Medical doctors surveyed cited "fear of malpractice" as the top reason for unnecessary care. Researchers suggest that aspiring MDs learn about overtreatment well before it becomes a concern.
Despite years of industry emphasis on curbing costly and potentially harmful unnecessary care, physicians believe that overtreatment remains an ongoing problem, according to a research from Johns Hopkins University School of Medicine published this week in the journal PLOS ONE.
The findings, based on a survey of more than 2,000 physicians, revealed that most physicians surveyed (64.7%) believe that at least 15% to 30% of medical care is unnecessary. Those surveyed were from a subgroup of the American Medical Association’s Physician Masterfile.
“Unnecessary medical care is a leading driver of the higher health insurance premiums affecting every American,” says Martin Makary, MD, MPH, professor of surgery and health policy at the Johns Hopkins University School of Medicine and the paper’s senior author.
In addition, most respondents (70.8%) believed that physicians are more likely to perform unnecessary procedures when they profit from them. And most respondents believed that de-emphasizing fee-for-service physician compensation would reduce healthcare utilization and costs.
The top three selected potential solutions for eliminating unnecessary services were training medical residents on appropriateness criteria for care (55.2%), easy access to outside health records (52%) and more evidence-based practice guidelines (51.5%).
“Addressing overtreatment can have a major impact on rising healthcare costs in the US,” the authors wrote. “Using the IOM’s estimate of excess costs arising from overtreatment, a 50% reduction in ‘unnecessary services’ would result in $105 billion in savings each year, or about 4% of total national healthcare spending.
While initiatives such as such as Choosing Wisely and Improving Wisely, which aim to reduce unnecessary tests and procedures, have raised awareness about overtreatment, future work should focus on the most high-volume over-utilized tests and procedures by specialty, wrote Makary and colleagues.
Finally, physicians should be taught about appropriateness early, beginning in medical school and continuing in residency, the authors urged, noting that healthcare utilization by physicians may be influenced by the cost environment in which they trained as residents.
Practice leaders explain how key metrics help groups meet their missions.
"We always thought we were doing a great job," says Meryl Moss, MPA, EMHL, chief operating officer of Coastal Medical, a primary care group practice in Rhode Island, with 19 locations throughout the state.
But when the group began measuring performance more deliberately to participate in meaningful use, the National Committee for Quality Assurance’s certification, and similar programs, practice leaders recognized that their perception didn’t align with reality.
For example, Moss and colleagues learned that elderly patients weren’t receiving flu shots as consistently across all clinics as they could be, and that numerous patients were using the ED unnecessarily.
As a result of standardizing and systematizing its operations, Coastal Medical can now empirically say that it received a Medicare Shared Savings Program quality score of 100% in 2015.
Prioritizing Performance Areas
"The idea of working toward quality for our patients fit in with Coastal’s culture," Moss says.
"Physicians here didn’t want to just jump through hoops to chase an incentive. They absolutely wanted anything we did to be connected to higher-quality care and better patient outcomes."
As a result, the group resolved to continue to tracking its performance in the following key areas, in order of importance:
Meanwhile, the growing prevalence of value-based reimbursement is driving medical groups’ emphasis on quality, says Scott Hayworth, MD, FACOG, president and CEO of CareMount Medical, PC, an independent multispecialty medical group in New York State, with 43 locations, including seven urgent care centers.
"We’re focused on quality and cost. And if we can provide patients with quality healthcare in a cost-effective way, that’s the key. That’s where many organizations are being driven, and that’s where we have been focused and will continue over the next five to 10 years," he says.
A Fifth Vital Sign
A healthy workforce is of prime importance for CareMount as well, says Hayworth, noting the symbiotic nature of many of the key areas medical groups track.
"We’re centered around our 550,000 patients; they are the primary responsibility of the organization," he says.
"On top of that, CareMount is focused on our employees and our physicians. In addition to patient satisfaction and quality, we are very interested in staff and physician morale—because if you don’t have engaged staff members, you’re not going to provide excellent care."
American Medical Group Association, American Hospital Association, weigh in on Medicare’s proposed rule.
Today, August 21, 2017, is the final day to submit comments to the Centers for Medicare & Medicaid Services (CMS) on its 2018 proposed rule updating the requirements of the quality payment program for physicians and other eligible clinicians mandated by the Medicare Access and CHIP Reauthorization Act (MACRA).
Key recommendations from the groups address the following:
Low-volume threshold—Under the proposed rule, CMS would increase the low-volume threshold under the Merit-Based Incentive Payment System (MIPS) to $90,000 or less in Part B allowed charges, or 200 or fewer beneficiaries. As a result, CMS estimates that more than 900,000 otherwise eligible clinicians will be exempt from the program.
AMGA: “In a well-intentioned effort to make the transition to value-based care as smooth as possible, CMS is delaying this transition,” said Ryan O’Connor, AMGA’s interim president and chief executive officer. “Excluding two-thirds of providers from the MIPS program does not meet Congress’ goal to transform Medicare into a value-based purchaser of care.”
AHA: “The AHA agrees that CMS’s proposal to raise the threshold… would provide needed relief and additional time to transition into the MIPS for small and rural providers. However, to provide additional transitional flexibility, the AHA also urges CMS to retain a continuous 90-day reporting period for the quality category for CY 2018, while allowing groups to report up to a full year if they are ready to do so.”
Medicare Advantage—This past May 31, AMGA along with nine other stakeholder groups including Premier, American Essential Hospitals, and the American Medical Association (AMA), forwarded a letter to the CMS Administrator arguing the agency has the regulatory authority to allow Medicare Advantage 10 (MA) providers to participate under the “Other” and “All Payer” Alternative Payment Model (APM) categories before performance year 2019.
AMGA: AMGA encourages CMS to allow providers that have contracts with MA plans that meet the risk, quality, and certified electronic health information technology requirements to be considered for advanced APM status. AMGA recommends that CMS include MA beneficiaries in the beneficiary threshold test. This not only recognizes the risk providers take with MA contracts, but provides an other option for providers to participate as advanced APMs.
AHA: The AHA supports the development of another payer advanced APM determination process and urges CMS to use it to mitigate provider burden where possible.
All-Payer Combination Option—CMS is proposing to make quality payment determinations under the All-Payer Combination Option at the individual eligible clinician (EC) level only.
AMGA: “AMGA does not support the proposal. AMGA fails to understand the assumption that an EC participating under the Medicare Option ‘would likely have little, if any common group level participation in the Other Payer Advanced APM.’”
AHA: “The AHA supports the development of an other payer advanced APM determination process and urges CMS to use it to mitigate provider burden where possible. The AHA also supports CMS’s proposal to allow APM entities to use the other payer advanced APM determination process when payment arrangements have not otherwise been reported by payer.”
“Healthcare professionals are realistically more aware of the danger” of violence in hospitals, researcher says.
While most members of the public regard hospitals as a safe haven, healthcare workers perceive higher levels of risk of vulnerability to an “active shooter” event or other forms of violence, according to a national survey conducted in March 2017 by the Hartford Consensus.
The research, led by Lenworth M. Jacobs, Jr., MD, FACS, Chairman of the Hartford ConsensusTM, and professor surgery and vice-president of academic affairs at Hartford (Conn.) Hospital, also examined both groups’ beliefs’ about healthcare workers’ duty to protect patients during such events.
The standard directive to “run, hide, fight” in active shooter situations has a different connotation in hospitals because healthcare professionals are responsible for patient care.
However, “how healthcare professionals should respond is an intensely personal decision,” the authors wrote.
More healthcare professionals (33%) believe the risk of an active shooter event to be “high” or “very high” in a hospital than do members of the general public (18%).
More members of the public (72%) believe that hospitals are “somewhat” or “very prepared” for an active shooter event than healthcare professionals do (55%).
In close agreement, 61% of the public and 62% of healthcare professionals responded that professionals have a special duty to protect patients, similar to the way police and firefighters protect the general public.
These strong beliefs dropped, however, when it came to the issue of personal risk, with 39% of the public and 27% of professionals believing that doctors/nurses should accept a “high” or “very high” degree of personal risk to help patients in harm’s way.
“Ten years ago an active shooter event was a non-concept for hospitals, but clearly things have changed,” Jacobs wrote. “Hospitals need to build resilience against such attacks as called for by Barak Obama’s Presidential Policy Directive 8, promoting a fully integrated preparedness system to strengthen the nation’s resilience to deal with natural and manmade disasters.”
Physicians older than 50 are motivated by a different set of factors than younger doctors, research suggests.
Physicians may not be as eager to retire as the industry has been led to believe, according to a recent survey of more than 400 physicians age 50 and older.
Overall, physician respondents said they intend to retire at age 68, compared to the average U.S. retirement age of 65.
The research was conducted by Hanover Research on behalf of locum tenens staffing firm CompHealth.
About half (51%) of respondents signaled interest in working part-time or only occasionally after retirement.
"That's good news," says Lisa Grabl, president of CompHealth. "With the physician shortage, we need all of the physicians who are able and willing to work we can get. We want to understand what will keep them engaged in the workforce."
The average respondent to the CompHealth survey respondents is 60 years old, works about of 45 hours per week, and has practiced medicine for an average of 28 years.
While a 2016 survey from the Physicians Foundation, indicated that close to half of the overall physician population plans to retire sooner rather than later, the motivations of later-career physicians are specific:
They're almost ready for retirement.
Out of the survey sample, 83% of physicians said they'd taken steps to prepare for retirement and 70% had taken advantage of employer retirement services such as a 401K or pension.
A 2015 study from Fidelity Investments, however, showed that physicians on average save just 9% of their incomes for retirement, short of the 15% recommended by finance professionals.
They value work-life balance.
If they got to do their careers over, 44% would have maintained a better work-life balance. "It came through loud and clear that physicians would have changed their careers if they understood what it was going to mean for their work-life balance," Grabl says.
"We work with many physicians who work as locum tenens specifically so that they can be more in control of their schedule and the amount of time they're committing."
To keep permanent physicians of any age engaged, she encourages conversations about work hour expectations and time off upfront.
They want to interact.
The loss of the social dynamic of the work environment was the leading retirement concern for respondents, followed by loss of purpose, boredom, loneliness, or depression.
Additionally, "enjoyment of the social aspects of working" was among the top three reasons given for wanting to practice medicine after age 65.
Most (91%) of respondents said they can still provide useful services to their patients and the community and 89% said they can still be competitive in the healthcare field.
The CompHealth survey did not ask physicians' opinions about age-based competency testing, for which the American Medical Association called for guidelines in 2015. The AMA currently has a task force working on possible solutions.
They like working.
"Not having to work anymore" neared the bottom of the list of favorable aspects of retirement, at 32%, while 76% said they were most looking forward to traveling more.
Moreover, "enjoyment of the practice of medicine" was the top reason given for practicing beyond age 65.
"When physicians are moving into that retirement phase, overwhelmingly what we hear is that they're not working in that late career phase for compensation. They're doing it because they enjoy practicing medicine and helping people," Grabl says.
Research findings confirm the problem’s severity, concluding that opioid-related demand for acute care services has outstripped the available supply.
The same day President Trump declared the opioid crisis a national emergency, the Annals of the American Thoracic Societypublished a study believed to be the first to quantify the impact of opioid abuse on critical care resources in the United States.
The findings confirm the problem’s severity, concluding that opioid-related demand for acute care services has outstripped the available supply.
According to the analysis conducted by researchers at Beth Israel Deaconess Medical Center’s (BIDMC) Center for Healthcare Delivery Science, overdose-related intensive care unit (ICU) admissions jumped 34% nationally from January 1, 2009, to September 31, 2015.
What's more, the average cost of care per ICU overdose admissions rose by 58%, from $58,517 in 2009 to $92,408 in 2015 (in 2015 dollars). Opioid deaths in the ICU nearly doubled during that same period.
“This study tells us that the opioid epidemic has made people sicker and killed more people, in spite of all the care we can provide in the ICU, including mechanical ventilation, acute dialysis, life support and round-the-clock care,” said the study’s lead author, Jennifer P. Stevens, MD, associate director of the medical intensive care unit at BIDMC and assistant professor of medicine at Harvard Medical School.
Among the more than 4 million patients requiring acute care between 2009 and 2015 across 162 hospitals, 21,705 patients were admitted to ICUs due to opioid overdoses, Stevens and colleagues found using a national hospital database.
Meanwhile, opioid-related ICU admissions increased an average of more than half a percent each year over the seven-year study period; and patients admitted to ICUs after overdose required increasingly intensive care, including high-cost and complex renal replacement therapy or dialysis.
The mortality rates of these patients climbed at roughly the same rate, on average, with deaths of patients admitted to the ICU for overdose rising more sharply after 2012.
Oregon Medical Group is using principles from Lean methodology to translate the organization's high-level goals into the daily work of clinicians and staff.
A saying from popular process improvement regimes is that "what gets measured gets done." That's important for senior healthcare executives to remember. But that truth leaves out the critical question of what should be measured.
The options are endless, but determining the most important metrics to measure in an era in which healthcare is transforming is no trivial decision.
The move toward reimbursement based on the value the healthcare organization provides to the patient and the payer, which is happening at vastly different rates in some geographical areas compared to others, means that asking and answering that question at regular intervals is crucial.
But defining success in those pillars is about more than scores on an annual report card or completing one-off projects, says Karen Weiner, MD, MMM, CPE, the group's CEO.
In the spring of 2016, the group began implementing a daily management system (DMS) that has taken the high-level goals of the organization and translated them into the daily work of clinicians and staff.
The DMS, an element of Lean business methodology, is especially interesting because it allows workers to choose their department's metrics.
For example, while the group tracks CGCAHPS (Clinician and Group Consumer Assessment of Healthcare Providers and Systems) scores to monitor patient satisfaction, the DMS has helped improve results around particular questions related to accessibility by telephone.
"We had low scores in that area, so the clinics decided we'd make a goal of fewer than 5% dropped calls," says Weiner.
The clinics then measure themselves against that goal daily, and report their results as part of an organization-wide huddle every morning that includes the central business office looking on via smartboard.
"Well, we did get more than 5%," Weiner says. But the group noted that the spike occurred between 10 a.m. and 11 a.m., so they shifted staff around so that there were no outbound calls during that hour, freeing everyone up to take inbound calls.
Solving Problems Upfront
"They problem-solve on the front end," she notes. "It's not the administration that has to come in and show them their stats and tell them they've got to fix it. They're right on it, and they celebrate their daily successes."
So far, seven of the group's 14 clinics have adopted the DMS and give a report during the daily huddle. The clinics that haven't been part of the deliberately slow, methodical rollout yet are eager to implement.
"It honestly takes 90 seconds to hear it all," Weiner says. "And the whole organization gets to hear what's happening across all clinics. And if there are problems that need to be kicked up, that's where they're kicked up, and everybody hears about it at the same time. It's changed everything," she says.
Another example of a goal set by Oregon Medical Group clinics is to have support staff all receive a 60-minute lunch break every day, which falls under the pillar of healthy workforce.
"It's a way to put your money where your mouth is and let the staff know this is something we prioritize," Weiner says.
One in five groups participating in MIPS plan to report the minimum amount of data to avoid a penalty in 2019.
Nearly half (49%) of medical practices surveyed by the Medical Group Management Association (MGMA) spent at least $40,000 per physician FTE to comply with federal regulations in 2016. And that’s just the tip of the regulatory-burden iceberg, suggest the responses from 750 group practices across the country.
Respondents, most of whom have 6–20 physicians, rated the following regulatory issues as “very” or “extremely” burdensome:
The Medicare Merit-Based Incentive Payment System (MIPS) (82%)
Lack of national electronic attachment standards (74%)
Payer audits and appeals (69%)
Lack of EHR interoperability (68%)
Within the MIPS program, medical groups cited clinical relevance (80%) as their top concern.
Meanwhile, 73% said they would characterize Medicare’s implementation of MIPS to date as, “a government program that does not support our practice’s clinical priorities.” The same percentage rated the MIPS scoring process as “very or extremely complex.”
Nonetheless, 84% of groups surveyed said they were participating in MIPS in 2017, with 41% planning to report the full set of MIPS data in hopes of a positive payment adjustment and to qualify for a performance bonus in 2019. Twenty percent said they intend to report the minimum amount of data to avoid a penalty in 2019.
When asked about their plans regarding Medicare’s Advanced Alternative Payment Model (APM), the largest group (40%) reported being unsure of whether they’d participate as an Advanced APM in 2017, while 13% reported they would participate as part of the Comprehensive Primary Care Plus (CPC+) program.
“The magnitude of regulatory demands on physicians forces medical group practices to needlessly focus precious time and resources on administrative tasks instead of patient care,” said Dr. Halee Fischer-Wright, MD, MMM, FAAP, CMPE, president and chief executive officer at MGMA.
“MGMA calls for national effort to relieve physician practices from excessive government regulation and looks forward to working with both the Administration and Congress to find meaningful solutions,” she said.
Most physicians haven't been taught how to care for transgender or non-binary patients, or even how to communicate with them. But the skills are teachable, says one expert.
While attention to transgender and non-binary issues is ramping up in our general culture, knowledge and protocols for treating these populations in the healthcare space is lagging.
Fundamentally, most physicians haven't been taught how to communicate with patients about gender identity, much less how to meet their medical needs.
For insights, HealthLeaders spoke with Alex S. Keuroghlian, MD, MPH, director of education and training programs at The Fenway Institute at Fenway Health in Boston. He is also an assistant professor of psychiatry at Harvard Medical School.
HealthLeaders: There is a lot of variation in terminology when it comes to services related to gender identity. What is the best way to describe healthcare for transgender individuals?
Keuroghlian: The term we use generally for this kind of care is gender-affirming care. So we talk about gender-affirming medical care, gender-affirming behavioral healthcare, and gender-affirming surgical care.
In terms of what that involves, there are several components, which include social affirmation, legal affirmation, psychological affirmation, medical affirmation, and surgical affirmation.
HealthLeaders: What are the questions to ask in determining a patient's gender identity?
Keuroghlian: You have to have a systematic way in which gender identity data are being collected and used accordingly by all clinicians and staff. Patients should be asked at registration or the front desk what their current gender identity is and their sex assigned at birth.
It's crucial to ask both questions—it's called the two-step process—because a lot of transgender people are otherwise just going to identify themselves as a man or a woman.
But when we ask about sex assigned at birth, we have more information to tailor care accordingly. For example, we will do preventive cancer screening based on the organs retained in someone's body, not just the sex listed on their insurance card.
The electronic health record should collect this information so that people have to provide it only once. If they're continually misgendered, you risk losing them [as patients].
However, you want to check in with some regularity about people's names, pronouns, sexual orientation, and gender identity because those things can evolve throughout a person's life.
HealthLeaders: What else is important to know about communicating with transgender people?
Keuroghlian: People need training in sensitive, effective communication across the board. This includes being taught not to make assumptions about people's gender identity or pronouns. This goes for everyone, from clinical to nonclinical staff, including the front desk, financial services and billing, the security guards, and everyone in between.
Affirming and effective communication expresses cultural humility and empathy.
HealthLeaders: Gender-affirming healthcare isn't part of most physicians' standard medical training. Do you foresee this changing?
Keuroglian: These are very teachable skills that all clinical teams can do. But obviously, medical and nursing curricula need to be modernized to teach them. It's not happening yet, but I am seeing a shift among young people—even people coming up five years behind me as more recent trainees—who are really passionate about this.
So I'm optimistic that something is going to shift because there's been an extremely swift sea change in how much of a priority this is and how passionate young clinicians are about this area. They view [gender affirmation] as the civil rights movement of our time. This is going to happen.
Cardiologists also reported receiving the highest average signing bonuses—of $26,536—upon joining their current practice. Meanwhile, the average signing bonus of the sample was $18,137.
Hospitalists were the most frequent recipients of signing bonuses for their current roles, at 44%, followed by cardiologists at 33% and urologists at 32%.
Nearly one-third of physicians surveyed (29%) reported having an outstanding student loan balance, which is noteworthy considering that the average tenure of the respondents was 11 years in their current role, and 17 years in practice.
Among those still carrying educational debt, about a third received some type of medical student loan assistance in 2016.
By specialty, dermatologists and psychiatrists reported the highest career satisfaction, while 11.8% of the entire sample reported being dissatisfied with their careers in 2016. Nearly half of the group (47.6%) reported being more than satisfied with their current roles.