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.
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.
