Schaal has three strategies for addressing the high-profile issues of physician burnout and well-being.
"We want to create a culture of wellness for physicians at Houston Methodist," she says. "We do not want a culture where physicians feel pressured to see as many patients as possible as fast as they can."
“The second thing we are focusing on for physician well-being is the efficiency of practice," she says. "There are many things in the modern practice of medicine that take up a physician's time, and we want to redesign our processes to make sure our physicians are practicing at the top of their licenses, and they have support to do things such as coding, billing, and answering messages."
"The third thing is personal resilience," Schaal adds. "We know there are ways that we can help physicians increase their personal resilience, which is related to a culture of wellness and efficiency of practice."
Schaal, who also serves as president and CEO of Houston Methodist Physician Organization, is leading a Joy in Medicine Initiative (JIMI) as well as reaching out to Houston Methodist physicians to see how they define a culture of wellness.
"I have to ask physicians, 'What does a culture of wellness mean for you?'" she says. "The idea behind JIMI is not to do a top-down assessment, then have me say, 'I think that a culture of wellness is defined by four elements, and here they are.' We are going to physicians and asking them about a culture of wellness."
Developing leaders
Schaal is also focused on leadership development this year.
Houston Methodist, which features an academic medical center and six community hospitals, has three leadership development programs: The Chair Academy, which serves the physician leaders who run the health system's clinical departments; the Administrator Academy, which mainly serves the administrative dyad leaders who are paired with clinical department chiefs; and a Physician Leadership Development Program.
"I truly believe that our leaders are the prime people who affect the efficiency, the morale, and the capabilities of their teams," Schaal says. "I want Houston Methodist to have the best leaders possible."
This year, the Chair Academy and the Administrator Academy are focused on three areas:
Leadership: Program participants will find out about the key components of leadership, including the qualities of a good leader, how leaders influence people, and team building.
Philanthropy: Program participants will learn about how to be well-versed in philanthropy to work with people who would like to donate to Houston Methodist or support an initiative that the health system believes is important. "Philanthropy is important because in medicine you need philanthropic help in order to go above and beyond for your patients," Schaal says.
Communications: Program participants find out about how good leaders communicate verbally, inspire people through communication, communicate with a team, and relay bad news.
The Physician Leadership Development Program is taught collaboratively with Houston Methodist executives and Rice University professors. The program is designed for physician leaders who are not department chairs, and it lasts for six months.
It's basically a condensed version of an MBA program, Schaal says.
"We have several modules that physicians learn, including strategy, organizational behavior, finance, and operational management," she says.
Quality and patient safety
Schaal is also focused on advancing quality and patient safety.
"In my role as chief physician executive, quality and patient safety is part of my responsibility," she says. "We deliver high-quality care at Houston Methodist as measured by organizations such as U.S. News & World Report, the Centers for Medicare & Medicaid Services, Leapfrog, and Vizient. All of our hospitals are top performers in these external rankings. When I came here in April 2023, a big part of my role was to take quality and patient safety one step forward."
Last year, Schaal conducted a listening and learning tour of Houston Methodist facilities to see how the health system could improve quality and patient safety. During this tour, she learned that Houston Methodist did not have a communications strategy for quality and patient safety.
"We devised a communications strategy to communicate all the great things we are doing," she says. "Now, we have a website for quality and patient safety. We have a newsletter called Quality Time and a podcast called Quality Time. This is a way for us to share everything that we are doing with each other and with the world."
Schaal also found a lot of variation in how quality teams were built at Houston Methodist. So the health system devised a "diamond structure” at each facility, comprised of the CEO, chief quality officer, chief nursing officer, and quality director to lead quality efforts.
"In the diamond structure, all four of these executives work together to lead quality at their facility," she says. "This standardization has been helpful because we have also built communities around our CEOs, chief quality officers, quality directors, and CNOs. They can share knowledge with each other, with the spirit that a rising tide lifts all boats. If we share with each other, we can solve problems together rather than acting in siloes."
Schaal says the health system wants to "capitalize" on quality and patient safety academically, rather than financially.
"We want to highlight our process improvement efforts and all of our ideas and innovations at Houston Methodist at academic conferences," she says. "We want to share the success of our quality and patient safety efforts with our colleagues in Texas, the nation, and the world. We want people in other health systems to learn from us, so they can also improve."
Photo: Shlomit Schaal, MD, PhD, MHCM, is executive vice president and chief physician executive at Houston Methodist. Photo courtesy of Houston Methodist.
Most behavioral health patients do not need to receive care in hospital emergency departments, the chief physician executive of WellSpan Health says.
By offering a wide spectrum of mental health services, WellSpan Health has been able to reduce the number of behavioral health patients seeking care in the health system's emergency rooms.
Crowding at emergency rooms has become a national problem. According to CMS data, the median wait time for patients in emergency rooms has increased from 2 hours, 18 minutes in 2014 to 2 hours, 40 minutes in 2022. The average overall length of stay for emergency room patients increased from 184 minutes in 2019 to 205 minutes in 2022, according to the Emergency Department Benchmarking Alliance.
WellSpan has embraced providing behavioral health services as a core element of the health system's mission, says Anthony Aquilina, DO, executive vice president and chief physician executive.
Pictured: Anthony Aquilina, DO, executive vice president and chief physician executive at WellSpan Health. Photo courtesy of WellSpan.
"WellSpan is the 13th largest provider of behavioral health services as a health system in the United States," he says. "It is a significant part of what we do. We certainly provide more behavioral health services to the people of south-central Pennsylvania than any other health system around us."
WellSpan offers a range of behavioral health services, including inpatient services, intensive outpatient programs, partial hospitalization programs, telemedicine, behavioral health specialists embedded in emergency departments, and residential care. In the spring of 2021, the health system launched an innovative behavioral health clinic, the Specialized Treatment and Recovery Team (START).
Offering a plethora of behavioral health services has helped reduce the number of behavioral health patients seeking care in WellSpan's emergency rooms. From January 2023 to January 2024, the number of patients seeking behavioral health care in the health system's emergency departments decreased 50%.
Most behavioral health patients do not need to be in emergency rooms, Aquilina says.
"Traditionally, these patients have gone to an ER or have waited months to see a behavioral health provider," he says. "There must be access to services somewhere in between those extremes. That is why we have things like our START program and other options as well. As a chief physician executive, I know our health system thrives when we deliver great care. The best care is delivered to patients at the right place at the right time."
In addition to contributing to emergency department crowding, there are negative consequences for behavioral health patients seeking care in emergency rooms, including a suboptimal patient experience, Aquilina says.
"The main drawback is if you go to an emergency room there is a triage process, and if you are not as sick as someone else you have to wait for care," he says.
Increasing access to behavioral health services
The START program at WellSpan has increased access to multidisciplinary behavioral health services.
The START clinic offers same-day and next-day appointments for people who need behavioral health services. The clinic is open 8 a.m. to 8 p.m. Monday through Thursday and 8 a.m. to 4 p.m. on Fridays. There are plans to have the clinic open on Saturdays.
The START clinic is focused on providing rapid access and stabilization, says Mitchell Crawford, DO, medical director of addiction services at WellSpan and medical director of the START program.
"It is not the long-term home for everyone, and it is not everything for everyone, but it is a place for patients who need immediate help and a place where patients can get stabilized until they can get to a setting that is more appropriate for longer-term care," he says.
The START clinic has a team-based approach to care, Crawford says.
"I serve as the medical director of the clinic, and we have two nurses, clinical leadership, social service specialists, crisis management specialists, peer specialists, and therapists for mental health and treatment of addiction," he says.
START has purposely designed care not to be paternalistic, Crawford says.
"We do not want to say, 'I'm the doctor. I know what is best for you. Here is your treatment plan for the diagnosis I gave you. Take this medicine, and I'll see you in two weeks,'" he says. "With that kind of approach, you do not hear the participant. You do not establish an alliance with the participant. They would take their treatment plan and prescription, then put them in a trash can on their way out the door. Then we would not see them again, and they would decompensate and end up in one of our emergency departments."
Crawford says START staff members ask program participants—they are not called patients—a key question: What is most important to you right now and how can we help? START clinicians provide participants with medical care, but if a social need is most important to a participant that gets addressed as well.
A program participant may be going through a divorce and have worries about eviction and putting food on the table, Crawford says.
"They have a hierarchy of needs beyond their mental health condition, which I offer a treatment plan for. But I also pull in our social services specialist, who is really the caregiver that the participant needs to talk to in that moment," he says.
Matthew Ewend is focused on patient and caregiver experience as well as balancing academic and community medicine.
The leading 2024 priorities for the chief clinical officer at UNC Health include improving the experience of patients and care providers.
"We want to make the experience of delivering healthcare and receiving healthcare better," says Matthew Ewend, MD, chief clinical officer of UNC Health and president of UNC Physicians. "Right now, it is not much fun to deliver healthcare and for many of our patients it is challenging to enter into the system and to get healthcare."
1. Supporting caregivers
Ewend says his number one priority is supporting his clinical care team.
"I want to use the position I have to ease barriers for my staff," he says. "I use the analogy of football, where the pulling guard is out blocking. I want to clear the path and break down barriers, so that the people on my team can work on things such as quality, high-value care, improving our clinic functions, and getting services to patients in rural areas who do not have access to care."
Technology such as artificial intelligence can improve the caregiver experience, Ewend says.
"For example, when I am in my clinic, I put my phone down on the desk, then I ask my patient's permission to use ambient listening," he says. "It listens to the conversation with the patient, and it generates a note. By the time I get back to my work station, I have an AI-generated note about the patient encounter. It is organized with the patient history, what I found during the physical exam, what tests such as X-rays showed, and the plan of care. It is not perfect, but it is better than me typing a note. This is an example of making it easier for providers to deliver care."
Managing messaging on the health system's patient portal is another way Ewend wants to support clinicians.
"When we created the patient portal, people thought we were creating a means to send messages to providers like they were messaging a friend. Patients felt they should be able to message anything at any time and get an answer back right away," he says. "So, we have set expectations for our patients. You can expect an answer within three business days, and you should ask questions that are a continuation of care that you have received. Some of the answers might be that the patient needs a virtual appointment, a phone call, or an in-person visit. So, we set expectations with our patients, and we set expectations with our doctors. We want our doctors to answer these questions, but we understand they cannot answer patient portal questions within 10 minutes."
By setting expectations and using technology and support staff to screen messages, UNC Health has been able to reduce the number of patient portal messages being sent to clinicians and decrease the amount of time clinicians are spending tackling messages, Ewend says.
"More importantly, we have made it so when a message reaches our doctors, it is only something the doctor can answer," he says. "They do not get messages about a patient expecting to be 15 minutes late for an appointment. That may be good to know, but it does not need to come to the doctor—it should go to someone else on the team."
Matthew Ewend, MD, chief clinical officer of UNC Health and president of UNC Physicians. Photo courtesy of UNC Health.
2. Patient experience
From the patient standpoint, Ewend wants it to be easier for patients to find their way to the right provider, at the right place, with the right expertise.
"The analogy we use is air travel. You can go online and book a flight to China on your phone, but it can be difficult to book an appointment with your primary care doctor," he says. "The problem is we are comparing receiving healthcare to a single, episodic event. It is easy to order protein powder from Amazon, but that is a much simpler thing to deliver than a kidney transplant."
To apply the consumer expectation that healthcare is going to be instantaneously available and at the patient's fingertips is very complicated, Ewend says.
"We want to offer online scheduling," he says. "We want patients to able to access their providers in a thoughtful way and to be able to get information about their care through patient messaging, but we know when that is done badly it overwhelms our providers."
3. Balancing academic and community health priorities
Ewend plays a role in balancing UNC Health's academic mission with its commitment to serve communities across the state of North Carolina.
"We want to be at the forefront of academic discovery, research, training the next generation of healthcare providers, and providing complex subspecialty care. But we also have the mission of serving the entire state of North Carolina and improving the health of the people of North Carolina," he says. "So, our health system is trying simultaneously to serve all the people of North Carolina and also to be at the forefront of developing new knowledge, new technology, and new research breakthroughs, as well as training the next generation of care providers."
Harnessing the collective power of the health system's academic and community physicians is among Ewend's top priorities.
"I want to clear the path so that our community physicians, who are a crucial part of our mission, are able to do the work that they do, which is providing high-quality care close to patients in their hometowns. At the same time, I want to support our academic group in doing groundbreaking research, training, and providing the quaternary care that they do."
Using technology to make things easier for clinicians is one of four top priorities on J.P. Valin's schedule this year.
With stress and burnout at high levels this year, Intermountain Health's chief clinical officer wants to make things simpler.
"When I think about simplification for our physicians and APPs, with whom I work most closely, we need to look at some of the emerging technologies and to deploy emerging technologies that are going to reduce some of the tasks that they do and free up time for direct patient care," James P. Valin, MD, says.
"On the physician and APP side, I am really interested in some of the ambient listening tools. We are looking at a couple of different tools that will listen to a doctor-patient interaction to transcribe that and turn it into a note, which will simplify work for our physicians and APPs."
Here are four of Valin's priorities for Intermountain and how he plans to make it simple.
1. Simplicity
Valin, who was named CCO of the eight-state, 33-hospital health system in 2022 after its merger with SCL Health, lists simplicity as one of his four top priorities this year.
He says initial piloting of ambient listening technology at Intermountain has been promising in terms of freeing up time for physicians and APPs, reducing documentation time by as much as two hours a day.
"This can be life-changing for our providers," he says.
He's also looking forward to the enterprise-wide deployment of a single electronic medical record.
"We currently have a mix of electronic medical records across our footprint, and we are working to be on one platform—Epic," he says. "We will be spending a lot of this year planning for that transformation and doing the build for deployment in 2025. Enterprise-wide, we will be on a single longitudinal electronic health record. This is an opportunity to simplify our work and streamline a lot of our care processes."
J.P. Valin, MD, chief clinical officer of Intermountain Health. Photo courtesy of Intermountain Health.
2. Improving access to care
Another priority for Valin is improving healthcare access for patients. This includes opening new clinics, recruiting new physicians and APPs, and creating space within existing clinics to be able to accommodate more patients.
"We are in three of the fastest growing metropolitan areas of the country—Salt Lake City, Denver, and Las Vegas," he says. "There is a tremendous need for care in the population we serve, and we are focused on meeting that need."
Intermountain is facing the challenge of recruiting more physicians and APPs in a tight clinician labor market, Valin says.
"Our goal is to make Intermountain the best place to work and provide care," he says. "Some of that is giving our physicians and APPs the right tools such as ambient listening—we think that will be a differentiator. We have focused a lot on physician and APP well-being. We have put a lot of support tools around our physicians and APPs. In 2023, we were able to recruit more than 900 physicians and APPs to our organization."
Other efforts include building a talent pipeline. The health system is partnering with medical schools, graduate medical education programs, and APP schools as well as creating learning experiences across the organization for student learners.
To boost physician and APP well-being, Valin says Intermountain's leaders have spent a lot of time understanding the clinician experience.
"That has led to targeted efforts around simplification and making it easier to practice medicine," he says. "We also have a dedicated focus on keeping clear lines of communication open across our organization between our physicians and APPs and their leaders in the enterprise. Those efforts have helped people to feel connected and have a sense of belonging."
3. Value-based care
Valin is also at the forefront of moving the health system from fee-for-service to value-based care.
"As an organization, this is an enterprise-wide priority for us," he says. "We absolutely believe that the future for healthcare is in the value-based care arena, where we are taking full clinical and financial accountability for more patients."
Intermountain has a broad footprint across eight states, and each market is in a different place in its value-based care journey. The health system's goal, Valin says, is to identify and meet those markets where they are and increase partnerships with payers to advance value-based care.
Intermountain's primary value-based care strategies include increasing preventative services and embracing early interventions for illnesses, both of which can improve the overall health of the population.
The health system is also pursuing value-based care arrangements with commercial payers and participating in the Medicare Shared Savings Program and accountable care arrangements in Medicare Advantage.
4. Post-merger integration
Valin is also continuing integration efforts tied to Intermountain's merger with SCL Health.
"We are continuing to move and advance our clinical integration; as part of that, we are doing a lot of work with clinical best practice implementation at scale," he says. "Intermountain has had a long history of identifying clinical best practices and deploying them across a broad footprint, so that we have a high degree of reliability and consistency in care delivery. We can spread that even further across the legacy SCL Health footprint."
Valin says he wants to create a consistent clinical experience for patients regardless of where they interact with Intermountain.
"It starts with what it feels like when you walk into a clinic or a hospital," he says. "The feel and the interaction should be the same at all of our facilities. It is also about how people interact digitally and how they interact in terms of care processes. We want to ensure that our care processes are aligned and feel the same at our clinics and hospitals."
Urgent care centers can treat many conditions commonly treated in emergency rooms, including sprains, fractures, lacerations, and urinary infections.
More than two dozen members of the U.S. House of Representatives have written a letter to the Centers for Medicare and Medicaid Services (CMS) asking the agency to pursue policies that would encourage patients with non-emergent needs to visit urgent care centers rather than emergency rooms.
Crowding at emergency rooms has become a national problem. According to CMS data, the median wait time for patients in emergency rooms has increased from 2 hours, 18 minutes in 2014 to 2 hours, 40 minutes in 2022. The average overall length of stay for emergency room patients increased from 184 minutes in 2019 to 205 minutes in 2022, according to the Emergency Department Benchmarking Alliance.
Daniel Roth, MD, executive vice president and chief clinical and community division operations officer at Trinity Health, says the health system is experiencing widespread crowding at its emergency rooms.
"Across Trinity Health, we are seeing crowding in our emergency rooms," he says. "It has a negative impact on care and our caregivers, and it leads to long wait times for our patients."
Emergency room crowding results in several negative consequences, Roth says.
"First and foremost, it is not a good patient experience—patients wait a long time in emergency rooms," he says. "Emergency room crowding can have a negative impact on care—care processes get slowed down. Emergency room crowding creates strain on caregivers—it is creating a strain on an already stressed group of nurses, technicians, and physicians, who are working harder than ever."
Solution for ER crowding
Urgent care centers represent a solution to the problem, the members of Congress said in their letter to CMS.
"Despite growing acknowledgment of the challenges caused by overcrowding in emergency rooms, few efforts to mitigate this problem have been successful. Resolving these issues will require significant public and private investment, and we believe that urgent care centers are an easily accessible resource that can reduce crowding by providing treatment to non-emergency patients in a more appropriate setting."
The lawmakers cited two 2019 studies that indicate urgent care centers can ease crowding at emergency rooms and reduce costs. A National Bureau of Economic Research study found that up to half of the annual 137 million emergency room visits could be treated at a less emergent facility. A Medicare Payment Advisory Committee report found that one-third of nonurgent emergency room claims could be appropriately treated in an urgent care center at a third of the cost.
Kevin DiBenedetto, MD, chief medical officer of Premier Health, which specializes in urgent care center joint ventures with health systems and hospitals, says urgent care centers can help ease emergency room crowding across the country.
"There are more than 14,000 urgent care centers in the country, so there are many of them in every state and Washington, DC," he says. "We think there is still room for more urgent care centers, but they are spread across every region of the United States."
DiBenedetto says many conditions that are commonly treated in emergency rooms can be treated at urgent care centers.
"Many conditions treated in hospital emergency departments can be treated at urgent care centers," he says "These conditions include sprains, fractures, lacerations, musculoskeletal injuries, respiratory illnesses, and urinary infections. Urgent care centers also can perform X-rays and diagnostic lab tests."
Urgent care centers are a key element of Trinity Health's care delivery strategy, Roth says.
"We are continuing to work in our partnership with Premier Health and with other urgent care centers across Trinity Health to try to improve access and to make sure patients know they have access to high-quality care in our urgent care centers when they need it and when they want it," he says. "We are committed to growing our urgent care centers, which serve our communities by providing access to healthcare at a low cost with high quality."
What CMS can do to promote urgent care centers
CMS should pursue policies in the Fiscal Year 2025 Physician Fee Schedule to encourage Medicare beneficiaries and Medicaid enrollees to use urgent care centers for non-emergent care needs, the lawmakers said in their letter.
Roth and DiBenedetto say CMS can help raise awareness about the benefits of treating nonemergent patients at urgent care centers rather than emergency rooms.
"Across Trinity Health, we provide communications, marketing, and patient information about what care is appropriate for seeing a primary care physician, urgent care centers, and emergency rooms," Roth says. "We are working in all of our communities to make sure patients have information about where they should go for certain conditions to help them be empowered consumers."
"It is a matter of awareness and getting primary care physicians to refer patients to urgent care centers," DiBenedetto says. "Urgent care centers are open seven days a week and, most of the time, 365 days a year. We are open more hours than a primary care doctor. Patients need to be made aware that no appointment is needed—it is on-demand care."
Miscommunication in the hospital setting is a major driver of medical errors and malpractice claims.
Appalachian Regional Healthcare (ARH), which operates 14 hospitals in Kentucky and West Virginia, is adopting a structured communications program for clinical care transitions that has been shown to reduce medical errors.
Miscommunication during clinical care transitions is a major factor in medical errors and malpractice claims. A study published in the Journal of Patient Safety showed that during a 10-year period nearly half of all medical malpractice claims involved communication failures, 77% of which could have been prevented with an effective patient handoff tool.
With financial support from the Kentucky Hospital Association, ARH is implementing I-PASS, a communications bundle for clinical care transitions developed by the I-PASS Patient Safety Institute. I-PASS has been adopted by more than 100 healthcare institutions.
I-PASS is a bundle of interventions to try to improve patient handoffs and communication in hospitals.
"The primary element is to get caregivers to speak with each other in a consistent way about patients as they are passing off patients at the change of a shift or a change of location," says Christopher Landrigan, MD, MPH, co-founder and executive council member at the I-PASS Patient Safety Institute.
The I in I-PASS stands for illness severity, so caregivers have a solid understanding of a patient's medical status.
The P in I-PASS stands for the patient summary, which summarizes the condition of the patient, why they are in the hospital, and what care has been provided since the patient was admitted to the hospital.
The A in I-PASS stands for action list, which is a list of things that are expected to happen in a patient's care.
The first S in I-PASS is situational awareness, which includes telling caregivers what is special about a patient.
The final S in I-PASS is synthesis by receiver, which is designed to make sure that when there is a handoff of a patient that the caregivers are on the same page.
I-PASS includes infrastructure that supports improved communication, Landrigan says.
"We think a lot about how we train people, how we implement I-PASS in a way that is going to stick, how we build tools into the electronic health record, and how we use devices in a hospital to push the program forward," he says. "We want to pass along patient information in a reliable manner every day."
Research has shown that I-PASS significantly reduces medical errors and adverse patient events.
A study on I-PASS published by the New England Journal of Medicine found a 23% reduction in medical-error rate and 30% reduction in the rate of preventable adverse events after the implementation of I-PASS. The researchers reviewed 10,740 patient admissions (5,516 preintervention and 5,224 postintervention).
I-PASS is a better framework for communication, says Anthony Stumbo, MD, regional chief medical officer at ARH.
"If a patient comes in with pneumonia, you may think they are going to get better, but you may get a call in the middle of the night that the patient cannot breathe and must be placed on a ventilator," he says. "Communication is key. I-PASS standardizes communication."
Stumbo expects ARH will generate several benefits for the health systems and its patients once I-PASS is implemented at the 12 ARH hospitals in Kentucky. "I expect better communication. I expect better clinical outcomes. I expect better quality. I expect less medical errors. I expect decreased malpractice claims. I expect better care transitions. The handoff of a patient from one nurse to another or one clinician to another is critical—there must be a flow of information," he says.
Investment and ROI
The implementation of I-PASS is going to require limited investment by ARH, Landrigan says.
"The good news for ARH is that the Kentucky Hospital Association has committed to the adoption of I-PASS at ARH," he says. "The hospital association has put up most of the funding to make this program happen. Certainly, the leaders and care teams at ARH are going to have to invest time and energy."
The return on investment from I-PASS includes lower malpractice claims and efficiency gains, which can generate a 3-to-1 ROI, Landrigan says.
"We have found that nursing overtime and the amount of time it takes nurses to do a patient handoff has decreased significantly," he says. "That has benefits in overtime costs and the quality of life for nurses, who can get out of the hospital when they are scheduled to get out of the hospital. With the nursing shortage across the country, anything we can do to improve the work-life balance of nurses is beneficial."
Anne Zink, credited for life-saving work during the pandemic, is leaving her CMO role in seach of work in healthcare data.
Anne Zink, MD, is stepping down from her role as chief medical officer of Alaska effective in April.
Alaska's CMO is a position within the state Department of Health that reports to the commissioner of health. It is a position that is appointed by the governor, but it does not have to be confirmed by the legislature. The primary responsibilities of the role include providing clinical advice to the governor and the Alaska Department of Health.
Zink's successor has not been named.
U.S. Sen. Lisa Murkowski (R-Alaska) has credited Zink with saving many lives during the coronavirus pandemic.
"The big thing that I credit for the successes during the pandemic in Alaska was our partnership with communities, including tribal leaders, municipalities, and local individuals at community healthcare organizations," Zink says. "I also was inspired by the ingenuity, creativity, and problem-solving attitude of Alaskans. Despite the fact that we had no commercial testing for the virus in Alaska when the pandemic began, we were the most tested state in the nation in the first year of the crisis. When the vaccines rolled out, we were able to get vaccines out and were the fastest vaccinated state in the country despite being bigger than Texas, California, and Montana combined."
Zink says she was involved in "countless initiatives" during the coronavirus pandemic.
"I participated in daily news briefings with the governor to make sure that communities were aware of what was happening and were able to make the best decisions they possibly could," she says. "Alaska repatriated the first flight from Wuhan, China, so we were very involved with the federal government's response to the virus from early on. We stood up our emergency response system in January 2020, so we were involved in the pandemic response early on. In testing, we manufactured our own swabs, we created our own testing platform that we got FDA-approved, and our public health labs did most of the testing in the first year of the pandemic. We were the first state to offer monoclonal antibodies in a community-based setting as a treatment option. We set up the first airport testing site."
Anne Zink, MD, is chief medical officer of the state of Alaska. Photo courtesy of the Alaska Department of Health.
Zink has been involved in several initiatives beyond her work during the pandemic.
"I have been focused on how we can make systems work better for patients, instead of asking patients to take on the burden of our complex and broken systems," she says. "I have also been focused on how we can have a healthcare system focused on health instead of a healthcare system responding to illness."
Since Zink started as the state's CMO in July 2019, she has been focused on complex care to serve patients with multiple behavioral health and physical medical needs as well as focused on data.
"I have worked to make sure that we have secure data that is patient-centric, so that a patient has access to their own information—what I call data democratization," she says. "I have tried to make sure that public policy officials such as the governor have the information that they need in terms of healthcare data and public health data to make decisions. I have tried to simplify data so that healthcare providers on the frontline have the information they need to care for their patients in real time."
A practicing emergency medicine physician, Zink says working in an emergency room has provided a solid foundation for serving as Alaska's CMO.
"In emergency medicine, you have a frontline view of all the ways that the system does not work. I have been able to work in the emergency department and see problems, then go back to my day job and find ways to make the system better," she says. "There were about four months when I didn't see patients during the peak of the pandemic because of the demands of the CMO job. I quickly realized that I needed to see patients to stay grounded in the purpose of what I was doing. It has been an amazing opportunity to do both jobs simultaneously. I can serve patients and work on high-level policy issues."
After she leaves the Alaska CMO role, Zink says she plans to find a position working in healthcare data.
"For both healthcare and public health to do their mission of improving the health and well-being of populations, data is at the core," she says. "Data is going to be one of the key ways we provide insight to understand the challenges, solutions, and how we move things forward. If you do not have the data, you cannot tell the story in healthcare. I have had the honor to work in the CMO role for nearly five years, and I have seen many times that the data element has been lacking."
Physicians should seize on opportunities to work in the CMO role, Zink says.
"For a hospital or health system CMO, many hospitals and health systems are really doing public health. They are starting to think about and are being financially rewarded for population health efforts," she says. "There is a real need in hospital leadership as well as in larger health system leadership to have a clinical voice to say, 'What makes sense for the patient? What makes sense for the clinicians who are practicing?' As a hospital or health system CMO, you can play a major role in finding solutions."
SOMOS Community Care serves 1 million Medicare and Medicaid beneficiaries in New York City.
For the past decade, SOMOS Community Carehas risen to the challenges of serving thousands of Medicare and Medicaid beneficiaries in New York City.
For healthcare providers, Medicare beneficiaries pose challenges including multiple chronic conditions. Serving Medicaid beneficiaries can be equally challenging, with relatively low reimbursement rates.
One of the most important factors that has led to SOMOS's success in serving Medicare and Medicaid patients is the way that the physician network has built a Social Care Network model to serve 1 million Medicaid and Medicare patients in predominantly Latino and Asian American communities across New York City, says Chief Medical Officer Yomaris Peña, MD.
"When patients visit one of SOMOS' 2,500 providers, we don't just address their conditions or health at face value," she says. "SOMOS providers pay special attention to social determinants of health, including housing conditions, nutrition, socio-economic status, language barriers, and immigration status, and we connect them to resources to help them mitigate the effects of these factors on their health."
When SOMOS providers work with their patients, they fundamentally understand patient concerns, Peña says.
"When a patient needs to change their diet, SOMOS providers help the patient alter their nutrition without losing their traditional foods," she says. "When a patient needs exercise, providers tell them about the free pool in their neighborhood. When a patient is hesitant to talk about their mental health, providers screen at every appointment and come to them from a place of understanding to help them work through culturally prominent stigmas. We have family offices, embedded in the neighborhoods and communities that they serve, with open-door policies and welcoming atmospheres."
SOMOS has a Social Care Network with a focus on addressing health inequities as well as providing solutions for a broad array of social care needs for those who are chronically sick, hardest to reach, and persistently overlooked, Peña says.
"To break down these systemic inequities and fully address whole-person health needs with a preventative focus, SOMOS engages in community-based public health engagement and education with a trusted workforce that is part of the fabric of the community," she says. "SOMOS establishes partnerships with community-based organizations for the provision of comprehensive social assistance for community members including housing and food assistance."
SOMOS has embraced value-based care to rise to the financial challenges of serving Medicare and Medicaid beneficiaries. SOMOS was founded in 2014 as the only physician-led Performing Provider System in New York State's Delivery System Reform Incentive Payment (DSRIP) program. Advanced value-based care models mean building stronger preventative care services, mental health screenings, and addressing issues such as nutrition and housing so patients have better long-term outcomes, Peña says.
"SOMOS has demonstrated that advanced value-based care models intertwined with culturally competent healthcare is the most efficient way to improve patient outcomes for the Medicaid population, all while saving New York State tax revenue over the course of the five-year DSRIP timeframe," she says. "We have also successfully implemented our accountable care organization model for a decade, ensuring our Medicare population is taken care of and not overlooked."
Culturally competent care is a cornerstone of the SOMOS model of care, Peña says.
"SOMOS's approach to connecting with patients in their own language and shared cultural context has been proven to decrease healthcare costs and to reach New York's goal of reducing hospital admissions and readmissions," she says. "When our patients walk into the waiting room and the exam room, they feel understood, welcomed, and like they can fully express their concerns in the way they are most comfortable. Culturally competent care can be as simple as a doctor advising patients on their carbohydrate intake, for instance, recommending a Dominican patient to limit their plantain intake or suggesting a Mexican patient to reduce their tortilla intake. At its core, it's about truly understanding the patient and meeting them where they are, in a way that builds trust."
Healthcare has reached one of the most challenging inflection points in more than 100 years, Donald Yealy says. And that requires new ways of addressing challenges.
Donald Yealy, MD, chief medical officer and senior vice president of the health services division at University of Pittsburgh Medical Center (UPMC), says 2024 is a challenging year for CMOs.
Yealy says the top challenges include change management, improving healthcare access, and learning from the coronavirus pandemic to prepare for the next existential threat to healthcare.
1. Change management
Yealy says healthcare has reached one of the most challenging inflection points in more than 100 years because of three factors.
The push for consumerism in healthcare that began several years ago is now "unassailable," he says. People seeking healthcare want and will have a much more dominant voice in what that healthcare is and how it is assessed to be helpful or not helpful. In the past, there was much more trust in how, when, and where to get healthcare on the professional side. Now, healthcare is more of a partnership or driven by individual people seeking care. Their expectations and desires have become more important.
Healthcare economics are changing dramatically, he says. Patients want all of the goodness and availability of healthcare, but they want healthcare in a manner that fits their ability to access it from a financial perspective. Decades of growth in expenditures on healthcare are likely over, Yealy says.
There is not a single human endeavor that has continued for an extended period of time without an ability to adapt to new demands and find new ways to do things better, and healthcare is not an exception, he says.
When you put these three factors together coming off a once-in-a-lifetime pandemic, there is tremendous pressure for change, Yealy says.
"As a CMO, I have to get people to understand the need to change, what the change is, and the tools to achieve change," he says. "That is not easy, and change needs to happen in a compressed timeframe. Up until this year, we would think about change in the months-to-years horizon, but healthcare providers do not have months to years to figure this out. We must get better much more quickly, and better in a way that not only we feel is better but also the people we are serving feels is better."
Health systems and hospitals need to take a hard look at what they do and do not do well, Yealy says. Then they need to be willing to let go of things that do not serve the people who come to them for care well.
"You must have the insight as well as the ability and the discipline to change," he says. "The ability to change is not going to just involve new tools such as artificial intelligence, new diagnostic devices, and molecular personalized medicine. All of those are tools to do the job better, but we need to get our individual providers such as physicians, nurses, and advanced practice providers to embrace them in a much quicker fashion."
During the pandemic, the vaccine program was a great example of how the healthcare sector developed something from the best available data and had it up and running within a year rather than decades.
"This is the model for change—having an idea, testing it quickly, then getting it out to the people we serve," Yealy says.
Donald Yealy, MD, chief medical officer and senior vice president of the health services division at University of Pittsburgh Medical Center (UPMC). Photo courtesy of UPMC.
2. Improving healthcare access
Healthcare providers must recognize the needs of people seeking care and meet them in ways that are most comfortable and efficient for them, Yealy says.
"For older patients who seek care, the traditional approach of coming to a hospital or physician's office is probably still OK," he says. "But for other patients who are younger or face barriers to coming to a healthcare setting, we need to think about all of the different platforms that we can use. It could be through a smartphone or regional locations. We need to make healthcare accessible to everybody, whether they are in a big city or rural area."
While providers can use technology ,such as smartphones and other deployed devices, to reach patients, health systems and hospitals need to look at ways to build care opportunities that are nearby and accessible to people who have a healthcare need, he says.
"There are different ways we can construct our use of healthcare providers and healthcare locations, whether they are formal bricks-and-mortar facilities or something else," Yealy says. "It will be a combination of virtual and electronic methods as well as a different type of footprint for bricks-and-mortar locations."
Health systems must push ahead with a bricks-and-mortar strategy that goes beyond traditional hospitals, he says.
"We need to deploy more micro hospitals, urgent care centers, and other outpatient settings that have a different footprint than we have been used to for decades," he says. "These facilities need to be embedded in communities and to serve basic and acute needs while being connected to other parts of the healthcare delivery system to ensure ongoing wellness."
3. Learning from the pandemic
The healthcare system is on the tail end of the pandemic, Yealy says, and CMOs need to lead the charge to determine what has been learned from the crisis to be ready for the next threat. Providers need to look at the opportunities that were fumbled away during the pandemic, as well as the successes and failures at several levels: individual sites of care, health systems, states, and the nation.
"While we are doing some of this work, it is not well coordinated, he says. "For example, the communication during the pandemic left a lot to be desired. There has been a degradation in the public trust in the government and healthcare providers because people feel that they did not get straight or consistent answers. We need to concentrate on communicating better."
With messaging, people need clarity about a health threat and what their response to the threat should be, he says, while providers need to embrace the fact that a new threat may not be completely understood.
"Substituting a clear message for a truthful message is a dangerous thing," Yealy says. "We can say things that are dramatic and elicit behavioral changes, but if what we say ends up not being true, it is hard to get trust back. We learned from the pandemic that we should not substitute simplistic clarity for truthfulness in our messaging—they both must be present, not one or the other."
The industry learned some hard lessons with regard to the supply chain, he says. For years, health systems and hospitals honed the supply chain to have what was needed immediately available at the best possible price, but not enough thought went into what happens during a disruption in the supply chain.
"At the beginning of the pandemic, there were shortages of personal protective equipment such as masks and gowns; we learned a lesson from that," Yealy says. "Before the pandemic, we thought we managed PPE well because we only had what we needed. We found out that need can change dramatically, and the supply can change as well."
The report, which was published by the New Jersey Health Care Quality Institute, was authored by more than a dozen experts.
A recently published report raises alarm about a primary care physician shortage in New Jersey and calls for the adoption of advanced primary care in The Garden State.
There is a shortage of primary care physicians across the country. The recent report shows that the shortage is not limited to rural areas.
A co-author of the report, which was published by the New Jersey Health Care Quality Institute, says the primary care physician shortage is widespread in New Jersey.
"All of New Jersey has had a shortage of primary care physicians, particularly family physicians and general internists. The report focuses on adult medicine, where we have the biggest shortage of primary care physicians," says Mary Campagnolo, MD, MBA, medical director of value-based programs and payer contracts at Virtua Health's Virtua Medical Group, a board member of the New Jersey Health Care Quality Institute, and a primary care physician.
She cited data from the American Board of Family Medicine, which tracks how many family physicians there are in the states for every 100,000-resident population. "New Jersey and Connecticut have the lowest concentration of family physicians at about 17 per 100,000. Many other states have 50 family physicians per 100,000 of population, so we are understaffed," Campagnolo says.
RWJBarnabas Health, New Jersey's largest integrated healthcare delivery system, is experiencing a shortage of primary care physicians, says Andy Anderson, MD, MBA, chief medical and chief quality officer at the health system.
"Currently, we are actively recruiting between 30 and 40 open positions for primary care physicians," he says. "Over the past five years, we have been trying to recruit the primary care workforce that we need for the future."
One of the main drivers of the primary care physician shortage in New Jersey is low reimbursement rates, the report says. "New Jersey's primary care spending as a percent of total health spending is one of the lowest in the country. … Fee-for-service payment rates for primary care are also low compared to other states. N.J. Medicaid pays primary care rates that are only about 50% of Medicare rates. Commercial primary care payment rates in New Jersey are on average 93% of Medicare rates compared with the U.S. average of 120% of Medicare," the report says.
Reimbursement rates for primary care physicians are problematic in New Jersey and at the national level, Anderson says.
"It has gotten a little bit better over the past five years—there has been an incremental increase in reimbursement for primary care, but it is not at the level it needs to be to influence physicians to go into primary care and to build out the workforce that we need for the future," he says.
The low reimbursement rates drive many primary care physicians who are trained in New Jersey to move to other states. Virtua Health works to provide competitive salaries and benefits to retain primary care physician trainees, Campagnolo says.
"We regularly assess the market rates in the Delaware Valley," she says. "Then we try to pay the median salary or higher. That helps to attract and retain primary care physicians. We have a good benefits package that is not always available to primary care physicians in private practices. We have good medical insurance coverage. We have a good retirement account. These strategies have helped us retain our trainees."
RWJBarnabas has pursued multiple strategies to retain its primary care physician trainees, Anderson says.
"We are trying to retain trainees through financial incentives and through partnerships with high-performing practices," he says. "We also have a model called the patient-centered medical home. In that model, the physician is the captain of the ship, but there are other health professionals in the model such as social workers, nutritionists, dieticians, and nurses who are part of providing a comprehensive environment for patient care. That type of a model is attractive for physicians because it is a team-based model."
Campagnolo says chief medical officers in New Jersey and across the country should be concerned about primary care physician shortages.
"If you are the chief medical officer of a health system that has multiple services, the referral source for those services is the primary care physicians. So, if you do not have primary care physicians, you do not have the ability to get patients to any of the other services," she says.
Promoting advanced primary care
The report calls for support of advanced primary care in New Jersey.
The National Academies of Sciences, Engineering, and Medicine (NASEM) define advanced primary care as integrated, accessible, and equitable healthcare provided by interprofessional teams that are focused on most of the health and wellness needs of individuals. Advanced primary care includes preventive care, management of chronic conditions, and a longitudinal perspective on patient health and well-being.
Anderson says RWJBarnabas' patient-centered medical home model for primary care is similar to the advanced primary care approach.
"We are practicing advanced primary care in the patient-centered medical home model of care," he says. "We have a team-based approach to primary care. We have physicians working with other health professionals to provide services focused on prevention, wellness, and chronic disease management. It is a good model in terms of providing better access, better support services, and better continuity for patients. It also provides more expertise in the primary care setting because everyone is working to the top of their license. For example, if you have a dietary expert, they really understand the field and can counsel patients at a high level."
The report makes three recommendations to support advanced primary care in New Jersey:
The state should raise Medicaid FFS primary care payment rates to the level of Medicare and it should direct Medicaid managed care organizations to also pay Medicare rates for primary care.
The state should take an active role in developing and encouraging advanced primary care in New Jersey.
The state should report annually on primary care spending as a percent of total healthcare spending and on the use of alternative payment models that promote value-based care.
Matthew Ewend, MD, chief clinical officer of UNC Health and president of UNC Physicians. Photo courtesy of UNC Health.
J.P. Valin, MD, chief clinical officer of Intermountain Health. Photo courtesy of Intermountain Health.
Anne Zink, MD, is chief medical officer of the state of Alaska. Photo courtesy of the Alaska Department of Health.
Donald Yealy, MD, chief medical officer and senior vice president of the health services division at University of Pittsburgh Medical Center (UPMC). Photo courtesy of UPMC.