The growth of urgent care visits before the pandemic continued in 2020 and 2021, an Epic Health Research Network study shows.
The coronavirus pandemic resulted in unprecedented increases in infectious disease testing and immunizations at urgent care clinics, according to a new research article.
Urgent care visits were on an upward trend before the pandemic. The new study shows that upward trend has continued during the pandemic, with the exception of a decrease in visits early in the crisis.
After dropping in the first couple months of the pandemic, urgent care visits rebounded with a dramatic increase in infectious disease testing. "This increase represented a significant change in the distribution of the types of visits seen in urgent care as testing peaked at nearly 40% of urgent care visits in October 2020," the study's co-authors wrote.
Immunizations helped to drive an increase in urgent care visits in 2021. "Immunization visits at urgent care are typically seen at small volumes, peaking at around 3% to 4% of visits in the late fall, likely due to the timing of influenza vaccinations. However, in 2021 immunization visits peaked at nearly 20% of urgent care visits in March of 2021, a five-fold increase from previous peaks," the study's co-authors wrote.
Interpreting the data
The decrease in urgent care utilization early in the pandemic mirrors the drop in utilization at other healthcare facilities, a co-author of the study recently told HealthLeaders.
"People were just not going to healthcare facilities at the beginning of the pandemic. In March, April, and May of 2020, people were not seeking healthcare for things that they would have done in the past. Patients were not going to their primary care offices and specialty visits. There was a drop in all access to healthcare during that time. We have seen this reflected in screening tests for mammograms, colonoscopies, and Pap smears—all of those tests decreased in the first three months of the pandemic," said Sam Butler, MD, a clinical informaticist at Epic Systems Corp.
The increase in infectious disease testing at urgent care clinics in the second half of 2020 was unprecedented, he said. "As soon as the COVID-19 test was available, it became a significant portion of urgent care clinics' business. Infectious disease testing went from a small amount of urgent care visits for things such as influenza and strep throat to close to a third of all visits. That was before there were home tests for COVID-19, and urgent care clinics were one of the few places you could get tested."
Similarly, immunization rates at urgent care clinics in 2021 reached levels never seen before, Butler said.
"In general, not just in urgent care, we have not seen an immunization be delivered to so many people in a short period of time, even though we still suffer from not enough people getting vaccinated. We vaccinated hundreds of millions of patients in the United States in a very short period. It was unprecedented to see so many immunizations at urgent care clinics. The increase in visits was not as dramatic as the testing increase, but it was significant. At its peak in 2021, immunizations were about 20% of urgent care visits," he said.
The most interesting part of the study was how urgent care was growing before the pandemic and has continued to grow except for the drop off in early 2020, Butler said. "We think that urgent care has its place, but primary care with a physician that knows you can be better care. So, we have to watch this trend. The care that we provide in urgent care needs to continue, but it does not replace the value of primary care. … Urgent care is well-suited to things such as acute injuries, but it would be less than best care for all of your care to be done at an urgent care clinic."
In 2021, the coronavirus pandemic has exacerbated healthcare worker burnout and the prospects for next year are bleak unless C-suite executives act.
Healthcare worker burnout has reached crisis proportions and urgent action is required to turn the tide, a national burnout expert says.
Bernadette Melnyk, PhD, RN, APRN-CNP, is chief wellness officer of The Ohio State University and dean of the university's College of Nursing. She is a nationally recognized leader on healthcare worker burnout and well-being. Melnyk has published dozens of research articles on healthcare worker burnout and well-being in peer-reviewed journals.
HealthLeaders recently spoke with Melnyk to gauge healthcare worker burnout and well-being in 2021 and the prospects for 2022. The following is a lightly edited transcript of that conversation.
HealthLeaders: Characterize the level of healthcare worker burnout in 2021? How does the level of burnout compare to the pre-pandemic levels?
Bernadette Melnyk: The levels of burnout this year have soared among healthcare professionals. The levels were high prior to the pandemic, but we have several studies that show they definitely have worsened. So, continuing problems with burnout are escalating—compassion fatigue, depression, mental distress are all super high right now.
Prior to the pandemic, you would see burnout rates on average in the range of 30% to 50%. We are seeing levels now that range from 40% to 70%. What is so disturbing about the increase in burnout is not only is it negatively impacting our population of clinicians, but we know when clinicians are burned out, depressed, and suffering from compassion fatigue it negatively impacts healthcare quality and safety.
In the nursing professions specifically, many of the nurses who were planning on working for another five years are retiring now. Younger nurses are leaving the profession—there are turnover rates between 30% and 60% in new graduates. This is creating a healthcare crisis. We do not have enough nurses now—especially in rural areas—to meet the demands. Patient-nurse staffing ratios have gotten worse, which means nurses who are fatigued and burned out are getting higher workloads.
C-suites across the country must fix system issues that we know are causing burnout, or the costs of burnout are going to be horrific.
HL: What are some of the systemic changes that the C-suite should be making?
Melnyk: There are too many tasks. There are staffing ratios that are not appropriate. One nurse taking care of 10 or 12 patients is not an acceptable ratio. Shifts are too long—my research alone in national studies over the past two years has shown that the longer the shift work the poorer the nurse outcomes and the more medical errors that are made. We must stop 12-hour shifts.
We also must do a better job with our electronic health records. It takes up way too much time and it is taking clinicians and nurses away from their patients to the point where it is taking their joy away. Most of us went into the profession to take care of people and to be with people.
These system fixes are critical, in addition to creating wonderful wellness cultures and making available great evidence-based programs to equip clinicians with resiliency skills that they need given the high rates of mental health distress that we are seeing.
HL: In 2021, characterize the impact of the pandemic on healthcare worker well-being and burnout.
Melnyk: We are losing clinicians—that is creating staffing shortages, which is putting more pressure on the ones who are still working. Because of the pandemic, our clinicians have been exposed to a lot of trauma. Many of our clinicians have watched their colleagues die from COVID-19. They have been the sole support for dying patients because of restrictions that were placed on visitation of loved ones. The past 20 months have been traumatic for many of our clinicians.
There is a mental health tsunami that is occurring among healthcare workers. In my latest study with travel nurses, not only did they report high rates of burnout and depression, but the pandemic also impacted their lifestyle behaviors. People have attempted to cope in unhealthy ways. We have seen increases in alcohol use. We have seen increases in unhealthy eating. We have seen declines in physical activity. Downstream, that is going to lead to higher rates of chronic disease, and we must be prepared for that.
HL: What are the prospects for healthcare worker well-being and burnout in 2022?
Melnyk: For the C-suites at health systems throughout the country, if they want to see this improve, they have got to fix their system issues that we know are causing problems. They also must invest in their clinicians' well-being. It is not an expense—that investment will have a huge return on investment and value for the organization.
The C-suite must recognize that unless their clinicians are mentally and physically well, healthcare safety and quality is going to be negatively impacted as well as costs and patient outcomes.
Unless the C-suite acts, healthcare worker burnout and wellness is going to get worse because the pandemic is going to continue to place strain and burden on our already compromised clinicians. They are already suffering. We must treat this urgently. This is an epidemic inside of the COVID-19 pandemic.
Although there have been efforts to raise the visibility of this issue, we have a way to go. We must treat it with urgency, or the future is going to be even more bleak.
HL: In 2022, what can health systems and hospitals do to address healthcare worker well-being and burnout?
Melnyk: First, they need to invest in appointing a chief wellness officer. Somebody must be ultimately charged with improving clinician well-being. They cannot be a title only. A chief wellness officer must be given resources to be able to improve clinicians' health and well-being.
Leaders, managers, and supervisors have got to walk the talk. They must build cultures of well-being that make healthy choices easier for their clinicians to make. Health systems need to offer anonymous screenings for their clinicians for depression and suicidal ideation. The suicide rates for physicians and nurses are higher than they are for the general population. There is still a lot of stigma surrounding mental health, including among clinicians. We must emphasize that recognizing that you need help is not a weakness—it is a strength. There is no shame in seeking help.
HL: How can health systems and hospitals create a culture of wellness?
Melnyk: At Ohio State, we take a multicomponent approach to creating a culture of wellness. We target evidence-based interventions to our top leaders, managers, supervisors, and the grassroots of the organization.
Then you must measure your outcomes. Taking an evidence-based, outcomes-management approach is important.
However, changing culture takes time and patience. In many instances, what happens is leaders do not see an immediate outcome, they get frustrated, and they give up. Culture change is not going to happen in a year or two. It takes time and it takes investment. You must get to the point where the culture is one where people feel supported because perception of wellness culture and support impacts what people feel and what they do. Our research has shown this.
HL: What kind of outcomes do you need to measure?
Melnyk: You need to measure burnout, depression, suicidal ideation, stress, anxiety, engagement, intent to leave the profession, and well-being. We measure all these things. For perceived wellness culture, we have a validated scale that we integrate into our annual personal wellness assessment. Perception of wellness culture impacts what people do and how they feel.
A code response team for agitated patients was modeled on response teams for other acute conditions such as stroke.
A team-based approach to responding to agitated patients in the Emergency Department (ED) setting can result in a significant decrease in the utilization of physical restraints, a recent journal article says.
Agitation is defined as excessive psychomotor activity that causes violent and aggressive behavior. It has been estimated that 1.7 million instances of agitated patients occur in acute care settings every year. Although use of physical restraints for agitated patients is common, earlier research has associated them with several poor outcomes, including psychological harm, physical trauma, respiratory depression, and death.
The recent journal article, which was published by Annals of Emergency Medicine, describes the design and implementation of an agitation code response team at Yale-New Haven Hospital in New Haven, Connecticut.
The agitation code response team was developed in three phases over a five-year period, resulting in a 27.3% decline in the physical restraint rate.
"With the implementation of a structured agitation code response team intervention combined with design and administrative support, a decreased rate of physical restraint use occurred over a five-year period. Results suggest that investment in organizational change along with interprofessional collaboration during the management of agitated patients in the ED can lead to sustained reductions in the use of an invasive and potentially harmful measure on patients," the co-authors of the journal article wrote.
A multidisciplinary agitation management task force was formed to oversee the design and implementation of the initiative. Members of the task force included emergency medicine physicians, nursing managers, protective services lieutenants, and ad-hoc staff members from administrative leadership, pharmacy, and patient relations.
5-part agitation code response team protocol
The agitation code response team was modeled on response teams for other acute conditions such as stroke. The protocol for the agitation code response team features five elements.
1. Activation: "Any licensed nurse or clinical provider could initiate overhead activation of the code response team if (1) patient agitation required more than one staff member to manage, (2) if there was an immediate safety risk identified related to agitation, or (3) when a notification was received from prehospital services regarding an incoming patient who may be a potential safety risk due to agitation, with approval by a senior nurse on shift," the journal article's co-authors wrote.
2. Roles and responsibilities: There are three essential members of the agitation code response team.
A senior physician or advanced practice provider serves as the team lead. This team member performs the primary patient assessment, attempts de-escalation with the patient, and assesses whether the patient requires chemical sedation and/or physical restraint.
A primary nurse monitors the patient's status, administers care, and documents in the health record.
A lead protective services officer monitors the physical safety of the patient and staff, stabilizes patient extremities if physical restraints are required, and defers to the team lead before any physical maneuvers are made on the patient, unless officers perceive an immediate risk to staff.
3. Process and workflow: "The process and workflow of the code response team provided guidelines for transporting the agitated patient immediately into one of the resuscitation bays if possible and recommendations to attempt initial de-escalation for every patient but apply physical restraints and chemical sedation if immediate danger to self or others was present. It also described processes related to written and verbal handoffs between the code team and staff receiving the patient in other care areas once the initial response ended and it was safe to transition care," the journal article's co-authors wrote.
4. Health record support: The agitation code response team protocol includes "standardized phrases for documenting decision-making and clinical course in the provider notes, nursing flowsheets and narrators, and order sets for sedation and restraint," the journal article's co-authors wrote.
5. Continuous quality improvement: "We standardized a continuous quality improvement process for the intervention with (1) regular audits and observations of responses by task force members, (2) encouragement of clinical debriefs after each response, (3) anonymous feedback from staff members through a [Quick Response] code posted in each resuscitation bay, and (4) monitoring of patient safety incident reports and charge nurse reports related to code team activations and responses. Any potential issues, areas for improvement, and sentinel cases were fed back to the task force to review and make iterative improvements during regular biweekly meetings," the journal article's co-authors wrote.
The leader of the Federation of State Medical Boards calls the increase in misinformation complaints "staggering."
State medical boards are being impacted by the dissemination of false or misleading information about COVID-19, and they are taking action to address the problem, according to the Federation of State Medical Boards (FSMB).
The spreading of misinformation about COVID-19, which has included false or misleading information from some physicians, has been a troubling aspect of the coronavirus pandemic. The misinformation has included erroneous recommendations related to treatments and vaccination.
Last week, the FSMB released data from the organization's 2021 annual survey of member state medical boards. The survey includes three key data points on COVID-19 misinformation and state medical board actions to address it.
67% of survey respondents reported an increase in complaints about licensee dissemination of COVID-19 misinformation
26% of survey respondents reported making statements about the dissemination of misinformation
21% of survey respondents reported taking disciplinary action against a licensee for dissemination of misinformation
The leader of the FSMB says the increase in complaints is alarming, and he hailed the response of state medical boards.
"The staggering number of state medical boards that have seen an increase in COVID-19 disinformation complaints is a sign of how widespread the issue has become. We are encouraged by the number of boards that have already taken action to combat COVID-19 disinformation by disciplining physicians who engage in that behavior and by reminding all physicians that their words and actions matter, and they should think twice before spreading disinformation that may harm patients," FSMB President and CEO Humayun Chaudhry, DO, said in a prepared statement.
In July, the FSMB Board of Directors issued a statement alerting physicians that they could face disciplinary action from state medical boards for disseminating misinformation about COVID-19 vaccination.
"Physicians who generate and spread COVID-19 vaccine misinformation or disinformation are risking disciplinary action by state medical boards, including the suspension or revocation of their medical license. Due to their specialized knowledge and training, licensed physicians possess a high degree of public trust and therefore have a powerful platform in society, whether they recognize it or not. They also have an ethical and professional responsibility to practice medicine in the best interests of their patients and must share information that is factual, scientifically grounded and consensus-driven for the betterment of public health," the board statement says.
The FSMB Ethics and Professionalism Committee is crafting a policy on guidelines and recommendations for state medical boards on the dissemination of misinformation by licensees. The FSMB House of Delegates is expected to vote on adoption of the policy in April 2022.
Clinical event debriefing efforts serve three purposes, linking safety, quality, and staff wellness.
Clinical debriefing efforts can drive several benefits at health systems and hospitals, according to the NYC Health + Hospitals presenters of a session at this week's IHI Forum.
The Agency for Healthcare Research and Quality provides a definition of clinical debriefing: "A dialogue between two or more people whose goals are to discuss the actions and thought processes involved in a particular patient care situation to encourage reflection on those actions and thought processes and incorporate improvement into future performance."
"Three key things stick out to me: dialogue, reflection, and improvement," said Mona Krouse, MD, patient safety officer at NYC Health + Hospitals.
Clinical debriefings are a way to capitalize on information, said Suzanne Bentley, MD, medical director of the Elmhurst Satellite Simulation Center at NYC Health + Hospitals.
"It captures reflections and gets them down with each other and why we are doing things and how we can do them differently. So, it serves to supply information. It allows us to identify knowledge gaps. It offers reflection on local culture, workforce, and team functioning, including identifying issues or struggles when they are present. Above all else, debriefing can serve as a change agent for work toward becoming a culture that has more of these conversations and more sharing so we can all come together to be better," she said.
The purpose of clinical debriefings is trifold, linking safety, quality, and staff wellness, Bentley said, adding that boosting wellness is often underestimated in clinical debriefing efforts.
"Wellness is not a hidden agenda, but it is definitely an unrecognized benefit that comes with debriefing. We should be debriefing with a lens toward wellness and how we are supporting the participants who are filtering in useful information. No one can truly engage in discussions around patient safety and around quality healthcare while they are in distress. There is literature that backs this up. … Additionally, no one can truly heal without having a safe outlet to share their ideas and their suggestions for how things could have gone differently," she said.
Debriefing not only improves patient outcomes but also improves staff outcomes, Krouse said. "Especially now during the COVID-19 pandemic, the crisis hit home for a lot of people in healthcare. Personally speaking, this has been a very tough time, and debriefing offers a space to talk about how you are feeling. In studies, debriefings have been shown to reduce stress and anxiety, improve morale, improve work satisfaction, and decrease burnout."
Overcoming barriers to debriefing
The IHI Forum session also addressed barriers to implementing clinical debriefing efforts.
For example, one of the primary barriers is the perception that it is hard to debrief in the right way, said Komal Bajaj, MD, MS, chief quality officer, Jacobi Medical Center, NYC Health + Hospitals.
"What we have learned over time is that there is not one right way to debrief. There are many published models that all have a few common themes. One is an attention to psychological safety. Two, there is some acknowledgment or solicitation of reactions. Three, there is some discussion about the case itself—what went well and what are the opportunities for improvement. Four, there are takeaways—either takeaways for the individual or takeaways for actions," she said.
Whatever model of debriefing you use, you can craft it to fit your organization, Bajaj said. "It is about picking the tool that meets your needs. As you are thinking about your clinical debriefing program, look at it as a buffet, where you are able to pick and choose formats or questions that seem to make sense for your environment. At the end of the day, we as humans are used to having conversations all the time, with our patients and with each other."
Planning for clinical debriefing programs
Before a clinical event debriefing program is established, key stakeholders and leadership should find answers to a series of questions, Bajaj said.
Who are the stakeholders who need to be engaged? "There are some powerful examples that you can share from the literature as to why debriefing can improve wellness, culture of safety, and quality. Those are powerful examples to share with stakeholders. There is a return on investment for this work," she said.
What debriefing framework works best for your environment? "It depends on what you want to accomplish. There is no one way to debrief," she said.
Who will serve as debriefing champions? "The best examples we have seen are interprofessional. Anyone can serve as a debriefing champion, but there needs to be some discussion about who will serve as a debriefing champion and what training they will need," she said.
How can you foster psychological safety? "We implemented our first debriefing program eight years ago, when debriefing was a dirty word. For the weeks and months leading up to launching our debriefing program, we asked, 'What is debriefing?' It is not meant for individual blame—it is meant for conversations. Our intention was to learn and to be better. The first couple of debriefings we had, there were only two or three people participating. … As people saw that what we talked about got fixed and changed—the idea of closed loop debriefing—debriefing began to be embedded into the culture," she said.
What clinical events should be debriefed? "It is good to start with events that are not the most serious or have the most unfavorable outcomes. You should think about the day-to-day things that can be debriefed, so those muscles are ready when there is a more challenging discussion," she said.
The Institute for Healthcare Improvement has developed five guiding principles to promote workplace equity: assess, build, commit, defend, and evaluate (ABCDE).
As part of its effort to promote joy in work at healthcare organizations, the Institute for Healthcare Improvement has adopted a framework of five guiding principles to foster workplace equity.
"When we are talking about workplace equity, one of the drivers of joy and wellbeing in work is psychological safety," says Marina Renton, MPhil, a research associate at the Institute for Healthcare Improvement. "We see workplace equity as an important component of ensuring psychological safety for staff members. Workplace equity is a vital component of their ability to find joy in the workplace and to feel safe at work. It is foundational to starting to work toward improving staff experience."
1. Assess: The first step for an organization is to assess workplace equity to gain an understanding of the gaps that exist for staff members in the particular settings targeted for improvement.
"Assessment is the first component of the framework because it is fundamental. Collecting and reviewing organizational data allows you to understand where the equity issues are at the organizational level, and that allows you to think about what changes you would like to test. You can find out whether disparities in staff experience exist," Renton says.
Organizations should stratify the data that they collect, she says. "For example, you should stratify data by racial equity in the workplace. If you just ask staff how satisfied they are with their job, and you do not look at that by race, you will get an overall picture, but you may miss disparities."
Assessment should be a collaborative effort between leadership and staff members, Renton says. "In the assessment phase, it is also important to get information on what matters to staff. What is impacting their joy in work? What aspects could be improved? This foundational data collection will allow you to make staff-centered changes that do not involve assumptions."
2. Build: Once the gaps are understood and an aim is identified, the next step is to build—to make structural changes from the top down, with engagement at all levels to prevent equity work from running into barriers.
Leadership must be actively involved in workplace equity efforts, she says. "One of the reasons it is important to make structural changes is you cannot expect staff members to take on this work or for satisfaction to improve without a clear commitment from leadership. For example, achieving equity goals is embedded into executive compensation at Robert Wood Johnson University Hospital."
Planning and allowing time for change to occur are pivotal, Renton says. "You cannot launch into this work without a clear plan and clear supports in place. The building principle includes ensuring that you are guaranteeing adequate time to addressing workplace equity."
3. Commit: Organizations need to make a concrete commitment to equity improvement initiatives through allocating financial and staff resources to the work, rather than expecting staff members to take on the work in addition to their regular responsibilities.
Commitment is a factor in ensuring that initiatives get off the ground and are sustainable, she says. "You have collected the data. You know that you want to make a change. You know you are committed to equity in the workplace. But you need to make the next step. Dedicating financial resources and staffing resources is an important piece of making a commitment to workplace equity. Without a budget, there is risk of the work stalling or being relegated to the periphery. A clear and concrete commitment is crucial."
Robert Wood Johnson University Hospital has business resource groups—affinity groups for employees with shared identities—that have executive sponsors and equity budgets to support equity at the workforce, patient, and community levels.
4. Defend: Equity intersects with principles of physical and psychological safety if there is biased behavior from patients. Organizations can enact systems and workflows to defend and protect staff members quickly and decisively.
The defend principle applies directly to workplace equity during the coronavirus pandemic, Renton says. "Tensions are running high, healthcare decisions are being politicized, and the political climate has been polarizing. So, staff members are at risk of facing instances of bias from patients."
An Annals of Internal Medicinearticle published last year lists recommendations for medical centers to address patient bias toward healthcare workers, including the following:
Creating a policy that explicitly addresses patient bias
Establishing trainee-specific procedures because they are at higher risk
Making considerations for the role of bedside nurses
Creating a mechanism for reporting patient bias toward healthcare workers and supporting staff members to use it
Designating a team to support staff and implement policies and procedures
Ensuring adequate training for confronting bias-based patient behavior
5. Evaluate: An organization's progress on workplace equity and staff wellbeing should be continuously evaluated and overseen by a board-level committee.
Every project can start with the best of intentions, but you need to make sure that the aim is being achieved, Renton says. "We recommend that this work start at the board level because that is the governing body of the healthcare organization. The charter of whatever committee is devoted to equity should include looking at equity within the workforce. Ongoing evaluation makes sure that your efforts are being directed in the right way and have the intended consequences."
Selecting metrics should be guided by the aims of workplace equity efforts, she says. "What is the organization aiming to achieve? What is the organization aiming to understand? What is the organization aiming to learn about workplace equity? Based on that selection process, an organization can determine what measures might be most meaningful and valuable to both leaders and staff in understanding equity."
For any data collected, there should be a clear plan for how the data will be used, Renton says. "That plan should be clearly communicated to the people being asked to contribute the data. Better yet, that plan should be co-designed with staff."
The president and CEO of the Institute for Healthcare Improvement predicts there will be a movement toward outcome-based measurement for health equity next year.
The IHI Forum is being held virtually this week. More than 6,000 people have registered to attend the annual event, which features more than 150 sessions and 375 presenters.
Yesterday during a press briefing, IHI President and CEO Kedar Mate, MD, and IHI President Emeritus and Senior Fellow Donald Berwick MD, MPP, discussed health equity trends for 2022.
Next year, there likely will be a movement toward outcome-based measurement for health equity, Mate said.
"There is new leadership at the National Quality Forum, with Dana Safran at the helm there. She is a patient-centered outcomes researcher. You are going to see a lot more movement toward outcome-focused measurement, and part of that will be about guidance around outcomes stratification using race, ethnicity, language, disability, sexual orientation, and gender identification. There will be guidance around how to stratify measures of outcomes on those dimensions," he said.
Stratification of health equity data likely will be a key trend in 2022, Mate said.
"With outcome-based measurement in hand, we are also going to see organizations such as the National Committee for Quality Assurance inviting healthcare organizations to start stratifying their data. So, we are going to have outcome measurement, more stratification, and encouragement from organizations that manage large measure sets such as the HEDIS measures at NCQA to use those standard definitions of what outcomes look like and how they should be stratified so that we are looking at data in a more stratified manner," he said.
There likely will be more public reporting of health equity data in 2022, Mate said. "You will see more public reporting of stratified measures particularly around race and ethnicity. We are already beginning to see that. You are going to see more health plans and other organizations publish that data going forward."
Mate expects modest progress on health equity incentives in 2022.
"I don't think we will see incentives to remediate inequities. What we will see is economic incentives to collect the data and report the data in a more transparent fashion over the next year. Two to three years out from now, we will start to see incentives from payers to provider organizations not only to collect the data but also to reward health systems for having made meaningful progress on remediating specific inequities," he said.
Berwick said federal legislation bodes well for health equity in 2022.
"The legislation that has passed in Congress and the pending Build Back Better bill have embedded in them the biggest potential progress on health equity this country has seen since the 1960s. So, a lot of the progress on health equity depends on whether Congress will end up supporting the Build Back Better bill, which has levers for health equity embedded in it. Already, we have the infrastructure bill, which has a lot in it. If these pieces of legislation are properly executed, it should be helpful," he said.
Officials in the Biden administration appear to be committed to tackling health equity, Berwick said.
"In conversations with Biden administration officials, I don't think I have had a single conversation with anyone in this administration that has not included—and often led with—the pursuit of health equity as a priority. President Biden is walking the talk on health equity. The optimist in me wants to say that we will be seeing progress. … I am excited by the policy initiatives we are seeing coming out of this administration," he said.
Data analysis finds the male-female gender pay gap for physicians accelerates in the first 10 years of practice.
Through a simulated 40-year career, male physicians earn an average adjusted gross income that is about $2 million higher than female physicians, a new study found.
Earlier research has shown a persistent gender pay gap in physician compensation. Other recent research indicates that bias impacts job satisfaction for female physicians and medical researchers.
The new study, which was published today by Health Affairs, is based on data collected from more than 80,000 full-time physicians. Physician characteristics and annual income data were collected from Doximity, an online professional network for physicians. The study includes data collected from 2014 to 2019. Income was adjusted for factors that could impact compensation, including hours worked, clinical revenue, practice type, and specialty.
The study features several key data points.
On average, male physicians had higher income ($42,454 difference) than female physicians in the first year of practice. The gender pay gap increased in the first 10 years of practice then remained stable thereafter. On average, male physicians earned $90,298 more than female physicians in the 10th year of practice.
In the first year of practice, the gender pay gap was similar for primary care and other specialties: the adjusted income difference between male and female physicians was $18,245 for primary care, $19,150 for nonsurgical specialties, and $21,999 for surgical specialties. By the 10th year of practice, the gender pay gap by specialty had widened: the adjusted income difference between male and female physicians was $30,245 for primary care specialties, $38,611 for nonsurgical specialties, and $54,777 for surgical specialties.
For physicians overall, the 40-year simulated career income for male physicians was $8,307,327 and $6,263,446 for female physicians, for a difference in adjusted income of $2,043,881. The career gender pay gap was lowest for primary care physicians ($917,851) and highest in surgical specialties ($2,481,622).
Several factors likely contribute to the gender pay gap, the study's co-authors wrote.
"Gender bias on the part of employers, structural sexism, compensation models that disadvantage female practice styles, and different expectations of female physicians may be important drivers of the gender differences in income that were observed to start early in women's careers and remain elevated over time. In addition to these more traditional explanations, other explanations may be needed to account for the fact that the gap in salary between male and female physicians widens in the first decade of practice. One possibility is that female physicians are less willing or able to change jobs or practices, limiting their bargaining power for a raise," they wrote.
The study's co-authors offered an explanation for why the gender pay gap accelerates in the early years of practice.
"The observed early acceleration of gender differences in income occurs at a time when many female physicians bear a disproportionate burden of domestic and family responsibilities, such as childrearing, or are facing fertility challenges including fertility treatment. Similar income trajectories have been observed for other highly trained professionals. In these other settings, policies such as family leave provisions and broader coverage of childcare have been linked to reduced gender differences in income," they wrote.
Several mitigation strategies could address the gender pay gap, the study's co-authors wrote.
"Increased salary transparency, protections via laws such as the Massachusetts Equal Pay Act, and systematic measurement and reporting of gender differences in income by organizations could help lessen income differences between female and male physicians. To the extent that gender differences in income early in women’s careers persist throughout their careers, policies that eliminate those differences early on may lead to reduced differences over time as well," they wrote.
The strongest negative predictors of workplace satisfaction among female physicians and researchers were male-dominated culture, lack of sponsorship, and lack of mentoring.
Gender biases negatively affect workplace satisfaction for female physicians and researchers at academic health organizations, a new research article indicates.
Earlier research has established the existence of gender bias against female healthcare staff members. For example, bias experienced by women in medicine includes harassment and discrimination as well as gender wage gaps.
The new research article, which was published by Advances in Health Care Management, is based on survey data collected from nearly 300 women working in medicine. The organizations where the women worked included academic medical centers in 19 states.
The study features several key data points.
The strongest negative predictors of workplace satisfaction were male-dominated culture, lack of sponsorship, and lack of mentoring.
"Queen bee syndrome," in which women are targets of aggression from other women in leadership positions, was also associated with workplace dissatisfaction.
Survey respondents reported the highest degree of agreement about constrained communication. "Most notably, women in our sample reported being mindful of their communication approach when exercising authority (96%); downplaying accomplishments (89%); and exercising caution when self-promoting (87%). Similarly, 68% of participants reported being interrupted by men while speaking," the study's co-authors wrote.
Survey respondents reported several gender gaps. "Women in our sample also reported having to work harder than male colleagues for the same credibility (70%); that decisions in their organization are made by men (61%); and that they have made less money than their male counterparts (66%)," the study's co-authors wrote.
With the number of women enrolled in medical schools exceeding the number of men, addressing gender bias in medicine should be a priority, the co-authors wrote. "As more women enter the field of medicine, identifying and eliminating gender bias is vital to reducing its harmful effects on the personal lives and career trajectory of these women as well as the industry as a whole."
Addressing gender bias
Healthcare organizations can take several steps to mitigate gender bias, the co-authors wrote:
"Institutions should first endeavor to assess bias against their women employees. Using the assessment data on aspects of bias present in their organizations, managers should conduct an inventory of structure, hierarchy, and processes to determine where points of inequity reside."
"To address male culture, institutions should ensure equity in decision-making, alter promotion policies, adjust meeting schedules, restructure the role of the chair, and improve reporting relationships. Organizations will benefit by developing formal career pathways early in the onboarding process and developing communication channels that celebrate achievements of women and men equally."
"By focusing on lack of mentoring and lack of sponsorship, leaders should implement targeted initiatives that support women through formal mentorship as well as advocacy and sponsorship activities while attenuating men's fear or apprehension of mentoring women. Leaders who mentor and sponsor junior women should be rewarded."
"Organizations should communicate clearly that queen bee behaviors will not be tolerated and create safe reporting mechanisms for victims."
Despite its power and pervasiveness, there are practical steps institutions can take to mitigate the impact of male-dominated cultures on female physicians and researchers, the lead author of the study, Amber Stephenson, PhD, MPH, associate professor of healthcare management at Clarkson University, told HealthLeaders.
"Leaders of academic health science environments should first publicly acknowledge the existence of gender bias to begin to challenge deeply established—yet inequitable—social norms. Openly rejecting male-dominated social norms sends a clear message that such practices are not endorsed. Organizations should engage in a deep and honest assessment of the prevalence of male-dominated culture within divisions and departments. Academic medical centers can analyze organizational structures to identify unbalanced power within the hierarchy and assess the representation of women in leadership. They can safeguard equitable decision-making through the establishment of formal processes that include broad stakeholder groups and standardize processes for hiring and promotion," she said.
A lack of women to serve as mentors should not stop organizations from creating and supporting mentoring opportunities for women, study co-author Leanne Dzubinski, PhD, interim dean at the Cook School of Intercultural Studies at Biola University, told HealthLeaders.
"Organizations can sponsor formal mentoring programs for women and find creative ways to support and encourage informal mentoring relationships. Something as simple as providing a monthly lunch meeting to discuss professional development can be highly effective. Additionally, mentoring can happen one-on-one or in small groups. And those relationships could be formally organized or could be encouraged to develop organically through affinity groups such as research support groups. Finally, women can benefit from female mentors who have successfully navigated issues unique to women. Male mentors can also be beneficial as they may have better access to institutional knowledge and resources, and they may be better positioned to act as a sponsor," she said.
There are several ways that organizational leaders can help female physicians and researchers be heard and acknowledged, study co-author Amy Diehl, PhD, chief information officer at Wilson College, told HealthLeaders.
"First, help women with self-promotion by soliciting reports of their achievements and by naming and celebrating accomplishments in meetings and other public forums. Second, to combat interruptions, meeting organizers can set a 'no interruptions' rule for meetings. When interruptions happen, the facilitator should intervene: 'Julie was speaking, let's let her finish her thought.' Last, train your entire staff on bystander interventions. For example, when women are ignored or their ideas are stolen, meeting facilitators and bystanders can help by calling it out: 'Aisha just mentioned that idea, let's hear her thoughts,'" she said.
HealthLeaders talked to several health system and hospital executives who identified three primary challenges in their behavioral health programs. They struggle with inadequate reimbursement for behavioral health services, patient access, and workforce shortages of psychiatrists and other behavioral health professionals.
Sabina Lim, MD, MPH, system vice president for behavioral health safety and quality at Mount Sinai Health System in New York, says inadequate reimbursement has far-reaching consequences. "One of the biggest challenges is the lack of appropriate reimbursement for behavioral health services. In many ways, this challenge drives a lot of the other issues. Most behavioral health providers are under-reimbursed. That affects the ability to attract workforce, which affects access issues."
Wayne Sparks, MD, senior medical director of behavioral health services at Atrium Health, says meeting the demand for patient access is a daunting challenge. "For us, the biggest challenge is access for patients to get care. We know there are many people dealing with mental health issues, and that has been on the rise even before the pandemic. One in five American adults have a diagnosed mental illness, and about half of those with chronic mental illness start before the age of 14. So, we are trying to do more to provide screening and access."
The shortage of psychiatrists is acute, he says. "There is a shortage of about 25,000 psychiatrists in the country. An amazing stat is that about 60% of practicing psychiatrists are over the age of 60. That is a frightening stat."
Behavioral health nurses are also in short supply, says Christian Thurstone, MD, director of behavioral health at Denver Health. "On the inpatient side, there are staffing shortages particularly with respect to nurses. We have 57 beds on the adult side, and our average daily census for the year is at about 41, but that is only because of staffing. If we were fully staffed, we believe we would fill all 57 beds every day. The challenge of hiring nurses and retaining them has been considerable and has limited our census."
While these challenges exist, the health system executives also shared insights about how they solved these three top issues at their organizations.
Address inadequate reimbursement
A primary strategy to address inadequate reimbursement of behavioral health services is subsidization, says Doug Henry, PhD, vice president of the Allegheny Health Network Psychiatry and Behavioral Health Institute.
"What we do is rely on the generosity of our network and our enterprise, which is Highmark Health. AHN and Highmark recognize that underdiagnosed and undertreated mental health disorders are a great burden on the community. They contribute negatively to overall medical spend and community unwellness. Our health system is willing to accept losses in behavioral health for a larger cause, which is community wellness. It is both good business for the health network and good dedication to the community," he says.
Lim says subsidization is critical to keep Mount Sinai's behavioral health programs running. "We need to continue to be subsidized because our health system is heavily invested in behavioral health. They believe it is the right thing to do. Behavioral health needs keep growing and growing. So, the health system is invested, but it puts pressure on other parts of the health system. We have about a $200 million budget. We are close to meeting our direct costs, but the indirect costs are subsidized substantially."
Subsidization is necessary because patient revenue does not cover the costs of all behavioral health services, Sparks says. "We do get subsidy from the overall system because if we only relied on patient revenue, it would not cover what we are doing."
Even in a good financial year, subsidization is required, says Thurstone.
"As a department, we are typically budgeted to lose about $4 million. This year, we will lose much less than that. I attribute a lot of this performance to the increase in telehealth and the increase in demand. For example, our outpatient visits are up 30%, and we attribute that to COVID and telehealth, which leads to fewer no-shows. Our inpatient child unit has been running at capacity because of COVID demand. We are not making money for the hospital system, but we are losing a lot less money than we were budgeted to lose. We were budgeted to lose about $4 million, and we will probably lose about $1.5 million," he says.
Optimizing revenue cycle helps to ease financial losses in behavioral health programs, Lim says.
"Behavioral health finances are complicated—they are often paid under different payment systems. We have many codes that are difficult, and there is a tremendous variation in the types of codes. So, we have worked over the past eight years to dive deeply into revenue cycle. We have decreased our inpatient denials and outpatient denials by huge percentages. We have focused heavily on how we can make sure that we are correctly sending out our bills and making sure that we appropriately advocate and fight for all inappropriate denials. The revenue cycle work has been tremendously helpful for us not only to increase our bottom line but also to think about how we do work and how we do work more efficiently," she says.
Behavioral health programs can also address financial losses by cobbling together sources of financial support, Henry says.
"As administrators, we hustle hard to braid public and private financing. This includes grants from the federal government, grants from the counties, and grants from the state. We combine these grants with private funding, which includes foundation funding such as private foundations that support programs in the schools. We braid these funds with third-party insurance revenue in ways that allow us to build sustainable programs," he says.
Philanthropy is a significant source of financial support for behavioral health services at Denver Health, Thurstone says. "We have gotten several private foundation grants recently to expand services related to infant mental health and substance treatment. Everybody seems to be talking about behavioral health. It is a hot topic, and that has created some philanthropy dollars that have helped us expand as well as cover some of the financial gaps. These grants have been about $2 million over the past two years."
Grant funding and philanthropy have bolstered the finances of Atrium Health's behavioral health services, Sparks says.
"Financially, we have been able to leverage our ability to get some innovative programs started with grant funding. There has been a snowball effect with one of our funding sources—The Duke Endowment. It seems that once you get a good program going, they want to hear more. This is how we got a virtual patient navigation program started. When we get programs started with grant funding, we can share our data with our overall organization, show benefits, and get the support to continue. We also rely on philanthropy. Our foundation has been successful getting donations from the community. We recently got a $350,000 donation from a former patient's family because of their experience and how well the patient did," he says.
Financial losses at behavioral health programs need to be viewed through a broad lens, says Ruth Benca, MD, PhD, professor and chair of the Department of Psychiatry at Atrium Health Wake Forest Baptist.
"The big picture is about the overall medical spend. It is not just about what psychiatry can do to make money. It should be about how we can provide cost-effective mental healthcare that is going to improve the overall health of our population. We know that poor mental health contributes to poor physical health and disability, and that is what is costing us billions and billions of dollars," she says.
Behavioral health programs reduce the total cost of care at health systems, Sparks says.
"As an organization and as a service line, rather than focusing on the revenue bottom line we have tried to focus on how the behavioral health program fits into the larger health system. In an organization like ours, we have been focusing as much as we can in moving toward a population health model and value-based model. We know that you really cannot do a population health model without significant behavioral healthcare. We have tried to look at finances in that way—not looking at how much behavioral health is bringing in but how much we are able to lower the overall cost of care for patients," he says.
Improve patient access
A primary strategy for addressing patient access is integrating behavioral health into specialty practices—particularly primary care, Henry says.
"We put behavioral health professionals and psychiatrists into primary care practices and other medical subspecialties. We began doing that in 2019 and have just completed our 75th integrated practice. So, just in the past couple of years, we have added 75 new access points for behavioral health services in Western Pennsylvania. Fifty of those sites are primary care practices, and 25 are other medical subspecialties such as pain, neurology, endocrinology, gastrointestinal, orthopedics, and oncology," he says.
Integrated behavioral health can be achieved by utilizing social workers, says James Kimball, MD, a psychiatrist at Atrium Health Wake Forest Baptist. "Essentially, we are reaching out to primary care practices through a social worker. The social worker is doing some basic counseling with patients and doing depression and anxiety ratings scales. A psychiatrist will supervise them and advise the primary care clinician on possible medication options for the patient in a way that can better manage depression and anxiety."
Atrium Health has established a virtual behavioral health integration program, which operates in about 60 of the health system's 200 primary care practices, Sparks says.
"The primary care provider can connect with our team virtually, and a licensed clinician will evaluate a patient in the office at the time of the primary care visit. Then patients can connect with services through our program. The primary care clinician can connect on the spot with a provider such as a psychiatrist or an advanced practice provider to get recommendations for any medications or any revisions of medications," he says.
The virtual behavioral health integration program has performed well on key metrics, Sparks says. "We have had a significant decrease in patients coming to our emergency department and going into the hospital because of this program. It has been about a 25% reduction in avoidable inpatient stays and about a 13% reduction in emergency care."
Opening new facilities is another strategy to address patient access.
Mount Sinai is planning to open a new comprehensive behavioral health center in Lower Manhattan next year, Lim says. "We basically are creating a wide continuum of behavioral healthcare in one building. We will have inpatient services, intensive outpatient services such as partial hospitalization, and crisis and respite beds where people can stay seven days a week if they are experiencing a behavioral health crisis."
Mount Sinai is also set to open a new behavioral health ambulatory center in Uptown Manhattan that will include adult and child psychiatry clinical services as well as a partial hospitalization outpatient program, she says.
The metrics for evaluating the new facilities will include the impact on psychiatric hospitalizations and quality-based measures such as suicide prevention, Lim says. "It is extremely difficult, but we are always aiming for zero suicides. We will also be looking for decreased no-shows and increased visits."
AHN is opening several community mental health centers, says Henry.
"Our approach is neighborhood-centric. That is harmonious with Allegheny Health Network's overall strategy of serving neighborhoods instead of building large medical centers in urban areas. We heat-mapped the points of most frequent origination for more acute psychiatric needs. We did this by ZIP code, and we dropped outpatient and intensive outpatient behavioral health clinics into regions that had the highest frequency of need. We have opened three clinics in the past year using that methodology. We will open three more clinics next year, and we will open three more in 2023," he says.
Shore up workforce shortages
Compensation is a primary strategy to address workforce shortages, Henry says.
"Several years ago, we designed a new compensation plan that set a productivity target for our physicians. Beyond that productivity target, physicians can keep 100% of the average net revenue that we bring in for their efforts. For example, if somebody has a large student loan burden, they can work a little extra and it absolutely gives them an opportunity to make more money," he says.
Allegheny Health Network has also raised base compensation for psychiatrists, says Anthony Mannarino, PhD, vice chair of the AHN Psychiatry and Behavioral Health Institute. "Our base compensation for psychiatrists has risen over the past five to six years. Ten years ago, it was much lower than it is now. We have tried very hard to look at the benchmarking standards to make sure that our base salary is as competitive as possible to recruit and retain physicians."
At AHN, a base salary is about $225,000 for an outpatient psychiatrist and $240,000 for an inpatient psychiatrist, Henry says.
Denver Health is looking for ways to decrease pressure on nursing resources, Thurstone says. "I have asked my team about whether anyone has seen other staffing models that utilize licensed practical nurses or behavioral health technicians to the maximum of their potential. I also have asked whether there is a way to protocolize care on our inpatient units so that we could utilize behavioral health technicians more. I am looking for staffing models that are not as heavily dependent on registered nurses."
Atrium Health Wake Forest Baptist has adopted a team approach to behavioral healthcare to address staffing shortages, Benca says. "One of the ways that we are addressing not having enough psychiatrists is developing treatment teams. The idea is to have several mental health providers all working up to the highest level of their license. By having teams that include nurses, mental health workers, psychologists, social workers, and psychiatrists, we can start to provide different levels of care to patients and move them up the ladder as needed. It also allows us to provide more cost-effective care to patients."
Atrium Health is trying to boost its number of clinicians through internal training, Sparks says.
"Five years ago, we started a residency program, so we are trying to build our own pipeline of residents. We also have built an advanced practice provider fellowship. This is for nurse practitioners and physician assistants who have finished their training but have decided that they want to focus on behavioral health and psychiatry. They come for a year with us as a fellow. They are employees, so they see patients with guidance similar to a residency program. Over the eight years of the program, we have retained 75% of the fellows to be a part of our workforce," he says.
There is a key metric for staffing success, Sparks says. "It is mainly the ability to keep our programs going. If we can keep our programs fully staffed and move to a point where we can expand services, then we feel we have been successful."
