The Chicago-based health system has utilized a range of technology to connect with patients and restructured case management, social work and physician advisors.
In recent years, UI Health has taken several steps to better serve underserved communities.
Health equity has emerged as a pressing issue in U.S. healthcare during the coronavirus pandemic. In particular, there have been COVID-19 health disparities for several racial and ethnic groups that have been at higher risk of getting sick and experiencing relatively high mortality rates, including Black, Hispanic/Latino, American Indian, and Alaska Native communities.
At UI Health, serving underserved communities is a priority at the Chicago-based health system, says Rani Morrison, MS, MSW, chief diversity and community health equity officer. "With our payer mix, a lot of our patients could be considered underserved—we have nearly a 50% Medicaid payer mix. So, we have to be creative in how we connect with our patients."
UI Health is utilizing a range of technology to connect with patients, she says.
"Nearly five years ago, we partnered with CipherHealth and that is how we updated doing post-discharge calls. We were doing manual calls to our patients after discharge to make sure that they understood their discharge instructions and hopefully reduce readmissions. We switched to an automated system with CipherHealth, which increased our reach rate to our patients and allowed us to have different options to reach patients. We can reach them in the language that they prefer. We can reach more people. We can reach them at different times of day. If there is a problem or an issue that is identified, we make a call with a nurse within hours to problem-solve. That is a way that we have leveraged technology to work with our patients who may not have the full range of technology or be sophisticated with the patient portal."
A new patient portal has also boosted contact with patients, Morrison says. "We switched to Epic as our electronic health record 15 months ago, and we have been proud that we have had a high level of adoption of our patient portal. We have been able to do things like send reminders to patients through the patient portal. We can take payments through the patient portal. We were able to leverage the portal heavily for coronavirus vaccines when we did our mass vaccination clinic last winter and spring."
In addition, UI Health is utilizing "soft technology" to connect with patients, she says. "You can call our call center, which we also used for our mass vaccination clinic. We did reverse calling for those who did not have the Internet and could not navigate the patient portal. We try to do a balance of outreach because we know that not all of our patients are similarly situated."
Restructuring case management
In March 2020, UI Health initiated a restructuring of case management from a dyad model to a triad model, Morrison says. Under the dyad model, a team of nurses managed both the discharge planning and the utilization review function for patients. Under the triad model, the nurses have split responsibility with a team of nurses that just does utilization review, a team of nurses that just does discharge planning, and social workers who focus on psycho-social needs and discharge planning specific to skilled nursing facilities and sub-acute rehab.
Effective case management is crucial to serving underserved communities, she says.
"The great thing about case management is that it is truly designed to serve underserved communities because case management is about holistic care. We are supposed to be assessing the patient, their environment, their supports, and what they are going to need to successfully transition from the hospital setting to whatever the next appropriate setting is. When case management is done properly, it is supposed to evaluate the people who have the least amount of resources to make sure that they can go to the most supportive environment. Case management is well-suited for those who are underserved or do not have as many resources as other patients."
The educational role of case managers is pivotal for underserved communities, Morrison says. "Education is critical, particularly for the underserved because sometimes their understanding and knowledge of the different post-acute care options may be less than other patients in terms of understanding the concepts of healthcare and health literacy. We must educate them to make sure they understand everything that we give them at discharge and their options. We want patients to be involved and engaged, so they feel they are part of the process no matter their resources and no matter their baseline health literacy."
Improving social work resources
At the same time that case management was revamped, UI Health improved inpatient and outpatient social work services, she says.
"We increased the social work complement during our restructuring effort. We drove down caseloads of the social workers on the inpatient side who are the counterparts of the nurse case managers. We also added some additional assessment tools that social workers have to better assess the psycho-social needs of patients. We have adopted some additional resources to give us information about different social service options so that social workers can access better referral information. So, if a patient needs mental health resources or substance use resources, we have more referral information and we have leveraged technology to provide referrals to the patients via text or in their discharge summary."
Revamping physician advisor program
UI Health has also improved the physician advisor program at the health system's hospital, Morrison says.
"We increased the number of physician advisors. We identified a new lead physician advisor, who was a member of the faculty. They have been able to leverage reporting and data so that they understand the trajectory of the patients. We gave the physician advisors new training to make sure everybody understood the ideal model. The physician advisors have increased their involvement—they are attending multidisciplinary rounds every day with the attending physicians, residents, case managers, social workers, physical therapists, and the nursing staff. They give feedback, ask questions, and give input into the progression of care for patients. They are also heavily involved in the utilization management committee to make sure that we are keeping an eye on the ball when it comes to our patients, how we are doing in terms of managing patients, and making sure that they understand our contracts, such as our Medicaid managed care contracts."
Physician advisors play a key role in helping to serve underserved communities, she says. "The physician advisors have been instrumental in pushing systemic changes around our patients and our patients' needs, which has been helpful to our underserved patients because the physician advisors can identify issues and take a step back to have a 360-degree view. They are also practicing physicians with inpatient and emergency department duties—they are seeing what is in front of them as attending physicians and can give feedback."
Researchers collected data from 31 health system-affiliated physician organizations associated with 22 health systems in four states.
Despite the push to shift from fee-for-service to value-based payment (VBP) in U.S. healthcare, physician compensation remains overwhelmingly based on volume of services rather than value, a new research article says.
Over the past decade, public and private payers including Medicare have introduced alternative payment models (APMs) and VBPs to encourage healthcare providers to provide services based on value rather than volume. A primary goal is to shift healthcare providers away from providing care only when patients are sick toward more preventive and wellness-oriented care.
The new research article, which was published by JAMA Health Forum, is based on data collected from 31 health system-affiliated physician organizations (POs) associated with 22 health systems in four states (California, Minnesota, Wisconsin, and Washington). The study was conducted by the RAND Center of Excellence for Health Care Performance with funding from the Agency for Healthcare Research and Quality.
The study includes three key data points.
Volume-based compensation was the most-common type of base pay for more than 80% of primary care physicians and for more than 90% of physician specialists.
Although quality and cost performance financial incentives were used by health systems, the percentage of total physician compensation based on quality and cost was only 9% for primary care physicians and 5% for specialists.
Increasing the volume of services provided was the most commonly reported method for physicians to increase their compensation, with 70% of POs having such an arrangement. Among these POs, volume-based incentives accounted for more than two-thirds of compensation.
"Performance-based financial incentives for value-oriented goals, such as clinical quality, cost, patient experience, and access, were commonly included in compensation but represented a small fraction of total compensation for [primary care physicians] and specialists in health systems, operating at the margins to affect physician behavior. Taken together, these findings suggest that despite growth in APMs and VBP arrangements, these value-based incentives were not commonly translated into health system physician compensation, which was dominated by volume-oriented incentives," the study's co-authors wrote.
The research found that physician compensation is geared more toward volume of services than value to drive health system revenue, the lead author of the study said in a prepared statement. "Despite growth in value-based programs and the need to improve value in healthcare, physician compensation arrangements in health systems do not currently emphasize value. The payment systems that are most-often in place are designed to maximize health system revenue by incentivizing providers within the system to deliver more services," said Rachel Reid, MD, MS, a physician policy researcher at RAND.
The New York-based limited liability company has a network of more than 500 organizations serving 22 counties.
A limited liability company formed as part of the Medicaid redesign in New York State is helping managed care organizations and healthcare providers to connect patients with social determinants of health needs with social services.
Social determinants of health (SDOH) such as housing, food security, and transportation can have a pivotal impact on the physical and mental health of patients. By making direct investments in initiatives designed to address SDOH and working with community partners, healthcare organizations can help their patients in profound ways beyond the traditional provision of medical services.
The Alliance for Better Health was founded in 2015 as part of the Medicaid redesign in New York State. In 2018, Alliance for Better Health formed Healthy Alliance IPA as an affiliated limited liability company. The independent practice association helps managed care organizations and healthcare providers to connect patients with social determinants of health needs with social services.
"We have a network of participants, which includes clinical affiliates such as health systems in addition to social care providers. We have more than 500 of those organizations in the network, spanning 22 counties, with more than 1,000 social services. The services include transportation, food, housing, and job training," says Erica Coletti, CEO of the Troy, New York-based Alliance for Better Health.
Healthy Alliance IPA has many healthcare providers in its network, she says. "We have several health systems in our network such as St. Peter's Health Partners and Ellis Medicine. We have many primary care practices in our network. We also work closely with federally qualified health centers."
Healthy Alliance IPA plays an intermediary role between managed care organizations and healthcare providers and their patients, Coletti says. "We are a convenor that has put together a network of social service providers. We are providing the support and function around the social services network. … We work with multiple social service providers—we meet with them monthly to give them data on services they have provided through our network."
People are referred to Healthy Alliance IPA for social services in several ways, she says. "We get referrals from managed care organizations, health systems, hospitals, and physician practices. We also get referrals from community organizations—if they are working with an individual and they do not provide a service that the individual needs, they can make a referral to us."
Decreasing medical costs and improving health equity
Connecting people with social determinants of health needs with social services can reduce medical costs, Coletti says.
"A good example is someone who has diabetes with a blood sugar problem who has to go to the emergency room. If they had access to healthy food and nutrition counseling before they reached a crisis point, they could save significant medical dollars. Another example is someone with an addiction who needs to go to Narcotics Anonymous and transportation becomes a barrier for them. Unless you can provide a transportation service, that person can end up in an acute care setting. Addressing that barrier of transportation makes a big difference," she says.
Healthy Alliance IPA is also addressing health inequities, Coletti says.
"Our focus is on improving the health of the underserved. By addressing social issues that end up resulting in health issues, we expect to level the playing field by reducing social care barriers, which in turn will support health equity. The underserved disproportionately includes racial and ethnic minorities, and they have many more social determinants barriers than others. So, by removing those barriers and getting the underserved appropriate social supports, we are helping to level the playing field," she says.
Measuring the impact
Stanford University is going to be conducting a study to measure the impact of Healthy Alliance IPA, Coletti says.
"The Stanford University study is an economic study, so we will be looking at the past three years of data for people who are involved in our network and seeing whether the network bends the cost curve on medical utilization. So, we will be looking at cost of care, acute care utilization such as avoidable emergency room visits and hospitalizations, and health outcomes for people in the network versus comparable people who are not in the network. We will also be looking at the impact based on race and ethnicity."
During the omicron surge, Children's National Hospital is admitting about three times as many children with COVID-19 than in earlier phases of the pandemic.
The omicron coronavirus variant is having a significant impact on children and parents should be getting their school-aged children vaccinated, the president and CEO of Children's National Hospital told The Washington Post this week.
Children have not been as severely impacted by COVID-19 as adults. Children have had lower hospitalization and death rates.
Children's National Hospital has been treating a higher number of children with COVID-19 during the omicron surge than in earlier phases of the pandemic, Kurt Newman, MD, president and CEO of the hospital, told The Washington Post.
"Through the beginning parts of the pandemic with the original variants, we would see routinely at a peak maybe 20 patients in the hospital … and about a third of them would go to the ICU. And people were thinking, well, maybe it didn't have that much impact on children. … Now with this omicron variant, we've seen what a false kind of set of conclusions that was. This variant is hitting children hard. It's hitting them differently. And it's really impacting our hospital. … With the other variants, our peak would be about 20 kids in the hospital at a time. Lately, it's been about 60 or 70," he said.
The omicron variant poses a particular danger to younger children, Newman said.
"The science that we're seeing is that the kids are coming in with a little bit different presentation. Instead of deep in the lungs, … this omicron variant seems to hit the upper airway a little harder. And the real problem for children with that, particularly the smaller children and the babies—and we're seeing increased numbers of babies and smaller children—is that their airway is smaller. So, they can't take a lot of inflammation or infection," he said.
The omicron variant has strained the hospital's staff, but the Washington, D.C.-based facility has been able to maintain operations, Newman said. "They're stressed. But I am so proud of how our hospital has stepped up. We have not turned a patient away. We haven't closed a clinic."
Coronavirus vaccination for children
Children's National Hospital staff are anxious for coronavirus vaccination to be available for children under 5, he said. "We can't wait for the vaccine that will be approved, hopefully this spring, for children under 5, because they're unvaccinated and they are at risk."
Coronavirus vaccination rates for children aged 5 to 11 have been significantly lower than vaccination rates for adults, which is a concerning, Newman said. "I'm very disappointed because I did expect a much higher uptake among parents and children … to get that rate up where it needs to be."
For children who are eligible for vaccination, he said there are two priority groups who should get vaccines. The first priority is to vaccinate children who have underlying conditions such as cancer, sickle cell disease, and obesity. The second priority is to vaccinate children who struggle with access to vaccines such as children living in poverty. "We want to get those kids vaccinated," Newman said.
For parents who know children face lower risk from COVID-19 than adults and may want to take a cautious approach to vaccination, he said vaccination should still be encouraged. "Doing the right thing for your child may mean doing what's right for the public good as well. And your child may be impacted by what goes on with other children and families. … We've had enough experience now with these vaccines that they're safe. They're protecting your own children. … Maybe most importantly of all, they're protecting all of our children."
Parents with vaccination hesitancy for their children should also consider that new variants of coronavirus may arise that will have a greater impact on children, Newman said. "Having huge amounts of circulating virus … creates the opportunity for new variants and things that we don't know that could impact [children] in different ways. So, I would say study it all, talk to your pediatrician, talk to the public health authorities, and make that decision for your child."
About 30,000 to 40,000 opioid use disorder patients are hospitalized with sepsis each year.
The Sepsis Alliance is highlighting the intersection of sepsis and opioid use disorders.
Sepsis develops in response to infection, and can lead to tissue damage, organ failure, and death. Sepsis is the leading cause of in-hospital death in the United States. More than 1.7 million Americans are diagnosed with sepsis annually.
On Jan. 27, the Sepsis Alliance Institute is hosting a webinar on the intersection of sepsis and opioid use disorder. The webinar features Chanu Rhee, MD, MPH, associate hospital epidemiologist at Brigham and Women's Hospital and assistant professor of population medicine at Harvard Medical School, and Simeon Kimmel, MD, MA, attending physician at Boston Medical Center and assistant professor of medicine at Boston University School of Medicine.
Rhee and Kimmel were interviewed recently by HealthLeaders. The following transcript of that conversation has been edited for brevity and clarity.
HealthLeaders: How prevalent are sepsis cases among people afflicted with opioid use disorder?
Chanu Rhee: You need to have the denominator—how many people have opioid use disorders. In 2018, the Centers for Disease Control and Prevention (CDC) estimated that about 2 million people in the United States had opioid use disorders. We also know how many adults are hospitalized with sepsis each year, which is about 1.7 million adults. In a paper that Dr. Kimmel and I published recently in Critical Care Medicine, we found that about 2% of hospitalized sepsis patients had opioid use disorder.
With those numbers, we can do some math. There are 1.7 million adults with sepsis each year, and 2% of those patients have opioid use disorder, so we are talking about 30,000 to 40,000 opioid use disorder patients who are hospitalized with sepsis each year.
HL: What are the primary elements of the intersection of sepsis and opioid use disorder?
Simeon Kimmel: Many people with opioid use disorder are using injection opioids. When somebody injects an opioid, there is penetration of the skin barrier with a needle, which introduces the risk of infection. That can be the result of bacteria that are living on the skin, bacteria on the injection equipment such as the syringe, or the substance that is being injected can be contaminated with bacteria. Especially in the era of fentanyl, which has contaminated the injection opioid supply, fentanyl is a shorter-acting opioid that requires more frequent injections. What we are seeing is that people are injecting very frequently, which leads to an increased risk of skin and soft tissue infection. We see blood stream infections, where bacteria get into the blood and infect the heart valves, bones, and joints—we see septic arthritis. We also see lung infections and other kinds of infections related to this dynamic.
Opioid use can lead to overdose, which can lead to the risk of developing aspiration and pneumonias. There is some evidence that suggests that opioid use itself may have some effects on the immune system that can predispose people to developing infections such as lung infections.
Rhee: Even with oral opioid use, overdose can lead to pneumonia, and pneumonia is a common cause of sepsis.
HL: What are the primary signs that someone afflicted with opioid use disorder is also developing sepsis?
Rhee: The signs of sepsis are generally the same for people with opioid use disorder as for people in the general public. There can be confusion, disorientation, shortness of breath, high heart rates, fever, shivering, extreme discomfort, and clammy or sweaty skin. A lot of these signs can overlap with the signs of opioid withdrawal, which can make it very hard to tell an individual is developing sepsis versus having withdrawal. This can be a challenge for patients and healthcare providers.
For healthcare providers trying to identify sepsis in opioid disorder patients, you need to look for signs that might localize specific infections such as cough and shortness of breath. If a chest X-ray is taken, providers should look for pneumonia. Providers should look for redness and signs of infection at injection sites to be on the lookout for skin and soft tissue infections. Providers should look at vital signs for low blood pressure, high heart rates, and low oxygen saturation. Providers should look at laboratory data such as white blood cell counts.
It is always a challenge looking for the warning signs of sepsis. There is no one perfect or sensitive sign. You have to put things together in a constellation of symptoms and signs to get a diagnosis. It can be particularly challenging in patients with opioid use disorder.
HL: What are the key data points that demonstrate the epidemiology of sepsis in opioid-related hospitalizations?
Rhee: In a recent paper, we sought to describe the epidemiology of hospitalized patients with sepsis and opioid use disorders. We looked at a couple million patients who were hospitalized at 373 hospitals between 2009 and 2015. We identified sepsis using CDC surveillance criteria. We identified patients with opioid-related hospitalizations using previously validated diagnosis codes as well as inpatient prescriptions for buprenorphine. The bottom line is we found sepsis was present in about 6% of opioid-related hospitalizations. Conversely, opioid use disorders were present in about 2% of sepsis hospitalizations.
In terms of the burden and the mortality, we found that patients with opioid use disorders who had sepsis had lower short-term mortality rates compared to sepsis patients without opioid use disorders. This was a trend that persisted even after risk adjustment.
Over half of patients who had opioid-related hospitalizations who ended up dying during their hospitalization had sepsis. That was higher than the mortality rate for non-opioid-related hospitalizations—about a third of those patients had sepsis. This data suggests that sepsis is a major contributor to death in patients with opioid-related hospitalizations.
Finally, the prevalence of opioid use disorders among hospitalized patients, and especially among patients with sepsis, rose during the study period from 2009 to 2015. It increased 41% among all hospitalizations, and when we looked at sepsis hospitalizations, it increased by 77%. It became a bigger and bigger problem over time.
HL: How can sepsis be prevented in people afflicted by opioid use disorder?
Kimmel: There are several important steps. The first is that people with opioid use disorder need to have access to supplies to inject substances as safely as possible. That means access to alcohol swabs to be able to clean their skin and access to sterile injection equipment.
Second, there needs to be education for people with opioid use disorder to understand that they should seek care early for their infections.
Third, we need to improve the care of people in the hospital, so people feel comfortable coming to the hospital when they are sick. I take care of a lot of people with opioid use disorder in a drop-in clinic, and I spend a lot of time helping people understand the risks and benefits from their perspective of coming to the hospital because there is fear of being in the hospital such as fear of experiencing withdrawal symptoms.
Fourth, we need to improve access for treatment of opioid use disorders. There has been a lot of progress over the past few years around increasing low-barrier access to buprenorphine and improving access to methadone, which are evidence-based medications that reduce the risk of developing sepsis.
HL: Can you offer other insights about the intersection of sepsis and opioid use disorder?
Kimmel: There is a growing recognition of the importance of training clinicians to be able to treat opioid use disorder. Increasingly, there are systems in place to improve the treatment of opioid use disorder in the hospital. There has been development of addiction consult services. There are a growing number of infectious disease doctors who also are dually trained in addiction medicine. These are encouraging developments in terms of normalizing and improving the treatment of opioid use disorder.
Rhee: The intersection of sepsis and opioid use disorder highlights an important message around sepsis in general. There is so much focus on early recognition and treatment of sepsis in the hospital, which is perfectly important and makes a lot of sense. However, we are not focusing on what causes sepsis to develop in healthy people or people without underlying issues. Opioid use disorder is the perfect example of an issue that leads relatively healthy people to develop sepsis. There is only so much we can do to address sepsis once someone is in the hospital—we need to get upstream on the factors that predispose people to sepsis.
With massive turnover in the healthcare workforce, hiring high-quality candidates and retaining staff is essential for physician practices.
MGMA has suggestions and resources to help physician practices hire and retain employees.
Workforce shortages have become one of the biggest challenges in U.S. healthcare. About one in five of healthcare workers have left their job during the coronavirus pandemic.
In the current healthcare employment market, it is crucial to have a multifaceted approach to hiring, says Andrew Hajde, director of consulting and assistant director of association content at MGMA.
"It is extremely challenging now, with so many practices having job turnover. You need to use as many channels as possible to find candidates—online job sites, social media, local job postings, and the local chamber of commerce. Some of the best sources of candidates are personal referrals and word of mouth—that can be critical to attracting high-quality candidates. When you have excellent employees, they often know many other people who work in the same industry. You need to leverage as many channels as possible to get the word out that you have openings and tie that into your wages, benefits, and culture," he says.
Utilizing compensation benchmarking data should be part of a physician practice's hiring strategy, Hajde says. "It is more important than ever to use compensation benchmarking data such as that available from MGMA. Many people are leaving healthcare because they can find better compensation and perks outside of healthcare settings, so it is critical for practice leaders to look for ways to attract those people back into the healthcare workforce."
Practices should also have remote career opportunities, he says.
"There are many positions in medical practices that work well in a remote setting. Offering remote positions can broaden your applicant pool. You can have remote positions in scheduling work such as a call center, where remote workers can take calls and make appointments—these are positions where an employee does not need to interact directly with patients at the front desk. Billing and authorization positions can be done remotely. There are even clinical positions such as nurse navigators that can work in a remote setting. Having remote workers can reduce your office's footprint and increase employee engagement and satisfaction."
Offering long-term growth opportunities can help practices draw job candidates, Hajde says.
"When you think about the different positions where practices are struggling the most such as medical assistants, practices should think about long-term growth opportunities that can be offered to attract candidates. For example, you can have tuition reimbursement or programs where you are encouraging your medical assistants to become registered nurses. Eventually, a medical assistant may move on to a nursing role—even if you do not offer that role at your practice—but it gives employees growth opportunities and keeps them engaged in your practice through their education process. So, you might have an excellent medical assistant for several years even if they eventually move on to a hospital setting or another practice."
Employee retention at physician practices
Compensation levels and good benefits are essential for employee retention, but there are other key considerations, Hajde says.
"Having competitive wages and benefits is always going to be important to employees. However, most people who leave their jobs do so because of a couple of different factors, which can include a lack of appreciation for the job they are doing or not liking their supervisor or work environment. Some staff members view their work environment as a toxic situation. So, executives and medical practice leaders need to make sure that they have strong leadership skills and that they work on having an attractive culture for their organization."
It is important that an organization's culture is employee-centric and takes into consideration employee feedback on the way the practice functions, he says. "You need to provide feedback and appreciation for employees who are doing things well. Practice leaders need to take employee thoughts into consideration when they use quality improvement techniques to improve their operations. You need to go to employees to find ways to optimize their workflows and make sure they are engaged in the overall goals and mission of the practice."
"It provides resources; best practices recommendations in the areas of hiring, recruitment, operational efficiency, culture, and retention; and staffing benchmarks. Those areas are critical to not only helping an organization find and hire new talent but also to retain employees once they have been hired. It is also critical to improve practice efficiencies to make the staff you have more efficient and to make them more effective in their roles. We also have great information on staff compensation, benefits, and many other practice data points that can be useful by geographic area, practice type, and other metrics to help practice leaders make decisions."
For MGMA members, the organization offers an online community focused on workforce issues. "Our Staffing Member Community is a place where medical practice leaders can post questions or comments for their peers across the country. Typically, when MGMA members post questions or comments, they are getting expert responses and guidance not only from MGMA staff but also from peers nationwide, generally that same day. It helps practice leaders make decisions based on what is going on across the country, and other leaders can make recommendations for their particular situation," he says.
MGMA also has a Career Center, where practices can post open positions.
During the coronavirus pandemic, Intuitive Health has experienced strong patient volume growth and has retained clinical staff.
A Plano, Texas-based healthcare provider that is operating an emergency room and urgent care model under one roof has been experiencing success during the coronavirus pandemic.
In 2021, Intuitive Health saw explosive growth in patient volume—patient facility usage across all locations increased by 52% over 2020. In 2020, patient volume was up 35% over the level in 2019.
Intuitive Health is also expanding its locations, with new facilities opened in 2021 in Ohio and Florida. The organization is now operating 14 facilities in Florida, Indiana, Ohio, New Mexico, and Texas. Intuitive Health plans to operate 28 facilities in 13 states by the end of 2022.
Intuitive Health's emergency room and urgent care model addresses a longstanding problem in healthcare, says CEO Thom Herrmann, MBA. "The problem is if a patient shows up in a hospital emergency department, and they only need urgent care-level services, they are going to spend $2,000 or more when it could have cost them or their payer only $200 if they went to an urgent care center. On the flip side, if a patient ends up going to an urgent care center and they are having a life-threatening emergency, they are putting their health at risk."
Intuitive Health has taken the uncertainty out of a patient's decision to seek care in an ER or an urgent care center, he says. "The uniqueness of our model is we have decided to simplify things for patients. Every one of our locations is a free-standing, 24-hour, seven-day-a-week emergency department that also treats urgent care conditions. If a patient is not sure whether they should go to an ER or an urgent care center, they can come to our facility at any time of day. They are going to be evaluated by an ER physician. We have all of the same services as a hospital emergency department; but if it turns out that the patient does not need ER care, they are going to get a much lower-cost urgent care bill."
Resource utilization determines whether a patient is charged for an ER visit or an urgent care visit, Herrmann says. "We use resource-based criteria to determine whether someone receives ER-level care or urgent care-level care. There are certain services that are only available in an emergency department such as a CT scan or a complex lab service. Depending on what our physician needs to order or do to diagnose and treat the patient determines whether a visit is going to be billed as an ER visit or an urgent care visit. Most of our patients walk out with an urgent care bill because most situations do not require a high, ER-level of care."
Intuitive Health has six facilities in the Dallas market that the organization owns and operates independent of health systems and hospitals. However, its other facilities and future facilities will be operated as joint ventures with regional health systems, he says. "When we come into a new market with a health system, each one of the locations that we open is going to be branded under the health system's brand, but we are operating that facility for our health system partner."
Drivers of patient volume growth
Pandemic-related factors have driven patient volume growth at Intuitive Health facilities over the past two years, Herrmann says. "Some of the growth is testing related—over the past twelve months, patients have been looking for COVID testing. But there is a much bigger underlying trend unrelated to COVID testing."
Since the pandemic began, patients have been trying to avoid hospital emergency rooms, he says. "In 2020, there was a lot of fear and attention focused on the chances of contracting a communicable disease such as COVID inside a hospital emergency department. Most people have an experience of going to a crowded, somewhat disorganized emergency department, and it is not a pleasant experience. It is inconvenient. There are usually a lot of sick people waiting in the lobby. Most patients have to wait a long time in the lobby. So, in 2020, patients did everything they could to try to stay away from hospital emergency departments."
Intuitive Health facilities are an attractive alternative to hospital emergency rooms, Herrmann says.
"If you walk into one of our typical centers, patients generally wait in the waiting room for less than 10 minutes before they are taken to a room. Our design is focused on rapid throughput for the patient. Our sites are also clean and sanitary. So, when patients have the opportunity to experience service in one of our facilities, they realize that we offer all of the same emergency services that they would get in a hospital emergency department. They also understand the value proposition that if they do not need ER services, they are going to get a lower-cost bill," he says.
Staff retention
During the pandemic, Intuitive Health has been able to buck the trend of clinical staff shortages. Early in the pandemic, childcare was a prime motivator for clinical staff to leave healthcare organizations, Herrmann says. "You had people who expected their kids to be in school, then the schools or their childcare center were closed. They faced dropping shifts to care for their child at home. The first step was working collaboratively with our staff to identify employees who had childcare challenges and have them change shifts with other employees who did not have those same kinds of challenges."
Intuitive Health also offered retention bonuses to encourage staff to remain with the organization, he says. "As market conditions changed and workloads changed, we introduced retention bonuses as a way to compensate employees for sticking through the challenging time of increased COVID patient volumes."
The organization also focused on safety, Herrmann says. "We made sure that clinical staff had all of the personal protective equipment that they needed, that they were working in a sanitary environment, and that we had screening protocols for patients who we thought were symptomatic or at high risk for transmission of coronavirus."
Burnout has been a top concern, he says. "We made sure staff were getting relief from long shifts. We made sure there was adequate staff support within all of our clinics—whether that was scribes or administrative support—to try to make life as easy as possible."
The multipronged effort to retain staff has been successful, Herrmann says. "All of these things in a cumulative sense allowed us to retain staff at a high rate and maintain high employee satisfaction scores."
From 2008 to 2019, the suicide attempt rate per 100,000 people jumped from 481.2 to 563.9.
Although suicide attempts in recent years have increased significantly, there has not been a corresponding increase in people seeking behavioral health treatment in the year leading up to their suicide attempts, a new study found.
Suicide has become a leading cause of death in the United States. From 1999 to 2018, annual deaths by suicide increased from 29,199 to 48,344.
The new study, which was published this week by JAMA Psychiatry, is based on data collected through the National Survey of Drug Use and Health from 2008 to 2019. The examination of the data focused on individuals 18 years old or older.
The new study has several key data points.
From 2008 to 2019, the suicide attempt rate per 100,000 people jumped from 481.2 to 563.9.
The rates of suicide attempts increased significantly for young adults aged 18 to 25 (adjusted odds ratio 1.81), women (adjusted odds ratio 1.33), the unemployed (adjusted odds ratio 2.22), those who were never married (adjusted odds ratio 1.60), and people who used substances (adjusted odds ratio 1.44).
Three clinical subgroups were associated with relatively high odds of attempting suicide: individuals with serious psychological distress (adjusted odds ratio 7.51), individuals with major depressive episodes (adjusted odds ratio 2.90), and individuals with alcohol use disorder (adjusted odds ratio 1.81).
From 2008 to 2019, the only sub-group that experienced a significant decrease in suicide attempts was individuals aged 50 to 64 years old.
From 2008 to 2019, 34.8% to 45.5% of adults who attempted suicide reported needing behavioral health services but not receiving them. "Specifically, there were no significant changes in the likelihood of having any outpatient, inpatient, or medication services for mental health reasons and no changes in the use of treatment services for substance use," the study's co-authors wrote.
The most common reason cited for not receiving behavioral health treatment was being unable to afford the cost, although those citing this reason did not increase significantly during the study period.
Two reasons for not seeking behavioral health treatment increased significantly during the study period: individuals who said they did not know where to go for treatment (adjusted odds ratio 1.96) and individuals who either lacked transportation or said services were too far away (adjusted odds ratio 5.15)
Interpreting the data
There has been an "alarming increase in suicide attempts," and there is a disconnect between suicide attempts and people seeking behavioral health treatment, the study's co-authors wrote.
"Despite an increase in suicide attempts, we did not find a corresponding increase in use of services among those who attempted suicide, and a large percentage of those reporting suicide attempts indicated that they had needed mental health services but did not receive them in the year of their attempt. Because prior suicide attempts are the single most important risk factor associated with future suicide, suicide prevention strategies must rely on use of services after an attempt. However, this study suggests that many individuals who need help are not receiving these potentially life-saving services," they wrote.
There is a need for suicide prevention efforts beyond formal treatment settings, the study's co-authors wrote. "Our finding that less than half of suicide attempters had clinical contact around the time of their attempt suggest that it is not only important to expand initiatives for high-risk individuals with clinical contact, but also to implement public health-oriented strategies outside the formal treatment system."
The study's results indicate where suicide prevention efforts should be targeted, the study's co-authors wrote. "Our findings identify subgroups with rising rates of suicide attempts among whom targeted interventions may be especially needed, including young adults, individuals who are unemployed or never married, and individuals who use substances. These findings highlight the potential importance of social media interventions, media-reporting guidelines, and initiatives on college campuses to target the rising rates of suicide attempts among young people."
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."
