Spectrum Health had well-being initiatives in place before the coronavirus pandemic and has launched more efforts during the pandemic.
Grand Rapids, Michigan-based Spectrum Health is one of 44 healthcare organizations nationwide to be recognized by the American Medical Association's Joy in Medicine Health System Recognition Program.
Healthcare worker burnout and well-being have been top concerns during the coronavirus pandemic. The Joy in Medicine Health System Recognition Program is designed to recognize health systems that are committed to improving physician satisfaction and decreasing burnout.
Spectrum Health has had a longstanding commitment to healthcare worker well-being, says Kristin Jacob, MD, medical director of the health system's Office of Physician and APP Fulfillment.
"Even before the pandemic, Spectrum Health was committed to focusing on work-related stress and reduction of burnout. The health system promoted a call to action to improve the well-being of our frontline caregivers, and part of that call to action is submitting an organizational commitment statement to the National Academy of Medicine, which states our dedication to reducing clinician burnout and improving well-being," she says.
The Joy in Medicine Health System Recognition Program provides accountability for well-being efforts at Spectrum Health, Jacob says. "We are continuing to collaborate with other organizations across the country that are doing work to reduce burnout and sharing best practices. The AMA Joy in Medicine Health System Recognition Program provides another layer of accountability for our organization to focus on measuring well-being, building leadership development, promoting teamwork, and measuring work done outside of working hours, which is a huge driver of burnout."
Addressing burnout and wellbeing
At Spectrum Health, the Office of Physician and APP Fulfillment was established in 2019 to initially focus on physicians and advance practice providers. "The reason for targeting this population first was twofold. First, we know that our physicians and APPs are at the highest risk for burnout, suicidal ideation, and a negative impact on patient care due to these factors. Second, we recognized that we needed to start somewhere," Jacob says.
Spectrum Health has been measuring well-being with a validated tool for several years, she says. "We use the Mayo Clinic Well-Being Index to measure the wellbeing of our physicians and APPs. This is crucial to be able to understand where we are and to create reports based on factors such as specialty, gender, age, and ethnicity to develop targeted interventions."
The pandemic has been taking a toll on healthcare workers at Spectrum Health, she says.
"We have seen a significant increase in the distress of our physicians and APPs over the past year as measured by our validated tool and our engagement surveys. We have seen similar increases in distress among our nurses and other team members. This aligns with the trends we are seeing across the country and puts data behind the toll that the pandemic has taken on us. When we think about the drivers of this distress, we are grappling with extreme staffing shortages that are leading to extraordinary workloads. Michigan is also experiencing, arguably, our worst COVID-19 surge, where most of the rest of the country has been turning the corner."
The Office of Physician and APP Fulfillment launched a well-being program called Med+Up before the pandemic, Jacob says. "Med+Up gathers small groups of physicians and APPs together to have monthly facilitated discussions about meaning in work. These gatherings are intended to be a relaxed setting outside of work to facilitate discussions. This is a best practice that has data behind it showing improvement in meaning in work and reduction of burnout. There are about 100 physicians and APPs who are participating in this program."
Spectrum Health also has employee benefit programs that are designed to boost well-being and reduce burnout, Jacob says.
"From a benefits standpoint, we have a robust healthy lifestyles program that promotes a healthy lifestyle, emotional health, and mental health. The healthy lifestyles program has a strong relationship with our employee assistance program, which can provide in-the-moment support as well as appointments. The employee assistance program is a vital component in supporting our team members. An additional benefit is we partner with Headspace, which is a mindfulness app with data behind it for reducing stress. Headspace was established as a benefit in early 2020 for all Spectrum Health employees."
The health system is committed to suicide prevention among patients and healthcare workers, she says. "We have a zero-suicide initiative that is for our patients, but we also have strong education and processes for team member suicide prevention. We have continued to improve education, awareness, and training around those efforts."
Spectrum Health has launched several initiatives during the pandemic to address healthcare worker well-being and burnout, Jacob says.
"First and foremost, during the pandemic, we have been addressing the basic needs of our workforce. Early in the pandemic, this effort included securing personal protective equipment. We have provided additional benefits to support backup childcare, compassionate paid time off, and support for unexpected time off. There have also been generous wage increases. With the support of many leaders, we have initiated widespread delivery of meals, snacks, water, and free coffee through our nutrition services. We also have wellbeing navigators who are rounding to check on people, see what they need, and connect them with resources. We have placed wellness carts in 150 of our highest acuity spaces that include wellness-related items and tangible resources," she says.
During a COVID-19 patient surge last November and December, Spectrum Health enlisted volunteers to pack more than 3,000 COVID support snack boxes that were delivered throughout the health system's clinical care units, Jacob says. "That effort has evolved, and we are doing targeted funding for our leaders so that they can support the basic needs of their teams and other creative ways to deliver meals to make sure that staff members can eat on their busy shifts."
The health system has been focusing on emotional support during the pandemic, she says. "We have had an extensive rollout of many support groups that we have launched for our caretakers over the past year. We also have had a lot of resources and education around psychological safety and secondary trauma. We recently launched a peer support program, which offers one-on-one peer support for colleagues to process difficult events and chronic stress as well as connect team members to resources."
Resources related to well-being at the health system include the employee assistance program as well as a critical incident stress management team and spiritual care team, Jacob says. "We also partner with Priority Health, which has a platform called myStrength that offers content related to mental health support online. Priority Health also provides access to a phone line so that staff members can seek mental health support outside of the employee assistance program."
Hopeful for the future
Despite the challenges posed by the pandemic, Jacob says she has a positive view about healthcare worker well-being. "The long-term prospects are optimistic. There are silver linings of the pandemic, including the way that the pandemic has brought attention and urgency about mental health awareness. In addition, the pandemic has brought attention and urgency to holistically care for the caregivers of our patients."
The pandemic could be a turning point in efforts to boost healthcare worker well-being, she says. "This may just be the pressure that we need to realign our values in healthcare and realize that human capital is our most crucial resource. There is still much work to do, but I am encouraged by our local leaders and their authentic desire to care for our team members. The conversation that is occurring at the national level is also encouraging—it is putting pressure at a high level to think about what regulatory agencies are doing to put standards of care in place that protect healthcare workers."
Clinical decision support tools help clinicians to have up-to-date information about medical conditions.
An effective clinical decision support tool is available at the point of care, is as current as possible, and is accurate, a chief medical information officer says.
Medical knowledge advances rapidly, with a plethora of new studies published daily. Clinical decision support tools can help clinicians stay up to date with the constant changes of information about diagnoses and treatments.
A good clinical decision support tool has three primary characteristics, says Jon Michael Vore, DO, chief medical information officer Southern New Hampshire Health. The Nashua, New Hampshire-based health system features a medical center and a network of more than 400 clinicians.
First, a clinical decision support tool must be easily accessible to clinicians at the point of care, he says. "You want clinical decision support at the point of care when you are taking care of a patient. If you are going to have a clinical decision support tool, it needs to be at your fingertips. If you have to go into a completely separate system or leave the room, it detracts from being able to use a tool. A clinical decision support tool should be directly integrated into your workflow."
Second, a clinical decision support tool must be as current as possible, Vore says. "A good clinical decision support tool should be up to date and peer reviewed. If you are sharing information with a patient, you want to make sure that you have the most up-to-date recommendations in regards to whatever you are talking about."
Third, a clinical decision support tool must be accurate, he says. "A good clinical decision support tool is trustworthy. You need to be able to trust the information that the tool is providing. These days, patients are doing their homework and they are checking up on you. When they leave the office, they are not absolutely assuming that the provider has given them 100% correct information. Many times, they are going home and following up and doing their own review and seeing if the information their clinician has provided is accurate."
Clinical decision support tool in practice
Southern New Hampshire Health has clinical decision support in the health system's electronic medical record as well as Wolters Kluwer's UpToDate clinical decision support tool.
"We have the Epic electronic medical record system. There are a lot of clinical decision support tools in Epic, where you get best practice advisories. You get medication and allergy interactions as well," Vore says.
At the health system, UpToDate is integrated into Epic, he says. "As we are doing our documentation or seeing patients, we have a hyperlink directly in Epic that will automatically log a provider into UpToDate and allow them to do a search for medical conditions. This allows providers to have a clinical decision support tool at their fingertips. Providers do not need to go to another Web browser or type in a URL. Having UpToDate integrated into our electronic medical record makes it quick and easy for clinicians to access information they need to verify their treatment or even review information with the patient in the exam room."
Using clinical decision support tools to address misinformation
A good clinical decision support tool can help clinicians to educate misinformed patients, Vore says. "If you know you have a trustworthy source of information that has the most up-to-date recommendations and the most up-to-date information from studies, that arms clinicians to have sometimes difficult conversations with patients. These days, patients will go to the Internet, go to blog sites, and go to social media such as Facebook. They often do not go to the most evidence-based resources to look for information."
A good clinical decision support tool will approach areas where there is information that needs to be debunked, he says. "Many times, these tools will present information in a way that can be easily transferred to the patients. That may or may not change the outcome with the patient, but the best that clinicians can do is provide them with the most up-to-date information and recommendations to help them move in an appropriate direction for their overall health."
Administrative spending accounts for about a quarter of total U.S. healthcare spending, report says.
Three kinds of interventions could reduce administrative spending in healthcare by $265 billion annually, a new report says.
According to the new report, which was published this week by McKinsey & Company, total U.S. healthcare spending in 2019 was $3.8 trillion, with administrative spending pegged at $950 billion. "The goal is not to reduce administrative spending to zero but rather to gain the highest value for each administrative dollar spent without sacrificing quality or access," the report says.
More than a quarter of administrative spending could be eliminated through three kinds of interventions, the report says.
"Within" interventions are cost-cutting measures that can be made by individual organizations. Within interventions could achieve about $175 billion in annual savings, which represents about 18% of total administrative spending. Examples of within interventions include automation of repetitive back-office work such as human resources and finance.
"Between" interventions are cost-cutting measures that can be made through agreement and collaboration between organizations. Between interventions could achieve about $35 billion in annual savings, which represents about 4% of total administrative spending. Examples of between interventions include creating payer-provider communications platforms that provide unified messaging to patients.
"Seismic" interventions are cost-cutting measures that can be made with broad and structural agreements and changes throughout the U.S. healthcare system. Seismic interventions could achieve about $105 billion in annual savings, which represents about 11% of total administrative spending. Seismic interventions such as new technology platforms and changes in payment design are often based on partnerships between the public and private sectors to coordinate incentives for change.
"Many seismic interventions address the same sources of spending as the within and between ones but take the savings a step further. Accounting for this overlap, we estimate total savings across all three types of interventions at about $265 billion, or 28% of total administrative spending," the report says.
Some organizations have already achieved cost-cutting through within and between interventions, the report says. The keys to success in these efforts include four factors, the report says: "prioritizing administrative simplification as a strategic initiative; committing to transformational change versus incremental steps; engaging the broader partnership ecosystem on the right capabilities and investments; and disproportionally allocating resources, such as capital and talent, to the underlying drivers of productivity."
Seismic interventions are more challenging to achieve than within and between interventions because they are opportunities for change related to a lack of motivation to innovate at the organizational level, the report says. Three stakeholders can drive seismic interventions, the report says.
"Government could set the framework in which other organizations operate. Federal and state bodies can set guardrails for payers, hospitals, and physician groups."
"Investors can prove ideas with pilots. They might create public-private partnerships to test interventions within a state and then scale up success stories nationally."
"Third parties, such as foundations and bipartisan groups, can conduct objective fact gathering and analyses. An arbiter of facts can galvanize action."
The conditions are ripe to tackle administrative spending, co-authors of the report wrote in article published by the Journal of the American Medical Association.
"Economic downturn often leads to health system change. With COVID-19 creating enormous disruption to the healthcare system, a known opportunity to capture more than a quarter-trillion dollars in the next few years without compromising the U.S. healthcare system’s ability to deliver care could be quite attractive. The sooner healthcare administration is simplified, the easier it will be for all to engage the U.S. health care system," the wrote.
Scott Allen, MD, says patient safety must start at the top of a health system's leadership team and extend to the frontline staff.
The new permanent chief medical officer of Farmington, Connecticut-based UConn Health says listening is a key leadership skill in healthcare.
Scott Allen, MD, served as interim CMO at UConn Health for two years before recently being elevated to the permanent role. Allen joined UConn Health as a clinician-educator in 1994 and served as program director of the Primary Care Internal Medicine Residency Program for eight years. He then established the health system's Quality Department and served as chief quality officer before assuming the interim CMO role.
HealthLeaders recently spoke with Allen on a range of issues, including clinical quality, aligning physicians with population health initiatives, and the primary factors for CMO success. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: What are the keys to quality leadership at a health system?
Scott Allen: I refer to the old adage—two ears, one mouth. You need to listen more than you talk.
You need to listen to people and understand what they do. When I was the chief quality officer, I could not work on something unless I understood what the staff did and what their workflow was like.
When we do a safety event analysis I ask questions, not because I am pointing fingers, I just need to understand what happened. Sometimes, I go to the physical site where a safety event occurred to visualize the situation. To me, listening is more important than speaking, so that you understand where the other person is coming from.
Secondly, you need to focus on the patient experience. Quality requires putting the patient first. Part of that is the six Institute of Medicine aims—everything that we do should fulfill the six aims: being safe, effective, equitable, timely, efficient, and patient-centered. If we can keep all six of those aims in mind when we are working on a project or handling a particular issue, it keeps the patient experience in mind. Everything should be about the patient, and you should demonstrate that to everyone in the organization.
Thirdly, you should try to get buy-in from all clinical areas. For example, I have an initiative to try to get the institution to use scorecards. We are seeking to focus on metrics that are meaningful to the clinicians. The acronym that I use to get clinicians to think about these metrics is SMART goals—specific, measurable, achievable, relevant, and time specific.
HL: How do you align physicians with population health initiatives?
Allen: You need to make the case for the "why" for the providers. Why should they be engaged? All providers want to perform well—it is just the nature of being in healthcare—and they want their patients to achieve optimal health. You need to link both of those together. What are the population health outcomes that the doctor wants to perform well and what are the factors to help the patient be healthy—you put those two together and you engage the providers.
We have a population health department at UConn Health and many of the things that they do make it easier for the providers, so they are going to be more engaged.
HL: How does your daily Safety Huddle work?
Allen: We started safety huddles in 2008. At that time, it was called All Hands on Deck. It is a meeting that still occurs Monday through Friday from 8:30 to 9 a.m. Originally, we had all of the clinical units and some of the ancillary departments. The chief nursing officer and I would run the meeting. The CEO would attend. We would have quality reports and initiative reports.
We transformed the meeting and renamed it to the Safety Huddle. We reinforced the tools and techniques of high reliability because we were part of a collaborative with the Connecticut Hospital Association. When everybody went around the room to do their reports, everyone was in tune with the fact that the primary focus was safety.
The other important piece about Safety Huddle and how it has evolved over the years is that we have about 50 individuals who can present reports at Safety Huddle. We have all of the clinical units such as the emergency room and the inpatient units, and we have added many other units such as physical therapy, facilities, clinical engineering, and fire and police. Everybody reports out because every unit is important to patient safety.
HL: How do you get through 50 reports in 30 minutes?
Allen: It is quick. We have a safety event reporting system called Safety Intelligence, or SI for short. Any SI report that has been submitted in the previous 24 hours has to be brought up for quick discussion during Safety Huddle. Some of them do not require delving into details—some of them do. For example, if there is an elevator situation, facilities must report on that. If there is a problem with pharmacy, they must report out. So, the number of reports depends on the day.
HL: What are the keys to promoting patient safety?
Allen: It starts with leadership and your board of directors. It must start from the top. Structurally, our board of directors has a panel called the Clinical Affairs Subcommittee, which is charged with overseeing the medical center. The chair of that subcommittee holds us accountable. Being accountable to an invested board helps drive quality and patient safety because we must answer to the board.
The subcommittee meets publicly. We share our safety event rate. We have developed an institutional scorecard, with input from the board in terms of what they want to see, which is focused on safety. During that meeting, we have peer review. As part of that peer review, we delve into root cause analyses for serious safety events that require a deep dive.
Having the daily Safety Huddle is also important because leaders of the institution—right now it is the chief nursing officer, the interim chief operating officer, and myself as chief medical officer—show management at all levels the importance of safety. With 50 leaders reporting out and as many as 90 people on the call, the meeting demonstrates that all facets of the organization are important when it comes to safety.
The Safety Intelligence medical error reporting system is also important. We have done a lot of training around the SI system for reporting without blame. We want SI to be a reporting tool, not a blame tool. We have made it very easy to get into that system. It is a link within our Epic electronic health record, so all the clinical folks can just click on it, get into the system, and make a report.
Finally, you must involve the frontline staff. Getting the frontline staff involved in safety event analysis has been one of our initiatives. There is a tool that we call Apparent Cause Analysis—ACA for short. When we see the safety events that come in, some of them require a deeper dive so we can find out the causes and prevent them from happening again. This is not as deep a dive as a root cause analysis. We have about four or five ACAs per week and managers are assigned to a multidisciplinary meeting once a week to report out. We talk about the ACA and we come up with a corrective action plan.
We want to make sure that what we have learned from an ACA is getting back to the frontline staff. About three years ago, we created "ACA on the road." We do the debrief of the ACA with frontline staff. It is about a 10-minute meeting. We go over the ACA, which is presented by a nurse manager, then we talk with the frontline staff and get their input.
HL: What are the keys to success for a chief medical officer?
Allen: You must build trust and credibility. You are the bridge between the health system administration and the medical staff. You live in both domains. To play that role, you must be trusted by the health system administration and providers as well as the nurses and other departments that you are affecting.
It helps to have small wins, so people see you as trustworthy and you are set up to take on the bigger battles that are coming.
My style is to lead quietly. I like to listen and understand, then communicate based on a level of trust and credibility. I want to get things done without being flamboyant or autocratic. That is how you build trust and credibility.
It is also important to understand the electronic health record. Everybody uses the EHR for everything. We use Epic. I still maintain some clinical activity, so that keeps me grounded. It helps me appreciate the role that our information technology department and Epic plays for our providers. It also makes me appreciate any changes to the EHR.
Bon Secours Community Hospital is maintaining financial sustainability and working through a $40 million revitalization project.
Bon Secours Community Hospital in Port Jervis, New York, is bucking the trend of struggling rural hospitals.
Rural hospitals across the country are facing multiple challenges—most notably financial woes and workforce shortages. As of July 2021, the Cecil G. Sheps Center for Health Services Research at the University of North Carolina reported that 138 rural hospitals had closed since 2010.
"Rural hospitals face financial challenges. In general, rural hospitals rely heavily on government support and that adds to the challenges these hospitals are facing," says Mary Leahy, MD, MHA, CEO of Bon Secours Charity Health System, which operates three acute care hospitals including Bon Secours Community Hospital. Bon Secours Charity Health System is part of Westchester Medical Center Health Network (WMCHealth).
Rural hospitals face multiple challenges, she says.
"If we start with the people who are living in rural areas, access to rural healthcare is a major issue. When we look at how rural hospitals struggle with low patient volumes, that causes financial hardships for rural hospitals. Another challenge is keeping up with technology—making sure that we have appropriate technology so we can continue to recruit and retain young healthcare talent. When you are talking about rural hospitals, where patients have challenges with transportation and they often must travel long distances to a hospital, it makes the challenge of operating a rural hospital much greater," Leahy says.
Bon Secours Community Hospital has been able to rise to its financial challenges, she says.
"We offset low revenue predominantly with grant funding and funding opportunities through our foundation. Despite the financial challenge, we are trying to provide services so that we can keep care local. We do not want patients to feel that they must leave the area to get the care that they need. That attracts patients to come to our facility, which boosts patient volume. There are also benefits to being part of WMCHealth. They make sure that we are financially sound and can provide all of the services that are necessary to operate a rural hospital," Leahy says.
Grant funding has enabled the hospital to carry out an ambitious $40 million revitalization initiative. "We applied for a state grant and received $24.5 million. It is a $40 million project and we have been very fortunate in the grant money we have received," she says.
The rest of the financing for the revitalization initiative, which is also known as the medical village project, has come from several sources, Leahy says. "We have had other grant opportunities through various private foundations and New York State programs. We have also utilized our fundraising arm to raise money. We are also supporting the project with operations money from Bon Secours Charity Health System and WMCHealth."
The medical village project is making major upgrades to Bon Secours Community Hospital, she says. "Part of our $40 million renovation plan is expanding the emergency department to 10,000 square feet, including behavioral health areas. We have new observation areas for patients who may not need to be inpatients. We are looking at private rooms, which is important for infection control and patient satisfaction. One of the highlights of the medical village project is a brand new, state-of-the-art imaging area that we have established in partnership with Philips. Again, this will attract talent by making sure that young doctors have the tools that they need to provide care."
Committed to accountable care
Bon Secours Charity Health System has established an accountable care organization that helps Bon Secours Community Hospital provide high quality, coordinated care for Medicare fee-for-service patients, Leahy says.
"We are an accountable care organization, and we have strong care management capabilities. We have teams that focus on transitions of care and provide outreach into the community. We make sure that patients who are discharged from the hospital or discharged from the emergency department have what they need to get back to good health. We make sure they do not fall through the cracks and fail to get a follow-up appointment with a primary care provider. We make sure they have access to a specialist if necessary," she says.
Health systems and hospitals are under several pressures to increase their scale, Kaufman Hall report says.
A new report prepared at the request of the American Hospital Association (AHA) finds that there are several benefits generated from hospital mergers, acquisitions, and partnerships.
Many hospitals face challenges to maintaining their viability in a changing healthcare landscape. As of July 2021, the Cecil G. Sheps Center for Health Services Research at the University of North Carolina reported that 138 rural hospitals had closed since 2010.
Mergers, acquisitions, and partnerships are often the best strategy for hospitals to pursue to continue serving patients and communities, AHA President and CEO Rick Pollack said in a prepared statement.
"America's hospitals and health systems—and the 6 million women and men who work there—are cornerstones of their communities, and that has never been more apparent than during the ongoing public health emergency. Some hospitals have found that partnerships, mergers and acquisitions were a necessary response to a changing environment in their community and have allowed them to maintain the vital services they provide each and every day to patients and communities," he said.
The new report, which was prepared by Kaufman, Hall & Associates LLC, says health systems and hospitals are under multiple pressures to increase their scale.
Demographic and economic factors are increasing Medicare's and Medicaid's share of the payer mix at hospitals. With Medicare and Medicaid paying below hospitals' cost of care, hospitals are under pressure to increase efficiencies of scale to reduce costs and control financial losses. With increased scale, hospitals can also spread fixed costs across more facilities, which lowers per unit costs of care.
Health systems and hospitals are entering value-based contracts that are crafted to reduce total cost of care. Assuming risk requires patient populations that are large enough to diversify risk.
The ongoing shift of care from the inpatient to the outpatient setting has led to disruptive competitors such as national retail chains that do not have the high costs associated with providing acute care. Health systems and hospitals need to achieve larger scale to ensure access to capital on competitive terms. Scale also allows health systems and hospitals to attract intellectual talent.
The coronavirus pandemic has had a negative financial effect on health systems and hospitals. According to Kaufman Hall, about a quarter of hospitals had negative operating margins before the pandemic. As of the beginning of 2021, the consultancy says patient volume decreases and increased pandemic-related costs have resulted in half of hospitals operating with negative operating margins.
Legislative and regulatory changes such as site-neutral payment policies and Medicare sequester payment cuts are likely to place new financial pressures on hospitals.
The increased scale achieved through mergers, acquisitions, and partnerships drives three key benefits for hospitals and the patients and communities they serve, the new report says.
Boosting patient experience by investing in consumer-centric strategies that increase care access and convenience
Enabling value-based arrangements with payers that increase the affordability of care for patients
Helping hospitals ensure the most efficient use of resources by obtaining funds for capital improvements, innovation, and intellectual capital at favorable rates
Addressing financial struggles
A significant percentage of hospitals involved in merger, acquisition, and partnership transactions face financial peril, the new report says.
Kaufman Hall analyzed 463 hospital transactions between 2015 and 2019, with some of the transactions including more than one hospital.
About 20% of hospitals (92) cited financial distress as a primary factor in the transaction
Of those 92 hospitals, 31 of the transactions involved hospitals that had declared bankruptcy
The 31 transactions involving bankrupt organizations featured a total of 34 hospitals and only six of these hospitals have closed after the transactions
"Although not necessarily the right choice for all hospitals, partnerships, mergers, and acquisitions have been an essential tool for adapting to a changing environment. Hospitals will need continued flexibility to seek partners as they work to recover from the pandemic's impacts on their staff, operations, and financial health," the new report says.
Daniel McQuillen, MD, says the IDSA has played a leading role in the pandemic response and needs to address misinformation about COVID-19.
The new president of the Infectious Diseases Society of America (IDSA) says his organization is focused mainly on the ongoing coronavirus pandemic.
Daniel McQuillen, MD, took on the leading role at the IDSA last week. In addition to serving as president of the IDSA, he is a senior physician in the Division of Infectious Diseases at Beth Israel Lahey Health and Lahey Hospital & Medical Center, and an assistant professor of medicine at Tufts University School of Medicine in Boston.
He recently spoke with HealthLeaders about a range of issues, including his agenda as IDSA president and the role of infectious disease specialists during the pandemic. The following is a lightly edited transcript of that conversation.
HealthLeaders: What are the primary elements of your agenda as the new president of the IDSA?
Daniel McQuillen: It is obvious that the COVID-19 pandemic is not going anywhere fast. That is going to be something that our society must pay a lot of attention to. My role is to help us get through the pandemic work successfully, both for the members of the society and for our role in trying to move the country along during the pandemic.
Our board developed a five-year strategic plan in 2019, and we were all set to move forward with initiatives such as speeding up our guideline development. We also felt that we needed to spend time communicating what is valuable about having infectious disease specialists, trying to grow our workforce, making sure that we are appropriately compensated, and driving national progress on antimicrobial resistance. Those were the areas that we wanted to focus on; and when we started to dig in and get to work, COVID hit.
We had to pivot what we were doing. Since the onset of COVID, our staff, who were all heavily involved in our board's priorities, have been heavily involved in our response to the COVID pandemic. Probably 85% of their time is spent on work related to the pandemic. In addition to addressing the pandemic, we will be focusing on the workforce and compensation issues for the next 15 months.
HL: Why is the infectious disease specialist workforce a priority issue for the IDSA?
McQuillen: Over the past decade, one of the things we have had trouble with is attracting trainees. When we talked with people who had considered going into the infectious disease specialty, the number one reason they moved in a different direction was that the pay for infectious disease physicians is among the lowest of all the medical subspecialties and considerably lower than specialties where physicians do procedures. When you come out of medical school with an average debt of at least $200,000, compensation is a major consideration when selecting a specialty.
HL: How has the coronavirus pandemic illustrated the importance of infectious disease specialists?
McQuillen: Every day, you turn on the news and you see at least two infectious disease specialists—Anthony Fauci and Rochelle Walensky—talking about issues that inform how the country is dealing with the pandemic.
Personally, when we had our initial COVID patient surge here in Boston, our group of five infectious disease doctors at Lahey Hospital & Medical Center saw nearly every patient in our hospital, from March through the end of May 2020, who either had COVID or was suspected of having COVID. Like many physicians during that time, none of us had any days off.
We played a role in both diagnosing cases and figuring out treatment plans. We also developed protocols for keeping our providers safe in terms of what kinds of protective equipment they needed to wear. We are still doing that protocol work.
The IDSA and the National Institutes of Health are the two main sources of both infection prevention and treatment guidelines for COVID. We managed to get our guidelines out before the NIH did. We have been updating our guidelines whenever there is new peer-reviewed information that would impact care.
One of the big things IDSA has done in terms of messaging is that the Centers for Disease Control and Prevention came to us early in the pandemic and asked us to go into a cooperative agreement with them. That cooperative agreement involves more than a dozen other societies, and we have developed the COVID-19 Real-Time Learning Network, which is an online resource for any healthcare worker that includes links to the NIH guidelines and addresses any particular issue that COVID patients have. The learning network site is updated daily. We have IDSA members who volunteer to do that work.
In addition, the IDSA has been doing twice monthly webinars for frontline healthcare professionals—not just infectious disease doctors. These webinars typically get 800 to 1,000 viewers.
In the community, many of my colleagues have served as infectious disease consultants for organizations such as churches, school boards, and universities to help them figure out how they can get back to normal activities and keep people safe at the same time.
The infectious disease profession is central to getting our country through and out of the pandemic. Our profession is also central to looking back and seeing what things were not successful in trying to prevent the pandemic. We will be trying to figure out how we can get an infrastructure in place so that when the next pandemic comes along, we will be ready for it. That is vitally important.
HL: As the pandemic drags on, what other roles should infectious disease specialists be playing?
McQuillen: There is also another pandemic going on—misinformation about COVID on all levels. There is misinformation about the vaccines, medications, and the virus and illness itself. We feel that the IDSA is an authoritative voice to counteract the misinformation. We want to get the data out, so people can understand it.
In addition to being a reliable source of information, infectious disease specialists need to be thinking ahead to what the next pandemic is going to be. It is not necessarily going to be a virus. It could be a bacterial infection. Antimicrobial resistance is already a pandemic. Even before the coronavirus pandemic, we started to see a lot of bacteria for which we might have one or two antibiotics that are effective.
HL: Why is reimbursement reform a top issue at the IDSA?
McQuillen: The problem is that infectious diseases is a cognitive specialty. I am not doing a procedure on the patient. I am thinking about the symptoms the patient has, I am figuring out what infection the patient has, then I am helping to treat the patient by either giving an intervention such as an antibiotic, or advising the patient that they need a procedure such as getting an abscess drained. I am not draining the abscess—those procedures often get paid more than what I get paid spending an hour with the patient figuring out a diagnosis and treatment plan. The system does not reward infectious disease specialists for their work.
At the same time, we do services for our health systems and hospitals such as the response to COVID-19 that do not involve direct patient care. Those services that are non-direct patient care do not get paid well despite the positive impact that we have on hospitals and other healthcare organizations. For example, we have an impact on readmissions to the hospital within 30 days and length of stay, and the penalties on hospitals go down.
We are working on creative ideas to try to compensate us for the extra effort we are doing. It is a long battle.
HL: What advice would you offer to new physicians considering a career as an infectious disease specialist?
McQuillen: As an infectious disease physician, I get to see every kind of patient in the hospital and clinic system. I am not restricted to doing just diabetes, lung disorders, and other conditions. I see everybody.
It is an incredibly challenging field, but it is also incredibly intellectually stimulating. It is fascinating to see patients, figure things out, and make a difference in people's lives.
The new virtual primary care practice, CloseKnit, offers a full range of primary care services along with behavioral health care.
Telehealth has expanded exponentially during the coronavirus pandemic. Healthcare organizations have launched telehealth offerings in a wide range of specialties, including primary care, behavioral health, cardiology, oncology, and neurology.
Among those organizations include Baltimore-based CareFirst, which recently launched a virtual primary care practice.
CareFirst is a not-for-profit healthcare company that offers a comprehensive portfolio of health insurance products and administrative services to 3.5 million individuals and employers in Maryland, the District of Columbia, and Northern Virginia. In early September, CareFirst opened its CloseKnit subsidiary, which is a virtual primary care practice available to commercial health plan members.
"CloseKnit is a primary care practice [that] offers a full range of primary care services, including sick care, well care, and preventive care. It also has behavioral health integrated, so it has behavioral health specialists. It has insurance navigation and care coordination—those are nonclinical functions in the sense that they are not involved in the delivery of care, it is more supporting people in getting and receiving care. These are dedicated teams that work on behalf patients," says Mary Jane Favazza, MBA, CEO of CloseKnit.
CloseKnit patients will have a clinician who serves as their primary care provider. In addition, they will have a full complement of professionals who work with the PCP to help with care, including physician assistants, nurse practitioners, insurance navigators, care coordinators, and mental health specialists.
CloseKnit is designed to be patient-centric, Favazza says.
"We are trying to build true longitudinal relationships with patients by putting them at the center of care. We do a lot of research on patients, particularly with those who are not engaging in primary care. We want to know the kinds of things that are causing patients not to engage in primary care—what are the obstacles and barriers that get in their way. They talk about things such as unavailability of appointments on a timely basis, or the wrong time of day relative to their work schedules, or the difficulty of getting their mental health professional and their physical health professional on the same page working together. Patients end up having to do a lot of legwork to make that kind of coordination happen," she says.
The virtual primary care practice offers telehealth visits on a 24/7/365 basis.
"One of the top reasons that people told us it was hard to find a primary care provider who worked for them was because of the lack of evening and weekend availability. If a patient is working certain shifts, they may not have the typical 9-to-5 availability that others do. So, it was an important feature for us to create access for patients who have significant barriers to accessing primary care," Favazza says.
To be able to offer visits around the clock throughout the year, CloseKnit has hired a full-time staff of clinicians, she says.
"It is a full-time staff of MDs, DOs, physician assistants, and nurse practitioners. We do not employ a model that many others use, where we allow clinicians to sign up for available space in the system. We have dedicated, full-time employees who work for CloseKnit. We just think that works better for our model—we want to build relationships with patients, so they can see the same provider all the time. To do that, we need to have providers who are working full-time for CloseKnit—not just working at times when they have availability."
Insurance navigation and care coordination
Insurance navigation is an important service for CloseKnit patients, Favazza says. "Insurance navigation is there to support patients. For example, insurance navigators can say what the benefit allows patients to do in terms of steps that they might have to take such as whether a referral is required and who are the specialists beyond primary care that are in network who are close to the patient."
Care coordination is equally important, she says. "Care coordination includes getting appointments, getting the scheduling done, and if patients need to see someone else, that gets followed through. Care coordinators make sure that records get back to primary care—we work hard to reduce care fragmentation and make sure the PCP can know where you are in the healthcare system."
Price transparency
CloseKnit is committed to price transparency, Favazza says.
"As any provider does, we have access to information about how much a patient's set of responsibility is for any given service. We are choosing to promote the fact that we work with patients to make that responsibility visible to them, talk with them about their options, and we do that in a way that does not require a visit. Patients can chat with a navigator and say, 'What would this cost? What would the difference be if I did the service here versus there?' We are hoping that moving that conversation upfront and before things happen gives people the support that they need to make good choices and fully understand what is going to happen."
Patients have a couple of options to have conversations about the cost of services, she says. "You can ask to speak to someone straight away and you can chat asynchronously. We are trying to make ourselves as available as possible to people based on their preferences for communication."
Virtual visits versus in-person visits
At CloseKnit, whether a patient needs a virtual visit or an in-person visit is up to the discretion of the CloseKnit clinicians, Favazza says.
"Often, the providers reach a point in the conversation where a visit needs to be done physically. Some of those are easy to tell upfront such as if a patient needs a women's health exam that requires a Pap smear or pelvic examination. We know there are limits to things that can be done virtually. Then there are situations that may start as a virtual visit—there can be questions about a rash or about abdominal pain and the provider can go through the care process. If they feel that the patient needs to be seen in-person, they just make that decision and transfer the patient to in-person care."
When an in-person visit is required, CloseKnit can refer patients to clinicians who are in CareFirst's network of providers, she says. "We work with the patients to say, 'What is important to you? Is it better to be closer to home? Is it better to be closer to work?' We ask whether the patient has preferences about the type of in-person specialist that they might need to see. It can be about gender or training, whatever the case may be. We do our best to find somebody who fits the patient's immediate need."
Researchers show that rural hospital mergers result in decreased services for maternal and neonatal care, surgical care, and behavioral health care.
Mergers of rural hospitals with health systems or other hospitals can achieve financial sustainability, but the deals can be followed by the reduction of services lines that are essential to the community, a new research article says.
Adults living in rural areas are more likely to be poor, have health conditions, and have greater unmet health needs than adults in living in urban areas, the new study says. Rural communities often depend on their hospitals to provide acute inpatient care, as well as outpatient services such as routine chronic, urgent, and emergency care instead of primary care, the new study says.
The research article, which was published today by Health Affairs, focuses on 172 rural hospitals that merged between 2009 and 2016 in 32 states as well as 549 comparison hospitals. The study features several key data points.
Before the mergers, 74.5% of hospitals that merged provided maternal and neonatal services. This percentage decreased 13.4 percentage points after the mergers to 61.1%. The percentage of the comparison hospitals providing these services was stable during the merger time period (64.3% and 65.1%.)
The surgical service line decreased by 5.0 percentage points at merged rural hospitals versus the comparison hospitals.
As measured by hospital discharges, average mental health and substance use disorder volume fell by 10.4% at merged hospitals but the discharges increased 41.1% at comparison hospitals.
In examination of catchment area data, there was no lasting decline in inpatient care at merged rural hospitals, which indicates that hospital mergers did not reduce inpatient care access. "However, whereas stays for mental/substance use disorders in the catchment areas of merged hospitals remained stable from the pre to the post period (1.0% decrease), they increased by 12.4% in areas of comparison hospitals," the study says.
Interpreting the data
After mergers, rural hospitals eliminated some service lines, the study says. "This study found that rural hospitals that merged were more likely than hospitals that remained unaffiliated to eliminate certain services lines in the first and second years postmerger, specifically for maternal/neonatal and surgical care. Merged hospitals in rural areas also showed reductions in the volume of mental/substance use disorder stays, whereas hospitals that remained unaffiliated showed increased volumes."
Mergers impacted utilization of behavioral health services, the study says. "The stable trend of mental/substance use disorder discharges within the catchment areas of merged hospitals, versus comparison catchment areas where mental/substance use disorder discharges increased, suggests that communities with merged hospitals may have experienced decreased access to behavioral health care."
Although mergers can boost rural hospitals financially, the deals come at a cost to the communities that the merged hospitals serve, the study says. "Although mergers might salvage hospitals' sustainability, they do not necessarily mean that all service lines are retained or that hospitals are as responsive to community needs as before the merger. Specifically, we found that merged hospitals had reduced maternal/neonatal, surgical, and mental/substance use disorder services."
The Delta variant, which is highly transmissible, has led to a surge of COVID-19 patients across the country.
The spread of the Delta coronavirus variant put financial strain on health systems and hospitals through August, a new Kaufman, Hall & Associates LLC report says.
The highly transmissible Delta variant has led to a surge of COVID-19 patients nationwide. The surge has been accompanied by longer length of stay for patients in the inpatient setting and greater numbers of high acuity patients.
The Kaufman Hall report, which was published this week, features several key data points.
The 7-day moving average of new coronavirus cases increased 80.8% from 88,143 on Aug. 1 to 159,333 on Aug. 31, according to the Centers for Disease Control and Prevention. The 7-day moving average of new hospital admissions increased 72.3% from 7,105 on Aug. 1 to 12,243 on Aug. 31.
Hospital operating margins remained low in August. The median Kaufman Hall Operating Margin Index was 3.1% in August, not including federal CARES Act funding. With the federal aid, the operating margin index was 3.9%, which was down 11.8% from pre-pandemic levels.
Operating margins for the first eight months of 2021 were up considerably compared to the losses reported in the first eight months of 2020. Operating margin increased 83.1% year-to-date and operating EBITDA margin increased 57.1% year-to-date, not including CARES Act aid.
Key metrics for hospital volumes remained down compared to pre-pandemic levels but above 2020 levels. Adjusted discharges were down 4.8% year-to-date compared to the first eight months of 2019 but up 8.7% year-to-date compared to 2020. Emergency department visits dropped 11% year-to-date compared to 2019 but increased 7.3% year-to-date compared to the first eight months of 2020.
The average length of stay increased above 2019 and 2020 levels as hospitals experienced more high-acuity cases requiring longer hospital stays—including more severe COVID-19 cases—which also increased expenses. Average length of stay increased 7.9% year-to-date compared to 2019 and increased 4.5% year-to-date compared to 2020.
The increase in higher acuity cases boosted hospital revenues compared to both 2019 and 2020 for a sixth consecutive month. Gross operating revenue rose 9.6% year-to-date compared to 2019 and 16.6% year-to-date compared to 2020, not including CARES aid. Outpatient revenue posted the biggest increases at 10.0% year-to-date compared to 2019 and 20.3% year-to-date compared to 2020. Inpatient revenue increased 5.6% year-to-date compared to 2019 and 11.8% year-to-date compared to 2020.
Costs were higher than both 2019 and 2020 levels. Total expense per adjusted discharge increased 16.6% year-to-date compared to 2019 and 1.3% year-to-date compared to 2020. Non-labor expense per adjusted discharge increased 18.3% year-to-date compared to 2019 and 0.7% year-to-date compared to 2020. Labor expense per adjusted discharge increased 15.1% year-to-date compared to 2019 but decreased 0.1% year-to-date compared to 2020.
There is little relief in sight for hospitals this fall, the report says.
"The fall months hold continued uncertainties for hospitals and health systems. While overall cases and new hospital admissions began to taper in the first half of September, hospital officials in areas hard hit by the Delta variant said their organizations may need to ration care due to shortages in equipment, staffing, and beds to accommodate high acuity patients. With cooler temperatures coming, vaccinations waning, and increases in severe COVID-19 infections—especially among the unvaccinated—the continued pressures on the nation's hospitals are unlikely to abate anytime soon," the report says.
