Whether using simple techniques or complex technologies, physicians must consider a patient's social needs in order to engage them and elevate care, say panelists at Partners HealthCare's Connected Health Symposium.
Alicia Cole of Sherman Oaks, CA, is a survivor ofnecrotizing fasciitis—flesh-eating bacteria—that she contracted following routine surgery in 2006. She was bedridden for months and needed more surgeries to overcome her devastating ailment.
The struggle and trauma was bad enough. Yet there was something else that really troubled Cole during her hospital stay: Healthcare providers and nurses weren't calling her by her name.
"Being in the hospital for two months, it's very disconcerting to have someone refer to you, standing right there, and talking about 'Patient 25.' I'm thinking, 'You know me.' My name is Alicia. Please refer to me in that way,'" Cole says. "It dehumanizes the patient. There is a disconnect," adds Cole, who has formed a patient advocacy group, Alliance for Safety Awareness for Patients.
In East Greenwich, RI, Pat Mastors recalls a generally more positive experience when she maintained a day-and-night hospital vigil for her 26-year-old daughter who was hospitalized when suffering Guillain-Barre Syndrome.
Although she ran into staffers who said, 'Sorry, that's not my job,' Mastors researched her daughter's illness and needs, and "compelled [healthcare staff] to connect."
"They stepped up their game, they really worked as a team, I saw this happen many times, " Mastors says. Once, a physician in leadership helped push her daughter's gurney, to the surprise of other staff. "A technician holding up the rear of the gurney said, 'Oh, my God, I've never seen the chief of radiology move a patient before,'' Mastors recalls, seemingly stunned by hospital politics.
Mastors also learned the importance of patient or family involvement in care when her father died seven years earlier from complications following a surgery that, she says, "made no sense to me." She created and is CEO of Pear Health LLC, maker of a patient engagement and empowerment tool.
Patients Can Help Shape Care Plans
Patient focus is something that needs to be welcomed, not discouraged, says David Judge, MD, medical director of the Ambulatory Practice of the Future at Massachusetts General Hospital in Boston. This program establishes a process in which there are health coaches designated for each patient, in part to free up physicians to spend more for patient care. Patients, too, are dubbed as "experts" in their care. That distinction is crucial, Judge says.
"The experience on the care team is very rewarding," he says. "It blows us away."
Despite the positive outcomes demonstrated by his program, some physicians resist patient engagement, Judge says. He notes that Massachusetts General Hospital uses a patient portal that details precisely what physicians are doing and why.
Some doctors think it's "crazy" to set up a patient portal. But, he says, patients "are going to see what is being put on the chart. There's nothing crazy about that, it's fantastic and safer [care]."
"We engage patients in designing a process. They need to be at the center of care and experience to design what they need, what they want," says Judge.
Unfortunately, "you have to understand how our own [physicians'] traditions run counter to that," he adds.
Connected Health
Cole, Mastors, and Judge were among speakers at last week's Partners HealthCare's Connected Health Symposium in Boston, which focused on collaborations and innovations to engage patients and elevate care.
Part of "connected health" is focusing on simple tasks, such as remembering a patient's name; or rethinking care processes, such as teaming with patients and their families.
Such work comes against the backdrop of many technological developments that could be implemented to improve patient care. Patient advocacy representatives, consultants, and vendors at the Connected Health Symposium pointed to new dashboards that help patients collaborate with physicians and empower the patients to take themselves off medications. An innovative facial recognition computer program was touted as a way to help monitor a patient's medication adherence.
Whether using simple techniques or complex technologies for patient engagement, physicians must consider a patient's social needs, and may need to weave more of that into care plans beyond the routine patient-physician visit, panelists said.
That's what Massachusetts General Hospital's patient advisory council tries to do, Judge says. Patients are asked "How do you define health and wellness; what is your goal?" he says. Often, the answer is not straightforward, he says: "It's not my blood pressure, it's the kid who may be on drugs, the boss. That's a big lesson for us."
Rebecca Onie, co-founder of Health Leads and a winner of a MacArthur Foundation genius award, has operated clinics in which physicians not only prescribe drugs for patients but also advise patients what kind of food they should eat, or suggest they raise the thermostat in the home.
"Every day we have patients who come into the clinic with asthma exacerbation, but I know the real issue with the patients there is no food at home," Onie said at the Connected Health Symposium. "The other issue is they are living in substandard apartments filled with asthma triggers."
"The realities of my patients' lives are outside the four walls of the clinic," she says. That's a lesson for all healthcare providers.
The non-profit ECRI Institute suggests that "hospitals should be diligent about the presence of anyone who isn't a staff member in the OR because of potential risk management concerns."
This article appears in the October issue of HealthLeaders magazine.
They stand alongside the physicians and nurses. Like the medical professionals, they scrub in and wear masks before entering the operating room, where they check out the nuts, screws, braces, and other orthopedic devices.
They stand alongside the physicians and nurses. Like the medical professionals, they scrub in and wear masks before entering the operating room, where they check out the nuts, screws, braces, and other orthopedic devices. They are medical device sales reps.
Having sales representatives in the OR is a common practice, even though some healthcare leaders say it is an unwelcome presence.
"Vendors go in and tell about a new item; it's an angle they are going to take," says Larry Kennedy, CMRP, the materials management director of Jefferson Regional Medical Center in Pine Bluff, Ark. He says it's obvious some reps are trying to influence sales. "That's their job. But we don't allow them to push products in the OR or cath lab. We make them schedule a meeting with us."
The ECRI Institute, a nonprofit based in Plymouth Meeting, Pa., that researches cost-effectiveness in patient care, said in a July report this year that while hospitals generally do not allow "outsiders" in the OR, exceptions are "frequently made" for medical device sales representatives. That especially occurs when the sales reps can provide "assistance with a particular device."
As ECRI notes, however, "hospitals should be diligent about the presence of anyone who isn't a staff member in the OR because of potential risk management concerns and should establish policies to oversee sales representatives involved with devices."
While hospitals allow vendors in operating rooms, in part because physicians often press for that presence to ensure they are properly using the medical devices, leaders are crafting policies that place limits on such vendor involvement. The Loma Linda (Calif.) Medical Center has reduced the number of cases in which sales staff are in the surgical suites, especially for a majority of routine cases, says Gary Botimer, MD, chairman of the orthopedics department at the 970-bed facility.
"This is only for the cases that the surgeon does not feel he needs them there," he says. "There will always be legitimate advances in care [for which] it is helpful to have a company representative there, but for the routine cases [as established by the surgeon evaluation team], the presence of a company representative is unnecessary."
William Martin, PharmD, administrative director for sourcing and value purchasing at Beaumont Health based in Troy, Mich., acknowledges that while physicians are ultimately responsible for decisions on medical devices, "the device representative is there in the operating room as well. While his or her intent is to make money, there are select procedures that are complex, and it's not all negative when they try to help physicians. I think there may be some value when you are undertaking a complex revision surgery, because the device representative is incredibly familiar with the product."
For the most part, though, Martin says that the presence of the vendor representatives is "an unnecessary activity." The vendor sales staff "gets paid a very handsome wage and may live in the same subdivision as the doctors. The rep may represent anywhere from 30% to 40% of the costs of implants. It's unbelievable, and in my mind, it's what is upside down in healthcare."
This article appears in the October issue of HealthLeaders magazine.
Orthopedic physicians and hospitals are developing new procedures and processes to better select and procure surgical implants for hip and knee pain, spine care, and joint replacement.
This article appears in the October issue of HealthLeaders magazine.
As the need for devices for implants and other orthopedic procedures soars against falling reimbursements in a growing service line, hospital and health system leaders are imposing more aggressive measures to oversee quality and cost controls for orthopedic implants, whether they are for hip and knee pain, spine care, or joint replacement.
Hospitals and physicians sort through an array of devices with a range of prices and weigh input from vendors and medical providers, trying to find the best product at the best price. Many hospitals are assembling special teams to evaluate costs, keep track of purchases through real-time reviews, and align with physicians to monitor wasteful spending. Among the areas they examine is the prospect of imposing spending caps, with some health professional teams saying there is a "gaming of the system."
A host of variables, uncertainties, pricing issues, and overtreatment concerns about devices plague the providers who offer hip and knee replacements, spine surgery, and other procedures. At the same time, hospital officials and government authorities are stepping up monitoring of devices because of overutilization and overtreatment. Hospitals are trying to have greater control over physicians in implant procedures.
"We see significant 'tweaks' in these devices that are very expensive to rationalize and very expensive to digest," says Gene Kirtser, president and CEO of ROi (Resource Optimization and Innovation), an integrated supply chain company founded and owned by Mercy Health System, a 32-hospital system based in Chesterfield, Mo.
"There's a lot of marketing glitz from all the manufacturers, the latest and greatest tweaks to their devices. And there's not enough clinical evidence to show that it leads to better outcomes," he says.
For many health systems, "we end up believing sales representatives' pitches to the detriment of our cost position and so it's a never-ending struggle within providers to adopt technology at the right rate," Kirtser adds. "No one wants to retard the growth of technology if it truly has an impact on patient care."
A counterbalance to all this concern is the fact that the devices have improved dramatically, paving the way for procedures that have resulted in improved outcomes, with patients spending less time in the hospital.
Reimbursement challenges
Orthopedics has traditionally been a prosperous service line, and implants are a big part of that. There has been increasing demand for implants, but there are also reimbursement challenges, prompting hospitals to retool for greater efficiencies. An extensive American Academy of Orthopaedic Surgeons study published in December 2012 describes a "negative gap" in practice and operational costs compared to reimbursements that has "progressively worsened" over 18 years, from 1992 to 2010, the period that was reviewed.
An example, the report stated, included the reimbursements for total knee arthroplasty. In 1992, the national Medicare physician reimbursement rate for that orthopedic procedure was $2,100. By 2010, the reimbursement was $1,470. An "apples-to-apples" comparison through inflation, the report stated, showed the 2010 reimbursement was equivalent to $666.58 in 1992 dollars—a "drop of 68%," the report stated.
Hospitals themselves have a significant role to play in orthopedics costs. There is a "significant variation" across the country in how services are charged for a given inpatient stay, according to the Department of Health and Human Services. In a federal report released in May this year, the average inpatient charges a hospital may provide in connection with a joint replacement ranged from $5,300 for a hospital in Ada, Okla., to a high of $223,000 for a hospital in Monterey Park, Calif.
The wide range of implant costs also has fiscal impact within the healthcare organization. "The cost of a knee implant could range from $2,500 to $3,800 depending on the vendor," says William Martin, PharmD, administrative director for sourcing, purchasing, and value analysis at Beaumont Health based in Troy, Mich., which includes three hospitals. That's why hospitals should have physicians engaged in the process, and Martin consistently urges doctors in his organization: "You should be getting a good price mix."
Reimbursement concerns also can undercut innovation, Martin says. While Beaumont is trying to gain a niche for reverse shoulder replacement procedures because its staff includes a top specialist, the estimated $7,000 cost for the procedure is not reimbursed any differently than a less complicated $4,000 shoulder operation, he says. "CMS governs the amount of DRG [diagnosis-related group] payment. We don't get any more reimbursement for the reverse shoulder. That's a big challenge when you want to be on the leading edge of technology. A problem is that CMS reimbursement lags behind any new technology introduction. We end up paying a premium for innovation."
As orthopedic implant costs rise, hospital leaders are finding it essential to work more closely than ever with orthopedists to ensure that devices are purchased in a manner that reduces expenses, despite doctors' long-term personal preferences for certain devices, companies, or sales representatives.
"The demand for orthopedics is projected to climb at a significant rate, with the aging baby boomers," says Gary Botimer, MD, chairman of the department of orthopedic surgery at the 789-bed Loma Linda (Calif.) University Medical Center, part of Loma Linda University Health, which reported about $1.8 billion in net revenue in 2012. "The best way for hospitals to reduce costs is to follow what all other successful industries have done to provide products at affordable rates—elimination of unnecessary expenses in their processes."
Gaining physician trust isn't easy, and sometimes contentious relationships arise, but hospitals are making inroads by establishing programs that include physician leadership, negotiating discounts with implant vendors, and capitated pricing.
"One of the most important things is you want engagement and alignment of surgeons from the get-go," says Michael R. Jablonover, MD, MBA, FACP, president and CEO for the 144-licensed-bed University of Maryland Rehabilitation & Orthopaedic Institute in Woodland, just outside of Baltimore. He acknowledges the great variation in device expenditures, but emphasizes the need for multidisciplinary team approaches to properly evaluate them, including physician input. The institute is part of the University of Maryland Medical System, a 12-hospital system of academic, community, and specialty hospitals that reported $2.29 billion in net patient revenue in 2012. The hospital specializes in advanced rehabilitation services and orthopedics, such as joint replacement surgery.
As they evaluate medical devices, hospitals are weighing different options, ranging from restricting the number of implant devices considered and ranges of acceptable costs, says Fred McQueary, MD, an orthopedic surgeon, senior vice president of clinical integration for Mercy health system, and president of the system's Mercy Clinic–North Central Communities. Mercy health system has operating
revenue of $4.6 billion.
Mercy's supply chain company, ROi, plays a role in improving relationships and reducing costs for implant devices, McQueary says. "There is a huge benefit to make these chain links tighter."
Beaumont Health System developed an implant purchasing management program "to track our implants by patient, by product, and by physician, for any moment in time," says Martin. "I know by end of that day what is happening, and I don't have to wait a month for data."
Revision procedures are becoming more necessary with aging and replacement implants needing to be evaluated, says Alan Wilde Jr., vice president of system services for the 1,032-bed University Hospitals health system based in Cleveland.
"What's happening is the stuff we put into patients 10 or 15 years ago is wearing out. For patients who are still active in their 60s and 70s, the implants are wearing out," Wilde says.
Quality will be the ultimate determinant for orthopedic care, says Wilde. For patients, "it will be like going to a good mechanic or a bad mechanic."
By 2014, device companies will be required to collect data about payments, gifts, and other transfers of value they provide to physicians. It will give hospitals and physicians an added incentive to reduce conflicts of interest or the appearance of questionable relationships.
Success key No. 1: The team approach
When it comes to selecting medical devices, physicians often rely on their favorite vendors or tools. That can be costly for hospitals, many of which are trying to rein in docs through negotiations to lower costs. Physician engagement and responsibility is one of the most important aspects of reducing a hospital's medical device costs.
The Beaumont Health System involves physician leadership on teams who evaluate the costs of medical devices. By strictly monitoring physician relationships with vendors and eliminating devices deemed too expensive, the system reported a nearly 20% reduction—more than $6 million—from $35 million budgeted for implants, says Martin, the administrative director for sourcing and value purchasing.
Beaumont's value analysis teams are considered central components of the health system's work toward reducing costs and engaging in cooperative agreements with purchasing organizations. The group focuses on implants, especially for knees, hips, and spines.
Physician involvement has been a key component of the teams, says Martin. The VATs work with a group purchasing organization and vendors to eliminate items they do not want to buy, and to get the best price and quality for the items they will use. Team members include physician leaders and an administrative representative with supply expertise, management engineers, and an RN. An oversight committee for the shared savings program is headed by a CMO.
"How do you align physicians? We struggled with that at the beginning," Martin says. "For the physicians, we said, 'What's good for the hospital is good for you.' We knew we were asking them to make a change. The physicians have to support it; the physicians can't come back saying, 'This is the device I want to use.' "
The hospital spurred physician involvement by establishing a program where members of the orthopedics team would receive incentives under a shared savings program whenever they reduce costs for medical devices, says Martin. Over time, the hospital increased the amount of money that physicians could use for training, education, and clinical work once they achieved savings, he adds. Initially the shared savings program allotted 20% for physician projects, and later it increased it to 50%.
The shared savings program "has been a great way to provide incentives for the department," Martin says. "The strategy centers on reducing the number of vendors in the space and changing market shares."
Success key No. 2: Collaboration with other health systems
Large and small hospitals are coordinating their programs in an effort to reduce implant costs, especially those related to orthopedic surgeries.
A group of Northeast Ohio health systems formed a purchasing collaborative in 2011, Community Health Collaborative, to improve efficiency and effectiveness of care. In 2013, the health systems joined with University Hospitals and Premier, a large performance improvement alliance of more than 2,800 hospitals and 93,000 other healthcare sites, to form POWR, the Purchasing Organization of the Western Reserve. It focuses on managing costs of medical devices, and within a year University Hospitals saved nearly $1 million in spine implant and other medical device costs, says Wilde, the system services vice-president at University Hospitals. The reduced costs included $250,000 on physician preference items.
The larger collaborative enabled the smaller hospitals to obtain better prices on items because of the ability of the larger organization to expand its volume. "We didn't see a downside at all," says Wilde.
"University Hospitals benefits as well since aggregation often leads to better pricing for all because the additional volume drives better price points," Wilde says. "Cooperating in purchasing also can lead to our hospitals working together more closely in the clinical areas."
Further south, in Missouri, Mercy health system's for-profit supply chain management company, ROi, is run as a separate unit from Mercy and handles supply chain management for the system's acute care hospitals. ROi not only negotiates pricing directly with manufacturers but also purchases and distributes supplies from its own 100,000-square-foot consolidated service center in Springfield. Through its total joint program, ROi reported that it generated cost savings of 10% for Mercy.
ROi services include group contracting, clinical and operational consulting, pharmaceutical repacking, custom procedures and tray manufacturing, print operations, purchasing, and master item file management. The supply chain team, founded by Mercy, includes physicians and clinical researchers.
ROi enables providers to run an "integrated system" to control pricing through negotiations with commercial distributors, manufacturers, and consultants, says McQueary, the Mercy Clinic North Central Communities president. "Our philosophy is still to maintain a lot of choices [for implants], although some systems have taken the approach of limiting choices," he says. "We're not going down that road, but it remains a possibility."
ROi's CEO, Kirtser, says that he is hopeful that the emergence of accountable care organizations can help providers gain better control over purchasing of implant devices, in evaluation and quality. Too often, providers now face device costs that represent nearly 50% for sales and general administration, while only a small percentage, about 6%, accounts for research and development designed to improve devices, he says. "I think over time change will come and there will be comparative effectiveness in the near future," he says, to improve alignment of physicians to evaluate payment models.
In 2010, ROi/Mercy joined Geisinger (Danville, Pa.), Intermountain Healthcare (Salt Lake City), Kaiser Permanente (Oakland, Calif), and Mayo Clinic (Rochester, Minn.) to form the Healthcare Transformation Group; the members share best practices and collaborate on supply chain improvements, including strategies to reduce medical device costs.
Success key No. 3: Capping prices
Loma Linda University Medical Center is one of the hospitals capping prices in negotiations with vendors, a "hard-fought" move, says Botimer, the orthopedics department chair.
The hospital took that approach because it found that vendors would mark up prices on devices, such as prostheses, that would end up costing $1,000–$2,000 more than the hospital was willing to pay.
In one instance, a company charged the hospital $16,000 for a prosthesis that would usually cost $4,000, says Botimer. The company in question had paid royalties to an "outside surgeon" who had demanded the hospital use the vendor, he recalls. In another instance, the medical center purchased small pins at $400 each that were supposed to be reusable, and "suddenly became disposable." The hospital "caught the practice" and immediately halted it.
"We have discovered many techniques that some company representatives use to increase their charges to the hospital to get around the agreed-upon prices," Botimer says. "By taking back control of the process, we eliminate a lot of the gaming of the system that has been going on. We must all strive to be transparent."
Because the cost for orthopedic implants is increasing at a rate higher than other medical devices, it made sense to cap the prices, Botimer says. Hospital officials focus on the process, not the specific product.
"We just want to cut the waste out of the system," he says. By evaluating the devices and not strictly relying on vendor recommendations, the hospital finds it can "reduce the cost for the same product 50% to 60%," he says. The surgeons are then considering various devices instead of those recommended by vendors. The process "has helped the medical team become informed buyers," Botimer says.
Unlike some other health systems, Loma Linda physicians receive no financial incentives to be involved in controlling costs, Botimer says. "The reward comes in maintaining our commitment to patients to provide the highest-quality care with better accessibility," he says.
Beaumont also sets price caps and imposes rules on what devices it will purchase, often setting the stage for intense discussions with vendors.
"We're the No. 2 hospital in the United States for joint replacement volume, and I leverage that position," says Martin, the head of the health system's value-purchasing program. If vendors object, he says the message is clear: "If you want to play in this sandbox, this is what we're willing to pay for a knee joint. If you don't want to play, you are out."
At one point, Beaumont purchased spinal implants from 33 different vendors, and fewer than half—13—agreed to supply Beaumont under new price guidelines. Its value analysis teams reduced the vendor lists after requesting competitive bids.
The hospital excludes certain vendors who are not aligned with the program for as many as 90 days, which frustrates them and delivers incentives for them to become involved in the hospital pricing. "When you can't come back for a full quarter, that's very impactful" to vendors, Martin says.
While organizations such as Beaumont and Loma Linda are making inroads in cost reductions for purchases, health officials elsewhere are making a concerted effort to study why costs for implants and medical devices are so varied.
Success key No. 4: A cost-reduction journey
The 333-staffed-bed Jefferson Regional Medical Center often relied on its orthopedic surgeons to offer advice on what devices to use for total joint replacements or similar procedures. But the expenses mounted, so in 2010, the hospital decided to change its implant purchasing policies, says Larry Kennedy, CMRP, director of materials management.
The change was worth it, Kennedy says: The hospital saved more than $1.3 million in implant costs over a two-year period from 2010 to 2012 and saved $1.9 million from 2010 to 2013.
One of the first things that the hospital did was reduce the number of vendors with which it would negotiate and from which it would purchase items. Eventually, the hospital moved to single-source purchasing after the vendor agreed on a discount. Savings were seen quickly, particularly with total joints and orthopedic trauma devices, Kennedy says. Within the first year of the program, the hospital saved $661,000 for total joints.
Jefferson Regional Medical Center was able to negotiate the savings through a joint task force, particularly with involvement of its orthopedic surgeons, he says. At the outset, surgeons told hospital officials they focused on certain vendors.
"The physicians tell us point-blank: It's got to do with representation and relationships," Kennedy recalls. Hospital officials had a differing view: "A total knee is a total knee, a total hip is a total hip," he says, noting that the product and the quality are important, not the vendors specifically. "We tried the best approach to maximize contract savings."
Meeting with physicians, Kennedy and other hospital leaders involved in device purchasing outlined potential costs, savings, and quality outcomes. "We broke down each price component of the device for each physician; how many cases each physician did each year, who did the most knees, who did the most hips, the total cost per case. The physicians looked at the DRGs, the actual payouts over the past several years, and the margins."
Physicians appreciated what hospital leaders had recommended for the sole sourcing, Kennedy says. "The 100% sole sourcing offered the best amount of savings."
In the end, "it took some persuading. The [physicians] didn't want to do it; they didn't want to change," says Kennedy. "But they saw the value for the community and the hospital, and how much money it would mean for the hospital. We can't stress enough the need for partnership with the physicians. Overall, it's a tough journey, but we showed it can be done."
Reprint HLR1013-6
This article appears in the October issue of HealthLeaders magazine.
A program at VUMC is making significant inroads in helping physicians turn around their practices or behaviors after patients complain about them, either because of the doctors' actions or their clinical work.
If you are having trouble with your patients or not cutting it in clinical matters, you may get a visit from a "peer messenger." Often the news they bring isn't great.
And that's the idea.
Often, you don't have a clue you aren't passing muster, but the hospital has the data that shows you are not doing as well as you think. To help physicians get on track, The Center for Professional and Patient Advocacy at Vanderbilt University Medical Center in Nashville several years ago designed the "peer messengers" program.
The point is to keep physicians on track after patients complain about them, either because of the doctors' actions or their clinical work, before they become targeted for lawsuits. And the plan involves fellow physicians helping them. The messengers are physicians who you may see down the hall, in the cafeteria, or at board meetings.
"We don't come down on them with a ton of bricks, but we send a peer review team to say, 'Here's a heads up," says James W. Pichert, PhD, co-director of the medical center's Center for Patient and Professional Advocacy, which runs the peer messenger program. "This is holding up a mirror to the physicians, and it shows that 'this is your data of what you are doing.' It's not a gotcha. We always appeal to their great sense of professionalism."
Physicians who are named peer messengers are nominated by hospital leadership, undergo training, and represent various disciplines within the hospital. They interview and help counsel docs who are targets of patient complaints that may range from how they communicated with to how they were billed.
Generally, these doctors have not committed violations of their practice. In severe cases, where violations are alleged, lawyers likely would be involved. Instead, the docs that the peer messengers see have practices that are falling "outside the norm of expectations, or the norm of best practices," Pichert says. For the most part, these doctors "are absolutely unaware that they stand out in that way," he adds.
VUMC is finding that the peer messenger review process is making significant inroads in helping physicians turn around their practices or behaviors, Pichert says. A dozen other community and academic medical centers also are using a similar peer review process, he adds.
A four-year study which ended in 2005 evaluated 375 physicians deemed to be at "high-risk" for possible litigation. After peer messenger involvement, 64% of the targeted physicians had shown improvements in their work, Pichert and his colleagues report in The Joint Commission Journal on Quality and Patient Safety. About 19% of the physicians did not change their behavior, and 7% actually worsened, the report states.
In what Pichert called outright successes, 34% of physicians who met with the peer messengers for two years improved their "risk scores." The peer messenger's first visits averaged barely over a half hour, and follow up visits took less.
Overall, peer review is becoming an increasingly important element in determining physicians' conduct and helping them on the straight and narrow, whether it involves clinical quality or bedside manner.
Although the Centers for Medicare & Medicaid Services provides guidance for managing complaints and grievances about physicians, "the value of such reports lie in what the organization decides to do with information thus learned," Pichert says. And that's where the peer messenger review process helps fill the gap, he adds.
It's also important for hospitals to stem patient complaints especially because of the link between them and litigation related to malpractice lawsuits, Pichert says. "There's a high risk of complaints generated by patients that lead folks to go to a plaintiff attorney. Then there's an unexpected outcome and it may be unnecessary," he adds.
A main element of a peer messenger review program, of course, is the makeup and structure of the groups themselves, which are formally known as the Patient Complaints Monitoring Committees.
During the period of Pichert's study, about 178 physicians—14 emergency and medicine physicians, 87 medical generalists, or specialists and 77 surgeons—agreed to be peer messengers. One or more physicians may represent the committees in discussions with doctors being reviewed. Then the committees meet to discuss courses of action.
The Peer Messengers "Widely Respected"
When Vanderbilt looks for peer messenger review members, they look for standardized qualities: peer messenger members were identified as being "widely respected" and "known for their commitment to professionalism, confidentiality and fairness," Pichert says.
And when the peer messengers meet with physicians, they ask them why patients complained about them in the first place. In the Pichert review, at least 48% of the physicians attributed their "high-risk status" to patient complaints related to systems or logistics problems. About 41% blamed their personality or communication style.
The peer messengers tap into data about specific behaviors or clinical outcomes used by the university's Center for Patient and Professional Advocacy (CPPA). They schedule "confidential collegial visits" with identified physicians to share data about their standing, compared to local and national CPPA norms related to the complaints. Data is shared with targeted physicians in a 'respective, non-punitive, nonjudgmental, and nondirective fashion," Pichert wrote.
The peer messengers are "willing to intervene with colleagues over an extended period of time," Pichert says.
If anything, the peer messengers are told to avoid any tendency to be "fixers" of problems. If necessary, they initiate a process for additional hospital intervention if they don't make inroads in helping the physicians.
Success Factors
To improve physician clinical work and behavior, two elements are among the most important for success, Pichert says: hospital leadership and the doctors under review themselves.
"Overall success of an intervention process depends not only on peer willingness and skill to provide feedback but also on leaders who will hold others accountable," Pichert writes in the report.
Ultimately, Pichert told me, it is "self-regulation" among the physicians themselves that matters most.
Physicians encountering patients seeking oxycodone and other pain medications in the emergency department are using electronic medical records and prescription monitoring programs to identify doctor-shopping patients and to get them help.
An emergency department patient asks for a pain medication by name, saying he is allergic to other non-narcotic drugs. And the pain is so severe, the patient says, nothing else seems to work.
That scenario, usually a weekend occurrence, is among the red flags physicians should consider when facing one of the most pressing and continual healthcare issues: the doctor-shopping, drug-seeking patient, Scott Weiner, MD, MPH, FACEP, an emergency physician at Tufts Medical Center in Boston, MA, tells me.
Physicians have long tried to deal with the doctor-shopping phenomenon, often linked to patients seeking opioid analgesics, including morphine, oxycodone, and methadone, drugs associated with abuse.
Often, these patients go from physician to physician seeking drugs that can feed an addiction. But there have been few studies about patients who go to the Emergency Department for drugs once their doctors' offices are closed, or they are worried their personal docs may get suspicious.
For drug-seeking patients, overcrowded EDs may seem like easy targets because, in part, emergency physicians are dealing with so many matters that they may not be as attuned to potential manipulations.
Weiner evaluated doctor-shopping ED patients who had narcotic prescriptions from 10 or more providers in a year. These patients went to the doctors a lot. The average number of providers that the doctor-shoppers had seen in the previous year was 17, as opposed to 1.6 for those who aren't drug seekers, Weiner says.
In the abstract to an upcoming paper presented last weekend at the American College of Emergency Physicians Weiner acknowledges that in the ED, "recognition of patients that have aberrant drug-related behaviors is difficult" in part because physicians "do not have a high sensitivity or positive predictive value for detecting drug-seeking patients."
More than ever, physicians need to see through the differences, especially because the "Physicians might place too much weight on gestalt or stereotyping and need to rely on more objective criteria such as a patient requesting an opioid by name," Weiner wrote last July in the Annals of Emergency Medicine .
Drug-seeking behavior at the ED has been defined in various ways, he says, but includes patients who had seen at least 4 providers in 12 months before an ED evaluation. Drug overdose death rates in the U.S. have more than tripled since 1990, and "have never been higher," according to the Centers for Disease Control and Prevention. The misuse and abuse of prescription painkillers were responsible for more than 475,000 ED visits in 2009, a number that nearly doubled in five years.
"Treatment of pain is an essential responsibility of emergency practitioners," Weiner wrote in this month's AEM report. "However, many studies have demonstrated that pain is poorly controlled in the ED and for patients discharged from the ED with a painful condition."
The problem has been especially troublesome for those physicians in the ED who are seeing these patients for the first time. And sometimes, the situation doesn't seem clear-cut, Weiner says.
"You could be going to see your primary care doctor; you might be going to your orthopedic surgeon; you might be seeing a couple of residents; and you could easily have four or more prescriptions and more providers and get them legitimately," he says.
A flurry of abstracts of academic papers released last week at the American College of Emergency Physicians conference in Seattle, show the importance of electronic medical records to track drug-seeking patients and what's more, to get them help.
One of those successful programs is being developed in San Diego. There, University of California San Diego researchers found that patients who made more than two ED visits for alcohol, substance abuse, or psychiatric problems "were identified and flagged by electronic medical records, and placed in non-medical detox programs."
As a result, ED repeat visits were reduced from 137 or (5.27 per week) to 10 total visits or (1.67 visits per week) over a 6-month period, according to Alfred Joshua, MD, an emergency medicine specialist at the University of California, San Diego.
A major national effort to track drug-abusing patients has been carried out in individual state prescription monitoring programs, which collect, monitor and analyze prescribing and dispensing data submitted by pharmacies. About 42 states have PMPs that are operational, and seven more have pending legislation for such programs, according to the Alliance of States with Prescription Monitoring Programs.
Tracking is uneven, however, because different states don't cover all scheduled drugs. Still, the Prescription Monitoring Program has been effective for a hospital such as Tufts Medical Center, Weiner says.
"That has made a big difference," Weiner adds. "Now on a statewide basis, I can see where patients had their prescriptions filled. Before I had to use my own judgment. I would think, 'Oh, I think this guy is a drug seeker. No, I don't think this guy is a drug seeker.'' I could have been entirely wrong."
In fact, ED physicians do almost as well on their own as prescription monitoring programs.
Weiner reviewed 544 patient visits to emergency departments at two healthcare facilities in a year between June 2011 and June 2013. He compared the "emergency provider impression of drug-seeking behavior" and data from the Prescription Drug Monitoring Program. Generally, there was "fair agreement" between emergency providers' impression of drug-seeking behavior, and what was found in prescription drug monitoring program data, Weiner wrote.
Physicians are getting a good sense of who would be a drug-abuser or not. But the prescription monitoring programs have the data that helps in talking to patients, Weiner says. Supported by data, doctors can show proof of their drug-taking practices.
"It makes the patient aware that we are aware" of the drug-abusing potential he or she may have, Weiner says. "We can tell [a patient] 'you told me you didn't have these prescriptions, and the data base says you have 20. What's going on? That can start the screening and that can lead to interventions."
Still, it's unfortunate that the Prescription Monitoring is limited in the amount of data it can capture, Weiner says. Emergency department physicians are taking steps toward getting a handle on drug-abusing practices, but they are still far from where they want to be, Weiner says.
"We're at the stage of dealing with (the drug-abuse issue), just at the point of identifying the problem."
Beaumont Hospital in Royal Oak, Michigan has built a cardiovascular center of excellence. Physicians there collaborate with nurses to implement hospital processes and sets goals. And physician champions are named to help oversee quality goals and needs.
Whether it's in cardiovascular service or orthopedics care, healthcare leaders have no choice but to align their physicians with the day-to-day fabric of running their hospitals if they want to succeed. And they do want to succeed. Both are crucial growth areas for hospitals.
In fact, the heart and vascular and orthopedics service lines are among the top service lines expected to have strategic significance over the next two to five years, according to a HealthLeaders Media Intelligence report [PDF]. And what's the biggest challenge to achieve service line success overall? An estimated 61% of leaders say that physician alignment is number one, the report states.
A primer on putting together a successful physician alignment strategy came into focus for me earlier this week when I was at Beaumont Hospital in Royal Oak, Michigan, for a Health Leaders Media LIVE event on cardiovascular leadership.
Beaumont has built a cardiovascular center of excellence, on the bedrock of physician and administrator collaboration. Beaumont's panelists at our event, including two physicians in white coats who rushed in from the OR, focused on a team-theme: Physician-Led. Nurse-Partnered.
Before the discussion, I toured the Beaumont facility, from its oncology wing to its pediatric center. From a glass-enclosed room, I observed the hospital's 1,600-square foot hybrid/cath lab/operating room at the Suzanne & Herbert Tyner Center for Cardiovascular Interventions, where minimally invasive, yet complex heart procedures are performed.
When I arrived, a patient was being attended to by a dozen doctors, nurses, and other staff in the OR suite. Cardiovascular surgeons led the team. It appeared to be a comfortable and spacious setting. No elbows got in the way. As a group of doctors focused on the procedure, others checked medical devices, passed instruments back and forth, and scanned overhead monitors.
At one point, a staffer in the OR did a little dance, obviously a sign that everything was going well. That's a sign that things are in alignment.
Cardiology Alignment
The Beaumont OR team focuses on building improved outcomes and patient satisfaction. Physician leadership is designated for each of the hospital system's committees, hospital officials told me. Physicians collaborate with nurses to implement hospital processes and sets goals. And physician champions are named to help oversee quality goals and needs.
The doctors take good care of patients, but hospital leaders want them to go further, by taking the time to sit in patients' rooms and listen.
Marc Sakwa, MD, chief of cardiovascular surgery at Beaumont, and physician leader of Beaumont Health System's Heart and Vascular Center of Excellence, explained how the hospital leadership opened the door for direct physician involvement. "As the leaders, you will set the goals that you need in order for all of us to be successful," the hospital told physicians, Sakwa says.
Such processes don't stop at the cardiology suite.
Orthopedics Alignment
As I prepare for the HealthLeaders Oct. 16 webcast on physician involvement in orthopedic service lines, a common theme emerges with the cardiologists: aiming for physician alignment. The orthopedics service line, like cardiology, is a large and competitive service line, with the need for evidence-based strategies and team approaches in care.
The physician alignment ingredient is essential, for better collaboration and performance, but sometimes lacking in orthopedics, says James D. Holstine, DO, of the center for orthopedics and sports medicine at PeaceHealth and St. Joseph Medical Center in Bellingham, WA.
"For me, it's about relationships, alignments, trust, and transparency," says Holstine, one of the presenters for the upcoming webcast. Now, "I think there's less trust than there's ever been. It's not due to malcontent. It's poor communication because of the volume of change. I think the volume of information is so rapid and fast we don't have good information dissemination."
The other webcast panelist is Marshall Steele, MD, orthopedic surgery medical director of Stryker Performance Solutions. For 15 years, he was medical director of surgical business development and of the operating room at Anne Arundel Medical Center in Maryland. In 2005, Steele founded Marshall Steele & Associates.
Hospitals can establish their relationships with physicians through co-management agreements, establishing solid fiscal arrangements such as through bundled payments, and physician employment, he says.
Oh, and there's something else. Steele has been a big proponent of physicians being employed by one hospital, and not working at competing facilities.
If physicians are aligned with one hospital, they can improve quality of care, he says.
A HealthLeaders Media webcast, Orthopedics Service Line Success: Physician Engagement, Efficiency and Quality, is scheduled for October 16, 2013 from 1:00 to 2:30 p.m. ET. Speakers are Marshall Steele, MD, orthopedic surgery medical director for Stryker Performance Solutions, and James D. Holstine, DO, of the Center for Orthopedics and Sports Medicine, PeaceHealth St. Joseph Medical Center, Bellingham, WA.
A group of Florida physicians opts to skip the golf course and instead, climbs an 11,000-foot mountain range to get away from healthcare. In the process, the doctors learn to work together and hone their leadership skills "under a carpet of stars."
In what Herdley Paolini, PhD, LP, PSS, the facilitator of Florida Hospital's Labor Day weekend camping trip called a "leadership development retreat," 10 doctors took 15 hours of continuing medical education while hiking 30 miles in the woods and mountains at Flat Tops in Colorado, about 200 miles due west from Boulder.
At one point, they had to trudge seven miles while running low on potable water. Some of them had never camped before. No computers, cell phones, or electronic devices were allowed on the trip. Pen and paper were allowed.
The physicians learned to depend on each other. "Just seeing the bonds that developed was great," Paolini told me. "With doctors, sometimes there's this conspiracy of silence and nobody talks about things. Here, the resolve was great," Paolini says. "They were empowered and worked together, under a carpet of stars."
Paolini heads Florida Hospital's Physician Support Services in Orlando, FL, which sponsors several retreats every year for doctors. Paolini ran the program with co-facilitator Burt Bertram, EdD, LMFT, LMHC.
The doctors—all part of the Florida Hospital system—talked about healthcare against a beautiful natural backdrop. Do they have enough time for their patients? Are they fulfilling their expectations as part of a multidisciplinary team? After the camping trip, one participant wrote to Paolini: "I learned new ways to better myself, and improve my leadership skills, like deep listening and self-reflection."
Once they returned to their practices or the hospital, there were other more sobering realities waiting for them, like taking care of sick patients. But the Florida Hospital effort was a way of getting people together, and of emphasizing teamwork, for a group of medical providers who often rely too much on themselves, and don't reach out in a meaningful way, Paolini says.
Indeed, the alignment of physicians, as a team or especially with hospitals where they work or are employed, is challenging, and critical in healthcare, with the demands of evolving regulations, reimbursement cutbacks and the move toward value-based purchasing.
Months before the Florida doctors' long weekend camping trip, at a hotel in Nashville, TN, a separate group of hospital and healthcare executives got together at a HealthLeaders Media Roundtable where the need for improved coordination among hospitals and physicians also came into focus. The panelists emphasized the importance of forming clinically integrated networks, with physician collaboration or involvement with hospital leadership essential.
"Whenever you are going into a clinically integrated network, that means partnership," said panelist Humayun Khan, MD, CMO for St. Joseph's Hospital and Sacred Heart Hospital, of the Hospital Sisters Health System in Western Wisconsin Division, in Eau Claire, WI. "Physician groups have typically been quite autonomous. Now to come into a partnership and try to meet certain goals is suffocating for many physician groups that we are dealing with."
The Hospital Sisters Health System has a large, independent physician organization, Khan says, that is on a path of building a clinical integration network. "I think this strategy is going to (help) us, not only with the care provided within the community, but also when we go into contracts with third parties," Khan said.
Having an employment model was important toward developing a medical staff and ensuring significant savings, observed another panelist, Rand Wortman, President & CEO of the Kadlec Health System in Richland, WA. Still, six years after putting together a team of 100 employed physicians, "We're still struggling with how do you put it together? How do you build the culture?" Wortman asked.
Not only do physicians have responsibilities in developing a proper culture environment, but so do hospitals, Wortman said. "I'm adamant that my team has to deal with physicians with respect," Wortman said. "Frankly, not all hospital systems do. Part of it is consistency in how the administration behaves or the institution behaves." Of doctors, he said, "When you deceive them, they never forget."
Two other panelists addressed the need to develop physician leadership abilities, and the fact that doctors have to work more closely with hospital administrators.
Physicians will not only have to get along with one another and their superiors, but more likely there will be a need to have better frameworks of care with mid-level providers, to fill more gaps in the system. "So that is definitely an area that I think will continue to be a problem," said Jordan Asher, MD, CMO and CIO of MissionPoint Health Partners in Nashville.
"It's absolutely critical as we go forward with whatever alignment strategies are, that we enable our physicians to be leaders," said Oliver Rogers, president of hospital-based services for TeamHealth in Knoxville, TN. "How do we jump-start the leadership skills for these physicians, because we don't have time for them to learn by the school of hard knocks? I think that emphasis on formal leadership training is going to be critical to this process of alignment."
Developing physician leadership seems to be one of the most difficult and important aspects of evolving care post healthcare reform, and is essential for clinical integration. I asked Carson F. Dye, co-author of the book, Developing Physician Leaders for Successful Clinical Integration about his feelings on the issue. There are many definitions of clinical integration, Dye wrote, but a "common theme emerges; quality improvement facilitated by physician engagement and leadership."
Dye sees clinical integration as a salvation of healthcare systems, citing a need for both physicians and hospitals to share in their work, technologically and clinically.
Physicians must get comfortable being partners with a hospital, especially about the business of number crunching. "While there are several elements that support successful clinical integration efforts, perhaps the most important one is the willingness of physicians to share quality data and consider the metrics that support quality improvement," Dye told me.
"Of course, this presumes a strong clinical data system and high integrity of data," Dye adds. Sharing the data "goes to the heart of the professional practice," he says.
Those healthcare organizations that have successfully improved their clinical integration practices are definitely willing to involve physicians "to a much greater degree in decision-making and operations," Dye says.
"On the flip side, the biggest failure at this time is organizations that do not see the physician as having a true place at the table in strategy and decisions," Dye says. "But without that full level of physician involvement, clinical integration efforts will be doomed from the start."
Whatever it takes. Sometimes, docs need to find their way as team players outside their offices, and go to the mountain – whether it's the Rockies or somewhere else.
As Paolini tells it, the physicians on her trip experienced "leadership education from the inside out," and ultimately, it "forced us to rely on each other."
Pain represents a growing patient concern and a flourishing service line for healthcare. Hospitals are creating pain management centers with a focus on chronic and acute pain, relying on interventional and multidisciplinary procedures targeting long-term pain.
This article appears in the September issue of HealthLeaders magazine.
Physical pain is beginning to define America. Back pain. Knee pain. Spinal disorders. Headaches. Arthritis. Shingles. Migraines. Pain can be here today, gone tomorrow, or a constant presence, gnawing, clawing, endless. Whether sporadic or chronic, pain prompts patients to move from physician to physician, hospital to hospital, seeking the elixir, the magic cure, the one last surgery, even for some tentative relief.
In fact, pain is the most common reason patients visit doctors, hospitals, and health systems. The pain condition is so ingrained that it is dubbed the fifth vital sign by medical professionals.
As such, pain represents a flourishing patient market for healthcare. Hospitals are creating pain management centers with a focus on chronic and acute pain, relying on interventional and multidisciplinary procedures targeting long-term pain.
Pain impacts more Americans than diabetes, heart disease, and cancer combined, and costs the nation up to $635 billion each year in medical treatment and lost productivity, according to a 2011 Institute of Medicine report brief. Hospitals are responding to the booming pain market by focusing on various aspects of care. For hospitals, a key strategy is structuring their pain programs, from evaluating acute and chronic pain, to providing psychological evaluation if needed and patient education.
Hospitals also recognize the need to improve pain management outcomes to improve patient satisfaction scores on the Hospital Consumer Assessment of Healthcare Providers and Systems survey. The HCAHPS survey, which is linked to CMS payments, asks patients about pain management.
Patient pain management is a "big part of patient satisfaction," says Thomas A. Mathew, MD, an internal medicine physician and hospitalist at the 1,100-licensed-bed Christiana Care Health System in Wilmington, Del., which has seen significant growth the past two years in pain management.
For years, its pain management program was part of its palliative care program, but the growth in patients who presented with pain as a complaint prompted the system to create a multidisciplinary team specializing in pain care, including anesthesiologists and interventional radiologists, Mathew says. Over time, pain management has overtaken palliative care.
The 1,158-licensed-bed Barnes-Jewish Hospital in St. Louis expanded the size of its Washington University Pain Management Center from 5,000 to 10,000 square feet to accommodate a growing patient population. In the meantime, it restructured its pain program into two areas, concentrating on chronic and cancer pain in the one area and acute perioperative pain in the other. The Pain Management Center is part of the hospital's Center for Advanced Medicine, and it includes outpatient and inpatient programs.
"We recently moved to a larger facility because of a growing need, with more and more patients to be seen and procedures to be done. You compare year-to-year and month-to-month, and those numbers are going up steadily," says Michael Bottros, MD, director of acute pain service at Barnes-Jewish Hospital and assistant professor of anesthesiology at the Washington University Pain Management Center. "We are seeing a variety of patients, from those with head and neck pain to low back pain to postsurgical pain."
The organization intends to offer pain care for a multitude of service lines. "If you improve patient management, you also indirectly improve everything else," Bottros says. "It has a rippling effect. With service lines such as oncology or surgery, pain is a factor in all of them. It's a common underlying feature. We are ensuring that appropriate pain care paths are developed for the patient based on the condition and the type of surgery they've had."
At the 907-bed Massachusetts General Hospital in Boston, the number of pain patients has increased steadily, from 600 per month in 2007 to more than 1,000 this year. At least 70% are seeking treatment for spine-related pain: chronic low back pain, spinal stenosis, and herniated disks, says Chris Gilligan, MD, MBA, director of the center for pain medicine at MGH. As many as 30% of the patients are treated for other pain conditions, such as musculoskeletal pain, arthritis, shingles, and cancer-related conditions.
With increasing numbers of patients needing pain care, MGH has tried to make treatment more efficient, Gilligan says. For instance, back pain patients are admitted to the hospital's emergency department observation unit instead of an inpatient floor, as had been done previously. Consequently, patient length of stay in the hospital has been reduced, he adds.
"In the observation unit, we perform pain service consults in a very timely fashion," Gilligan says. "If we need imaging and/or injection, they happen quickly and we can reduce length of stay substantially compared to regular hospital admission."
Hospital pain treatment centers are becoming more prominent, especially since many general practitioners are reluctant to become involved in pain management because of their concerns about increased law enforcement scrutiny and widespread misuse of prescription drugs, says Tiffany Meert, chief operating officer of the Northern Nevada Medical Center, a 55-staffed-bed facility in Sparks, Nev. Those concerns have prompted the hospital to become involved in a partnership with a physician group to oversee pain management, she says.
Accidental drug overdoses that result in deaths have been rampant across the country. "It's a huge problem," says Gilligan of MGH
Mathew, the Christiana Care physician, says it is essential for healthcare leadership to overcome obstacles like potential drug overdoses to improve pain management. Pain care itself is "one of the biggest opportunities for improvement in medicine in healthcare, and the place where we just don't have adequate rules in the game because everybody's perception of pain is different and what the
expectations are."
Success key No. 1: Dealing with prescription drugs
Arnold Feldman, MD, a longtime interventional pain specialist in Baton Rouge, La., didn't want to be associated with the word pain. Indeed, he removed the word from his practice sign several years ago and replaced it simply with "The Feldman Institute." While he continues to treat patients afflicted with pain, specializing in interventional pain management outpatient procedures, he wants to distance his practice from less scrupulous providers.
Law enforcement, especially the U.S. Drug Enforcement Administration, is increasingly scrutinizing physicians because of so-called drug or pill mills, physician practices that overprescribe powerful drugs that are linked to the abuse of painkillers. Opioid analgesics—including morphine, oxycodone, and methadone—are among the prescription drugs most often linked to abuse.
Drug overdose death rates in the United States have more than tripled since 1990, "and have never been higher," according to the Centers for Disease Control and Prevention. Nearly three in four prescription drug overdoses are caused by opioid pain relievers, the CDC states. The misuse and abuse of prescription painkillers was responsible for more than 475,000 ED visits in 2009, a number that nearly doubled in five years.
"[Law enforcement] are scrutinizing doctors like crazy," Feldman says. "We don't want to be associated with drug or narcotics mills." Law enforcement's focus has prompted many primary care physicians to shy away from prescribing pain pills at all. "Family doctors used to treat people with pain," he explains. "They will not anymore. One of the reasons is poor education about opioids and the fear of government scrutiny and prosecution."
Hospitals, too, are specifically organizing pain treatment programs not only to relieve pain but also to coordinate care that thwarts potential abuses. The American Medical Association has called for a multidisciplinary clinical approach to the treatment of chronic pain with a focus on responsible prescribing of opioids. Physicians, hospitals, and health systems also are touting nondrug therapies and integrative approaches to treat pain without narcotics.
The government has taken steps to assist hospitals in overcoming problems with opioids. The Joint Commission, for instance, issued a Sentinel Event Alert that urges hospitals to take specific steps to prevent serious complications or even deaths from opioids. A growing number of states are enacting policies that promote the delivery of effective pain management, according to an American Cancer Society Action Network report.
Pain treatment programs are focusing on medication reconciliation as a key element in helping to improve treatment of patients and combat overprescribing of drugs. Such programs are often linked to sophisticated electronic medical records that keep tabs on patient usage of drugs and physician prescribing.
"We have made a huge effort in our center the past several years to have our medication reconciliation be more effective," says Gilligan of MGH. Under the protocol, patients are evaluated and educated about the impact of their medications. The dosages and the responses are registered in medical records. The medical record indicates what medication is appropriate and what interventions are needed.
"Every single time, someone goes over what medications [patients] are taking, what those medications do, and this is done even before the doctor sees them, and [the doctor] again goes over it all," Gilligan says. As they leave the hospital, patients review a summary report. The physicians are monitored, too. If a physician makes a mistake related to the dosage ordered, "the EMR triggers a response. It isn't perfect, but it greatly reduces the chances for errors."
General practitioners and nurses aren't the only team members involved in medication reconciliation, Gilligan says. "If a patient has behavioral or mental health issues, and not just the chronic pain, there are people on staff to deal with that—psychologists and psychiatrists. The psychiatrists have additional training in pain and substance abuse." Neurologists also are included in the pain unit, he says.
Barnes-Jewish Hospital routinely updates prescribers, interns, residents, and nurse practitioners in the hospital about patients' medications, especially for those patients transferred from one area of the hospital to another. With its medical record, the hospital's pain management center coordinates medication the patients take in the home and hospital.
Barnes-Jewish Hospital also implemented the Pasero Opioid-induced Sedation Scale to improve assessment of opioid medication administration in non-ICU inpatient nursing units. "A lot of us are moving away from opioids as a frontline therapy," says Bottros. "We have a system-based approach."
Physicians in pain management programs are increasingly striking a balance between ordering proper medications and trying to ward off potential drug abuses, the American Cancer Society Action Network has found.
"Keeping the patients' perspective and needs in focus is extremely important in prescribing painkillers," says David Woodmansee, associate director for state and local campaigns for the American Cancer Society Cancer Action Network. "That is the essence of balance."
Success key No. 2: Treating children's pain
While many hospitals are launching programs primarily to help adult patients cope with pain, others are focusing on children, especially cancer patients. A major concern is that younger children may have trouble communicating the extent of their pain, making diagnosis and treatment difficult. And, too often, physicians and hospitals lack expertise in providing proper medication and integrative or nonpharmacological therapies for children in pain, says Stefan Friedrichsdorf, MD, medical director of pain medicine, palliative care, and integrative medicine at the 381-staffed-bed Children's Hospitals and Clinics of Minnesota in Minneapolis.
An independent, not-for-profit healthcare system, Children's of Minnesota provides care through more than 12,000 children inpatient visits and more than 300,000 emergency room and other outpatient clinic visits every year. By establishing a specific pain management program, the hospital
has added protocols that have resulted in improved outcomes and reduced length of stay for its patients, says Friedrichsdorf. The multidisciplinary team includes physicians, nurses, social workers, psychologists, and massage therapists. The pain management program has increased its volume of patients in each of the past several years, from a total of 1,117 children seen in 2008 to 1,440 in 2012.
Focusing on patient management has resulted in savings and reduced lengths of stay. One of the most significant efforts was establishing an advanced analgesia-sedation protocol for babies and children who had undergone open heart surgery. In pediatric circles, it is known that pediatric sedation requires a balance between risk and procedures. Studies have shown that the demand for procedural sedation for diagnostic and therapeutic procedures is increasing.
Hospitals must establish proper protocols to provide safe and high-quality sedation. The Minneapolis analgesia-sedation protocol has resulted in reduced length of stay from eight to seven days, and it intubated children four hours earlier, despite the fact that the children were considered generally "sicker" from their cardio scores, according to Friedrichsdorf.
In the cardiovascular ICU, process improvements also meant workflow changes, he adds. Adjustments were made to team roundings, such as the requirement that twice each day—from 7 a.m. to 8 a.m. and again from 4:30 p.m. to 5:30 p.m.—a team nurse, respiratory therapist, intensivist, cardiologist, cardiac surgeon, pharmacist, and pain physician round on every patient. If a rounding occurs at a cardiac ICU, a cardiac intensivist is involved.
The hospital's readmission rate within seven days, for any condition, was as low as 3.5% from January to December of 2012, which is notable when compared to 24 other children's hospitals, the lowest of which had a readmission rate of 4.1%, according to the Pediatric Health Information System, a database operated by the Alexandria, Va.–based Children's Hospital Association. Generally, Children's of Minnesota has "sent their patients home faster and that drives up satisfaction for the patients and their parents," Friedrichsdorf says.
Managing children's pain at hospitals across the country has been erratic, in part because of uncertainty among physicians in providing proper doses of medication for pain, says Friedrichsdorf. By not incorporating multidisciplinary teams to focus on children's pain needs, hospitals are coming up short for children, especially for those with acute chronic pain, he adds.
"Most children's hospitals are not even implementing the basic principles of acute or chronic pain management," he says. Among the places where these principles should be applied are in children with acute pain, postoperative pain, and cancer pain, after open-heart surgery and orthopedic procedures, and for chronic pain, such as abdominal and musculoskeletal pain.
"Children with cancer pain, they probably receive too little medication, and pediatric patients with chronic pain and headaches probably get too much," Friedrichsdorf says. "It's quite easy to prescribe strong medication and say, 'I'll see you in two weeks.' These kids need physical therapy and normalized lives. We extubate the children when they are admitted to our hospital and they receive advanced pain management. This is a business model that hospital leadership can get behind."
Success key No. 3: Comanaging pain
A pain management specialist looked around the Nevada desert and noticed it lacked more than water: There weren't many pain doctors around.
"Over the past few years, there has been only one pain management doctor for every 10,000 patients who come in for pain treatment," observes Denis Patterson, DO, now medical director of Northern Nevada Medical Center's Pain Management Center. "There's definitely a need for pain management, a huge need really, and pain management is very much underutilized in the community."
Patterson and his physician group were eager to establish protocols in a niche market, especially for patients who were clamoring for lower back pain care. The doctors reached a comanagement agreement with Northern Nevada Medical Center. Both physicians and hospital representatives comprise the leadership team that oversees pain management programs at the hospital's Pain Management Center.
"At the Pain Management Center, our goal is to return patients to a maximum level of functioning and independence by identifying the source pain and using advanced techniques to reduce the level of pain and suffering," says Patterson.
For the Northern Nevada Medical Center, teaming up with the physicians group was a good fit. The hospital was known in the community for its orthopedics program and had launched an outpatient rehabilitation and sports medicine unit, "which has been a fast-growing program," explains Meert, the hospital's COO. "Opening a pain management center was a natural fit for our continuum of care and for the population we serve," she says.
The comanagement program allows the hospital to have "highly respected, fellowship-trained pain management physicians at Nevada Advanced Pain Specialist to comanage quality outcomes and indicators as well as program enhancement and efficiency," Meert says. The hospital "invested capital" in the pain management program, especially with added imaging equipment and surgical staff. Within a year, the hospital began to recoup its investment by especially focusing on patients with lower back pain, she says, adding that "so many patients were in need." It was important that the hospital focus on "enhanced quality," Meert says. "It's a constant state of education."
More than 50% of patients report having knee pain, and when combining that statistic with those reporting low back and neck pain, that represents 85% of patients, according to Patterson. The hospital's pain management program is comanaged by the Northern Nevada Medical Center and a physicians group, the Reno-based Nevada Advanced Pain Specialists, which specializes in stroke, knee replacement, hip replacement, and spine surgery. The program received the Joint Commission's Gold Seal of Approval for low back pain.
At the Pain Management Center, patients undergo an evaluation that may include x-rays, magnetic resonance imaging scans, or nerve studies to find the specific disk, nerve root, joint, or tendon causing pain. After a physician identifies the source of pain, he or she may use image-guided techniques to deliver steroids, burn nerve endings, or perform other targeted therapies at the precise area causing pain.
The physicians group initiated the working relationship with the hospital after seeing the great need for pain care in the Sparks and Reno area of Nevada, say Meert and Patterson. Too often, primary care physicians lack knowledge about pain management, Patterson says. "Part of what we do is educating primary care doctors what patient management is, and that what we are trying to do is in the best interest of the patient."
With the comanagement arrangement, the hospital expanded staff, particularly surgery and imaging. Like other pain management programs, the staff includes therapists and acupuncturists. Physicians have increased referrals for patient care, Patterson says. The message to physicians is: "If it hurts, send them." Once patients are examined, "that allows us to triage them, work up a program, and see what's happening."
For both the hospital and the physicians, it's a good working relationship that allows for more patients into the program and reciprocal incentives for the medical group, Patterson says. The hospital reduces overhead costs for physicians, who bring patients to the facility. "It's nice," he says. "It lowers my overhead and they have a center where we can see patients. In return, we do a lot of cases at the hospital, and the hospital gets a facility fee. They make a profit in the end, and they have supplies for us."
The comanagement program involves leadership from both the physicians group and the hospital, Patterson says. It includes the physician partners and the hospital's CFO and CEO. "It's a win-win situation in the sense [that this is] an underutilized field," he says.
Success key No. 4: Pain management satisfaction
At Massachusetts General Hospital, daily meetings include physicians and administrative staff who review data and results from HCAHPS surveys, which score how patients say the hospital managed their pain. How often was the patient's pain well controlled during the hospital stay? Did the staff do everything they could to help patients with their pain?
MGH officials believe the hospital hasn't scored quite as well as it should, says Gilligan, the pain management director, even though the patients' perception about the hospital's level of care surrounding pain issues is consistently at or above the state average. "I think we score consistently low on that," he says. Most recently, in a survey of 300 patients from 2011 to 2012, 72% of patients reported that the pain was well controlled, which is comparable to the state average of 72%, and above the national average of 71%, according to Hospital Compare.
Gilligan says the hospital would score much higher if it weren't "very conservative with using narcotics for noncancer pain." Some patients say the hospital "doesn't listen to me" when they ask for more powerful drugs, he says. Still, the hospital's pain management center maintains its conservative approach.
Other hospital officials acknowledge that they, too, would get better satisfaction scores if they catered more to patients' requests for more drugs to relieve their pain. "To get great patient outcome scores, a lot of patients might say, 'Give me more drugs,' right?" notes Patterson of the Northern Nevada Medical Center. "It's a juggling act. I want to make sure the patients who are coming in are not just doctor shopping or trying to get drugs," he adds.
"That's a hard part of pain management. Could I get better patient satisfaction scores if I gave more opioids?" Patterson asks, perhaps rhetorically. "But after all, at the end of the day, I've got to do what's medically appropriate; I've got to sleep at night."
At the hospital, Patterson says, "I think we have a reputation as the strictest in town. The 'drug-seeking patients,' they'll come in for easy meds. They say, 'No offense, you're too strict. I'll go somewhere else.' " He tells the patients, "Hey, good luck. Let me help you out the door."
Hospital procedures themselves cause pain. Each year, hospitals perform about 10 million inpatient surgeries and 17 million outpatient surgeries, all of which require pain management.
So how does a hospital improve its patient satisfaction scores when it comes to pain management? Within the past year, Barnes-Jewish Hospital has made inroads in patient satisfaction score improvements through changed protocols, especially involving anesthesiologists in a revised process of care, says Bottros.
It is important that pain management is developed for the appropriate pain condition and the type of surgery a patient has had. The hospital has made "simple" rather than drastic changes to improve patient satisfaction scores, Bottros says. Barnes-Jewish Hospital has anesthesiologists in a leadership role in pain management, which has been important for postoperative care and postoperative pain control.
"There's a growing trend for anesthesiologists to show their worth as perioperative physicians, not just in the operating room but in preoperative assessment and planning. It is using anesthesiologists in a more robust fashion," Bottros says.
The hospital focuses on consistent pain management, implementing a multidisciplinary team focus, with an emphasis on communication and proper protocols. For instance, the team consistently paces the use of epidurals for pain associated with surgeries, and acetaminophen is used, not just the
narcotics. It's important that the nursing staff consistently communicates with patients about their pain, and that message is directed to physicians.
The Barnes-Jewish Hospital has found ways to improve patient satisfaction scores dealing with pain. "In a very short time, the scores have increased robustly," Bottros says. In scores from patients who had gynecological surgery, patient satisfaction scores improved from 67% to 85% in two months in early 2013, he says.
Bottros noted that pain is sometimes difficult to control following surgery in orthopedics cases, such as knee replacement or hip pain. Yet those patient satisfaction scores also increased, from 55% to 83% for knee surgery, and 78% to 94% for hip surgery from September 2012 to April 2013.
Among colorectal surgical patients, for instance, patient satisfaction scores increased from 66% to 83.3% within the same six-month period, he says. "The only thing we changed is that we made sure the care path includes epidurals for perioperative pain, as well as other adjutant therapies."
In another area, knee replacement—where hospitals often have had difficulty achieving good scores among patients following surgery—the hospital's pain satisfaction scores jumped significantly from 55.4% to 83.3% from September 2012 to April 2013.
Because the reported improved patient satisfaction scores covered only a short period of time, Bottros concedes it's not a large, long-term sample. But he says the increased scores reflect the hospital's inroads into pain management and relief for patients.
"We try to ensure that we don't just stick to one particular technique," especially for postoperative pain management, he says. "For some surgeries, like abdominal, we use epidurals in combination with adjuvant medications such as IV acetaminophen or ketorolac, a nonsteroid anti-inflammatory drug," he adds. "For other surgeries, we use IV PCA [intravenous patient-controlled analgesia] in combination with adjuvant medications such as acetaminophen."
Patient attitudes about how hospitals control their pain is impacted by their perception of how the staff listens to them and cares about how they feel, with communication a key, Bottros says.
"I think in today's society, patients are a little less stoic than they might have been in the 1950s. Today people are more open to discussing their pain. Today patients are a lot more vocal about their problems and more vocal about their complaints," he says.
"If you improve pain management, you are also indirectly improving other aspects of patient satisfaction," Bottros says. "If a patient is happy with pain control, it does impact other scores as well."
Years ago, physicians were taught that pain control was "a symptom of some underlying disease, and as pain becomes more and more prevalent, and more chronic, that pain becomes a disease in itself," Bottros says. "We have started thinking outside the box a little bit, stopped trying to search for that elusive Pandora's Box, and now we're trying to accommodate patients."
Reprint HLR0913-8
This article appears in the September issue of HealthLeaders magazine.
Physician compensation will increasingly include incentives, but the transition may be more of an evolution than a revolution. Meanwhile, primary care doctors may continue to get a "bump up" in salaries.
The discussion at a recent hospital compensation committee meeting focused on dwindling physician salaries, recalls Jim Otto, senior principal for the Hay Group consulting firm that works with healthcare officials on physician payment. Before they finished the meeting, a hospital official asked: "Who's going to tell these physicians that they are not going to make as much in the coming years as they had?"
Nobody jumped to volunteer, that's for sure.
While physicians' total pay will still increase this year, the percentage salary growth will be lower than in previous years, says Otto, of the Philadelphia-based Hay Group, referring to the organization's 2013 Physician compensation prevalence and planning report. At least 50 physician groups and hospitals participated in the survey, conducted in March, which covered 132 specialties.
Overall, there has been a "slowdown in pay increases" for specialists, but a "bump up" for primary care physicians, Otto says. That reflects the general demand for primary care and federal reimbursement enhancements for generalists, he adds.
In the meantime, "there may be more emphasis for incentive payouts" in the years ahead, Otto says. Generally, incentive pay has been pegged at 10% to 15% of base salaries annually.
Although annual incentive plans for physicians were being used in 63% of physician group and hospital settings in 2013, compared to 64% in 2012, Otto predicts that the future holds a growing emphasis on incentive payouts in income negotiations.
"We expect an evolution, not a revolution, in incentive plan design for physicians in coming years," Otto added in a statement. "Providers are looking to translate their organizational goals in a more tangible way that will drive the desired behaviors and outcomes they want to achieve."
Generally, physicians across all organizations expect median salary increases of 2.4% in 2014, compared to actual increases of 2.5% in 2012 and 2.7% in 2011, according to the survey. The Hay Group is still calculating the 2013 increase, but that was projected at 2.6%.
Physicians in group-based practices in 2014 expect pay increases of 3.7%, compared to doctors in hospital-based settings, whose average increases are projected at 2.2%. Within the past year, the median percentage increases in physician salaries ranged from a low of 2% to a high of 5%, with much of that dependent on productivity and performance, according to the survey.
Primary care physicians can expect slightly higher salary increases than specialists in 2014, particularly in hospital-based settings. While primary care physicians and specialists in hospital settings each received 2.3% pay increases in 2012–2013, primary care physicians at hospitals are budgeted for 2.6% increases in 2014, while specialists at hospitals are scheduled for 2.3% budgeted increases, according to the Hay report.
"If you were to look at the [physician pay] environment 10 years ago, going into medical school, primary care was not something you were encouraged to do, certainly for economic reasons," Otto says. "The money was in specialties. At that point CMS started to [ramp] up reimbursement to encourage primary care. I think that's been reflected in the pay levels over the past several years.
"But there's still a big delta gap between what primary care is paid and specialists. Will that gap ever close? I'd be surprised if it did," Otto says. "Specialists will continue to be paid more than primary care, but I think with the emphasis on primary care in the context of all going on in healthcare, you may be starting to see pay increases overall, perhaps at a rate higher and faster than we've been seeing."
Incentive Payouts
Incentive plan designs have been "typically married to production, meaning, 'I'll pay you a base salary if you are hitting the production number,'" Otto explains. But measurement of quality outcomes and patient satisfaction is on the rise, he says.
"What I'm seeing is employers, hospitals, and healthcare systems using their incentive plans for physicians in a way that gets to process results or outcomes that are supporting what they are trying to do throughout their systems," Otto says. "The incentive plan designs are really to encourage behaviors that are consistent [with] not only what they expect of a physician practice but how it fits within a system."
"We're moving into a world, at least in theory, where [physicians are told] 'I'm not going to pay you because you are just doing things,' but practices and systems want to do the right things and hit quality outcomes," Otto adds. "Over the next five years, I can see us moving from fee-for-service to global capitation or some other structure and pay for quality, and not pay for something like three MRIs."
Still, "we aren't all there yet," Otto says.
That's reflected in the Hay Group report on salaries, which states: "Among physician group practices and hospital-based facilities, the majority of physicians' pay increases are determined individually, based on productivity and performance."
Overall, however, incentive payouts are beginning to reflect the move toward quality and patient satisfaction, Otto says.
In the Hay Group report, 71% of pediatric practices reported incentive payouts in 2013, and 54% of primary care physicians. Other specialties were at 50% at minimum.
Of the incentive payouts, most involved bonuses or recruiting incentives (28%); administrative differentials (23%); and on-call differentials, relocation packages, or tuition reimbursement (each 16%). Administrative differentials refer to the rate of pay to doctors for interim administrative responsibilities beyond the scope of their normal positions. On-call differentials refer to pay for doctors on a standby status.
For individual physician performance, the percentage of organizations that linked at least some of their incentives to quality increased to 86% in 2013, compared to 77% in 2012; and for patient satisfaction, it was 70% in 2013, compared to 66% in 2012.
Group performance metrics in physician incentive plans also showed similar payment related to quality and patient satisfaction in their incentive plan metrics. About 69% of those organizations linked payment to quality in 2013, compared to 56% in 2012; and 60% in patient satisfaction in 2013, compared to 50% in 2012.
Physicians are facing obstacles as they move toward improved quality and a "growing list of new demands" that include learning new EHR systems for new cost and business models, Otto says, adding that these trends influence how employers want to address compensation increases.
Designing incentive plan packages may be difficult, Otto says. Pay plans may involve complicated clinical structures such as ensuring vaccinations in pediatric practices or treating adult diabetic patients. They may result in measurements of not only long-term processes of care, but also outcomes. "It's a big challenge everyone is facing, with outcomes-based performance measures," he says.
Overshadowing incentives for physicians is the question of declining reimbursements and overall revenues.
"Among the issues coming down the pike is, 'How do you not only sustain current salaries, yet provide for increases?,'" Otto says. "I don't know the answer."
Should a hospital's top-ranking doc maintain a license to practice medicine? One hospital system with facilities in Florida says it is often "inadvisable" for a practicing physician to be a CMO.
Editor’s note: The original column stated that Dr. Leighton Smith's lack of a medical license at Northwest Community Hospital prompted him to resign. HealthLeaders Media retracts that assertion, and the article has been amended.
Physicians must commit considerable effort to secure and maintain a license to practice medicine, but not every physician leader does so, nor is required to do so. For example, Leighton B. Smith, MD, does not have a license to practice medicine but serves as chief medical officer at 156-bed Florida Hospital DeLand and at the nearby 175-bed Florida Hospital Fish Memorial in Orange City. Florida Hospital is part of the Adventist Health System.
A Florida Hospital spokeswoman, Lindsay Rew, confirmed that Smith was named the hospitals' new CMO in March and said Florida Hospital officials had no problem with him taking the job, knew about his background, and added that it is "often inadvisable" for a CMO to be active on the medical staff.
Rew says Florida Hospital officials have confidence in Smith. She released a statement saying that Smith is an "accomplished physician executive with more than 25 years of leadership experience, both in hospitals and medical education environments." Smith's experience includes serving as CMO at Northwest Community Hospital in Chicago for eight years, also without a license to practice.
While the value of a medical license is clear—the American Medical Association has stated that "members of the medical profession should always remember that the business of medical licensing boards is to protect the public from unqualified and unfit physicians"—should that also apply to physicians in the C-suite?
"The position of CMO is an administrative role and does not directly provide any patient care," says Rew, emphasizing the lack of importance of a practicing physician in the post.
"In fact, in order to gain a better perspective on how to improve the quality of care within a hospital, it is often inadvisable for a CMO to be an active member of the medical staff."
As hospitals weigh filling CMO positions, many believe the post has greater weight and complexity in the healthcare reform era. The role's mission is to improve not only clinical care but organizations' business portfolios. Children's National Medical Center in Washington, D.C., earlier this year namedjoint chief medical officers, both practicing physicians, to handle what its leaders termed the "complexities of the evolving healthcare landscape."
With such complexities comes the growing importance of hospital-physician alignment. Many organizations are finding value in placing practicing physicians in leadership positions, in part to improve relationships by sharing that first-hand clinical experience.
As for the two Florida hospitals, they have full confidence in Smith as their CMO. In his role, Smith "will work to continually strengthen the relationships between physicians, clinicians, and nonclinicians," spokeswoman Rew says.
The ability to do the job could be enhanced, however, if those relationships included a common bond based on a shared clinical experience.