A nearly palpable uproar continues over gun violence in the aftermath of the mass killings in a Newtown, CT elementary school last week. This was the latest bullet-induced atrocity and among the most horrific in recent memory, as the majority of those killed were young children.
As everyone tries to examine the whys behind the tragedy, physicians are moving closer to the front lines of the debate, with mass murder becoming a chronic condition in this country.
Indeed, even as authorities continue to gather whatever information they can on the Newtown shooting, the American Medical Association has been involved in heated litigation 1,000 miles away in Florida. There the debate is over whether physicians can take steps to prevent guns in homes if they feel it's necessary.
Who can say when the level over gun violence is suitably horrific that we have had enough? Maybe the latest uproar over the loss of such young and innocent lives is the threshold.
The caskets are so small as to remind us how much life was missed. Surely, concerted outrage is rife, as President Obama has supported a plan by Sen. Dianne Feinstein, (D-CA) to introduce legislation to reinstate an assault weapons ban. He has also appointed Vice President Joe Biden to lead a group to conduct an in-depth examination of the country's gun issues.
As in many of these cases, gun control is only part of the debate, as AMA President Jeremy A. Lazarus, MD, acknowledges that some may question whether "physicians missed an opportunity to protect the public from individuals who might perpetuate such actions."
In an interview, he also raises soul-searching questions about this country's mental health programs, which he says are overburdened, underfunded and inadequate.
"I do think physicians are educated about the public health issues about guns and gun safety, so we could always do more, and this will probably spur us to do more," Lazarus tells me. "This issue has been a policy of the AMA for a long time about educating physicians about gun safety."
As for as the mental health system, "we presume we have sufficient ability to evaluate people, but where do we put them?" Lazarus says. "It raises the issue of a mental health system that is underfunded, and overburdened. Basically, these people are put in jails and prisons, and we don't have a lot of hospital beds. It raises a lot of issues along those lines."
Whether there were opportunities to stop Adam Lanza before he allegedly carried out his rampage will always be an unknown. Lanza, 20, is believed to have shot his mother four times in her bed, and then gunned down 26 other people, including 6 adults, in the killing spree at Sandy Hook Elementary School.
As far as his condition, there is media speculation, but no confirmation, that Lanza had Asperger's syndrome—which is not a mental health issue.
Referring to mass killings in America, Lazarus says that "more than half of those [killers] had [acknowledged] mental illness and a significant number did not." But mass murders by shooting aren't the only problem facing America related to violence, he says.
In 2010, there were 31,000 people killed in gun violence in some way, "homicides, suicides, or accidents," he adds. "You've got an enormous number not in mass killings."
For those whose mental illness is a contributing factor in their decision to shoot people, the system that could help them, if they seek help, is severely strained, Lazarus says. "A lot of family physicians treat patients with depression and anxiety disorders, but those with severe mental illness put a severe strain on the system."
One of the most concrete things the AMA is doing regarding gun control, is attempting to protect the "doctor-patient relationship to assure that physicians can discuss firearm safety with parents and adults." The AMA last month filed a friend-of-the-court brief opposing the state of Florida's attempt to revive a law preventing doctors from asking patients and families about guns in the home.
"Questions about home firearm possession should be and are a routine part of the patient history inquiries that physicians ask of their patients, usually conducted near the onset of the relationship as part of the general assessment of everyday risks, " the AMA said in court papers.
"If the governor prevails, this could have a chilling effect on doctors asking about guns in the home and gun safety," Lazarus says. "Other states might consider the same which would be terrible from our point of view. We feel strongly that physicians shouldn't be gagged in any way from talking to their patients about things that would be important to their health," he adds.
"We should not be prevented from discussing anything with patients about their health. So that's the overarching concern even beyond the gun issue."
Bernard Wollschlaeger, MD, FAAFP, a family practice physician in Miami who is among the group of physicians who successfully sued to halt the Florida law, has counseled patients about gun use.
"We need a collective effort of our entire society. I do not see politicians as catalysts of change," Wollschlaeger told me after the Connecticut shootings. "We can't rely on politicians to resolve this problem. It's a collective effort. For a mentally unstable person, to give him a weapon of war, it is crazy. These are weapons intended to hunt, not weapons to be used for self-defense. These weapons should be in the hands of law-abiding citizens. For what purpose could it be? Armageddon? It's insane."
The AMA is expected to discuss the shootings soon. Lazarus says in the interview that education is needed among "public and policy makers and there is also a need for more (mental health) services" including more specialists in mental illness care.
In his blog, Lazarus health leaders must "work together as a medical community and [with] the public to make evidence-based interventions when available, and continue public discussions on some of the important tradeoffs between individual rights and protection of the public. We must not keep blaming ‘the system.'"
When will the gun control debate return to a subterranean slumber as it often does, waiting for the next tragedy to wake it up? It won't go back underground, at least, not if some physicians have their way.
The Sustainable Growth Rate formula , the scourge of physicians, detested by both Republicans and Democrats, may be on the brink of being eliminated if the Obama administration has its way, according to healthcare sources.
For years, major physician groups have sought to get rid of the formula, which has meant proposed payment declines for doctors. And ironically, government actions to avoid the so-called "fiscal cliff" may open the door to elimination of the SGR.
The White House has reportedlyproposed to get rid of the SGR as among its plans for avoiding the economic effects of tax increases and spending cuts that will occur in January if current laws are not amended.
The budgetary negotiations between President Obama and House Speaker John Boehner, R-Ohio have been intense, but inconclusive.
"Our antennas are up for stuff happening," Jeremy Lazarus, MD, head of the American Medical Association, said. "Obviously, we want the SGR repealed and we're pleased the president said that." The AMA sent a letter to lawmakers Wednesday in which it called the stalemate "inexcusable."
The Sustainable Growth Rate formula has been established to control spending for physicians. Each year since 2003, Congress has passed a "doc fix" to avoid significant cuts. Such funding shortfalls were pegged at 27% for 2013. It has become almost a tradition for Congress to fill the SGR gaps, with many saying that lawmakers have "kicked the can down the road" on the issue.
While it appears there are discussions on Capitol Hill about the SGR fixes, no one is making promises. "We've got to see what comes down, obviously the other negotiations going on, lot of moving parts, things are very fluid at this time," Lazarus says.
Still, healthcare officials were buzzing with reports about the SGR Thursday. On Capitol Hill, however, there was no official word about any discussions on the issue from the White House or Boehner.
Most of the discussions focused on what Republicans termed a "Plan B" to avert the fiscal cliff, which would include blocking tax increases for anyone exceed those whose incomes exceed $1 million.
"The details are soft right now," says Jeffrey Cain, MD, president of the American Academy of Family Physicians, referring to any plans regarding the SGR. "We've heard rumors and whispers." Still, with the issues swirling around the ‘fiscal cliff," there is a feeling that "this is a good time to really do something about the SGR," Cain adds.
"We're excited to learn of the interest from the House and Senate, and the President. Keeping the SGR in place means that healthcare costs will continue to escalate, and it will be harder for physicians to invest in new payment models like the patient centered medical home, Cain says.
"There [have been] calls for repeal of the SGR since 2003, and we don't want decades to fix this," Cain adds. "We want to see carefully what proposals are put forth and we want to work closely with Congress."
Elimination of the SGR doesn't fully resolve all the fiscal problems as far as physicians are concerned, and the government must confront funding gaps that must be restored. The AMA has estimated that eliminating the SGR and freezing physician payments from Medicare over 10 years would cost $245 billion, based on Congressional Budget Office reports.
While the SGR is a target of physician groups, there is still a possibility that some doctors may face salary cuts, depending on their specialty, regardless of whether the formula is eliminated.
Cain concedes that "payment enhancement" for primary care physicians is needed, and the "difference between specialty and primary care pay needs to be narrowed in order to have the highest quality" care.
Still, the SGR's got to go, Cain says.
"You're hearing a very strong physician community fed up with this," Cain says of the SGR. "The sword of Damocles is over our heads," Cain says.
The deans of medical schools who gathered recently at the Association of American Medical Colleges in Washington D.C. talked with some urgency about physician needs in their areas.
"One said, 'We can't hire enough orthopedic surgeons.' Another who lives across the country said, 'We can't hire enough gastroenterologists,''' said Christiane Mitchell, director of federal affairs for the AAMC, recalling the conversations for me.
"There's no single specialty shortage or single region that has the biggest shortage," she says. "If you look at the physician supply in Boston, there are plenty of physicians. If you go to western Massachusetts, where I used to live, there are no physicians," in a manner of speaking, she adds. "You have to go to Albany, NY or to Vermont for healthcare or back to Boston. It's hard to say what the big need is; it varies from region to region."
The potential impact of looming physician shortages on the patient population may seem like old news, but there's a new "physician training fiscal cliff" looming due to the country's budget woes. Maybe we should call it "the frozen fiscal cliff."
Indeed, some physician training programs haven't had additional funds since 1997, Mitchell says, and AAMC is desperately pushing for a change.
If not, physician shortages may worsen in years ahead because trained physicians won't have residency options without the adequate funding, she explains. And as President Obama and Congress try to sort out deficit reduction plans, there is still the possibility that they may decide on further physician training cutbacks, according to Mitchell.
At this point, "we're probably going to see the first physicians graduate from medical school with no place to train," Mitchell says. "If you don't do your residency, you don't get your license."
The AAMC sees it this way: while medical schools are educating new doctors to help address anticipated shortages, those docs may not be able to complete their training and enter practice unless Congress removes "a 15-year-old cap" that has limited federal support through Medicare for residency positions at teaching hospitals.
That's the message Darrel G. Kirch, MD, president and CEO of the AAMC, wrote in a letter to Congress this week. The AAMC is a not-for profit association representing 141 accredited medical schools in the U.S. and 17 in Canada, 400 teaching hospitals and health systems, as well as 51 Department of Veterans Affairs medical centers and dozens of academic and scientific societies.
The Medicare Payment Advisory Commission has estimated that there would be $454 million cuts from major teaching hospitals, according to AAMC. "Cutting GME will worsen dramatically and potentially double the shortage of 90,000 physicians we already expect by the end of the decade," Kirch wrote.
According to the AAMC, the U.S. faces a shortage of 90,000 physicians by 2020, and that number is expected to grow to more than 130,000 by 2025.
Deficit proposals to reduce Medicare GME support would "threaten access to critical services unavailable elsewhere and reduce physician training at a time when patient needs are increasing," Kirch wrote.
For Mitchell, it's a big part of her job to keep tabs on physician shortages and what she terms "inactivity in Congress and the administration" related to funding of physician education, as well as the pending collision of physician shortages and the patient demand for care. In a little over a year, as many as 32 million Americans will enter the health care system with health insurance, as the U.S. experiences the physician shortage.
That shortfall in medical service providers is exacerbated by the fact that one in three physicians is 60 or older, the typical age of retirement for doctors, Mitchell says. "Just like the general population is aging, and the Baby Boomers aging into Medicare, we have the physician Baby Boomers are approaching their retirement," she says.
The problem of medical school education funding, or as Mitchell puts it—"the massive cuts in support for physician training"—isn't as widely debated as the other issues, but may certainly add to the physician shortage as the AAMC sees it.
"Congress must lift the freeze on Medicare-supported residency positions," the AAMC said in a report this year. "Because all physicians must complete three or more years of residency training after they receive an MD degree, Medicare must continue paying for its share of training costs by supporting at least a 15% increase in GME (Graduate Medical Education) positions, allowing teaching hospitals to prepare another 4,000 physicians a year to meet the needs of 2020 and beyond."
Over the last several years, medical schools committed to increasing their enrollment by 30%, and "they did that with very little government support," Mitchell says. Those enrollment goals should be reached by 2016. However, during that time, there has not been a proportionate increase in residency positions, which the students need to practice in the U.S. and get their license, Mitchell says. That's because government funding has been essentially "frozen" for the past 15 years; those funds were part of the balanced budget act of 1997.
"Not only are they not increasing (the funding), they are proposing significant cuts. It would seem only logical that Congress and the administration try to make sure Medicare beneficiaries have access to care," Mitchell adds.
"The logic of cutting funding at this point... there is no logic," she says. "It's a shortsighted view, not a long-term view. It takes three years at minimum to train a primary care physician, five to seven years for an orthopedic surgeon, and nine years to train a neurosurgeon."
For the last several years, the AAMC and other physician groups have lobbied intensely to seek financing changes. Recently, the AAMC has changed tactics, and has attempted to show they are training physicians for a changing world with "high performance healthcare systems." That includes instruction of physicians as part of "true patient care teams," Mitchell says.
That focus was part of bipartisan legislation that was introduced this year that would expand the number of residency training positions in Medicare by 15,000 over five years, with funding to back it. The legislation has not been adopted, and is not expected to be with a lame duck Congress.
"Everything came to a halt in the 112th Congress," Mitchell says. "We're hoping for a bigger policy discussion next year."
In our annual HealthLeaders 20, we profile individuals who are changing healthcare for the better. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. All of them are playing a crucial role in making the healthcare industry better. This is the story of Gerilynn Sevenikar.
This profile was published in the December, 2012 issue of HealthLeaders magazine.
"We're getting more cash back from our patients, but the better news we're getting letters from our patients saying how much they appreciate this."
Gerilynn Sevenikar, vice president of patient financial services for the 2,092-licensed-bed Sharp HealthCare System in San Diego sees herself as upbeat, but her optimism was surely tested in 2009. The balance sheets weren't looking good: Collections from the uninsured population were decreasing, while unemployment was increasing in San Diego County. There was so much uncertainty it would not have been surprising if Sevenikar may have wondered if should have chased her early dreams of becoming an airline pilot. Instead, she was juggling so many things as a financial leader at Sharp it was not unlike being an air traffic controller.
Indeed, back in the 1970s, when she started her career at Sharp, she had been thinking of becoming an airline pilot, and in fact, has a pilot's license. Those vocational plans changed, however, as work at Sharp became more fulfilling, and certainly challenging.
When the fiscal climate appeared dire a few years ago, Sevenikar found ways to help the uninsured, or self-pay patient population gain federal or state funding, and also opened the door for Sharp to obtain millions of dollars in payments it would not otherwise obtain. She also has tried to make the bureaucratic process more manageable for patients and more efficient for providers.
One of the key actions that Sevenikar took was helping Sharp team up with Foundation for Health Coverage Education, a San Jose, Calif.–based nonprofit that assists in helping people understand their healthcare eligibility status. Under the collaboration, Sharp initiated the FHCE's eligibility quiz (www.CoverageForAll.org) into the emergency department registration process to reduce the numbers of self-pay patients by finding public and private health insurance eligibility information to help them access to coverage. The effort has resulted in helping more than 32,000 self-pay patients "navigate through a maze" of government health coverage programs, Sevenikar says. Over three years that Sharp has partnered with FHCE and through other internal initiatives, it's recovered $4.7 million in revenue, according to Sevenikar.
As she wades through paperwork and balances the needs of patients and demands of the hospital system, Sevenikar says she understands providers must be tough yet sensitive while seeking payments. Along the way, patients have sent her heart-felt emails expressing "thanks," and some surprised her.
Sevenikar recounted the story of a patient lacking insurance who wondered the kind of reception she would receive at the hospital. Sevenikar and her staff made her feel comfortable. "Upon arrival I was so afraid I would not be seen because I was uninsured; not only was I not turned away, I wasn't treated differently than anyone else," the woman wrote to Sevenikar. "Everyone in the department was very nice, and skilled at their profession."
Such comments make her feel terrific, says Sevenikar. "It means we're making a difference!" she exclaims.
Not every patient is happy, of course, nor would Sevenikar expect that. "There's not going to be a 'thank you, Sharp, for sending me the bill,'" Sevenikar says. "That's not happening. There's always going to be some dissatisfaction."
Still, she takes the lessons from 2009, and is carrying them forward. That year, during the economic downturn, Sharp was tested, like many healthcare organizations. Sevenikar says she started seeing steep declines in self-payments, about $3.4 million in one year. At the same time, there was an increase in self-pay volume, about 7%. That coincided, not surprisingly, with a significant rise in San Diego's unemployment from around 8.7% to 12%.
"I did the analysis and it was truly a reflection of the economy," Sevenikar recalls. "People were just feeling the pain. We looked at how we were handling the process with our patients. We wanted to be sensitive to what they were going through. How were we going to bridge the gap for them? What's the right thing to do? What's the reasonable thing to do." Eventually, she says, "We're partners in this process."
One of the ways that Sevenikar believed Sharp could improve payments was to help patients navigate the system better. She began working with Foundation for Health Coverage Education to help patients consider their coverage options. After reviewing data, Sevenikar says that more than 80% of Sharp's uninsured patients are eligible for some assistance.
"We did the research for patients and we asked what sort of funding programs they could be eligible for," Sevenikar says. "When they came into our emergency rooms, we gave them the information and application and everything they needed to apply for funding, so they can move forward with some kind of assistance."
That focus paid off, Sevenikar says. Within the first two years, payment collections increased 6.5% and 4.4%, Sevenikar says. "We're getting more cash back from our patients, but the better news is that we're getting letters from our patients saying how much they appreciate this," she says.
While Sevenikar already has faced some tough economic hurdles, more financial cutbacks loom. Healthcare reform offers more challenges, including anticipated increases in the uninsured population, Sevenikar adds. For the most part, Sevenikar says, technology will be of overwhelming importance as hospitals confront any potential problems.
"We are moving toward stronger automation, that's what I tell my employees," Sevenikar says. "I tell them embrace technology, become an expert at it, and become invaluable to the organization."
More and more, though, she's knows that patient satisfaction is a crucial element of what she does. "When you are thinking about patient billing and collections, the bottom line is, 'Are you doing the right thing?' "
In our annual HealthLeaders 20, we profile individuals who are changing healthcare for the better. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. All of them are playing a crucial role in making the healthcare industry better. This is the story of John E. Wennberg, MD.
This profile was published in the December, 2012 issue of HealthLeaders magazine.
"There's been a lot of progress: Not that there has been a substantial change in the variation problem, but there's been a lot better understanding of the causes of it, and the remedies we need to put into place to actually reduce variation."
While living in Vermont in the 1970s, John E. Wennberg, MD, MPH, was flabbergasted when his studies revealed that, in one area, children might have a 75% chance of their tonsils being removed, but if they lived 100 feet away, within the border of another school district, only 20% of the kids did.
Wennberg, founder of the Dartmouth Institute for Health Policy and Clinical Practice in Hanover, N.H., has repeated this seminal story about his findings many times over the past 40 years about the variation of healthcare delivery, since it shaped his view of healthcare in America—and his life's work.
For "Jack" Wennberg, that research started a journey in which he has consistently criticized the health system for ordering too many unnecessary procedures and producing too much variation of healthcare across regions. These practices manifest themselves in results like uneven care for the chronically ill, or a national healthcare system that simply spends twice as much as it should. Wennberg's mantra has become indelibly stamped in healthcare: "More care doesn't mean better care."
For the white-haired, soft-spoken Wennberg, the data he has compiled and analyzed roars resoundingly throughout national debate on these matters.
From the outset, Wennberg saw that differences in U.S. healthcare spending were often the result of location. Among the more significant Dartmouth findings over the years has been the surprising discovery that, in some areas of the country, more aggressive care was the norm, and spending was twice at much. At the same time, he found that such spending did not necessarily improve outcomes.
Those variations of care are "still a persistent problem, definitely," Wennberg says. "If you do the same measurement we did then," he says of previous reports, "you hit the same story. For most things, they vary and vary idiosyncratically. One region will be high on this end, and will be low on another, when you are talking about surgery anyway."
Wennberg has consistently been putting his footprint on the wide swath of healthcare spending since the early Vermont study. In 1988, Wennberg started the Dartmouth Institute for Health Policy and Clinical Practice, which has been the driver of the research and studies. It was then called the Center for Evaluative Clinical Sciences at Dartmouth Medical School. After stepping down several years ago from running the institute on a daily basis, Wennberg continues his passion to study the foibles of healthcare delivery. He is the Peggy Y. Thomson Professor Emeritus in the evaluative clinical sciences.
Wennberg is also founding editor of The Dartmouth Atlas of Health Care, which examines patterns of medical resource intensity and utilization in the United States. The Atlas project has reported on patterns in end-of-life care, inadequate use of preventive care, and Medicare reimbursement failings.
Wennberg and his colleagues discovered that patients in high-spending areas would see 10 or more specialists during their final six months of life. And yet, chronically ill patients who receive the most intensive, aggressive, and expensive treatment fared no better than those who receive more conservative care.
In a 2004 study of 77 of the country's top hospitals, Wennberg and his colleagues reported what he termed "huge differences" in the management of patients with chronic conditions during the last six months of life. Nationwide, Wennberg reported that hospital days per patient during the last six months of life ranged from 9.4 to 27.1, the number of physician visits from 17.6 to 76.2, and the percentage of patients who saw more than 10 physicians ranged from 15.9% to 58.5%. Even within the same city, different hospitals revealed significant differences in "patterns of patient management," Wennberg wrote.
"That's the whole nub of the issue," Wennberg says. "It's the intensity of treating chronically ill patients that is responsible for differences in spending in places, such as Los Angeles and Minneapolis, among Medicare populations."
With findings like these, Wennberg and his colleagues have generated many headlines, and continue to reach a wide audience, as an integral part of the nation's burgeoning discussion on healthcare reform. While healthcare leaders are listening about the problems of variation of care, that doesn't mean the problems are solved, he says.
"There's been a lot of progress: Not that there has been a substantial change in the variation problem," Wennberg says, "but there's been a lot better understanding of the causes of it, and the remedies we need to put into place to actually reduce variation."
Eventually hospitals and health systems, as well as doctors and other healthcare professionals, must look beyond the costly and unnecessary procedures, but also at the money spent for increasing capacity that may not be justified by the need, Wennberg says.
Such variation is important because it is wrapped around essential elements of healthcare that can be expensive and also wasteful. That waste includes frequency of visits to physicians, the number of hospitalizations, how often people are sent to ICUs or get an MRI, Wennberg says. "There are variations associated with overall capacity, how many doctors you have, how many beds," he adds.
Not only do health systems need to have "better organization," but also it is increasingly important to provide a shared program with patients themselves, Wennberg says. "Getting patients engaged has been one of our principle goals, and we are seeing some progress in reducing variations in elective surgery." Wennberg refers to findings in a study by Group Health Cooperative in Seattle that showed a 39% reduction in knee replacement spending once health systems adopted the concept of shared decision-making about what is medically necessary. Wennberg was not involved in the study.
A graduate of Stanford University, Wennberg received his MD at McGill University, and also took post-graduate training in internal medicine and nephrology at Johns Hopkins University. While there, he became increasingly interested in epidemiological principles in the healthcare system, so he pursued a master's degree in public health.
That led him to study the tonsillectomy variations in Vermont as director of a northern New England medical program. Wennberg recalls how he and his colleague tried to shop around their findings, but were roundly rejected. "They weren't ready for it, that's for sure," Wennberg has said. The journal Science published the study.
Hospitals and health systems must continually examine their spending, but it won't be easy, he says. "They have mortgages on them, have bonds to pay off. The capacity is currently adjusted through the current cash flow, and in turn it is based on utilization, and reducing it is a problem," Wennberg says. He believes that accountable care organizations may be a way out—"to the extent that shared savings is implemented in a sophisticated way ...It would mean the management and physicians at a given institution could reduce capacity without bankrupting the institution or screwing up the bond market. Ultimately, things need to be worked out."
Wennberg continues to see how healthcare can "work out." Two years ago, he wrote a book, "Tracking Medicine: A Researcher's Quest to Understanding HealthCare."
In it, he writes that: "...much of health care is of questionable value and that informed patients often prefer a form of treatment other than the one their physicians actually prescribe. More care is not necessarily better at least when it comes to managing chronic illness. Care coordination and intelligent management of patients over the course of their illness which typically lasts until death counts far more than simply providing medical services."
Wennberg says he will keep studying the intricate flaws in healthcare as a means to finding ways to improve it. Even with four decades of research behind him, the opportunities for new, promising insights are enough to keep him busy for years to come.
Top docs have a message for the C-suite: Get physicians involved, really involved, in your cardiology programs, and you'll improve patient care and earn plenty of money.
OK, maybe it's not that easy.
But with some work, and coordination, the potential is there. Good outcomes and financial rewards await a healthcare system that arranges cascading benefits to physicians. Sure, it's a gamble. That's how Geoffrey Rose, MD, FACC, FASE, an adult cardiologist and director of medical imaging at Carolinas Health Care System's Sanger Heart and Vascular Institute sees it.
But it's worth a throw of the dice, especially for one of the more profitable service lines. "Those who embrace a collaborative approach will be playing with all the chips; he says. He insists, "consolidation is coming."
During a recent "Cardiology Service Line: From Volume to Value" webinar hosted by HealthLeaders Media, Rose and top officials of the Wellmont Health System in Kingsport, TN, and Sacred Heart Hospital in Eau Claire, WI explained how they have improved efficiencies.
The positive impact resonates in areas ranging from having integrated physician networks and easing the transition for independent physicians who work in competing groups, to negotiating better pricing from vendors.
Getting physicians on board for hospital governance—both figuratively, and literally—is essential for cohesive cardiology service lines. "Through meaningful transparent dialogue, we have been able to instill in cardiologists a sense of ownership of the program," says Andrew Bowman, RN, clinical director of cardiovascular services at Sacred Heart Hospital.
At Sacred Heart, the ownership isn't of the bricks and mortar variety. Aligning with physicians is important to overcome the day-to-day issues of running a cardiovascular service line: scheduling the catheter labs; supply chain management, and standardizing protocols.
Bowman emphasizes the importance of physician alignment and also flexibility. "Don't rely on a single methodology for physician alignment," he said. "Understand your market and be open to different strategies for partnerships."
Sacred Heart is considering a co-management leadership structure with physicians, but it isn't there yet. As of now, the hospital runs a cardiology management committee, which includes physician partners that represent competing cardiology groups. Physicians are having more leverage in how the hospital runs its administrative business, including human resource management, areas "vetted and acted upon" by the cardiology management committee, Bowman says.
Having competing physician groups at the table is no easy task. "Those conversations were difficult at the beginning, sitting across the table with some history of competition that initially could not be overcome. It took many meetings and a lot of time and energy to get through it," Bowman says.
Having competing physician groups at the table is no easy task. "Those conversations were difficult at the beginning, sitting across the table with some history of competition that initially could not be overcome. It took many meetings and a lot of time and energy to get through it," Bowman says.
The hospital developed its service line to overcome what started as "unstable coverage" of a single cath lab in 2001, when two competing physician groups were involved, he says. Now, there are two cath labs accessed by eight cardiologists, who perform 2,500 procedures annually.
"The cardiology management committee set the foundation for how we engage physicians. The ... committee consists of one representative from each of the three competing cardiology groups," he says.
Gradually, the hospital coordination has resulted in substantial savings for the cardiology service line. In 2007, strategic performance improvements saved about $5 million, Bowman says, which he attributed to "front line staff, administrative operational leadership, and physician leaders."
Wellmont, an 8-hospital system in northeastern Tennessee and Western Virginia, has been evolving their cardiovascular service line within a co-management structure with physicians, according to Tim Attebery, system VP of cardiology vascular services.
The cardiovascular co-management agreement with a cardiovascular group, which includes a dyad leadership model, was established several years ago and led to formation of the Wellmont CVA Heart Institute, which includes eight hospitals and ambulatory facilities.
Physicians' leadership and involvement also have generated savings and efficiencies at Wellmont, Attebery says, including the system's relationship with vendors.
Wellmont includes a chest pain center and expanded STEMI (ST-elevation myocardial infarction) heart attack program designed to improve clinical outcomes, identifying physicians as "accountable care leaders," Attebery says.
An estimated $5 million in cost reductions occurred between 2003 to 2006. He attributes the savings to standardization in major supply items, achieved when physicians pushed unit price reductions with suppliers and vendors.
Rose of the Carolinas Health Care System's Sanger Heart and Vascular Institute also emphasized the physician involvement in care and the importance of "a definite institute vision" to "create value from the cardiovascular institute."
Coordination has led to improved treatment in the Carolinas Health Care System's STEMI program, with quick times reported for patients moved from the emergency departments to the cath labs. The Carolinas Health Care System's treatment time is 48 minutes, less than half of the 90-minute benchmark issued by the American College of Cardiology, Rose says.
Invariably, data are reviewed and discussed in plenty of meetings among physicians and other hospital staff around the cardiovascular service lines. Ultimately, "trust" is the most important element, Rose says.
"Trust and collaboration among the stakeholders—how do you get to that point of trust?" Rose asks. "The interest of the stakeholders needs to be aligned and executed very well."
Rose realizes that vision statements are sometimes seen as simple exercises, but their importance should not be underestimated. "It's not just an exercise, but sets the stage for what you want to be and how to get there. It helps to overcome the very difficult task of building trust."
After 25 years of using paper records, Winfield Young, MD, recently dove into electronic medical records for his Virginia Beach, VA, pediatric practice. "Today is the first day of training. I'm tickled pink," Young told me.
Young wants to maintain his freestanding practice and not be employed by a hospital. With an EMR, he envisions the possibility of increasing his income, and definitely more efficiency. "We see the importance of better documentation of diagnosis, and it's going to be easier to track," he says.
Independent primary care physicians often think they don't have the time, money, or resources to implement EMR, even with government subsidies. Still, they know they need to adapt to the changing environment. Patients are demanding more transparency and the government is incentivizing the shift. A growing number of physicians seem to figure they have no choice. To survive, they must opt for EMR, though they know the journey may not be easy.
Joel L. Fine, MD, of Fine & Associates in Snellville, GA, who runs a solo practice with his wife Stefanie overseeing the records, was certain for many years that he wasn't going to bother with EMR. "I fought the idea of electronic health records," Fine told me. "My feeling was: I don't need one. It doesn't help my practice; I don't see any benefit to it." Just the idea of dealing with vendors was daunting, Fine says, "with all of them geared to taking advantage of you."
But his thinking changed gradually. He remembers attending a vendor meetingwhere a show of hands was asked for physicians who weren't getting EMRs. "My hand was the only one up," Fine recalls. "Here I am, I thought, at 45 years old, at my peak of my career, and would be recognized among my peers as an outlier."
Fine converted. He is far from alone. More than 69% of primary care physicians reported using EMRs in 2012, up from fewer than 46% in 2009, according to a newly released Commonwealth Fund report published in Health Affairs.
Despite the spread of EMRs, U.S. primary care physicians trail doctors in other countries. The report says that U.S. and Canadian doctors lag behind the United Kingdom, New Zealand, and Australia in use of EMRs and healthcare IT to perform a range of functions, like generating patient information and ordering diagnostic tests.
Even so, U.S. doctors are exceeding goals set by the federal government. In August, the Department of Health and Human Services announced that 120,000 eligible health care professionals and more than 3,300 hospitals had qualified to receive incentive payments under the "meaningful use" rules for EHR adoption that went into effect in January 2011. That exceeds HHS's goal of 100,000 set earlier in 2011.
There's a twist, however: while U.S. doctors are moving forward in using electronic medical records, the mere presence of this technology is among the reasons they are moving out of their existing private practices and toward hospital employment, according to a report from Accenture.
Accenture says that over the next 18 months, more doctors are expected to leave private practice for hospital employment, due to "rising costs and technology mandates."More than half the doctors (53%) cited EMR requirements as a main reason for leaving private practice. The Accenture findings resulted from extensive market analysis on U.S. physician employment and a survey of 204 physicians in independent practice conducted in March 2012.
"On the technology side, many physicians we surveyed were daunted by the cost and complexity of certain technology mandates such as [EMRs]," says Kaveh Safavi, MD, JD, Accenture's health industry leader for North America. "Everything from the selection of an electronic medical record to the maintenance of the technology infrastructure and the compliance, it's all very complex and something that has been frustrating for many small practices."
Even IT companies that are working with physicians like Fine and Young in developing EMRs acknowledge the reluctance of physicians to embrace it. Fine and Young both use Hello Health, a New York–based web-based patient management platform for medical records and messaging. According to Hello Health's Primary Care Physician Attitudes survey conducted this summer, 37% of physicians see EMRs as their number-one challenge—the same percentage that see practice financial issues as their foremost concern.
Fine says it was important to have extensive technical support with the Hello Health platform while starting up an EHR. "We have a patient portal and the training was for free," Fine says.
The Hello Health survey showed that, among physicians who said that practice financials were among their biggest challenges, 51% felt implementing an EHR would help their practices, especially in dealing with coding and documentation.
Coding may have been the last straw for Young as he switched to an EMR.
"I've got 25 years of experience in using paper charts," Young says. "What, we're talking about more than 25,000 codes for ICD-9 [diagnostic codes] and then a lot more for ICD-10? Already, practice work is time-consuming with paper. I'm looking for the promise of what's ahead."
This article appears in the November 2012 issue of HealthLeaders magazine.
Before neurologist Andrei Alexandrov, MD, joined the 1,146-bed University of Alabama at Birmingham Hospital more than five years ago, the hospital had an uncertain vision for a comprehensive stroke program, which was more piecemeal than programmatic; the hospital addressed only certain aspects of stroke care. Then Alexandrov and his colleagues drew up a planning document approved by the C-suite that proposed dramatic changes in neurology care that would cascade through the system. This vision encompassed new multidisciplinary teams, revamped hiring practices, new clinical approaches, and innovative research.
Since then, the hospital has developed a proven comprehensive care program, and gave it a name that befits its purpose: The Comprehensive Stroke Research Center has a team of neurologists and nurse specialists who cover a wide swath of specialties, including a neurological urgent care center, and a memory disorders clinic for a variety of neurological conditions such as Alzheimer's, Parkinson's, and other diseases that affect the brain.
As one of dozens of hospitals dubbed a center of excellence by various organizations, the University of Alabama at Birmingham Hospital has tripled the number of patients enrolled in its neurological programs the past five years and is now at approximately 1,000 stroke patients per year. In addition, 60% of ischemic acute admissions are treated in less than two hours from symptom onset. Treatment should be carried out within three hours of onset, according to American Hospital Association guidelines.
What Alabama has done demonstrates the approach to neurological care geared to excellence that is changing the landscape for neurological patients, especially those in need of stroke care. "To organize such a program you need an institutional commitment for change. That's No. 1," Alexandrov explains. "Years ago, the traditional practice of stroke care meant you reacted to a problem and did the bare minimum. Diagnose. You give the patient some aspirin. But the idea of a comprehensive stroke center or a neuroscience center of excellence is that the buck stops here, for care. If a patient needs the most sophisticated procedure or complex care, that's where the patient should go."
Hospitals are finding a path to excellence in different ways. Successful programs are specializing in stroke care, offering advanced procedures, building a case for a primary care stroke center, and taking on strategic opportunities by coordinating programs with other hospitals that have limited programs.
Lacking resources, some hospitals rely on connections with more advanced hospitals that obtained the primary stroke center certification for expanded stroke care delivery for patients. Stroke care is a complicated series of procedures and different specialties, especially focused on what has become a healthcare mantra in dealing with strokes: "Time lost is brain lost."
Most strokes are ischemic, caused by lack of blood flow in the brain usually due to a blockage or blood clot. The window for treatment to reverse the damage from an ischemic stroke is measured in hours. One minute of brain ischemia can kill 2 million nerve cells and 14 billion synapses, thus reducing the odds of a good outcome as time elapses before intravenous thrombolysis, according to the American Heart Association and the American Stroke Association.
Echoing many healthcare leaders, Angie West, RN, MSN, CNRN, CCRN, director of neuroscience/stroke for MemorialCare Neuroscience Institute, part of the MemorialCare Health System, in Long Beach, Calif., says, "Time is brain. The longer patients wait, the more brain cells die, and [patients] have less-functional outcomes. Time is of the essence."
The hospital achieved the AHA's Get with the Guidelines Stroke Gold Plus Performance Award, which showed that it achieved 85% or higher adherence to guidelines for two or more consecutive 12-month intervals and compliance with quality measures.
Timeliness is reflected in the overall target of bringing a patient to be treated within 90 minutes of an attack. Without such attention, a patient can face complications related to other damaging and costly issues, such as readmissions within 30 days. A campaign created by the AHA and American Stroke Association—Target: Stroke—is designed to help hospital teams achieve door-to-needle treatment delivery times of 60 minutes or less for ischemic stroke patients who receive thrombolytic therapy. This prompt care is accomplished by providing evidence-based strategies, clinical decision support, measurement tools, and other resources.
Some hospitals working to achieve those "speed" goals are also wasting no time in developing comprehensive, coordinated stroke programs. Some aren't stopping at building stroke centers and are rounding out a vision for more comprehensive neurological centers, which many hospital leaders say eventually will be accredited by groups such as the Joint Commission.
"We have seen neurosciences as an up-and-coming service line," says Mona Euler, RN, vice president of neuroscience at the 3,326-bed Indiana University Health, based in Indianapolis. "It's relatively new compared to other service lines, but it is being driven by the need of patients. Millions of Americans are suffering at some point from neurological disease and need treatment. The neuroscience service line is just an excellent area for most hospitals to get into."
Euler says Indiana University Health has developed a "one-stop shop" for neuroscience care for various neurological system disorders. The system's health neuroscience center is combining resources with the Indiana University School of Medicine for multiple neuroscience specialties.
By having a coordinated approach, Indiana University Health has been certified as a primary care stroke center, a recognition of making an exceptional effort to foster better outcomes for stroke care. Demonstrating compliance with the Joint Commission's national standards and performance measurement expectations may help obtain contracts with purchasers and help control costs and improve productivity, the commission states. The Joint Commission's Primary Stroke Center Certification program was developed in collaboration with the American Stroke Association.
"We want to offer the most comprehensive care in neuroscience," Euler says. "It was a vision of our senior leaders. We wanted to unite research, education, and clinical all in one. We felt we were fragmented by being in different locations before."
Success key No.1: Coordination
By implementing a coordination of care program, the 86-staffed-bed Saint Luke's Neuroscience Institute has increased its speed in responding to stroke patients sent to the hospital. As a result, the Kansas City, Mo.–based facility has been able to use a significant medical therapy for stroke patients more often than other hospitals have.
Saint Luke's Neuroscience Institute has specialized in tissue plasminogen activator (tPA), the only FDA-approved therapy for acute ischemic stroke.
Despite being widely available since 1996, the therapy is still significantly underutilized. That can be attributed, in part, to the fact that tPA must be used on patients within three hours of a stroke's onset. In 2009, tPA treatment rates nationwide were only up to 5.2%, about twice the rate from 2005, according to Marilyn Rymer, MD, medical director and director of research at Saint Luke's Neuroscience Institute.
Saint Luke's uses the treatment at a rate twice the national average, says Rymer. Its initiatives have resulted in greater access to treatment, showing an increase of 23% in volume from 2005 to 2010. Overall, the total number of stroke patients treated at Saint Luke's increased 19.6%, from 567 to 678 from 2010 to 2011. The tPA treatment increased from 136 to 177, a 30% increase from 2010 to 2011, she adds.
"The first barrier is getting people to the right facility in time for treatment, with the IV tPA time window of three to four-and-one-half hours for treatment," Rymer says. "The next barrier is that many hospitals do not have acute stroke teams to attend to the patients very quickly. The CT scan is essential before treatment, and some hospitals do not have 24-hour access."
Saint Luke's also implemented key program initiatives to drive excellence in stroke care, including standardized care sets and care paths, and interventional stroke reversal protocols to extend the treatment window. By showing improved outcomes, Saint Luke's has reached agreements with other community hospitals for a regionalized program in which its hospital staff evaluates and offers assistance to others, she says. Other facilities in a 150-mile area, through agreements with Saint Luke's, have 24/7 access to its stroke expertise.
"We decided to organize stroke care in 1993, before any therapies were available," Rymer says. "Early in the game we evolved, and engaged these 60 or 70 emergency service providers in the area, and we have streamlined our process for transporting patients for referral hospitals."
Success key No.2: Dedicated critical care unit
For many hospitals, being named a center of excellence means possibly gaining the services of a neurosurgeon they were courting or developing grant proposals that may bring dollars that otherwise they could not obtain.
The Joint Commission has certified several dozen hospitals across the country as primary stroke centers or centers of excellence for treatment of stroke. As such, these hospitals have specialty-trained staff with innovative equipment and proven strategies to offer better overall care.
Those strategies include focusing their work on an interdisciplinary unit such as the University of Alabama at Birmingham Hospital's 64-bed combined neurology-neurosurgery unit, which includes an ICU for stroke patents.
"The patient needs to be coming on time to the hospital; there needs to be public education, so the comprehensive stroke center should be visible to the community," Alexandrov says. "We need to provide therapy as a standard of care, 24/7 and 365 days. That's a commitment as an institution. Physicians are recruited and prepared for that."
Although academic institutions may have access to resources needed for complex clinical and research programs, it is important for large community hospitals to expand their reach to include clinical research in stroke care as well, says Chere Gregory, MD, medical director of neurosciences for the 921-licensed-bed Forsyth Medical Center in Winston-Salem, N.C., a nonprofit regional medical center. Forsyth received the Get with the Guidelines Gold Plus Performance designation.
Coordinated, comprehensive care is important for dealing with a wide array of neurological issues, says Gregory. Smaller hospitals must transfer patients to another location, she adds. Forsyth Medical Center has its own neurological intensive care unit, with 28 beds in the stroke unit to focus on patients with stroke, brain injuries, and other neurological conditions. "We decided to create a center of excellence for stroke care by having a comprehensive interdisciplinary approach to providing that care," Gregory adds.
A key part of the program is having a neurosurgeon and neurointerventional radiologist available around-the-clock "for those acute therapies when needed," Gregory says. Because timing is so critical in stroke care, "even accounting for that 15-minute drive that a patient makes to the hospital is crucial, and we can make a difference having a neurosurgeon and neurointerventional radiologist there, ready," she adds. "It has become important to shave off time any way we can. Few hospital systems have a neuro-critical care unit dedicated to the critically ill. In effect, we are changing the face of neuro-stroke care."
Success key No. 3: Improving awareness
While healthcare organizations acknowledge that speed is essential in stroke care, some patients may not be aware that they are having a stroke simply because they are unfamiliar with the symptoms. A stroke sufferer may misinterpret a headache or trouble moving a leg, not realizing that the situation is potentially serious.
Because of that lack of knowledge among the general public, some hospitals are committed to increasing education programs for patients. There is much work to do. Long Beach (Calif.) Memorial began offering an array of education programs after it realized that less than 20% of stroke patients seek hospital care quickly after identifying possible symptoms, says Angie West, the stroke care program director for the MemorialCare Neuroscience Institute, part of the MemorialCare Health System, which has 1,549 beds. "Less than 10% get here in the right amount of time to make a difference," West says.
Generally, the AHA and the ASA aim to increase the number of eligible acute ischemic stroke patients who receive IV rtPA in 60 minutes or less, but that hasn't been easy to do. In a review of more than 2 million patient records contained in the organizations' Get with the Guidelines Stroke registry, only 19% to 22% of patients had a "door to needle" time of less than 60 minutes within the past two years.
Long Beach Memorial runs community meetings to spread the message about stroke care. West coordinated one recently for a group of aeronautical engineers in Southern California. The hospital reached out to the group because of the lack of understanding about strokes, she says.
"We work in the community and try to encourage people in the community to know what the signs and symptoms of stroke are," she says. "The problem with stroke or the challenge with stroke is that it doesn't hurt; people ignore it, because you don't have crushing chest pain or symptoms such as slurred speech or heaviness in the arm. People wait and don't act on it, so it's really important to push the community to get here in the hospital for care," she says.
Hospitals are taking different steps to improve educational processes for patients. The 840-licensed-bed Wake Forest Baptist Medical Center in Winston-Salem, N.C., implemented a coaching program that focuses on stroke patients. The coach is often a nurse, but could be another healthcare professional or a social worker, for instance, says Cheryl D. Bushnell, MD, associate professor of neurology and director of Wake Forest Baptist's primary stroke center.
The coaching program has been included in a pilot project that also includes educational screening tools to help identify hospitalized patients who may be at higher risk for a second stroke or are having trouble with their medications or appointments, says Bushnell. The idea is to improve transition from hospital to home and avoid potential rehospitalization, she adds.
Hospital officials get a sense of patients' health literacy, "such as their confidence in filling out medical forms without help," she says. In her study, 93.9% of those in a coaching group knew what to do if there were problems or if their conditions worsened, compared to 77.8% who weren't coached, she adds. Overall, 93.8% of the patients who had been in the coaching group saw their primary care providers after discharge, while only 60% in the control group made such a visit.
"We are assessing the best way for patients to learn new information through the coaching program," she says.
Success key No. 4: Targeting the TIAs
A big concern for a hospital system is ensuring that patients don't go back to the hospital as 30-day readmissions. The Forsyth Medical Center has reduced its readmission rates in stroke care by working to "bridge the gap" of those who are discharged, says Gregory. The program is run out of the stroke center's Transient Ischemic Attack Center, a dedicated facility for rapid diagnosis and treatment of patients who experienced a TIA stroke, often known as a "ministroke."
The Stroke Bridge Clinic, another Forsyth Medical Center initiative, is an outpatient facility; it provides 30-minute follow-up appointments, as well as coordinating 20 minutes with a pharmacist and 20 minutes with a stroke navigator for stroke patients within one to two weeks after they are discharged from the hospital.
"Our data shows that a stroke patient has a greater chance of being readmitted to the hospital if they do not visit the Bridge Clinic," says Gregory. Indeed, 8.8% of patients who did not receive Bridge Clinic follow-up were readmitted in 2011, but only 2.6% of those who visited the Bridge Clinic were readmitted. Overall improvement continues. From January through July in 2012, readmission rates were 6% for non-Bridge and just 0.4% for Bridge patients.
A TIA occurs when a blood clot interrupts blood flow to the brain, and can last anywhere from a few minutes to 24 hours, but produces no visible damage and can disappear quickly. However, a TIA can be a precursor of things to come, with studies showing that half of all strokes are preceded by a TIA. Studies have shown that people who suffer strokes within 48 hours after experiencing a TIA often have a more debilitating or potentially deadly stroke.
The TIA Center at the Forsyth Stroke and Neurosciences Institute provides for fast-track diagnosis so treatment can be carried out quickly, reducing the risk of a full-fledged stroke in the future. The unit also treats diabetes, heart, or blood pressure problems, and high cholesterol and other conditions that could increase the risk of stroke.
With new protocols, the hospital also has substantially decreased lengths of stay as well as the 30-day readmissions, Gregory says. Both TIA lengths of stay and readmission rates were much lower in the TIA Center than for patients with TIAs admitted to other parts of the hospital. Average length of stay in the TIA Center from January to July of this year was 1.5 days, but was 2.8 days for all other hospital units, the hospital stated.
At the Stroke Bridge Clinic, a neurology nurse practitioner reviews patients' treatment plans to make sure that recovery is progressing as well as it should, according to the hospital. A stroke navigator also guides patients and their caregivers through the recovery process, answering questions and helping with arrangements such as transportation and appointments.
"About seven to 10 days after someone is discharged from the hospital, they go to Bridge Clinic and a specially trained nurse practitioner and educator and a pharmacist have discussions with patients and caregivers," Gregory says. A multispecialty team, including radiologists, pathologists, ED physicians, as well as counselors, an internal medicine physician, and a neurosurgeon, is involved in program planning.
The best use of the Bridge is to provide clarity of information for patients, who are often confused while in the hospital because of the sheer volume of information they receive, she says.
"Clearly, there's a distinct difference for patients who are in Bridge and for patients who are in the hospital right after a stroke," Gregory says. "In the hospital, they get so much information, and it's really difficult to wrap your head around all of it.
"While we created a bridge between the hospital and outpatient," Gregory adds. "We don't replace the family doctor. We partner with them. We want to ensure that patients have everything they need, because they are still at risk for having another event. There has to be an understanding about the medications they need, about their need to make their appointments."
Challenges to patients are mirrored by challenges to hospitals that are likely to see a rising tide of stroke patients needing care with the aging population. How they organize to meet this influx will be a decision that can save lives and elevate the reputations of their institution.
This article appears in the November 2012 issue of HealthLeaders magazine.
These days, any trained observer of the medical landscape is aware of emerging excitement about patient-centered medical homes. In this new era of value-based care, with the move toward Accountable Care Organizations, many groups are wrapping their hopes for improved patient care around the model.
The goal of the medical home is to facilitate cooperative relationships among physicians, patients, and their families to improve care and outcomes.
Paul Nutting, MD, MSPH, a professor of family medicine at the University of Colorado Health Sciences Center and director of research at the Center for Research Strategies in Denver, CO, knows that many in medicine believe the medical home is "a critical step" in reforming the U.S. healthcare system.
But as more plans for medical homes get underway, small physician practices appear to be struggling with the concept, Nutting says. The problem lies with the physicians themselves, he explains.
In a report in this month's Health Affairs, the professor cites the "tyranny of the small primary care practice culture" as a significant obstacle toward medical home development.
Nutting is no mere academic, lobbing grenades from an ivory tower. A family physician with more than 40 years experience in primary care and health services research, he was a founding director of the division of primary care with the Agency for Healthcare Research and Quality (AHRQ).
"When I trained, back in the 1960s and 1970s," Nutting told me, "it was a model in which the physician was everything. You would have a nurse and you, and that was it."
"I have huge respect for primary care physicians, but they are going to have a huge challenge as they redesign their practices," Nutting says.
One of the major challenges for doctors who are either sole practitioners or have only a few colleagues on their staff " is the overreliance on the physician as being at the center of everything," Nutting adds. "The way primary care physicians have been trained, and the way they organize their practices, the feeling is, 'If you want to do something, you do it yourself.' You are thinking right out of the gate that the physician will be the center of it."
There are many examples reflected in small physician practices, he says. For instance, a patient may have an issue that he may want to discuss, but if it is nearing the end of an appointment and not an emergency, such a discussion may be put off. The doctor may say, 'Oh, by the way, make another appointment," Nutting says. "That isn't patient-centered, and we shouldn't pretend that it is."
Nutting says he sees some of the changes needed exemplified in a demonstration project involving the American Academy of Family Physicians that began last year.
The demo includes 1,300 family physicians, including some small practices that tested a bundled payment model, which includes fee-for-service, a per-patient-per-month care coordination fee, and shared savings. In a statement, AAFP President Glen Stream, MD, viewed the initiative as a "game changer" because it aligns public and private payers included in medical home models.
In their review of the AAFP project, Nutting and his colleagues found instances in which "practices made much progress in the transformation to [the] patient-centered medical home." Among other things, physician leadership approaches changed dramatically, he says.
"This most often involved rethinking the mission and strategies of the practice; embracing the need for a meaningful care team approach and adopting a pro-active population-based approach to care," Nutting wrote.
The AFFP demonstration project isn't reflective of what's going on in small practices across the country, according to Nutting.
"In most of our work with more typical small practices, however, we have only rarely observed similar transformations among physician leadership, particularly without sustained external support," Nutting wrote.
The major obstacles for small practices to become involved in medical homes include, according to Nutting:
Physician Centricity:
While small primary care practices may focus on schedules, they may "find it difficult to innovate" to maximize patient-centered care. Nutting says: "Most practice-level decisions are made with little input from those who see the patient experience from other perspectives."
Lack of Common Vision, Communication and Shared Experience:
While many physicians value an "autonomous practice," many rarely engage in "meaningful communication" about their overall practice vision, such as approaches to patient care, their clinical priorities, as well as individual strengths and weaknesses.
For instance, a physician may not have much of a clue how a partner may approach a patient's depression or behavioral changes, except in general terms, Nutting says.
Leadership Behaviors (Authoritative):
In their review of physician practices, Nutting says he and his colleagues continually saw physician staff members seeing their bosses as "powerful leaders" because of their training, clinical knowledge and societal role.
"We have observed many behaviors, usually unintended, that reinforce the power differential between physicians and others," Nutting wrote. Those perceptions manifest themselves throughout the offices: when the physician may not pay enough attention to having staff involved in important office discussions.
Unimaginative Roles of Mid-Level Clinicians:
Mid-level clinicians often do nearly the same work as physicians, Nutting says, but they are "clearly remaining at the lower level of the clinical hierarchy."
He wrote: "We rarely observed mid-level clinicians' being engaged by the practice to perform activities that provided a value-added service, such as care coordination, behavioral health, mental health, family life, or dietary counseling, as they often do in large integrated systems.
Nutting recognizes that in some ways there are elements beyond the physicians' control, such as reimbursement problems. Indeed, payment reform should be considered as part of maintaining the medical home model, he adds.
Bundled payments for episodes of ambulatory care comprise one model that could "incentivize" teams for population-based care, he says.
While reimbursement changes are in order, Nutting says that professional physician organizations should do more to assist small practices for a population-based approach to care, and overcome physician characteristics that are "deeply ingrained."
A "transformation will require new strategies, workshops, and other learning and personal development formats to help physicians," Nutting writes.
Physician groups must help lead the way toward helping small practices change behaviors if they are to become involved in medical homes, Nutting tells me. "I point to the American Academy of Family Physicians, and the American College of Physicians and the American Academy of Pediatrics " among others, Nutting says. "They have to step up and help change the culture. I'll probably get a nasty letter from them for saying this. I just hope we have a reasonable conversation."
In a sweeping series of recommendations, the American Medical Association's governing body this week issued "guiding principles" for physician employment, reaffirmed its opposition to ICD-10, sought improved government payments, and acknowledged the need for improved clinical care on issues ranging from genetic testing to whooping cough.
In meetings over the last two days, the AMA's House of Delegates voted on economic, clinical, scientific and public health issues that the nation's largest physician organization wants to advance in order to "shape the healthcare agenda" of the nation.
The organization's sessions began Monday and ended Tuesday in Honolulu, Hawaii, but even the AMA's top leaders acknowledge that the association is not in a position to shape the entire healthcare agenda.
Indeed, the AMA continues to be frustrated and confronts nagging issues such as pending implementation of the ICD-10 coding. Those frustrations were reflected in what was described as "vigorous debate."
For many physicians, some of the biggest concerns revolved around the workplace. As more doctors are becoming employed by hospitals, the AMA adopted new guiding principles that govern physician relationships with the institutions, AMA President Jeremy A. Lazarus, MD, told HealthLeaders Media in a phone interview.
The guiding principles are intended to help physicians address potential conflicts in hospital relationships, Lazarus said during a break in the AMA's semi-annual policy-making meeting.
The principles address six potentially problematic areas of employer-employee relationships, including:
Conflicts of interest
Advocacy
Contracting
Hospital-medical staff relations
Peer review and performance evaluations
Payment agreements
"It's important that the patient-physician relationship is protected and the patient comes first in terms of what we are doing for them," Lazarus said. "We want to make sure in the employment relationship that there is unfettered communication and that we make sure we do what is best for patients."
Essentially, the AMA Principles for Physician Employment provide a framework to help "guide physicians and their employers as they collaborate to provide safe, high-quality and cost-effective patient care," AMA board member Joseph P. Annis, MD said in a statement.
Physician employment trends are expected to continue, with more doctors entering into employment and other contractual relationships with hospitals, group practices, and other health systems. Nearly one-third of final year residents list hospital employment as their first choice of practice setting, according to physician recruiting firm Merritt Hawkins.
"We are moving into an area where more physicians are employed and we are guiding physicians for that employment," Lazarus added. "And that fits very well with our strategic plan. We spent a lot of time educating our members about the plan."
Earlier this year, the AMA adopted a five-year strategic plan to ensure that enhancements to healthcare are physician-led, advance the physician-patient relationship and ensure that healthcare costs are prudently managed.
While the AMA again flatly sought to rid the government of the sustainable growth rate formula, (SGR) its officials were enmeshed in a "lot of vigorous debate" about the ICD-10, Lazarus said. The AMA has opposed implementation of ICD-10, the disease coding set with an October 2013 launch deadline.
"It's our policy [that] we want to get the ICD-10 stopped, but there was a lot of vigorous testimony on different sides of that. There was recognition by some people that we need to move on to something different." Still, Lazarus said, "the House of Delegates made it very clear we want (ICD-10) stopped."
In other actions, the AMA board:
Outlined a set of principles to guide physician leaders of healthcare teams. "The future of health care delivery is patient-centered and will require a team approach, and physicians and health care professionals need to be prepared to efficiently work together to provide quality patient care," said AMA Board Member Carl A. Sirio, M.D, in a statement.
Presented a report on "workplace violence" in non-hospital work environments. An AMA survey found that 12% of physicians who responded said they were a victim of "at least one incidence of workplace violence in the past 18 months." The most commonly reported form was characterized as verbal complaints.
"In order to provide the best possible care to patients, and maintain a rewarding work environment for physicians and other health professionals, all forms of workplace violence must be addressed," AMA Board Member Patrice A. Harris, M.D., noted in a statement. "This report is an important step towards enhancing the health care workplace setting for both physicians and patients."
Urged the removal of barriers to generic medications. The AMA board adopted a policy to end the practice of "pay for delay" in prescription medicine. That refers to the practice of brand prescription drug manufacturers paying generic drug manufacturers for not creating generic versions of their medications.
Sought federal legislation or regulatory changes to stop Medicare and Medicaid from decertifying physicians due to unpaid student loan debt. The current practice of decertifying physicians with outstanding loan debt stops them from accepting Medicare and Medicaid patients and undermines their ability to repay the student loans, AMA officials say.
Recognized "next-generation" genomic sequencing in clinical applications "for dramatically reduced costs, but said that "implementation challenges must be addressed" to realize the potential of the technologies for improved outcomes.
Advocated for encouraging birth-year based screening practices for Hepatitis C in line with recent Centers for Disease Control and Prevention recommendations. About 3.2 million Americans are infected with Hepatitis C virus, according to the AMA, but more than half are unaware they have the virus, the CDC estimates.
Urged Medicare to improve vaccination coverage for whooping cough by covering Tdap (Tetanus, Diptheria, Acellular Pertussis) vaccines under Medicare Part B. Tdap vaccinations are currently not reimbursed under Medicare Part B, but the rates of whooping cough, formally known of Pertussis, are increasing.
Supported Medicaid expansion in the wake of the Supreme Court decision that upheld the Affordable Care Act. Under the law, it is optional for states to expand Medicaid eligibility to 133% of the federal poverty level. The AMA board advocates for an increase in Medicaid payments to physicians and improvements in Medicaid that will "reduce administrative burdens and deliver healthcare services more efficiently.
Despite the Medicaid expansion vote, sure enough, there wasn't much debate on the Affordable Care Act, a subject of much contention among physicians over the last few years.
"We're moving ahead to implement the Affordable Care Act," the AMA's president says. "There wasn't a lot in the House action related to that."
There was another issue, a longstanding and frustrating one, for the AMA, that made its presence felt at the board meeting. And that's the Sustainable Growth Rate (SGR) formula, which is slated to cut Medicare rates by 30% in 2013.
AMA's "position is very clear" on the SGR: It wants to get rid of it. This week, although there was some discussion about it, the board didn't take a vote on it, Lazarus says. "The Medicare cuts may come in January, and we are looking at the lame duck Congress. The SGR is the looming issue for the next couple of months."