Unintended consequences of assigning hospitalists to one or two inpatient units include the temptation to increase patient loads on the clinicians.
Assigning hospitalists to an inpatient unit—also known as geographic cohorting—increases direct care time with patients but often comes with unintended consequences, a new journal article says.
Geographic cohorting of hospitalists is becoming a common practice at U.S. hospitals, with a 2017 survey finding that 30% of medicine group leaders reported clinicians rounded daily on one or two inpatient units. Other research associated geographic cohorting with reduced costs, length of stay, and mortality when the staffing method was included in an accountable care team model.
The new journal article, which was published online by Journal of Hospital Medicine, features a time-motion study of geographic cohorting (GCh) hospitalist teams and non-geographic cohorting (non-GCh) hospitalist teams.
"Cohorting’s benefits are theorized to include increased hospitalist time with patients, while its downsides are perceived to include increased interruptions," the journal article's co-authors wrote.
The new research data supports the theories:
GCh hospitalists were found to have the highest predicted time for direct care encounters with patients at 9.5 minutes.
GCh hospitalists were interrupted at a significantly higher rate than non-GCh hospitalists. In the morning, GCh hospitalists were interrupted once every 14 minutes and non-GCh hospitalists were interrupted once every 13 minutes. In the afternoon, GCh hospitalists were interrupted every 8 minutes and non-GCh hospitalists were interrupted every 17 minutes.
Interpreting the data
In comments provided to HealthLeaders via email, two of the journal article's co-authors discussed their research findings, including the observation that GCh hospitalists spent more time with their patients.
"The increased proximity between the physician and the patient may facilitate multiple visits with patients on the same day, as well as longer visits," said Michael Weiner, MD, MPH, professor of medicine, Indiana University School of Medicine, Indianapolis, and research scientist, Regenstrief Institute, Indianapolis; and Areeba Kara, MD, MS, assistant professor of clinical medicine, Indiana University School of Medicine, and hospitalist, Indiana University Health, Indianapolis.
Interruptions appear to be a drawback of geographic cohorting, they said. "Interruptions were pervasive among hospitalists but more commonly noted in the geographically cohorted group. With geographic cohorting, the increased presence of the hospitalist on the unit fosters interprofessional relationships and collaboration, which may increase both timely and untimely communication."
The time-motion study found that the time of each patient visit decreased 14% when the patient load on hospitalists increased from 10 to 20 patients. Hospital leaders should avoid the temptation to increase patient loads on GCh hospitalists, Weiner and Kara said.
"Experience suggests that the anticipated gains in efficiency from cohorting lead to an expectation that cohorted teams should be able to manage more patients. This was noted in our study and has also previously been raised as a concern in a national survey of hospitalists. Ironically, higher patient loads were associated with shorter visits, thus seeming to erode the benefits of cohorting."
The four different approaches to establishing geriatric emergency department services vary in the amount of resources required.
Over the past five years, four primary models for geriatric emergency departments have emerged, according to a new journal article.
The number of Americans over age 65 is expected to double to nearly 100 million by 2060. With multiple chronic conditions and high costs of care at end of life, older adults have relatively higher healthcare costs compared to younger Americans. In 2010, citizens over age 65 were 13% of the population but accounted for 34% of healthcare spending.
In 2014, guidelines were published for the formation of geriatric emergency departments based on consensus reached by the American College of Emergency Physicians, The American Geriatrics Society, Emergency Nurses Association, and the Society for Academic Emergency Medicine.
"The guidelines were developed to help every ED improve its care of older adults. The geriatric ED guideline recommendations span the care continuum from out-of-hospital care, ED staffing, protocols, infrastructure, and transitions to outpatient care," the co-authors of the new journal article published by Annals of Emergency Medicine wrote.
The article presents four models that serve as "practical examples" for establishing geriatric EDs.
1. Geriatric ED unit
A geriatric ED unit is a dedicated space within an emergency department that can include enhancements such as flooring and beds that are designed for older adults to reduce risks, including falls and delirium.
Screening assessments are used to determine which older adult patients should be treated in a geriatric ED unit, the co-authors of the journal article wrote. "Screening tools or criteria for the unit are required because for most EDs the volume of older adults is higher than the capacity in these units, and ED resources must be focused on patients who will most benefit."
Advantages of geriatric ED units include having the expertise of a dedicated staff, which often features geriatric practitioners, social workers, physical therapists, occupational therapists, palliative medicine consultants, and pharmacists. In addition, training costs are relatively low because education is focused on a single team rather than the whole ED staff.
Limitations of geriatric ED units include the potential for limited operating hours because of staffing constraints and disparities of care when the unit is closed.
2. Geriatrics practitioner model
This model provides geriatric care throughout an ED rather than in a specialized unit within an ED, the journal article co-authors wrote.
"The entire ED adopts a geriatric-focused approach that may include structural changes, screening with geriatric assessment tools, or both. A geriatric nurse, nurse practitioner, allied health specialist, geriatrician, or all four are available in the ED. Evaluation by these geriatric practitioners occurs concurrently with routine ED care."
Geriatric practitioners work with social workers, case managers, or nurses who are adept at care transitions and matching patients with community resources such as home health care.
Advantages of this model include geriatric assessments provided by caregivers with specialist training as well as lower costs and increased flexibility compared to the geriatric ED model.
Limitations of this model include the potential for long ED length of stay to accommodate interdisciplinary geriatric evaluations.
3. Geriatrics champion model
In this model, there is no geriatrics clinician in the ED, but a geriatric champion plays a leadership role in initiatives and establishing care pathways.
"This model may be chosen because of small patient volumes or staffing costs of a geriatric practitioner. Instead, the model relies on initial assessment in the ED and close ties to outpatient resources and outpatient geriatric assessment for patients. The geriatric champion is a physician or nurse with expertise in geriatric ED care," the journal article co-authors wrote.
A key role of the geriatric champion is to provide staff training and to develop protocols that improve ED care.
When ED physicians determine that a patient needs a geriatric assessment, the patient is either hospitalized or is referred for timely follow-up with a geriatrician in an outpatient setting.
An advantage of this model is improving geriatric care at low cost.
A limitation of this model are barriers to outpatient care coordination. "Outpatient care coordination can be challenging to initiate during an ED visit if appropriate resources are not in place, and clinicians may revert to traditional care practices on high-volume days or when time is limited," the co-authors wrote.
4. Geriatric-focused observation unit model
This approach is a combination of the geriatric ED unit and the geriatrics practitioner models.
"An ED observation unit is a unit within the ED (typically 10 to 20 beds) that divides patients into cohorts for evaluations longer than a 4-hour ED stay but not requiring an inpatient stay beyond 48 hours. The targeted 8- to 24-hour observation period allows a full interdisciplinary geriatric assessment," the journal article co-authors wrote.
With the potentially long ED length of stay, patients can be held overnight then receive geriatric assessments from in-hospital consultants or interdisciplinary teams the next morning.
"This model can be used with a dedicated geriatrics team in the observation unit or in conjunction with the hospital's inpatient geriatric consultation service, eliminating the need to hire ED-specific staff. This model adapts and repurposes already existing inpatient services (geriatrics, physical therapy, speech therapy, occupational therapy, pharmacists, case managers, and other consultants) for ED patients," the co-authors wrote.
Advantages of geriatric observation units include decreasing return ED visits and hospitalizations, research shows.
Identifying patients who can benefit most from a geriatric observation unit can be difficult, the co-authors wrote. "High-risk patients may require greater resources than those available within a 24-hour stay, or may need a full qualifying admission for nursing facility placement."
New research largely supports the claims of freestanding emergency department critics.
Freestanding emergency departments increased spending on emergency care in three of four states examined in a recent study.
Advocates of freestanding emergency departments claim they can ease overcrowding at hospital-based emergency rooms and provide prompt care in convenient locations. Opponents of freestanding emergency departments claim they increase spending on emergency room services because the care can often be provided in lower cost settings such as urgent care centers.
The recent study, which was published in the journal Academic Emergency Medicine, examined freestanding emergency department data collected in Arizona, Florida, North Carolina, and Texas from January 2013 to December 2017. The researchers focused on total spending on emergency care, out‐of‐pocket spending, utilization, and price per visit.
The research generated three key observations, the lead author of the study told HealthLeaders.
"Entry of an additional freestanding emergency department in a local market was associated with an increase in spending per capita in three of four states. Entry was generally associated with an increase in emergency visits per capita, as well as out-of-pocket spending," said Vivian Ho, PhD, director of the Center for Health and Biosciences at Rice University's Baker Institute for Public Policy in Houston, Texas.
The research features several data points:
In local markets in Florida, North Carolina, and Texas, entry of an additional freestanding emergency department resulted in a 3.6 percentage point increase in emergency provider reimbursement per insured beneficiary
In local markets in Arizona, entry of an additional freestanding emergency department resulted no significant reimbursement change
In local markets in Arizona, Florida, and Texas, entry of an additional freestanding emergency department increased the number of emergency care visits by 0.18 per 100 insured beneficiaries
In local markets in North Carolina, entry of an additional freestanding emergency department did not significantly change the utilization rate
In local markets in Arizona, Florida, and Texas, entry of an additional freestanding emergency department increased the average estimated out-of-pocket payments for emergency care by 3.6 percentage points, but out-of-pocket payments decreased 15.3 percentage points in North Carolina
Interpreting the data
The research is a cautionary tale about freestanding emergency departments (FrEDs), Ho and her co-authors wrote. "Rather than functioning as substitutes for hospital‐based EDs, FrEDs have increased local market spending on emergency care in three of four states' markets where they have entered. State policy makers and researchers should carefully track spending and utilization of emergency care as FrEDs disseminate to better understand their potential health benefits and cost implications for patients."
The utilization findings provide weak support for proponents of FrEDs, Ho told HealthLeaders.
"Some of the observed increase in utilization may have led to increased convenience for patients seeking emergency care. However, the overall increase suggests that FrEDs don't serve as a substitute for hospital-based emergency care. And other studies in the literature have found that entry of FrEDs do not lower waiting times at nearby hospital emergency departments," she said.
The spending findings support the claims of FrED critics, Ho said. "The results are consistent with critics' concerns that FrEDs increase spending on emergency care. FrED operators have come to realize that, 'If you build it, they will come.' Other research suggests that much of the care that patients receive at FrEDs could be obtained at much lower costs at urgent care centers."
Patient experience has become a top priority in the healthcare industry as the transition to value-based care unfolds. In the current market conditions, patient experience not only drives consumer loyalty but also helps health systems and hospitals to gauge whether they are delivering value to their patients.
To that end, UnityPoint Health has been investing resources to improve patient experience.
This year, West Des Moines, Iowa–based UnityPoint Health's UnityPoint Clinic division achieved a top 10% ranking from Press Ganey Associates, a national leader in patient satisfaction surveys.
In a conversation with HealthLeaders, David Williams, MD, president and CEO of UnityPoint Clinic and UnityPoint at Home, highlighted four examples of initiatives and capabilities that have boosted the health system's patient experience.
"It's our job to grow out an exceptional experience. We have been trying to do that in pockets of our organization forever, but we're better organized now and able to spread an exceptional experience throughout the health system," he says.
1. 'High touch' readmission reduction program
In 2016, UnityPoint implemented its "Heat Map" readmissions reduction program, which combines predictive analytics with the efforts of nurse care managers.
"We take our analytics and analyze hundreds of data points in a readmission reduction tool. We have found many of the triggers to find out before someone decompensates and gets sick," Williams says.
The Heat Map program allows UnityPoint to target patients who are at risk of readmission, he says.
"For many years, we had been seeing patients one week after hospital discharge for follow up. With our readmission tool, we have found that our follow-up visits miss some patients because many decompensate about three days after they get out of a hospital. For other patients, they look great a week after leaving a hospital, then two to three weeks after their hospitalization they decompensate," he says.
Nurse care managers play a crucial role in the program, he says.
"We use our readmissions reduction tool and put it in the hands of our care managers—that's where the personal touch comes in. These nurses reach out to the patients. Many times, they know the patients on a personal basis. They not only have an empathetic relationship with the patient but also have the patient's confidence. If these nurses tell patients when to get in for follow up and what they need to do to care for themselves, we find patients follow that direction almost 100% of the time. The care coordinators develop trust, they get patients into our clinics before they decompensate, and it is the best example we have of patient segmentation," Williams says.
The Heat Map program has attained a significant reduction in hospital readmissions, Williams says.
"There has been a dramatic drop in patients who have been readmitted by using both the predictive analytics and the high touch of dedicated care coordinators. Our early findings over the past year have shown that we have decreased the rate of readmissions in a fragile population by two-thirds. It's not statistically proven yet, but we'll get there."
2. LGBTQ-friendly clinics
UnityPoint has launched two LGBTQ-friendly clinics. In January 2018, the health system opened the first clinic in Waterloo, Iowa. In April, the second clinic was opened in Des Moines, Iowa.
"These clinics came into being because we had dedicated physicians who wanted to take care of a population that has been discriminated against and underrepresented in healthcare. It's a shining example of the personalization of care that we can provide," Williams says.
Staff in the clinics receive Safe Zone training, which covers issues such as letting patients choose the pronoun they want to be identified with and overcoming biases, he says.
The clinics are open every two weeks at night. "These are doctors and nurses who work in our regular clinics during the day," Williams says.
There are plans to open several more of the LGBTQ-friendly clinics, he says. "We currently have nine regions in three states. These are the first two LGBTQ clinics, and we will be expanding them to other communities. I have had medical leadership in every one of our regions ask about opportunities to open these clinics."
3. Patient service representative training
In April, UnityPoint initiated "PSR University" to bolster the training of patient service representatives.
These employees play an essential role in patient experience as they are the first people who make contact with patients, such as scheduling appointments and warmly greeting people as they come through the clinic's doors, Williams says.
PSR University, which is a yearlong program, is designed to strengthen the ranks of patient service representatives, he says.
Twenty patient service representatives were selected to participate in the first PSR University class, Williams says.
"We have a cohort of people who can help address patient complaints and do a better job when problems arise. We have them as brand ambassadors and role models in each one of their regions," he says.
The trained patient service representatives also participate in hiring new representatives to ensure that the patient experience culture stays consistent, Williams says.
4. Patient portal
Williams shares three examples of popular capabilities on the health system's MyUnityPoint patient portal that have had a positive impact on patient experience:
Online scheduling for primary care visits
Access to clinician notes documented in the Epic electronic health record system
A "Fast Pass" feature texts patients if an appointment with a specialist becomes available earlier than a scheduled appointment
"The key to our digital transformation is definitely our patient portal. This is where we have built our brand ambassadorship," he says.
There are personal and professional barriers that block pediatricians from addressing gun safety in their patients' homes.
Pediatricians are less likely to ask about home gun safety than other safety concerns, recent research indicates.
Guns are a leading cause of death for American children. For Americans aged 10 to 19, the rate of suicide by guns has increased since 2008. There are about 4.6 million children who live in homes where at least one firearm is stored loaded and unlocked.
The recent research, which was published in JAMA Pediatrics, compared child-well visit questions about gun storage and smoke alarm safety in patient homes. The questions were programmed into a university health care system's electronic health record simultaneously in January 2016.
For firearms safety, there were buttons in the EHR to indicate whether firearms were stored in a gun safe or locked cabinet, and whether they were equipped with trigger locks. There were adjacent buttons for smoke alarm safety, which indicated whether there were functioning smoke alarms in a patient's home.
Data was examined from more than 16,000 well-child visits with medical residents and faculty members from January 2017 to June 2018. The researchers generated several key data points:
Smoke alarm queries were documented in 77.9% of the well-child visits.
Gun queries were documented in 53.8% of the well-child visits.
The rate of gun queries declined significantly among residents after the October 2017 mass shooting in Las Vegas, Nevada, and the February 2018 mass shooting in Parkland, Florida.
"Despite EHR cues, queries were less likely for guns than smoke alarms," the researchers wrote.
Interpreting the data and influencing clinician behavior
The lead author of the research told HealthLeaders that psychological factors likely played a role in the gun safety query reductions after the mass shootings in Las Vegas and Parkland.
"Avoidance is a common response to trauma. In fact, avoidance is one of the criteria that defines post-traumatic stress syndrome. A mass shooting is a shared traumatic community event, and the residents may have avoided talking about gun injury to protect themselves or the parents from thinking about the event," said Carole Stipelman, MD, MPH, medical director of the University Pediatric Clinic in Salt Lake City, Utah.
There are personal barriers that impact whether clinicians asked parents about gun safety, she said.
"Smoke alarms are noncontroversial, and physicians are familiar with them because they have them in their own homes. Medical training does not include education about gun safety options and physicians may lack confidence in discussing these devices with gun-owning parents. Physicians should be taught to speak about trigger locks and biometric gun locks with the same confidence as discussing other safety measures."
There also are professional barriers to overcome, Stipelman said.
"Clinicians may be uncertain about how to begin the conversation without appearing intrusive. The well-child check-up schedule is frequent—12 visits are recommended in the first three years. To be effective, these visits require maintaining a strong bond of trust with the family. Some clinicians may lack confidence about their ability to talk about keeping children safe from guns without damaging this trust."
Gun safety should be included in medical school training, she said. "Medical school education should include training to discuss gun safety in the home with a collaborative approach that preserves trust in the pediatrician-parent relationship."
The new measure compares actual spending on patient care over a 12-month period against the expected level of spending.
Indiana University Health is exploring a new frontier in measuring value in care delivery.
One of the great quests in population health is determining how to define and measure the value of care that is delivered to patients. Currently, value is often defined through quality measures rather than outcome measures.
"Currently, much of the conversation with providers focuses on the silos of risk adjustment scores and their level of participation in individual quality metrics. What is needed in the world of managing risk in population health is a single instrument that melds risk adjustment, adherence to accepted quality metrics, and clinical outcomes," says Anthony Sorkin, MD, executive medical director of population health at Indianapolis-based IU Health.
To improve measurement of value, Sorkin and colleagues at IU Health have developed the Healthcare Economic Efficiency Ratio (HEERO), which features gauging actual spending on patient care against expected spending on patient care. HEERO is based on claims data for patients attributed to Medicare Advantage health plans or a Medicare accountable care organization.
New performance measure
The highlights of how HEERO works are as follows:
Actual 12-month spend divided by expected 12-month spend equals Healthcare Economic Efficiency Ratio
A ratio of 1.00 indicates spending at the expected level
A ratio of more than 1.00 indicates spending at a higher than the expected level
A ratio of less than 1.00 indicates spending at a lower than expected level
IU Health's HEERO program was formally launched this summer. So far, the program has focused on the efficiency of primary care physicians (PCPs) in two of IU Health's four regions across Indiana. Data is being shared with physician leaders and individual PCPs.
The key to the HEERO program is the kind of conversations that are prompted with PCPs, says Ed Lee, MBA, executive director of healthcare economics outcomes at IU Health.
"The key is the conversation that occurs with physicians. What happens most often today is there is a constant stream of people going into primary care physicians' offices telling the physicians how to practice, telling the physicians what they are doing right or wrong, and telling the physicians about new initiatives—whether they are about more accurate diagnosis coding, gaps in care, or something else. No physician is excited about that kind of conversation," Lee says.
The HEERO data provides information that can show PCPs how efficient they are compared to their peers. The HEERO information also includes data on prime utilization categories such as inpatient stays, emergency room visits, and skilled nursing facility stays, so doctors can see where spending behavior is impacting their HEERO score.
"The difference about the HEERO measure is it is more of an outcome measure rather than a process measure. So, of the patients who are attributed to a primary care physician or group of physicians, we are looking at the estimated number of dollars that those patients should spend versus the actual spend of those patients. This tells the physicians how they are doing overall," Lee says.
"HEERO is an indicator; and once physicians buy into that indicator, then they welcome having a discussion to practice differently," he says.
HEERO examples
The HEERO measure can be used to generate data about individual physicians or physician groups.
Example 1. Individual PCP:
PCP with 161 attributed patients enrolled in a Medicare Advantage health plan or an accountable care organization
Actual spend was $1.466 million
Expected spend was $1.454 million
HEERO score was 1.01
"The difference in dollar value is so minimal that it tells us the physician is managing patients well. The patients are spending approximately as much as the CMS risk score predicted," Lee says.
Example 2. PCP clinic in an IU Health administrative area with nearly a dozen clinics:
The PCP clinic had 372 attributed patients enrolled in a Medicare Advantage plan or an accountable care organization
Actual spend was $2.650 million
Expected spend was $2.811 million
HEERO score was 0.94
Several of the other clinics had HEERO scores over 1.00, with one clinic posting a HEERO score at 1.24
"We can conclude that they are managing their patients more efficiently than others," Lee says of the clinic that posted a 0.94 HEERO score.
Physician engagement
Although the HEERO program is in its infancy, the new metric has been well received by physician leaders and individual PCPs, Sorkin says. "HEERO allows us to get very granular with each physician, find those who are struggling, and pinpoint areas for improvement either in risk score coding accuracy or in spending behavior."
The HEERO program appeals to the competitive nature of most physicians, he says. "Every physician who has seen the HEERO data gets to see how they are performing against their peers, and they all want to get better. So, our physician engagement is through the roof. Everyone wants to see this data, understand it, and improve on the care they are delivering to patients."
A new report that presents five approaches to hospital-based opioid use disorder care focuses on organizational best practices.
A new report provides five system-level strategies with specific initiative examples for hospitals to improve prevention, identification, and treatment of opioid use disorder.
Hospitals are on the frontline of the opioid epidemic. In 2016, the rate of opioid-related inpatient stays in hospitals increased to about 300 per 100,000 population—nearly double the 2008 rate, according to the federal Agency for Healthcare Research and Quality. From 2008 to 2017, opioid-related emergency department visits more than doubled, according to AHRQ's Healthcare Cost and Utilization Project.
The new report was released this week by two Boston-based healthcare organizations: the Institute for Healthcare Improvement and the Grayken Center for Addiction at Boston Medical Center. The report says hospitals can play a key role in addressing the opioid epidemic.
"In response to the growing volume of inpatient admissions and outpatient visits for individuals with a substance use disorder, hospitals are the primary point of care for many patients in need of comprehensive substance use care. Fortunately, hospitals also have the opportunity to make a major impact in reducing morbidity and mortality related to opioid use, from prevention, to screening, to treatment, to engaging with communities to reduce harms," the report's coauthors wrote.
The five strategies described in the report are focused mainly on organizational best practices rather than specific forms of clinical care.
1: Identify and Treat Opioid Use Disorder Patients in Key Clinical Settings
Identify patients with opioid use disorder in the emergency room and provide urgent treatment and referrals. For example, ER clinicians should be trained to treat acute withdrawal.
Identify and treat inpatients with opioid use disorder. For example, provide peer services and case management.
Integrate addiction treatment into primary care and other appropriate care settings. For example, nurse care managers can conduct consistent follow up.
Boost specialty addiction treatment offerings. For example, build links to specialty addiction treatment programs for targeted groups such as adolescents and young adults.
Improve clinician training and competency to offer evidence-based comprehensive treatment—medications in combination with behavioral therapy. For example, educate clinicians about substance use disorder treatment throughout their training from medical school to continuing medical education courses.
2. Minimize Harm and Maximize Benefit in Opioid Prescribing
Improve prescribing practices for acute and chronic pain patients. For example, opioids are not first-line medications for many acute pain conditions and alternatives should be tried first.
Improve opioid dispensing. For example, require clinicians to check your state's prescription drug monitoring program before dispensing opioids and to make treatment referrals when appropriate.
Prevent diversion of opioids from patients to other people for illicit use. For example, create secure drug disposal sites at community facilities such as pharmacies and police stations.
Increase access to multimodal pain management strategies. For example, improve clinician pain management training.
3. Train Stakeholders About Opioid Use Disorder Risks and Prejudice
Educate healthcare professionals, patients, and the public about opioid risks. For example, provide clear information on addiction risk to patients.
Decrease prejudice about substance use disorders. For example, speak clinically rather than judgmentally with patients.
4. Identify and Screen High-Risk Patients
Screen high-risk patients for developing opioid use disorder and educate them about addiction risks. For example, screen patients with a co-occurring substance use disorder or a history of substance use.
5: Reduce Substance Use Disorder Harms
Improve access to supportive social services and connections to ongoing, comprehensive treatment. For example, increase access to social services that support recovery such as affordable housing agencies and childcare.
Develop and promote harm reduction services that boost the safety of patients with addictions. For example, provide syringe exchanges and safe use instructions.
International medical school graduates are more likely to be primary care physicians than their U.S. medical school counterparts, says the president of an international medical school.
With the country's physician shortage forecast to worsen for more than a decade, international medical school graduates could play a key role in addressing staff shortfalls.
The physician shortage could expand to nearly 122,000 clinicians by 2032, including a shortfall of about 55,000 primary care physicians, according to the Association of American Medical Colleges. In 2017, the AAMC estimated the overall physician shortage at 20,400 clinicians.
To gauge the impact of international medical school graduates on the physician shortage, HealthLeaders recently spoke with G. Richard Olds, MD, president of St. George's University in True Blue, Grenada, in the West Indies. St. George's draws students and faculty from 140 countries. According to St. George's University website, the university "has become the second-largest source of doctors for the entire U.S. workforce."
Before taking the top executive role at St. George's, Olds was the vice chancellor for health affairs and founding dean of the School of Medicine at the University of California, Riverside. He earned his medical degree at Case Western Reserve School of Medicine in Cleveland and received his internal medicine training at Massachusetts General Hospital in Boston.
Following is a lightly edited transcript of Olds' conversation with HealthLeaders.
HealthLeaders:What is driving the physician shortage in the United States?
Olds: There's a lot of talk about the doctor shortage, and there's no question there is a doctor shortage. But more importantly, there is a marked maldistribution of doctors, and a marked maldistribution of specialties that doctors go into. Although we are short of doctors overall, we are extremely short of doctors in rural areas of the United States and urban underserved areas. We actually have a surplus of doctors in many affluent areas of the United States.
The other problem is that the doctors trained in the United States largely become specialists. So, we have a growing shortage of primary care doctors.
HL:Why do U.S. medical schools produce high numbers of specialists?
Olds: If you look at U.S. medical schools, about 70% of the graduates specialize. They not only train at university hospital tertiary centers, the vast majority of faculty at U.S. medical schools are specialists. So, not surprisingly, they train people to be like them.
HL: Is there more of an emphasis on primary care training at international medical schools?
Olds: Yes. At our school, we largely train at community hospitals, and our faculty are primarily primary care faculty. So, we have the reverse statistic—70% of our graduates go into primary care and only 30% specialize.
We need about half of all medical school graduates to go into primary care. So, one of the reasons why international medical schools will continue to be important is that if the U.S. medical schools are going to turn out mostly specialists, then the primary care doctors are going to be mainly international medical school graduates. Until the U.S. medical schools change their statistics, there will always be a need for international medical school graduates.
HL: Are international medical school graduates who end up practicing in the United States mainly foreign-born individuals?
For international medical graduates, the assumption of many people is that these are all foreigners, which is not true. More than half of international graduates practicing in the United States are U.S. citizens, many of whom just missed getting into U.S. medical schools. They go to international medical schools, do everything that they would have done in a U.S. medical school, then return to do their residencies in the United States and, ultimately, practice in the United States.
HL:Why do you believe that international medical school graduates are more likely to gravitate to underserved areas of the country than U.S. medical school graduates?
Olds: About 25% of the doctors in the United States are international graduates—we're not talking about a rare occurrence. In rural areas and urban underserved areas, that percentage goes up to as high as 40%. So, international graduates are disproportionately going into primary care specialties and disproportionately practice in underserved areas, which is why they are crucial in trying to address the real doctor shortage—maldistribution by specialty and geographic area.
International medical school graduates who train in the United States such as the ones at my school train largely in federally qualified healthcare centers and community hospitals. So, they are taught medicine in settings where they ultimately practice.
In addition, many U.S. medical school students come from affluent communities and ultimately practice in those geographic areas. So, the differences in who gets into medical school and the differences in where we train them clinically are major reasons why international medical school graduates end up practicing in underserved areas of the United States.
HL:Are there benefits to having diversity in the U.S. physician workforce beyond helping to address the physician shortage?
Olds: St. George's doctors train with doctors from all over the world, which makes them more skilled at taking care of patients from a variety of ethnic backgrounds. So, both from the standpoint of better training of doctors to take care of all types of patients and from the patients' standpoint of liking to have doctors who come from a diverse background, international medical school graduates are better positioned than U.S. graduates. But having diversity among physicians and all healthcare professionals is good for our country.
HL: Has the Trump administration's efforts to reduce immigration impacted the ability of foreign-born international medical school graduates to work in the United States?
Historically, hospitals short of doctors could sponsor foreign-born physicians through an H-1B visa process. However, in their attempt to decrease immigration, the current U.S. government has unfortunately made it more difficult for international physicians to come to the United States, despite that we are desperate for more primary care doctors to work in underserved areas.
Right now, the visa situation is still reasonable. Most international medical school graduates can still train and practice in the United States, but the situation with H-1B visas has made it more difficult and will exacerbate the primary care physician shortage in the short run.
A new report focuses on the four steps in active pain management: screening and prescribing, dispensing and administering, monitoring and ongoing management, and tapering and discontinuance.
A new report from a national medical liability insurance company highlights how healthcare providers can reduce risks and improve patient safety in opioid treatments.
The human and economic costs of the country's opioid crisis have been severe. The Centers for Disease Control and Prevention says 700,000 people died in the opioid epidemic from 1999 to 2017. The annual economic burden of prescription opioid misuse has been estimated at $78.5 billion, according to the National Institute on Drug Abuse.
The new report from Boston-based Coverys focuses on four steps in the process for active pain management: screening and prescribing, dispensing and administering, monitoring and ongoing management, and tapering and discontinuance. "Each step has associated risks that can contribute to opioid dependence and persistent use. Coverys malpractice events involving opioid adverse outcomes demonstrate that this process can break down at any step along the way."
The report features data collected from five years of closed claims that identified 165 patient events involving prescribed opioids. There are several key data points:
Opioids are most commonly prescribed for acute pain
80% of indemnity payments were made for opioid prescriptions generated in inpatient hospital settings, emergency department surgical units, and physician practices
Chronic pain was the second highest driver of opioid prescriptions, with 60% of chronic pain events in the Coverys cases originating from physician practices or outpatient clinics
39% of indemnity payments were associated with screening and prescribing
29% of indemnity payments were associated with dispensing and administering
31% of indemnity payments were associated with monitoring and management
Risk reduction recommendations
To manage risk, the first step for healthcare providers is to conduct an assessment to identify risk exposures and prioritize areas for improvement, the report says. "Assessment should include review of internal processes related to opioid screening and prescribing, dispensing and administration, monitoring and management, and discontinuance and prevention of drug diversion. Self-assessments will help identify organizational strengths, areas of opportunity to enhance patient care, and may reduce your potential liability."
The report makes four general recommendations for all steps in the pain management process:
Conduct ongoing patient assessments for risk factors and opioid therapy effectiveness.
Educate patients about opioid side effects—particularly addiction. Check your state's prescription drug monitoring program (PDMP) database for information on specific patients.
Perform screening and laboratory tests as indicated.
Document patient assessments, effectiveness of opioid treatment, results of PDMP reviews, test findings, and communications with patients and other treating clinicians.
Strategies to improve physician engagement include giving clinicians a voice in decision-making and addressing toxic work environments.
Physicians are the least engaged members of the healthcare workforce, according to a new report published by South Bend, Indiana-based Press Ganey Associates.
In healthcare, the impact of workforce engagement has commonalities with other industries such as productivity, turnover, and financial performance. However, healthcare workforce engagement also impacts the health, safety, and wellbeing of patients.
"High workforce engagement is associated with improved or maintained patient experience scores from one year to the next, while no such improvement or maintenance is seen in the presence of low workforce engagement," the Press Ganey report says.
Physician engagement data
Data in the report was drawn from engagement surveys conducted in 2018 of more than 1.8 million physicians, nurses, and other healthcare workers.
The report features several key findings about physician engagement:
Physicians posted the lowest mean engagement score by job category on a scale of 1 to 5: 4.02. Senior management posted the highest mean engagement score at 4.60. The data shows that the closer a healthcare worker is to providing patient care, the lower the engagement score.
Length of service had a significant impact on physician mean engagement scores. Physicians with less than six months of service posted a 4.29 score. Physicians with three to five years of service posted a 4.06 score. Physicians with 21 to 25 years of service posted a 4.16 score. The engagement data shows a honeymoon period, followed by a steep decline, then recovery toward the end of physicians' careers.
Physicians scored lowest for resilience, which Press Ganey measures with two primary components: decompression, which is the ability to disconnect from work; and activation, which is the ability to connect with the meaning of work. Physicians scored lowest for overall resilience at 3.96.
Physicians scored lowest for ability to decompress at 3.34. "This finding helps explain physicians' increased vulnerability to burnout and the growing number of physicians who are experiencing it," the report says.
Boosting physician engagement
There are 10 ways to improve physician engagement, Martin Wright, a partner in strategic consulting at Press Ganey, told HealthLeaders.
1. Consistent measurement and understanding of physician needs is crucial, he says. "Organizations are not asking physicians what gets them engaged or about the challenges to be engaged on a consistent basis. So, leveraging a scientifically based, psychometrically sound survey measurement tool is the first step."
2. It is important to connect physicians with their meaning in work. "Storytelling can be effective in daily experience or safety huddles. Meetings can start with great stories of patient experiences, which can reconnect physicians with the importance of their work," Wright says.
3. Physician voices should be heard in the executive suite. "Year over year, we see that one of the drivers for physician engagement is the ability to influence decision-making. Having a pathway for physicians to share their voice and influence decisions is absolutely critical," he says.
4. Systemic factors can create a great culture in which to practice. "These factors are universal—they are not limited to one set of caregivers. For example, there can be an organizational commitment to zero harm. Systemic factors give caregivers something to rally around and build engagement," Wright says.
5. "It helps to truly put the patient at the center of everything a healthcare provider organization does, including work processes, vacation schedules, and parking garages to help caregivers to center themselves on what is most important and reconnect on why they decided to work in healthcare," he says.
6. Physicians should understand the interconnectivity of multiple work streams. "Many times, there are initiatives for safety, for quality care, for patient experience, and for engagement. Those initiatives are interconnected. If we can bring those initiatives together and streamline them so we are not asking physicians to do 20 things on top of their patient care routine, then we can create a more effective and efficient work environment," Wright says.
7. Data in healthcare should be used effectively and not simply collected. "An effective way to drive physician engagement is to build a comprehensive data strategy that improves transparency and helps everybody understand the objectives to which the organization is driving. For example, there can be a balanced scorecard that helps physicians understand what is expected of them in a transparent way. Those scorecards help promote a natural competitive spirit that is common among physicians," he says.
8. The presence of toxicity in an organization's culture should be curbed. "In some organizations, bullying and incivility reigns. It's hard to build engagement in that type of an environment. You need to create a just culture and allow space for collegiality," Wright says.
9. Organizations that are accelerating improvement on engagement have focused on building leadership abilities among physicians, he says. "Leadership skills are not always taught in medical school, but we call on physicians to be leaders every day. So, organizations can adopt intentional physician leadership development programs for physicians who are not only formal leaders but also informal leaders in places like the operating room."
10. Accountability structures for what is expected are important. "In a traditional leadership structure, we ask a group of physicians to do something, we train them on it, we expect them do it, then whoever leads the department checks back to see whether the physicians did what they were asked to do. But that type of accountability alone is not enough to drive engagement. For example, we need create space for peer-to-peer accountability such as the ability to have meaningful dialogue with peers," Wright says.