Most patients are not struggling to schedule new visits with generalists and specialists, new survey finds.
The U.S. physician shortage may not be as dire as previously predicted, according to a new survey report commissioned by the Houston-based Texas Medical Center Health Policy Institute.
The Association of American Medical Colleges has published alarming estimates of the country's physician short. Earlier this year, AAMC forecast that the physician shortage could expand to nearly 122,000 clinicians by 2032, including a shortfall of about 55,000 primary care physicians. In 2017, the AAMC estimated the overall physician shortage at 20,400 clinicians.
The new survey report, which is based on data collected from 2,000 patients and 750 physicians, says the AAMC's physician shortage estimate could be overstated. In particular, the survey report found that only 19% of patients struggled to have a new visit with a generalist and only 15% struggled to set a new visit with a specialist.
"The best way to tell if we have a doctor shortage is by asking patients whether they can easily get an appointment. For now, they overwhelmingly say 'yes,'" Arthur "Tim" Garson Jr., MD, MPH, director of the Texas Medical Center Health Policy Institute, said in a prepared statement.
The survey, which quizzed patients and physicians on a range of healthcare issues, was conducted this year in June and July.
Despite the positive finding on patients' ability to schedule new visits, physicians surveyed are bracing for doctor shortages:
90% of generalist physicians predict there will be a shortage of generalists within five years
78% of specialist physicians predict there will be a shortage of specialists within five years
Easing physician shortages
The survey report highlights four approaches to address future physician shortages if they worsen.
1. Nurse practitioners: Both generalist and specialist physicians expect nurse practitioners to ease their workloads over the next five years: 77% of generalists and 70% of specialists said they expected to see fewer patients as nurse practitioners saw more patients.
2. Postponing of retirement: About 4 in 5 of physicians said they would consider postponing retirement under certain conditions. The top condition was doubling the amount of time available to spend with each patient, with 34% of generalists and 30% of specialists saying more time with patients could delay retirement. The second-highest condition cited was a 10% increase in income, with 21% of generalists and 20% of specialists saying that the higher compensation could delay retirement.
3. Service requirement in underserved areas: There was a significant measure of enthusiasm for a graduation requirement that medical degree students serve two years in an underserved area before their residency training. Among generalists and specialists, 45% said they were either very enthusiastic or somewhat enthusiastic about the graduation requirement.
4. Education reform: Nearly half of the physicians surveyed said the United States Medical Licensing Examination does not test candidates for what is required to be a practicing physician: 45% of generalists and 40% of specialists.
Walmart employees and their dependents in three states will have access to primary care and behavioral health visits with just a $4 copay.
A new telemedicine partnership between retail giant Walmart and Doctor On Demand features a primary care model with integrated behavioral health services.
Telemedicine is one of the hottest growth areas in U.S. healthcare. The U.S. telemedicine market is expected to reach $64.0 billion by 2025, according to MarketWatch. In 2018, the web- and mobile-based telemedicine segment held a telehealth revenue share of $11.8 billion, and the telehospital segment accounted for $12.7 billion, MarketWatch says.
From 2010 to 2017, there was steady growth of telehealth services at the country's hospitals, according to the American Hospital Association. In 2010, 35% of hospitals offered telehealth services to their patients. In 2017, that figure more than doubled to 76%.
The new partnership between Walmart and Doctor On Demand features an innovative approach to primary care through telemedicine, says Hill Ferguson, MBA, CEO of the San Francisco–based telehealth services provider.
"This partnership involves not only having a primary care physician assigned to employees but also having a care team that works behind the physician of nurses, pharmacists, coaches, and nutritionists that can help engage patients, many of whom have chronic conditions. We can help patients manage chronic conditions from the comfort of their home, keep them out of the emergency room, and make sure that if they need in-person care that we can route them to the right place where they will optimize for quality and cost," he says.
The partnership has transformative potential, Lisa Woods, Walmart’s senior director of U.S. benefits, said in a prepared statement. "If we get this right, we can raise the tide for all healthcare."
Deal details
The new partnership provides primary care and behavioral health services via video-based telemedicine to Walmart employees and their dependents in Colorado, Minnesota, and Wisconsin.
Walmart is the second large organization to reach a deal with Doctor On Demand since the telehealth services provider launched its Synapse virtual primary care platform earlier this year. Humana was the first to adopt the platform.
Walmart is self-insured, and the financing of visits is fully integrated into Walmart's and Humana's insurance carrier networks, so Doctor On Demand is reimbursed through those payers, Ferguson says.
"The way it works financially is we have a component of cost that is assessed on a per-employee-per-month basis and a component of cost that is assessed on each patient visit. Depending on the type of visit, the price may vary—it may be an urgent care visit, or an initial psychiatry visit, or a follow-up psychology visit. They will all have different visit fees," he says.
Walmart is paying for the bulk of the telemedicine services. "Walmart contracts directly with Doctor On Demand, and they pay us for the services that we provide. Then they offer our services to their employees for the $4 copay. In effect, they are subsidizing almost all of the cost for the delivery of the care that we are providing," Ferguson says.
Doctor on Demand's primary care model
Doctor On Demand features video telemedicine visits available on mobile devices and home computers. The telehealth service provider's physicians are employed by the company.
"These are fully employed physicians who have joined our medical practice. We have several specialties—family medicine, internal medicine, pediatrics, psychiatry, and psychology. We have built an integrated model where it's virtual primary care with integrated behavioral health. That model has formed the foundation for our future direction and for deals like the one with Walmart. We can do so much more than simply talk on the phone to a patient and determine whether they need an antibiotic," Ferguson says.
In the Walmart deal, Doctor On Demand will be auto-registering populations of employees and their dependents in Colorado, Minnesota, and Wisconsin. Initially, the only requirement for employees is to create a password on the Doctor on Demand website or the company's mobile application.
"Employees will be able to see the virtual primary care physician we have assigned to them—you can read about their background, you can see what they look like, you can see where they went to medical school, and you can see what languages they speak. If employees decide to have different providers, they can search our directories and pick a new provider," Ferguson says.
The Doctor on Demand primary care model mirrors the services provided in brick-and-mortar practices, he says.
"We encourage employees to have an initial visit to establish a baseline with their provider. In some cases, there may be a preventative care visit. If a patient has a chronic disease, the provider may create a care plan that involves a number of virtual interactions with our care team through text messaging, or phone calls, or video visits. We may order a lab test for patients; for example, if you are 45 years old and you have no idea about your cholesterol levels."
Sometimes, patients receive referrals for in-person care, Ferguson says.
"We resolve about 92% of our cases virtually. The rest of the cases are referred to brick-and-mortar facilities. Sometimes, it will be for lab tests. Sometimes, it will be for an MRI. A referral could be for a specialist consultation such as an endocrinologist for an advanced form of diabetes. For specialist referrals, Doctor on Demand works with Walmart and finds a high-quality provider in their network," he says.
Improving access
Telemedicine partnerships like the Walmart and Doctor On Demand deal have the potential to grow exponentially and help address healthcare access problems and physician shortages nationwide, Ferguson says.
"We believe the largest impact we can have on healthcare is expanding access to primary care beyond routine conditions such as colds, flu, and pink eye. We're talking about real primary care, where a patient engages with a physician over a long period of time, and that physician treats most of the patient's conditions, then helps the patient make smart decisions on where to get in-person care. We think we are part of the solution for our broken healthcare system. It's just not practical to think that everyone can go in person every time they need to see a doctor," he says.
A unique element of the new training program features strategies for delivering bad news to patients and family members.
A new training program for workplace violence in healthcare settings emphasizes de-escalation and addressing four distinct stages of crisis situations.
Healthcare staff carry a heavy workplace violence burden, with about three-quarters of workplace assaults occurring in healthcare settings. Workplace violence is prevalent in the emergency department—78% of emergency physicians have reported being targets of workplace violence in the prior 12 months.
"What we teach is that you can't control what is happening with a person—their backstory or the neurocognitive challenges they might be facing—but you can absolutely control your responses to escalating behaviors. We train that changing your approach can change everything about an encounter," says Susan Driscoll, president of the Milwaukee, Wisconsin-based Crisis Prevention Institute.
She says CPI has developed a four-stage framework to describe and address workplace violence situations.
1. Anxiety: "The first stage is anxiety, where somebody is showing they are agitated. They might be pacing. They might be clenching their hands into fists," Driscoll says.
In the early stage of a crisis, she says how staff members say something or what they say make a difference. Staff members need to be empathetic and listen. They need to allow agitated patients and family members time to vent. Those principles can usually get someone back to a normal state.
2. Defensiveness: "The second stage is when someone gets defensive. At this stage, someone is likely to verbally challenge a staff member. They're starting to lose control. They may refuse to do something they are asked to do," Driscoll says.
The new CPI training program features a "verbal toolkit" to address defensive patients or family members, she says. "One of the strategies is to distract the patient or family member who is in crisis. If they are escalating and getting irrational, you change the subject. A specific example is if somebody challenges you with an inappropriate comment, you can say, 'I understand that, but we need to get back to what we are trying to do.'"
3. Risk behavior: "The third stage is risk behavior, where someone might try to intimidate a staff member. They literally are losing control such as looking for something to throw or punching. This is where the situation becomes dangerous," Driscoll says.
"Our most advanced programs include restrictive practices. So, if someone is out of control and is a danger to themselves and other people, our advanced programs teach the physical holds to safely control someone or move them out of a location."
4. Tension reduction: "The fourth stage is tension reduction. After someone goes through a crisis episode, there tends to be a release of energy. They might appear to be exhausted. They might cry. They generally apologize profusely," she says.
What happens after a crisis is just as important as what happens during a crisis, Driscoll says. "We teach what we call therapeutic rapport—the techniques for getting you as a staff member and the person who was in crisis back to a normal functioning state."
Incident reporting
Documenting workplace violence incidents is essential in the healthcare setting, she says. "Having a strong policy about incident reporting is critically important. Sometimes, there are patterns in a person's behavior that are not readily apparent. But when incidents get documented, you see those patterns and better quality of care can be delivered."
Incident reporting can identify solutions to workplace violence situations, Driscoll says.
"In a crisis, we believe that every behavior is a sign of distress, and the goal should be to prevent that distress through early intervention. When incidents are reported—even when the person in crisis was not aware of what they were doing—sometimes you can identify an underlying trigger."
Delivering bad news
One of the aspects of the new CPI workplace violence training for healthcare workers that distinguishes it from CPI's other training programs is guidance for breaking negative news to patients and family members.
"Doctors and nurses in healthcare often have to deliver bad news to a patient or family member. That is a time when escalation can occur quickly," Driscoll says.
The CPI training for healthcare workers provides seven strategies for delivering bad news:
Keep yourself safe
Get to the point
Remain objective
Rationally detach, which is a concept presented in all CPI training programs
There are several considerations for both physicians and administrators, including notice periods and how to initiate retirement discussions.
Healthcare organizations should create a positive culture and effective processes for physician retirements, according to a recent survey report published by Alpharetta, Georgia-based Jackson Physician Search.
Physician retirements pose multiple challenges, the survey report says: by next year, about one-third of physicians will be over 65 and nearing retirement; and open positions impact patient satisfaction, staff morale, and revenue. For example, a hospital can lose about $150,000 in revenue per month when a specialist retires and is not replaced.
Physicians and healthcare organization administrators should work cooperatively to manage retirement transitions, the survey report says. "Differences remain on length of notice and whose responsibility it is to bring up retirement, but when handled respectfully and conducted in a non-discriminatory way, both parties can find the ideal way to transition the retirement with proper planning and processes."
The survey report, which features data collected from more than 550 physicians and 100 administrators, has several key findings:
For physicians, lifestyle was identified as the most important factor in retirement decisions, with lifestyle cited by 44% of physicians surveyed. Financial stability was the next most important factor, cited by 23% of physicians. Other factors included burnout and frustration with the "current state of medicine."
Most physicians (80%) said it was their responsibility to broach the topic of retirement, but only 52% said they were comfortable discussing retirement.
Only 37% of administrators said it was their responsibility to broach the topic of retirement, but 74% said they were comfortable discussing retirement.
Physicians and administrators were at odds over the ideal notice period for retirement. The largest percentage of physicians (40%) expressing a notice preference said six months or less was appropriate, and 34% said no notice of retirement was required. Nearly 50% of administrators said notice of retirement should ideally be one to three years.
Physicians and administrators also had widely varying views on post-retirement employment. Nearly 40% of administrators said they expected retiring physicians to stop practicing entirely, but only 17% of physicians said they planned to leave practice entirely. More than a quarter of physicians said they would work full-time or part-time after retirement at another healthcare organization, or they would pursue other employment opportunities such as locum tenens work or telemedicine.
Initiating retirement conversations: Physicians
For physicians, there are three primary considerations when broaching the topic of retirement with healthcare organization administrators, Tony Stajduhar, president, Jackson Physician Search, told HealthLeaders.
1. Coping with uncertainty: It is OK to discuss retirement even if you don't have a set date. Because recruiting a physician is difficult and takes time, approach the topic early prior to having a firm date. This will give administration the time it needs to identify the right candidate to try and fill your role and fulfill your legacy.
2. It never hurts to ask: Present your ideal scenario to the administration—they may be willing to work with you because your services are highly valued. There may even be an option to shift from full-time practice to part-time if desired.
3. Make retirement mutually beneficial: Approach the topic as a win-win, whether you want to transition slowly or fully retire. You want both parties to have mutual understanding.
There are also three primary considerations when administrators broach the topic of a physician's retirement, Stajduhar said.
1. Retirement is not a taboo topic: Work in close coordination with your human resources department to make sure physicians know they work in a safe environment and that they will not be fired or let go early for bringing up the topic of retirement.
2.Be flexible: Knowing what physicians really want while winding down their career is important. The more flexibility you can offer, the longer the physician will stay, ideally full-time but possibly even part-time for the long-term. Offering employment options potentially avoids the need for expensive locum tenens coverage.
3. Establish guidelines: Work with your HR department to have a retirement policy in writing or as part of hospital bylaws, and make sure the policy is communicated in writing.
Ongoing recruitment
The survey report recommends that administrators consider having an ongoing process for physician recruitment. For administrators, there are three best practices for ongoing recruitment, Stajduhar said.
1. Be knowledgeable about recruitment timelines: Some specialties are more difficult to recruit than others. Know how long it has taken you in the past and work backward from there. To serve patient needs, a little extra capacity is always better than a vacancy.
2. Have a strong recruitment partner: If a retirement is unexpected and it is crucial to fill the position quickly, explore the option of working with an established recruitment firm. They often have access to a larger pool of resources and experienced consultants to provide expert advice.
3.Time is not on your side: The longer you wait to actively start your search, the longer you will have a vacancy. Residents and fellows are very time sensitive and usually interview in the fall. Sometimes, residents and fellows interview as early as the spring of the previous year for a start date the following summer—almost 18 months out.
A new report identifies diagnostic errors as the top patient safety risk in ambulatory care settings.
A watchdog group has identified the top four risks for patient safety at ambulatory care settings, according to a new report.
Ambulatory care facilities such as physician offices and outpatient clinics are the most widely used settings in U.S. healthcare, according to the ECRI Institute PSO report published last week. Ambulatory care settings provide a wide range of services to patients such as consultation, diagnosis, and interventions.
"As healthcare delivery shifts from hospitals to ambulatory care settings, it can be challenging to coordinate care among various clinicians, systems, and facilities, raising the potential for errors that put patients at risk. Reducing and eliminating adverse events in an outpatient environment will require an unprecedented commitment to collaboration and coordination," Marcus Schabacker, MD, PhD, president and CEO of the ECRI Institute, said in a prepared statement.
The watchdog group is based in Plymouth Meeting, Pennsylvania.
According to the ECRI Institute PSO (patient safety organization) report, the top four risks for patient safety at ambulatory care settings are diagnostic testing errors, medication events, falls, and security incidents.
ECRI Institute PSO examined more than 4,300 ambulatory care patient safety events from December 2017 to November 2018. Diagnostic testing errors accounted for the most events (47%), followed by medication safety events (27%). Highlights of the findings and recommendations are below.
1. Diagnostic testing errors
Patients can experience several negative impacts from diagnostic testing errors such as missed or delayed diagnoses, delayed interventions, and duplication of services. According to the ECRI Institute PSO report, the most common diagnostic testing errors involved laboratory tests (69%), followed by imaging tests (21%).
The report's recommendations to curb diagnostic testing errors include the following:
Establish decision support tools to help clinicians order appropriate tests
Establish processes for communicating test results such as a chain of command that includes a reporting provision when the clinician who ordered a test is absent
Establish standard operating procedures in writing for specimen, collection, preparation, and delivery
2. Medication events
Medication safety events are a leading cause of malpractice claims in ambulatory care. In a Coverys analysis of more than 10,000 closed malpractice claims, medication errors were the fourth most common cause of medical professional liability claims, and 42% of the errors occurred in an ambulatory setting.
In the ECRI Institute PSO analysis, the most common medication safety event (67%) involved "wrong" errors such as wrong patient or wrong drug, followed by monitoring errors (16%). "Such events can occur during any stage of the medication process and are rarely the fault of one person; rather, as with most adverse events, they result from a series of failures within a system," the ECRI Institute PSO report says.
The report's recommendations to reduce medication errors include the following:
Identify priority areas for medication safety improvement such as medication-event reporting and medication safety education
Establish standardized policies and procedures that feature best practices for each phase of the medication management process
Establish and communicating management processes for high-alert medications such as chemotherapy drugs, including storage and administration
3. Patient falls
Patient falls accounted for 14% of the events in the ECRI Institute PSO analysis, with most falls occurring in the physician practice setting.
"Falls are often preventable occurrences that can lead to patient injury, cause hospitalizations, and significantly increase healthcare costs. Falls occurring in hospitalized patients are a major source of risk for acute and long-term care providers. In ambulatory care, screening for the risk of falls is an important component of preventing falls whether in the office setting, at home, or elsewhere," the report says.
The report's recommendations to decrease falls include the following:
Screen patients for falls during every visit, when there is a change in medical condition, and after a fall
Train staff to identify fall risks during a range of patient interactions such as welcoming and conducting medical assessments
In the electronic medical record, flag prescriptions of medications that have a fall risk when the drug is ordered and during medication reconciliation
4. Security incidents
About three-quarters of U.S. workplace assaults occur in healthcare settings, according to a federal Occupational Safety and Health Administration report. Most of the security events examined in the ECRI Institute PSO analysis involved verbal threats or disruptive behavior by patients or patient visitors.
"Unfortunately, security and safety issues, such as workplace violence, are common in healthcare, including ambulatory care settings. Although most episodes of disruptive behavior or violent acts are perpetrated by patients, some are perpetrated by family members of patients, other visitors, employees, or ill-meaning trespassers," the ECRI Institute PSO report says.
The report's recommendations to address security incidents include the following:
Establish a well-resourced workplace violence prevention program
On at least an annual basis, conducting an all-hazards risk assessment that includes patient risks, environmental risks, and operational risks that gauge the potential for violence
On at least a monthly basis, have security and safety surveillance rounds
In the New Orleans area, LCMC Health is making strides toward value-based care by taking a population health services organization approach to its new clinically integrated network.
A New Orleans–based health system has crafted a new clinically integrated network (CIN) as a population health services organization.
One of the major challenges in healthcare is managing the shift from the traditional fee-for-service model for delivery of medical services to value-based models. The primary goal of these efforts is to replace fee-for-service contracts with payers with value-based contracts such as shared savings arrangements that include financial rewards for reducing cost of care.
LCMC Health formally launched the New Orleans health system's new population health services organization CIN in January 2018 in a business relationship with St. Louis–based Lumeris. There are five essential elements in the initiative, says Meg Vitter Greene, MHA, vice president of population health and network development at LCMC Health.
"What is unique about building a population health services organization is that it is a commitment to building out the five components that Lumeris identifies as being part of a PHSO: governance and leadership, physician engagement, payer strategy, care delivery, and technology and analytics. Many clinically integrated networks may do one or two of those well, but they do not focus on all five. Without building all five and making sure that they all have adequate attention, I don't think you can be successful," Vitter Greene says.
Population health services organization CIN by the numbers
LCMC Health's population health services organization CIN, which is called LCMC Healthcare Partners, enjoyed a measure of success in its first year, generating $3.6 million in gains from value-based contracts based on quality metric performance and shared savings in 2018, she says. About $1.5 million of the total was shared savings.
"We had success in both categories. For the quality metric dollars, we receive them throughout the course of the calendar year. For shared savings, we have an annual evaluation as to whether we have reduced the cost of care. In 2018, we earned shared savings with Medicare Advantage payers, and we earned quality metric dollars across all types of payers, including Medicare, Medicaid, and commercial insurance," Vitter Greene says.
The LCMC Healthcare Partners network features all five of LCMC Health's hospitals: a safety-net academic medical center, a children's hospital, and three community hospitals. There are nearly 900 physicians in the network—about 270 primary care physicians split evenly between adult care and pediatric care along with about 600 specialty clinicians.
In January 2018, LCMC Healthcare Partners launched with about 65,000 lives managed in value-based contracts, and that figure could be as high as 90,000 by the end of this year, she says. "For now, about 70% of our patients are still in the fee-for-service world."
Vitter Greene shared some of the highlights of LCMC Healthcare Partners' five-part strategy.
1. Governance and leadership
The first big step in developing LCMC Healthcare Partners was educating the health system's senior leadership about the benefits of increasing efforts to shift from fee-for-service to value-based care, she says.
"Without that commitment, embarking on a long-term strategy like this just won't work. So, there was a lot of time and energy educating our leadership on the value of providing population health across our patient base and educating leaders about the movement to value-based care. We educated people about why this was better for our patients and physicians, why it would improve the quality of the care we provide, and why it would reduce the overall cost of healthcare."
The health system's senior clinical leaders were convinced that a value-based approach to population health would garner significant benefits, Vitter Greene says. "We have physician leaders and quality leaders throughout the organization who are focused on preventative medicine and focused on keeping patients healthy instead of waiting to treat them until they are sick. They are interested in improving the overall health of our patient population."
2. Physician engagement
LCMC Healthcare Partners has several physician engagement initiatives, including educational sessions at physician practices and large physician groups that are part of the network, along with identifying physician champions at employed and community physician practices, she says.
A significant component of the physician engagement effort is a "pod structure" to reach individual physicians in the network, Vitter Greene says.
"We have associate medical directors working over groups of practices who share information about performance and care gap closures with physician champions at the practice level. Then those physician champions get information down to the individual physician level. We think the pod structure will encourage physician engagement and healthy competition among our physicians to perform well in value-based contracts and take great care of their patients."
3. Payer strategy
LCMC Health has a diverse payer mix, including many patients covered through Medicaid who receive services at the health system's safety-net academic medical center and the children's hospital. As a result, LCMC Healthcare Partners' payer strategy involves seeking value-based contracts with a range of payers, she says.
"To build a clinically integrated network that can support all of our hospitals, we have to have an all-payer, all-population network. Oftentimes, clinically integrated networks will focus on Medicare such as a Medicare accountable care organization—managing one specific population well. We can't do that because the mission at LCMC Health is to take care of all patients. It's an ambitious goal, but we believe that we can build an all-payer, all-population model."
LCMC Healthcare Partners is striving to establish value-based contracts with as many payers as possible, which has impacted the network's managed care strategy, Vitter Greene says. "We are focused on a managed care strategy that straddles across Medicare Advantage, traditional Medicare, commercial payers, and Medicaid."
4. Care delivery
The health system's diverse population and payer mix has implications for care delivery such as case management, she says.
"We have our own case managers, but we need them to be diverse. We can't just have case managers who have experience in doing adult case management—we need case managers who have experience with behavioral health issues and experience in pediatrics. So, we're always looking to make sure we are being as thoughtful as possible in building out a case management team that can take care of the diverse population we serve."
5. Technology and analytics
Harnessing data is an essential function at LCMC Healthcare Partners, Vitter Greene says.
"We've been able to take claims data from all of the payers that we work with and marry it with data from our electronic medical record that we have at LCMC Health. Then we put all of that information in one population health tool, which analyzes and risk stratifies our patient population so we can prioritize patients for outreach. Through that identification of patients for outreach, our case managers can execute on their workflows."
The Leapfrog Group's surveys collected data from more than 300 ambulatory surgery centers and more than 1,100 hospital outpatient departments.
For the first time, The Leapfrog Group has collected patient safety and quality information about ambulatory surgery centers (ASCs) and hospital outpatient departments (HOPDs).
Leapfrog has been collecting patient safety and quality data about hospital inpatient facilities for years. With more than 60% of surgical procedures now possible to perform at ASCs and HOPDs, the Washington, DC-based watchdog organization decided to expand collection of data to these same-day surgery settings.
The data was reported recently in a report based on two surveys. A new survey collected data this year from 321 ASCs. In an expanded Leapfrog Hospital Survey, data was collected this year from 1,141 HOPDs. "Both surveys were developed with guidance from national experts and include standardized, evidence-based measures of care specific to places that perform ambulatory and outpatient procedures," the report says.
The surveys generated several key data points, including the following:
Life support: All ASCs and HOPDs reported having a board-certified clinician for advanced cardiovascular life support present while adult patients undergo procedures and recovery. However, fewer of the facilities reported always having a board-certified clinician present for pediatric advanced life support: 89% of ASCs and 96% of HOPDs. "This displays a potential gap in ability to perform life-saving actions if complications arise for pediatric patients," the report says.
Surgery board certification: Leapfrog found that 1 in 3 same-day surgery facilities do not have 100% board-certification among surgical professionals.
Anesthesia board certification: Nearly 30% of ASCs reported that not all providers administering anesthesia are board certified. Nearly 20% of HOPDs reported that not all providers administering anesthesia are board certified. "Though 71% of ASCs and 83% of HOPDs report that all individuals who administer anesthesia are board-certified, there is still significant room for improvement," the report says.
Surgery consent materials: Relatively few ASCs and HOPDs provided surgery consent materials to patients before the day of surgery. Consent materials were provided to patients at least three days prior to surgery at 17% of ASCs and 21% of HOPDs. Consent materials were provided to patients one to three days prior to surgery at 14% of ASCs and 21% of HOPDs. Consent materials were provided to patients the same day as surgery at 65% of ASCs and 49% of HOPDs. "Providing consent materials prior to the day of the procedure gives patients the opportunity to adequately consider the risks involved," the report says.
Anesthesia consent materials: ASCs and HOPDs reported similar data for provision of anesthesia consent materials to patients. Anesthesia consent materials were provided to patients at least three days prior to surgery at 8% of ASCs and 10% of HOPDs. Consent materials were provided to patients one to three days prior to surgery at 8% of ASCs and 12% of HOPDs. Consent materials were provided to patients the same day as surgery at 80% of ASCs and 71% of HOPDs.
Antimicrobial stewardship: Only 18% of ASCs reported they had adopted antimicrobial stewardship programs. "ASCs are encouraged to adopt a program to promote the appropriate use of antimicrobials (including antibiotics), which can in turn improve patient outcomes, reduce microbial resistance, and ultimately decrease the spread of infections," the report says. Although data was not available for HOPDs, 93% of acute care hospitals have reported having antimicrobial stewardship programs.
Interpreting the data
Erica Mobley, director of operations at The Leapfrog Group, told HealthLeaders that the survey result on antimicrobial stewardship at ASCs was "certainly a concern."
"Antibiotic and antimicrobial use in ASCs is different from that administered in other healthcare environments, which is why Leapfrog chose to include this safety protocol on its survey. Many resources and toolkits have been developed to help ASCs with implementing an antimicrobial stewardship program, and we are confident this number will grow in the future," she said.
The findings that 11% of ASCs and 4% of HOPDs do not always have a clinician present who is certified to provide advanced life support for pediatric patients is also concerning, Mobley said. "If unexpected complications arise, these facilities may not be well-equipped to care for pediatric patients. ... Parents should inquire about the availability of clinicians certified in pediatric advanced life support prior to scheduling a procedure for their child."
When selecting an ASC or HOPD for a surgical procedure, patients should consider the presence of board-certified clinicians performing procedures and administering anesthesia, she said.
"Board certification is a voluntary process separate from licensure. Medical professionals who pursue it demonstrate a desire to grow their skillset to keep pace with the latest advancements in their specialty. Consumers considering their options for surgery should inquire whether the healthcare team consists of board-certified individuals to inform their decision of where they seek treatment. In some cases, the absence of board-certified clinicians may mean that experts who have the skillset to treat true complications are not present in the facility."
CMS Administrator Seema Verma vows to take 'aggressive actions.'
The Centers for Medicare & Medicaid Services (CMS) have announced a five-part strategy to combat fraud, waste, and abuse in the Medicare program.
About 25% of U.S. healthcare spending is wasteful, according to a recent article published in the Journal of the American Medical Association. The JAMA researchers focused on six categories of waste: failure of care delivery, failure of care coordination, overtreatment or low-value care, pricing failure, fraud and abuse, and administrative complexity.
Administrative complexity accounted for the largest amount of estimated annual wasteful spending at $265.6 billion. Medicare has drawn criticism for decades over administrative complexity.
In a blog post published last week, CMS Administrator Seema Verma outlined the agency's five-part "program integrity strategy."
"CMS defines program integrity very simply: 'pay it right.' Program integrity must focus on paying the right amount, to legitimate providers, for covered, reasonable and necessary services provided to eligible beneficiaries while taking aggressive actions to eliminate fraud, waste and abuse," Verma wrote.
The five approaches to improve program integrity are stopping bad actors, preventing fraud, mitigating emerging programmatic risks, reducing provider burden, and leveraging new technology. Highlights of the strategies are below.
1. Stopping bad actors
Verma says several agencies are actively involved in identifying Medicare fraud and referring cases to law enforcement, including CMS, the Office of the Inspector General, the Department of Justice, and Unified Program Integrity Contractors. "We work with law enforcement agencies to identify and take action on those who defraud the Medicare program," she wrote.
For example, she says "healthcare fraud takedowns" in recent months targeting orthotic braces and genetic testing saved Medicare $3.3 billion dollars.
2. Preventing fraud
As opposed to Medicare's "pay and chase" model of combatting fraud in the past, CMS is developing approaches to prevent fraud, waste, abuse before claims are paid, Verma wrote.
"After we identify bad actors and their schemes, we make system changes to avoid similar fraudulent activities in the future. CMS' oversight, audit, and investigative activities allow us to analyze data to identify potential problem areas. We then work with our law enforcement partners to develop policies, regulations, and processes to prevent vulnerabilities from being exploited before claims are paid."
For example, CMS took measures to prevent fraud during the recent effort to send new Medicare cards to beneficiaries, she wrote.
"CMS implemented an enhanced address validation process to verify beneficiaries' identities and addresses against multiple information sources. This ensured that we mailed new Medicare cards to the right person at the right address. We reviewed over 61 million cards for address accuracy, which we estimate saved billions of dollars in fraudulent claim payments."
3. Mitigating emerging programmatic risks
As Medicare shifts from the program's traditional fee-for-service payment model to value-based payment models, CMS is committed to developing safeguards to ensure the integrity of the new reimbursement processes, Verma wrote.
"New payment models have been very beneficial but also have the potential to cause new challenges in identifying improper payments, beneficiary safety issues, and other program integrity concerns. CMS is continuing to explore ways to identify and reduce program integrity risks related to value-based payment programs by looking to experts in the healthcare community for lessons learned and best practices."
4. Reducing provider burden
While CMS steps up efforts to combat fraud, abuse, and waste, the agency is mindful that it should not create inappropriate time and cost burdens on healthcare providers, Verma says.
"To that end, we have increased efforts to educate providers in CMS program rules and regulations and remedy onerous processes to assist rather than punish providers who make good faith claim errors. That's the purpose of our Targeted Probe and Educate (TPE) program and our efforts to streamline our recovery audit processes. It's vital to separate providers who make clerical errors from truly nefarious actors."
Through the TPE program from October 2017 to February 2019, she says CMS provided one-on-one education for 20,000 healthcare providers and medical goods suppliers to decrease honest mistakes. "As a result, approximately 80% of those providers and suppliers were released from further review," she wrote.
5. Deploying new technology
CMS is committed to deploying new technology to boost the efficiency of fraud, waste, and abuse reduction efforts, Verma wrote.
"Today, the Medicare fee-for-service program relies on clinician reviewers—human beings—to review the medical records associated with items and services billed to Medicare. Providers also have to send us copies of medical records, which is time-intensive and burdensome. That is why we only review less than 1% of medical records. Looking forward, CMS is seeking new, innovative strategies and technologies, perhaps involving artificial intelligence and/or machine learning, which are more cost effective and less burdensome to both providers, suppliers and the Medicare program."
For example, CMS is hoping to upgrade the agency's Fraud Prevention System and case management systems, she wrote. "While these systems have helped us to obtain a positive return on investment, we believe that by adopting cutting edge technology—such as AI and machine learning tools—we can achieve greater savings for taxpayers and allow us to review more claims."
Comments on the CMS Center for Program Integrity initiative can be submitted electronically via email at ProgramIntegrityRFI@cms.hhs.gov. Documents should be submitted in PDF format.
A new clinician burnout report from the National Academy of Medicine includes six recommendations to address the problem.
The National Academy of Medicine has released an extensive report on how the country can respond to burnout in the medical professions, with the president of the organization calling burnout an epidemic in need of urgent action.
Research indicates that about half of physicians nationwide are experiencing burnout symptoms, and a study published in October 2018 found burnout increases the odds of physician involvement in patient safety incidents, unprofessionalism, and lower patient satisfaction. Burnout has also been linked to negative financial effects at physician practices and other healthcare organizations.
The new report was unveiled Wednesday at an event held in Washington, DC. Victor Dzau, MD, president of the National Academy of Medicine, made a passionate call to action.
"Our nation is facing an epidemic of clinician burnout. Over the past several years, the medical community has recognized an alarming crisis of physician burnout and suicide, although the public remains largely unaware of it. So, it is in the interest of ensuring quality patient care and well-being of our clinicians that today's report is released to shine the spotlight on the crisis and recommend solutions to prevent it," he said.
Burnout is widespread throughout the medical community, Dzau said.
"The epidemic of burnout affects both those in training as well as those in practice. Over 50% of physicians and 45% to 60% of medical students and residents have symptoms of burnout. Furthermore, physician rates of depression or suicidal ideation remain very high—as high as 40%. This issue is not unique to physicians. There are high prevalence rates of symptoms of post traumatic stress disorder and emotional exhaustion among nurses and many other health professionals."
Burnout among healthcare workers has significant implications for patient care and society at large, he said.
"Burnout has been linked to self-reported errors, patient dissatisfaction, a reduced ability to express empathy, increased familial problems, stress-related illnesses, automobile accidents, and substance abuse. Clinician burnout also is a threat to the quality of patient care."
The new report was crafted by the National Academy of Medicine's Committee on Systems Approaches to Improve Patient Care by Supporting Clinician Well-Being. To address burnout among healthcare professionals, the report makes six recommendations, which are highlighted below.
1. Foster positive work environments
Healthcare settings should be transformed in ways that prevent and reduce burnout, support professional well-being, and promote quality care.
For example, senior leaders of healthcare organizations should be committed to monitoring and improving the clinical work environment. "Specifically, governing boards should hold organizational leaders accountable for creating and maintaining a positive and healthy work environment," the report says.
2. Promote positive learning environments
Medical education and training should be improved to create learning environments that prevent and reduce burnout as well as promote professional well-being.
For example, learning environments should support quality patient care with a collegial approach to learning. "Enhance the ability of learners to contribute meaningfully to patient care while learning, and implement strategies that build relationships among and between learners, faculty, and other health professionals with the intent to build social support and interprofessional practice," the report says.
3. Decrease administrative burden
Actions should be taken to address the negative side effects of laws, regulations, policies, and standards set by government agencies, professional associations, and accrediting organizations.
For example, resources should be allocated to assess the impact of laws, regulations, policies and standards. "Formal assessment should be conducted both prior to and following implementation in order to evaluate how the requirements affect clinician workload and whether they are redundant or conflict with other requirements. Regulations, policies, and standards should then be modified accordingly," the report says.
4. Develop technology solutions
Health information technologies should be redesigned and improved in ways that help clinicians to provide high-quality care.
For example, health information technology enhancements should focus on improvements that support clinicians and other healthcare professionals. "Health IT vendors and healthcare organizations should design and configure systems to improve the clinical work environment, including attention to cognitive load and workflows that reduce the demand of clinical documentation and automate non-essential tasks," the report says.
5. Support clinicians and trainees
Efforts should be made to decrease prejudice against healthcare professionals who experience burnout and to tear down barriers to receiving support and services to address burnout.
For example, barriers to receiving burnout support and services in training settings should be identified and brought down. "Health professions educational institutions, healthcare organizations, and affiliated training sites should identify and address those aspects of the learning environment, institutional culture, infrastructure and resources, and policies that prevent or discourage access to professional and personal support programs for individual learners and clinicians," the report says.
6. Promote research
Funding should be allocated to support research of clinician professional well-being.
For example, federal agencies such as the Agency for Healthcare Research and Quality, the National Institute for Occupational Safety and Health, and the Health Resources and Services Administration should lead efforts to research burnout and burnout interventions. Federal agencies should work in public–private partnerships with a range of stakeholders, including professional associations, foundations, payers, healthcare organizations, and professional liability insurers.
"Organizations need to be willing to test, learn, and share in order to accelerate the pace of change," the report says.
Paul King has served in leadership roles at some of the country's premier healthcare organizations, including Mayo Clinic and the University of Michigan.
After serving in leadership positions for more than three decades, the new top executive at Stanford Children's Health has a wealth of insight to share about management principles and pediatric care.
In January, Paul King, MHA, was named president and CEO of Stanford Children's Health and Lucile Packard Children's Hospital in Palo Alto, California. He started his career at Mayo Clinic, including working as the operations manager at the Mayo Clinic facility in Scottsdale, Arizona, when it was opened in 1987.
King has worked in pediatric medicine administration since 1996, when he joined Children's Hospital Los Angeles as president and CEO of the organization's Pediatric Management Group. He worked at CHLA for 18 years. Before joining the chief executive leadership team at Stanford Medicine, King led the University of Michigan's C.S. Mott Children's Hospital and Von Voigtlander Women's Hospital as executive director.
HealthLeaders recently spoke with King to find out about his perspectives on pediatric medicine and healthcare leadership. Following is a lightly edited transcript of that conversation.
HL: Why have you devoted the bulk of your career to pediatric healthcare?
King: The ability to have an impact on a child's life is pretty intoxicating.
From a fundraising standpoint, whenever we have an opportunity to meet with some of our supporters, the most powerful moments are when we can bring out a former patient who has an extraordinary story to tell with some sort of health condition. Then there's a tearful moment, when they introduce their family. They bring out their babies and their children. You see the full circle of life—we were able to intervene in a meaningful way to change their lives to the point where they have a family of their own.
Another attractive part of pediatric medicine is the sharing of knowledge. Compared to adult care, there are higher rates of cure and faster rates of improvement in pediatric medicine. In the pediatric space, we tend to share with each other. When we find something that works—we share that broadly with everyone.
HL: What is the most daunting challenge in pediatric medicine?
King: When we think about kids, they are a small portion of the national spend on healthcare. And when you are talking about pediatric care, you are often talking about Medicaid. We all agree healthcare needs to be reformed. The challenge for us in children's healthcare is to make sure that as healthcare is reformed it is done in a way that does not harm kids.
At most children's hospitals, close to half of their patients have their bills paid for by government programs—primarily Medicaid. So, the top 20 children's hospitals such as Stanford have a significant part of their budget supported by the government. Here at Stanford, about 40% of our budget is supported by California's version of Medicaid: Medi-Cal.
So, when you think about the best children's hospitals in the country, they are good because of the fundamental supporting structure that is provided by the government. That is not exactly intuitive when you think about the Medicaid program—most people tend to think about that program as being for poor kids. But it provides an infrastructure that supports all kids. We think that is a message that resonates whenever we get in front of our legislators—the unraveling of the public safety net can lead to the unraveling of the entire healthcare system.
HL: What is an emerging area of pediatric healthcare that you find most exciting?
King: One area where Stanford Medicine would like to carve a niche and make us more distinctive is precision medicine. We can look at a patient's genome and figure out a specific disease such as cancer and how we can customize an intervention or a care plan that is unique to the patient's genetic makeup. A traditional medication may be effective for a high percentage of patients across a population, but it may not be effective for specific individuals.
For example, with precision medicine you can create an intestine in a test tube, then provide medications and interventions to that organoid rather than having to put the patient through treatment directly. We think that precision health is the future of medicine, particularly as more and more organizations learn about genetics. That's an area for children's health that is very exciting.
HL: What is a primary area that needs to be addressed to improve maternal mortality?
King: The good news is that here at Stanford some of our staff members and researchers have been leaders in this space. Also, California has been bucking the trend that has been seen nationally. While maternal mortality rates have gone up nationally, California has been reducing maternal mortality rates.
One question is why the doctors at Mayo or Stanford are better than doctors elsewhere. It's not that they are better—it's that practice makes perfect. Most of the better health centers have higher volumes, so they are used to seeing complications and they can recognize them more easily.
One of the factors to improving maternal mortality is making sure the data generated from high volumes of activity is shared broadly, and we need to engage as many partners in that improvement process as possible. You get better performance by sharing your results with others. Then, when those other centers share their results, it becomes a virtuous cycle.
HL: What advice do you offer to emerging healthcare leaders?
King: I have been very blessed to have been recruited to every job I have had in 35 years in the healthcare field. The main factor that contributed to my good fortune was my willingness to be curious, and my willingness to pursue opportunities that may not have appealed to me right out of the gate.
It's also important to surround yourself and expose yourself to people who are different than you. When you think about diversity, equity, and inclusion, you can't limit yourself to the workplace. You should be thinking about these areas more broadly—this kind of education doesn't just happen in the classroom or the workplace. It's about how you live your life.
HL:Why is exposure to diversity so important for healthcare leaders?
King: For example, there is the inequity in the issue of maternal mortality for African Americans. When you think about the healthcare access barriers for the different populations in this country to get prenatal care, there are social determinants such as economics and culture impacting the kind of experience that a patient will have when they come in for care. They will ask unique questions of their care providers, and there will be different power differentials created when they are interacting with their care providers—these will be different with different patient populations.
The more experience you have with a diverse group of colleagues, the more you will learn that people don't look at the same issues in the same way. Men and women are different. There are different cultures. Diversity is more than skin deep. It's diversity of thought and diversity of economic background. All of those things bring a richness of experience to solving problems that a singular way of thinking just does not provide.