A closer look at general surgery resident attrition reveals key reasons for departures—and why they afflict women more often than men.
Resident attrition from general surgery training programs is high, but a meta-analysis of 22 studies published in JAMA Surgery shows why residents leave programs and how to improve retention.
The review found that the overall rate of attrition among general surgery residents was 18%, but that female residents were more likely to leave (25%) than male residents (15%). Leading causes of attrition for both genders included:
Choosing another specialty (13% switched to anesthesia)
Relocating to another general surgery program due to family issues or geographic preference
Lead author Zeyad Khoushhal, MBBS, MPH, from the Division of Vascular Surgery, St. Michael's Hospital in Toronto, Ontario, Canada, and colleagues noted several factors that may disproportionately drive female residents to leave or change training programs, including lack of appropriate role models for female residents, a lack of sufficient support or mentorship, and a perception of sex discrimination.
Adding credence to the latter notion is a separate study of practicing cardiologists that revealed female physicians experience nearly three times the rate of discrimination of all types than men.
In a commentary about the study, Julie A. Freischlag, MD, of the University of California Davis School of Medicine, stressed the importance of mentorship in boosting surgical residents' success.
"Mentorship and support is especially important for women," she wrote. "As a woman who has built a career in a traditionally male-dominated field, I can understand the unique challenges that female residents face, particularly conscious and unconscious biases that remain pervasive despite recent efforts for equality," the commentary continued, adding that men can make good mentors for women, too.
Moreover, Freischlag and coauthor Michelle M. Silva, BA, also of UC-Davis Med, noted the importance of a "mentorship culture," that can foster a sense of camaraderie that enables residents to listen to one another, collaborate on research, and enjoy outside activities together.
Leaders attending the inaugural HealthLeaders Physician Organization Exchange shared their guiding principles for managing the most challenging element of medical practice finances.
How much financial incentive or risk does it take to influence physician behavior? What's the best way to update compensation plans? How do leaders give physicians annual raises in the face of rising inflation and flat reimbursement rates? And how can they expect to retain good physicians without adequate compensation?
These are just some of the questions addressed at HealthLeaders' inaugural Physician Organization Exchange, a gathering of nearly two dozen invited senior executives in La Jolla, CA, in December 2016.
There are no universal answers, but there are some common themes to keep in mind.
1. Create a Quality-focused Culture
The first step in achieving physician alignment with organizational value-based goals isn't immediately tying metrics to incentives, but creating a quality-focused culture.
"If [achieving value] is just dependent on the money, it won't work in the end anyway," said Mitchell Schwartz, MD, chief medical officer and president of Anne Arundel Medical Center's Physician Enterprise, LLC, in Annapolis, MD.
"Money doesn't tell the whole story. It's really about the why. Is this really good care? Why are we doing such and such? Money only opens the door to the discussion," he said.
When money does inevitably come into play, Schwartz emphasized some keys to making it meaningful. "We're going to have to add a lot more transparency, like we've seen with patient satisfaction," he said. "And if it's going to be just a small amount of money, it won't have an impact."
2. Bind Rewards to Feedback
Furthermore, it's not just the amount of money that helps drive alignment, but also the way it's connected to clear and timely feedback, noted Mark L. Wagar, president of Heritage Medical Systems, a Palm Springs, CA-based affiliate of the Heritage Provider Network.
"The bonuses can't just end up being viewed as tip money. They have to be part of a fundamental change in physician access to and management of funding for their patients that drives their compensation when they do better, not just more," Wagar said.
"These types of incentives can enable practices to be proactive, and make primary care financially viable again. But if an incentive doesn't come for a year or two, or is watered down by confusing and late data, that's what it ends up being—tip money."
3. Strive for Continuous Improvement
Finally, remember that improving healthcare—a common denominator among discrete initiatives—is a continuous process.
"Moving forward, we will continue aligning specialists' quality incentives with both specialty-specific and ACO-level population health metrics," said Chris DeRienzo, MD, MPP, chief quality officer for Mission Health, an integrated health system in Asheville, NC, which includes one of the largest ACOs in the nation.
"It's been a gradual process of alignment, not without bumps in the road, but we've made purposeful shifts in the right direction in 2017," DeRienzo noted.
"At the end of the day, if we're able to generate ROI through pay-for-value programs, then not only do our patients experience better outcomes, but we also take in enough reimbursement to pay out quality incentives in the first place. I anticipate the broader market will similarly move in that direction over time," he said.
Despite reporting high career satisfaction rates, female cardiologists experience discrimination nearly three times as often as men. Here's what to do about it.
Much has changed in medicine throughout the past 20 years, not the least of which is the growing prevalence of female physicians, who now make up about half of medical students.
What hasn't improved as much is women physicians' representation in the field of cardiology—at around 13%—while heart disease has remained the nation's leading cause of death for both genders.
This disparity makes it difficult for female heart patients to find a cardiologist of the same gender, which many patients prefer, says Martha Gulati, MD, chief of cardiology at the University of Arizona College of Medicine in Phoenix and Physician Executive Director for the Banner – University Medicine Cardiovascular Institute.
"Personally, I think cardiology is a great career for men and women," she says.
In fact, 90% of male cardiologists and 88% of female cardiologists surveyed in 2015 reported that they were "moderately or very satisfied" with their careers, versus 92% and 80%, respectively, in 1996.
Despite High Overall Job Satisfaction, Gender Imbalances Persist
While the proportion of men reporting any type of discrimination has remained close to 22% over the past two decades, the rate of women experiencing discrimination is still nearly triple, at 65%. It has decreased, however, from 71% in 1996.
The types of discrimination reported by female cardiologists ranged from inappropriate sexual comments to what the researchers termed "parenting discrimination," Gulati says.
This might occur if a parent "were leaving work or couldn't make a meeting, which would result in them not being included in certain things," she says.
"Comments might be made such as, 'OK, go home, Mom.' And that is not the environment we want to create when trying to get more women into our field."
Gulati offers several ways healthcare leaders can attract and retain more female physicians to any specialty:
1. Offer Family-friendly Flexibility to All
Increasingly, work-life balance matters as much to male physicians as it does to females. Instead of scheduling meetings during times when parents need to drop off or pick up their children, Gulati suggests mid-day meetings when everyone is likely to be available.
"Or take a poll and ask what will work best," she says. "Or make it possible for them to call in. Just because things were done a certain way 20 or 30 years ago doesn't mean they need to be done that way now."
2. Balance Leadership
"Don't assume women don't want leadership roles even if they are in a time when they're having children," Gulati says. "There are many women who are ready to step up to the plate."
Moreover, high-ranking females can help squelch discrimination. "Certainly when I was a fellow, I would never stand up and say that [discrimination] wasn't right; but now as an attending, I feel I have to be the voice to call people out and say, 'We don't talk like that here,'" she says.
3. Provide Equal Pay for Equal Work
"We know nationwide that women are significantly underpaid compared to their male colleagues, even after controlling for everything you can imagine," Gulati says.
"I hear over and over again from women of all ages that they'll find out that they're underpaid, and it makes them feel undervalued. When you start feeling undervalued, you don't enjoy your job anymore or you start looking elsewhere," she says.
"It costs a lot to recruit a new person. So make sure [women] know they are being rewarded and that their work is valued."
MACRA implementation is underway. What is the best payment model for your organization? How can physician organizations successfully execute important checklist items? Learn how DuPage Medical group overcame these and other challenges by watching this live HealthLeaders Media webcast, Specific Strategies to Embrace MACRA Without Missing a Beat, on March 20.
Leaders of physician organizations are taking responsibility for relieving medical doctors of some of their pain points. Those who are succeeding understand it takes a personal touch.
"As leaders, our job is to encourage physicians to identify and articulate what they need to be happy," said Karen Weiner, MD, MMM, CPE, chief medical officer and interim CEO at Oregon Medical Group, a physician-owned multispecialty clinic in Eugene, OR, at HealthLeaders' inaugural Physician Organization Exchange.
The subject of physician burnout was a hot one—no pun intended—among the nearly two dozen invited senior executives gathered in La Jolla, CA, in December 2016. A common theme of the burnout solutions proven by these leaders, many of them physicians: Getting out of the office to engage face-to-face.
And as Weiner indicated, facilitating this in-person dialogue is leaders' responsibility.
Mingle with a Mission
Mission Health in Asheville, North Carolina, organized a leadership retreat for a dozen or so physicians as part of an effort to achieve a positive work environment by analyzing how the physicians were operating and address how they could shift from volume to value.
"It became clear to the physician leaders that there was a big culture problem," said William R. Hathaway, MD, FACC, chief medical officer and senior vice president of the system.
During the retreat, the group developed 10 guiding principles. They included putting patients first, being safety focused, and taking a team approach. "The important part was not the words that were used, but the process by which we developed these principles," Hathaway said.
"We use this to guide any challenging decisions. It's helped change our culture and direct our focus on what's important for physicians," he said.
Annual meetings represent another opportunity for physicians to connect with colleagues—and their deeper sense of purpose in their work.
Physician staffing company TeamHealth is planning a presentation that does just that at its next meeting, said Lynn Massingale, MD, FACEP, executive chairman of the Knoxville, TN-based outsourcing group.
"We're going to present a patient case in which that person will stand up and talk about how their life was saved," he said. "We'll also have the doctor who saved that person's life discuss it—to remind us of why we all do this in the first place."
Another often-cited solution to burnout is to relieve physicians of busywork not directly related to patient care. According to leaders at the Exchange, however, this process isn't just about delegating tasks, but also fostering relationships between physicians and support personnel.
Atrius Health in Newton, MA, established an 'IT swat team' that travels to each site and helps redesign workflows to reduce the number of clicks on the EMR/EHR, said Steven Strongwater, MD, president and CEO of the system.
"We coordinate that with retraining our MAs so they [can] clear out the inbox before the day is over," he said.
At Oregon Medical Group, Weiner took a similar approach to help unburden physicians following the rollout of ICD-10.
"We built up our coding department to take over [more coding responsibilities]," Weiner said. "As a result, our coding accuracies have gone through the roof. We've also developed relationships with the coders and physicians so they meet regularly."
More of the discussion from the Physician Organization Exchange sessions can be found in the Physician Organization Exchange Insights Report.
In response to continuing high demand for clinicians, the average amount of signing bonuses in 2016 rose 4.8% from the previous year, according to The Medicus Firm.
Organizations recruiting physicians and advance practice clinicians in 2016 were very likely to sweeten the pot with generous signing bonuses, according to data from The Medicus Firm, a national search firm specializing in permanent placement of physicians.
Nearly 90% of clinicians (87.4%) hired through the firm received a signing bonus last year, up from 68% in 2015. Among physicians, 90.4% of placements included a signing bonus.
The top five types of providers, based on volume of placements in 2016 were:
Internal Medicine Physician
The average amount of signing bonuses in 2016 rose 4.8% to $24,802, up from $23,663 in 2015. At the higher end of the spectrum, 34.2% of physicians were offered a signing bonus in the range of $25,000–$75,000, while for 4.2% of physicians, signing bonuses exceeded $100,000.
"In physician recruiting, pairing a signing bonus with a competitive salary offer is still one of the most conducive ways to increase the odds of filling your search, and doing so more quickly," notes the report.
"In 2016, the recruiting regions that had the highest average salary offers and greatest increases in salary offers, also had the highest placement volume, among The Medicus Firm's national client base."
Other data points identified by the 2017 Physician Placement Report:
The average relocation amount offered reached its highest since 2010, at $12,996.
Placements made in rural communities fell to 26.4% in 2016, the lowest in at least four years, possibly due to intense market competition for physicians.
Forty-four percent of 2016 placements took place in mid-size communities with populations of 25,001–500,000.
The 2016 placement rate of international medical graduates (31.77%) was slightly higher than the proportion of IMGs in the physician population, which is about 25%, according to data from the Association of American Medical Colleges and American Medical Association.
The hiring of internists, pediatricians, and family practitioners accounted for 35% of placements made in 2016.
The hiring of nurse practitioners and physician assistants comprised 12% of total placements, up from 8.3% in 2015.
Hospital-based physicians, which include emergency medicine and hospitalists, decreased in proportion of total placements, from 13.04% to 10%, over the past year.
Texas Health Resources has developed a strategy to both recruit and retain top physicians by remaining competitive in an ever-changing marketplace. Learn THR's top tips for physician recruitment and engagement by watching this on-demand HealthLeaders Media webcast, Key Physician Recruitment Strategies from Texas Health Resources.
From full wraparound treatment programs to tweaks in the ED, hospitals have ample opportunity to address chemical dependency and prevent deaths.
This article first appeared in the March 2017 issue of HealthLeaders magazine.
Addiction is seen by some as a moral weakness or a character flaw, but as healthcare leaders point out, it is a brain disease—a chronic medical condition that providers must approach and treat with the same skill and compassion as cancer and heart disease.
"Simply put, you have to invest in behavioral medicine. It's a brain disorder, so you treat it like any other organ that you're treating, and it makes sense for addiction medicine to become a service line that you value and that you integrate into the other components of your health system," says Clay Ciha, president and CEO of Alexian Brothers Behavioral Health Hospital in Hoffman Estates, Illinois.
While not new, this way of looking at and treating addiction has only recently gained favor in the American healthcare industry, granted clinical credibility in Facing Addiction in America: The Surgeon General's Report on Alcohol, Drugs, and Health.
"Over the past few decades, we have built a robust evidence base on this subject. We now know that there is a neurobiological basis for substance use disorders with potential for both recovery and recurrence," wrote Vivek H. Murthy, MD, MBA, vice admiral, U.S. Public Health Service, Surgeon General, in his office's December 2016 report.
"We have evidence-based interventions that prevent harmful substance use and related problems, particularly when started early," Murthy continued. "We also have proven interventions for treating substance use disorders, often involving a combination of medication, counseling, and social support. Additionally, we have learned that recovery has many pathways that should be tailored to fit the unique cultural values and psychological and behavioral health needs of each individual."
For hospitals and health systems, leveraging this knowledge means doing more than pumping stomachs, administering fluids, or giving emergency opioid-reversal drugs. Such treatments, while life-saving, address only the surface of addiction.
According to a National Institutes of Health study, more than 23 million American adults have struggled with substance use disorder at some point in their lives. Addiction medicine service lines could unearth and manage the complexities of chemical dependence at their deepest levels, oftentimes repeatedly for each individual patient, as suggested by healthcare leaders.
Success key No. 1: Optimize the moment of crisis using a care continuum approach
"You have a very small window—of 48 to 72 hours—to try and get people engaged in ongoing management before they are likely to start backsliding," says Gregory Teas, MD, chief medical officer of the behavioral medicine service line for AMITA Health Behavioral Medicine, which includes Alexian Brothers Behavioral Health Hospital.
AMITA's addiction medicine services span a continuum of behavioral and medical treatments across a range of acute and ambulatory settings, says Ciha. "We are able to address every aspect of addictions at every level of care."
However, an organization needn't become a major behavioral health institution to play a key role in patients' recovery, Ciha says.
For example, systems can work closely with surgeons to build awareness of best practices in prescribing and monitoring postop pain medication, enhance physician education around pain management, and create pathways from various points of care to behavioral health resources.
With these steps, "and by being integrated with other providers, we are able to work collaboratively in the best interest of the patient to ensure we are not creating problems by eprescribing," Ciha says.
One of the opportune settings to convert rescue into recovery is the emergency department, says Kyle Martin, MD, medical director of emergency services at St. Mary's Hospital in Madison, Wisconsin, part of SSM Health, a nonprofit health system that includes 20 hospitals and more than 60 outpatient care sites.
The ED is where many patients suffering from addictions interface with the healthcare system, he notes. "A lot of them don't have primary care physicians, and aren't accessing care in any other way than through the ED, so that's really the only place we're going to be able to touch their lives," Martin says.
Outreach during that critical window can make all the difference. "I'd imagine people have seen some adverse effects of their addictions, but it's a powerful moment to wake up in the ED and have a physician explain that you were basically dead."
Martin's ED in Madison, which receives about 38,000 visits per year, saw more than 180 cases of opioid overdoses in 2015—or about one every other day.
In the hopes of bringing overdose rates down, St. Mary's has launched a program modeled after the Rhode Island–based Providence Center's AnchorED, which deploys "recovery coaches" to the ED to counsel patients treated for opioid overdose and introduce them to resources for addiction recovery. The coaches, all of whom have overcome their own addictions and received special training in counseling, also follow up with patients after meeting in the ED to help them stay engaged in the process.
Similar programs exist or are in development at hospitals in New York, Pennsylvania, New Hampshire, and Massachusetts.
Martin says he hopes to see his hospital's pilot succeed and expand throughout SSM Health and beyond. "We in the ED can get into this cycle in which someone comes in and they have overdosed; we reverse them and watch them for a while, but don't actually know how to break the cycle. That's what this program hopefully will be able to accomplish."
Success key No. 2: Identify funding opportunities
The St. Mary's recovery coach program would not be possible without the organization's partnership with Safe Communities Madison and Dane County, a $7,500 grant from the Wisconsin Medical Society Foundation, and $15,000 from Dane County, Martin says.
He recommends that healthcare systems reach out to their outpatient addiction communities to learn about organizations that may be able to help.
"Often, I think the outpatient and inpatient worlds are kind of operating in isolation, or in parallel. The key is making a bridge through an organization like Safe Communities so you can get people who have real-world experience in the community and are really plugged in," he says.
With the passage of the 21st Century Cures Act in December 2016, which includes $1 billion in state grants over two years to address opioid abuse and addiction, such opportunities may expand.
The appropriation of these funds notwithstanding, addiction medicine is among the most cost-effective services a healthcare organization can provide in an increasingly value-driven environment, says Ciha.
"If you can offer people a treatment option and give them a structure for prolonged recovery, that's going to be more cost-effective than if you treat people as they show up in the ED," he says. "But remember that there is a lot of relapse in addiction treatment—because it's a hard thing to treat. We try to pull out everything in our arsenal to help somebody in their recovery, because ultimately it's a lot cheaper to treat somebody in a behavioral health setting than in an ED setting."
The cost saving isn't limited to payers and providers, notes Teas. "According to government statistics, for every dollar you spend on addiction treatment of people who get into the criminal justice system, you save $5–$7 for the taxpayer."
What's more, up to 40% of all patients in acute care hospitals, if carefully inspected, would meet diagnostic criteria for an alcohol use disorder, Teas says. "By not identifying and treating these individuals, you're going to see recidivism and increased organ system disease that will only mount medical costs in the future."
"For every dollar you spend on addiction treatment of people who get into the criminal justice system, you save $5–$7 for the taxpayer."
Success key No. 3: Watch for recidivism
While a degree of relapse is inevitable, lower recidivism rates are a key indicator of service line success, says Ciha. "You definitely want to look at your EDs and see how many patients come in again for drug-related detox or drug-seeking behavior and then try to engage them in long-term recovery that will decrease the need for episodic inpatient treatment."
At St. Mary's, leaders will be watching those metrics, as well as overdose rates, to gauge the success of their recovery coach pilot. "The most powerful question will be whether we're able to get [patients] to their own homes and maintain a recovery program so they don't have to come back to the ED."
One way to curb the revolving-door effect is to use the time substance-addicted patients do spend in hospitals more productively, says Teas. "A lot of detoxification throughout our country is done in medical units without any behavioral health component. A lot of these individuals are simply lying in bed watching TV and not receiving any programming related to recovery."
But introducing elements such as motivational interviewing and resource education to detoxification settings in medical units can go a long way toward reducing relapse rates, according to Teas. "And those are numbers that really have to be paid attention to in this modern era of value-based care."
Finding clinicians and counselors qualified to handle addiction medicine is easier said than done, however. Addictionologists—psychiatrists who specialize in addictions—are in particularly short supply, says Ciha.
"As it becomes more difficult to recruit, I think you're going to see a focus on training exceptional midlevel professionals to provide these services, which would include advanced practice nurses and physician assistants, who can help extend the reach of the psychiatrist and maintain quality care," he says.
In addition, Teas says he expects to see more primary care physicians willing to provide medication-assisted therapy. "The real future, from my perspective, is with the licensed independent providers who can join forces with the physicians to expand our coverage for the population we're talking about."
Success key No. 4: Help maintain patient recovery in the real world
Even with access to comprehensive addiction medicine services, going about sober life in the real world can be fraught with difficulty.
To help patients maintain their recovery, AMITA Health is experimenting with an array of smartphone applications that patients in recovery can use to identify triggers that can cause them to use drugs or alcohol, and that clinicians can use to analyze data about places or people that might influence an individual to relapse.
"There's a whole host of apps designed for addictions—including some that allow you to message with patients—and we're going to be incorporating them into our treatment programs," Ciha says. "I think that's the way things are going, and to not explore them is to miss an opportunity to help people better succeed in their recovery."
An emerging area of research looks at how physician characteristics affect outcomes. International medical graduates are the latest group found to have better results than U.S.-trained medical doctors.
Medicare patients treated by international medical graduates (IMGs) are less likely to die than patients treated by non-IMGs, according to a study published by The BMJ this month.
More specifically, 30-day mortality rates were 11.2% among patients treated by IMGs and 11.6% among patients treated by physicians who trained in the United States, according to the analysis of Medicare data for more than 1.2 million hospitals covering more than 44,000 internists between 2011 and 2014.
Study co-author Yusuke Tsugawa, MD, MPH, PhD, a research associate at the department of health policy and management at the Harvard T.H. Chan School of Public Health, shared his insights into the findings. The transcript below was lightly edited.
HealthLeaders Media: You conducted this study years before President Trump's travel ban was ordered. What made you want to research outcomes of IMGs then?
Yusuke Tsugawa, MD: We knew that the U.S. heath system was relying on foreign-trained doctors in terms of quantity. One in four doctors in the United States is foreign-trained, and these doctors are more likely to deliver care in rural and underserved areas.
However, little has been studied about the quality of care delivered by foreign-trained doctors. We found that foreign-trained doctors are a valuable part of the workforce for the U.S. health system, both in terms of their quantity and quality.
HLM: Is medical education and training for IMGs a possible reason for the lower mortality rates seen among their patients? Or is the differentiator something about the personal attributes of IMGs?
Tsugawa: Our study did not compare the quality of medical education in the United States and in other countries. What our findings suggest is that the United States is allowing the best and brightest to come and practice medicine by setting a high bar. And I think that is the reason why foreign medical graduates had slightly better outcomes.
Tsugawa: The difference in patient mortality for foreign vs. U.S. medical graduates was about the same size as the difference between male and female doctors. I think the difference was modest but clinically meaningful.
HLM: Your research also found that costs were slightly higher for patients treated by IMGs. To what do you attribute that variation and why is it important?
Tsugawa: Slightly higher costs for foreign medical graduates may be because they order more diagnostic tests or more often consult with specialists.
HLM: What do you want healthcare leaders to take away from your research? Are there action points to help U.S. trained physicians achieve better outcomes?
Tsugawa: I think healthcare leaders should not judge trainees based on where they got their medical education—especially for foreign-trained doctors—because it is hard to evaluate the quality of education of foreign medical schools.
Instead, they should assess doctors based on valid and reliable evidence that is readily available by analyzing the claims data or EHR for each physician in many institutions.
HLM: Do you have plans to follow up on this research?
Tsugawa: We are currently studying other characteristics of physicians that may be associated with better patient outcomes at lower costs.
Texas Health Resources has developed a strategy to both recruit and retain top physicians by remaining competitive in an ever-changing marketplace. Learn THR's top tips for physician recruitment and engagement by watching this on-demand HealthLeaders Media webcast, Key Physician Recruitment Strategies from Texas Health Resources.
Physician organization leaders are trying to plot business strategies for a post-ACA landscape of increased healthcare consumerism, lower reimbursement, and new partnerships.
Attendees invited to attend the first annual HealthLeaders Media Physician Organizations Exchange, in La Jolla, CA in December, discussed the fate of the Patient Protection and Affordable Care Act and assessed a post-repeal-and-replace future for their organizations in stark business terms.
Physician organizations of all sizes are taking a hard look at the revenue they stand to lose if the individual mandate and Medicaid expansion end, how they might work with private insurers, and what strategic pricing and partnerships they can build.
Simply put, the business implications of a potential ACA repeal are "gigantic for us," says William R. Hathaway, MD, FACC, chief medical officer and senior vice president of Mission Hospital, a 763-bed medical and surgical hospital in Asheville, NC, a state that did not expand Medicaid.
"We are heavily dependent on governmental payer sources, with about 70% Medicare, Medicaid, or no-pay. The proposed changes would translate to tens of millions in lost revenue, which could be devastating to us," said Hathaway.
"How do you cut hundreds of millions of dollars out of your system when you're already cutting every year and trying to grow?"
Hathaway isn't the only one who's troubled by that possibility. The nation's uncompensated care bill could soar from $656 billion to $1.7 trillion over a 10-year period if the ACA is repealed with no replacement, according to research from the Urban Institute.
As many as 30 million people could become uninsured through the elimination of Medicaid expansion, premium tax credits for the purchase of marketplace coverage, and the individual mandate, according to the Urban Institute.
Reconciling the Past
Predicting that future is made even more difficult given the complexities of quantifying the impact of ACA implementation in the first place, notes David Carmouche, MD, president of Ochsner Health Network System, a non-profit academic, multi-specialty, healthcare delivery system based in New Orleans.
"So much has happened over the past several years. We used to have a high uninsured population in Louisiana, and now some of them have subsidies and commercial insurance," Carmouche said.
"We also had straight Medicaid expansion under the ACA, but our bad debt for the commercial insurers has grown because many people who are getting subsidies don't pay their remaining premium."
Patient nonpayment creates a reimbursement gap for physicians because the ACA imposes a mandatory 90-day grace period for patients to pay their outstanding premiums during which insurers are required to reimburse providers for the first 30 days only.
For days 31 to 90, providers must work directly with patients to collect the balances for services rendered.
"So we have millions of dollars of bad commercial debt alone. When you do the math, I'm not sure what the net impact was on our institution," Carmouche says.
Handling More HSAs
Going forward, momentum toward healthcare consumerism is likely to pick up steam, possibly exacerbating existing challenges.
"We're already in a retail world and don't even know it," says Carmouche. Last year, Ochsner Health System alone had 260,000 unique patients see its primary care doctors, he explains. Approximately 57% of those patients were commercially insured and in that group, 70% had high-deductible plans.
"Let's just take the low end of that—that's $311 million in discretionary out-of-pocket expense for our patients who see primary care doctors," Carmouche says.
It's becoming more commonplace for people to ask questions about the costs of MRIs and CTs, and make decisions based on that information, he says. “Frankly, we have a hard time competing with freestanding imaging centers and similar competitors."
As a result, the organization has had to think about strategic pricing and work with payers to implement changes, he says.
In more than 14,000 physicians across 30 specialties, according to that report, the highest rates of burnout (slide 9) appear in physicians who self-identify as Chinese (56%) and other Asian (53%). Vietnamese and white/Caucasian ethnic groups tied for third (52%), while the lowest percentages occurred among respondents who defined themselves as Asian Indian (46%), Japanese (47%), and black/African American (48%).
JudyAnn Bigby, MD, a senior fellow with Mathematica Policy Research, offers some insight and analysis of the problem. While Bigby was not involved in the Medscape survey, she has researched the correlations of physician ethnicity, bias, and professional satisfaction extensively over her nearly 30-year career practicing general internal medicine.
For starters, determining the true breadth of the difference in burnout rates among ethnicities is difficult when dealing with small numbers in the categories themselves, notes Bigby.
In the Medscape survey, just 4% of respondents self-identified as Chinese, which makes their 56% burnout rate tough to compare to Caucasians, who represent 69% of respondents. Furthermore, respondents to the survey could choose more than one ethnic classification.
Nonetheless, previous research by Bigby and colleagues identified a similar pattern to the Medscape survey. In their 2004 study published in the Journal of the National Medical Association, Hispanic physicians reported significantly higher job and career satisfaction compared to white physicians, but no significant difference in stress. Meanwhile, Asian or Pacific Islander physicians averaged lower job satisfaction and higher stress.
Takeaways for Leaders
Physician burnout is far from skin deep. Based on a career spent studying such matters, Bigby offers three takeaways for physicians and healthcare leaders:
Mission matters. "Satisfaction is in some ways related to how well the work you're doing aligns with your mission-driven sense of why you went into medicine," Bigby says.
"Hispanic and African American physicians are much more likely to serve in under-resourced and underserved communities, and so the understanding is that there may be a relationship between their goal of doing that service and the ability to serve those communities."
Community is crucial. "Having a sense of being part of a community [is] one of the factors that predict[s]" whether physicians are satisfied or experiencing burnout, she says.
Healthcare leaders, therefore, should do more to reward and value the time physicians spend interacting with the community outside of clinical practice. "Especially in this day when there's a lot of attention paid to the impact the community context has on individual health…that's a valuable contribution physicians can make."
Satisfaction is contagious. "Studies show that when physicians are not satisfied, their patients are less likely to be satisfied," Bigby says. "So there's something about physician satisfaction that spills over to their work—whether it's the appearance of being rushed or frenzied or irritable or something else—but there is a correlation.
So as work is ongoing to make healthcare delivery more patient-centered, it's really important to pay attention to physician satisfaction." In addition to the above points, key ways to reduce the burden on physicians include offloading bureaucratic tasks onto other qualified professionals, she adds.
As the industry transitions to value-based care, healthcare organizations are developing programs and solutions to find success in the new environment. View this HealthLeaders Media webcast, Maximizing Patient and Family Advisory Councilsto Improve HCAHPSlive on February 14 and learn how one organization successfully created and upholds a highly effective advisory council.
Interventions to improve quality of life for the seriously ill are often provided haphazardly under current frameworks. Here are five keys for transforming palliative care in your hospital system.
This article first appeared in the January/February 2017 issue of HealthLeaders magazine.
Making the case for providing palliative care isn't the challenge.
The specialty helps patients live not just happier, but also longer lives with their disease—while also reducing costs, University of Pittsburgh Medical Center research shows. As a result, palliative care has caught on. As of 2013, 90% of hospitals with 300 or more beds reported having a palliative care program, as did two-thirds of hospitals with at least 50 beds, according to a study published in the Journal of Palliative Medicine in 2016.
However, despite making inroads into health systems nationwide, palliative care programs often have room for improvement. A 2014 report from the Institute of Medicine called for sweeping changes to strengthen both palliative and end-of-life care nationally.
The IOM committee that produced the report titled Dying in America, noted that patients nationwide often encounter barriers to integrated, person-centered, family-oriented, and consistently accessible care near the end of life. These obstacles include disparities between the services patients and families need and the services they can obtain, barriers in access to care, and "inadequate numbers of palliative care specialists and too little palliative care knowledge among other clinicians who care for individuals with serious advanced illness."
Success key No. 1: Define your objective
To achieve the necessary buy-in to make improvements in all of these areas, organizations must begin with a clear message about what palliative care truly means.
The leading misconception about palliative care—among the public and within the healthcare industry—is that it's synonymous with hospice or end-of-life care. Although hospice and end-of-life programs often include palliative care, this service is not just for the dying.
According to the Center to Advance Palliative Care, "Palliative care is specialized medical care for people with serious illnesses. This type of care is focused on providing patients with relief from the symptoms, pain, and stress of a serious illness—whatever the diagnosis. The goal is to improve quality of life for both the patient and the family. Palliative care is provided by a team of doctors, nurses, and other specialists who work with a patient's other doctors to provide an extra layer of support. Palliative care is appropriate at any age and at any stage in a serious illness, and can be provided together with curative treatment."
With this understanding comes an imperative for patients to receive palliative care earlier in their disease trajectory. This requires a cultural shift that starts with physicians, according to Mohana Karlekar, MD, medical director of palliative care at Vanderbilt University Medical Center, a collection of several hospitals and clinics, as well as the schools of medicine and nursing associated with Vanderbilt University in Nashville, Tennessee. Combined, among its four hospitals, Vanderbilt is licensed for 1,025 beds.
"When a physician is taking care of a patient and things aren't going well, often he or she will have this angst, and often will avoid these conversations until the last minute," she says.
But experts agree that the earlier palliative care is begun, the better. Research published in the New England Journal of Medicine in 2010, for example, demonstrated that patients with metastatic lung cancer receiving palliative care had better quality of life, less depression, and less aggressive end-of-life care than a control group. They also lived almost three months longer, on average, than the patients who received standard care only.
Success key No. 2: Invest in midcareer training
As noted by the IOM, a top challenge in providing access to high-quality palliative care is an inadequate workforce pipeline, says R. Sean Morrison, MD, director of the Hertzberg Palliative Care Institute at the 1,000-staffed-bed Mount Sinai Hospital in New York City and director of the National Palliative Care Research Center.
"Because we're a relatively new specialty and because of caps in residency and fellowship training programs, there are just not enough specialists to meet the needs of every person with a serious illness in this country," Morrison says.
To manage this shortcoming, Morrison's first recommendation is to use palliative care specialists judiciously, enabling specialists to take care of the most complex cases, lead community-based teams and programs, and conduct research to advance the field.
The other piece of the equation, he says, is to rapidly expand training in core palliative care skills to nonspecialists, thus facilitating a team-based approach to taking care of patients' social, spiritual, and medical needs.
Morrison notes that during the 10 years of his own medical education—right up through fellowship—he received no instruction about pain management or how to tell a patient about a serious diagnosis. "In fact, almost anybody in any profession has gotten as much training as I did about how to tell somebody they have cancer."
Also known as "midcareer training," the concept of improving all clinicians' skills in communication, pain management, and symptom control is critically important, says Diane Meier, MD, FACP, FAAHPM, a professor of geriatrics and palliative medicine at the Icahn School of Medicine at Mount Sinai in New York City.
Many organizations have formally launched programs to improve palliative care skills and knowledge throughout their organizations. Vanderbilt, for example, created its own curriculum to train midlevel practitioners and nurses in core palliative care skills. The training sessions, often led by Karlekar, involve active role-playing and occur at convenient times during trainees' workdays.
"We're not asking them to do something extra," Karlekar says. "We try to make it as simple and user-friendly as we can make it." The response from trainees has been overwhelmingly positive, she adds, because nurses appreciate obtaining skills they can use immediately at the bedside.
The Center to Advance Palliative Care, which Meier directs, also offers an online curriculum for midcareer training. However, organizational commitment is necessary for success, she says.
"That commitment comes from the very top of those organizations—the CEO, the board—recognizing that, through no fault of their own, medical schools have completely failed to prepare future clinicians with these essential skills and that health systems really have to compensate for that by investing in compensatory training for their staff," she says.
Success key No. 3: Screen for need
After building a competent palliative care team, health systems' next priority should be creation of a consistent and standardized approach for identifying patients and families who would benefit from palliative care, Meier says.
Similar to the way hospitals screen patients on admission for hearing loss or fall risk as a condition of accreditation, they should routinely ask patients about poorly controlled symptoms such as pain or shortness of breath, inquire about caregiver exhaustion, and note red flags such as repeat hospitalizations, she says.
"Anybody who meets one or more of those criteria would benefit from a comprehensive palliative care assessment and appropriate interventions. But right now, we don't screen for those issues, and if you as a patient get palliative care in a hospital, it's because you're lucky. If your treating physician doesn't think about making the referral, you almost certainly will not access the care," says Meier.
Morrison agrees. "My worry is what's happening now is what we call self-triage. We [physicians] are selecting the people that we think are most in need, and those typically are people closer to the end of life with a higher symptom burden," he says. "However, people more upstream can benefit from our services equally, if not more so. So we have to have a more strategic way of identifying who can benefit from what service and getting them into those services."
Done well, such screening can ensure patients receive the right level of care.
Success key No. 4: Spread out
One of the more unique qualities about Vanderbilt's palliative care program is that it stems from the hospital's division of general medicine, which is under the department of medicine. "We are not connected in any formal way to any specific specialty, so the breadth of the different types of patients that we get is different than most programs," Karlekar says.
Oncology referrals account for approximately 15% and heart failure referrals account for approximately 12% of all palliative care referrals at Vanderbilt, with surgical, trauma, burn, stroke, and other serious conditions making up the rest, she says.
"We're embedded in heart failure, so we see people before they get transplants," she adds. "We see a lot of liver patients as well. It's earlier in the trajectory, and it's a much wider population specialty base."
Vanderbilt has run a dedicated inpatient palliative care unit since 2012. There, "we are the primary team taking care of those patients, some of which come in to have their symptoms managed, some of which will not leave the hospital because they're too unstable to get to hospice," Karlekar says. "In some cases, there's some uncertainty about how they're going to do. Maybe they'll go to rehab, but we're not sure."
What's more, the program that began as an inpatient consultative service also provides extensive outpatient services.
Mount Sinai also provides services on an inpatient and outpatient basis, with care teams embedded in certain high-risk programs, including oncology and the intensive care unit. An embedded model for advanced heart failure patients is in the works.
In addition, palliative care is embedded in Mount Sinai's home-based primary care program, while a community palliative program for patients of lower acuity is under development with support from an endowment.
Success key No. 5: Monitor metrics
The metrics that correlate with palliative care success are also more diverse than for other service lines. According to experts, the following benchmarks are the most important to watch:
Patient satisfaction. "It's critically important to document satisfaction with care and symptom relief," says Morrison. "You want to make sure that people are staying comfortable, that their families are satisfied, and that care is being delivered appropriately in a timely fashion." Moreover, many of these measures, commonly captured by HCAHPS, are also used by Medicare and other payers to assess quality of care," Meier notes.
Avoidable hospitalizations. In particular, keep an eye out for emergency department visits that occur outside typical business hours, says Morrison. "Unless you have 24/7 support and can take care of people after hours, you're not doing as well as you could be."
Time from admission to palliative care service delivery. "There are now a number of studies showing that if you receive palliative care within the first 48-72 hours after being admitted to the hospital, it has a much larger impact on how you do and how quickly you get out," says Meier. "Any later than that, a lot of damage has already been done."
Penetration rate. This measures the percentage of annual admissions to your hospital that are served by your palliative care team. According to the National Palliative Care Registry, palliative care service penetration has increased by 78% since 2009, from a mean 2.2% in 2009 to 3.9% in 2009. Some better-performing hospitals have penetration rates as high as 10%, Meier notes. "It's a measure that tells a hospital or health system, 'Okay, you've invested in this service. You're paying salaries of X number of people. This is how well they're actually reaching people in need,' " she says.
30-day readmissions and hospital mortality. Both of these figures are markedly reduced among patients who've received palliative care, says Meier, adding that hospitals are also held accountable for these metrics under Medicare. "To the extent that a hospital could stand to improve on those—as most could—a well-staffed, adequately capable palliative care team and broad midcareer clinician training is probably the most effective thing hospital leadership can do to reduce penalties."