The Boston-based physician organization wants social drivers of health included in payment models for healthcare services.
The Physicians Foundation is pressing the Centers for Medicaid and Medicare Services (CMS) to adopt new measures for social drivers of health.
The Physicians Foundation has adopted the term social drivers of health rather than social determinants of health. As detailed in a Health Affairsarticle published last year, social drivers of health is a more precise term, which also does not strip people of "their agency to manage their own health and well-being—as though their struggles to access food or housing were pre-determined and thus unalterable."
In a recent interview, HealthLeaders spoke with Gary Price, MD, president of The Physicians Foundation, about his organization's work on social drivers of health. The following is a lightly edited transcript of that conversation.
HealthLeaders: What are the primary CMS measures for social drivers of health that The Physicians Foundation has proposed?
Gary Price: The Physicians Foundation recently released Improving America’s Health Care System: Recognize the Realities of Patients' Lives and Invest in Addressing Social Drivers of Health, which outlines four principles with 17 pragmatic steps that are needed to address social drivers of health (SDOH) that impact physicians and patients across the country. These actionable recommendations focus on how to address SDOH in how we pay for and deliver care to improve health, while reducing costs and easing administrative burdens on physicians. One key principle is the imperative to create new standards for SDOH quality, utilization, and outcome measurement.
Every year, CMS invites recommendations for new measures aligned with the agency's priorities, and the agency recently declared a priority to develop and implement measures that reflect social and economic drivers. Consistent with the recommendations we recently released, The Physicians Foundation submitted the first-ever SDOH CMS measure set to be included in federal payment programs:
Percentage of beneficiaries 18 years old or older screened for food insecurity, housing instability, transportation problems, utility help needs, and interpersonal safety
Percentage of beneficiaries 18 years old or older who screen positive for food insecurity, housing instability, transportation problems, utility help needs, or interpersonal safety
CMS has included these SDOH measures in its "measures under consideration" list for the Merit-based Incentive Payment System (MIPS) and the Hospital Inpatient Quality Reporting Program. Importantly, these measures—stratified by race and ethnicity—have been well-tested in over 600 clinical sites across the country through the CMS innovation center's Accountable Health Communities model.
HL: Why is adoption of the proposed CMS measures important?
Price: Despite the well-documented impact of SDOH on health outcomes and costs and their disproportionate impact on communities of color, there are still no drivers of health measures in any federal healthcare payment or quality programs. Reducing total cost of care and achieving health equity are only achievable by addressing SDOH. Yet, this is not how our system operates.
For example, under federal payment and quality frameworks, the healthcare system codes, screens, measures, and risk-adjusts for diabetes, but not for food insecurity—even though diabetics who are food insecure have worse health outcomes and cost on average $4,500 more per year than those with access to healthy food. A system that does not collect and act on food insecurity data cannot address rising healthcare costs or reduce racial disparities, especially given that Black Americans face the highest rates of both food insecurity and diabetes.
Likewise, SDOH lead to physician burnout and effectively penalize physicians for caring for affected patients via lower MIPS scores. A recent JAMA study, from The Physicians Foundation Center for the Study of Physician Practice and Leadership at Weill Cornell Medicine found that SDOH were associated with 37.7% of variation in price-adjusted Medicare per beneficiary spending between counties in the highest and lowest quintiles of spending in 2017. Yet even with an ongoing pandemic that has painfully brought these issues to the forefront, SDOH are still not included in any geographic adjustment or cost benchmarks.
Physicians are held responsible for patients' health through quality measures and financial rewards or penalties that focus almost entirely on clinical care. As SDOH drive 70% of health outcomes and associated costs, we must create financial incentives and risk models to account for the realities of patients' lives.
HL: What are the primary goals for addressing SDOH at The Physicians Foundation?
Price: We aim to continue building broad-based understanding of the SDOH and their implications for patients and physicians. We have been pursuing this goal for more than a decade through research, education, and innovative grant making.
For example, The Physicians Foundation collaborated with Health Leads to develop and implement the first-ever system to help enable physicians to screen their patients for SDOH and automatically connect or refer them with the basic resources they need to be healthy.
The healthcare sector is increasingly recognizing that America cannot improve health outcomes or reduce healthcare costs without addressing SDOH, but greater action is required in four arenas:
1. Address SDOH in combatting COVID-19: The Physicians Foundation recognizes the imperative to incentivize and invest in addressing SDOH as a key facet of tackling the pandemic and its aftermath, for both physicians and their patients.
2. Integrate SDOH into payment policy: Federal and state policymakers and private insurance companies have increasingly held physicians responsible for patients' health through quality measures and financial rewards and penalties that focus almost entirely on clinical care.
3. Create new standards for SDOH quality, utilization, and outcome measurement: Develop standard measures to address and quantify the impact SDOH have on health outcomes, costs, and disparities; understand barriers to effective care; more accurately risk adjust payment models and establish cost benchmarks; and quantify latent financial risk in the healthcare system.
4. Make SDOH central to an innovation agenda: the Center for Medicare & Medicaid Innovation has field-tested addressing SDOH via its Accountable Health Communities model, which has screened about 1 million patients for social needs, and its Comprehensive Primary Care Plus model, in which 93% of practices are now screening for SDOH. A number of states have also integrated SDOH into care delivery. Building on this experience and data, CMS and states now have the opportunity to spur further action on these issues.
HL:What is the role of physicians in addressing SDOH?
In The Physicians Foundation's 2020 Survey of America's Physicians: COVID-19 and the Future of the Health Care System, 73% of physicians indicate that SDOH such as access to healthy food and safe housing will drive demand of healthcare services. Additionally, almost 90% of physicians said their patients had a serious health problem linked to poverty or other social conditions. It is critical that physician and patient voices remain central to the discourse and decision-making on health reform and SDOH. Individual physicians are closest to these issues and their perspectives are critical to improving patient outcomes.
HL: What are the prospects for the medical community addressing SDOH? How far have we come, and how much further do we need to go?
Price: As mentioned previously, The Physicians Foundation has been recognizing and acting on addressing SDOH for more than a decade, which was long before most stakeholders in the healthcare system. However, with a federal administration committed to operationalizing equity; a pandemic that has exacerbated rates of food insecurity, housing instability, and other SDOH, and the clinical disease burden linked to these factors; and the Medicare Trust Fund projected to be insolvent in five years; now is the moment our community can take major strides to have SDOH comorbidities be recognized and acted upon.
In addition to federal efforts, the medical community in each state needs to work collaboratively with their state legislature and department of health and human services to embed SDOH within financial incentives and quality measures.
A hospital merger in New York City decreased mortality, improved HCAHPS scores, and reduced hospital-acquired conditions.
A full-integration approach to a hospital merger was associated with quality improvements including a reduction in mortality rates, a recent research article says.
Earlier research has shown that hospital consolidations have more than doubled since 2009. Other earlier research has found hospital mergers can have a negative impact on quality, including increased mortality rates associated with a reduction in hospital competition.
The recent research, which was published by JAMA Network Open, highlights the acquisition of Lutheran Medical Center by the academic health system NYU Langone Healthin 2016. Lutheran Medical Center, which was a 450-bed safety net hospital, was renamed NYU Langone Hospital—Brooklyn.
The study examined data before the merger from September 2010 to August 2016 and after the merger from September 2016 to August 2019. The primary focus of the research was in-hospital mortality, but the study also examined 30-day readmissions, patient experience, and hospital-acquired conditions.
NYU Langone Health's full-integration approach to the merger had five facets, the study's co-authors wrote: "(1) early administrative and clinical leadership integration with the academic health system; (2) rapid transition to the academic health system electronic health record; (3) local ownership of quality metrics; (4) system-level goals with real-time actionable analytics through combined dashboards; and (5) implementation of value-based and other analytic-driven interventions."
The study features several key data points for NYU Langone Hospital—Brooklyn.
From before the merger to after the merger, unadjusted mortality decreased 0.71% on an absolute basis and 27% on a relative basis.
From before the merger to after the merger, risk-adjusted mortality decreased 0.95% on an absolute basis and 33% on a relative basis.
Three years after the merger, there was significant improvement in HCAHPS survey performance. For example, more patients registered 9 or 10 ratings to the question, "Using any number from 0 to 10, where 0 is the worst hospital possible and 10 is the best hospital possible, what number would you use to rate this hospital during your stay?"
There were improvements in hospital-acquired conditions. There was a reduction in central line infections per 1,000 catheter days and a reduction in catheter-associated urinary tract infections per 1,000 discharges.
There was no significant change in 30-day readmissions.
"These results suggest that a full clinical and operational integration approach to a hospital merger may improve outcomes as measured by quality and safety metrics, including mortality rates," the study's co-authors wrote.
Keys to success
The merger was not driven by financial factors, which may explain the positive impact on quality, the study's co-authors wrote. "The goal of the merger was not revenue-driven; this uncommon full-integration approach was designed and executed to improve quality."
NYU Langone Health was committed to a value-driven approach to full integration, which included a common governance structure and a common electronic health record and cost-accounting system, the study's co-authors wrote.
"This focus on robust integration was balanced with identification of local opportunities, implementation of site-specific quality improvement interventions, and a systemwide adoption of some of these novel approaches. These innovations included nurse-driven and EHR-supported programs to reduce unnecessary urinary catheterization and, subsequently, [catheter-associated urinary tract infections]; physician-led root cause analyses and occurrence reviews; and multidisciplinary workgroups to reduce the frequency and duration of hospitalization for high users of care," they wrote.
The study's results indicate that hospital mergers can achieve improvements in quality, the researchers wrote. "This study of a system merger with a safety net hospital found that a full-integration approach to hospital consolidation was associated with improvement in quality outcomes. Despite evidence that mergers usually reduce quality, we found that strategic consolidations can be associated with substantially improved quality when performed effectively."
For decontaminated respirators, researchers assessed fit on human subjects and examined filtration efficiency.
N95 respirators can be safely and effectively decontaminated with vaporized hydrogen peroxide (VHP) over 25 reprocessing cycles, a new research article says.
In the early months of the coronavirus pandemic, N95 respirators were in short supply, which created a safety concern, particularly for healthcare workers. Decontamination is one strategy to address shortages of N95 masks.
The new research article, which was published by American Journal of Infection Control, is based on data collected at a large tertiary care academic center in Boston from June 15 to Aug. 31, 2020.
Over the course of the study, the researchers tested a total of 35 3MTM brand N95 respirators for fit and seal. From the 35, seven of the N95 respirators were tested for filtration efficiency.
There are several aspects in the methods of the research.
The primary goal of the study was to determine whether the function and effectiveness of decontaminated N95 respirators was comparable to unprocessed respirators. "Function was defined as continued filtration efficiency greater than or equal to 95% of airborne particles of 0.3-micron or greater diameter. Effectiveness was defined as passing user seal check after every reprocessing cycle and retention of both qualitative and quantitative fit," the study's co-authors wrote.
Male and female human subjects were used for fit testing rather than mannequins.
A Bioquell BQ-50 hydrogen peroxide vapor generator was used to conduct the VHP decontamination.
If a respirator was visibly soiled, it was removed from the study.
To ventilate the respirators and the processing room, fans were used to push natural air through the room and open windows.
The testing generated two key data points.
All decontaminated N95 respirators met benchmarks for function and effectiveness. The decontaminated N95 respirators passed 25 user seal checks as well as eight quantitative and four qualitative fit tests.
Decontaminated N95 respirators achieved filtration efficiencies of at least 95%.
"VHP reprocessing appears to be a safe, viable means to augment N95 respirator supply in future epidemics. However, successfully implementing large-scale reprocessing requires multidisciplinary teams to ensure disinfection efficacy and end-user safety, as well as significant logistical support," the study's co-authors wrote.
Additional insights
N95 respirators decontaminated with VHP are comparable to unprocessed respirators, the lead author of the study told HealthLeaders.
"Based on the findings of our study, the specific brand of N95 respirators we looked at had equivalent filtration efficiency, fit, and seal to that of new N95 respirators even after 25 cycles of VHP reprocessing. To evaluate for significant degradation, we conducted a visual inspection of the N95 respirators for physical wear and tear after each decontamination cycle before participants donned them. If we saw anything suspicious, we were to dispose them per protocol. Reassuringly, we never had to dispose any of the N95 respirators we tested," said Christina Yen, MD, an infectious disease attending physician at UT Southwestern Medical Center in Dallas and associate director of antimicrobial stewardship at Clements University Hospital in Dallas.
Although the decontamination period lasts only 40 to 45 minutes, the overall process can take more than two hours, Yen said.
"This is because there are other important steps involved to ensure efficacy and safety. First, the vaporization of liquid hydrogen peroxide; second, the settling of gaseous hydrogen peroxide onto the N95 respirators; and finally, an aeration phase to ensure that all and any residual hydrogen peroxide gas breaks down into water vapor and oxygen. The final phase prevents the gas from lingering on the masks, which can cause skin irritation to the wearer," she said.
In assessing N95 decontamination, using human subjects is superior to using mannequins, Yen said. "Participants have a range of facial structures unlike mannequins. People also have differences in their baseline N95 respirator fit. Our team felt it was important to consider these real-world variations when conducting this study and assess whether they would impact fit and seal."
There are three primary elements of a conversation with healthcare workers about the safety and effectiveness of N95 respirator VHP decontamination, she said.
"First, organizational leadership's support of the use of VHP decontamination ensures that the technology has been vetted by multiple stakeholders and experts; this helps ensure safety and accountability when implementing this technology. Second, clear, routine messaging within the organization lets healthcare workers know that, while VHP decontamination of N95 respirators is still an area of active research, safety and efficacy are being prioritized and that usage of this technology is based on the latest, high-quality evidence with their wellbeing in mind. Finally, healthcare workers need to feel empowered to share their concerns about the technology and safety. Otherwise, organizations will not know what type of education, information, or gaps of knowledge are present among their healthcare workers," Yen said.
Physicians were grouped into four categories of telehealth adoption: innovators, early adopters, majority adopters, and persistent nonadopters.
Female, behavioral health, and primary care physicians were more likely to be early adopters of telehealth during the coronavirus pandemic, a recent study found.
In the first year of the pandemic, telehealth expanded dramatically at health systems, hospitals, and physician practices. While telehealth during the pandemic has been associated with several benefits such as convenience for patients and limiting exposure to the coronavirus, variable adoption by physicians raises concerns about access to services.
The recent study, which was published by JAMA Network Open, is based on data collected for more than 3,400 physicians at Mass General Brigham, which is a Boston-based health system that includes Massachusetts General Hospital and Brigham and Women's Hospital as well as 10 other hospitals. The data was collected from Oct. 1, 2019, to Dec. 31, 2020.
The researchers examined several physician characteristics and their impact on telehealth adoption such as gender, specialty, and generational cohort. There were four generational cohorts: Silent Generation, born 1928-1945; Baby Boomers, born 1946-1964; Generation X, born 1965-1980; and Millennials, born 1981-1996.
Physicians were grouped into four categories of adoption: innovators conducted virtual visits before March 15, 2020; early adopters conducted virtual visits during the week starting March 15, 2020; majority adopters conducted virtual visits on March 22, 2020, or later; and persistent nonadopters conducted no virtual visits through Dec. 31, 2020.
The recent study features several key data points.
Female (odds ratio 1.23), behavioral health (odds ratio 2.92), and primary care (odds ratio 1.69) physicians were more likely to be early adopters of telehealth
Silent Generation physicians (odds ratio 0.39) and surgical specialty physicians (odds ratio 0.46) were less likely to be early adopters
13.8% of physicians were innovators, 45.0% of physicians were early adopters, 35.6% of physicians were majority adopters, and 5.6% of physicians were persistent nonadopters
Physicians in younger generations were more likely to be innovators and early adopters
When examining the data by specialty, behavioral health (30.2%) and primary care (9.4%) had the highest proportion of physicians who were innovators
The older the generational cohort, the more likely physicians conducted audio-only virtual visits: Silent Generation had a median of 41.5%, Baby Boomers had a median of 35.6%, Generation X had a median of 30.2%, and Millennials had a median of 28.5%
"In this cross-sectional study of more than 3,400 physicians providing ambulatory care in our large regional health system, the overwhelming majority of physicians (94.4%) transitioned to include virtual health care in their practice by the end of 2020. There were minor differences by generational demographic cohort, and female physicians and behavioral health physicians were the most likely to be early adopters," the study's co-authors wrote.
Interpreting the data
The study's co-authors offered two explanations for why female physicians were more likely to be early adopters of telehealth.
"The toll of the pandemic on women in caregiving roles has been well described, and this group may have found that virtual care provided a flexible solution that enabled them to balance or maintain their many roles. Although many things happened simultaneously during the early weeks of the pandemic, we note that the peak of early adoption coincided with the state-mandated school closure date of March 16, 2020. An alternative potential explanation may be found in communication practices. Female physicians have previously been shown to have more patient-centered communication and to spend more time with their patients, and it is possible that their earlier transitions to virtual health care were a result of being more responsive to their perceptions of their patients' needs with rapid changes early in the pandemic," the study's co-authors wrote.
The study's co-authors also offered an explanation for why early adoption of telehealth was prevalent among behavioral health physicians. "Behavioral health visits may be more amenable to virtual care given that they are typically less reliant on an in-person physical examination or procedure. It is also likely that patients with behavioral health needs had particular challenges forgoing medical care when in-person visits were restricted at the onset of the public health emergency, and thus these challenges motivated their physicians to make a rapid transition to virtual care."
The study's co-author's hypothesized that generational differences would play a major role in telehealth adoption, but the data showed modest correlations.
"The only generational association that we noted was that the small number of physicians in our system from the Silent Generation were less likely to be early adopters. However, more than 90% of those older physicians ultimately did transition to providing virtual healthcare at some point in 2020, and membership in the Silent Generation was not associated with persistent nonadoption. When considering physicians in the Baby Boomer generation, we found that they were as likely to be early adopters as physicians in the Generation X or Millennial groups," the study's co-authors wrote.
A Northwestern University Feinberg School of Medicine professor offers his insights on likely developments in behavioral health this year.
An increased public recognition of the need for behavioral health treatment is one of the top trends in behavioral health care for 2022, an expert says.
Jason Washburn, PhD, MA, is a professor of psychiatry and behavioral sciences at Northwestern University Feinberg School of Medicine as well as a member of the board of advisors at Owl. His research interests include nonsuicidal self-injury, suicide, and implementation of psychological practices.
HealthLeaders recently asked Washburn about the top behavioral health trends for 2022. The following is a lightly edited transcript of his comments.
1. Public awareness about behavioral health treatment: One of the things that is very clear from 2020 and 2021 is an increased public recognition of the need for behavioral health treatment. We have heard over and over for the past year and a half that increased access is needed for behavioral health services, particularly as a lot of people are struggling with mental health not only in an adjustment to the coronavirus pandemic, but also the ongoing stressors in society.
We certainly have heard quite a bit about the call for access. One thing we need to hear as well, and hopefully we will hear more of it in 2022, is not only increased calls for access to care, such as making telehealth a permanent option for providers and patients, but also to make sure we are providing quality mental healthcare. There is always going to be a marketplace response to the calls for access, but it is one thing to say 'here is more access' and another thing to say 'here is more access to high-quality care' that results in improvement and helps patients to deal with their symptoms.
Whether we see increased calls for quality behavioral health services in 2022 is dependent on many factors, but access by itself is not the solution because accessing care that does not help people get better or is variable in its response to people's needs is not going to be the solution by any stretch of the imagination.
2. Value-base care: There is a broader, longer-term trend that we have seen and will likely pick up in 2022, which is the increasing pivot toward value-based care. This is a long-term issue and when it is exactly going to happen is unclear. What is the tipping point?
We are seeing increasing numbers of payers looking toward the direction of value-based care in behavioral health services. Certainly, providers are looking in that direction. There are many opportunities right now for value-based care. This is a huge area that needs to be taken in full opportunity because we are not there yet in terms of utilizing all that value-based care has to offer.
I doubt that we will see a retreat in value-based care. I expect that we will see more arrangements in that direction. It is a slow process—it is a long-term process. But the providers and payers that can get behind value-based care will see greater benefit, especially for their patients and the value that they are getting.
In the current fee-for-service scenario, I, as a provider, do a service, I bill for that service, and I get reimbursed for that service. Rarely does anyone check to see what value my services provide. There is an incentive to bill as much as I can—I do not have an incentive to make patients better. The incentive is to support the provision of services—not the outcome of services.
A value-based approach would look at things such as whether patients get better and how quickly they get better—are you more efficient in getting patients better. I could be a provider who gets all patients better, but it takes three years to do it. We should be incentivizing providers who get patients better more efficiently than that. There could be patients who do take three years to get better, so we must be careful with a value-based framework to make sure it understands the severity of our cases and understands that patients respond differently to treatment. This is one of the reasons why value-based care is taking so long in behavioral health—it is not easy to do.
3. Measuring outcomes: To provide value and quality in behavioral health, there will be an increasing emphasis on measuring outcomes. Some of the common payer-based outcomes are quite limited in terms of what is currently available. For example, payers will often look at measures such as utilization of emergency room services and the number of behavioral health sessions. Basically, they are looking at how often services are being accessed, and that often is not a true indicator of how people are doing.
Certainly, in terms of improving outcomes, we want to see people's use of emergency rooms going down, but that is a blunt instrument. It does not tell us much about whether symptoms are improving in patients who are not using emergency rooms.
Understanding the severity at the beginning of treatment helps you to understand your case mix. You should expect different outcomes for people with severe depression compared to people with mild depression—you should expect a different amount of time in therapy to get to the same outcome. We also need to develop ways to measure severity over time as a way to capture value. The blunt instruments that are currently available, such as how many times a patient went to the ER or how many sessions a patient got, do not tell the full story. They do not provide the level of precision that is needed to truly understand how well a provider is performing in managing their population. Patient-reported outcomes are critical in assessing mental health services.
4. Spike in anxiety: We are likely to see some immediate escalation of anxiety in response to the omicron coronavirus variant. I recently got a text from my brother, who had just visited a pharmacy. Close to a fight broke out over a new box of COVID-19 test kits; people were yelling and screaming at each other. The amount of anxiety is going to increase dramatically with omicron. It was already a problem over the past 20 months, but omicron is showing that we have increased vulnerabilities, and that is making people very distressed.
If we continue to experience new variants, we as a country are going to have to figure out how we are going to manage the associated mental and behavioral health impacts.
5. Telehealth: I expect that we will see increasing utilization of telehealth in behavioral health services. Telepsychology and telepsychiatry will become part of normal operations for behavioral health organizations. Telehealth is going to be integrated into what we do daily, and it is going to be factored into decisions that health leaders must make. For example, how do you expand services for telehealth versus in-person visits? How do you make sure you are not cutting your in-person access too much? You need to provide enough in-person access for those who need it but also provide telehealth access for those who need it as well.
We are transitioning to a mixed model. Over the past 20 months, mental health services have been provided almost exclusively through telehealth. In 2022, as we transition to much more of a mixed model of telehealth and in-person visits, there are going to be a lot of adjustments. How much space do we need for in-person visits? How do we monitor and control quality of care when a provider is working from home? These issues are going to play out both from a provider and payer perspective. In 2022, the mixed model will give us a glimpse of what care is going to look like for the next five to 10 years.
Physician-driven factors such as closed physician offices have played a major role in foregone medical care for Medicare beneficiaries during the pandemic, study finds.
Forgone medical care for Medicare beneficiaries during the coronavirus pandemic has decreased over time and forgone medical care was more pronounced among Medicare beneficiaries who reported mental health problems, a recent study found.
Before the pandemic, delayed or forgone medical care was a known healthcare issue and previous research had linked it to poor health outcomes that inequitably impacted vulnerable patients. Other previous research has showed that about 40% of U.S. adults have reported forgone medical care during the pandemic, with fear of COVID-19 exposure cited among the reasons.
The recent study, which was published by JAMA Health Forum, includes data collected from more than 23,000 Medicare beneficiaries in three time periods: June 7 to July 12, 2020, Oct. 4 to Nov. 8, 2020, and Feb. 28 to April 25, 2021. The data was gathered from the Medicare Current Beneficiary Survey COVID-19 Supplement Public Use File.
The recent study features several key data points.
11.5% of Medicare beneficiaries reported forgone medical care because of COVID-19
Dental care was the most common care that was delayed or forgone (4.3% of survey respondents), followed by prevention (4.0%) and checkups (3.9%)
Rates of forgone medical care decreased in all three of the periods examined in the recent study, with the largest decrease found between June 7 and July 12, 2020 (22.4% to 15.9%)
Most Medicare beneficiaries forwent medical care due to physician-driven factors, with the percentage of beneficiaries who forwent medical care because of physician-driven factors dropping from 66.2% in the week of July 7, 2020, to 44.7% in the weeks of April 4 to April 25, 2021
From June 7 to July 12, 2020, the most common reported physician barrier was that the physician's office was closed
From April 4 to April 25, 2021, the most common reported physician barrier was that the physician had reduced appointments
The most common reported patient factor for foregoing care was that the patient felt risk of COVID-19 exposure and wanted to stay home
Medicare beneficiaries who reported feeling more stressed or anxious than those who did not had a likelihood of foregoing medical care 4 percentage points higher
Medicare beneficiaries who reported feeling more lonely or sad than those who did not had a likelihood of foregoing medical care 3 percentage points higher
Medicare beneficiaries who reported feeling less socially connected than those who did not had a likelihood of foregoing medical care 3 percentage points higher
"The results of this cross-sectional survey study suggest that public health emergencies, such as pandemics, may exacerbate existing barriers to care and cause patients to delay needed care. Factors unique to the pandemic included closed physician’s offices, reduced appointment availability, and patient fear of contagion. Medicare beneficiaries who are experiencing heightened mental health problems associated with the COVID-19 pandemic appear to be particularly vulnerable to forgone medical care," the study's co-authors wrote.
AMA President Gerald Harmon, MD, criticizes reduction of isolation periods from 10 days to five days.
New Centers for Disease Control and Prevention (CDC) COVID-19 guidance on quarantine and isolation is "confusing" and risks spreading the virus, the president of the American Medical Association (AMA) says.
CDC guidance on quarantine and isolation for those who have been exposed to someone with COVID-19 or people who test positive for COVID-19 has changed several times since the beginning of the pandemic. Under certain circumstances, the new guidance reduces the amount of time that people must quarantine or isolate themselves from 10 days to five days.
The new CDC guidance was last updated on Jan. 4.
In a prepared statement released on Jan. 5, AMA President Gerald Harmon, MD, expressed disappointment over the new CDC guidance. "Nearly two years into this pandemic, with omicron cases surging across the country, the American people should be able to count on the Centers for Disease Control and Prevention for timely, accurate, clear guidance to protect themselves, their loved ones, and their communities. Instead, the new recommendations on quarantine and isolation are not only confusing, but are risking further spread of the virus," he said.
The new CDC guidance that reduces the time for isolation is misguided, Harmon said.
"According to the CDC's own rationale for shortened isolation periods for the general public, an estimated 31% of people remain infectious five days after a positive COVID-19 test. With hundreds of thousands of new cases daily and more than a million positive reported cases on January 3, tens of thousands—potentially hundreds of thousands of people—could return to work and school infectious if they follow the CDC's new guidance on ending isolation after five days without a negative test. Physicians are concerned that these recommendations put our patients at risk and could further overwhelm our healthcare system," he said.
A negative test should be required for ending isolation after someone tests positive for COVID-19, Harmon said. "Test availability remains a challenge in many parts of the country, including in hospitals, and we urge the administration to pull all available levers to ramp up production and distribution of tests. But a dearth of tests at the moment does not justify omitting a testing requirement to exit a now shortened isolation."
New CDC isolation guidance highlights
The CDC says isolation should be used to separate people with suspected or confirmed COVID-19 from people who have not been infected.
The CDC has the following guidance for isolation. "At home, anyone sick or infected should separate from others, or wear a well-fitting mask when they need to be around others. People in isolation should stay in a specific 'sick room' or area and use a separate bathroom if available. Everyone who has presumed or confirmed COVID-19 should stay home and isolate from other people for at least 5 full days (day 0 is the first day of symptoms or the date of the day of the positive viral test for asymptomatic persons). They should wear a mask when around others at home and in public for an additional 5 days."
If someone has COVID-19 and has symptoms, they should isolate for at least five days, the CDC says. For these people there are six recommendations for ending isolation, the CDC says.
Isolation can be ended after five full days if you are fever-free for 24 hours without using a fever-reducing medication and other symptoms have improved.
After ending the five-day isolation period, people should wear a well-fitting mask around others at home and in public for an additional five days.
If fever persists and other symptoms do not improve after five days of isolation, you should not end your isolation until you are fever-free for 24 hours without the use of fever-reducing medication and other symptoms have improved.
After ending isolation, travel should be avoided until a full 10 days after the first day of symptoms. If you must travel on days six through 10 after your first day of symptoms, you should wear a well-fitting mask when you are around others while traveling.
You should not frequent places where you cannot wear a mask such as restaurants and avoid eating around others at home and work until a full 10 days after your first day of symptoms.
Toward the end of the five-day isolation period, there is no requirement to get testing, but the "best approach" is to take an antigen test if the test is available and the person wants to test. The test should be conducted only if you are fever-free for 24 hours without the use of fever-reducing medication and other symptoms have improved. "If your test result is positive, you should continue to isolate until day 10. If your test result is negative, you can end isolation but continue to wear a well-fitting mask around others at home and in public until day 10," the CDC says.
Although in-hospital COVID-19 mortality was similar for Black and White patients, it was 3.5 percentage points higher for Hispanic patients and other racial and minority patients compared to White patients.
In a recent study of Medicare beneficiaries during the coronavirus pandemic, racial and ethnic disparities in mortality were found in COVID-19 hospitalizations and mortality disparities widened in non-COVID-19 hospitalizations.
Earlier U.S. research has documented racial and ethnic healthcare disparities during the pandemic. For example, an earlier study found that death rates linked to COVID-19 for Black and Hispanic populations have been about double the death rates for White populations.
The recent study, which was published by JAMA Health Forum, is based on an analysis of fee-for-service Medicare inpatient data for more than 31 million beneficiaries and more than 14 million hospitalizations from January 2019 through February 2021.
The study features several key data points:
Although in-hospital COVID-19 mortality was similar for Black and White patients, it was 3.5 percentage points higher for Hispanic patients and other racial and minority patients compared to White patients
For non-COVID-19 hospitalizations, in-hospital mortality for Black patients went up 0.5 percentage points higher than the increase for White patients
Unadjusted in-hospital mortality for COVID-19 hospitalizations was 16.6% for White patients, 17.0% for Black patients, 21.7% for Hispanic patients, and 21.0% for other racial and ethnic minority patients
In adjusted analyses, in-hospital mortality for non-COVID-19 Black patients increased 0.48 percentage points more than it increased for non-COVID-19 White patients
Non-COVID-19 hospitalizations for White patients decreased from 17.9 per 1,000 beneficiaries per month before the pandemic to 13.4 per 1,000 beneficiaries per month through February 2021, representing a 25.0% decrease
COVID-19 hospitalizations for White patients through February 2021 were 1.4 per 1,000 beneficiaries per month
Non-COVID-19 hospitalizations for Black, Hispanic, and other racial and ethnic minority patients through February 2021 decreased 22.9%, 30.6%, and 26.4%, respectively
COVID-19 hospitalizations for Black and Hispanic patients through February 2021 were 2.8 and 3.6 per 1,000 beneficiaries per month, respectively
"Among COVID-19 and non–COVID-19 hospitalizations, racial and ethnic disparities in mortality were evident. As the pandemic evolves, efforts to understand the sources of pandemic-associated disparities and to improve health equity are needed," the study's co-authors wrote.
The data shows three primary changes in hospital care linked to the pandemic, the study's co-authors wrote.
Non-COVID-19 hospitalizations decreased sharply for all racial and ethnic groups, which is in line with other research that has shown decreased healthcare utilization during the pandemic.
Hispanic and other racial and ethnic minority patients experienced higher COVID-19 in-hospital mortality than White patients.
There were racial and ethnic disparities in non-COVID-19 in-hospital mortality during the pandemic. For example, Black patients experienced a nearly 0.5 percentage point differential increase in in-hospital mortality compared to White patients.
HealthLeaders covered many of the most pressing coronavirus pandemic stories last year, including lessons learned, vaccination challenges and efforts, behavioral health challenges, and operational issues at healthcare providers.
For the second year in a row, the coronavirus pandemic dominated the healthcare landscape in 2021. The following are the Top 10 HealthLeaders clinical care stories of the year about COVID-19.
By multiple measures, COVID-19 has challenged healthcare providers more than any other public health crisis since the 1918 influenza pandemic. As the coronavirus pandemic entered its second year, many health systems, hospitals, and physician practices remained in crisis mode. A pair of physician leaders at Cincinnati-based UC Health spoke with HealthLeaders to discuss how the health system has grappled with COVID-19 and shared four primary lessons learned from the coronavirus pandemic.
Sutter Health—an integrated network of hospitals and physician practices in Northern California—has successfully navigated several challenges during the coronavirus pandemic. In the Sacramento, California–based health system's response to the pandemic, functioning as an integrated network generated several advantages, says William Isenberg, MD, PhD, chief quality and safety officer.
At health systems and hospitals, adopting a crisis command culture has operational benefits during the coronavirus pandemic, a pair of experts told HealthLeaders. The crucial aspect of crisis command culture is the ability to make good decisions quickly, says Stephanie Mercado, CEO and executive director of the National Association for Healthcare Quality in Chicago.
When health systems need to open a field hospital during a public health emergency such as the coronavirus pandemic, they should be guided by emergency management principles, the lead author of a journal article on opening a field hospital told HealthLeaders. Several states across the country have had to open field hospitals during the coronavirus pandemic to accommodate COVID-19 patient surges. A common strategy has been to use field hospitals to treat low-acuity COVID-19 patients who can be transferred from hospitals and cared for safely before being discharged home.
Clinicians need to take a multipronged approach to communicating with their patients about coronavirus vaccination, a Yale New Haven Health expert told HealthLeaders. There are four best practices clinicians should follow when communicating with people to encourage them to get coronavirus vaccination, said Richard Martinello, MD, medical director of infection prevention at Yale New Haven Health in New Haven, Connecticut.
A volunteer "COVID Line Team" at a Los Angeles–based medical center has boosted the efficiency of placing central and arterial lines in COVID-19 ICUs and taking pressure off busy critical care teams. The COVID Line Team was formed in March 2020 during the first coronavirus patient surge in Los Angeles, said the team's leader, Evan Zahn, MD, director of the Guerin Family Congenital Heart Program at Cedars-Sinai's Smidt Heart Institute.
In the hospital setting, automated contact tracing is far superior to manual contact tracing, a California-based hospital's chief medical officer told HealthLeaders. Methodist Hospital of Southern California adopted automated contact tracing in November 2020. "With automated contact tracing, which we do with SwipeSense, we can get contact tracing information in about five minutes. It is a total game changer," said Bala Chandrasekhar, MD, CMO of the Arcadia, California facility.
There has been a significant increase in healthcare-associated infections during the coronavirus pandemic, a research article found. The characteristics of the coronavirus pandemic that drove increases in central-line-associated bloodstream infections, catheter-associated urinary tract infections, ventilator-associated events, and antibiotic resistant staph infections were "clearly multifactorial," Arjun Srinivasan, MD, associate director for healthcare-associated infection programs at the Centers for Disease Control and Prevention, told HealthLeaders.
A Shreveport, Louisiana-based behavioral health hospital has opened a 30-bed unit for coronavirus-positive patients who need immediate behavioral health care. In January 2021, a joint venture between Plano, Texas-based Oceans Healthcare and Ochsner LSU Health Shreveport opened a new 89 bed behavioral health hospital—Louisiana Behavioral Health.
Louisiana Behavioral Health established a 30-bed unit for behavioral health patients who also have a COVID-19 diagnosis. The behavioral health unit meets a critical need, Stuart Archer, MBA, CEO of Oceans Healthcare, told HealthLeaders. "When you take a behavioral health patient who has a unique set of needs and on top of that has an active COVID diagnosis, you have a patient who needs a special inpatient unit. Historically, these patients would be stuck in an emergency room for days or weeks. Or they could take a bed in an inpatient medical unit. There really wasn't anywhere to move that patient."
Coronavirus "long haulers" are experiencing several behavioral health conditions, according to an expert at Doctor On Demand. "At Doctor On Demand, we are seeing a lot of depression and anxiety among long haulers. Particularly when you experience long-term anxiety symptoms, the condition has the opportunity to differentiate itself into other more specific anxiety disorders such as generalized anxiety disorder, panic disorders, and posttraumatic stress disorder," Nikole Benders-Hadi, MD, medical director of behavioral health at Doctor On Demand, told HealthLeaders.
Access to integrative healthcare services such as exercise counseling increases a breast cancer patient's odds of survival, a recent study indicates.
Offering integrative oncology services such as nutrition counseling and patient support groups benefits many breast cancer patients, a recent research article says.
Oncologists rely mainly on conventional medicine such as chemotherapy to treat their patients. Integrative oncology combines complementary and lifestyle therapies such as meditation with conventional medicine.
The recent research article, which was published in the Journal of Oncology, features breast cancer patient data collected at 103 oncology institutions from January 2013 to December 2014. The study divided the oncology institutions into four cohorts based on a scoring system that ranked the organizations as low integrative score, low-mid integrative score, mid-high integrative score, and high integrative score.
The key findings of the study include that low-mid institutions posted 5-year survival odds three times higher than low institutions, and mid-high institutions posted 5-year survival odds 48% higher than low institutions. "Crossing the threshold beyond 'low' involvement in integrative oncology represents a new path to incremental survival benefit for many cancer patients," the study's co-authors wrote.
The study's co-authors recommend that oncology institutions should boost education, access, and funding for a core set of six integrative oncology services: nutrition counseling, exercise counseling, patient support groups, spiritual services, meditation, and psycho-oncology support. The core set of six therapies were offered significantly more often at high integrative score institutions than low integrative score institutions:
76% of low integrative score oncology institutions offered nutrition consultation compared to 100% of high integrative oncology institutions
68% of low integrative score oncology institutions offered exercise counseling compared to 100% of high integrative oncology institutions
80% of low integrative score oncology institutions offered patient support groups compared to 100% of high integrative oncology institutions
48% of low integrative score oncology institutions offered spiritual services compared to 100% of high integrative oncology institutions
20% of low integrative score oncology institutions offered meditation compared to 97% of high integrative oncology institutions
56% of low integrative score oncology institutions offered psycho-oncology support compared to 97% of high integrative oncology institutions
"Although 12 [integrative oncology] modalities were researched in this study, five are highlighted in the results that are more commonly adopted. These are exercise counselling, nutrition counselling, psycho-oncology support, chaplain services, and patient support groups. … We recommend adding meditation as a sixth key 'core modality.' These six represent an attractive bundle that addresses patients' needs physically, mentally, socially, and spiritually, is often accepted as part of usual care, and provides some degree of choice for patients," the study's co-authors wrote.
Interpreting the data
There are clear benefits to having integrative services as part of an oncology program, the senior author of the study told HealthLeaders.
"Multiple cancer organizations such as the American Society of Clinical Oncology and the American Cancer Society have emphasized the importance of enhancing supportive care for cancer patients, both during and after specific cancer treatments. These guidelines are based on extensive evidence and documentation of value. Often these recommendations focus on behavior change and lifestyle, including nutrition, stress management, and exercise. Growing evidence in both cancer and non-cancer populations have shown non-pharmacological approaches such as acupuncture, yoga, mind-body, and other practices can enhance quality of life. Some of these have indicated a possible extension of life as well," said Wayne Jonas, MD, executive director for integrative health programs at the Samueli Foundation.
The study demonstrates the benefits of integrative oncology, he said. "Since it is known that these practices improve quality of life, we did this study specifically to explore whether a combination of these efforts at cancer institutes across the country also had an impact on survival. It did. This would indicate that incorporating integrative oncology into routine cancer care could have benefit both in enhancing the quality of life and prolonging the life span of cancer patients."
The core set of six therapies such as nutrition counseling should be widely adopted in cancer care, Jonas said. "These core six therapies are those with the strongest evidence for enhancing quality of care and quality of life, and many of them are already incorporated into international guidelines for cancer care. In the case of spiritual care, this had high demand from patients. Thus, we think it behooves cancer institutions to integrate at least these six therapies into the routine management of patients with cancer."
Integrative oncology should be a best practice for all cancer patients—not just patients with breast cancer, he said. "These supportive and integrative oncology approaches are not unique to breast cancer patients. Many of them are basic wellness approaches that enhance healing in any condition. Thus, we think they should be incorporated into the care of any type of cancer."
