Considerations for selling a medical practice depend on whether the seller is retiring, financially distressed, or making a strategic move.
There are successful strategies to employ and key steps to be taken when selling a medical practice.
In the short-term, the coronavirus pandemic has placed many medical practices in dire financial straits and selling a practice may be unavoidable. In the long-term, small medical practices have been selling to larger medical groups and health systems for years, and that trend is likely to continue.
The considerations for selling a practice depend on the seller, says Barry Posner, JD, BS, a partner at Kudman Trachten Aloe Posner LLP in New York City. "There are three kinds of sellers: there is the seller who is retiring, there is the seller who is in distress, and there is the seller who is selling into growth or selling strategically."
Succession is a primary consideration for the sellers who are retiring, he says. "For retiring doctors, if it is a one-physician practice, more than likely they are going to pass the practice to a successor or somebody who they have trained. But those situations are getting more and more rare."
For distressed sellers, they can either align themselves with a buyer that can make them more profitable, or they can become employees or contractors of a larger practice group, Posner says. "It often comes down to cost savings. They may have high-cost equipment. They may have high-cost rent. Selling the practice relieves distressed doctors of those burdens. That way, they can get back to practicing medicine and let other people deal with the business of medicine."
More commonly, there are practices that just are not as profitable as they used to be, and they want to make a strategic move to become more profitable, he says. "The way you achieve more profitability by selling to large practice groups or health systems is by getting cheaper purchasing by volume, sharing high-cost equipment such as CT scans, and lowering back-office costs through centralized billing and collections."
Determining the value of practices
Revenue is a pivotal element of a medical practice's valuation for sale, Posner says.
"Medical practices are generally valued off a multiple or fraction of revenue. The most common general practices would be in the 0.5 to 0.7 times their annual revenue range. As you get to higher end specialties, you can go to 0.8 to 1.0 times annualized revenue. The 0.5 or 50% of revenue valuation would be typical for an internist, podiatrist, and general practitioners. As you get to shorter supply specialties such as neuroradiology and oncology, you can get to a higher multiple," he says.
For example, if a practice was crafting a deal on a calendar-year basis for 2020, and the practice had $2 million in revenue, and the negotiated percentage was 70%, the value of the practice would be $1.4 million.
Avoiding the biggest pitfall
The most daunting pitfall when selling a medical practice is avoiding buyers that have weak financial standing, Posner says. "There are some very fine health systems and large practice groups that are well-funded and well-sponsored either through private equity firms or physicians who have been very successful over the years. I have seen examples that go the other way."
To avoid a financially troubled buyer, owners of medical practices that are up for sale need to have a strong team in place to help them, he says. "The biggest pitfall is ensuring that the medical group that you are selling into is financially sound. Due diligence is critically important. And the way to conduct due diligence is by getting your accountant, your lawyer, and business broker or banker involved in the process as early as possible."
Prepping a practice for sale
To sell a medical practice successfully, physicians need to lay solid groundwork for the sale, Posner says.
"Prepare, prepare, prepare. Get your lawyers and accountants lined up early. Get your documentation together—whether it is your payer contracts for reimbursement, your licenses, or your financial statements. All the documents that would be typically requested by a buyer should be prepared and at your fingertips. When you are asked, you should be able to hand over documents immediately," he says.
Delays due to ill-prepared sellers can have adverse consequences, Posner says. "I am a believer that time kills deals, and the quicker you can respond to due diligence questions from a prospective buyer, the better off you are."
The health system has supported healthcare workers, adopted new modalities of care, improved communication, and boosted emergency preparedness.
By multiple measures, COVID-19 has challenged healthcare providers more than any other public health crisis since the 1918 influenza pandemic. As the coronavirus pandemic enters its second year, many health systems, hospitals, and physician practices remain in crisis mode.
A pair of physician leaders at Cincinnati-based UC Health recently spoke with HealthLeaders to discuss how the health system has grappled with COVID-19. Following are four primary lessons learned from the coronavirus pandemic.
1. Strain on healthcare workforce
Healthcare workers have risen to the challenge, says Dustin Calhoun, MD, medical director of emergency management at UC Health.
"In emergency management, there is a concept that in a major disaster such as this pandemic only 50% to 60% of your healthcare workers will show up for work. In the face of personal danger to themselves and their families, a significant number of healthcare workers would stay home. We had always planned based on that concept, but that turned out to be very much not true," he says.
Particularly at the start of the pandemic, UC Health's workforce faced daunting uncertainty, Calhoun says. "The amount of willingness of healthcare workers to put themselves in danger has been remarkable. Our personal protective equipment practices are excellent now and our supplies are excellent now, but we did not know that in the beginning."
"When the pandemic started, we did not know a lot about the virus. In the first few months, there were educated guesses at best. Yet, healthcare workers took those educated guesses, put the PPE on, and took care of the patients. For most healthcare workers, this is probably the first time in their career that doing their job put them at significantly more risk than they anticipated when they went into the field. We all knew there were risks in healthcare such as needle sticks. But in the beginning of the pandemic, the perceived risk of personal danger was high," he says.
Huddles have played a pivotal role in supporting healthcare workers during the pandemic, says Jennifer Forrester, MD, associate chief medical officer and an infectious disease specialist at UC Health.
"We started having huddles before work shifts prior to the pandemic and that was one of the things that was helpful for the staff over the past year. Instead of coming to work, getting your assignment, and doing your job, you come to work, and everybody meets before the shift begins. Some of the people from the prior shift meet with the people from the new shift," she says.
"During these huddles, you not only talk about patients but also talk about what is going on in the bigger picture. You discuss what everybody needs for their shift. And the huddles are not limited to the micro level of a clinic or a unit. We made a system that allows concerns raised in the huddles to escalate to the executives, including employee well-being, which is one of the things stressed in the huddles," Forrester says.
The health system's employee assistance program (EAP) has also been critically important to supporting healthcare workers, Calhoun says.
"The employee assistance program pushed out their availability. We know that among healthcare workers and the entire population that psychiatric illness from the very mild to the more severe has certainly been more pronounced during the pandemic. The EAP made sure that there were programs available for employees who were experiencing the effects of serious stressors," he says.
2. Unconventional treatment modalities and new ways of providing care
Adoption of telehealth has been a transformative change at UC Health, Forrester says.
"Probably the biggest new way of providing care has been the use of telehealth. It was up and coming at the beginning of the pandemic—mostly used by primary care physicians, but most of us in specialty care were not using it routinely. The pandemic skyrocketed the use of telehealth, which is great for patients. Telehealth is excellent for patients in rural areas, especially for accessing subspecialists at an academic center. It can be a two-hour drive for a visit, which is a lot to ask of patients," she says.
Proning of seriously ill coronavirus patients is a great example of unconventional treatment techniques utilized during the coronavirus pandemic, Calhoun says.
"When I went through medical school, ventilatory proning—the idea of venting a patient while they were laying on their stomach—was an extraordinary technique that we only used with super sick patients in the ICU. It was found out early in the pandemic that the pathology that occurs in the lungs due to COVID is responsive to the proning technique of ventilating. We began invasively proning patients in the emergency department as well as proning patients who were still breathing spontaneously and not on a ventilator. We just positioned them in ways that made it easier for their lungs to function," he says.
Proning was initiated early in the pandemic, Calhoun says. "We started proning in mid-March of last year. Our intensivists, our pulmonologists, and our infectious disease doctors were very aggressive at recognizing that this was a useful procedure."
3. Improving communication
Effective communication strategies have been pivotal during the pandemic, Calhoun says.
"We have learned a tremendous amount about the most efficient methods of communicating with our clinical staff, our employees, and our patients as well as communicating with the community in general. We have utilized trusted partners in the community to communicate with particular groups. Even though we like to think of ourselves as being very trusted by the community because we are healthcare workers and our purpose is to help the community, there are barriers sometimes. Standing beside another trusted partner significantly improves our ability to communicate with particular groups," he says.
For internal communications, UC Health has ramped up utilization of an online resource that was in place before the pandemic, Calhoun says.
"An internal communications tool called The Link has had a major impact during the pandemic. It is essentially an internal communication online tool that is intended to be the source of truth for UC Health's healthcare workers. The amount of use of The Link now is tremendous. Early in the pandemic, our marketing and communications team very adeptly put The Link at the center of our pandemic communications. We put our protocols on The Link—it became where you looked for answers," he says.
Email also has been an effective internal communication strategy, Forrester says.
"We set up dedicated email addresses to answer questions about certain things. Employees can just send an email to a COVID-19 address and ask questions. For example, employees can ask questions about personal protective equipment. When the vaccines became available for our employees, we set up a dedicated email for the vaccines; so, if staff had questions about vaccination scheduling or side effects, they could get reliable information. These dedicated email addresses link our employees to the right people," she says.
Externally, taking a multi-faceted approach to communication has been successful, Forrester says.
"From a community standpoint, the multipronged approach of meeting people where they are was critical, whether it be on television, social media, or our website. The different ways to communicate have been expanded during the pandemic. Particularly with the vaccine, we want to reach as many people as possible, and we will do that in any way possible. In this area, working with our community groups and leaders has been very important," she says.
4. Honing emergency preparedness
Improving emergency preparedness at UC Health has been one of the silver linings of the pandemic, Calhoun says.
"Unlike the 2014 Ebola outbreak, which was relatively short-lived, the prolonged nature of the coronavirus pandemic has taught us what really is and is not important. We have made emergency management part of our daily plan. There are few times in my career when I have seen emergency management become part of daily healthcare operations. That is when emergency management works really well—when it is truly integrated into operations. The duration of the pandemic has forced that integration," he says.
The coronavirus pandemic also has impacted a major emergency department renovation at UC Health, Calhoun says.
"We are renovating a very old emergency department. After seeing what we went through with Ebola and seeing what we have been going through with the pandemic, we saw the need for integration of capabilities. For example, we have taken a second look at how many negative pressure rooms we are going to have and how much 'blow out' space we need to expand capacity when necessary. The pandemic demonstrated the importance of integrating those kinds of things into the design of this new emergency department. The timing of the pandemic in this remodeling process will benefit the community significantly," he says.
Survey data shows at least half of critical care physicians experienced emotional distress in the first nine months of the COVID-19 crisis.
In the critical care setting, emotional distress and staffing shortages have persisted during the coronavirus pandemic, a recent survey report says.
Critical care physicians are essential caregivers for seriously ill COVID-19 patients. They are not only well-positioned to assess emotional distress and shortages in the critical care setting but also pivotal personnel who can have a negative impact if they become burned out.
The survey report, which was published by Critical Care Medicine, is based on data collected from more than 2,300 critical care physicians in the spring of 2020 and more than 1,300 critical care physicians in the fall of 2020. The survey report has several key findings.
In the spring survey, 67.6% of critical care physicians reported moderate or high levels of emotional distress. In the fall survey, 50.7% of critical care physicians reported moderate or high levels of emotional distress.
Compared to their male counterparts, female physicians reported higher levels of emotional distress in both the spring and the fall surveys. In the spring survey, 75.0% of female physicians reported moderate or high emotional distress. In the fall survey, 67.7% of female physicians reported moderate or high emotional distress.
Reported critical care staff shortages were nearly unchanged in the spring and fall surveys, with 48.3% of survey respondents reporting staff shortages in the spring and 46.5% reporting staff shortages in the fall.
The worst staff shortage was among ICU-trained nurses, with 34.2% of survey respondents reporting ICU-trained nurse shortages in the spring and 33.1% of survey respondents reporting shortages in the fall.
Reported shortages of personal protective equipment fell by more than half from the spring survey to the fall survey. In the spring survey, 52.7% of respondents reported PPE shortages. In the fall survey, 21.9% of respondents reported PPE shortages.
"Stress, staffing, and, to a lesser degree, personal protective equipment shortages faced by U.S. critical care physicians remain high. Stress levels were higher among women. Considering the persistence of these findings, rising levels of infection nationally raise concerns about the capacity of the U.S. critical care system to meet ongoing and future demands," the survey report's co-authors wrote.
Interpreting the data
The lead author of the survey report told HealthLeaders that the persistent moderate or high levels of emotional distress are troubling.
"It is very concerning, especially since this survey was conducted just at the start of the winter surge. We also found that this distress was similar across hotspots. This suggests that, at least in part, emotional distress is global and cumulative. As we face a new surge this is even more of a concern. That said, at least to some degree a contributor to emotional distress was risk to self. As many physicians are being vaccinated, this might help mitigate distress a little. However, there are other contributors to stress that are not affected by vaccines," said Bradley Gray, PhD, senior health services researcher at the American Board of Internal Medicine.
Having nearly half of critical care physicians reporting staff shortages is another area of concern, he said. "This finding was for ICU-trained staffing shortages. This is concerning because these are the people who really know what they are doing and not having enough of these specialized workers adds to the emotional distress of physicians and we presume other ICU-trained staff."
The relatively large reported shortage of ICU-trained nurses is likely having negative consequences, Gray said. "This is a major concern because ICU-trained nurses and critical care physicians play a pivotal role in the ICU. ICU-trained staff in general are the best equipped at dealing with COVID patients. Also, the degree to which non-ICU-trained nurses are being utilized taxes the ICU-trained staff including physicians because they likely must supervise and assist the non-ICU-trained nurses. That results in the ICU-trained nurses feeling a double burden."
The survey report found that at least half of critical care physicians experienced moderate or high levels of emotional distress for the first nine months of the pandemic. If this problem continues deep into 2021, the impact could be dramatic, he said.
"Bright red is my level of concern. Many states are experiencing increased hospitalization rates, and this will shoot up as the spring 2021 surge builds. Again, the emotional distress seems cumulative. When you look at what physicians are telling us, many are saying that the loosening of COVID restrictions in the face of a new surge is one factor that adds to emotional distress. I think these docs get frustrated that the only thing that seems to move the state policy needle is death and hospitalizations. We know the wave is coming, why can't we take steps now to reduce future deaths and hospitalizations?"
The new study corroborates earlier research that found sexism and racial/ethnic bias are common in surgical settings.
Sexist and racial/ethnic microaggressions against female and racial/ethnic minority surgeons and anesthesiologists are common and linked to physician burnout, a new study finds.
Burnout is one of the most vexing challenges facing physicians and other healthcare workers nationwide. Research published in September 2018 indicates that nearly half of physicians nationwide were experiencing burnout symptoms. Female physicians tend to experience burnout more than their male counterparts—a Medscape report published in January found that 51% of female physicians were burned out and 36% of male physicians were burned out.
The new study, which was published by JAMA Surgery, is based on survey data collected from nearly 600 surgeons and anesthesiologists at Southern California Permanente Medical Group. The study includes several key data points.
94% of female survey respondents reported experiencing sexist microaggressions
81% of racial/ethnic survey respondents reported experiencing racial/ethnic microaggressions
47% of survey respondents reported physician burnout
The odds of experiencing physician burnout were high for female physicians (odds ratio 1.60) and racial/ethnic minority physicians (odds ratio 2.08)
The likelihood of burnout was high for female physicians who experienced sexist microaggressions (odds ratio 1.84 for racial/ethnic minority female physicians and odds ratio 1.99 for White female physicians)
The likelihood of burnout was high for racial/ethnic minority female physicians who experienced racial microaggressions (odds ratio 1.86)
The likelihood of burnout was high for racial-ethnic minority female physicians who experienced both sexist and racial/ethnic microaggressions (odds ratio 2.05)
"In this survey study, there was a high prevalence of sexist and racial/ethnic microaggressions against surgeons and anesthesiologists. Racial/ethnic minority female physicians, specifically [Black, Hispanic, and Hawaiian/Pacific Islander] physicians, experience the highest prevalence and severity. Furthermore, sexist and racial/ethnic microaggressions were associated with physician burnout," the researchers wrote.
Interpreting the data
The lead author of the new study told HealthLeaders that sexist and racial/ethnic microaggressions are one of several factors that contribute to physician burnout.
"The cause of physician burnout is multifactorial and has been described as chronic work-related stress that leads to a constellation of emotional exhaustion, depersonalization, and low personal achievement. We know that microaggressions negatively impact one's morale and psychological well-being. The extra energy required to address these microaggressions, the responsibilities of being a physician, and our essential roles directly contribute to burnout," said Neha Sudol, MD, a member of the Department of Obstetrics and Gynecology at Southern California Permanente Medical Group and UC Irvine Medical Center.
Sexist and racial/ethnic microaggressions likely impact all three dimensions of physician burnout, she said. "We hypothesize that repetitive microaggressions in the workplace specifically contribute to emotional exhaustion and, perhaps, the other components of burnout to a lesser degree."
With sexist and racial/ethnic microaggressions, there is an intersection of sex, race/ethnicity, and physician burnout, Sudol said. "We found that female and all racial/ethnic-minority surgeons and anesthesiologists were more likely to experience burnout compared to White, male colleagues. We then identified an intersection between microaggression experience and physician burnout whereby female racial/ethnic-minority physicians who experienced microaggressions were more likely to experience burnout compared to their White, male colleagues."
Sexist and racial microaggressions contribute to pervasive workplace inequity faced by female and racial/ethnic surgeons and anesthesiologists, she said. "Workplace inequity, by definition, is rooted in bias and unfair circumstance. Microaggressions are acts of discrimination toward marginalized groups and, thus, directly contribute to inequity. Our findings, that female and racial/ethnic minority surgeons and anesthesiologists experience microaggressions at a high prevalence, corroborate previously published reports that surgical environments are wrought with sexism and racial/ethnic bias."
The are actions that can be taken at the individual and institutional levels to address sexist and racial/ethnic microaggressions, Sudol said. "At an individual level, value and respect should be placed on addressing microaggressions in a non-accusatory manner and holding each other accountable. From a larger institutional standpoint, the data highlights the importance of establishing codes of conduct and other initiatives that empower marginalized groups and encourage allyship."
Spectrum Health West Michigan's new senior vice president of quality, safety, and patient experience shares his insights.
There are golden opportunities to improve patient safety and patient experience at healthcare organizations, a new top executive at Grand Rapids, Michigan-based Spectrum Health says.
Spectrum Health has hired James Moses, MD, MPH, to serve as senior vice president of quality, safety, and patient experience at Spectrum Health West Michigan, which is one of two healthcare delivery divisions at the health system. He is set to begin working in his new role in April.
Moses comes to Spectrum Health from Boston Medical Center, where he has served as chief quality officer and vice president of quality and safety. The board-certified pediatrician and pediatric hospitalist earned his medical degree at the University of Chicago Pritzker School of Medicine.
HealthLeaders recently discussed issues related to safety and patient experience with Moses. The following is a lightly edited transcript of that conversation.
HealthLeaders: What are the primary elements of patient experience?
James Moses: Patient experience is extremely important. The main elements are patient-centeredness and thinking through how care is personalized for every patient. Patient experience is more than just patient satisfaction. Patient experience is about the experience we are providing to patients and whether they walk away feeling like the experience was something they felt positive about.
The patient experience is also about respect. When you do not tailor care to individuals, it is a form of disrespect. If providers are not doing their homework prior to clinical visits to really understand the patients who are in front of them and the active issues, that can be perceived as a sign of disrespect. If patients do not feel that their concerns are being heard, that is not achieving the patient-centeredness and the personalization aspect that you want in the patient experience.
Eventually, what we are seeing in telemedicine and digital health will help facilitate and accelerate the personalization of healthcare. That is something to be excited about.
HL: Where do you see the opportunities to improve patient experience?
Moses: One area of opportunity is continuity of care. The team of providers needs to act as a team.
Sometimes, you go to one provider, and they act completely independent of other the providers and specialists. You have a one-off experience instead of continuity and a sense that your caregivers know you. Too often, I see providers asking patients for an update on what the other doctors have said, which is not patient-centered and not the right patient experience. There needs to be much better effort around systems of healthcare and ensuring that they are functioning in a coordinated way across multiple services, so that care can be tailored across the care continuum in a way that makes the patient feel respected and their physicians are all on the same page.
Patients need to know that the right thing is going to be done in clinical decision-making as well as the coordination of evaluations, diagnostic workups, and treatments. In healthcare, patients fend for themselves quite a lot, and we have to remove those types of barriers and remove discoordination in their care.
HL: Patient safety has been a top goal in healthcare since the publication of To Err Is Human two decades ago. Which patient safety areas remain problematic?
Moses: One of the continuous areas of opportunity is around diagnostic errors. There has been a lot of discussion around why providers and clinicians make the wrong diagnosis and what is happening around their decision-making process that is getting them to head down the wrong path. We need to make sure that clinicians can step back and take a nuanced view to ensure that they are making the right diagnosis and to confirm that the diagnoses they are making are in line with what they are seeing clinically.
Another area is related to growth of procedures happening in the ambulatory space. Historically, we have had a lot of surgical procedures and other types of invasive interventions in the hospital-based environment, which is a very controlled setting. One of the areas that has presented new risk is a push toward having ambulatory procedures and not necessarily having the same safeguards in place as we had in the hospital-based operative arena.
Another area is communication among teams and across transitions. We still have work to do to ensure that we have robust communication around transitions and ensuring robust continuity of care between teams. That is going to be a continued area of priority and focus for all of healthcare for the foreseeable future.
HL: Where are the opportunities to improve communication?
Moses: Handoffs and transitions of care continue to be an opportunity.
When the emergency department is admitting patients to the inpatient area or there are surgical patients coming up from the operating room to a surgical ICU, there continues to be opportunity to ensure that teams are using standardized communication tools to help with the adequacy of handoffs and to make sure that everybody understands the key areas of care that need to be handed off.
In the transitions of care between providers and the ambulatory space, you are not in such an acute situation. But often, we see providers side-step direct communication between specialists and primary care doctors—they often communicate through their medical documentation, which is not the same as having huddles around complex patients with specialized needs. Patients would benefit if there were more planned communications.
HL: In healthcare, how far away are we from seeing the degree of safety that we see in the aviation industry?
Moses: Unfortunately, we are pretty far away from that level of safety. Healthcare is not like flying one airplane at a time. It is like flying hundreds of thousands of planes every day all at the same time. So, there is a high level of complexity that we deal with in healthcare. We do not have the safeguards we need to have in place to the extent that they should be in place.
It is going to be a long journey, but it does not need to be a forever journey. What I would like to see is a national focus on safety events and harm from safety events. That would help organizations to understand the true north of keeping patients safe. Having a national priority on patient safety would make the journey quicker as well as more robust and transformative.
It also would be beneficial for organizations to be more transparent about the frequency of harm events. When you look at the measures that we report, they are preventable harm measures and patient experience measures. But we do not have a national framework for reporting serious safety events in a way that allows folks to come together to learn best practices and to objectively understand how one organization may be doing a better job or worse job.
New policies are needed to close hospital patient safety gap between Black and White patients, researchers say.
Differences in the quality of hospitals that Black and White patients access are a driver of patient safety disparities between Black and White patients, a new report says.
Racial care disparities have been a concern in U.S. healthcare for decades. These disparities have drawn heightened attention during the coronavirus pandemic because Black, Hispanic, American Indian, and Alaska Native COVID-19 patients have experienced disproportionately high rates of negative outcomes including mortality.
The new report, which was conducted by researchers at the Urban Institute with funding from the Robert Wood Johnson Foundation, examines 2017 hospital discharge data from the Agency for Healthcare Research and Quality's Cost and Utilization Project. The researchers also used AHRQ software to focus on 11 patient safety indicators.
Four of the patient safety indicators were categorized as "general," including pressure ulcer rate and central venous catheter-related blood stream infection rate. The other seven patient safety indicators were categorized as "surgery-related," including perioperative hemorrhage or hematoma rate and postoperative sepsis rate.
The researchers also categorized hospitals as "high quality" or "low quality" based on whether a hospital was above or below the median value of each patient safety indicator.
The new report features four primary findings:
Compared to White patients, Black patients experienced worse care quality for six of the 11 patient safety indicators. The care disparity was particularly notable for surgery-related patient safety indicators, with Black patients experiencing worse care quality compared to White patients for five of the seven measures.
When the researchers focused on Medicare beneficiaries, there were similar Black-White disparities in patient safety indicators.
Black patients were less likely to be admitted to high quality hospitals for 9 of the eleven patient safety indicators. The care disparity was particularly notable for surgery-related patient safety indicators, with Black patients less likely to be admitted to high quality hospitals for six of the seven patient safety indicators. White patients were 9 percentage points more likely to be admitted to high quality hospitals on four patient safety indicators and more than 7 percentage points more likely to be admitted to high quality hospitals on six indicators.
Compared to White patients, Black patients were less likely to be admitted to high quality hospitals for two or more of the four general patient safety indicators. Compared to White patients, Black patients were 7.9 percentage points more likely to be admitted to low quality hospitals for all seven of the surgery-related patient safety indicators. Compared to White patients, Black patients were 4.9 percentage points less likely to be admitted to high quality hospitals for all of the surgery-related patient safety indicators.
"This study finds that Black and White patients face different standards of patient safety and that some of this disparity can be attributed to differences in the quality of hospitals patients access. Black-White disparities in patient safety are larger for quality measures surrounding surgical procedures, and Black patients are significantly less likely than white patients to access the hospitals best able to minimize these adverse surgery-related patient safety risks," the report says.
Interpreting the data
The propensity of Black patients to access low quality hospitals more often than White patients is a driver of quality disparities in hospital care, the lead author of the new report told HealthLeaders.
"We have known that Black and White patients experience different quality of hospital care for decades. The focus of this study was to ask whether these differences are, in part, driven by differences in the overall quality of hospitals that Black and White patients can access. The answer is, 'yes.' We find that White patients access high quality hospitals that are best able to minimize adverse safety events such as hospital-acquired illnesses or injuries," said Anuj Gangopadhyaya, PhD, a senior research associate at Urban Institute.
There have been several policies implemented in the past several decades that might have been expected to narrow differences in the quality of care, he said. "Those policies include Medicare discontinuing reimbursing hospitals for services treating specific hospital-acquired conditions as well as penalties enforced under the Affordable Care Act. Nonetheless, we continue to see persistent differences in patient safety across hospitals."
New policies are needed to close the Black-White patient safety gap, Gangopadhyaya said. "Black patients are consistently more likely to be admitted to hospitals that are on the worst end of patient safety measures. This is evidence that the current policies that are attempting to improve patient safety and narrow patient safety gaps are either sluggish or ineffective."
Disparities in surgery-related patient safety measures are "concerning to say the least," he said.
"The biggest disparities and patient safety gaps between Black and White patients are for surgery-related patient safety measures. At the population level, Black patients are far more likely than White patients to suffer from sepsis infections, pulmonary embolism, respiratory failure, and other horrible conditions that occur during or after a surgical procedure," Gangopadhyaya said.
The Affordable Care Act has not been effective in addressing this disparity, he said.
"It was well established before the Affordable Care Act that Black patients were consistently more likely to receive treatment at hospitals that were considered low quality with regard to surgery performance. In our research, we were interested in whether that story had changed at all in the post-Affordable Care Act world. The ACA was intended to improve healthcare access and affordability for vulnerable populations. Our results suggest there has been little change on this front. We continue to see patient safety gaps and differences in the quality of hospitals used by patients, particularly for surgical procedures."
COVID-19 has many parallels to earlier outbreaks including lack of preparedness, healthcare inequities, and politicization of pandemics, medical historians say.
Medical historians say there are pivotal lessens to be learned from the coronavirus pandemic and previous widespread outbreaks.
The coronavirus pandemic is the worst infectious disease outbreak in the United States since the 1918 influenza pandemic, with each virus claiming more than a half million American lives. There are instructive parallels to be drawn between the coronavirus pandemic and outbreaks such as the 1918 flu, a quartet of medical historians from Michigan Medicine's University of Michigan Medical School says.
Preparation and health equity
Howard Markel, MD, PhD, director of the Center for the History of Medicine at the medical school, says the coronavirus pandemic has illustrated the necessity to prepare for global pandemics in the future.
"We have to be on guard and fix the things that led to this pandemic. This is the worst crisis of our lives, and the biggest collective experience since the Great Depression. If this doesn't teach us once and for all to start preparing for pandemics in the modern world, where an outbreak anywhere can go everywhere, I don’t know what will," he says.
Investing in public health is like investing in public safety, Markel says. "I have a firehouse two blocks from where I live, and I have never called it. But I pay my taxes and I'm glad it's there in case we do need it. That's what we have to be doing with public health at the local, state, national and international level."
Inequity has taken a heavy toll in lives during the coronavirus pandemic and earlier outbreaks such as the typhus epidemics two centuries ago in London, he says. "The poor don't get sick because they're bad or unworthy, they get sick because they're poor, living in crowded conditions, without access to healthcare."
In terms of inequity, history is repeating itself during the coronavirus pandemic, Markel says. "Now we have a different pandemic and what a surprise, the poor are more affected than the wealthy. But what I fear is that like pandemics and epidemics past, the last act of this one will be amnesia, and going back to life like it was."
Parallels to earlier pandemics
There are several similarities between the coronavirus pandemic and the 1918 flu, says Powel Kazanjian, MD, PhD, chief of infectious diseases at the medical school and a medical historian. "A surge of infection that overwhelms capacity is similar with 1918 flu, as is the government downplaying of infection that led to a lack of concerted, centralized guidelines, and the loneliness of social isolation."
Placing personal liberty and economics ahead of public health concerns is common in the history of infectious disease outbreaks, he says. "I am not surprised by the differences in the adherence to social distancing guidelines by individual states, or the prioritization of economy over public health issues—a that has been seen before."
Public health interventions
Public health recommendations targeting behavior such as social distancing and mask wearing proved effective in both the coronavirus pandemic and the 1918 flu, J. Alexander Navarro, PhD, assistant director at the Center for the History of Medicine says.
Public health measures "had a major positive impact on the case count and death toll in those places that implemented them early, used multiple interventions, and kept them in place for as long as possible," he says.
The coronavirus pandemic and earlier outbreaks show the necessity of funding public health, Navarro says. “When budgets are tight, public health spending is low-hanging fruit. That is, until a crisis suddenly pops up and we need to call on a robust infrastructure that has been allowed to crumble."
Pandemic politics
The coronavirus pandemic is generally comparable to the 1918 flu, but the influenza pandemic is not the best prior U.S. example of politicizing an outbreak, says Joel Howell, MD, PhD, Elizabeth Farrand Professor of the History of Medicine and director of the medical school's Program in Society and Medicine.
"The obvious, and most comparable, is the 1918 flu pandemic. But there are lessons to be learned from comparisons as well to the onset of AIDS, especially in the ways that the epidemic was used to justify a set of political and moral beliefs," he says.
Political leaders including members of the Reagan administration targeted the gay community in the early phase of the HIV/AIDS outbreak in the 1980s.
History tells us that there will be more major infectious disease outbreaks, Howell says. "This will not be the last pandemic. We need to be ready for the next one, which could be a lot worse."
The new facility in Cleveland will combine a range of services, including intensive rehabilitation, skilled nursing, and a multi-specialty geriatric practice on-site.
Two Ohio-based health systems have signed a collaborative agreement to operate a comprehensive skilled nursing and rehabilitation center in the Old Brooklyn neighborhood of Cleveland.
Traditional skilled nursing facilities are often standalone institutions with limited connections to acute care hospitals and home health services. The new facility in Cleveland, which is set to open by the end of the year, is being designed to have smooth transitions of care from the hospital setting to the home setting.
The new partnership features Toledo-based ProMedica and The MetroHealth System in Cleveland. The new facility, which will be located in the former Deaconess Hospital, will be called ProMedica Skilled Nursing and Rehabilitation at MetroHealth and will serve a mainly senior population.
ProMedica Skilled Nursing and Rehabilitation at MetroHealth is envisioned as a new approach to post-acute care for seniors, says Julie Jacono, MBA, senior vice president and chief strategy and innovation officer at MetroHealth.
"Most skilled nursing facilities are a disconnected campus. The patients get transported from one place to another. Physicians from a health system may come into the facility or they may not come into the facility. What is different with our new facility is this is a fluid continuity of care from multiple stages of care. It is one team following the patients all the way through their care. We feel that continuity of care and joint accountability for how the patient does in the end is what makes this new facility very different," she says.
The new facility will have 96 beds for lengths of stay expected to be less than 30 days. It will provide medically complex and intensive rehabilitation services for patients transitioning from hospital to home as well as 24-hour skilled nursing care. The facility will offer outpatient care and convenient access to inpatient rehabilitation services, geriatricians, and geriatric specialists.
ProMedica Skilled Nursing and Rehabilitation at MetroHealth is being designed as the skilled nursing facility of the future, says Randy Oostra, DM, president and CEO of ProMedica.
"We have tapped healthcare industry experts, architects, infection preventionists, and other specialists. A lot of their features are included in this partnership such as all private rooms. The facility will have some rehab capabilities that will be enhanced. And there will be the kind of monitoring you would expect in more modern facilities. When people walk in, the facility will look, operate, and feel very different than the senior facilities that were built 20 years ago," he says.
Key elements of the partnership
ProMedica Skilled Nursing and Rehabilitation at MetroHealth will be jointly staffed by the health systems, Jacono says.
"With the exception of the physicians and the therapists, the caregivers will be ProMedica staff. They will be hired and managed by ProMedica Senior Care. That is why this is a partnership. We will be jointly staffing elements of the care team. It is why we feel very optimistic about this partnership because ProMedica has done this before, and they were open and excited to work with us collaboratively," she says.
ProMedica and MetroHealth are well-suited for this kind of partnership, Oostra says. "We are both strongly mission-based in that we are committed to addressing social determinants of health and we have a lot of focus on working in our neighborhoods. In talking with MetroHealth, we have a lot of focus on the next level of care coordination for seniors as they come out of acute care and how you integrate that better."
ProMedica Skilled Nursing and Rehabilitation at MetroHealth will be a cornerstone of the Old Brooklyn neighborhood, Jacono says.
"That entire campus is dedicated to the unique needs of seniors as they move across the continuum of care, and it is in a great neighborhood. Surrounding that campus, there are several apartment complexes that serve large numbers of seniors. At both ProMedica and MetroHealth, we see this as a community facility. So, we have worked diligently with community partners, and they see this facility as a new asset in the Old Brooklyn community. It can drive quality of life and economic development in that community. Residents in this community see this facility as a great alternative for them to remain healthy and age in place," she says.
Preparing patients for success
For seniors, the new facility will serve as a bridge between the hospital setting and the home setting, Oostra says.
"Patients coming out of a hospital are often not prepared to go about their normal lives. With penalties for rehospitalizations, what we have been seeing at health systems is the need to link hospitals more closely with senior facilities to prevent rehospitalization or declines in health. One of the services this new facility will be providing is intensive rehabilitation to set up patients to thrive at home," he says.
A comprehensive approach to care will be a crucial aspect of ProMedica Skilled Nursing and Rehabilitation at MetroHealth, Jacono says.
"It is innovative because it is part of a larger system of care. In one campus, we are having some of the top physical medicine and rehabilitation doctors and our geriatric doctors working together. What we envision is a physical representation of a patient-centered medical home. We have the physical asset to be able to bring patient-centered care around our seniors," she says.
A wide array of services will be available in the new facility, Jacono says.
"Over the past five years, we have made a series of investments to make the Old Brooklyn Campus our primary hub for acute rehabilitation, spinal cord injury, and bringing the rest of our assets around geriatrics. On this campus, you are going to have a comprehensive personality for outpatient geriatric care, skilled nursing geriatric care, acute rehab, and research related to rehabilitation. McGregor PACE is a partner in that building—they have a great day program for seniors who are trying to avoid going to a nursing home," she says.
The new facility will help seniors make the transition to their homes, Jacono says.
"Our teams will work collaboratively, so that when a senior is ready to be discharged from the skilled nursing facility back into their home, we will have the right home care set up to be successful. We will assess social determinants of health, so if what a patient needs to be successful at home are additional services, we have the McGregor PACE program and a strong relationship with our local agency on aging to make sure that discharge is not just a checked box. We will not be saying, 'You are done with your rehab—good luck!' We will be taking responsibility for a patient's success and outcomes as they transition home," she says.
ProMedica Skilled Nursing and Rehabilitation at MetroHealth will provide a model of care that should be attractive to other health systems, Oostra says.
"We think these kinds of partnerships will start to evolve across the country, and that more and more health systems that may not have traditionally focused on senior care will look at this as a model for what they can do not only for patients leaving their hospitals but also what they can do to address aging in neighborhoods," he says.
Health system executives surveyed early this year are optimistic about service volumes despite ongoing uncertainty linked to the coronavirus pandemic.
Although hospital service volumes decreased significantly in 2020, health system leaders expect most service volumes to rebound by 2022, a new survey found.
Particularly during the early phase of the coronavirus pandemic, healthcare providers experienced sharp declines in service utilization. The drivers of reduced utilization included state restrictions on elective surgery to accommodate coronavirus patient surges and patients deferring care because they feared exposure to the virus in healthcare settings.
The new survey, which was conducted by New York-based McKinsey & Company from Jan. 17 to Feb. 5, collected information from 30 of the largest nonprofit and for-profit health systems in the country.
A surprising finding of the survey was significant optimism about the future despite continuing uncertainty linked to the pandemic, says Kyle Gibler, MD, MBA, a partner at McKinsey & Company.
"When we talk with clients, many are concerned about a slow recovery of volumes to pre-COVID levels. But in our survey, most health systems predicted a near-return to historical levels by the middle of 2021 for most clinical areas. Even emergency department volumes, which many health systems have publicly talked about potentially never returning to pre-COVID levels, were projected to fully return by 2022," he says.
The survey includes several key data points:
Inpatient admissions: On average, hospitals surveyed experienced a more than 20% decrease in inpatient admissions from March to June 2020. Survey respondents reported that inpatient admissions rebounded by the end of 2020, ending the year at about 7% below 2019 levels. Survey respondents expected inpatient admissions to remain at 2019 baseline levels in early 2021, but they forecasted an increase of 7% to 8% in 2022 and 2023.
ED visits: Hospitals surveyed experience about a 14% decrease in ED visits in 2020, and they expected to remain below pre-pandemic levels this year. Survey respondents expected ED visits to return to baseline by 2022 and to increase about 5% over 2019 baseline levels by 2023.
Outpatient visits: Health systems surveyed experienced a more than 15% decrease in outpatient visits in 2020. They expect outpatient visits to rebound to baseline by the second quarter of this year and to increase about 7% above 2019 baseline levels by the end of this year.
Surgical volume: On average, health systems surveyed experienced about a 14% decrease in operating room procedures in 2020, and they expect surgical volume to return to baseline by the third quarter of this year. Survey respondents expect OR procedures to increase about 8% above 2019 levels by 2022.
Interpreting the data
Last year's decrease in inpatient admissions was partially offset by higher acuity among hospitalized patients, says David Bueno, PhD, a partner at McKinsey & Company.
"What we saw was that the number of patients hospitalized over that period certainly decreased, but what we also saw was an increase in acuity. So, while there were fewer patients in the hospitals, the patients who were in the hospitals were sicker. If we look more recently in the last quarterly report, we see revenue per adjusted admission up in the range of 15% year-over-year. So, there was smaller volume but sicker volume. That certainly helped hospitals sustain themselves from a financial perspective," he says.
Lower ED volumes could be a long-term trend, Gibler says.
"While ED volumes are starting to recover in the most recent quarter, many health systems expect ED volumes to remain below historical baselines for a while if not indefinitely as lower acuity patients seek other channels of care such as urgent care, primary care offices, and virtual care visits. What we expect is for hospitals to change their channel strategy. They will likely decrease the size of their ED footprint and increase in-person access points in the community such as urgent care and primary care as well as adopt digital offerings to make care more convenient," he says.
In EDs, patient acuity has had a similar effect on emergency room visits as inpatient admissions, Gibler says. "While ED volumes have been down, the average acuity has been above historical levels over the past 12 months. So, there has been some natural offset of the decreased volume by seeing sicker patients coming through the ED."
Preventive care is likely to be a primary driver of increased demand for outpatient services, Bueno says.
"We have certainly seen an outpatient visit drop-off. One of the things that we are looking for in the future is as an increasing percentage of the population becomes vaccinated for COVID hopefully health systems will see the number of preventative care visits increase, which would increase the total number of outpatient visits," he says.
Health systems are taking three approaches to the decrease in surgical volumes, Gibler says.
Some health systems are operating business as usual, with below historic volumes because they are taking whatever demand that they get. But they are not changing operations to accommodate any of the expected backlog of procedures such as knee replacements.
Some health systems are changing their bread-and-butter clinical operations and making improvements such as fixing their turnover times and making other improvements that are known levers to improve operational performance.
The bold approach is using the down time in 2020 and 2021 to completely rethink how health systems are running their ORs to accommodate volume increases after the pandemic passes, Gibler says. "They are redesigning their OR operations by using new digital tools to automate parts of the process and increase reliability. They are engaging patients in new ways to make sure that patients are not artificially deferring care longer than they need to. They are using analytics to better and more agilely match supply to demand. So, the health systems that are redesigning their OR operations will capture an outsized share of the backlog."
Historical influenza trends illuminate how to roll out coronavirus vaccines to underserved racial, ethnic, and socioeconomic groups.
Influenza vaccination trends provide valuable insight into the equitable rollout of coronavirus vaccines, a new report says.
The coronavirus pandemic has exposed inequities in the U.S. healthcare system, particularly for racial and ethnic groups, according to the Centers for Disease Control and Prevention. Research published by JAMA Network Open shows Americans with low incomes are also suffering disproportionate coronavirus infection and death burdens.
The new report, which was published by Urban Institute researchers with funding from the Robert Wood Johnson Foundation, examines historical trends for flu vaccination that indicate ways to address racial, ethnic, and economic inequities in the rollout of coronavirus vaccines. The report is based on data from the 2016 to 2018 National Health Interview Survey.
The Urban Institute report focuses on three risk groups: Nonelderly adults from 19 to 64 who are a low risk of severe COVID-19 illness, nonelderly adults from 19 to 64 who are at high risk of severe COVID-19 illness, and elderly adults 65 and over who are at high risk of severe COVID-19 illness due to their age. The report includes several key data points.
Low- and high-risk nonelderly Black and Hispanic adults had lower flu vaccination rates than their White counterparts. For example, among low-risk nonelderly adults, the flu vaccination rate for Black adults was 26.2% and the vaccination rate for White adults was 40.6%.
Risk was associated with likelihood to receive a flu vaccine among nonelderly adults with public forms of health coverage. High-risk nonelderly adults with Medicaid (34.2%) and Medicare or other public coverage (51.2%) had a higher likelihood of getting a flu vaccine than their lower risk counterparts with the same coverage (29.5% and 42.9%, respectively).
American Indians and Alaska Natives had flu vaccination rates that compared favorably with Whites. For example, among low-risk, nonelderly adults, the AI/AN vaccination rate was 45.2% and the White vaccination rate was 40.6%.
For all three COVID-19 risk groups, the presence or absence of a usual source of care was highly associated with flu vaccination rates. For example, among elderly adults, those with a usual source of care had a 69.2% flu vaccination rate compared to a 33.4% flu vaccination rate for those with no usual source of care.
Uninsured nonelderly adults had the lowest flu vaccination rates: 15.4% for low-risk nonelderly adults and 16.9% high-risk nonelderly adults.
"These findings emphasize the need to explicitly consider racial and socioeconomic equity in prioritizing rollout of the COVID‑19 vaccine. This will involve addressing access issues by expanding delivery site options and providing assistance with appointment scheduling and other logistics," the Urban Institute researchers wrote.
Four coronavirus vaccine insights from flu vaccination trends
The historical flu vaccination trends have four primary implications for the equitable rollout of coronavirus vaccines, the researchers wrote.
1. Risk has a significant impact on ethnic, racial, and socioeconomic likelihood to get vaccinated. "Among the nonelderly Black, Hispanic, Medicaid/CHIP and lower income adult populations, the higher risk group was more likely to receive their flu vaccine than their lower risk counterparts, and this pattern was particularly pronounced among lower income Black and Hispanic adults. The health conditions that put individuals at higher risk may also increase their contact with and trust in their healthcare providers and thereby increase vaccine uptake," the researchers wrote.
2. The relatively high flu vaccination rates of the American Indian and Alaskan Native populations provides insights for rolling out coronavirus vaccines to other groups that have historically experienced healthcare disparities. "Early evidence suggests that the COVID‑19 vaccine rollout among Native Americans has been very successful, with many tribes using call centers rather than online systems to schedule appointments and taking advantage of a variety of existing outreach media including newsletters, radio announcements and direct mail," the researchers wrote.
There is a lesson to be learned in avoiding reliance on the Internet to engage and enroll people for vaccination, they wrote. "Some of these strategies, especially less reliance on Internet‑based scheduling and extremely targeted outreach to the most vulnerable, could improve access for other older, less tech savvy populations."
3. It will be crucial to address low vaccination rates among uninsured adults and adults without a usual source of care. "Low vaccination rates in the South may also be related to lower rates of insurance coverage, and in the absence of progress on Medicaid or other coverage expansions, it will be important to focus on community health centers and other delivery sites that serve the uninsured," the researchers wrote.
Adults without a usual source of care would be well-served by nontraditional vaccine delivery sites, they wrote. "These may include retail pharmacies, which have also started receiving direct shipments of COVID‑19 vaccines in an effort to improve equity of vaccine distribution, and mass vaccination sites such as stadiums and convention centers."
4. Employers and community groups need to be enlisted to distribute coronavirus vaccines, the researchers wrote.
"Given that most nonelderly adults who did not receive a flu vaccine were working, employers could potentially play an important role in outreach and as delivery sites as the economy continues to reopen and vaccine supply increases. Similarly, leveraging the communication networks of places of worship, schools, sports leagues, and other trusted community organizations to promote vaccination will be critical in reaching individuals who may not regularly interact with the healthcare system."
