The task of identifying and grooming physician leaders for C-suite posts is complex. A physician may wield a surgical instrument with precision, but could lack the compassion needed to win loyalty from staff and trust from patients. In the post-healthcare reform era, physician leaders who show emotional and clinical strength will be a valuable commodity.
Some health systems are cultivating physician leaders by encouraging empathy, beginning in medical school. This week, a program called, SELECT (Scholarly, Excellence, Leadership, Experiences Collaboration Training Program) was launched in Tampa, FL. It focuses on leadership training and development for medical students, with a specific emphasis on compassion and patient-centered care, elements often missing from science-focused medical school programs.
Students will spend two years studying at University of South Florida Health followed by two years of training at its partner in SELECT, the Lehigh Valley Health Network in Allentown, PA, to complete their medical degrees. At least 19 students were selected for SELECT. Another 48 will be picked in the next academic year.
They were chosen not only because of their academic credentials, but for what school officials termed their high level of emotional intelligence, with a hope that they can be "catalysts for change."
"We really think this is an idea whose time has come," said Alicia Monroe, vice dean of educational affairs who leads USF's undergraduate medical education program. "There's a need to redesign medical education to prepare physicians to cope with 21st century complexities. That means working in teams and to embrace the importance of the patient-centered experience. There has been a resistance for what we have all known is the key in the provider/patient relationship. The patient needs to be the center of healthcare."
USF Health worked with the Teleos Leadership Institute in Elkins Park, PA, to interview and assess students' emotional intelligence for the program. Students were asked about significant moments in their lives, for example, and how they responded, and what they learned.
Besides emphasis on teamwork, the students will focus on quality improvement and patient safety "more than regular medical students are trained," said Robert Brooks, MD, MA, MBA, MPH, a former secretary of health for the state of Florida and currently associate vice president for health leadership at USF.
Such instruction over a four-year period along with the regular medical school teaching lays the groundwork for students eyeing potential leadership positions in their careers, he said.
Brooks said, a "truism" holds that it's "technical skills that generally get someone into the C-suite, but it's the lack of emotional intelligence that gets them out."
"You read these horror stories about some CEOs and whether they did something inappropriate or problematic," he says "We shake our heads and realize that a reasonable amount of self-awareness, of relational understandings, would have helped address these problems."
"Whatever particular specialty or type of career these students may go into, whatever role they choose to play as part of the healthcare industry, we believe these tools will show integrated learning over four years, and with a focus on emotional intelligence, will make them better suited for success."
During the first 36 hours of instruction this week, the discussions at USF Health focused on students' interpersonal experiences beyond their clinical knowledge, says Kanchi Batra, 23, a student with SELECT who graduated last year from Northwestern University in Chicago with a major in biology
"There already has been a lot of reflection," Batra says of the initial classes. The other day the students and physician faculty discussed what she called a "lifeline exercise."
"They said, 'tell us what you are proud of; what helped you along; what were your obstacles.' Physician leaders talked about their own issues along with the students," she says. "There was the sense of trust among us."
Batra knew at an early age that she wanted to be a physician. During her freshman year at Northwestern, she "shadowed" a doctor for several months. "It opened my eyes about the daily rigors and stresses," she says.
Batra says she's looking forward to future studies, and sees the SELECT program and her part in it as emblematic of "what the public needs and what the public wants."
"They aren't looking for someone who only has the technical skills to treat heart disease, but someone who can respond to what a patient needs in an empathetic way," she says.
The EMRs (electronic medical records) bugged him worst of all. Throw in the stress of dealing with patients, procedures, even family life, and he was cranky. Steven Feeney, MD, admits he was not a terrific guy to work with.
Feeney, 55, an internist at Johnson Memorial Hospital system in tiny Dawson, MN, also didn't realize he was becoming something of an archetype: the disruptive physician.
Through much of the past year, "things were getting frustrating for both me and the other physicians; different problems were affecting us," Feeney recalls. "We had our own frustrations with the level of work, the relations with administration, and also very big frustrations with the new EMR system. The stresses and strains were telling in our lives." says Feeney.
Feeney mentioned various 'frustrations" three times in two sentences. Like many physicians feeling angst, he had been for a while, and had been acting out those frustrations on others. Feeney grumbled or spoke out more than he thinks he should have, but other physicians have behaved worse – yelling, name calling, tossing things and hurting colleagues.
Those incidents are spelled out in a white paper on "Disruptive Physician Behavior," from the American College of Physician Executives and QuantiaMD. The report tallied 70% of 840 physician leaders who said disruptive behavior occurs at least once a month at their organizations, and more than 10% say such incidents occur daily. At least 77% physician executives say they are concerned about disruptive behavior.
Most alarming: 99% say that disruptive behavior affects patient care.
Physician disruption at his hospital mostly manifested itself in doctor relationships with nurses, Feeney says. It was typically triggered by "a culmination of a series of problems that occurred before" someone lost their temper.
Feeney says he's seen outbursts at the hospital where physicians, in his words, were "acting like four-year-olds," he among them. "There have been times where I've had to deal with these individuals (causing disruptive problems), and sometimes I've had to deal with myself," Feeney says. "That behavior is not tolerated and will not be tolerated in the future. We can't bury our heads in the sand."
Experts say physician disruption issues start in medical school. "Combating this phenomenon is an uphill battle," Barry Silbaugh, MD, MS, FACPE, CEO of American College of Physician Executives wrote in a foreword to the organization's report. "For many of us, this is behavior we learned from abusive instructors in medical school. The constant stress, long hours, and bureaucratic quagmires inherent in health care serve to exacerbate the situation. It's not getting any easier in this era of reform, where the rules seem to shift from day to day and the financial rewards may be shrinking."
Still, too many physicians still don't recognize that "heal thyself" applies to them.
Alan Rosenstein, MD, medical director of Physician Wellness Services, Minneapolis, MN, which advises physicians dealing with stress and burnout issues, says there haven't been enough advances in dealing with physician misbehavior issues.
"If you look at the results in the current ACP (report), it's exactly the same kind of results we were seeing in other studies in 2000, 2005, 2008 and 2010," Rosenstein says.
"We've got to promote a safe patient environment," he says. "Until we address the human behavior issues, we're never going to get to the point where we need to be. This issue is still difficult for organizations to address, particularly the physician behavioral issue. Many organizations are taking this to heart and a lot of people are trying to prevent bad things from happening."
Silbaugh says disruptive physician behavior is an issue that won't go away. "Despite the best efforts of many, our profession is still plagued by doctors acting in a way that is disrespectful, unprofessional, and toxic in the workplace," he says.
Feeney and officials at Johnson Memorial Hospital want to banish disruptive physician behavior, although they admit it's a challenge. They have been discussing stress and burnout with Physician Wellness Services. Feeney concedes he was apprehensive when the sessions began several months ago.
"We're all trained to help others and when we have to help ourselves, we think we're not supposed to have these problems," Feeney says. "That ego problem, a lot of time, is fed by inner doubt. How everybody wants everything perfect all the time."
The hospital administration and physicians are working diligently to change behaviors and "I'm seeing responsiveness on the part of physicians and administration that wasn't there before," he adds.
"You need to let go of the things that bothered you in the past, they are done, they are over with and you move on," Feeney says. "I asked myself, how can I look at things different, how can I act differently?" he asks.
Since confronting his own disruptive demons, Feeney says he's seeing positive changes, in his own behavior, a step forward.
About those EMRs? "Doing electronic prescriptions, I thought at first it was a hassle and too much work," he says. Now, he adds with a slight laugh, "I love it. I change the prescriptions with it. It works well."
Industry-sponsored research that paid millions of dollars for some physicians touting a bone growth product used in spinal fusion surgery has left other doctors flabbergasted. Their diagnosis: trouble.
Eugene J. Carragee, MD, editor-in-chief of The Spine Journal was one of those flummoxed by the resultant studies that he and his co-editors vehemently assert failed to mention potential problems with the product.
As Carragee notes, spine care involves a small circle of physicians. He's had dinner with some of the physicians he is now sharply criticizing and has attended conferences with them. The circle is now broken.
"This is not a big community," Carragee told HealthLeaders Media. "I know all of them by sight, and probably [have]had dinner with them. They are charming people, great dinner companions, with a lot of energy and good surgical skills, but that's not what we are talking about here."
Carragee, who won a Purple Heart for his military service in Iraq, acknowledges he's not one to shy away from controversy. He's now involved in one that's not going to go away soon.
An orthopedic surgeon with the Stanford University School of Medicine, Carragee and a team of experts wrote a scathing analysis last month in The Spine Journal debunking reports written by physicians who made millions of dollars from a device manufacturer that found no complications with its bone growth product.
The Spine Journal is the scientific, peer review journal of the North American Spine Society, comprised of more than 6,200 members.
While the physician reviewers found no problems with Medtronic's Infuse product, The Spine Journal team said it uncovered plenty, characterizing the other physicians' reports as misleading and biased. Medtronic, the nation's largest maker of medical devices, is being scrutinized over promoting Infuse, a bioengineered material used mostly in spinal fusions. The company estimates that Infuse is used in about one quarter of the more than 400,000 spinal fusions performed in the U.S. annually.
Specifically, The Spine Journal report contradicts early industry-sponsored clinical research on rhBMP-2, a controversial synthetic bone growth product often used in spine fusion surgeries. That research reported no adverse or complications involving hundreds of patients over 10 years.
But The Spine Journal, in a series of reports comprising the June issue, asserts that the use of rhBMP-2 has been associated with various early inflammatory reactions, cancer, infections, implant dislodgement, and occasionally life-threatening complications. The dispute underscores what Carragee says is the search for "transparency" in a tangled web of money and potential conflicts involving physicians and device manufacturers, with patient care in the balance. Those issues are at the core of multiple federal investigations into what the five physician authors wrote in The Spine Journal as "biased and corrupted research" that reflect special interests and are potentially harmful to patients.
Meanwhile, the physicians who have been criticized by Carragee and his team have denounced the The Spine Journal reports, blasting them as inaccurate. An official of Medtronic did not respond to a HealthLeaders Media request for comment, but the company's chairman and CEO, Omar Ishrak, issued a statement that "integrity and patient safety are my highest priorities," according to The New York Times.
Recently, there have been a back-and-forth series of letters – and attacks – that is nothing short of astounding. These aren't politicians. These are physicians. The media has described The Spine Journal's across-the-bow commentaries as unprecedented, but Carragee says he and his colleagues are just doing what they have to do. He has an easygoing demeanor and laughs a lot. He wants to right what he perceives as wrongs.
Carragee says The Spine Journal anticipates publishing more reports on clinical trials in an effort to improve "transparency in medical reviews published in journals that he says is long overdue.
A few years ago, Medtronic received approval to use Infuse for bone growth use in what Carragee called a "narrow indication" from the Food and Drug Administration. Since then, "there has been an explosion of use off-label," Carragee says. "There weren't complications listed in multiple papers from the industry. That was a red flag; that was not credible," he adds.
"By 2009, we started looking at it. We certainly weren't the only people thinking something pretty weird was going on," Carragee says.
The Senate Finance Committee has begun investigating whether Medtronic's large payments to physicians played a role in the lack of reporting complications. Senate Finance Committee chairman Sen. Max Baucus, (D-MT), and senior committee member Rep. Chuck Grassley, (R-IA), have asked the medical device manufacturer to "produce documents related to its controversial bone growth product Infuse," the committee stated. The committee raised concerns in a letter sent to Medronic "over recent media reports that indicate medical researchers in charge of Infuse clinical trials may have been area of and failed to report evidence that the product may cause sterility in men and potentially-harmful growth." The letter notes "many of these investigators had substantial ties to the device manufacturer."
The product, officially called Infuse Bone Graft, represents about $700 million in annual sales for Medtronic. The Justice Department opened an inquiry into the off-label use of Infuse in 2008, according to The Wall Street Journal. Carragee says he's given the Senate Finance Committee "some documents ahead of (publication)," adding, "There are a lot of papers in the pipeline."
Investigators and the media are scrutinizing physician relationships with Medtronic, The Wall Street Journal further reported. Over the past decade, 15 surgeons have collectively received $62 million from the medical device company, for unrelated work, based on an analysis of Medtronic documents and financial disclosures.
Thomas Zdeblick, director of the University of Wisconsin-Madison Spine Center and professor and chairman of the Department of Orthopedics & Rehabilitation in Madison, is one of the physicians who allegedly wrote studies supporting Infuse without characterizing its potential detrimental impacts, according to The Spine Journal. He did not respond to a HealthLeaders Media e-mail.
In a response letter to the publication, Zdeblick wrote that The Spine Journal's criticisms were "Inappropriate and irresponsible."
"Although interesting, a single publication in the medical literature does not constitute a 'truth," Zdeblick wrote.
Referring to Carragee's overseas stint in the military, he described his "18-month" hiatus as impacting his style as a surgeon. "I am concerned not only with the validity of the conclusions drawn but also with the tone of the commentary chosen to accompany the article," Zdeblick added.
Carragee and his colleagues responded to Zdeblick in a letter, writing that the physician made "unwarranted personal and professional attacks."
''The old saying is 'follow the money' and in this case, there is plenty to follow," Carragee and his co-authors wrote. Carragee wrote that Zdeblick had a "$23 million financial relationship" with Medtronic that has been the "subject of a publicly documented investigation by Sen. Charles Grassley (R-IA)." Zdeblick also receives "millions of royalty dollars" from a tapered fusion device product sold separate from the Infuse Bone Graft, but must be used together with the product, they wrote.
"If a guy has done good work and discovered great things and gets royalties for it, he should get paid for whatever the market bears," Carragee says. "The question is: should he be writing the basic seminal paper on it as well. Or maybe he should be writing a white paper for the company."
"I think we have to separate advertising copy from scientific articles," he adds. "If you want to write advertising copy, plenty of people will have a section for it."
Carragee criticized the lack of proper procedures in documenting disclosures and other areas that could reveal potential conflicts of interest. The Spine Journal also is changing its disclosure requirements for its top staff, he says.
The journal has taken steps to restructure its editorial process ensuring divestiture and disclosure of potential conflicts.
"If we want people to be transparent, we ought to be transparent," he says.
In the wake of healthcare reform, Mark Newton, CEO of Swedish Covenant Hospital, in Chicago, IL, points out in HealthLeaders Media's June intelligence report, Better Care and the Bottom Line, that the country's mental health delivery system is "close to fracture."
For the American public, the January 8 shooting of Rep. Gabrielle Giffords, (D-AZ) and the killing of six people at a Safeway supermarket in Phoenix, where she was meeting constituents, focused attention on the mental health system in Arizona and elsewhere in the states. Her alleged shooter, a 22-year-old college dropout, was declared by a federal judge incompetent to stand trial. Mental health experts say he suffers from schizophrenia.
Community-based mental health service providers are reducing services, and relying more on hospitals to provide psychiatric care. The National Alliance of Mental Illness (NAMI) notes in a statement that economic conditions in the U.S. have "dramatically impacted an already inadequate public mental health system." From 2009 to 2011, "massive cuts" to non-Medicaid state mental health spending totaled nearly $1.6 billion, with deeper cuts anticipated through next year, which also impacts community and hospital-based psychiatric care and patient access to medication, according to NAMI.
Newton says dealing with mental health is among the "deeper, more fundamental issues" at play for healthcare leaders as they address other issues, such as accountable care organizations, physician integration, and overall planning for healthcare facilities.
"We see a lot of mental health issues involved with patients coming through the emergency rooms, and then there are co-existing conditions as well," Newton told me. "I actually think that mental health is underplayed."
Adding to the debate, a study reported in Health Affairsshows that mentally ill people may face "barriers" to receiving elective surgical procedures as a result of societal stigma and the cognitive, behavioral and interpersonal deficits associated with mental illness. Some of those barriers include the attitudes of the treating physicians, Yue Li, an assistant professor in the Department of Internal Medicine at the University of Iowa in Iowa City told me the other day.
Those disparities, he says, could be linked to communication difficulties as well as negative attitudes on the part of the physicians. So when medical issues revolve around people with mental illness who have physical conditions, patients can be shortchanged in the process. Li and his colleagues write in Health Affairs that mentally ill people are up to 70% less likely than others to receive high cost surgeries like hip and joint replacements, pacemakers, and other organ transplants, which often require referrals from physicians
As a result, Li says these patients are at a "heightened risk" for developing medical morbidities such as coronary heart disease, compared to other patients. In addition, mentally ill patients may have poorer outcomes following treatment of their medical conditions.
As Li sees it, the mental issues often conflict with the physical issues, and sometimes physicians have trouble ensuring that the mental aspect of care is fully covered.
The actual "presence of mental and behavioral abnormalities could complicate the physicians' referring decisions by distracting attention away" from the physical issues, Li writes. And that has a snowball effect, leading to a "negative attitude on the part of the referring physician," he says.
Patients afflicted with mental illness also may have their communication efforts thwarted, in part, by their mental condition. "Mentally ill patients may be less able than others to communicate proactively with the physicians," Li and his colleagues wrote. "Accordingly, they may be less able to assert their preferences for more aggressive surgical treatment when they do wish to go that route. Taken together, these factors could place patients with coexisting mental illnesses at a disadvantage when their doctors are deciding what type of treatment to recommend."
Such conditions, as Li notes in the study, have an impact on healthcare systems, related to longer length of stays, worse post-operative outcomes and more frequent 30-day readmissions, as well as higher risk of short and long term mortality, all issues that healthcare reform is trying to address. Among the mental health diagnoses includes schizophrenia, other psychosis, major depression, bipolar disorder, substance abuse and post-traumatic stress disorder.
As the aging population continues to grow, the number of older people with psychiatric and substance abuse disorders is projected to double in the next decade. Mental illness is prevalent among the Medicare population. About 26% of Americans aged 65 or older have a major psychiatric condition such as depression or anxiety and more than 1.7 million have an active substance abuse disorder.
Li notes that other studies have shown that mentally patients with coronary heart disease may also face barriers in receiving diagnostic catherization and revascularization procedures.
"Physicians in general practice have to pay increased attention to mental health issues," says Li.
Hospital systems, as well as physicians, also must address the evolving economics in mental healthcare. As an example, the Stormont-Vail West Hospital, in Topeka, KS, recently began to try to fill the void created by the closure of two psychiatric hospitals in the area. "When I think about the future of psychiatric care, I'm worried because of the budget cuts to community mental health centers," Julie DeJean, administrative director for behavioral health services at Stormont-Val Health Care, told the Topeka Capital Journal. "We could end up taking care of patients who don't have services anywhere else."
Some hospital systems are taking steps to improve psychiatric care within their buildings. The Mineral Area Regional Behavioral Health Center in Farmington, MO, has initiated a geriatric unit and adult unit under a new behavioral health center for improved psychiatric treatment in the community.
Co-existing conditions wrapped around mental health issues of patients are among the crucial problems healthcare systems face as they embark on healthcare reform, according to Newton.
"I don't think (mental health)" is on the healthcare radar across much of the country, says Newton. "It's a perplexing issue. It is something difficult to diagnose, a little amorphous. When someone has diabetes, you look at the glucose levels. There is no quantitative assessment for mental health."
"I just think people tend to forget that mental health conditions are often co-existent with other problems, and the country's healthcare system does not easily accommodate the treatment of mental illness," Newton says.
When it comes to drug abuse in America, particularly prescription drug abuse, you get the sense America is on one Long Day's Journey into Night.
In 2006, I was a spectator in a Congressional hearing room in Washington D.C., as a mother pleaded for lawmakers' action regarding prescription drug abuse after her college age son died. It was July 27, 2006 – five years ago, almost to the day -- as I sit in my office typing these words.
During that hearing, the chairman of the subcommittee on criminal justice, drug policy and human resources talked about a problem of "epidemic proportions."
Today, the non-medical use or abuse of prescription drugs is the fastest-growing drug problem in the U.S., according to the White House Office of Drug Control Policy.
Indeed, there is a lot of determined talk in Washington D.C. Still, the prescription drug abuse problem continues, unrelentingly. As for any issue involving medication, physicians are on the front lines. If someone gains weight, they admonish people to cut out the cake. If someone smokes, some doctors order their patients: Stop now. (Not enough, probably).
But in discussions with patients who may be potentially abusing drugs, including prescription drugs, doctors appear reticent, and reluctant to press too hard on the issue. At least that's what top officials of the National Institute of Drug Abuse tell me.
The idea is for physicians to get a handle on the massive prescription abuse problem facing the country by digging deep into which medications patients really need, and which ones they don't. To help physicians, federal officials are tapping into the dramatic arts to get the point across about the problems of substance abuse.
Over the last several months, the National Institute on Drug Abuse (NIDA) has been conducting workshops that include a dramatic reading of Act III of Eugene O'Neill's Long Day's Journey into Night, to prompt discussions how to incorporate screening and interventions in substance abuse treatment, as well as talk about addicted patients in primary care settings.
They are also exploring the role of individual biases and beliefs about people who abuse drugs and how these beliefs affect physicians in screening and treatment of patients.
The project is part of NIDA's educational outreach to practicing physicians, physicians in training or other health professions. The NIH also has handed out toolkits and informed physicians about possible dialogue with patients under its Addiction Performance Project.
The Addiction Performance Project, a free continuing education program, offers providers the opportunity to gain compassion and understanding for patients. The programs, usually linked with other medical meetings, have attracted more than 1,000 people in Boston, Phoenix, and Washington D.C. this year. Shows are scheduled through 2012.
Gaya Dowling, PhD, deputy chief, science policy branch for the NIDA, says the lack of physician questioning about the drug issue with patients is puzzling, but not surprising.
"A major priority for us is engaging the medical community in screening for substance abuse," says Dowling. "We think it's a problem that affects a lot of people. A lot of those people aren't going to seek treatment on their own, but they are going to see their doctor. Physicians are really in a unique position to identify people who have substance abuse problems or may potentially develop them, but physicians don't routinely ask about substance abuse."
There are a number of immediate reasons why physicians aren't engaged in that dialogue, she says. "They don't have time, don't know what to ask, and are not comfortable with the issue. So we are taking a multipronged approach to address those." Showing the piece of Long Day's Journey into Night and subsequent discussions are among the "unique ways of addressing the physician who says: I don't feel comfortable with talking about this issue," Dowling says.
Also, NIDA's Addiction Performance Project "is a creative way for doctors to earn (continuing medical education) credit while raising the stigma issue associated with drug addiction," she says.
As NIDA officials tell it, a fraction of people who need specialty treatment for drug or alcohol addiction receive it each year. In 2009, more than 23 million people aged 12 or older needed such treatment for drug or alcohol problems. An overwhelming number – about 21 million – didn't get the help they needed. .
A lot can be done, though, to promote reduced alcohol and tobacco use. For instance, NIDA reports say that a growing body of literature also cites the benefits of screening and intervention for illicit or non-medical prescription drug use.
"We've been wrestling with physicians handling the prescription drug abuse issue," Dowling says, "and I think physicians have been wrestling with it." Physicians must confront the issues of "overprescribing or being duped into prescribing for someone who is drug seeking," Dowling says.
"Every physician is going to ask: what medication is the patient on?" Dowling asks. "If the patient is showing signs of drug abuse, there's a way to open the dialogue."
Dowling blames the lack of medical school training for physician failure to penetrate drug abuse. "It's not taught well in medical schools," she says. (Physicians) don't feel comfortable addressing it. Physicians have such a huge burden on them, how much they have to do in a short period of time, and they don't know if they have the tools to address it."
To improve the system, the NIH is working to "get substance abuse questions incorporated into electronic health records to make it easier to address the issue," Dowling says. "This wouldn't be accusatory, [but] something the physicians asks routinely of his patients," she said. In addition, NIH is working with centers of excellence to develop curricula to help train physicians regarding substance abuse.
A Long Day's Journey into Night is a powerful play, with Act III "completely surrounding the matriarch addicted to morphine, the family dynamics with alcohol abuse," says Dowling.
Dramatic readings spur debate and emotion. And real life testimony in the halls of Congress about a woman's loss of her son touches the soul. Both send home the message: physicians need to take action to stop drug abuse, prescription or otherwise.
A few months ago, while researching an article about women's cardiac care for this month's issue of HealthLeaders Media magazine, I kept hearing female physicians telling me that male doctors don't always pick up the fact that their female patients may have a cardiac issue because often no pain is reported.
Certainly, we're not talking about a majority of physicians, but there are still some out there who treat women differently in cardiac care, and not in a good way. There is not only a great need for women patients to learn more about heart issues, and the differences with men in that regard, as well as some physicians themselves.
Cardiac disease is a top killer of women, but too often patients don't know how important their symptoms are, and aren't conveying them properly to doctors. While chest pain, for instance, may be a telling sign of a heart problem for men, the symptoms for women may be more subtle, such as jaw pain or simply feeling sluggish.
If we are going to learn more and be more instructive about women's heart health, there need to be more clinical trials in the pipeline for women. As of now, there are still too few women enrolled in cardiovascular-related clinical trials.
That is disturbing.
Physicians, many of them female, are prodding hospitals to do a better job in improving cardiac outcomes for women, through education programs, as well as reaching out to their colleagues to recognize the potential warning signs or symptoms of heart disease in women versus men. The lack of awareness often results in less aggressive treatment by healthcare providers for women and that has to change.
"Most women who died from heart attacks never had chest pains in the manner in which men often report chest pains prior to a heart attack," says C. Jennifer Dankle, DO, the vascular specialist who supervises the University of Minnesota Physicians Heart at Fairview Southdale Hospital's women's clinic in Edina, MN. "The idea is to raise awareness among hospital staff as well as patients themselves that the presentations for a possible heart condition is different for men and women.
A 2006 survey conducted by the American Heart Association found that 43% of women are unaware that heart disease is the leading cause of death among women. Among primary care physicians, only 8% knew that more women than men die each year from cardiovascular disease, according to the AHA.
There are other disparities. Although women of color and of low socioeconomic status are disproportionately affected by heart disease, according to the AHA, only 31% of black women and 29% of Hispanic women knew that heart disease was their greatest health risk, compared to 68% of white women.
Recently, Dankle tells me she has been working more to get the word out to providers and patients alike about women's cardiac issues. In February, Fairview Southdale Hospital hosted its "first annual" Women's Cardiology Care Conference – Matters of the Heart," which Dankle says was "very well attended and received by community providers"
"We continue to host several patient educational events to reach out to the community and increase awareness of heart disease in women," she says. "I am starting a women's support group for perimenopausal women who suffer a heart attack or are diagnosed with heart disease."
Such programs are important because "this particular group of women has been shown to have the lowest rate of followup care – cardiac rehab – which has proven effectiveness in reducing the recurrence rate of cardiovascular disease," Dankle says.
"I believe part of the reason for this is lack of support" Dankle said the other day. "I have so many young women that have suffered heart disease, tell me they felt 'out of place' at cardiac rehab because they were the youngest attending. I want these women to understand they are not alone."
One of the problems in healthcare is the relatively small number of women included in clinical trials about cardiac disease, which would increase understanding of cardiac care for women.
Rebecca Ortega, director of Women In Innovations, a Washington DC-based program launched by the Society for Cardiovascular Angiography and Interventions to educate interventional cardiology community about heart disease in women, says women account for only 30% of patients enrolled in most cardiovascular disease trials. That percentage should be about 40%, she says.
A WIN study also cites data that shows differential treatment between men and women. For instance, when showing heart attack symptoms, women are often less likely than men to have an electrocardiogram done within 10 minutes, to be cared for by a cardiologist during their inpatient admission, or to be given heparin or another medication, according to WIN.
"We don't have a lot of data with men vs. women when it comes to these various cardiovascular issues," Ortega says. There are complications to be overcome in the clinical trial process, she says. For instance, when women exhibit pain related to heart conditions in their jaws or exhibit fatigue, "by then their (heart) condition may be further along and they will not be eligible for enrollment" in a clinical trial, Ortega says. In addition, some women may be more reluctant to be enrolled in clinical trials than men, Ortega says. "From where I'm sitting, it's a multipronged problem and there's no one solution."
One of the ways to improve care has been through legislation, says Dankle.
Senators Debbie Stabenow, D-MI, and Lisa Murkowski, R-AK, have reintroduced a measure that would, among other things, require the Department of Health and Human Services to submit an annual report to Congress on the quality and access of care for women with cardiovascular disease.
That, says Dankle, is a beginning toward resolving the inequities of cardiovascular care for women. Still, there is a long way to go.
At this point, the matter of physician owned distributorships is another Washington D.C. tale of political intrigue. Whether it becomes spine-tingling remains to be seen.
The Senate Finance Committee is looking into PODs, signaling what may be an all-out government assault on the highly controversial practice, with questions about the role of physicians and medical device chains, and opposing high powered law firms in the fray and big-buck physicians as big targets.
Or it may fall flat.
""It is a complicated issue,"" the committee states. No kidding.
The issue is churning in the wake of a Senate Finance committee report issued last week, Physician-Owned Distributors: An Overview of Key Issues and Potential Areas for Congressional Oversight. The report says that under PODs physicians act as middlemen between manufacturers and hospitals or surgical facilities, in lieu of manufacturer representatives.
The committee noted, for example, that there was a marked increase in spinal fusion surgery with the expansion of PODs, and it cited examples of patients put at risk. The suggestion is that physicians are exerting undue influence.
I've spoken to both sides of the debate. POD critics say growing numbers of physicians are improperly making big money in spine and total joint replacements, and are branching out to other areas such as cardiac implants, pacemakers, and defibrillators with their questionable links to device manufacturers. Patients are paying the price, critics say, in a practice that "smells to high heaven."
POD proponents lash back, saying what they are doing improves hospital and physician alignment, and undermines the big profits of device makers and "is threatening to a very powerful industry."
"It makes all the sense in the world," says John Steinmann, MD, an orthopedic surgeon based in Redwood, CA, and involved in PODs. "One thing I won't disagree with is there is potential for abuse. We've worked very hard to instruct our models to put in place excellent compliance programs and there isn't one with a shred of abuse. There are individuals, not surgeons, using them for personal financial enrichment. But that's where the discussion should go: This is a model that absolutely makes sense, and how can we establish appropriate safeguards? We've gone a long way toward establishing those."
The blockbuster Senate report charges that in the interest of financial interests, physician investors in PODs may perform more procedures than necessary or may use implants of inferior quality or not best suited to the procedures. Five senators, working in a bipartisan manner, have asked the Inspector General of the Department of Human Services for an investigation.
The senators' letter also asks the IG to review the structure of PODs be reviewed in terms of the federal anti-kickback laws, designed to protect patients and federal healthcare programs form the potential influence of financial arrangements.
"Our main concerns are pretty much expressed in the Senate report," Thomas N. Bulleit, a partner with Hogan Lovells, a law firm based in Washington, D.C., which has represented medical device makers, and staunch opponent of PODS, tells me. "I think on its face it violates the law, and even if it didn't violate the law, (PODs) smell to high heaven," Bulleit says. "It gives the doctor financial incentive to pick one device over another, instead of letting the decision be based on what is right for the patient."
Among the patient-related concerns noted in the Senate report:
One surgeon provided examples to the committee of elderly patients who received eight to ten back fusion surgeries despite the serious health risks posed by the procedures.
Another example was of an elderly patient who had a herniated disc and ended up receiving four fusion operations based on the recommendation of the surgeon, who happened to be a member of a POD.
Other surgeons provided examples of patients who had died from multiple operations.
While there should be a crackdown of those who abuse the POD practice, general criticism against PODs is wrong, says Steinmann.
Steinmann describes it as the most effective means of hospital/physician alignment, and reflective of what healthcare reform is all about. The Senate report noted that in 2009 a POD in California asserted that its model helped save the hospital they were affiliated with 34% over a two-year period on the purchase of implantable devices, with a total savings of more than $1 million.
The example sounds exactly like the one that Steinmann says he has been involved in. When it is set up correctly, surgeon owned distribution models would ensure lower cost and demonstrate transparency, Steinmann says.
All this criticism of the PODs is wrapped around self-interests of those in the medical device industry to thwart competition, says Steinmann and W. Bradley Tully, an attorney with the Los Angeles-based Hooper, Lundy and Bookman.
"What you are seeing in Washington DC, [is a] lobbying effort by the medical device industry to eliminate a threat of competition," Steinmann says.
"The difference is sales reps have a commission structure of 40%," Tully says. "It's very large and a [POD] doesn't need a sales rep. It's a functional difference in the delivery of the devices."
In the wake of the Senate Finance Committee report, nearly all parties involved await the release of an Office of Inspector General Report on the issue, expected sometime in August.
"The IG has spoken on this several times," says Bulleit, with a bit of frustration in his voice. "They wrote a letter in 2006, and there was congressional testimony. In each case, they said in essence the same thing: They had serious concerns for potential abuse of patients and programs and were worried when doctors had a financial interest in PODs."
Bulleit describes the expansion of PODs as the result of "the absence of government action." He says that the strongly worded Senate report "shows it is already giving this a serious look. They are not just dabbling; this isn't just fishing. A lot of investigating has been going on."
The major problem is that the POD model "changes the game" in the medical device field, says Steinmann.
Whether the game changes or not may depend on the next move, by the Inspector General's Office, in August, when it gets really hot and muggy in Washington.
With all the negative chatterabout accountable care organizations from healthcare leaders and in public comment forums, it is interesting to see which healthcare systems are ready to leap at the chance to initiate ACOs.
Often the ones at the head of the pack are the ones who feel their current systems are so locked in and on target, that they seemingly can't wait to get started.
The Essentia Health System in Duluth, MN seems to have that attitude. Essentia is getting ready to transition to an ACO after receiving data showing the effectiveness of its disease management program. While national heart failure readmission rates are about 40 to 50% range, the sickest heart failure patients in Essentia's program have admission rates between 0 and 2%, says Linda Wick, NP, RN, manager of the Essentia Health System's heart failure program, formerly known as St. Mary's Duluth Clinic Heart Failure Program.
ROUNDS: The Real Value of ACOs August 16, hosted by Norton Healthcare. Register today for this live event and webcast.
Readmission rates were estimated at 3% to 7%.
One of the most significant aspects of care that the system does, and does successfully, is disease management, working with the patients, tying that in with a telemonitoring scale program linked to patients with cardiovascular conditions, says Wick.
"Disease management is the thing," she says. "I think a lot of people don't fully understand what that means. We look at patients with the understanding we are responsible for them 24/7," Wick said.
She is a nurse, and from that perspective Wick says the nurses have guided the process of the disease management program, especially in ensuring follow-up care. "We are giving patients the skills and resources they need to manage their own disease, and they know we are available," she explained.
Under the program, the hospital has reduced 911 calls and admittances to the emergency departments, as well as showing hefty savings, she said. An Essentia Health study with Blue Cross Blue Shield of Minnesota revealed $1.25 million in healthcare savings for evaluation of 29 patients over a six-month period, according to Wick.
Essentia has established what she terms a true team, of nurses and physicians, overcoming the fact, she says, that physicians, generally, have not been adept at disease management. In the healthcare reform era, that is something that physicians must continue to work on, she says.
"I'm not picking on physicians, but they haven't really been trained in disease management," Wick said. Not all physicians are fuzzy with disease management. "Primary care docs, they get it, they totally get it," she explained. The particular area of concern in developing disease management programs with physicians involves the specialty physicians, such as cardiologists.
Disease management is all about keeping tabs with patients who may lose their way. For instance, as Wick says, patients' doctors may have taken away their salt shakers, and that is all well and good, but deep down, patients are still having a problem with sodium intake. "They still may have that chicken sandwich at McDonald's and they think it's OK, but it's loaded with salt," she says. "That piece of disease management, discussing that, is something nurses are trained to do."
Referring to the subspecialties who sometimes stumble at disease management, Wick says, "I
"I think cardiologists are trained as procedurists and it's harder for them to understand disease management," she says.
To augment its system, the hospital uses a telemonitoring scale system, in which a patient sets up a scale in his or her home, which takes their weight, for instance, and that information is linked into the hospital. The system poses questions about the patient's health and it is something that the patient is supposed to step on every day. Information is transmitted to a cardiac nurse, who can make adjustments if necessary, based on medication, and track the patient's condition.
When the hospital initiated its program using the telemonitoring scale, and consistent follow-up care of patients, some physicians were concerned that they were going to be caught up in the details of follow-up care that would interfere with all their other work.
"If you are dealing with all these patients, we are going to get all these calls,''' Wick recalls physicians telling the nursing staff.
Hospital officials also were concerned about an anticipated overflow of the emergency department patients, especially among those who have had debilitating cardiac conditions, and whether the telemonitoring scale system would actually make them more nervous. She acknowledged that the telemonitoring scale system, generally, across the nation, has had mixed results. For Essentia, however, it's working, Wick says.
The hospital system's disease management process has put a lid on calls of anxiety from patients and visits to the Emergency Department, Wick says. "The 'calls' aren't there, because they are well managed," she says of the patients. "They are well managed and they don't call," she says. "The onus is on us to partner with our patient. How we manage this so it's not a crisis, it's about preventing a crisis.
About 200 of 1,200 patients in the healthcare system's cardiac program are involved in the telemonitoring scale program, she says. The hospital ensured only those who really need the extra support of the scale would be part of that process, she says. Indeed, the hospital receives no reimbursement for the scale, which is estimated to be part of an overall $10,000 telemonitoring cost for each patient, she says.
"In our philosophy of preventing crisis, we're seeing people on a regular basis and managing them; sometimes it's a phone call and sometimes it's patients seen at a clinic, but that's really where our success lies," Wick says. "The scales are important tools. Everybody loves technology but you have to target the resources appropriately," Wick says.
As Essentia moves forward, it is formulating an ACO plan. "Everything we do in our program fits in the current definition of ACO," she says. "I love it, it works and it's patient centered and you are paying us for the right thing. Now we are paid for failure if I don't manage these patients well. That's not the right thing for the patient and the patient is suffering."
What Essentia is doing with disease management and its telemedicine scaling program has attracted the attention of the Healthcare Innovations Exchange,
part of the Agency for Healthcare Research and Quality. In May, AHRQ invited Wick to display the health system's concepts at its headquarters in Rockville, MD.
The concept has proven to help patients and reduce costs, Wick says. "We are a team and we are winning."
In the wake of healthcare reform, data is becoming more important than ever in issues such as the need for primary care physicians.
The findings of a recent Dartmouth Institute for Health Policy and Clinical Practice report say mortality and hospitalizations are significantly lowerin areas where there are more primary care doctors who work fulltime and are taking care of patients in ambulatory care and office settings.
Looking past those general findings, however, reveals other issues. The report also takes aim at the American Medical Association's database of physicians and questions the accuracy of its findings, and its breakdown of primary care physicians in certain areas, the co-author told me. Ironically, the Dartmouth study is published in the Journal of the American Medical Association.
"The (data) that the AMA is using to estimate the number of primary care doctors is not accurate," say Chiang-Hua Chang, MS, PhD, an instructor in Dartmouth Institute for Health Policy and Clinical Practice. "What the AMA is using does not accurately reflect what the doctors are doing." What the listed primary care doctors are actually doing, says Chang, is "going into subspecialties."
Essentially, "primary care doctors listed on AMA are not all doing primary care, many of them are actually providing specialty care," she says.
Recognizing the difference is not only important to improve primary care clinician measurement, but also reflects the drift of physicians into nonprimary care careers. The manner in which primary care physicians are practicing is important in the healthcare reform era, especially with the established great need for primary care physicians. As Chiang-Hua Chang noted, the training capacity of family medicine and internal medicine may have "disappointing patient benefits if the resulting physicians are primary care in name only."
Currently many clinicians licensed and counted as primary care doctors actually work in hospitals, emergency departments, in research, or in public health, or may not take care of Medicare beneficiaries at all, Chang says. In some cases, they have gone on to specialize in other fields such as cardiology.
"In healthcare, we are trying to figure out how many primary care doctors are really in the U.S.," Chang explained. "We don't have a good number; based on estimates that are inaccurate. It may be more certain in some areas, than in others."
The number of U.S. medical school students going into primary care has dropped 51.8% since 1997, according to the American Academy of Family Physicians, which predicts a shortage of 40,000 family physicians in 2020.
Chang explains a key element in evaluating the number of physicians in which there is a projected "large shortage of general internists and family physician to care for a growing number of elderly patients."
The Dartmouth study offers a "cautionary note" that having more physicians trained in primary care in an area, by itself "does not ensure substantially lower mortality, fewer hospitalizations or lower costs."
That other cautionary tale in Chang's report involves the AMA data itself. As Chang and co-authors note in the report, "Despite a widespread interest in increasing the numbers of primary care physicians to improve care and moderate costs, the relationship of the primary care physician workforce to patient level outcomes remains poorly understood."
At issue is the AMA's data Masterfile Dataset of doctors who list themselves as primary care providers. The AMA data is the "most commonly-used national measure of primary care physician workforce," as Chang notes.
"The AMA Masterfile misclassifies some specialist physicians, such as hospitalists and emergency department physicians, as general internists and family physicians," according to the Dartmouth report.
Sources for the AMA dispute some of Chang's findings, saying that the association relies on many databases for information. However, the AMA did not immediately respond for comment on the Dartmouth report.
As far as Chang is concerned, research and healthcare planning that relies on the AMA Masterfile "will not accurately measure the "primary care workforce."
"Many of the physicians who would be classified as providing primary care by the AMA Masterfile were either not providing care to fee for service Medicare beneficiaries or were providing nonambulatory or specialty care."
"Similarly," it adds, "a significant proportion of the physicians delivering primary care services as per Medicare were not classified as office-based primary care physicians in the AMA Masterfile."
In driving home its point in the study, the researchers decided then not to rely solely on the AMA Masterfile because of questions of its accuracy, Chang says. As part of their review, they also used clinical primary care FTEs derived from Medicare claims for beneficiaries as a "secondary measure of primary care physician workforce."
The researchers based their findings on a sample of more than 5 million Medicare beneficiaries in in 2007 in 6,542 primary care service areas and their hospitalization claims for 12 conditions that can be avoided when good care is provided within a clinic or office visit.
Chang says she believed it was important for her study to verify exactly where funds were allocated related to primary care services, particularly in outpatient settings.
"If they allocate and put the resources only to train primary care that may not be much help," she said.
The American Medical Association and the American College of Surgeons leaders and those of other physician groups last week testified before the House Energy and Commerce Committee's health subcommittee, once again urging them to reform what they called the "deeply flawed" SGR formula. We have all heard that refrain. But now they are adding a twist. They are coming before Congress with a distinct long range plan to get rid of the SGR with value-related projects such as bundling, and a separate formula for various physician categories instead of a general formula affecting all physicians.
There will be more committees to hear what they say, with testimony expected soon before the powerful House Ways and Means Committee. In March, the Energy and Commerce Committee sent a letter to a whopping 51 medical associations seeking feedback on how to improve the physician payment system. Twenty-nine responses are listed on the House committee's web site.
The medical groups are looking at the future and seeing a hazy picture, but there's a problem, right now: where's the money for it? In Congress, there is talk of $65 million for the yearly "doc fix," but as far as the medical groups are concerned, more than $300 billion is really what's needed to get rid of the SGR once and for all, and start anew.
The latest "doc fix" is scheduled to expire in January 2012, with a proposed cut. The cuts were delayed for months last year.
The groups are seeking "stability" in the structure for the next three to five years before implementing other procedures, and in the process throw out the SGR, which has been controversial and probably ineffective since its implementation in 1997 for calculating Medicare reimbursement for physician services. The SGR was enacted to determine physician payment updates under Medicare Part B.
The 10-year cost of a long-term solution has grown from about $48 billion in 2005 to nearly $300 billion today, the physician groups say. Congress passed legislation last year that freezes Medicare reimbursement to physicians through the end of 2011 and averted a 25% pay cut scheduled for January 1, 2011. Earlier in the year, Congress passed at least five delays to the cuts.
"The system that is currently used to pay physicians for providing services to beneficiaries in the Medicare system is broken and has been for some time," said Rep. Joseph R. Pitts, (R-PA), subcommittee chairman, in a statement. "The dilemma that currently threatens doctors and Medicare beneficiaries alike is all too familiar. According to the most recent Congressional Budget Office estimate, if nothing is done, physicians will see reimbursement for services provided to Medicare patients by 29.4% on Jan. 1, 2012, according to Pitts.
According to the AMA, many physicians, faced with cuts, want out of Medicare. As many as 82% of physicians say they will need to make significant changes in their practices that will affect access to care, according to the AMA. We have been here before.
Meanwhile, the cost of fixing the problem continues to grow, as Pitts calculates it. In March, the CBO estimated that the price just to wipe out the accumulated debt and return to a baseline of the SGR would be about $298 billion.
"We've been doing this for 10 years, dealing with the 'doc fix.' In reality it's not good for doctors, it's not good for patients; just in terms of going through this every year," says Christian Salgian, director of the division of advocacy and health policy for the American College of Surgeons. "Somewhere around October, November, or December, depending on the year, it gets down from discussions of a long term fix, 'let's get something done here' to "let's stop the cut." There is a shift in mindset with some kind of desperation. It's just kicking the can for another year, and nobody supports that. We're talking about 30% cuts for another year, and all we would be doing is hiding the cuts for another year."
Salgian says Congress has to deal with the $300 million in possible cuts and get rid of the SGR. Once the SGR is eliminated, legislators can work on a timeframe that would allow demonstration projects to be examined under a new Medicare physician payment system, the subcommittee was told by the physicians, and not a "one-size-fits-all formula."
Specifically, they are proposing to replace the SGR with a separate service system that they say recognizes the unique various types of physician services, while allowing for increased payments for areas experiencing workforce shortages like primary care.
Unlike the SGR, which bases reimbursement on the overall spending on all physician services, a proposed new system, the "separate service category growth rates" (SCGR) would determine reimbursement based on the spending and volume growth among services. Among the advantages: it recognizes that all physician services are not alike, and lower growth services, such as primary care, would no longer be the subject of the "blunt cuts" of the SGR, according to Salgian.
"There's a recognition of a need for three to five years of stability and let's figure out what this new replacement can look like," Salgian says. "The healthcare reform law has a number of demonstration projects in there, including accountable care organizations, bundling projects, shared savings models, and shows what this system may look like."
Indeed, according to the HealthLeaders Media Industry Survey 2011, more than half, (52%) of physicians surveyed said they expect to be part of an ACO within the next five years.
"Quality improvements have got to be part of this," Salgian adds. "We understand that costs need to be brought down and quality improvements help bring those costs down. We are working with other physician groups to put together these proposals. There should be a separate service category where primary care, surgery and others, three to five separate targets, rather than one global target for all physicians,"
David Hoyt, MD, FACS, a trauma surgeon and executive director of the American College of Surgeons, testified before the House Energy and Commerce health subcommittee, noting that the "current fee-for-service model" is unsustainable.
"Any new payment system should be part of an evolutionary process that achieves the ultimate goals of increasing quality for the patient and reducing the growth of health care spending – goals we do not believe are mutually exclusive," Hoyt said in his testimony.
"The first step towards reforming the Medicare payment formula is to immediately eliminate the SGR and set a realistic budget baseline for future Medicare payment updates, which fairly reflect the costs of providing quality health care, preserving the patient-physician relationship and ensuring patients have continued access to the physician of their choice," Hoyt told the subcommittee.
It is terrific that there are specific alternatives now on the table for Congress to complete. But there is still is the big question, one that will be wrapped in much politics, certainly. What about the $300 million cost?
And these physician groups are seeking at least three years of stability while they examine potential payment models or try them out. Stability?
"How do you get to that period of stability?" Salgian says, repeating my question. "Frankly, it's going to cost some money. Somebody is going to have to invest in real money, not small money, that each year hides the problem."
During that period of "stability" without the SGR, "we can test some models to replace the SGR. We can't put the resources appropriately if we are still fighting these cuts year after year," Salgian says.
"Everybody agrees it's a problem. Everybody agrees we've got to find a solution," he adds. "Everybody agrees this is not a long term solution, but when it comes down to paying for it, that's the problem we have."
Sen. Kent Conrad, D, ND, chairman of the Senate Budget Committee, has indicated that he would include a "doc fix" proposal as part of a 2012 budget plan. A spokesman for Conrad says there was no timetable for release of the plan although many expected it this week.
Lately, the discussion in Washington has centered on temporary "doc fix" legislation, but that's not exactly the permanent solution that the physician groups seek, as I see it.
With a couple of congressional committees potentially exploring the SGR issue, Salgian expects a "little bit of turf" battles.
Salgian is closely monitoring congressional actions. "Do I feel confident? We've doing this dogfight for 10 years," he says. "Frankly, how they are funding this now is like paying the minimum of a credit card bill."
The SGR isn't the only concern facing physician groups.
They are worried about the impact of the Independent Payment Advisory Board, which is scheduled to make recommendations on overall Medicare spending in 2014. The Patient Protection and Affordable Care Act established a 15-member IPAB to "extend Medicare solvency and reduce spending growth through the use of a spending target system and fast track legislative approval process," according to a House health subcommittee memorandum.
"Should the SGR remain in place when the IPAB takes effect, physicians will be subject not only to the SGR but to the further reductions in Medicare reimbursement based on IPAB's authority," Hoyt told Congress.
But that's another problem up the road, another potential headache. First things, first: the SGR.
