online reviews of 100 randomly selected acute care hospitals in the United States.
Based on an analysis of Yelp online reviews, acts of discrimination in the hospital setting can be categorized in six recurring patterns, including acts of commission, stereotyping, and intimidation, a recently published research article found.
Earlier research has shown that discrimination based on minority patients' race, sex, gender, sexual orientation, age, or disability generates worse health outcomes. The co-authors of the recently published research article found that Yelp online reviews provide insight into discrimination in the hospital setting that cannot be gleaned from traditional healthcare performance measures such as Hospital Compare.
The study, which was published by JAMA Network Open, is based on Yelp online reviews made from January 2011 to December 2020 of 100 randomly selected acute care hospitals in the United States.
The reviews were filtered with 31 keywords drawn from the Everyday Discrimination Scale such as race, racist, slur, threat, hate, and bias. A total of more than 10,000 reviews were collected and nearly 3,000 reviews were determined to be potentially related to discrimination. The research team identified 182 reviews that described at least one act of discrimination.
The study features several key data points.
53 reviews (29.1%) were categorized as institutional racism
72 reviews (39.6%) cited individual actors as sources of discrimination such as security guards, nurses, and physicians
89 reviews (48.9%) described acts of discrimination that occurred in clinical settings
25 reviews (13.7%) described acts of discrimination that occurred in nonclinical spaces such as lobbies
66 reviews (36.3%) included acts of discrimination by patients directed at healthcare workers
The researchers found that the acts of discrimination could be categorized in six patterns.
1. Acts of commission: "Instances in which actors showed their biases through purposeful acts of physical or verbal harassment. In extreme examples, a few reviews mentioned instances when actors violated patients' consent in carrying out abuses."
2. Acts of omission: "Acts of omission described instances in which medical care or basic needs, such as food or assistance with activities of daily living, were neglected or delayed by hospital staff. … Acts of omission frequently manifested around discussions of pain. Consumers described how a lack of attention to pain ultimately led to a missed or delayed diagnosis of an acute medical issue that was only discovered after seeking second or third opinions."
3. Dehumanizing: "Dehumanizing manifestations portrayed the consumer feeling dehumanized or devalued compared with others because of a particular personal attribute. For example, one consumer wrote, 'Why wasn't I greeted with enthusiasm, let alone greeted at all? Was it because of the color of my skin? Am I less of a person? Or was it because of age discrimination? In all my time here in the healthcare systems in [city], I’ve never once felt this invalidated.' Most frequently, consumers reported feeling dehumanized because of being ignored in a variety of settings."
4. Stereotyping: "Consumers often reported on racial and gender stereotypes that perpetuated poor health care treatment, including dismissal of symptoms and pain severity. In these scenarios, the patient came to the practitioner seeking treatment, only for their symptoms to be overlooked because of the practitioners’ prejudices and biases. These experiences occurred often among self-identified Black people and women."
5. Intimidation: "Intimidation manifested as verbal and physical tactics used by health care workers, such as threats of using specific medical protocols as punishments or intrusions into consumers' personal space, to bully and harass consumers during health care visits. Consumers reported being frightened by individual or institutional discrimination. Frequently, acts of intimidation occurred during psychiatric visits and toward self-identified women or older adults."
6. Unprofessionalism: "Discrimination described as unprofessional manifested as disrespectful or unprofessional behaviors, often including terms such as mean, rude, and condescending. In addition, several consumers noted that unprofessional individuals shared personal thoughts and opinions that expressed bias, judgment, microaggression, and macroaggression. In such instances, respondents believed that perpetrators’ negative attitude and treatment was caused by bias and in violation of the standard of care."
Interpreting the data
Institutional discrimination was present when an entire hospital or clinic was described as discriminatory, the lead author of the study told HealthLeaders.
"The reviews typically cited the hospital as the source of discrimination in these cases. A specific example was a consumer who said, 'Worst hospital ever. I went to the emergency room with my daughter, who had a non-stop running nose. Their customer service was horrible. They treated people not nice, like they were racists. I am Asian.' In that instance, the consumer cited the entire hospital. There was not just a specific nurse, receptionist, security officer, or physician. They associated the entire institution as the source of racism," said Jason Tong, MD, general surgery resident and national clinician scholar fellow, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia.
Categorizing discrimination into patterns is helpful in addressing discrimination, he said.
"Discrimination is known as a difficult concept to study and target. Oftentimes, discrimination is thought of as a very experiential concept. However, by helping to organize discrimination into a taxonomy of recurring patterns, we can think of more effective ways to approach it. For example, as we highlight in our article, acts of omission have been used to describe a variety of patient safety issues such as medication administration errors. Importantly, people have already developed tools and approaches to types of acts of omission. So, by now thinking of acts of discrimination as another type of act of omission, we can apply pre-existing tools to address and study discrimination."
The research team deemed discrimination to be a form of patient harm, Tong said. "It goes back to the recurring patterns that we identified. The way that we did our study is we first went through many reviews, then the patterns emerged out of the data. At first, when we thought about it, a lot of the patterns seemed very familiar, and we went into the literature and found that all six of the recurring patterns had been previously described within the context of patient harm and patient safety, which is why we made the link to patient harm."
About $260 million of annual excess healthcare expenditures from primary care physician turnover is linked to physician burnout.
Turnover of primary care physicians (PCPs) causes about $979 million in excess healthcare expenditures for public and private payers each year, a recently published research article found.
Care continuity between PCPs and their patients has been linked to better outcomes, including diagnostic accuracy, fewer emergency room visits, and lower hospital admissions, the co-authors of the research article wrote. Continuity of care has also been associated with lower costs, they wrote.
The research article, which was published by Mayo Clinic Proceedings, found that about $260 million of annual excess healthcare expenditures from PCP turnover is caused by PCP burnout. The cost of PCP turnover linked to burnout should be a powerful motivator to improve PCP well-being, the lead author of the study said in a prepared statement.
"Turnover of primary care physicians is costly to public and private payers, yet there is an opportunity to decrease unnecessary healthcare expenditures by reducing burnout-related turnover. Physician burnout is preventable and payers, healthcare organizations, and others have a vested interest in making meaningful changes to reduce physician burnout," said Christine Sinsky, MD, lead author of the study and vice president of professional satisfaction at the American Medical Association.
The methodology of the study has several essential points and conservative estimates.
The average patient panel for PCPs was set at 1,000 individuals
The average number of Medicare beneficiaries in a PCP patient panel was set at 196 and the average number of non-Medicare beneficiaries was set at 804
Data from a survey of more than 5,000 physicians was used to estimate the prevalence of burnout and intention to leave a practice within two years
Based on earlier research, it was estimated that Medicare patients generate $189 in excess healthcare expenditures in the first year after turnover of a PCP
It was estimated that non-Medicare patients generate $61 in excess healthcare expenditures in the first year after turnover of a PCP
Based on the most conservative estimate in the literature, it was estimated that 25% of physicians intending to leave their practice in the next two years would actually leave
The study generated five primary data points.
In the first year after leaving practice, the excess healthcare expenditure per PCP was estimated at $86,336
11,339 PCPs were estimated to leave practice annually
Given the excess healthcare expenditure per PCP and the estimated number of PCPs leaving practice annually, annual excess healthcare expenditure associated with PCP turnover was estimated at about $979 million
Annual PCP turnover attributable to burnout was estimated at 3,006 physicians
Given the excess healthcare expenditure per PCP and the estimated number of PCPs leaving practice annually due to burnout, annual excess healthcare expenditure associated with burnout-related PCP turnover was estimated at about $260 million
"In this analysis, we estimate that each instance of a PCP's leaving current practice results in $86,336 in excess healthcare expenditures during the following year. We estimate that PCP turnover results in $979 million in annual excess healthcare costs across Medicare and non-Medicare patients, of which $260 million (27%) is attributable to burnout. Physician burnout is therefore costly to public and private payers, who bear most of these excess healthcare costs," the study's co-authors wrote.
Brian Tiffany, MD, PhD, says ensuring physicians feel that they have a voice in a healthcare organization is the crucial element of physician engagement.
The new chief physician executive of the Dignity Health Southwest Division has developed an executive leadership style that is heavily influenced by his background in emergency medicine.
Brian Tiffany, MD, PhD, has succeeded Keith Frey, MD, in the chief physician executive role. Frey retired in January.
Tiffany has worked at Dignity Health for two decades. Prior to moving into his new role, he served as chief medical officer at Dignity Health's Arizona General Hospital Phoenix. An emergency medicine physician since 1990, Tiffany joined Dignity Health in 2003 as a member of the medical staff at Dignity Health Chandler Regional and Mercy Gilbert Medical Centers.
The Dignity Health Southwest Division includes six hospitals in the Phoenix area, three hospitals in Nevada, and 14 free-standing emergency departments.
Tiffany recently spoke with HealthLeaders about a range of topics, including his new role, promoting clinical excellence, physician engagement, and the coronavirus pandemic. The following transcript has been edited for clarity and brevity.
HealthLeaders: What are the primary elements of your leadership style?
Brian Tiffany: My leadership style grew out of being an emergency physician. That is who I am—I still think of myself as an ER doctor. I still practice, although not at the level that I used to practice.
An ER is a very close-knit team. There is no captain of the ship in the ER—there is very little of a power gap in the ER. An experienced ER nurse will save your bacon as an ER doctor many times through the course of your career. When a nurse says, 'I need you in Room 4,' you do not ask why you are needed in Room 4, you go to Room 4.
You listen to suggestions. You communicate as a team. You take care of each other as a team. I think about leadership in those terms. You know your people. You are present. You are not the boss—you are most responsible for making sure we get to where we need to go, but the whole team must be involved. No matter how small the ER, no ER physician knows everything that is happening in a given moment. But collectively, we know exactly what is going on. That applies all the way up the line to the division-level leadership. No single person can run everything—you must have a team around you.
HL: How do you envision serving as a chief physician executive?
Tiffany: The most important thing is to work effectively together as a division to deliver high-quality healthcare. We have great diversity in our division, from academic teaching facilities to community hospitals, and a significant network of urgent care clinics. What I am here to do is to help us work together as a division—particularly in the physician realm—in the delivery of care to patients at the appropriate level of service. We want to provide care to patients as close to their home as possible at the right level of care and the right site.
HL: What is the biggest challenge you foresee in your new role?
Tiffany: The diversity of facilities is part of the challenge—bringing academic physician groups, employed physician groups, and independent practices together to work as a team. It takes a lot of interpersonal relationship building. It takes team building.
HL: How do you promote clinical excellence?
Tiffany: A big component of clinical excellence is reducing variation in how we deliver care. You need to identify best practices, then adapt them to local conditions—each hospital has its own set of local challenges and its own community—to provide better care.
Over the past six years, the division has been on a journey to achieve high reliability. Some of our hospitals have already gone through that process. A major component of high reliability organizations is teamwork. It's reducing the power gap between physicians and members of the staff. It's helping everyone to work together as a team. Every member of a team should feel the freedom to speak up, ask questions, and stop the line if they perceive that there is a safety concern. That is a way of reducing errors and delivering better care.
HL: Give two examples of your division's approach to high reliability.
Tiffany: Stop the line is a good example. A housekeeper who sees something that does not look right should not feel intimidated about speaking up and saying, 'Is this OK? Should this be happening this way?' No one can penalize someone for bringing up a concern—that kind of questioning should be welcomed at all levels of the organization.
Another big component of high reliability is checks and balances. When a physician writes an order, that order just does not get executed blindly. The order is seen at several levels—the nurse sees that order, the pharmacist sees that order, and we use an electronic health record and there is error checking that occurs in the EHR. Those checks and balances make it very difficult for any error to reach a patient.
HL: How do you build strong physician engagement?
Tiffany: Physicians need to feel heard—that is the biggest component of physician engagement. We conduct physician surveys here to gauge how they feel about the organization and how they like working here. The Number One thing for physicians is to make sure they have a voice—we do a good job at that, but we want to do a better job at that.
For me, in this role, I want physicians to know that I have an open door—that I will listen to their concerns and the organization is interested in their concerns. As in any leadership role, it is crucial that you hear someone's concerns, but it does not necessarily mean that you should do what they think should happen. However, they should understand why you are doing what you are doing. Whether they agree with you or not, they should know that their voice was heard.
As an organization, another major component of physician engagement is that a physician should have absolute confidence that their patients are going to receive excellent care. That goes far beyond the physician—it is the care that is being delivered when they are not standing at the bedside. The organization must perform reliably and with excellence.
HL: What lessons did you learn from being a member of the Dignity Health Southwest Division COVID-19 Incident Command?
Tiffany: It was a lesson in the value of talking with each other. In the Phoenix area, we were six independent hospitals working together. This pandemic has drawn us together in many ways. We must share resources. We must load balance between our institutions. The pandemic got all of our leaders to be more than acquaintances—they got to know each other well and work in the trenches together well.
Another great lesson from the Incident Command is the value of cooperation and working closely with other healthcare entities. There is a CMO group that is constantly talking with Banner Health, HonorHealth, Valleywise Health, and hospitals all over the state of Arizona. We have regular phone calls, so these healthcare organizations can know what is going on in multiple areas. We move resources around as needed. We go as a unified front to the state when we need something.
The omicron coronavirus variant forces hospitals to endure lower revenue and higher expenses.
The omicron coronavirus variant wreaked havoc on U.S. hospitals in January, according to a new National Hospital Flash Report from Kaufman, Hall & Associates LLC.
The omicron variant has fueled the latest surge in the coronavirus pandemic. The omicron variant was first detected in the United States on Dec. 1, 2021, and by Jan. 15, 2022, the variant accounted for 99.5% of sequenced specimens in the country, according to the Centers for Disease Control and Prevention. The highest daily 7-day moving average of cases during the pandemic was reported during the week of Jan. 9, 2022, at 798,976 daily cases, the CDC says.
The omicron variant had a damaging impact on hospital finances in January, the new National Hospital Flash Report says. "Hospital margins declined dramatically as many providers temporarily halted nonurgent procedures, the numbers of inpatients requiring longer hospital stays rose, and expenses continued to climb due to widespread staffing and supply chain issues," the report says.
The report is based on data collected from more than 900 hospitals. The report features several key data points.
The median Kaufman Hall Operating Margin Index for hospitals in January was -3.68%, without Coronavirus Aid, Relief, and Economic Security Act funding. With CARES funding, the median operating margin index was -3.3%.
The median change in operating margin dropped 71.3% from December to January, not including CARES funding. The median change in operating margin was down 23.7% compared to January 2021.
The omicron surge decreased outpatient care volume as hospitals and patients delayed nonurgent procedures to avoid spreading the virus and COVID-19 hospital admissions spiked. From December to January, operating room minutes fell 15.7%. Compared to before the pandemic in January 2020, operating room minutes were down 20.4% in January.
In January, there was an increase in severely ill patients requiring longer hospital stays. From December to January, average length of stay rose 8.6%. Compared to January 2021, average length of stay rose 4.9%.
From December to January, outpatient revenue fell 7.5%, which drove a 4.7% month-over-month decline in gross operating revenue, without CARES funding. Gross operating revenue declined despite a 2.7% rise in inpatient revenue from December to January.
Wage pressure associated with workforce shortages as well as global supply chain problems drove hospital expenses higher. From December to January, total expense per adjusted discharge increased 11.6%, with labor expense per adjusted discharge increasing 14.6%. From December to January, non-labor expense per adjusted discharge increased 7.8%.
Expenses were up precipitously compared to pre-pandemic levels. Compared to January 2020, total expense per adjusted discharge rose 43.5%, labor expense per adjusted discharge rose 57%, and non-labor expense per adjusted discharge rose 35.5%.
"The first month of 2022 was devastating for hospitals and health systems nationwide as they were hit full force by the omicron tidal wave. COVID-19 cases and hospitalizations peaked at record levels in January due to rapid spread of the highly contagious variant," the report says.
Gerald Harmon, MD, says the United States has endured a twin pandemic—the health effects of COVID-19 and an erosion of trust in healthcare experts.
The president of the American Medical Association delivered a national address today marking the end of the second year of the coronavirus pandemic.
The pandemic has been the gravest public health emergency in generations. As of today, the pandemic has claimed 5,941,607 lives globally and 966,736 lives in the United States, according to worldometer.
"This month marks the two-year anniversary of the first known death to COVID-19 in the United States and there isn't a single person I know who isn't worn out, frustrated, or just physically exhausted. We've experienced trauma, lockdowns, economic difficulties, and at least five distinct viral surges," AMA President Gerald Harmon, MD, said today in an address delivered via livestream from the National Press Club in Washington, DC.
The pandemic will have a lasting impact on the country, he said. "It's my opinion, two years into this tragedy, that our nation is suffering a type of battle fatigue from our long fight with COVID, and the full impact of this pandemic on our national psyche may not be known until long after this difficult period ends."
Harmon said the nation has endured a twin pandemic—the ongoing struggle with the health effects of COVID-19 and an erosion in trust.
"COVID-19 will be with us for the foreseeable future, and we must understand what that means and make every effort to protect the most vulnerable among us. That means becoming fully vaccinated against the virus and receiving booster shots when eligible. And it means vaccinating our children, when they are eligible. I encourage anyone with questions to talk to their doctor or another trusted health professional about the safety and efficacy of COVID-19 vaccines," he said.
The erosion of trust in health professionals is nearly as damaging as the pandemic itself, Harmon said.
"Sadly, COVID-19 isn't the only pandemic we are fighting in America. The other pandemic is a profound loss of trust in the advice of experts, including doctors and scientists, to help us make sense of what's happening and make informed decisions about our health. This pandemic of mistrust was probably beginning before COVID-19, but the extreme polarization during this crisis has profoundly hampered our nation's ability to respond. It is a major reason why the U.S. has a far higher death rate from COVID-19 compared to other well-resourced countries," he said.
Six primary factors have contributed to the climate of mistrust, Harmon said.
Inadequate funding of pandemic preparedness and public health agencies
Unclear lines of responsibility
Uneven use of federal authority to produce masks and other personal protective equipment, as well as testing and supplies
Mixed messaging on masks, social distancing, isolation, and quarantine
Political and sometimes personal attacks on scientists and physicians
An inadequate response to the omicron variant surge and a shortage of coronavirus tests more than 18 months into the pandemic
"Playing the blame game is an exercise in futility, but we do recognize these missteps. Our focus now should be learning from those mistakes and rebuilding the trust lost as a result," he said.
One of the main ways to restore trust in healthcare experts is to address misinformation and disinformation by a small number of healthcare professionals, Harmon said.
"Surprisingly to me, some of the loudest purveyors of misinformation and junk science during this pandemic have been a very small number of doctors and health professionals. These offenses are, in my opinion, the most egregious of all because they violate the ethics of our profession and each lie and untruth spread by the click of a mouse erodes the trust that is at the very heart of the patient-physician relationship—trust that is essential in our ability to provide care. This is why the AMA has called for state medical boards to respond swiftly when physicians spread falsehoods online and through the media, particularly disinformation relating to COVID-19," he said.
Fixing healthcare system, rebuilding trust, and responding to next major health crisis
Five steps must be taken to restore the U.S. health system and trust, as well as to prepare for the next colossal public health emergency, Harmon said.
"The first is to enhance our state and federal stockpiles of medically necessary supplies and improve the system for acquiring and distributing them. The shortage of PPE and other essential supplies in the early months of this pandemic slowed our nation's response and needlessly put lives of physicians and our frontline workers at risk. Given what we have experienced in this pandemic, global demand can quickly outpace supply for even simple items, such as cotton testing swabs. This should never happen in a country as rich in resources and manufacturing as ours."
"Second, we must significantly increase funding to bolster our nation's diminished public health infrastructure. Chronic disinvestment in government public health agencies puts lives at risk and has severely limited our ability to fight COVID-19. State public health spending has dropped 16% over the last decade, resulting in the loss of nearly 40,000 jobs at state and local public health agencies. It's gaps like these at the community level that contributed to a lack of widespread testing, resulting in more-rapid virus spread in the early stages of the pandemic."
"Third, we must learn from the process that led to the rapid-scale production of several safe and highly effective vaccines. Operation Warp Speed is, quite simply, one of the greatest scientific achievements of our lifetime. We believe the public-private partnership and operational structure of this plan should be preserved in some form for future pandemics or any time vaccines and therapeutics are needed in an emergency."
"Fourth, the rapid expansion and integration of telehealth and remote patient care has been a lifeline during this pandemic—not only for patients but for struggling physician practices during periods of intense lockdowns. The AMA has long championed telehealth and has provided expert guidance, support, and resources to help physicians implement it in their practices during the pandemic. But for telehealth to succeed the way patients and physicians want it to, we need the help of Congress.
"Finally, we must pause to consider the extraordinary pressure our nation's physicians and healthcare workers have had to shoulder the last two years—men and women on the frontlines of our emergency departments and intensive care units who have gone above and beyond in their service to all of us. They have worked extremely long hours, often for days at a time—through every surge—at great personal risks to themselves and their loved ones."
