In 2020, less than half of doctors worked in a practice wholly owned by physicians for the first time, according to American Medical Association data.
The historical shifts toward larger physician practices and away from physician owned practices accelerated between 2018 and 2020, according to a new American Medical Association data report.
Once a mainstay of the U.S. healthcare system, small physician practices are dwindling in number. In addition, the number of physician practices owned by hospitals or health systems is on the rise.
The new AMA data report is based on information collected in the organization's Physician Practice Benchmark Surveys. The surveys are nationally representative and collect data from post-residency physicians who provide at least 20 hours of patient care weekly. The surveys have been conducted every other year since 2012.
The new report includes several key data points:
In 2020, 49.1% of physicians worked in a private practice, marking the first year that less than half of doctors worked in a practice wholly owned by physicians. In 2018, 54.0% of physicians worked in a private practice. In 2012, 60.1% of physicians worked in a private practice.
There has been an ongoing shift from physicians owning practices to physicians working as employees. In 2020, 50.2% of physicians were employees. In 2018, 47.4% of physicians were employees. In 2012, 41.8% of physicians were employees.
Gender and age are correlated with the likelihood for a physician to be employed, with female doctors and younger doctors more likely to be employed than male doctors and older doctors. In 2020, 56.5% of female doctors were employed compared to 46.7% of male doctors. In 2020, 70.0% of doctors under age 40 were employed compared to 42.2% of doctors who were 55 and older.
The percentage of physicians working in small practices has fallen steadily. In 2020, 53.7% of physicians worked in practices with 10 or fewer doctors. In 2018, 56.5% of physicians worked in practices with 10 or fewer doctors. In 2012, 61.4% of physicians worked in practices with 10 or fewer doctors.
The percentage of physicians working in large practices has been rising. In 2012, 12.2% of physicians worked in practices with at least 50 doctors, with the numbers increasing to 14.7% in 2018 and 17.2% in 2020.
Interpreting the data
Physicians appear to be shifting from private practice to working at hospitals and health systems, the AMA data report says. "As the number of physicians in private practice has fallen, the share of physicians who work directly for a hospital or for a practice at least partially owned by a hospital or health system has increased, changing from 29.0% in 2012 to 39.8% in 2020."
There is an established trend of fewer physicians owning practices and more physicians working as employees, the report says. "The changes between 2012 and 2020 reflect the continuation of a longer-term shift from physicians as practice owners to physicians as employees of practices or of other organizations."
There are several possible ways that physicians have shifted to larger practices and practices owned by hospitals or health systems, the report says. "These include mergers and acquisitions among practices (or acquisition of a practice by a system), practice closures, physician job changes, and new physicians entering practice in settings different than those from which retiring physicians are leaving."
Horizon Blue Cross Blue Shield of New Jersey is targeting members with high social determinants of health needs.
Horizon Blue Cross Blue Shield of New Jersey is operating an ambitious social determinants of health (SDOH) program for targeted members in partnership with several healthcare provider organizations.
Social determinants of health such as food security and transportation are believed to have much more impact on a person's health status than clinical care. Healthcare providers have pursued two primary strategies to address SDOH: direct investment in social determinant programs or SDOH partnerships.
In April 2017, Horizon launched a pilot SDOH program in partnership with West Orange, New Jersey-based RWJBarnabas Health. The pilot program targeted about 1,000 Horizon members in four Newark zip codes. "They were high-cost members who were identified through predictive modeling. We built a community health worker model. Then we measured the impact after two years, both on cost of care and the health status of the members," says Allen Karp, MBA, executive vice president of healthcare management and transformation at Horizon.
The pilot program achieved a 25% reduction in total cost of care. "Those members were utilizing emergency rooms, they were being admitted to hospitals, they were being readmitted, and they were running up significant costs. They were not well-connected to the healthcare system—nobody was coordinating care for them," he says.
In April 2020, Horizon launched an expanded version of the pilot program called Horizon Neighbors in Health. The program includes 10 partners. Eight of the partners are healthcare provider organizations, including four of New Jersey's largest health systems—Atlantic Health System, Hackensack Meridian Health, RWJBarnabas Health, and St. Joseph's Health. The two other partners are Penn Medicine for community health worker training and NowPow, which features an online platform that can connect people with community-based resources.
How Horizon Neighbors in Health works
The Horizon Neighbors in Health program has five essential components, says Valerie Harr, director of community health for Horizon.
1. Community health workers: About 40 community health workers have been hired to work in the Horizon Neighbors in Health program. Horizon's healthcare provider organization partners recruit and hire the community health workers and Horizon pays for half of the salary cost.
"Community health workers are recruited from the local community. If we are working with St. Joseph's, the community health workers live in Passaic and Patterson. Resumes and degrees are not as important as being a trusted member of the community. Candidates need to understand the needs of the community and have the ability to connect with individuals," Harr says.
The community health workers are advocates for the members who are served by the Horizon Neighbors in Health program, she says. "People are often reluctant to ask for help. But if someone approaches them who is a neighbor, who speaks their language, and who looks like them, then they may open up. The community health worker is responsible to help identify the goals of the member and to make community connections."
The original plan for the community health workers was for them to have face-to-face interactions with members, but the coronavirus pandemic necessitated shifting to telephonic contact with members.
2. Screening: Community health workers screen targeted Horizon members for nearly two dozen SDOH. "These community health workers have conversations with our members—they build a rapport with members while going through the screening tool," Harr says.
3. Geographic approach: Horizon has used U.S. Census data to target members in communities with high SDOH needs, she says. "Horizon's footprint is nearly statewide, but Horizon Neighbors in Health is not yet in every county. We are in 15 counties and more than 120 zip codes. That is intentional. We are targeting the communities with the members who have the most need."
4. Personal health assistants: Horizon has hired and fully funded four personal health assistants to support the community health workers, Harr says. "They each have a provider partner that they are responsible for, and they have daily huddles with their respective partners to troubleshoot issues that community health workers are encountering. The personal health assistants can connect members with resources such as care management or our behavioral health team. They also troubleshoot issues around pharmacy."
5. Data analytics: "Working with McKinsey & Company consultants, our analytics team has built multiple predictive algorithms using claims data, consumer purchasing data, Census data, and other SDOH data to zero in on the members who can benefit most from having a community health worker engage with them," she says.
Emphasis on community resources
The primary goal of the Horizon Neighbors in Health program is to connect members with SDOH needs to community-based resources, Harr says.
"NowPow is known for having connections to community resources. In New Jersey, they have more than 20,000 community organizations loaded into their platform. When a community health worker engages with a member and identifies needs through the screening process, NowPow identifies the potential community resources for that member. For example, if a member has food insecurity, NowPow can identify a food pantry in that person's neighborhood," she says.
In some cases, Horizon pays to meet a member's SDOH needs, Harr says. "We do have funding set aside as part of the Horizon Neighbors in Health program to be able to pay for short-term assistance that may not be available through a community resource. For example, we had a member living on the second floor of a home with a broken chair lift. She had been crawling up and down her stairs. So, we paid for the installation of a new chair lift."
Metrics and mission
Horizon expects to have data that measures the impact of Horizon Neighbors in Health next month. The data will include several metrics, Harr says.
Process metrics such as how many members are reached, needs that are identified, and referrals
Excess spend, which is defined as avoidable emergency room visits and inpatient admissions
Total cost of care
Qualitative metrics related to chronic conditions
Pharmacy utilization
"Ultimately, for us to see whether we are having an ROI, we must engage a large enough pool of members and reduce excess spend. That will get us the ROI," she says.
A recently published progress report on the Horizon Neighbors in Health program includes three key data points through December 2020.
More than 2,500 Horizon members were enrolled in the program
The Top 3 needs identified were financial stability, access to basic healthcare, and food insecurity
The Top 3 referrals were food pantries, utility payment assistance, and rent and mortgage assistance
Horizon is dedicated to addressing SDOH, Karp says.
"We are committed to solving disparities in healthcare and underserved communities in New Jersey. We cover not only commercial members but also more than a million Medicaid members and a significant share of the individual insured market. We want to ensure that our members have appropriate access to care, so they can achieve their best health. Many members face a lot of barriers to care because of where they live such as lack of transportation and housing," he says.
The health system is expanding its virtual care services from the acute care setting to urgent care.
Dartmouth-Hitchcock Health (D-HH) has partnered with MDLIVE to offer virtual urgent care visits.
The virtual urgent care market is well established, with MDLIVE and several competitors in the space such as Teledoc, Doctor On Demand, and Amwell. Urgent care and behavioral health are two of the most common telemedicine services.
Launching D-HH Virtual Urgent Care is a logical and strategic step for the Lebanon, New Hampshire-based health system, says Mary Lowry, MBA, administrative director of Dartmouth-Hitchcock Connected Care. "At Dartmouth-Hitchcock, we started growing our telemedicine portfolio of services in the acute care space. We have launched virtual urgent care to round out our telemedicine portfolio."
D-HH Virtual Urgent Care, which launched on March 15, utilizes the MDLIVE telemedicine platform and offers visits via video or telephone. The service provides treatment for dozens of common conditions, including upper respiratory illnesses, allergies, rashes, bug bites, gastrointestinal maladies, and urinary tract infections. The service, which is offered 24/7 year-round including weekends and holidays, is available to anyone in any state or U.S. territory.
D-HH and MDLIVE physicians are staffing the service, says James B. Ebert Jr., MD, medical director of D-HH Virtual Urgent Care. "We have a core team of 14 Dartmouth-Hitchcock emergency medicine physicians who are all board certified and have a long history of telehealth experience. That core team provides the bulk of the service, but we also have our MDLIVE partnership that provides additional physician coverage when it is needed."
The physicians can prescribe medications and send prescriptions to a pharmacy of a patient's choice.
D-HH Virtual Urgent Care is designed to be convenient for patients, Lowry says. "There are a couple of different options. The patient can say that they want to see the next available provider, or they can schedule their visit for later in the day. Patients can also choose a provider from a list of who is available. It is all handled by the software, so we can ensure there is a smooth opportunity for patients to be seen without a long wait. The average wait for a virtual urgent care visit is about 10 minutes."
The fee for a D-HH Virtual Urgent Care visit is $49 for D-HH employees and dependents who are on the health system's insurance plan and $59 for other patients. "We based our fee on the lower end of the market price. We have a slightly lower rate for our employees who are on our health plan, and we didn't want there to be too much of a difference between the fee for our employees and the fee for other patients," she says.
At this point, the fees are self-pay, Lowry says. "We are working toward being able to accept and process insurance payments; but for now, we are leaving it up to patients to identify with their own health insurance plans whether the virtual urgent care visit is covered. Patients can use a debit card, credit card, and healthcare spending account card."
For patients with D-HH primary care providers, virtual urgent care visit notes are shared electronically with the PCPs. For other patients, visit notes can be shared with PCPs via e-fax.
Virtual urgent care best practices
There are several best practices for providing virtual urgent care visits, Ebert says.
Technology plays a significant role, he says. "If it is a video visit, having high-quality visualization of the patient is very important. Audio is also a factor—being able to clearly hear the patient is very important."
Clinicians should conduct virtual urgent care visits in a space that is quiet, free of distractions, and capable of maintaining patient confidentiality, Ebert says.
Physician engagement with the patient is essential, he says. "Even though you are not able to physically reach out and touch the patient, the engagement process and establishing rapport with the patient in an environment of trust and empathy is very important. That comes mainly through eye contact and tone of voice, which allows the clinician to gain a better capability to get a comprehensive history from the patient and ultimately leads to a diagnosis."
Open and honest communication builds trust, Ebert says.
"The clinician needs to be direct with the patient and to be honest about impressions of the case. With a health complaint, the clinician should create a differential of what the possibilities are. You need to be open. You need to clearly voice what you believe to be going on or what you do not know to be going on. Then you need to guide the patient to the appropriate resources if the case is beyond the scope of what you can do through telehealth."
WMCHealth shares the keys to success in the Hudson Valley's effort to vaccinate people as quickly as possible.
In New York State, health systems have played a pivotal role in coordinating the distribution and administration of coronavirus vaccines.
The coronavirus vaccination effort is one of the most ambitious public health campaigns in U.S. history. A primary goal of the effort is to achieve herd immunity, which would make the spread of coronavirus unlikely. Anthony Fauci, MD, President Biden's chief medical advisor, has said 70% to 85% of the U.S. population needs to be vaccinated to achieve herd immunity.
New York State designed its vaccination efforts by dividing the state into 10 regions, and each of the regions was assigned a vaccination hub. For example, in the seven-county Hudson Valley region, Westchester Medical Center Health Network (WMCHealth) is the administrator of the vaccination hub. In Long Island, Northwell Health is the administrator of the vaccination hub. In the Albany region, the hub administrator is Albany Medical Center.
The vaccination hubs are key players, says Josh Ratner, MPA, executive vice president and chief strategy officer at Valhalla, New York-based WMCHealth.
"Each hub was asked to put together a vaccination plan on how we would approach vaccine distribution and equity in our regions. After that plan was submitted, our primary purpose was to be the command and control as well as logistics coordinator for our regions. That includes a wide range of responsibilities except for making vaccine allocations—who gets how much vaccine is determined by the state," he says.
The Hudson Valley vaccination hub recently passed the 1.3 million mark for vaccine dose coordination, Ratner says. Vaccine dose coordination, which applies to first and second doses, includes the following activities:
If there is a provider who has too much vaccine and a provider who does not have enough vaccine, the vaccination hub redistributes the vaccine
Ensuring that nursing home staff and residents receive enough vaccines
Fielding hundreds of calls from providers who have had questions about eligibility criteria, documentation requirements, and scheduling based on New York State guidelines
Targeting Zip codes that fall below state averages for first-dose vaccinations—the vaccination hub can coordinate with provider partners to establish pop-up vaccination sites in particular Zip codes
Weekly and bi-weekly meetings with country health departments and county executives
When providers want to transport vaccine from one location to another, those requests are routed through the vaccination hub for approval
"At WMCHealth and the Hudson Valley hub, we monitor vaccine administration, and we ensure that there is regional planning, including redistribution of vaccine. That means we effectively make sure that no dose gets wasted and as many shots in arms happen as quickly as possible," Ratner says.
Promoting collaboration and health equity
WMCHealth has led the effort to form several groups to support the distribution of vaccine in the Hudson Valley region, including a provider workgroup, regional task force, and health equity task force.
The provider workgroup includes any organization that has been approved by the state Department of Health to be a vaccinator, whether they have received vaccine or not, Ratner says. "Up until recently, there were about 330 eligible locations where someone could be vaccinated. Whether they are a pharmacy, or a hospital, or a physician practice—we have a weekly meeting with representatives from those locations to touch base on what is going on. We collaborate with every provider who wants to be collaborated with."
The regional task force has more than 450 members, he says. "The regional task force was originally comprised of suggested groups such as community organizations, municipalities, social service organizations, and providers. Up until recently, the regional task force has met weekly to review data, get on-the-ground feedback, and discuss challenges and opportunities."
The health equity task force features more than 70 clinical experts and community stakeholders, including leaders of faith-based organizations and social service agencies. "The health equity task force is essential to ensure that we have fair and equitable distribution of vaccine across our region. The health equity task force makes sure that we are looking at health literacy, access issues, and vaccine hesitancy," Ratner says.
Effective communication has been essential in the collaboration efforts, he says. "The key to our success has been frequent and fully transparent communication with our region's providers. Over the past five months, we have been able to bring together groups that previously were not collaborating—certainly not on a weekly basis."
WMCHealth playing dual role
In addition to playing a leadership role in the Hudson Valley vaccination hub, WMCHealth is also administering vaccines.
"We are involved in the actual administration of the vaccine for our network, which has 10 hospitals in the Hudson Valley. So, we are not only responsible for the hub but also are a provider. We provide vaccine at each of our hospital locations. In addition, WMCHealth is the state's provider partner for all four of the state mass vaccination sites in the Hudson Valley. Our providers staff those sites," Ratner says.
So far, about 55% of the vaccine-eligible population in the Hudson Valley has received at least one dose, he says.
Field hospitals can ease pressures on existing hospitals during COVID-19 patient surges.
When health systems need to open a field hospital during a public health emergency such as the coronavirus pandemic, they should be guided by emergency management principles, the lead author of a recent journal article on opening a field hospital says.
Several states across the country have had to open field hospitals during the coronavirus pandemic to accommodate COVID-19 patient surges. A common strategy has been to use field hospitals to treat low-acuity COVID-19 patients who can be transferred from hospitals and cared for safely before being discharged home.
The recent journal article, which was published by Prehospital and Disaster Medicine, features the planning effort for a 500-bed field hospital at Michigan Medicine—the health system affiliated with the University of Michigan in Ann Arbor. Planning for the alternate care site (ACS) began in March 2020, when modeling predicted that Michigan Medicine's 1,000-bed acute care capacity would be overwhelmed by April 10.
"The goal of the ACS was to decompress the main hospital, allowing critically ill patients to remain on-site while low-acuity patients were accommodated within the ACS," the journal article's co-authors wrote.
Although the predicted COVID-19 patient surge did not materialize and Michigan Medicine did not have to open the field hospital, the health system conducted extensive planning for the ACS through May 2020. There were four primary lessons learned from the planning process, according to Sue Anne Bell, PhD, MSN, MSc, an assistant professor at the University of Michigan School of Nursing and lead author of the journal article.
1. Teamwork and community response: "We learned the importance of the strength in our health system in terms of all-in effort. When the decision was made to stand up the field hospital, there was a display of teamwork within the planning team and across the health system," Bell told HealthLeaders.
"We saw an all-hands-on-deck situation within the health system of people willing to work together and within the broader community as well. As we were facing the oncoming surge that would have required the field hospital, the community locked down. The community stringently followed public health guidelines to decrease the spread of the virus, which ultimately removed the need to open the field hospital," she said.
2. Tapping resources: "We learned the importance of using resources for field hospitals. There was existing guidance on how to stand up a field hospital that helped us. It was also helpful to talk with other health systems that were standing up field hospitals," Bell said.
3. Experienced planning team: "We benefited from having people on the planning team like myself who had worked in field hospitals before or had military experience. So, having a team with experience is very important," she said.
4. Multidisciplinary approach: "The planning team was multidisciplinary, with physicians, nurses, respiratory therapists, facilities managers, and logistics and procurement specialists all working together to make decisions. That team effort was important because it was not just a few people at the top making decisions. For example, a facilities manager who had experience with air flow in buildings and electrical capabilities worked with clinical team members to figure out where to put beds that might require a ventilator," Bell said.
Emergency management principles
To avoid pitfalls when opening a field hospital, Bell said health systems should concentrate on four tenets of emergency management—staff, stuff, space, and systems.
1. Staff: "You can't open a 500-bed field hospital with four nurses," she said.
Michigan Medicine planned to staff its field hospital mainly with in-house healthcare workers, including academic staff who volunteered to expand their clinical hours, Bell said. "We found a tremendous spirit of volunteerism. Before we even put out the call to staff the field hospital, we had people calling us asking to volunteer."
For health systems with less capacity to staff a field hospital with internal human resources, there are several strategies to rise to the staffing challenge. Externally, there are resources such as federal Disaster Medical Assistance Teams, she said.
Internally, health systems can take actions to redeploy healthcare workers, particularly to boost critical care staff, Bell said. For example, elective surgery can be suspended and that operating room-trained staff can supplement ICU staff.
In addition, "task shifting" can increase ICU staff capacity, she said. "You deploy healthcare workers to take care of some of the tasks in the ICU that do not require specialized skills. These are relatively routine tasks that critical care nurses would do in a 'normal' time. Task shifting frees up the critical care staff to take care of healthcare that requires more highly skilled types of care. For example, less skilled healthcare workers can do IV checks to make sure the lines are open and running."
2. Stuff: "You must have the stuff to operate a field hospital. You need to be able to source cots, linens, and personal protective equipment, for example," Bell said.
Acquiring PPE and other supplies was one of the biggest challenges in the planning effort for Michigan Medicine's field hospital, according to the journal article. "The surge of COVID-19 patients combined with the rapid scale-up of field hospitals and ACS at multiple places across the country meant essential supplies—outside of PPE—such as cots, linens, and privacy screens were difficult or impossible to source. Items were out of stock or no longer available for purchase, as huge competition existed regionally and beyond. The PPE shortages were an ongoing concern," Bell and her co-authors wrote.
In the future, it will be essential to have the Strategic National Stockpile of medical supplies more prepared to cope with the demands of a pandemic, Bell said. "There are already efforts to address the failures of the Strategic National Stockpile. That is the starting point for addressing procurement challenges, and it is happening."
3. Space: "To open a field hospital, you must have a space that meets your needs to safely house patients. The space must have contamination zones, so there must be a zone for patients who have tested positive for the virus, a zone where you don PPE, and a zone where full PPE is not necessary," she said.
In consultation with community leaders, Michigan Medicine chose to use a new 73,000-square-foot indoor track and performance center owned by the University of Michigan for its field hospital. The facility, which is a 12-minute drive from the main hospital, has several qualities that make it suitable as a field hospital, Bell and her journal article co-authors wrote. "It could provide a 'clean' and a 'dirty' side in order to reduce the risk of transmission and to form distinct areas of function to maintain organization. A draft layout was completed in roughly two days for 519 beds, including a 20-bed higher-acuity area for decompensating patients needing transfer."
4. Systems: Planners must put several systems in place to make sure a field hospital is safe and effective, Bell said. "You must have systems in place in order to open. For example, you must have a system in place for patients who decompensate, so you can transfer them to an established hospital. You must have a system for feeding patients. You must have a system for restocking supplies."
New Jersey program features physicians and services from 17 specialties.
Saint Barnabas Medical Center and RWJBarnabas Health Medical Group have created a multidisciplinary and comprehensive program to care for coronavirus "long haulers."
Many COVID-19 patients have experienced a range of symptoms for weeks or months after the acute phase of their illness has passed. The National Institutes of Health calls the long-hauler condition post-acute sequelae of COVID-19 (PASC).
In October, Saint Barnabas Medical Center in Livingston, New Jersey, and West Orange, New Jersey-based RWJBarnabas Health Medical Group launched the Post-COVID Comprehensive Assessment, Recovery and Evaluation (CARE) program to care for PASC patients. Over the past seven months, the Post-COVID CARE program has treated more than 120 patients.
The Post-COVID CARE program tailors treatment for each patient, says Vanessa Trespalacios, MD, medical director of the program and an RWJBarnabas Health Medical Group internal medicine physician.
"COVID-19 and PASC can affect any organ system. Our approach is a comprehensive and multidisciplinary approach. We feel that kind of approach is necessary because each patient experience is different, with varying degrees of impact on their health as well as on their quality of life. Some patients are extremely impaired, while others have milder symptoms that are cumbersome. The extent of their symptoms and their test results dictates referrals, testing, and the formulation of their entire treatment plan," she says.
The Post-COVID CARE program features physicians and services from 17 specialties, including behavioral health, cardiology, dentistry, dermatology, infectious diseases, pulmonology, neurology, radiology, and respiratory therapy.
"We are taking the patients as a whole and every patient has a different set of symptoms that need to be addressed by different subspecialists. That is what sets us apart because most of the programs that have been established are either focused and led by pulmonary practices or are rehab programs such as physical therapy. When you have a patient who has chest pains, physical therapy does not have a role there. When you have patients who have cognitive decline—which is often called brain fog—physical therapy and pulmonary do not have a role there," Trespalacios says.
Role of nurse navigators
A pair of nurse navigators are pivotal team members in the Post-COVID CARE program, Trespalacios says.
"The nurse navigator is the patient's first point of contact with the program once their appointment has been scheduled. The nurse navigator collects a thorough history of the patient's disease course, post-acute symptoms, and any prior testing and treatments that the patient has had. Once a patient has had a consultation with a clinician and a treatment plan has been developed, the nurse navigator then facilitates appointments for any testing as well as any referrals to subspecialists, physical therapy, or any other treatment that we feel is necessary," she says.
Communication is an essential element of the nurse navigator position, Trespalacios says. "The nurse navigator maintains open communication with the patients about their progress in between follow-up appointments. The nurse navigator communicates with patients about their test results, makes sure patients understand their treatment plans and why they are having tests and referrals, and helps in the collection of data for research."
The importance of research cannot be underestimated, she says. "We are going to be coming into a global healthcare crisis unless we can collect data on PASC and develop treatments for PASC symptoms. In addition to seeing patients, we are collecting data and doing research, so that we can have better information to better serve our patients and find some answers."
Keys to recovery
For PASC patients, Trespalacios says there at two keys to recovery: patience and follow-up care.
"Patience is very important not only because we are all still learning about this disease but also because it appears that in PASC recovery is very slow, which is different from other viral illnesses. The rehabilitation journey must be slow, steady, and sustained for patients to achieve any progress. Otherwise, many patients experience some regression or even a temporary exacerbation or worsening of their symptoms," she says.
"We have also learned that another key to the recovery process is frequent follow-up because these symptoms evolve. Some patients have some symptoms that are present initially that either resolve or change over time. Some patients develop new symptoms as time goes on. So, you must take a fluid approach to treatment. We have frequent follow-up with these patients to assess their symptoms and to change the course of treatment if necessary," she says.
In addition to Black physicians being underrepresented, there is an income disparity between Black and White physicians, U.S. Census data shows.
There has been a modest increase in the percentage of Black physicians in the healthcare workforce for more than a century and Black physicians remain underrepresented, a new journal article says.
Earlier research has shown benefits from racial diversity in the physician workforce. For example, a study published in 2019 found that patients are more likely to undergo preventive services when under the care of racially concordant clinicians.
The new journal article, which was published in the Journal of General Internal Medicine, is based on U.S. Census Bureau data. The journal article features several key data points.
In 1900, Blacks accounted for 11.6% of the U.S. population and 1.3% of physicians were Black.
In 1940, Blacks accounted for 9.7% of the population and 2.8% of physicians were Black. Only 0.1% of physicians were Black women.
In 2018, Blacks accounted for 12.8% of the population and 5.4% of physicians were Black. The percentage of physicians who were Black women was 2.8%
The data shows a significant racial income disparity between Black and White male physicians. In 2018 dollars, the income gap was about $68,000 in 1960 and $50,000 in 2018.
The author of the journal article wrote that the proportion of Black physicians has remained low for more than a century and a racial income disparity has persisted.
"Little progress has been made in increasing the representativeness of the physician workforce and in achieving racial equity in physician pay. The proportion of physicians who are Black has increased by only 4 percentage points over the course of 120 years. The proportion of physicians who are Black men remains essentially unchanged since 1940, with the increase since then in proportion of physicians who are Black coming from an increase in Black women," wrote Dan Ly, MD, PhD, MPP, an assistant professor at the David Geffen School of Medicine at UCLA.
Ly told HealthLeaders the lack of progress in increasing the proportion of Black physicians is concerning. "If we care about the health of the U.S. population, particularly the health of Black patients, we should care about how few Black physicians we have and the glacial progress we have made as a medical system in increasing that number," he said.
Medical education is a key factor in increasing the representation of Black physicians in the profession, Ly said. "That takes medical leadership, starting with leadership at medical schools."
Culture plays a pivotal role in essential areas such as physician enterprise and patient safety, Tower Health executive says.
A physician leader at Tower Health says helping to build an effective culture at the health system will be among the keys to success in her new roles.
Suzanne Wenderoth, MD, was recently promoted from senior vice president and chief clinical officer of Tower Health Medical Group to executive vice president, CEO of physician enterprise, and interim chief medical officer of Tower Health. The West Reading, Pennsylvania-based health system features seven hospitals and about 14,000 employees.
Prior to joining Tower Health in 2018, Wenderoth worked in four roles at Reading Health System, including medical director of the patient-centered medical home primary care service line and vice president of ambulatory clinical initiatives.
Wenderoth recently talked with HealthLeaders about a range of issues such as physician enterprise, quality improvement, and patient safety. Following is a lightly edited transcript of that conversation.
HealthLeaders: What are the primary elements of being a successful physician enterprise leader?
Suzanne Wenderoth: At the most basic level, physician enterprise leadership is about establishing a common cultural foundation. You need to establish a common mission, principles, and values. You need to let individual physicians know—regardless of where they work—that we are all aligned toward the same goals.
Another piece is that it is not only the physician component of the enterprise. It is important that we identify and align our goals with the other legs of the stool, including nursing and operations. We must establish coordination together.
Fundamentally, you must achieve aligned goals; and, often, physicians measure that through compensation. So, whether it is shared savings arrangements or other incentives, you must be able to deliver not only on the mission but also on the compensation.
Finally, one goal for physician enterprise leadership is to alleviate some of the physician frustrations. Whether it is with the electronic medical record or complex processes—alleviating frustrations is a critical part of the journey as well.
HL: Give a specific example of unifying physicians under one mission or culture.
Wenderoth: If you think about always putting the patient at the center of what you do, that is a simple value to remember. It also aligns us. If we pick any of our individual goals on a scorecard, if you always look at it from the patient-centered perspective, that is an example of a core value.
If you think about the mission as being patient-centered, you can take any one of your measures such as falls prevention and look at it from the patient perspective. You do not want to prevent patients from getting out of bed; rather, you can provide them with assistive devices and use remote monitoring to help them be mobile in a safe way.
HL: What are the primary elements of physician alignment?
Wenderoth: It is tricky because you need to know what you are aligning to. You need to align physicians and the health system, but you also need to align physicians and compensation.
No. 1, you need to match people's expectations with the strategy and the goals. Then you must share data transparently and ask physicians for their insights. You also need to match incentives to what is being reimbursed. We all have lots of great ideas in medicine, but if incentives are not matched with how we are being paid, that creates misalignment.
HL: What are the primary components of successful quality initiatives?
Wenderoth: The most important piece is to go to the frontline, which is where the work is really happening. You need to have those folks identify the most critical issues.
Then, you must have a fixed goal. It could be aspirational, and you might be concerned that you will not hit it, but that's OK. You must have a set goal, with a finite number or metric in mind. The goal also must come with a deadline or timeline. Then, as you design activities and measure improvement, you must give feedback in a regular fashion, with a cadence so that people can react to it.
You want to create standard processes that people can predict and anticipate.
HL: What are the primary components of successful patient safety initiatives?
Wenderoth: Here at Tower Health, we embody and embrace just culture. The idea is that humans are fallible. We are all going to make mistakes, but we need to be willing to talk about our near misses and our errors. As a culture, we need to be willing to address near misses and errors while not being shamed by them or embarrassed. Then, we need to be preoccupied with fixing problems.
You need to have an effective incident reporting system. We have a reporting system called RL Solutions that is quite transparent and nonpunitive.
A few years ago, we did not have nearly as many safety reports being placed as one would have expected or hoped. Since reporting is foundational to patient safety, it is important that you get enough people reporting. We realized that there were so many steps to the reporting process that we were creating a barrier for our employees. So, we initiated a process improvement effort and cut the number of reporting steps in half, and our reporting numbers went way up.
Another key to success in patient safety is building policies and processes that address errors. Without guiderails, people will continue to make errors.
Lastly, you need proactive education. You must tell friends and colleagues what you have learned, so everyone can capitalize on the knowledge.
HL: How can health systems and hospitals move toward zero harm in patient safety?
Wenderoth: So much of this is culture. Every healthcare worker must decide that patient safety is a fundamental component of how they will do their work throughout the day.
At Tower Health, we have taken a serious approach to change management. It is one thing to say you want to engage in change, but it is another thing to focus on the science of change management. You need to look at the number of people who are necessary to move change, and you must figure out how you are going to move culture. Changing culture is the first step to achieving zero harm.
Another factor is having an optimal learning system, so you can mine data and understand what your trends look like.
Then you must look at designing care improvement. One area that will be exciting in coming years is around engaging patients. The co-design of care can move you to high reliability and zero harm. You must have patient experience, patient committees, and patient voice in the co-design of care.
Decrease of service volumes during the pandemic and signs of rebound are driving changes in physician practice finances.
The coronavirus pandemic had a tumultuous impact on physician practices in 2020, but there are signs of recovery in 2021, according to the April Physician Flash Report from Kaufman Hall & Associates LLC.
Physician practices experienced reduced service volumes in 2020 as patients reacted to lockdowns and shunned in-person visits due to fears of coronavirus infection in healthcare settings. The reduced in-person visits were partially offset by increased utilization of telemedicine.
The April Physician Flash Report includes three key data points.
1. Investment per physician
In 2020, there was a 6.8% annual increase in median investment/subsidy per physician full-time equivalent (FTE) compared to 2019, according to the report.
A co-author of the Physician Flash Report explained the drivers of the increase in investment per physician FTE to HealthLeaders. "We saw a lot of health systems holding physician compensation whole during the pandemic—that was a deliberate choice to hold physicians harmless for changes in the market. So, overall, with a reduction in utilization and revenue, and constant compensation for physicians, the net impact was that the investment per physician increased," said Cynthia Arnold, MBA, BA, a senior vice president at Kaufman Hall.
Health systems and physician practices will have to address investment per physician, she said. "The investment per physician numbers have increased so much that it is impossible to ignore them going forward. For us to deal with the economic pressures of this increased subsidy, health systems are going to need to pull in their physician groups and work more closely with physician group leadership."
2. Net revenue per physician
Net revenue per physician FTE declined slightly from Q3 to Q4 2020 after hitting a low in Q2 of 2020, according to the report.
The decline in net revenue per physician FTE could be a negative trend this year, Arnold said. "We do not think this bodes well for 2021."
The decline in revenue is going to put pressure on physician practices to cut costs, she said. "There is going to be more pressure for automation. At the front desk, we are going to see practices using bots to take care of repetitive tasks. Automation to reduce administrative costs will happen relatively quickly. It will be harder to replace clinical providers such as nurses and medical assistants, but all of this is going to be up for consideration as we move forward."
3. Total direct expense per physician
Total direct expense per physician FTE fell 4.9% from 2019 to 2020, according to the report.
Reductions in front-office staff during the pandemic were a primary driver of the decrease in total direct expense per physician FTE, Arnold said.
"This is an important workforce question. At most health systems, the entry level for lower-income individuals is at physician practices. So, getting a job at the front desk gets you into a health system and let's you apply for other jobs. But we are not seeing the availability of that workforce, and they are not coming back very quickly," she said.
A 0.9% increase in total direct expense per physician FTE from Q3 to Q4 in 2020 reflects a rise in patient visit volumes at the end of last year, Erik Swanson, MPH, MS, BS, a senior vice president at Kaufman Hall, told HealthLeaders.
"As volumes return, you see some of the support staff starting to come back to work. We certainly expect total direct expense per physician FTE to increase as the volumes increase. It is going to be critical for organizations to monitor these types of trends on a more real-time basis, so that they can potentially adjust what those rates of return of expense will be over time," he said.
Forecasting the future
Last year was transformational for physician practices, which face a new operational and financial landscape, Arnold said.
"We are not returning to normal; we are moving to a new normal. We are going to need to be much more tuned into our patients and recognize that they are consumers. Our patients need to have choices. We are going to need to reconfigure our physician networks. Resizing the employed physician groups will be a big part of the change going forward, but we will also have to align physician leadership so that it can be much more helpful in understanding how the work gets done," she said.
The Physician Flash Report provides essential insights into physician practice economics, Swanson said.
"Number One, it informs the economic equation at play for physician groups and what level of investment is ultimately going to be acceptable to organizations. In addition, it informs investment and what you are getting for it. In this report, with the decreases in the patient volumes, some of those decreased volumes may not be returning because consumers have different choices. Organizations need to be thinking about how to reconfigure, rethink, and innovate," he said.
Work-life challenges have implications for retention off staff and trainees, survey finds.
The coronavirus pandemic has led many healthcare workers, particularly women with children, to consider leaving the workforce or reducing work hours, a recent study found.
In March 2020, 42% of U.S. workers transitioned to working from home. It is likely that employed women faced greater burdens because they spend 22% more time on household and care work compared to men. Studies have shown that healthcare workers have faced higher stress levels during the pandemic than before the pandemic.
The recent study, which was published by JAMA Network Open, features survey data collected in August 2020 from more than 5,000 faculty, staff, and trainees at University of Utah Health. The research includes several key data points.
49% of parents said that parenting was a stressor during the pandemic and 50% of parents said helping children with virtual education was a stressor
21% of survey respondents reported considering leaving the workforce and 30% reported considering reduced work hours
55% of faculty and 60% of trainees reported perceived decreased productivity
47% of survey respondents reported concern that the pandemic would impact their career development, with 64% of trainees reporting a high level of concern
81% of survey respondents said balancing childcare and work responsibilities was somewhat or extremely difficult
60% of survey respondents reported that continued opportunity to work from home was very or extremely helpful
68% of survey respondents reported that scheduling flexibility was very or extremely helpful
61% of survey respondents reported that knowing a work or training schedule one month in advance was very or extremely helpful
57% of survey respondents reported that have a supervisor who had a good understanding of work-life struggles was very or extremely helpful
"In this survey study, most participants with children did not have childcare fully available and many considered leaving the workforce and were worried about their career. Being female with children or having a clinical job role was associated with consideration for leaving the workforce and reducing hours," the study's co-authors wrote.
Health systems can take actions to address their workers' stress related to the pandemic, they wrote. "Health systems must develop effective strategies to ensure that the workplace acknowledges and supports employees during this unprecedented time, not only within the work environment, but also in managing unanticipated childcare responsibilities due to lack of childcare or in-person school. In doing so, health systems will improve the likelihood of retaining generations of well-trained clinicians, scientists, and staff."
Interpreting the data
One of the study's co-authors told HealthLeaders that two findings of the research were most concerning.
"We are particularly troubled by the fact that so many faculty members who have dedicated five-to-10 years of their life training to become physicians or scientists were considering leaving the workforce. Additionally, almost 50% of faculty and 64% of trainees (students, residents, and fellows) were worried that the pandemic had negatively impacted their career," said Angela Fagerlin, PhD, chair of the Department of Population Health Sciences at University of Utah.
There are three primary actions that health systems can take to support healthcare workers during the pandemic, she said.
Setting clinical schedules as far ahead of time as possible so healthcare workers can make childcare plans more effectively
Allowing for flexible work schedules as much as possible such as working from home and working sporadically through the day while making up time-off hours
Having supervisors better understand work-life struggles
Several factors are likely linked to those in clinical job roles considering leaving the workforce and reducing hours, Fagerlin said. "I imagine the lack of flexibility or the ability to stay home with children may have contributed. Non-clinicians such as PhD faculty had the flexibility to stay home, although as a PhD-scientist mother of three kids who only all went back to school recently, working while virtual-schooling is a different type of stress. Another feasible reason is the incredible stress resulting from caring for patients during COVID and the risks associated with that care."
