California has nearly 20% fewer practicing physicians than was assumed, and not nearly enough active primary care providers to meet the state's needs, according to the 2008 Medical Board of California's database. Though it has an "abundance" of specialists, half the counties don't have nearly enough.
The report noted further deterioration in physician supply "poses a significant threat to health access" and risks "compromising the health of the state's residents."
The report said that the 66,480 active physicians is much lower than the American Medical Association's figure of 80,000, which was attributed to an AMA overestimation of the number of full-time physicians.
California has only 59 primary care physicians now practicing per 100,000 population, lower than the 60 to 80 needed. Adding the number of osteopaths, California has 63 primary care physicians in patient care per 100,000 population, "at the bottom end of the estimated need range," the report said.
The report, entitled "Fewer and More Specialized: A New Assessment of Physician Supply in California," was compiled by Kevin Grumbach, MD., chair of the University of California San Francisco Department of Family and Community Medicine, and colleagues, with support of the California Program on Access to Care. It was released by the California Healthcare Foundation.
The supply of primary care physicians is the most troublesome, with only 16 of the state's 58 counties reaching a threshold of 60 primary care physicians per 100,000 population, as recommended by the Council on Graduate Medical Education.
If current trends continue, The Golden State's primary care physician shortage is likely to worsen, the report said, "exacerbated by a shrinking interest in primary care nationally among graduates of U.S. medical schools."
The report added the distribution of physician practices throughout the state is problematic because it leaves rural and underserved counties with fewer doctors than they need. The report says the supply of primary care physicians in these low population areas is "diminishing."
An additional concern is the number of active physicians who are nearing the end of their careers, with one-third of those practicing having reached age 56 or older, and nearly 10% who are at least 66.
The team recommended that the state find a way to resolve the issue in at least four ways:
Provide greater financial incentives to primary care physicians to set up practices in the state, especially in underserved areas, and pay more for patients covered by Medicaid and other government programs.
Support special targeted training for medical students to practice in underserved areas.
Provide more financial and technical assistance to modernize practices.
Support practice redesign to increase shared decision-making and learning through information technology.
The survey was launched because of concerns that physician supply estimates relied too heavily on projections from the American Medical Association's Physician Masterfile data.
Over the last five years, many health and hospital officials and physicians groups complained that they witnessed firsthand an increasing exodus of the physician workforce. Many left the state to practice in an environment with fewer cost or reimbursement constraints from managed care organizations or reduced their hours. Many took early retirement or left for other pursuits, such as academic research, or other medical fields, such as full or part-time work with institutional review committees, court testimony or publications.
To get a better handle on the problem, the Medical Board of California, which licenses and disciplines physicians, sent out a survey as part of relicensure and now has enough responses for the report.
Indeed, although the survey shows that there are 118,883 physicians who had an active medical license in 2008, less than half were out of training and practicing within the state at least 20 hours per week. Of these 34% were in primary care while 66% were non-primary care specialists.
Conversely, the AMA has estimated that 80,000 active physicians practice in California, a discrepancy this report attributed to the fact that the AMA overestimated the number of hours physicians practiced and listed many physicians as practicing in the state, who in fact are not listed as having a California medical license.
By county, the survey found the greatest number of physicians per 100,000 population are in heavily urban and affluent counties, such as San Francisco, which has 370; Marin, 271; Santa Clara, 239; Napa, 231; San Mateo, 213; and Alamada, 211. The lowest number per 100,000 population practice were in rural counties, such as Alpine, which has none; Sierra, 27; Modoc, 28; Glenn, 43; Trinity, 47; Colusa, 53; Mariposa, 53; and San Benito, 58.
Specialist physician supply is adequate, the report said, but they are poorly distributed. For example, the highest ratio of specialists is located in San Francisco, 265 per 100,000; Marin, 191; Santa Clara, 160; and Napa, 157. But 11 counties have fewer than half the 85 specialists per 100,000 population.
The University of Medicine and Dentistry of New Jersey will pay the federal government $2 million to settle a whistleblower lawsuit alleging that it bilked Medicaid in a double-billing scheme that went on for nearly a decade, according to the Justice Department.
From 1993 to 2004, UMDNJ's University Hospital in Newark submitted claims to Medicaid for outpatient physician services that were also being billed by doctors in the hospital's outpatient centers, DoJ says.
"Today's settlement demonstrates that the Department of Justice will not tolerate fraud on our Medicaid programs, which were created to serve our nation's low-income families, children and seniors," says Tony West, assistant attorney general for the Justice Department's Civil Division, in a media release announcing the settlement.
The case against UMDNJ and University Hospital originated in a whistleblower suit filed by Steven Simring, MD. The double billing was also the subject of a criminal complaint filed against UMDNJ by the U.S. Attorney's Office in New Jersey in 2005. Under a deferred prosecution agreement, the state of New Jersey recouped $4.9 million from University Hospital, half of which was to be returned to Medicaid.
After this week's agreement, UMDNJ will pay another $2 million to the federal government to settle the civil false claims act allegations. The total federal recovery when combined with the previous payment is $4.45 million. Simring will receive $801,000 as his share of the total federal recovery.
The federal government loses tens of billions of dollars lost each year in Medicare/Medicaid fraud. At a joint press conference last month, US Attorney General Holder and HHS Secretary Kathleen Sebelius announced the creation of a new interagency effort, the Health Care Fraud Prevention and Enforcement Action Team, and the expansion of Medicare "strike force" teams, now operating in Miami and Los Angeles, to Detroit and Houston.
"We cannot and will not allow billions of dollars to be stolen from Medicare and Medicaid through fraud, waste and serious abuse of the system," Sebelius said at the May 20 announcement. "It’s time to bring the fight against fraud into the 21st century and put the resources on the streets and out into the community to protect the American taxpayers and lower the cost of healthcare."
Hospitals commonly display visual aids, such as banners, posters, and signs to remind staff to practice proper hand hygiene, but nurses in Massachusetts General Hospital's same day surgery unit may have found a more memorable way to get the message across: creating a rap video.
Dubbed the "Cal Stat Rap," the humorous, educational music video depicts Pauline M. Albrecht, RN, BSN, as she rhymes about the importance of using the facility's Cal Stat sanitizers and performing proper hand-washing protocol to prevent the spread of infection. Various other hospital staff also have cameos in the film; some can be seen dancing with bottles of Cal Stat and others demonstrating when to use it.
The rap, written and produced by Albrecht, is the latest component of MGH's hand hygiene campaign, which formerly led staff in its neonatal ICU, medical ICU, and one cardiac unit to achieve 100% compliance before and after patient contact for three consecutive months. The facility's overall hand hygiene compliance is currently peaked at 90%.
Albrecht's recent creative hand-hygiene efforts are what Judy Tarselli, RN, in the infection control unit, describes as truly unique.
"We have more than 150 of what we call hand-hygiene champions who are peer leaders," she says. "Pauline was not a designated champion—but a nurse working on one of our units and just a perfect example of what can be achieved even if you're not officially affiliated with the improvement group. This is how ingrained hand hygiene has become in our culture."
Tarselli says it took Albrecht about two months to write and record the rap and another month to choreograph and film it. The end product, which is about two-and-a-half minutes, supports the tone of MGH's former infection control initiatives.
"It represents how we have tried to keep our improvement efforts positive and fun," says Tarselli. "Champions here have created everything from bulletin boards, to songs, to poems, to contests."
But while the rap addresses hand hygiene in a lighthearted manner, the lyrics of the "Cal Stat Rap" touch on some crucial hospital challenges, such as maintaining compliance with The Joint Commission (formerly JCAHO).
The lyrics read: So you better pay attention to the rules,
We gotta beat the nasty bugs we got the tools.
Too much sharing and not caring gotta cease
Says JCAHO and the Cal Stat police.
The "Cal Stat police" or undercover agents at MGH, such as Tarselli, have been directly observing staff on all units for the last seven years and have been conducting routine surveys. Both tactics have since enabled them to watch MGH's average hand hygiene compliance rates take off, according to Tarselli.
"You need a measure for improvement. And you can have hand hygiene among nurses and doctors, but that alone isn't going to get you anywhere," says Tarselli. "Everybody that is affiliated with patients and their environment must be included in the hand-hygiene program."
Wander down the medicine aisle in a Boston-area supermarket this spring, and you may stumble upon a Tufts Medical Center maternity advertisement—literally. The hospital placed ads on the floor in front of the home pregnancy test kits in more than 50 local grocery stores to advertise its obstetrics service line as part of an integrated campaign to promote awareness of its routine pregnancy services.
"We are extremely well known in the market for our high risk pregnancy services, but we are less known in the local community for our routine pregnancies," says Brooke Tyson Hynes, the hospital's vice president of public affairs and communications. "We wanted people in our surrounding community to know that they could come here, that there was a very convenient, high-quality option for them for routine pregnancies."
After seeing its number of routine deliveries plateau and hearing through word of mouth that many locals assumed the academic medical center only practiced high-risk deliveries, Tyson Hynes teamed with Partners+Simons, a Boston marketing firm, to create a campaign to highlight the hospital's expertise and community hospital feel.
"Tufts is known for high-risk pregnancies but has the expertise in routine as well and delivers it all in a very personalized environment," says Jennifer Goslin, Partners+Simons' brand director. "So that became the forefront of the message that we truly wanted to deliver to the public—that we do offer these services, from routine to high-risk, and we can give you everything right around the corner from where you work and live."
Are doctors and hospitals in rural settings expected to uphold the same strict code of ethics as their urban counterparts? Are the situations always comparable? Or are rural issues and circumstances so variable and vulnerable that a different, perhaps more lenient, standard is okay?
A recently published book, Ethical Issues in Rural Health Care, attempts to explore those and many other questions in 12 compelling essays. Authors describe actual situations that caused them to weigh their medical and moral obligations to their patients against the loyalty to their economically fragile institutions.
Rural providers often know their colleagues, patients and their families socially and intimately, as well as clinically, which poses awkward issues of loyalty, confidentiality and privacy, write the book's editors Craig Klugman and Pamela Dalinis. Klugman is assistant director for Ethics Education at the University of Texas Health Science Center in San Antonio. Dalinis is director of education at Midwest Palliative and Hospice Care Center in Glenview IL.
They orchestrated the volume to launch what they say is a "much needed conversation" about the lack of a platform to explore ethical issues in rural settings.
Let's face it. Rural healthcare providers and settings must overcome special challenges. One in five Americans live in areas defined as rural, but only one in 10 physicians practice in them. Rural doctors work longer hours than their urban counterparts. Their patients must travel farther, may wait longer, and may be poorer on average and sicker, and have much more limited access to specialists, many of whom the referring physicians may not even trust with his patients, some of the authors write.
Rural doctors may also hold other pillar roles, sit on boards or hospital committees, or even public agencies.
Critical access hospitals struggle to keep the doors open and the lights on, while maintaining their patients' confidence. What will the patients think if they're frequently told to go elsewhere?
The book is divided into three sections. In the first, essays explores the difference between rural and urban cultures with examples of unique obstacles, such as the lack of hospice services in low population areas and how that may alter expectations for providers and families.
A second section is devoted to stories and examples of ethical dilemmas as told by two physicians and a psychologist who practiced in rural settings.
One, Elwood Schmidt, MD, who was often the only physician where he practiced in rural areas of the Southwest, described the troublesome belief that rural medicine should somehow be allowed to uphold a lower standard than urban healthcare. Decades ago, he wrote, "Alcoholism was rife in our West Texas/southeastern New Mexico medical community and was winked at, ignored, and even accepted by us and our patients," he wrote.
Another problem was the lack of anonymity. "In a small rural town (patients) always knew that it was Dr. Schmidt who treated them," far different than in larger urban settings where patients may easily forget their physician's name.
The third section attempts to pose solutions, such as the creation of bioethics forums devoted to special problems in rural areas.
"To date, there has been virtually no research on healthcare ethics in rural settings," wrote Frank Chessa and Julien Murphy, who described the challenges in creating their Maine Bioethics Network. They advocate that rural providers "build a case" for bioethics discussion and networks.
Quality of care, and the obligation to disclose experience levels of providers, as well as alternative options and errors to their patients, comes up frequently.
When a rural town's long-time surgeon becomes ill and must retire, a junior partner is quickly trained to perform C-sections and his credentialing is fast tracked, writes Denise Niemira, MD, a family practitioner at the Women's and Children's Health Center in Newport, VT.
But a family physician whose patients may have complicated deliveries is worried about the lack of the surgeon's experience. He wonders if he has an ethical obligation to tell his patients and give them an option to go elsewhere.
"But he is also concerned about the fragile state of surgical and obstetrical services at the hospital" which has had trouble recruiting doctors to such a small town.
At another small rural hospital, doctors struggle with a decision on what to do with heart attack patients. Should they keep them at the hospital and administer clot busting drugs, thus maintaining the hospital's necessary cardiac volume, or sent to a tertiary facility 100 miles away for more appropriate interventional cardiology. "Underlying the discussion was the tension between the need to maintain a competent critical care unit for the community and the desire to serve the best medical interests of each individual patient," Niemira wrote.
One essay by Ann Freeman Cook and Helena Hoas, of the National Bioethics Project at the University of Montana-Missoula, highlighted some disturbing findings. In nine studies they conducted over four years, they interviewed a wide range of health professionals who worked in rural settings throughout the Western U.S.
The authors concluded that "most rural healthcare providers believe that they and their hospitals are genuinely concerned about patient safety. When asked to rate their ability to make healthcare safer, respondents . . . gave themselves high scores."
But, they wrote, "rural healthcare providers consistently demonstrate discrepancies in their abilities to recognize errors, report errors, allocate responsibility for patient safety, design interventions that increase patient safety, implement new practices and sustain change.
"Moreover, among healthcare disciplines there are vastly different perceptions as to what constitutes and error."
Physicians, they wrote, "generally viewed the errors contained in the case studies as 'practice variances,' 'suboptimal outcomes' or examples of differences in 'clinical judgment.'" And as such, they deemed an disclosure to their patients, notations in charts or filing incident reports "as unnecessary and inappropriate," Cook and Hoas wrote.
"As one respondent explained during an interview: 'We just don't talk about that (error) stuff with one another.'"
Klugman and Dalinis warn "the lack of relevant resources for the rural practitioner is troublesome."
They add, "the differences between rural and urban areas are so complex that some have called for specialized training for physicians working in rural areas."
Miles Sheehan, MD, of Loyola University of Chicago's Stritch School of Medicine in a review of the book in the May 27 issue of the Journal of the American Medical Association, wrote, "Reading the essays in this volume is like acquiring a new set of glasses. It made me better able to perceive differences in how ethics can be considered based on culture, population, geographic challenges, and personal connections."
The 224-page hardcover collection of essays is published by Johns Hopkins University Press. $50.
The Mobile Marketing Association claims that mobile marketing budgets will jump 26% this year, despite the fact that overall marketing spend will fall 7%. While the medium will still snare just 1.8% of total marketing budgets, total spend will grow from $1.7 billion this year to $2.16 billion in 2010, according to the new research. Half of brands and agencies polled by the group said they were experimenting with some type of mobile marketing.
Health plans are increasingly interested in whether disease management programs are producing positive ROI especially in this tough economy. In this podcast, Siva Namasivayam, chief executive officer at SCIOinspire, and Timothy Cahill, senior vice president of business development at SCIOinspire, speak about the best ways to gauge ROI for DM programs. [Sponsored by Emdeon]
Most employers are using blogs, Twitter, Facebook and other social media channels to communicate with employees, according to a recent study. If you're not yet convinced of the value of social media to reach patients and other healthcare consumers, internal communications might be a low-cost, low-risk opportunity to experiment with new forms of media, to measure reception and effectiveness, and to figure out which tools work for your organization.
In a survey of nearly 1,500 employers, 97% said they "frequently" use social media to engage employees. Another 19% said they occasionally use it and only 1% said they rarely or never do. (Kind of makes you wonder what that 1% is waiting for, doesn't it?)
Social media beat out even e-mails and intranets, which clocked in at 75% and 72% respectively, according to the Employee Engagement Survey released June 9 by the International Association of Business Communicators (IABC) Research Foundation and Buck Consultants.
Remember employee newsletters? Still popular among hospitals, overall they're on the decline, according to this survey: Only 28% said they use them regularly.
If the idea of using your employees as social media guinea pigs is appealing, consider starting by measuring whether the tactic is effective. Best practice measurement tactics for social media are still emerging, and most of the respondents in this survey still aren't using them. In fact, 46% aren't using any measurement at all—it was the leading response.
The most common measurement tactic was monitoring usage and other data (33%). That's not a bad place to start, but there's more you could (and should) be doing, such as conducting surveys and focus groups, for example. Only 1% reported that they use these tactics. Think about that for a minute: That means an overwhelming majority are pushing messages out to their employees without bothering to ask them what they think or trying to determine if it's working.
And, ironically, the ability to engage in two-way conversations is one of the greatest strengths of social media. Julie Freeman, president of IABC, says companies are starting to understand that.
"Companies are moving away from the one-way communication model where they would send out information hoping people would read it," she said in a release. "Using the various social media tools, companies can now engage employees in discussions and foster conversations between teams across geographic and other boundaries."
Some other key findings from the survey:
More than half of the respondents (52%) report their communication budgets have decreased and 35% report their communication staff has been reduced over the past 12 months
The most common reasons cited for communication budget and staff cuts were the economy (46%) and organizational mandates (42%)
Forty-eight percent report their employee communication strategy has stayed the same despite the economic downturn
The frequency of ongoing employee listening reflected an "all or nothing" approach, with 62% of respondents saying they regularly engage in employee listening activities such as surveys and focus groups and 30% percent saying they rarely or never engage in these methods
Fifty-six percent of top executives are not currently using social media, and nearly half (46%) of organizations are not measuring social media's effectiveness
Almost six in 10 respondents (59%) think their company has a well-established internal or employer brand
Note: You can sign up to receive HealthLeaders Media Marketing, a free weekly e-newsletter that will guide you through the complex and constantly-changing field of healthcare marketing.
Marketers understand the basics of HIPAA, but there are other uses of patient information?especially with the explosion of new forms of communication, such as social media?where things get a little ?fuzzy and dicey,? Kate Borton, a HIPAA consultant and author of the book A Marketer?s Guide to HIPAA says in this audio interview. Sandra Nunn, enterprise, content, and information manager for Presbyterian Healthcare Services in New Mexico, also talks about some of the new challenges that healthcare marketers face when it comes to HIPAA compliance. You can hear more from Borton and Nunn in the upcoming HealthLeaders Media Webcast, HIPAA Changes: New Compliance Strategies for New Marketing Models.
Depending on the breadth of a public plan and enrollment numbers, private plans could be either slightly affected or decimated. Private insurers and their supporters are in fighting mode, arguing that a public plan would have an unfair advantage over private insurers and would expand government-run healthcare.
Meanwhile, America's Health Insurance Plans, hoping to derail the public insurance option, has started to make concessions unheard of even a year ago. It has agreed to accept all members regardless of health status and to stop charging women higher rates for individual health coverage as long as the federal government mandates that all Americans have health insurance.
Private insurers' arguments against a public plan are valid, but I think they might have more support from the public and from politicians by taking a different tack. Namely, they should promote the idea that they are grounded in innovation. A number of health insurers recently told me that a public plan could cramp healthcare innovation. Creative thinking in healthcare does not come from the federal government, but through private enterprise, the argument goes.
Private insurers have introduced many healthcare innovations. Robert Zirkelbach, director of strategic communications at AHIP in Washington, DC, says private insurers have spearheaded quality improvements, care coordination, and chronic condition management programs. "Those kinds of things aren't being done in public programs today. A public plan could turn back the clock on all of those initiatives put forth," he says.
Sam Nussbaum, MD, executive vice president and chief medical officer at WellPoint, Inc., in Indianapolis, says programs like bundled payments, pay for performance, and value-based insurance design came from the private sector. In fact, VBID, which was spearheaded by private businesses Marriott and Pitney Bowes, is now featured in legislation that would test the idea in the Medicare population.
"I continue to like the current system with the ability to innovate, to do new things, to experiment with different approaches, and we're going to lose that under this government-directed centralized system," says Nussbaum.
One of the leading public insurance advocates isn't buying the innovation argument. Jacob Hacker, PhD, a University of California, Berkeley professor, says public insurance can work side by side with private plans and the system can benefit from both of their strengths. For instance, private insurers are better at customer service, care innovation, and delivery system structuring, while a public option could serve as a lower-cost option with low overhead costs and greater bargaining power, says Hacker.
Hacker disagrees that innovation would be lost with the public plan. By having direct competition, private plans would need to innovate or go out of business.
At the same time, Hacker suggests that a public plan could actually help private insurers because they will have to respond to the lower-cost option and streamline administration processes, which will ultimately make them stronger and better able to compete.
"I think it would affect the least innovative plans. The ones that are most like the public plan in their structure are the ones that won't have any value over public insurance," says Hacker.
Private insurers feel they are fighting for their lives with the possibility of a public plan, but Hacker warns that private insurers should be more concerned about the losses of the employer-based market. He makes an excellent point.
The potential loss of employer-based members is a much more pressing problem and private plans shouldn't wait (one healthcare leader told me last week health plans are "paralyzed and don't know what to do") to see how the public plan shakes out.
Hundreds of thousands of Americans are losing health benefits each month. In fact, Ian Duncan, president and founder of Solucia Consulting in Farmington, CT, recently told me one health insurer client is losing 0.5% of its membership monthly because of layoffs.
To combat layoffs and prepare for a public plan, health insurers should show some of that innovation that it is trumpeting. Some areas to explore include reviewing and expanding individual health insurance options, streamlining administration processes to cut costs, collaborating with employers to identify current needs, and offering lower-cost options to employers who are deciding between cutting benefits, laying off employees, or shutting their doors.
Private insurers are staring down an industry's destruction. How they respond to these issues will be a major factor as to whether private insurance remains. It's time to get innovative people.
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