A report from The Commonwealth Fund finds disparities in health outcomes, healthcare access, and quality and use of healthcare services.
A new report from The Commonwealth Fund finds that racial and ethnic health disparities exist in every state of the country.
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 many racial and ethnic groups that have been at higher risk of getting sick and experiencing relatively high mortality rates.
The new report is based on data collected for 24 indicators of health system performance, and the data was stratified by state and by race and ethnicity. The indicators were grouped in three areas: health outcomes, healthcare access, and quality and use of healthcare services. The report examines data for five ethnic and racial groups: Asian American, Native Hawaiian, and Pacific Islander (AANHPI); American Indian/Alaska Native (AIAN); Black; Latinx/Hispanic; and white.
In a teleconference yesterday, the report's lead author, David Radley, PhD, senior scientist at The Commonwealth Fund, summarized the state scorecard data.
"Six states stand out for having higher-than-average performance for all ethnic and racial groups that we measured. These states include Massachusetts, Connecticut, Rhode Island, New York, Hawaii, and Oregon. They also tended to have some of the smallest—albeit still evident—within-state disparities between the groups with the best and the worst performance. In other states such as Minnesota, Michigan, and Wisconsin, health system performance was particularly strong for white residents but lacking among Black, Latino, and Native Americans. These states had some of the largest within-state disparities. Finally, there were a number of states including Oklahoma and Mississippi where performance was weak overall for all racial and ethnic groups. In these states, despite low scores for even the highest performing groups, there were still sizeable inequities in each state," he said.
Health system performance scores by state and race/ethnicity show a stark health inequity between Black and white Americans. Health system performance for Black Americans was above the all-group median in only five states: Rhode Island, Massachusetts, Maryland, Connecticut, and New York. Health system performance for white Americans was below the all-group median in only three states: West Virginia, Oklahoma, and Mississippi.
Health outcomes findings
Even states that have scored high on overall healthcare performance can have significant racial and ethnic disparities, the report's co-authors wrote. "For example, Minnesota, which ranked third in The Commonwealth Fund’s most recent State Scorecard on Health System Performance, has some of the largest disparities between white and Black, Latinx/Hispanic, AANHPI, and AIAN communities."
Health outcomes, which were measured mainly by mortality rates and the incidence of health-related problems, vary significantly by race and ethnicity, the report's co-authors wrote. "In most states, Black and AIAN populations tend to fare worse than white, Latinx/Hispanic, and AANHPI populations. While enduring lower life expectancies for Black and AIAN individuals in the U.S. can be attributed in large part to generations of structural racism, oppression, and other factors beyond healthcare delivery, the healthcare system nevertheless has a crucial and often unfulfilled role in mitigating disparities."
Racial and ethnic disparities exist for treatable conditions, the report's co-authors wrote.
"Diabetes is an example of a disease that can often be effectively managed—for example, with consistent blood glucose monitoring and proven medications—but is nonetheless associated with profound racial and ethnic disparities in outcomes. Black and AIAN individuals are much more likely to die from diabetes-related complications than people of other races and ethnicities. Health systems striving for equity should bolster disease management resources among these communities to achieve better outcomes," they wrote.
Healthcare access findings
There are significant disparities in access to care between white and most nonwhite populations, according to the report.
Health insurance plays a crucial role in access to care, the report's co-authors wrote. "A key contributor to these access inequities is lack of comprehensive insurance coverage, or any coverage at all. Insurance alone cannot guarantee access, but it is necessary for getting needed healthcare without incurring substantial or even catastrophic financial risk."
In 2014, expansion of insurance coverage under the Affordable Care Act through the creation of an individual marketplace and the expansion of Medicaid in many states improved the uninsured rate for all ethnic and racial groups, but insurance coverage disparities persist, the report's co-authors wrote. "In nearly all states, uninsured rates continue to be higher for Black, Latinx/Hispanic, and AIAN people than they are for whites."
The lack of Medicaid expansion in 12 states negatively impacts two racial and ethnic groups, the report's co-authors wrote. "Black and Latinx/Hispanic communities are disproportionally represented in states that have not expanded Medicaid: 43% of Black and 36% of Latinx people live in the 12 nonexpansion states."
Insurance disparities have profound care access implications for people of color, the report's co-authors wrote.
"When people are uninsured, experience gaps in coverage, or are in private plans that do not provide comprehensive coverage, they often avoid getting care when they need it or pay high out-of-pocket costs when they do seek care. This is particularly burdensome for individuals with lower income and little wealth—disproportionately people of color. Because of these costs, Black, Latinx/Hispanic, and AIAN people are more likely to avoid getting care when they need it, more often have higher out-of-pocket costs, and are more prone to incur medical debt at all income levels," they wrote.
Quality and use of healthcare services findings
Disparities in the quality and use of healthcare services are widespread, the report's co-authors wrote. "Across and within most states, white populations overall receive better care than Black, Latinx/Hispanic, American Indian/Alaska Native (AIAN), and, often, Asian American, Pacific Islander, and Native Hawaiian (AANHPI) individuals."
Primary care disparities have a significant impact on the quality and use of healthcare services, the report's co-authors wrote.
"Primary care clinicians play an especially critical role in providing people with high-value services, including preventive care like cancer screenings and vaccines, as well as chronic disease management. … Expanded access to primary care improves health outcomes. And given the relatively lower use of primary care by Black, Latinx/Hispanic, and AIAN people, these groups in particular are likely to see a greater health impact from improved access and quality," they wrote.
New regional CMO at Dignity Health shares perspectives on leadership, patient safety, quality initiatives, malpractice, physician oversight, and graduate medical education.
A key component for chief medical officer success is impartiality, a new regional CMO at Dignity Health says.
Victor Waters, MD, JD, was recently named CMO of Dignity Health's Arizona Central and West Valley Market. He will provide strategic leadership for patient care, safety and quality, and physician oversight at Dignity Health St. Joseph's Hospital and Medical Center, St. Joseph's Westgate Medical Center, the Dignity Health Cancer Institute at St. Joseph's, and two freestanding emergency departments.
Waters' previous administrative roles include serving as CMO of Dignity Health St. Bernardine Medical Center in San Bernardino, California, and serving as interim president and CEO of Nexus Fort Washington Medical Center in Fort Washington, Maryland. He has experience in graduate medical education, including serving as a faculty member and Dignity Health physician liaison at University of California Riverside Medical School.
HealthLeaders recently talked with Waters about a range of issues, including hospital quality initiatives, patient safety, and graduate medical education. The following transcript of that conversation has been edited for brevity and clarity.
HealthLeaders: What are the keys to success for a CMO?
Victor Waters: Being neutral is important. It is like being a parent. If you have two children, you show neutrality and that you care for both. Favoritism in a climate as a leader is never helpful. You need to be impartial and fair to everyone. You need to be seen as objective to lead a medical staff and different departments. You need to be objective with private doctors, surgeons, intensivists, and long-term care facilities, for example. Whatever branch of service that you oversee, you should appear to be fair. That is a cornerstone of success for a CMO.
Second is to be able to use the toolkit of communication effectively. Those are things that physician leaders do not learn in medical school and residency training. They often learn through trial and error. I learned my communication toolkit through my law degree—how to communicate more effectively, how to address certain parties, and how to address contentious issues. That toolkit has benefited me as a leader.
Lastly, you need to be able to acknowledge when you are wrong. I am not fault free. In administrative roles, sometimes we miscommunicate. We misunderstand or just make a wrong decision based on whatever facts that we knew at the time. It is important to show humility for physicians, staff, nurses, and other leaders to respect you as a leader.
HL: What is a primary element of promoting patient safety at hospitals?
Waters: One of the basic keys is establishing safety huddles—they are a portal for all hospital staff including physicians to share any safety concerns. When you have a group that can be onsite or remotely, as we have done during COVID-19, you have a venue to share any safety concerns from almost every department. That is the landmark model for safety.
It raises administration support to hear safety issues.
It allows communication from anyone to share safety concerns.
You have broad stakeholders from every department—from nutrition, to clinical, to ICUs, to nursing, to others—to hear those safety concerns.
HL: What are the primary elements of successful quality initiatives at hospitals?
Waters: What I have found as a CMO, and being successful in quality initiatives, is recruiting the right team, and the key ingredient in having the right team is having a physician champion. You need a physician champion who is truly passionate about the measure you are seeking to improve. It may not be just one physician champion for a quality measure—it may be more than that depending on the complexity of the initiative.
For example, you may want to address sepsis and deaths related to sepsis. You can have many different types of team members on a sepsis initiative. The goal would be to have nursing, a key physician leader, and a key ICU physician because severely ill sepsis patients end up in the ICU.
Another primary element is having frequent meetings and looking at data in real time. Sometimes, if you do not keep ahead of what is going on with a particular quality metric, then you cannot intervene soon enough to make corrections. What flows from having the right team is their ability to analyze the data, look at opportunities, then develop a proactive action plan instead of looking to the past. Looking at data in real time is crucial to managing and leading a quality initiative.
HL: Give an example of a way to mitigate malpractice claims against physicians.
Waters: We have a program at Dignity Health that I have been proactively involved with and has shown success called Communication and Optimal Resolution (CANDOR).
If there is a bad event or an event that is at risk for liability, because there has been harm to a patient, and there is a certain amount of information that the patient does not know, in general, the culture has been to not say anything. That fuels the fire of the family members and often leads to litigation. Anger is what triggers malpractice claims.
The CANDOR program brings together the family members with the doctors, nurses, and anyone else who has been involved in a meeting where people can speak freely. The CANDOR meetings bring about closure because the doctors can share what happened and the family can ask questions. It is an opportunity for the doctors to say they are sorry for what happened. Saying you are sorry does not mean you are taking blame. It shows empathy for what the patient and the family have gone through, and it brings about closure.
HL: When there has been an adverse event involving a physician, how can a hospital conduct physician oversight?
Waters: When there has been a mistake or a misstep, physician oversight involves medical staff, leadership, and my role. What we have is a process. The first thing I practice as a physician leader is not to rush to judgment. I do not want to assume that I have a bad doctor. I look at an adverse event, and we have a process involving peer review where the doctor's peers look at the event and why it happened.
Many adverse events may not be tied to a physician. They may be tied to a process that failed, and the physician may be caught up in the process.
The physician should have an opportunity to speak about an adverse event and learn from it. If there is a pattern that is concerning, it rises to another level that we address. It may be something that we need to stop the surgeon or physician from doing. But overall, when adverse events happen, the mission is to treat the physician with dignity and respect, to look at the event objectively, to look at the facts, and to have an action plan that benefits everyone including the physician.
HL: What are the primary elements of good graduate medical education programs at hospitals?
Waters: Good graduate medical education requires physician leaders who are truly engaged and truly passionate about teaching. That is the starting point. If you do not have that, you cannot have a successful program; otherwise, the residents will feel they are just worker bees. They do not just want to be people doing a job. They want to learn. They want feedback. They want mentorship. So, you need physician leaders who are engaged in graduate medical education.
Second, the attending physicians that rotate with residents must be engaged in teaching, must not be overly critical, and must be patient because working with residents does slow down their normal process, whether it is in the operating room, on a hospital floor, or in a clinic. There is a real benefit if attending physicians are committed to teaching—they can share their experience.
In a joint venture, Geisinger is building two 96-bed inpatient behavioral health facilities.
Geisinger has entered a joint venture to build two behavioral health facilities and boost access to rural behavioral health services.
Providing adequate patient access is one of the primary challenges for behavioral health programs at health systems across the country. The challenge is particularly acute in rural areas such as those served by Geisinger in Pennsylvania. About 60% of rural Americans live in mental health professional shortage areas.
"Access to high-quality behavioral health services is a national issue. It is a challenge that is even greater here in rural America, and the COVID-19 pandemic has exacerbated those challenges," says M. Justin Coffey, MD, chair of the Department of Psychiatry and Behavioral Health at Geisinger.
Geisinger is facing high demand for behavioral health services, he says. "The good news is that safe and effective treatment exists. The challenge is that access to that treatment can be difficult. It certainly is not easy. Today, at Geisinger, we have 16,000 referrals to our behavioral health department. We are doing everything we can to manage that demand to take care of the incredible need that is in our communities."
To address access to inpatient behavioral health services, Geisinger has entered a joint venture with Acadia Healthcare to build two 96-bed inpatient behavioral health facilities in Moosic and Danville, Pennsylvania. Together, Geisinger and Acadia will be investing about $80 million into the new facilities, Coffey says. Geisinger will be a minority owner in the joint venture.
Meeting demand for care
The new facilities will address demand for inpatient care at Geisinger, he says. "Each of these facilities is going to serve adult and pediatric patients. Upon completion, the two facilities will address both the current and what we project will be future demand for both adult and adolescent patients who struggle with all kinds of psychiatric conditions."
The new facilities will offer a broad range of services, Coffey says.
"We will provide acute psychiatric care for adult and pediatric patients, especially those struggling with acute symptoms of psychiatric conditions such as anxiety, depression, bipolar disorder, schizophrenia and other forms of psychosis, post-traumatic stress disorder, and certain forms of substance use disorder. In addition, these facilities will offer transitional levels of care. For example, they will offer partial hospital programs and intensive outpatient programs. These are outpatient levels of care, where patients step up to them from outpatient services or step down to them from hospital-based services," he says.
The new facilities will also offer contemporary modalities of brain stimulation therapy, Coffey says. These are nonpharmacologic interventions such as electroconvulsive therapythat can treat some of the most severe forms of psychiatric illness.
The goal of the joint venture is to focus on the acute care side of the care continuum, he says. "In this region, we know that our communities are 'under-bedded' from an inpatient psychiatry perspective both in central Pennsylvania and northeast Pennsylvania. Through this joint venture, we will be constructing and operating two freestanding, state-of-the-art behavioral health facilities. These facilities are going to bring accessible, high-quality inpatient behavioral health services to our communities."
The Moosic facility is expected to open in the fall of 2022, and the Danville facility is expected to open in 2023.
For nine common maternal morbidities in 2019, medical costs were estimated at more than $18 billion and nonmedical costs were estimated at more than $13 billion.
In 2019, the estimated costs associated with maternal morbidity for U.S. births from conception through the child's firth birthday were $32.3 billion, a new study found.
The United States is experiencing a maternal health crisis. In 2019, the United States lagged other developed countries in maternal mortality ratio, with 20 maternal deaths per 100,000 live births.
The new study, which was published today by The Commonwealth Fund, examined the medical and nonmedical costs associated with nine maternal morbidities: amniotic fluid embolism, cardiac arrest, gestational diabetes mellitus, hemorrhage, hypertensive disorders, maternal mental health conditions, renal disease, sepsis, and venous thromboembolism.
Medical costs include treatment and hospitalization of mothers and their infants. Nonmedical costs include productivity loss and use of social services, such as the Supplemental Nutrition Assistance Program; Special Supplemental Nutrition Program for Women, Infants, and Children; Medicaid; and Temporary Assistance for Needy Families.
The research features several key data points for 2019 from conception to the child's fifth birthday.
Medical costs for the nine maternal morbidities were estimated at $18.723 billion
Nonmedical costs for the nine maternal morbidities were estimated at $13.576 billion.
Total costs for the nine maternal morbidities were estimated at $32.3 billion.
The costs associated with child outcomes were estimated at $24.0 billion.
The costs associated with maternal outcomes were estimated at $8.3 billion.
The healthcare system accounted for 58% of maternal morbidity costs.
Employers, public social services programs, and other nonmedical entities accounted for 42% of maternal morbidity costs, including losses in productivity ($6.6 billion) and costs linked to behavioral and developmental disorders in children ($6.5 billion).
In a prepared statement, the lead study author said maternal morbidity has a widespread impact on society.
"We show that the costs of maternal morbidity affect not only birthing people and their families but also all of us. Our findings highlight the need for more societal investments in maternal health, an area where the United States performs poorly in comparison to other developed nations, despite having the resources to prevent morbidity and mortality," said So O'Neil, a senior researcher and director at Mathematica.
Interpreting the data
The study's co-authors say that the costs associated with maternal morbidity are likely much higher than they have estimated.
"Our model estimated that nine common maternal morbidity conditions associated with births in a given year (2019) cost society $32.3 billion from the beginning of pregnancy through five years postpartum. The lack of comprehensive data for other conditions suggests that maternal morbidity has the potential to exact a much higher toll on society than what we have found, rivaling that of expensive chronic conditions like diabetes, whose costs run into the hundreds of billions of dollars," they wrote.
In addition, the availability of data also likely underestimates the costs associated with maternal morbidity in the study, the co-authors wrote.
"Of the costs documented, medical costs made up the majority (58%). This preponderance of medical costs is likely driven by the relative availability of hospital discharge data compared with other cost information. The focus of these costs on the delivery period also implies our estimates might further miss costs associated with later and longer-term physical and mental health consequences of maternal morbidity for birthing people and their children, including consequences for subsequent pregnancies," they wrote.
Nonmedical costs are also likely underestimated, the co-authors wrote.
"Nonmedical costs accounted for the other 42 percent of total costs, which mainly stemmed from maternal mental health conditions—the maternal morbidity for which we had the most complete information on outcomes and costs. While the literature contained fewer documented nonmedical costs for the eight remaining maternal conditions in this model, studies of other health conditions have found that nonmedical costs attributable to lost earnings, productivity loss, and other indirect costs can account for more than half of overall costs. Additional information on nonmedical costs related to maternal morbidity could raise our estimate of nonmedical and total costs," they wrote.
The co-authors conclude that addressing maternal morbidity must be a healthcare system priority. "The cost of maternal morbidity has significant implications for delivery system leaders and policymakers. System failures that result in today's severe maternal morbidity can result in tomorrow's maternal death, which makes preventing morbidity even more critical to addressing the U.S. maternal health crisis," they wrote.
The Mountain View, California-based health system helped develop one of the first electronic medical record systems.
As El Camino Health marks the health system's 60th year of operating in the Bay Area of California, the health system is celebrating its history of innovation.
Innovation has been a hallmark of the healthcare sector for more than a century. Innovation has driven advancements in a range of medical areas, including medical technology, surgical techniques, and patient experience.
It is critical for health systems and hospitals to be innovative, says Deb Muro, chief information officer at El Camino Health, which features two acute care hospitals.
"You are not going to be able to survive, thrive, and grow if you are not innovating. We all know that healthcare does not provide the best experience for patients—we know that we must innovate to get better. We have opportunities to do things better, and the only way to do that is to do things differently. Innovation is the way that we can make that happen," she says.
El Camino has a lengthy innovation track record:
In the late 1960s, El Camino Health collaborated with Lockheed Martin to develop a computerized physician order entry system. The system was implemented in the early 1970s and became the precursor to one of the first electronic health records.
El Camino Health participated in the development of MitraClip, a medical device that uses a catheter-based approach to repair the mitral valve in a beating heart. MitraClip has revolutionized therapy for mitral regurgitation and received Food and Drug Administration approval in 2013.
In 2014, El Camino Health was one of first hospitals in California to perform a new, minimally invasive aortic valve procedure using the Medtronic CoreValve System.
In 2019, El Camino Health's interventional pulmonology program was the first in the world to perform a robotic lung nodule biopsy commercially. Since then, El Camino's Ganesh Krishna, MD, has published findings showing that the use of robotic-assisted technology leads to more accurate diagnoses and more successful removal of hard-to-reach lung nodules.
In 2019, El Camino Health became the first hospital in California to perform bronchoscopic lung volume reduction, a minimally invasive procedure for severe chronic obstructive pulmonary disease.
One of El Camino Health's newest innovations gives patients the ability to communicate with the health system that they are on their way to the emergency department, Muro says.
"First of all, the patient can go on our website to see how long it will take for them to be seen in the ED. Then the patient, at that moment, can communicate that they are coming, along with a brief description of what is happening with them so we can be prepared when they arrive. We are in our infancy with this initiative, but there is so much that we can do with being able to be predictive. In other words, we do not only want to know what is going to be happening in this moment, we want to know what is going to happen in an hour, four hours, or 24 for hours in the future," she says.
'We have innovation in our DNA'
El Camino Health is committed to innovation as an organization, says CEO Dan Woods. "It is part of the culture of being in Silicon Valley. The people who live in this area have a mindset of new ideas and being innovative. So, innovation is fostered and nurtured within the community and the people who work at El Camino."
Innovation is deeply rooted at El Camino Health, Muro says. "We have innovation in our DNA. We love innovation. We take care of Google patients. We take care of Apple patients. We take care of high-tech industry patients. Innovation helps us to deliver great care and to differentiate us in the community."
There are several factors involved in promoting an innovative culture at health systems and hospitals, Woods and Muro say.
"You cannot be afraid to lead. Sometimes, hospital folks have a tendency to follow. You also need to heed the perspective of the consumer. We as healthcare leaders have a tendency to look at our problems through our own lens and through our own operations, as opposed to looking at our problems from the consumer perspective. You should not try to boil the ocean. Sometimes, hospitals and inventors feel they have to solve moon shots. You need to just try to move the dial one notch. That movement of one notch can start additional waves of innovation, like a pebble into a pond. In promoting innovation, you need to identify a problem or a friction," Woods says.
Fostering an innovative culture at a health system or hospital requires linking innovation to the goals of the organization and having a keen awareness of the market, Muro says.
"You need to place those goals front and center, then you need to determine how you can move the dial to achieve your goals. You need to think about doing things in different ways. Some of it is educating ourselves and going out into the market to see what opportunities are out there. We partner with startups. We partner with our technology vendors to see where they are going," she says.
Achieving innovation at a small health system or standalone hospital
When it comes to innovation, El Camino Health has several characteristics that have enabled the organization to succeed despite its relatively small size, Woods says.
"There is a high willingness to embrace change, which is related to accepting new ideas. There is a willingness to accept failure and to learn from failure. Finally, part of the reason I came to El Camino is because it is a smaller organization that is nimble. I wanted to use that nimbleness to our advantage. We can get things done much faster than larger organizations. We have tech companies that have come to us because we respond with a 'yes' or 'no' much faster than any of the large academic medical centers in California," he says.
Muro offered advice for other small health systems or standalone hospitals that want to aggressively pursue innovations.
"In a small organization, it is critical that you run the business well. Sometimes, the margins are tight, so you want to make sure that innovation helps financially, helps to drive growth, helps with quality, or helps improve the patient experience. If you can achieve those goals, it is an easier road," Muro says.
The study found that if all hospitals operated as efficiently as the most cost-efficient hospitals, the Medicare program would save $8 billion annually.
A new analysis by the Lown Institute lists the 10 most cost-efficient hospitals in the country.
Healthcare accounts for a significant share of the U.S. economy, according to statistics published by the Centers for Medicare & Medicaid Services. In 2019, national health expenditure grew 4.6% to $3.8 trillion, or $11,582 per American. In 2019, national health expenditure accounted for 17.7% of the country's gross domestic product.
The Lown Institute analyzed data from more than 3,000 hospitals. The study examined how much Medicare was billed and compared that figure to 30- and 90-day mortality rates.
For hospitals with average 30-day mortality rates, per-patient Medicare costs ranged from $9,000 to $27,000. The study found that if all hospitals operated as efficiently as the most cost-efficient hospitals, the Medicare program would save $8 billion annually.
The 10 most cost-efficient health systems and hospitals were as follows:
1. Pinnacle Hospital, Crown Point, Indiana
2. Saint Mary’s Regional Medical Center, Reno, Nevada
3. Mercy Medical Center Dubuque, Dubuque, Iowa
4. Encino Hospital Medical Center, Encino, California
5. Park Ridge Health, Hendersonville, North Carolina
6. Oroville Hospital, Oroville, California
7. Saint Michael’s Medical Center, Newark, New Jersey
8. UnityPoint Health-Meriter, Madison, Wisconsin
9. East Liverpool City Hospital, East Liverpool, Ohio
10. Maple Grove Hospital, Maple Grove, Minnesota
The study proves that hospitals can provide cost-efficient care with good outcomes, Vikas Saini, MD, president of the Lown Institute, said in a prepared statement. "If we want to keep costs low for the Medicare program and provide quality care for the 60 million Americans who depend on it, hospitals must be as efficient as possible. The best hospitals prove that you can save Medicare dollars and deliver great patient outcomes at the same time."
The study analyzed Medicare claims data for patients hospitalized from 2016 to 2018. Mortality rate and cost data was adjusted based on patient risk. Hospitals with the lowest mortality rates and lowest costs generated the best cost-efficiency scores.
Although clinician comfort with technology impacts the success rate of video visits, patient characteristics such as advanced patient age loom large.
Patient characteristics including older age and ethnicity are associated with the successful completion of video telemedicine visits, a new research article says.
Telemedicine visits have increased exponentially during the coronavirus pandemic. Challenges associated with access to telemedicine services such availability of broadband service for patients have raised concerns about equity.
The new research article, which was published by JAMA Network Open, examines the results of a quality improvement study of more than 130,000 scheduled video visits at an academic health system between March 1 and Dec. 31, 2020. Video visits were considered a success if the service was completed. Video visits were considered a failure if they were converted to a telephone visit.
The study generated several key data points.
90% of video visits were successful and 10% were converted to telephone visits
Lower clinician comfort with technology was associated with conversion to telephone visits (odds ratio 0.15)
Advanced patient age (66 to 80 years old) was associated with conversion to telephone visits (odds ratio 0.28)
Lower patient socioeconomic status including low access to high-speed Internet was associated with conversion to telephone visits (odds ratio 0.85)
Patient ethnic and racial minority status was associated with conversion to telephone visits (for Black and African American patients, the odds ratio was 0.75)
Relatively high patient income ($75,001 to $213,000) was associated with successful video visits (odds ratio 1.18)
Patient use of a tablet or laptop was associated with successful video visits (odds ratio 1.41)
"As policy makers consider expanding telehealth coverage and hospital systems focus on investments, consideration of patient support, equity, and friction [such as access to smartphones, computers, and quality Internet connections] should guide decisions. In particular, this quality improvement study suggests that underserved patients may become disproportionately vulnerable by cuts in coverage for telephone-based services," the research article's co-authors wrote.
Interpreting the data
Patient characteristics were the primary variable determining whether a video visit was successful or a failure, the research article's co-authors wrote.
"Clinicians were associated with some variability as a part of the equation, especially those working remotely, with poor network or with Wi-Fi network dropped connections, or those learning how to manage new equipment and workflows. However, this study showed that most of the variability in successful or failed video visits was associated with patient characteristics versus clinician characteristics, particularly regarding sociodemographic characteristics and age," they wrote.
Sociodemographic characteristics of patients such as Internet connectivity and technology literacy are essential to the success of a video visit, the co-authors wrote.
"Internet connection with sufficient bandwidth to facilitate a video visit is often a hurdle for various populations. One-fourth of rural households do not have access to broadband Internet; the digital divide is also present in urban communities, emphasizing the necessity of more inclusive Internet access. Video communication yields higher patient understanding and satisfaction compared with only telephone communication," they wrote.
Several factors may contribute to older patients converting video visits to telephone visits, and this group can benefit from telemedicine visits, the co-authors wrote.
"Older individuals may face more technology barriers, may have visual or movement disorders that make computing more difficult (especially on smaller devices), or may simply be more casual users of the Internet. Despite those assumptions, individuals who are older likely have a higher need for virtual care associated with transportation challenges to and from appointments or other impairments or chronic ailments that make leaving the house difficult," they wrote.
There is a learning curve that impacts the success or failure of video visits, the co-authors wrote.
"As patients and clinicians in the study population became more comfortable with technology, distinct learning curves were found in both user categories. The existence of a learning curve suggests that there are modifiable telemedicine program components, such as technical support or training, that may reduce video visit failures. Previous studies have shown that effective clinician training in telemedicine increases clinician confidence not only in using medical technology but in educating patients in how to have a successful video visit," they wrote.
The research article has important implications for policy makers and healthcare providers, the co-authors wrote.
"A future focus for policy makers should consider inclusion of telephonic services as a form of reimbursable telemedicine. Permanent expansion of low-cost or free broadband Internet for at-risk populations is also critical. For healthcare systems, it will be imperative to improve the ease of use of telemedicine as well as to provide support for patients to access such services," they wrote.
Jeff Ciaramita says being an effective chief physician executive starts with listening and being present.
The new chief physician executive of the Mercy health system's Mercy Clinic says it is essential in his new role to serve as an effective intermediary between clinicians and the health system.
Jeff Ciaramita, MD, was promoted to senior vice president and chief physician executive of Mercy Clinic in October. Mercy Clinic is a large medical group with more than 4,000 providers. The Mercy health system is based in Chesterfield, Missouri, and operates more than 40 hospitals in Arkansas, Kansas, Missouri, and Oklahoma.
Ciaramita first joined Mercy in 2008 as a noninvasive cardiologist and director of cardiovascular education. He served as section chief of cardiology at Mercy Clinic St. Louis for more than five years, then became president of Mercy Clinic South in 2017. In 2019, he became president of Mercy Clinic St. Louis.
HealthLeaders recently talked with Ciaramita about his new role. The following is a lightly edited transcript of that conversation.
HealthLeaders:How can a chief physician executive serve as an effective intermediary between clinicians and their health system?
Jeff Ciaramita: At the minimum, this is one of the most critical parts of my role.
Number One, a chief physician executive can serve as an intermediary by understanding what is going on at the local level. You need to be present and to ask the questions that need to be asked.
Secondly, it is also my role to understand the overall strategy of the ministry. Our primary strategy is to keep our patients at the center of everything. If our clinicians and their teams do not understand that underlying strategy, there is no way that they will be able to understand or accept the things that we need to do to evolve, or to get them the supports that they need to deliver care in their practices.
Lastly, from a strategy perspective within Mercy, most of our strategies to deliver superior clinical care come from our clinicians. So, it is very important for us to identify early on who can help guide us in the next generation of leadership and to look at ways to innovate and to transform healthcare. I need to find ways to collaboratively use my greater than 4,000 providers and their expertise to deliver care for the health system.
HL: What are the keys to success for a chief physician executive?
Ciaramita: First, it all starts with listening and being present. You need to listen to providers. You also need to understand the workforce, which includes physicians, advanced practice providers, and the staff who support them. You need to be willing to sit down and listen to what they have to say rather than tell them how healthcare should work.
Close behind is leading innovation. Healthcare has always been evolving and the rate of evolution today is probably faster than it has ever been, so you must be willing to fail. Part of innovation is failing along the way. In healthcare, physicians have been historically driven by evidence-based medicine and first do no harm. The training of physicians today completely goes against innovation and the willingness to fail.
HL: What are the primary elements of physician engagement at a large medical group?
Ciaramita: You must be present. COVID throws a wrench into that, but engagement is only possible when you are locally present and meet with the people who are responsible for delivering the care.
The second phase of engagement comes when you not only listen up front but also provide support. Listening will only get you so far—understanding how you need to support your physicians is important. You must follow up with support.
Lastly, with every large medical group, including Mercy Clinic, engagement comes down to the practice level. The Mercy health system likes to say we have one care model, and we have many operating and clinical standards that we know can deliver high quality care. But the reality is that engagement in a large medical group comes down to the relationships and collaboration with our practice managers. The focus is individual locations and making sure that despite a singular care model that they are still being heard and understood.
HL: How can a chief physician executive help to address provider burnout?
Ciaramita: Burnout is present unequivocally and unquestionably in physicians, advanced practice practitioners, and our other staff members. Until everybody in the health system acknowledges that, we will not be successful in addressing it.
I need to truly understand what leads to dissatisfaction from a provider's perspective. Burnout could be the result of working too many hours, but it could also be the result of ongoing non-employment issues, lack of support, or performing unwanted job duties. For example, a provider might think they went to medical school to operate on patients, but they spend a significant amount of their day writing notes and charting in the electronic health record, which they never wanted to do.
I need to understand the factors that lead to provider dissatisfaction, then find the tools that can minimize those distractions or sources of dissatisfaction. We will never find that out unless we address burnout individually with every single provider in our ministry.
HL: Are there examples of what you would like to do to address burnout as a chief physician executive?
Ciaramita: I would like to expand programs and minimize the stigma of burnout. I would also like to change the perception of the term burnout—we must realize that the possibility for burnout is going to exist for every single physician. Burnout is a universalizing term to say, "There are areas of my job as a care provider that I absolutely love, and there are other areas that I struggle with." I want to help find the tools for those areas that people struggle with or those areas that create dissatisfaction to allow providers to practice at the top of their license and be able to focus on areas that they enjoy.
I also want to encourage flexibility. In healthcare, taking care of the overall health of a community is not an 8 a.m. to 5 p.m. job. So, our approach to our providers might be creating opportunities for them to deliver healthcare in nontraditional manners and nontraditional hours. From a provider's standpoint, that creates another opportunity for us to be able to deliver care in ways that provide more joy and can address burnout individually.
Nine communities across the country received resources, coaching, and technical assistance from experts to test best methods to promote wellness and equity.
Nemours Children's Health has led an effort to develop a five-part toolkit to help community organizations advance health equity.
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 many racial and ethnic groups that have been at higher risk of getting sick and experienced relatively high mortality rates.
Jacksonville, Florida-based Nemours Children's Health worked with nine communities across the country to develop its five-part health equity toolkit. The communities were Bridgeport, Connecticut, Flathead County, Montana, Guilford County, North Carolina, Los Angeles, Paterson, New Jersey, Philadelphia, Sarasota, Florida, Ventura County, California, and Washington, DC.
1. Community organizations need to establish a common definition and understanding of equity.
Communities seeking to address equity must bring together multiple sectors such as healthcare, schools, and housing to achieve their goals, says Allison Gertel-Rosenberg, MS, vice president of national prevention and practice at Nemours Children's Health.
"When groups come together and agrees on a shared definition of equity, what they are really trying to get to is their North Star. It allows groups to coalesce better around strategy, around thinking who has the capacity and expertise to lead different components of an initiative, and around how the work and the leadership is going to spread across the groups. This way, all the groups can focus on what they do best; and, at the same time, they can focus on what they do best to get to the same goal," she says.
2. Community organizations need to heed the voices of real-world experts through governance and decision-making structures that solicit the perspectives of the community members whom the effort seeks to serve. Community members who participate in this process should be compensated for their expertise.
Enlisting community members to participate in equity efforts elevates the role of end users, Gertel-Rosenberg says. "If you think about other industries, a tech company would not develop a new phone without asking consumers what they wanted to do with the phone."
When communities create and design systems to tackle equity goals, initiatives should seize on the opportunity to ask community members what they want to happen, she says. "We can ask about what is not working. We can ask about what capacities and assets they have as a community that we can build on. Then we can take those answers and combine them with the expertise of people who do this work as their job to come up with the best strategies and best opportunities that will work in the community."
Community members should be compensated for their participation, Gertel-Rosenberg says. "Compensation is important. When we ask a community member who feels strongly about equity to take time away from their family or their job, we need to compensate them for their expertise."
3. Community organizations need to enact data-sharing and data-driven resource allocation to identify groups experiencing inequities as well as carry out community-led mitigation strategies.
She says data related to equity challenges is collected at several sources, including health systems, schools, social programs, and community organizations. "It would be great if we could take these data sets and combine them to start to draw a picture of what is happening in the communities that we are serving. The ability that data sharing presents to us is getting enough data to not only look at overarching data about a community but also start to disaggregate data to see where there are opportunities to address disparities and the inequities that are driving those disparities."
"For example, if we look at rates of food insecurity in a community, what the average looks like could be hiding significant disparities between different parts of the population that could be based on race, ethnicity, or geography. When we start to put that data together and disaggregate the data, we can look at solutions that target at-risk populations and start to raise them up," Gertel-Rosenberg says.
4. Community organizations should conduct "equity impact reviews" to assess the results and potential unintended consequences of current and proposed practices, policies, and strategies, which should be revised as needed.
Equity impact reviews are a tool in a community's equity toolbox, she says. "In the broadest way, equity impact reviews allow a community to break down what is happening with an initiative and what the intended or unintended consequences might be not only for the population as a whole but also for different parts of the population."
Equity impact reviews unify equity efforts, Gertel-Rosenberg says. "If we have communities that are using equity impact reviews, they are sharing data, they are ensuring the voice of the community is at the table, and they are having a shared language. By having equity impact reviews, communities can shape the best strategies that are going to address their shared goals."
5. Community organizations need to embed equity-promoting workflows into daily operations.
Embedding equity-promoting workflows into daily operations elevates equity efforts, she says.
"When we start to embed equity into our daily workflows, we ensure that we are talking about equity at every meeting. We ensure that we are asking questions about disaggregated data and the impact on different parts of the population at every meeting. We need to ask questions about equity and ensure that when we consider a new strategy or a new goal, we ask the same questions about the data, about how the community voices are integrated, and about the impact on different sub-populations. It is not enough to set a strategy or a goal and leave it."
About 90% of survey respondents report that regulatory burdens have increased over the past year.
The coronavirus pandemic has increased the regulatory burdens on medical practices, according to a new survey report from the Medical Group Management Association (MGMA).
Regulatory burden has been a top concern at medical practices for years. The "Annual Regulatory Burden Report" published this week by the MGMA highlights the pain points medical practices are feeling this year.
The survey report has responses from executives representing more than 400 group practices. More than 80% of the survey respondents work at independent practices.
The survey report features several key findings.
91% of survey respondents said the overall regulatory burden on their medical practice over the past year has increased
When asked which regulatory issue was very or extremely burdensome, the Top 3 issues were prior authorization (88% of survey respondents), COVID-19 workplace mandates (71%), and Medicare quality payment programs (71%)
92% of survey respondents said healthcare consolidation such as acquisitions of physician practices by health systems and hospitals is increasing
72% of survey respondents said consolidation is having a negative overall impact on the U.S. healthcare system
75% of survey respondents said regulatory requirements are a significant driver of healthcare consolidation
79% of survey respondents said the move toward value-based payments for Medicare and Medicaid patients has increased the regulatory burden on their practices
70% of survey respondents said the move toward value-based payments for Medicare and Medicaid patients has not improved the quality of care
70% of survey respondents said the move toward paying physicians based on value has not been successful so far
93% of survey respondents said the positive payment adjustments of Medicare's Merit-based Incentive Payment System (MIPS) do not cover the costs of time and resources spent preparing for and reporting under the program
80% of survey respondents said that Medicare does not offer an Advanced Alternative Payment Model that is clinically relevant to their practices
Interpreting the data
The pandemic has worsened the regulatory burdens on medical groups, says Anders Gilberg, MGA, senior vice president of government affairs at MGMA.
"Particularly early in the pandemic, it impacted the revenue of medical groups significantly. There was a drop of about 50% across the board in revenues in the early months of the pandemic. Revenue has bounced back but there was a shock to the system at medical groups. So early in the pandemic, it created a situation where the regulatory burden was still high, but practices were forced to furlough staff and lay off staff because they simply did not have patients coming in for visits. This put a strain on practices to keep up with regulatory burdens," he says.
This year, vaccine mandates have created new staffing shortages at medical groups, Gilberg says.
"There are still underlying staffing issues, but we are finding ramifications in 2021 from state mandates and vaccine mandates affecting practices. This is especially true in states where there is hesitancy about getting the coronavirus vaccine. Practices that are attempting to implement vaccine mandates are losing staff. On the administrative side, employees in some of the lower paying positions such as billing are making the choice to leave healthcare—they can find similar jobs outside of healthcare that do not have vaccine mandates. In addition, there is a large percentage of nurses who have been reluctant to get vaccinated, so practices have been losing staff on the clinical side as well."
The latest wave of staffing shortages is heightening regulatory burdens, he says.
"When you do not have administrative staff or clinical staff to process bills or to take care of patients, we are hearing frustration about the growing regulatory burden coupled with not having enough staff members to report quality measures, which practices do not feel are relevant. There are not enough staff members to sit on the phone with payers to administer prior authorizations. There is a confluence of events where the regulatory burden continues to grow, while the resources that medical groups have are shrinking. That is putting an incredible strain on medical groups."
Prior authorization is the most costly and time consuming regulatory burden at medical practices, Gilberg says. "When practices do not have the clinical staff to administer prior authorizations or when physicians are pulled out of direct patient care to authorize care, it creates significant strain on the practice in terms of time, resources, and finances. When you cannot be productive as a physician because you are on the phone with payers, it stresses a practice."
Many prior authorizations are unnecessary burdens, he says. "There are many services that require prior authorizations that are routinely approved, yet you still must jump through the hoops to get these services approved. That creates an unnecessary burden. There are also medical groups that are in value-based payment arrangements, where they are held accountable for cost and quality. In those arrangements, practices are already doing what they can to address the underlying issues that prior authorization also seeks to address."
Regulatory burdens are a significant factor in healthcare consolidation such as the acquisition of medical groups by health systems, hospitals, and other larger organizations, Gilberg says. "Especially in an environment where we have had a shock from the pandemic, which has affected the finances of independent practices as well as the staffing of independent practices, medical practices do not have the finances or the staffing to deal with growing regulatory burdens. As a result, the physicians who own independent practices think about getting someone else to deal with the regulatory burden."
Many medical groups feel trapped in the MIPS program, he says. "MIPS is a quality reporting program that was largely meant to be a bridge as Medicare and the Center for Medicare and Medicaid Innovation created new opportunities for physician to avail themselves of Alternative Payment Models. What we have seen is that many practices are stuck in the MIPS program. In our new survey report, most practices do not find that many of the Alternative Payment Models that are in the Medicare program are clinically relevant to their practices."
More Alternative Payment Models should be launched, Gilberg says. "We are looking for more Alternative Payment Models so we can move more practices out of the MIPS program. We need more Alternative Payment Models so we can create a win-win for value-based care. Many of our practices are optimistic about value-based care, and they would be interested in participating if there were programs that could help them both financially and clinically. But many practices do not have that opportunity. That's why the MIPS program rises to the top of our regulatory burden survey."
