Within a decade, a third of all U.S. physicians will hang up their stethoscopes for good and step into retirement while the supply of doctors will grow by only 7%, says a report by the U.S. Department of Health and Human Services.
In Massachusetts, the first state to adopt near-universal healthcare, the shortage of doctors is already being felt. When (if?) the Patient Protection and Affordable Care Act fully rolls out and millions are added to the rolls of the insured, the demand for doctors will only accelerate.
Amid all the anguish over changes to come from the implementation of the Affordable Care Act, perhaps this is the most daunting: the expected doubling in size of the patient load. But relief may come from community health centers, which have an important role to play in training future primary care docs, says this report.
So the announcement this week that philanthropist and NFL team owner Robert Kraft is giving $20 million to Partners Healthcare System to fund The Kraft Family National Center for Leadership and Training in Community Health to train community-based physician leaders comes at a very good time, not only for Massachusetts, but for the country (the center will be a national resource) and for healthcare philanthropy, which has been brutally battered by the recession.
Charitable giving to healthcare organizations fell 11% in 2009, the last year for which numbers are available, according to the Association for Healthcare Philanthropy.
Whether Kraft's gift signals resurgence in philanthropy remains to be seen. What it does indicate is a very good understanding of where the financial need is great. Kraft's gift includes
a fellowship training program for physician leaders in community health in primary care, internal medicine, family medicine, pediatrics, psychiatry, and women’s health
a loan repayment incentive of $50,000 for physicians who commit to a minimum of two years of service in a community-based program
a loan repayment incentive of $30,000 for nurse practitioners, nurse midwives, psychiatric nurse practitioners, and other master’s-prepared nurses who make the same commitment
Kraft is listed No. 269 on the 2010 Forbes 400 list, with a net worth of $1.5 billion. He is the owner of the New England Patriots and the New England Revolution (Major League Soccer). His largesse is a move straight out of the primary care provider wishlist playbook.
The new year is not yet a week old and already the healthcare industry is bracing for another turbulent year. Love the PPACA or loathe it, it is a source of anxiety for healthleaders. Republicans in Congress are already vowing to repeal the legislation and say they will put the matter to a vote before President Obama makes his State of the Union Address. If the law is rolled back, the consequences will be complicated for providers of all sizes.
Another source of uncertainty for healthcare leaders is the roiling business climate that is spawning a high volume of hospital mergers and acquisitions. How does one form a capital plan, conduct fundraising, or implement an EHR system, if a takeover is imminent?
The truth is, uncertainty is a fact of life and the best way to proceed amidst uncertainty is to identify weaknesses, and resolve to do better. Here are six initiatives that community hospitals should undertake this year:
1. Reduce readmissions
In less than two years, hospitals with higher than expected readmission rates will face federal penalties. There are numerous causes of hospital readmissions—from misdiagnosed pneumonias in older patients, to easily avoidable medical errors—but a closer look at the problem reveals some cutting-edge ideas for slashing readmission rates. Don't wait for the threat of federal fines.
2. RAC-proof hospital admissions
Now is the time to make your facility RAC-ready for 2011. The best approach is to have a strong compliance plan, says HCPro director of Medicare and Compliance, Kimberly Anderwood Hoy, JD, CPC. For example, wrong-setting" denials account for a third of all Recovery Audit Contractor reimbursement refusals, but can be avoided if hospitals work diligently toward the goal of ensuring consistent admission screening among patients.
3. Join a GPO
Group Purchasing Organizations have been shown to improve transparency, accountability, and fair product discounting by the Government Accountability Office. Last month, for example, Appleton (MN) Area Health Services, a community-owned critical access hospital, announced it had entered a volume purchasing agreement with Sanford Health. Sanford's volume purchasing power saves partner hospitals money.
4. Bring in some hospitalists
Physician shortages are on the rise and can be particularly acute in rural settings. One solution is to contract with hospitalists, a move that is gaining favor among hospital chiefs.
5. Raise patient satisfaction scores
Competition among community hospitals is keen. One way a facility can stand out is to elevate its patient satisfaction scores. A service as simple as room service, being handed an iPad on admission, or even being offered a beer or glass of wine can go miles toward making patients feel better about their hospital stay.
6.Implement an EHR/EMR system
Don't be swayed by a recent RAND study that called into question the value of electronic medicalrecords. It's time to plan for implementation now, and it's long past time to get physicians and other staff on board. Federal EHR incentives registration began this week, so there's no time to waste.
The week before Christmas, one of the happiest times of the year for families with children, a report came out of New Hampshire that, for rural families, was as sobering as a fly in the eggnog.
While much has been written about the nation's shortage of physicians, a report by researchers at the Dartmouth Institute for Health Policy and Clinical Practice and the Department of Pediatrics, Dartmouth Medical School homed in on specifics: kids in the heartland are lacking pediatric care.
The study, published in Pediatrics, examined growth in the primary care physician workforcefor children and in particular focused on the geographic distribution of theprovider workforce.
It turns out that between 1996 and 2006, the general pediatrician and family physician workforces expanded by 51% and 35%, respectively, whereas the child population increased by only 9%, the report says.
But here's the clincher: The distribution of providers is terribly askew. The report says, "Undirected growth of the aggregate child physician workforcehas resulted in profound maldistribution of physician resources."
Nearly 1 million children live in places where there are no local pediatricians. Those places tend to be rural and poor, the report says.
What's to be done? The authors say "Accountability for public funding of physician training should include efforts to develop, to use, and to evaluate policiesaimed at reducing disparities in geographic access to primary care physicians for children."
HHS took a step in that direction in October with a grant of $772 million for the construction, expansion, and renovation of community health centers. Over the next five years, the Affordable Care Act will provide $11 billion for this purpose. "The newly constructed or expanded community health centers will provide care to an additional 745,000 patients and much needed employment opportunities in both rural and urban underserved communities," Secretary Kathleen Sebelius said.
But without doctorsto staff those facilities, the problem of adequate access to care will remain. Rural hospitals should take a look at the efforts of Sanford Health, the primary healthcare network serving the six-state Frontier region, which includes the Dakotas. Sanford has learned to grow its own doctors. And that's a great start to making sure the kids in rural areas are all right.
In his most recent column, my colleague Philip Betbeze peers into the future and catches a glimpse of the healthcare system circa a decade from now. He says it "doesn't look good for independent standalone community hospitals, unless your hospital happens to be of the critical access variety."
But, all is not lost, Philip writes, in about 3 Actions That Could Save Community Hospitals. This line in particular caught my eye: "The growth is not in inpatient. If you don't have strong outpatient facilities, you don't have much hope."
When I read that, I dove into the HealthLeaders archives to see what I could find on outpatient care as a source of revenue. Here's what I found, neatly compiled into a list of resources for building up outpatient business:
1. Outpatient Care: Strategic Growth Lives Here This article from HealthLeaders magazine (written by Philip) says outpatient services will grow by 21.6% between 2009 and 2019, while inpatient utilization will plod along at only 1.7%. "Hospitals and health systems may be entering a window of time in which they have an opportunity to strengthen their hold on their local healthcare market because of payment changes that make it more difficult for physicians to independently carve out lucrative niches in the outpatient market." The article examines the expansion strategies of migrating formerly invasive procedures from inpatient to outpatient settings, and the proliferation of medical malls, which extend access to specialists, where they were previously unavailable.
2. Roundtable: Building and adjusting your outpatient strategy How do hospitals know where to spend their scarce dollars? What new ways to reach potential customers have proved successful? How will hospitals compete in the future? In this Roundtable discussion, a group of healthcare leaders discuss these questions as the hospital industry makes what could be a historic transition to a more patient-centric mode of operation.
3. Metrohealth: Competing with the Big Boys Metrohealth, a Cleveland-area public hospital, is where President Jimmy Carter was whisked to after becoming ill while travelling recently. In a competitive market, flanked by the prestigious Cleveland Clinic and University Hospitals, the choice may seem surprising, but "MetroHealth is in the midst of transforming itself into a provider of choice—rather than last resort—for Clevelanders and those in its suburbs. It's doing so by remaking its image as a comprehensive healthcare provider, not just a hospital for the indigent, says President and CEO Mark J. Moran." Running a more efficient outpatient operation is just one way it's turning itself around.
4.Rethinking the Future of Outpatient Chronic Care
Speaking of the Cleveland Clinic, this article details how the medical institution is preparing to treat a growing population of aging Americans and their chronic conditions. The Clinic has "decided to better track chronic conditions, coordinate treatment, and schedule timely interventions" mainly through continuous monitoring, following patients with multiple chronic diseases in a clinical setting and via patient self-management.
5.Four Ways to Accelerate ED Triage, Boost Revenue Long waits in the emergency department aren't just bad for patients. They're bad for hospitals, which are under increasing pressure to improve ED service, as delays can impact revenue. "Having a speeded-up ED process is something 'we take advantage of,' says the CEO of a 128-staffed-bed community hospital in New York State, 'We have a half-hour distance from our competitors. People have a choice where to go for their ED treatment. We're doing this because people are voting with their feet.'"
7. FACTFILE: Outpatient Trends
The growth of outpatient procedure volumes has been largely beneficial to hospitals, but for some procedure groups, hospital share has declined as nonhospital settings have shown share increases, notably in major outpatient surgery. Still, focusing on significant procedure groups, from 2007 to 2009, hospital-based outpatient utilization rates grew more rapidly (4.6% annually) than non-hospital providers (1.9%).
We've met some remarkable personalities this year, both in HealthLeaders magazine, and here, online. Some of the most memorable healthcare leaders we've interviewed and written about are not the ones who run complex medical institutions and sprawling health systems. These are the folks who keep finding ways to cut costs, consolidate operations, and raise funds for their institutions.
Meanwhile, they are implementing EHRs, forging ahead with ACOs, and waging war on HAIs. Their work is admirable, to be sure, but it stands separate from doctors who live and practice in places, far from cities, where the pace is slower, and healthcare can be hard to come by.
1.David Nichols, MD, is a primary care doctor who has for the past 31 years, has commuted once a week to Tangier Island, VA, where he has been the island residents' primary healthcare provider. For most of those years Nichols has piloted his own plane or helicopter to make the 15-minute flight. This year, ill with cancer, Nichols attended the opening of a medical clinic he spearheaded—his legacy—on the island. Nichols is profiled in 20 People Who Make Healthcare Better.
2. Trauma expert A. Brent Eastman, MD, chairman of the American College of Surgeons Board of Regents, helped create one of the nation's earliest trauma systems. This year he described to HealthLeaders senior editor Cheryl Clark his vision for a nationwide trauma system. "What I feel—I and others with the same passion for the care of injured patients—is that you could throw a dart at a map of the U.S. and wherever it lands, in 10 years, if you were injured there, you'd be assured that you'd be expeditiously transported to the level of care you needed," he said.
3.Anne Brooks, DO, is a 72-year-old Roman Catholic nun, who despite serious health problems of her own, earned a medical degree. Today she runs a health clinic in rural Mississippi. Many of her patients cannot pay, are "incredibly sick," and wouldn't have a clue what a wellness program is, she says. A tenacious advocate for rural healthcare, Brooks is bridging the gap—remarkably—between rural poverty and health information technology.
4. Surgeon Steven J. Smith, MD, moved to Florida's Upper Keys in the late 1970s for the fishing and boating. But he spends most of his time making house calls and follow-up visits and seeing patients in offices he keeps in two towns. In his neck of the woods, Smith is the doctor most likely to be on call for surgery. Says the administrator at one of the two hospitals he's affiliated with, "He's going to be one of those physicians who will work until he can't do it any longer. I don't see him stopping; there are very few people like him left in the world," she says. "But if, for some reason, he can't continue at this pace or must cut back, it will take two surgeons and an internist to replace him."
5. Unlike most of the others mentioned here, Ryan Flesher, MD, doesn't exclusively treat a vulnerable patient population. But he did achieve something unusual this year, and that's why I'm including him. Flesher was a frustrated emergency department doctor, unhappy with the healthcare system that had him mired in billing codes, malpractice concerns, exhaustion, and not enough time for either himself or his patients. So he went out and made a film. He calls The Vanishing Oath the first "physician-focused" documentary film. Track it down.
As the clock runs down on 2010 and thoughts turn to year-end gifts, let us consider some of the most sought-after goodies for physicians and healthcare executives.
Some rural hospitals and community health centers got early gifts this year. In October the Department of Health and Human Services announced that it would make available up to $335 million in Expanded Services grants for community health centers to boost access to preventive and primary healthcare. That's a big bowl of cash for financially strapped providers who work with some of the nation's most vulnerable patients.
Here are a few more choice items any doctor would be delighted to receive:
1. A Doc Fix That Sticks
Finances are never far from a physician leader's mind. This year is no exception. In the latest installment of the ongoing game of chicken between federal lawmakers and the nation's physicians, Congress on Monday approved a one-month delay in its scheduled 23% cut to Medicare reimbursements as defined by the sustainable growth rate formula. The Senate took similar action earlier this month.
With primary care docs threatening to drop Medicare patients and lawmakers withholding relief until the last moment, there's more manufactured drama here than on a season's worth of The Jersey Shore. Let's get this fixed.
2. A Strategy For Dealing With Bad Debt
Hospitals large and small, urban and rural feel the burden of bad debt. It's a plague on hospital balance sheets, but there are measures that can be taken to lessen the amount of red ink on the books. Here are six expert tips—from collecting a portion of patient balances at the point of service to instituting discounts for self-pay patients.
No one says trying to collect payments upfront will be easy, but there are methods and techniques that can be applied to collecting a significant percentage of outstanding revenue, while still preserving positive relationships with patients. And for hospital CFOs with a taste for analytics, there are data mining and predictive modeling software tools that can plug revenue leaks and uncover millions in missed charges.
3. An ACO Primer and Roadmap
I'll be blunt: No one really knows what an accountable care organization is. Great minds have a pretty good idea, but ACOs don't exist yet. Therein lies the trouble. We know that ACOs will involve payment reform of some sort, a shift that will leave the current fee-for-service model in the dust. Individual physicians, though they will be central to the ACO, are experiencing some anxiety. What is needed is clarity and direction.
4. More Help From Nurses
Don't get me wrong. They work hard. But nurses could be doing more, especially in community and rural health settings. With the proper training, nurse practioners could take on some of the tasks of primary care providers. And certified nurse anesthetists can safely ease patient loads even further. A California Superior Court judge last month rejected a petition filed by two medical groups who said that allowing unsupervised advanced practice nurses to administer anesthesia puts patients at risk. Stop fighting, and let these professionals contribute to their highest ability.
5. An iPad
Everything you've heard is true. Get one. Give one.
Here's the tale of a New England psychiatrist and advocate for rural and veteran's health, who has settled a series of claims and counterclaims with the federal government.
William Weeks, MD, a professor known for his expertise in rural healthcare, has agreed to leave the Veterans Administration and will receive a settlement in excess of $469,000 following his acquittal on federal charges of financial improprieties last month.
Weeks, a Department of Veterans Affairs psychiatrist for 18 years and a Dartmouth College professor, was accused of directing federal research funds to his personal accounts "while acting as both a VA representative and as Dartmouth's principal investigator" on five contracts totaling $1.5 million, according to the Associated Press.
A report in the Boston Globe last April described the prosecution's case: "Taking advantage of a policy that lets Dartmouth researchers keep surplus contract funds in personal faculty accounts, Weeks allegedly kept secret from his VA bosses the deal he had struck with Dartmouth to get the leftover funds. He hired fewer people than originally planned to do the work and at lower rates, and more than $567,000 was deposited into an account in his name at Dartmouth."
Weeks pleaded not guilty. His lawyer, Robert O'Neill, argued that Weeks operated within Dartmouth's rules.
In April a jury in U.S. District Court in Vermont returned not guilty verdicts on five counts of violating federal conflict-of-interest laws.
Weeks has long been an advocate for rural veterans, saying in 2004, "We need to think about veterans who live in rural settings as a special population, and we need to carefully consider their needs when designing healthcare delivery systems."
As a researcher, he found that rural veterans are in poorer health than their urban and suburban counterparts. But he said he "didn't know if that was a rural veteran issue or a rural issue," according to a 2006 article published in a Dartmouth publication. A 2009 study he published in Health Services Research found that VA healthcare users get most of their medical care from non-VA providers. Working-age VA users have less insurance coverage and rely more on VA care if they live in rural areas.
According to his bio on the website of the Dartmouth Institute for Health Policy and Clinical Practice, Weeks, who is working as an associate professor of psychiatry and of community and family medicine, "directs the VA Quality Scholars Fellowship Program, the Veterans' Rural Health Initiative, and the VA Outcomes Group Research Enhancement Award Program. His research interests lie in business and economic aspects of health services delivery, particularly as they relate to physician education, veterans who live in rural settings, and the quality and safety of healthcare."
As part of the settlement, Weeks will also pay the United States $47,500 to settle civil claims the government filed against him for conflict of interest and filing false claims.
Even for a healthy person with private insurance living in a major metropolitan area, finding a primary care physician who is taking new patients can be a lengthy ordeal. When one is found, a typical response from the doctor's office might be: "She's booking well-visit appointments 18 months out."
Some people find their spouses and start a family in less time.
For someone living in a rural community, the difficulties of finding primary care are even tougher. Physicians are scarcer than in cities and the geographical distance between patient and provider may be great.
There is, however, a pragmatic way to augment basic primary care services.
I'm talking about loosening restrictions on the 160,000 nurse practitioners in the U.S., so that they may take on some of the tasks of primary care physicians. No one is advocating for nurses to open craniums or resect colons at will, or to do any of the other work that only highly trained physicians can do.
What nurses with advanced training and certification want to deliver, and what patients in rural areas need, is greater access to primary care.
But don't take their word for it (or mine). Look at the findings of the Institute of Medicine after it examined how nurses can help attain the objectives of the 2010 Affordable Care Act. The two-year study culminated in the report, The Future of Nursing: Leading Change, Advancing Health.
One of the IHI's key recommendations:Nurses should be full partners with physicians and other healthcare professionals in redesigning healthcare in the United States.
In many states, certified registered nurse practitioners are already alleviating the case load of primary care physicians. But in states such as Alabama, regulations under which NPs may practice are so onerous that they need an MD to sign off on physical therapy orders for patients. That's not right.
The annual Pearson Report covers state regulations for NPs in great detail, showing state-by-state where physician involvement is required for NPs to diagnose and treat, and whether physician involvement is required for NP prescribing.
In Alabama, for example, CRNPs are required to work in collaborative practice arrangements with physicians. This constrains their work in rural areas where the need for their services is great. Legislative pushes that would allow NPs to work independently in the state have not yet succeeded.
While doctors groups cite patient safety as a concern, the more urgent issue is lack of access to care. Regulations can and should be amended to enable NPs to take on a greater role in serving the primary care needs of rural Americans.
Patient falls, a source of serious injuries and spiraling hospital costs, are about to knock the wind out of healthcare budgets. A 2008 Medicare rule about to come online will eliminates payment for the cost of treating preventable in-hospital falls. That's a blow to any hospital, but smaller facilities could be floored by having those payments withheld.
While many efforts have been made to reduce in-patient falls, it's been a tough nut to crack. "The problem is that most hospital patients are moderate fall risks. We can't find a magic prediction rule that appears to discriminate between people falling and people who fall and injure themselves," says Ronald I. Shorr, MD, director of the Geriatric Research Education and Clinical Center at the Malcom Randall VA Medical Center and professor at the University of Florida Department of Aging and Geriatric Research, both in Gainesville, FL. Shorr was interviewed in the October issue of HealthLeaders magazine.
To be sure, there is no magic involved, but the results of a randomized trial suggest that the use of a fall prevention tool kit (FPTK) can significantly reduce the rate of what researchers rather stiffly called "unplanned descent to the floor during the course of a hospital stay." The study, Fall Prevention in Acute Care Hospitals, is published in Wednesday's JAMA.
In what may be the first instance of health information technology being used for fall prevention purposes, the FPTK included:
A decision-support software application for use at the bedside
An over-bed poster
A patient/family education handout
A plan of care
Conducted at four Massachusetts hospitals, including one community teaching hospital, the goal of the study was to determine if FPTKs could prevent falls. Through the use of icons and plain-language alerts, fall risk was communicated to 5,104 patients over a six-month period. Of the 11 icons used to communicate fall risk, eight were related either directly to toileting or getting out of bed to toilet.
"Bedside alerts that communicate safe toileting strategies tailored to the needs of individual patients are particularly important for preventing falls in older adults, in whom toileting-related falls are most common and more likely to result in injury," the study notes.
Of the 5104 patients observed in the study, in the end, there were 67 falls among patients exposed to FPTKs and 87 falls among patients in the units without the kits. Researchers calculated that the kits could potentially prevent one fall every four days, 7.5 falls each month, and about 90 falls each year in the study units alone.
While the results showed success in reducing falls in patients over the age of 65, curiously, the overall fall rate increased in patients younger than 65, indicating that different messaging may be required for this group.
Amid all the anguish in the medical community over changes to come from the implementation of the Affordable Care Act, perhaps this is the most daunting: the expected doubling in size of the patient load.
The national problem of too few primary care physicians is only going to get worse. And for rural areas, where there are one-fourth fewer doctors per person than urban areas, the right word to use is "crisis." In fact, 68% of the communities with federally designated doctor shortages are rural.
But a report published by the National Association of Community Health Centers lays out the strengths of the community health center system and proposes that CHCs have an important role to play in training future primary care docs.
While hospitals across the country are jockeying for position by gobbling each other up in complicated financial transactions, the nation's Community Health Centers are quietly making preparations of their own.
With nearly $1 billion in federal funding announced this month alone, and much of that earmarked specifically to increase access to preventive and primary healthcare, CHCs are in a position to make wide-reaching and long-term impact on healthcare.
Here's how they can do it: Training: The ACA authorizes a program called Teaching Health Center (THC) that provides payments to eligible “teaching health centers” to cover the direct and indirect costs of primary care residency training. NACHC's report calls CHC residency training programs "extremely effective tools for the recruitment and retention of family practice physicians into community-based practice."
Retention: "Large proportions of graduates" either stay where they trained or migrate to other CHCs, the report says. The report adds that well-run training programs can be a draw for specialty physicians. It spotlights four health centers that have built successful physician residency training programs in Worcester, MA; Waco, TX; Santa Fe, NM; and Yakima, WA.
But even with the HHS cash spigot wide open —$11 billion more is slated for CHCs over the next five years — there are challenges. Balancing patient care with teaching responsibilities is one. Accreditation is lagging; NHCHC advocates for an expedited process of residency program accreditation.
One way NHCHC could help move physician training forward would be to in a triage-like manner, identify CHCs that meet the requirements for physician training and focus resources in those places.
By the way, the challenges of practicing medicine in rural areas of the U.S. are documented nowhere better than here, in a series of stories, photos, and videos published by the Wisconsin State Journal. The series is funded in part by from the nonprofit, nonpartisan Kaiser Family Health Foundation.