The American College of Physicians says gun-related violence is a public health problem that doctors should address with patients. But few physicians actually do.
It is time to recognize that gun-related violence is more than an endless and polarizing political debate. It is a public health problem that doctors need to start discussing with patients.
That's the unavoidable message from a new policy paper from the American College of Physicians published today in the Annals of Internal Medicine.
Citing the mass shootings in Aurora, Colo., Newtown, Conn., and most recently (and for a second time), at Fort Hood, Texas, ACP President Molly Cooke, MD, FACP, says physicians have a role to play in reducing gun-related injuries and deaths.
"We felt we needed to call the attention of our members and physicians in general to the regularity with which this is happening," Cooke told HealthLeaders Media. "We recognize gun ownership is a constitutional right, but we are intending to call attention to the risk associated with that right, and that people have a responsibility to manage their gun safely."
The ACP outlines nine recommendations for reducing gun-related violence, including waiting periods; a universal background check to prohibit gun sales to felons and people with a mental illness who are at risk for hurting themselves or others; a ban on assault and semiautomatic guns to civilians; safety features such as trigger locks; and more education on preventing gun injuries and death in medical schools, residency programs, and CME courses.
The ACP's position is not new, nor is the organization alone in calling for more physicians to talk to their patients about guns, says Daniel Webster, director of the Johns Hopkins University Center for Gun Policy and Research. The American Academy of Pediatrics advocates talking to patients about gun ownership as part of the general conversation about safety precautions.
"When I studied pediatricians about 25 years ago, even though they recognized guns as a safety hazards for children and teens, they hadn't felt it was their place to bring up the topic," says Webster. "But times have changed, and in pediatrics, asking about guns in the home has become more commonplace. Pediatricians can talk about guns in the context of child development (their impulsiveness, inability to consider long-term consequences) and injury prevention."
As the mother of a seven-year old boy, I'm very familiar with safety questions. In fact, they are old hat now, but I remember that first visit to the pediatrician. Did we always use a car seat? What type of bathtub were we using? How often was he eating?
As my son got older, the list got longer: Does he always wear a helmet when riding a bike? Do we use sunscreen? Does he know the rules about talking to strangers? Is there a gun in the house? Scratch that last question—I have never been asked it by my son's pediatrician. I have also never been asked that question by my own primary care physician. And chances are the question is foreign to you, too, as a patient and as a physician.
Few physicians discuss guns
In addition to its new recommendations for reducing gun-related injuries and death, the ACP also released a survey of 573 general internists, representative of the ACP membership. The findings concluded that 85% of internists believe gun-related injuries and deaths are a public health issue, yet most report they don't initiate these types of conversations.
The survey included five specific questions about how frequently physicians discuss gun-related issues. Only 3% say they always ask whether a patient has a gun in the home; 58% report never asking. When it comes to talking about ways to reduce the risk of a gun-related injury or death, 2% say they always have this conversation with patients, 21% say they do sometimes; and 77% reported never talking about it. The remaining questions garnered similar responses.
The gap in physicians' belief and action is noted in the ACP's survey results, and the authors state that further study is needed to determine why physicians are reticent to talk to patients about something they obviously believe is a public health issue.
Cooke suspects that one reason physicians don't bring up guns in the exam room is because they know it is a volatile issue.
"Doctors, in general, attempt to avoid politicized conversations with their patients," says Cooke, who admits to having been part of the majority of physicians who do not ask patients about guns in the home.
"I ask patients, 'Do you feel safe in your neighborhood? In your home? With your partner?' " she says. "I have had patients bring up the fact that there is a gun in the house in response to those questions. This policy paper has sensitized me to this issue. Now I know to ask, 'Do you have a gun in your house?' "
Webster also sheds some light on why guns are not part of routine questions physicians use to find out more about their patients.
"I've found that many people think of gun safety as something that deals with safe handling and storage of guns, and those don't seem to be within the wheelhouse of physicians," says Webster. "But when medical, behavioral, or social conditions come to the attention of the physicians that are relevant for self-directed or intrapersonal violence, the physician has credibility and a comfort zone to discuss gun-related risks and how to reduce those risks."
Viewing guns in the home as a risk to be mitigated in a doctor's office could take some of the political sting out of the conversation, though there has been legislation introduced in states to prohibit doctors talking about guns with patients.
The "Docs vs. Glocks" lawsuit spurred by a Florida bill passed in 2011 is the most well-known example, but a similar law in Tennessee was proposed this year. A federal judge issued an injunction in Florida that prevents the law from being enforced.
Cooke acknowledges that doctors will have to be educated on how to talk to patients about guns. It won't be easy, but the time has come, she says.
"Physicians are a trusted voice in the service of health and safety and we're not comfortable being silent when we see a significant public and health safety issue."
As physician reimbursement shifts from a fee-for-service model to a value-based structure, expect to see changes in how compensation plans are drafted.
Quality and patient satisfaction benchmarks are not only affecting physician reimbursement levels, but they are also a growing component of physician compensation formulas, multiple and independent studies show.
Hospitals and health systems have already been focused on HCAHPS scores, which attempt to measure patient satisfaction, though there is plenty of conversation about whether the survey is an accurate measure of how a patient is treated during a hospital stay. But there is a growing body of research that indicates physician and healthcare executive compensation is or will be tied to patient satisfaction, too.
A February 2014 study from Sullivan, Cotter and Associates (SullivanCotter), 2013 Physician Compensation and Productivity Survey Report, shows an increase in hospitals and healthcare organizations tying portions of compensation to metrics such as quality and patient satisfaction.
As a percentage of the total compensation package, the average amount that was tied to a quality metric was 5%. The dollar amount varied among primary care physicians and specialists, with specialists receiving more than PCPs, though overall, the report showed a higher overall increase in cash compensation for PCPs.
Kim Mobley, managing principal of SullivanCotter, said in a statement that the firm is also closely watching the correlation between patient satisfaction and compensation. "As reimbursement shifts from fee-for-service to value based, we expect to see some shifts in the balance of the compensation elements that comprise physician compensation plans," she said.
A similar survey of medical practice groups by SullivanCotter for the American Medical Group Association shows the same thing: Patient satisfaction is projected to be a part of a compensation package. The AMGA's 2012 report on compensation included multi-specialty groups, academic medical practices, and non-profit organizations. In other words, the shift in compensation models is not happening only in hospitals, but in academic settings, multi-specialty practices, health systems, and among insurers.
The finding mirrors HealthLeaders Media's research published in our November 2013 Intelligence Report, Restructuring Executive Compensation for the Shift From Volume to Value showing that more pressure is being put on C-suite level executives to meet qualitative benchmarks. For example, 65% of executives surveyed said indicated that patient satisfaction would factor into incentive payments for 2014.
Insurers in the Mix
Tying payment incentives to increases in qualitative benchmarks is nothing new to insurers, though some are aggressively expanding its base of who can participate in incentive payment arrangements.
Cigna last week announced that the collaborative accountable care (CAC) program it launched in 2008 targeting large physician groups that also have a significant primary care component is now available to smaller physician groups, specialists, and hospitals.
Cigna's CAC program financially rewards practices for better care coordination, reducing medical costs, and meeting other quality targets. For this smaller group of practices, the initiative is called Cigna Collaborative Care, and it's currently being piloted at four groups in Texas, New York, Florida, and Connecticut.
Reagan Armata, product director for Cigna, says the large groups consisted of 20, 50, or 100 physicians or more; the smaller group practices that are part of the new Cigna Collaborative Care are "substantially smaller."
The insurer is going after the smaller market because it has found that only 20% of its members with expensive or complex medical conditions were going to the larger medical groups. "By meeting them where they are, we can work with physician groups regardless of their size in a variety of ways," says Armata.
Cigna's overall goal, which it says is on track to meet, is covering 1 million insured through 100 collaborative agreements by the end of 2014.
Tying Incentives to Quality
The aim of handing out incentive payments to hospitals, physicians, and health systems is to ultimately improve quality while also reducing costs. Some studies show a positive relationship between the two, but there is also some tension about rewarding physicians for a patient's satisfaction.
Back in 2011, the popular physician-centric blog, KevinMD.com, ran a three-part series on the downsides of paying "popular" doctors more based on a patient's evaluation of the care they received. The series pointed out that doctors who are pressured into pleasing patients doesn't necessarily equate to good patient care.
The healthcare delivery system in this country is undergoing a sea change, with healthcare organizations scrambling to put in supports, carrots, and sticks, in order to respond to declining reimbursements, more patients, and physician shortages—not to mention physician stress.
It's hard to tell which lever will be the most effective at moving the needle closer to the triple aim, and whether it's right or wrong to tie patient satisfaction to compensation and reimbursement. But one thing is certain: The qualitative benchmark is a line in the sand that is here to stay.
Advances in cancer diagnosis and treatment and longer-term survival rates point to a growing need for interdisciplinary provider teams to meet the needs of patients as the supply of oncologists is predicted to decline.
We've been hearing dire warnings about physician shortages to come. Now we're starting to see specifics. A report on cancer released by the American Society of Clinical Oncology this month projects a shortage of 1,487 oncologists by 2025.
Richard Schilsky, MD
Chief Medical Officer of ASCO
An aging workforce, longer survivorship of cancer, and an increased need for oncology services will all contribute toward the future gap in supply and increased demand, the report finds. Closing that gap would require a bigger care team that is clinically trained and educated to care for cancer patients, says Richard Schilsky, MD. He is ASCO chief medical officer.
"We think it's important that the oncology care team in the oncologist's office be expanded to include nurse practitioners, and physician assistants, [and] advanced practice providers," says Schilsky. "They can see the uncomplicated patients; the patients who are in for a follow-up visit, leaving more time for the oncologist to deal with the very sick and very complex cases."
Giving NPs, PAs, and APNs a bigger role with patients probably sounds familiar. That's because these roles are also being pointed to as an answer to a projected PCP shortage, though some PCPs are not as open to the idea.
Oncology nurses are embracing the move to play a bigger part in patient care, says Mary Gullatte, PhD, RN, ANP, president of the Oncology Nursing Society.
"With advances in diagnosis and treatment, long-term survival has significantly increased, which requires more long-term care," says Gullatte. "Advanced practice oncology nurses are in an ideal position to work collaboratively as part of the interdisciplinary oncology team to meet the needs of patients with cancer and to fill the gap left by the shortage of other members of the cancer care team."
Because oncology nurses are already a key part of cancer care, Schilsky says it may be easier for his peers to accept and expect nursing's expansion in oncology.
"Part of it relates to the fact that oncologists are used to working with highly skilled nurses every day in our practices," says Schilsky. "Every oncology practice employs oncology certified nurses who give the chemotherapy, who are essential members of the oncology care team."
Shifting Oncology Workforce
An analysis of the current oncology workforce shows 13,400 medical oncologists and/or hematologists. But, the oncology specialty also mirrors the trend of medicine in general of an aging workforce. In 2008, there were more oncologists 64 or older, and that gap has continued to widen.
Also, demand for oncology services is currently projected to grow by 42%, while the workforce is expected to grow by only 28%. Those figures do not include demand from additional patients who will need and receive services through the Patient Protection and Affordable Care Act. Factoring those patients into the mix means an even bigger strain on oncologists and patients.
In addition to giving oncology nurses more responsibility, Schilsky envisions a bigger role for PCPs, too, especially when a cancer patient becomes a cancer survivor.
"In most medical communities, the PCP is the coordinator of care and therefore does have strong relationships with any number of medical specialists," he says. Educating PCPs on cancer care and follow-up is key to including them as part of a cancer team.
PCMH to the Rescue?
The looming shortage of oncologists boosts one physician's view that patient-centered medical homes may be an answer. John Sprandio, MD, FACP, who has developed a PCMH for his oncology practice in Pennsylvania, says ASCO's report supports the same goals as an oncology PCMH: efficient, consistent, personalized, and better patient care.
"It makes the case for an Oncology Patient-Centered Medical Home model of care that drives the consistency of cancer care delivery, leverages technology to maximally support physician oversight and efficiency, while meeting the needs of our patients and their families."
Sprandio's Consultants in Medical Oncology and Hematology (CMOH) was the first oncology practice to be certified as a level 3 PCMH by the National Committee for Quality Assurance, back in 2010. But it took years before it attained the level of highly coordinated care that exists in his three-location practice today. And that may be a barrier too high for some oncology practices to cross, says Schilsky.
"It's certainly a great idea, and it's certainly difficult to adopt," says Schilsky who notes that the ASCO worked with Sprandio on a grant to expand the oncology PCHM to other practices across the country. It didn't get funded, though they are looking for alternative funding alternatives.
"It requires a substantial investment in staff, and health IT infrastructure," says Schilsky.
In addition to expanding nursing's role in oncology and exploring alternative care models, ASCO's report also recommends trying to prevent professional burnout.
Harvard Medical School's Center for Primary Care uses staff social workers, community resource specialists, and, eventually, telepsychiatry to make mental health part of its healthcare practice.
Harvard Medical School launched an ambitious plan to transform primary care delivery and education four years ago with the opening of its Center for Primary Care. Aimed at developing models of sustainable transformation to help doctors deliver better care under tremendous cost and quality pressure, one of its recent projects is now tackling mental health.
Called the Alice Rosenwald Initiative, the program involves six primary care practices in Massachusetts that are taking steps to integrate mental health services for their patients using a team-based approach. Four of the primary care sites are affiliated with Cambridge, Mass.–based Cambridge Health Alliance, the integrated health system that is also a teaching hospital for Harvard Medical School. The other two sites are affiliated with Boston Children's Hospital. Eventually, the mental health integration initiative will be implemented at all six Harvard-affiliated hospitals as well as 19 practices.
"Mental health disorders are so common that it's really part of the skill set that primary care doctors need to have in order to be a resource and help their patients manage their health," says Russell Phillips, MD, director of the Center for Primary Care. Phillips is also a practicing primary care physician at HealthCare Associates, a primary care practice at Beth Israel Deaconess Medical Center.
Like other primary care docs across the country, Phillips has been on the front lines of seeing patients with mental health issues; however, at his practice, there are mental health treatment options for patients, something he acknowledges is not widespread.
"In my practice, we have four social workers who take care of about 40,000 patients," says Phillips. "They've been historically part of our practice since the mid-'70s; for us, [this] is not a new innovation. Across some of the other practices, it's brand new."
The social workers are considered to be part of the team at HealthCare Associates, says Phillips. If he sees a patient who is presenting with depression or anxiety at a visit, he can give a "warm hand-off" to a social worker who can help that patient quickly.
With social workers on site at the primary care office, Phillips has says he has noticed two significant and positive shifts. First, he says, because of the stigma that is often carried with mental health issues, the patients are more likely to return to a primary care practice setting, where they are familiar with the staff and physicians.
"The fact that it's not marginalized in sending patients somewhere else is important," says Phillips.
Second, because mental health is an issue physicians at HealthCare Associates are dealing with every day, it's not a topic they shy away from. "Because we have treatment resources, all of us are much more open to hearing about mental health issues that our patients are bringing to our practice," he says, noting that doctors who don't have such treatment options may feel stuck because they don't have a way to help.
"When you have no treatment approach, you have nothing to offer, and it's very easy just to not ask questions that are going to frustrate you because you don't have an answer."
In addition to social workers, HealthCare Associates employs community resource specialists, who act as social service coordinators for patients who may need financial, medication, and food assistance.
Even with all of these services, Phillips says one big piece of mental healthcare is missing. "What we don't have in my practice is psychiatry. It becomes a real problem when I want the expertise of a psychiatrist."
That's a sentiment many physician offices and hospitals share because there is a shortage of psychiatrists and mental health providers nationwide.
"That's a big issue right now because in Massachusetts, many psychiatrists don't even take insurance—they're paid out of pocket, and there's a lengthy wait," says Phillips.
Phillips says for the six primary care sites that are integrating mental health into their practices, telepsychiatry will help address the problem of access. Each site is picking its own psychiatrists to work with—an important relationship that needs to be built between each practice and provider, says Phillips. Those psychiatrists will be available for doctor and patient consults.
Another key piece of the care team at these six sites will be population managers who will track patients receiving mental health services. Phillips says the population manager's role isn't to provide treatment but to track the patient's progress, develop a relationship with the patient, and report back to the team.
"This gets to the issue [that] we need to be taking care of patients whether they're in the office or not," says Phillips. "We can't rely on the patient to come back in the office, and especially with something like depression, you have to have a way of reaching out and connecting."
Ninety percent of organizations use temporary physicians and other clinical staff, a figure one temporary staffing executive calls "incredible." And the profile of locum tenens physicians has changed: Seven in ten have two decades of experience and half are mid-career professionals, survey results show.
Hospitals and healthcare facilities have increased their use of temporary physicians significantly over last year, a new survey shows. Bonnie Britton, senior VP of Staff Care, an Irving, TX-based provider of temporary healthcare clinicians, says her firm's study results show 90% of healthcare organizations using locum tenens providers.
That's a 22% increase over the previous year, when use of locum tenens doctors was at 73.6%.
"To have 9 out 10 organizations using locum tenens—that's incredible," says Britton. "We've been doing this survey for 11 years, and we've never had these results before."
Britton attributes the growth, in part, to a "constrained" supply of physicians, and that supply is expected to continue to decline. The Association of American Medical Colleges estimates the physician shortage will be 131,000 by 2025, though there are already federally designated health professional shortage areas (HPSAs) across the country.
As of January, the federal Health Resources and Services Administration reported 6,000 primary care HPSAs and nearly 4,000 mental health HPSAs. These two categories of providers are the same ones that hospitals use locum tenens for the most.
To accommodate its need for more PCPs, Britton says healthcare organizations are increasingly turning to nurse practitioners. Last year's survey showed organizations' use of NPs at 7.8%; this year that jumped to 15.38%—a 97% increase. NPs are viewed by many to be an answer to physician shortages, but others, such as the American Academy of Family Practitioners, believe improving reimbursement is key to slowing down the looming doc shortage
Samuel Williams, MD
A Financial and Professional Boost
The profile of a locum tenens physician may be surprising. It's not the newly minted doctor who isn't sure where to put down roots. Instead, Britton says her research shows that half of all locum tenens physicians are mid-career professionals.
"We see that 90% of locum tenens physicians have 11 or more years of experience; 70% have more than 20 years of experience," she says.
Samuel Williams, MD, a general surgeon who retired from Carilion Roanoke Memorial Hospital in 2001 is an example of the latter. He's been practicing as a locum tenens provider for hospitals for five years.
"It's a boost, both financially and professionally," he told me while on his way to vacation with his family—something Britton points out as a perk of being a locum tenens doctor, particularly now because more physicians are looking for a work life balance rather than 100-hour work weeks.
"Anecdotally, locum tenens physicians are driven by three key factors: flexibility; travel; no office politics," says Britton.
Williams represents a smaller proportion of the type of provider hospitals hire temporarily (general surgery), but Williams says over the years he's noticed more turnover at rural hospitals.
"It's harder to attract a high quality general surgeon and keep them there," he says. "A lot of times I hear about pretty good places [to practice], but a year later they're advertising. In rural areas and smaller hospitals, it's a revolving door and there seems to be a lack of commitment on behalf of surgeons."
When that "lack of commitment" happens, Williams is happy to step in because practicing in a rural setting is what he prefers.
"I strive to be a complete surgeon, not just a warm body," he says. "I liked the slower pace and the bread and butter type general surgery."
A Place Holder While the use of locum tenens physicians has its roots in rural medicine, the survey results show that it has moved into metro areas that are facing pressure with the transformation of healthcare delivery.
Analyzing the survey's results from 2009, one year before the Patient Protection and Affordable Care Act was signed into law, is eye-opening. For example, back then, the main reason hospitals used locum tenens physicians was to fill in for staff who were vacationing or on leave for continuing education.
That is now the number three reason hospitals use a locum tenens physician. Back in 2009, the third most popular reason for hiring a locum tenens doc was to test market a new service. That reason has all but disappeared today.
Today the main reason for using locum tenens is to fill in for staff who have left an organization or to fill in until permanent doctor is found.
Stefan Trocme, MD, a 58-year old cornea specialist who retired as a tenured professor from Case Western Reserve University, has been filling in as a locum tenens for about a year, says the instability in healthcare is driving not only the need for more locum tenens, but also filling a pipeline with experienced physicians who still want to contribute to medicine.
"I have something I never had in my professional career—control over my time," says Trocme. "You were very limited in the amount of time you could spend away from work. And, having worked in academics, office politics took way too much time. As a free agent and entrepreneur, you are not so embroiled in all that.
For physicians, emotional intelligence is not about seeming happier around patients. It's about recognizing the best way to give a patient information, which can raise patient engagement levels and affect outcomes.
Rick Lopes, MD,
SVP of health networks at SCLHS
To meet the demands of healthcare's transformation from volume to value, organizations are increasingly focusing their efforts on how to better manage patients across the care continuum. Some systems are partnering with post-acute care providers, such as home health and skilled nursing facilities while others are investing in these services under their own umbrellas. Regardless of the business arrangement that hospitals and health systems settle on, physicians play a key role in their patients' care transitions.
Last March, Denver-based SCL Health Systems, a nonprofit system with eight hospitals in three states, announced a joint venture with Univita Health, a home care management company. The partnership is one of many examples health systems are turning to with the goal of better managing quality, outcomes, and patient experience.
Rick Lopes, MD, SVP of health networks at SCLHS, says they spent a lot of time picking the right partner. He says leadership got to know one another through workshops and LEAN management events SCLHS hosted. The two organizations also set out clearly defined goals and planned the details of each handoff.
It's at this transition, whether it's from hospital to home or hospital to rehab or another facility, where a physician can make a big difference in the patient's plan of care, says Christopher Zipp, DO, FACOFP, FAAFP, osteopathic director of medical education for Atlantic Health System, a nonprofit, five-hospital system based in New Jersey.
"With so many different provider touch points, it's harder to manage the patient throughout their continuum," says Zipp. "How do doctors "handshake" over patients? How is information delivered in a culturally competent manner?"
All key questions that need to be answered when considering not only a partnership, says Zipp, but also within a hospital's walls, from intake to nurse, from nurse to physician, etc. With each transition is an opportunity to win over or lose confidence with patients and their families.
The heightened awareness of patient experience and patient satisfaction has led hospital leaders to focus on communication techniques with patients. White boards in patients' rooms that identify the clinical care staff by name and spell out what to expect in treatment have become a common tool to close the communication gap between the hospital staff and patients.
Physicians' Emotional Intelligence
Paying more attention to patients' needs is a step in the right direction, says Zipp, but thinks that doctors need to go further. He says what medical schools have referred to as cultural competence is now known as emotional intelligence, and his goal is to raise it among the residents he oversees and physicians he works with.
"In the residency program I run, I teach them to consider the patient as a whole," explains Zipp, who tells residents to consider the biological, psychological, and social wellbeing of a patient. "We are all sculpted by our experiences… but I think it is also something that is teachable and learnable."
Residents learn to better communicate with patients by reviewing videos showing them interacting with a staged patient. Focusing on raising the emotional intelligence of physicians who are already in practice is more difficult, admits Zipp. He says the usual approach of going to physicians with data doesn't always work. Instead, Zipp says he tries to find a shared value, which is usually the care of the patient.
"One of the lines I've used before is, 'You may not be aware of how you're perceived, and this is how it affects your patient care,'" says Zipp who explains that it's hard for physicians to know they've missed the mark with a patient because they want to do a good job.
Financially Rewarding Behavior
A doctor who is able to understand the best way to give patients information in a way they will understand and find meaningful will likely be able to take advantage of alternative payment models that are being set up as part of healthcare's transformation.
Why? Because those patients are more likely to be engaged, says Zipp, which leads to better medication and plan of care adherence. It's not a silver bullet, but it could significantly reduce barriers that influence a patient's care when they are out of your hospital.
Zipp says emotional intelligence is not about making physicians seem happier or easier to be around. It's about recognizing the best way to give a patient information. Zipp uses the example of patients who have a paternalistic view of physicians. He says with these patients, it's probably not best to walk in the exam room with five or six options and then ask what he or she prefers. These type of patients expect a physician to be the expert.
"You have to go into with a couple of options and say, 'Here's what I recommend,' " he says. "It really comes down to how physicians relate with their patients and really access a patients' resilience and their ability to overcome or manage their medical condition."
"Patients' responses and [the] ability to read the room is something we can teach physicians to be perceptive of," says Zipp. "It's powerful, and it permits us to reflect upon our actions, and do better the next time."
When it comes to transitioning patients out of the hospital to another provider, Zipp says a doctors' relationship with the patient can impact the outcome.
"I think emotional intelligence speaks to the relationship a patient has with their physician," says Zipp. "It's going to put the patient in the best possible healing environment."
Rick Lopes, MD, SVP of health networks for SCLHS will be talking about the strategies used to pick Univita Health as a partner during our March 14 webcast. He will be joined by Amy Boutwell, MD, MPP, founder of Collaborative Healthcare Strategies. She is also a physician at Newton-Wellesley Hospital (MA) and co-founder of the State Action on Avoidable Rehospitalizations (STAAR) Initiative of the Institute for Healthcare Improvement.
On any given day, there are scores of psychiatric patients waiting in emergency departments for an inpatient bed. The strain on the healthcare system will worsen this year, as federal rules expanding behavioral health benefits come into play.
Federal rules for 2014 give Americans more access to behavioral health coverage, but providers' ability to meet what may be a pent up demand for services is questionable. That's because hospitals and health systems are already struggling to meet the needs of a growing number of patients with mental health diagnoses.
There is no shortage of examples that show the limits of mental healthcare in this country. On any given day, there are scores of psychiatric patients waiting in emergency departments for an inpatient bed. Known as boarding, the amount of time a psych patient waits in an ED varies across the country. In California, the average is 10 hours. In central Ohio, it's 19.
EDs are a common landing ground for psychiatric patients because over the last decade there has been a reduction of inpatient beds, psychiatrists, and state funding for mental health services.
California is one of the many states where the issue of psychiatric patients waiting in EDs is acute. Out of the state's 58 counties, says Sheree Kruckenberg, VP of behavioral services for the California Hospital Association (CHA), 26 have no psychiatric treatment facilities.
"Most counties have just washed their hands and are leaving it up to the hospital EDs to manage this population," says Kruckenberg.
"Our coastline in central California is doing quite well, and Los Angeles is doing quite well, but we've got some unique challenges in California," she says, citing a 2012 CHA study that showed a 47% increase in individuals presenting at the state's ED with a behavioral health diagnosis between 2006 and 2011.
The pressure on EDs to treat more and more psychiatric patients began almost a decade ago, but now, with the new mental health benefits granted to patients because of the Patient Protection and Affordable Care Act, access, or lack of access, is likely to become a heightened pain point this year.
Behavioral and mental health services are considered one of the 10 essential benefits that health insurance companies must offer in order to participate in the health insurance exchanges. As of this week, the Centers for Medicare & Medicaid Services announced that 4 million individuals had signed up for insurance on the exchanges nationwide.
Not much is known about this population yet, but since the exchanges were set up to insure people who didn't have access to insurance previously, it is a safe assumption that there will be an initial increase in utilization rates says Alan Whitters, MD, director of behavioral services at Mercy Medical Center in Cedar Rapids, Iowa.
"We know that patients who do have psychiatric disorders overuse the system," says Whitters. "What usually happens, due to liability concerns, is that ED physicians don't feel comfortable discharging a psychiatric patient. Someone says they're suicidal, they know the magic word to get into the hospital. Sometimes "three hots and a cot" does wonders."
For the psychiatric patients who are not overutilizers, Scott Zeller, MD, chief of psychiatric emergency services for the Alameda Health System in Alameda, CA, says too many organizations are not looking for alternatives to inpatient beds.
"It's the only area of medicine where the only solution for every [mental health] problem is admit to the hospital first and start treatment later," says Zeller. "It doesn't make any sense to me. It's as if you went to an ER having an asthma attack and they said, 'We're going to try to get you a hospital bed,' then finally they get you a hospital bed, and then start the inhaler treatment."
"It's the equivalent in psychiatry. Not nearly enough places are considering trying to do urgent treatment on arrival, seeing what they can do in those first 24 hours when so many patients can have their urgent symptoms relived."
Clarifications to the 2008 Mental Health Parity and Addiction Equity Act 2008 are also an additional component that could drive demand for more psychiatric care. Late last year, put more muscle behind the law, requiring doctors and insurers to treat mental illness the same as physical illness. This means services can get reimbursed easier, which could help meet the demand for psychiatric care, but it's too early to tell what the effect will be, says Zeller.
"It's a mixed bag," he says. "I don't think it's been established long enough yet that we have really been able to see if it is going to have a major effect; though even if you're getting a real solid reimbursement rate for psychiatric beds. If you've got a limited number of beds and you're not getting enough treatment in the emergency outpatient setting, it doesn't matter how good the reimbursement is unless you have a place for somebody to go."
And so starts the vicious and sometimes violent circle of psychiatric patients in the ED. After getting them out, where do they go? There are residential facilities, community homes, [and] psychiatric hospitals, but these are not the places where psych patients often end up, says Whitters.
"The pendulum has swung, and our society has determined that it's not okay to institutionalize people, but it is okay to put them in jail."
A flourishing community of support is emerging for entrepreneurial physicians who believe they may have the next great idea for healthcare.
Tim Gueramy, MD
As more physicians leave private practice to join hospitals and health systems as part of the employed workforce, some in the industry are raising questions about the disappearing identity of physician entrepreneurs.
If the definition of a physician entrepreneur is limited to a resident who opens a private practice, then it is easy (in some parts of the country) to say the days of physician entrepreneurs are drawing to a close.
But there are plenty of examples that point to a flourishing community of entrepreneurial physicians who believe they may have the next great idea for healthcare.
In Austin, Texas, Tim Gueramy, MD, an orthopedic surgeon, and Tracey Haas, MD, a family physician, head up The Walters Physician Incubator, a sort of training ground for doctors who want to pursue their own business idea. Gueramy and Haas are husband and wife who launched their own product two years ago, DocbookMD. It's an app that allows physicians to share HIPAA-compliant information. Haas and Gueramy say they are using the lessons they learned from creating DocbookMD to help their fellow "doctorpreneurs."
"Six years ago, we had a need," says Haas. "We went to our hospital, we went to Motorola, we went to big corporations and said, 'Doctors need to be able to communicate better, but we have to do it in a secure way,' and we got laughed at. So we started our own company, and we really think physicians stepping in to answer a problem is a trend."
Tracey Haas, MD
The Austin-based incubator formally launched in 2013 and is open only to physicians. What started out as informal Thursday afternoon conversations with other doctors at the DocbookMD headquarters has grown into structured monthly meeting with increasing interest. Haas says 97 physicians are registered to attend the next incubator meeting.
Physicians 'DIYers by Nature' "The doctors that come to our meetings are a diverse group," she says. "From residents to physicians in their late 60s. Some people are looking to improve processes, some have ideas for gadgets or surgical tools."
The meetings are free and there are only two rules:
You must be a physician.
You must have a business idea.
The incubator does not pair physician ideas with investors, though that may happen in the future as the incubator matures. Instead, Gueramy and Haas address what physicians need to do to launch their idea, which often starts with teaching them how to work and rely on other people. Physicians are DIYers by nature, explains Gueramy.
"Getting into medical school—you do it yourself; getting into residency—you have to do it yourself; you treat patients by yourself," he says. "We have been taught that we are an island to ourselves. You really have to change your view of how to work with other people."
Gueramy believes he and Haas are able to break through the cultural barriers because they had to learn the same lessons when bringing DocbookMD to market.
"We had to learn to open ourselves up," he says. "We had to talk to a lot of people; we had to be a lot more collaborative to get our ideas out."
'Compassionate Capitalism' The grass roots type of physician entrepreneurship building in Austin is not surprising, according to Arlen Meyers, MD, MBA, President and CEO of the Society of Physician Entrepreneurs (SoPE).
"Top-down, cluster-based innovation is being replaced or significantly supplemented by community-based innovation," he told me. "Most of the innovation is coming from the trenches, not from the academics."
Meyers has co-founded four companies, and is a professor of otolaryngology, dentistry, and engineering at the University of Colorado in Denver. He is passionate about the physician as an entrepreneur, which is why he helped start SoPE in the first place.
"The unmet need that I saw was based on my own personal experience of doctors having ideas, but either not knowing what do with them, or knowing what to do with them but having such a hard time getting the resources, they just gave up," he said.
Originally, SoPE was focused on "ear, nose, and throat surgeons who were gadgeteers," but it became all-inclusive when it garnered interest from other physicians. Meyers has written extensively on the opportunities and challenges of physicians becoming entrepreneurs, including the idea that medicine and entrepreneurship are not compatible.
"I call it compassionate capitalism," he says. "The primary interest has to be the patient. As soon as you replace the patient with a profit motive, you're toast."
The end of the sustainable growth rate formula is finally in sight, but the nation's primary care shortage and persistent drug shortage also made headlines this week.
While that story rightly got most of the media spotlight, other developments affecting physicians should not go unnoticed:
UT Bill Seeks 'Pipeline' to Primary Care
New Mexico Senator Tom Udall, a Democrat, has introduced federal legislation aimed at increasing the number of primary care services in his state. Only one county in the southwest state is not federally recognized as having a shortage of PCPs.
Udall's bill calls for what he calls a "pipeline" that would supply more primary care services to underserved areas. It's a mix of incentives for medical students to pursue providing care in a rural setting, funding centers that focus on rural healthcare, and "refocusing" funding for graduate medical education.
The pipeline strategy Udall wants to use is one that the American Academy of Family Physicians has recommended, too. Ted Epperly, MD, former AAFP president, suggested at a recent rural healthcare forum in Washington D.C. that developing a future workforce of physicians who want to work in rural areas could begin very early—with K-12 students.
The AAFP also wants to protect funding and increases for the Rural Training Track program, which offers medical training in both rural and urban areas. More than 70% of graduates who go through the RTT program end up practicing in a rural setting. RTT programs are paid for through federal, state, grant, hospital, and other intermediary sources, which are not stable.
Udall's bill includes reauthorizing the Teaching Health Center program, which is a community-based ambulatory center that serves as a primary are residency site.
UnitedHealth Loses in Federal Court, Again
The country's largest provider of Medicare Advantage plans was dealt another blow in federal court over cutting 2,200 MA doctors from its network in Connecticut.
UnitedHealthcare lost its appeal to dismiss the lawsuit initiated by the Fairfield County Medical Association and the Hartford County Medical Association. The associations content the insurer has violated federal law with the cuts because no explanation was offered to the physicians.
The three-judge federal appeals court panel last week also changed the terms of the restraining order UnitedHealthcare has been operating under since December. The court previously halted the cuts, but now says that the affected physicians have 30 days to appeal UnitedHealthcare's decision.
It's the second time a federal court has sided with the medical associations. In January, the court ordered both sides to mediation. UnitedHealthcare had requested that the temporary restraining order be lifted. Earlier this year, UnitedHealthcare spokeswoman Jessica Pappas, said the reason the insurer's MA physicians were being cut was due an increase in quality standards.
The Medical Society of the State of New York, as well as other medical associations, are watching the court case in Connecticut closely because of UnitedHealthcare's vast reach into the Medicare Advantage market. Any forced changed into how it designs, changes, or protects its MA network has implications nationwide.
Quality Problems Still a Factor in Drug Shortages
A report from the Government Accountability Office shows quality as a major contributing factor to drug shortages. The report analyzed data from the FDA, and the University of Utah Drug Information Service between 2007 and 2013.
The drug shortage peaked in 2011, and the GAO issued a reporting recommending that the FDA strengthen its oversight and enforcement of drug manufacturers. New FDA requirements were issued in 2012 based on the GAO's recommendations.
Based on feedback from individual drug manufacturers, the GAO has determined that quality is the main reason for the shortages. An audit of FDA data shows 40% of the drug shortages between January 1, 2011, and June 30, 2013, are due to quality concerns. Additional reasons for the shortages include manufacturing capacity, discontinuing products, availability of raw materials, and increased demand.
The GAO report recommends the FDA improve its internal processes to better analyze drug shortage data and well as being more proactive to mitigate the drug shortage risk factors.
The head of a multi-physician oncology practice and patient-centered medical home explains how his practice is "capable of signing any payment methodology that any payer could dream up."
The transition from volume-based care to value-based care is churning up anxiety about revenue and reimbursements among many physician leaders.
John Sprandio, MD, FACP, is not one of them.
Sprandio, founder and leader of Consultants in Medical Oncology and Hematology (CMOH), believes his three-location, eight-physician oncology practice in Drexel Hill, PA., is ready.
"I feel that we are prepared to respond to any changes in the payment system… I have no preference," says Sprandio. "We're capable of signing any payment methodology that any payer could dream up. I am not kidding."
Sprandio's confidence stems from years of fine-tuning the physician workflow at his practice to establish efficiencies for the doctors and reduce variability for the patients. His confidence also comes from CMOH's status as the first oncology practice to be certified as a Level 3 patient-centered medical home by the National Committee for Quality Assurance.
That certification came in 2010, and was sort of incidental. Sprandio says he was not working toward PCHM status, rather he was working toward the goal of giving his patients consistently good care.
"The heart of what we did, and the heart of this model, is really taking a critical look at the physician work environment and overcoming some of the barriers that we face as physicians on our way to becoming more accountable for quality and consistency of care and cost."
The work that led to gaining PCMH certification began in 2003 after Sprandio and others in the practice took to heart a 48-page white paper by Alice Gosfield and Jim Reinertsen MD, titled, Doing Well by Doing Good. It was a critical look at what Sprandio calls physician "time stealers" that prevented delivering consistent care.
"Variation is so common in healthcare delivery," he says, citing communication and documentation burdens as part of the reason for disparities among physicians, as well as systems that lack coordination, measurement, and outcome targets. "Anybody who says, 'There's five doctors or there's 20 doctors and we all do things pretty much the same,' they're delusional."
Instituting Standards Getting physicians to start acting in a coordinated fashion may seem counterintuitive to the "art" of practicing medicine. But Sprandio is a strong believer in giving patients, especially cancer patients who are very sick and scared, a level of care they can trust.
"That desire, to get more consistent care, had a tremendous, tremendous impact on our processes of care and our workflow," says Sprandio.
In the beginning, he says the goal was to minimize "clinically irrelevant" physician activity. For example, instead of having a patient tell both a nurse and a physician what their symptoms are, thereby repeating information and wasting time, Sprandio began having an oncology nurse grade a patients' symptoms based on toxicity.
One Team
That information was put into a progress note template so that the physician could be accountable for addressing the symptoms the patient articulated. Additionally, the management of those symptoms was also standardized because the protocols were agreed upon by the whole practice.
"It is one team," says Sprandio, explaining that even though there are eight physicians at his practice, they function as one entity. "The team works the same. There's no variation. There's no, 'Doctor so-and-so likes the nurses to do this and not do that,' we wanted standardization."
By instituting a robust EMR system with a custom software overlay to mirror the physician work environment, Sprandio was able to reduce the variation of many aspects of physicians' interactions, but it's not something he glosses over or cites as a determining factor in the success of where CMOH is today in terms of efficiency. Documentation is important, but it's "just one part" of consistent patient care. The real key, he says, is a physician-led care team committed to the same goal.
Sprandio says he tackled the process of standardizing workflows by prioritizing what was most important.
The telephone triage system for managing predictable and common symptoms was a work in progress for 15 years. Now, it is centralized in one practice location, and has netted some real success in reducing ER visits by helping patients manage symptoms at home. In 2006, 77.2% of all symptom related calls were managed at home. By 2012, that percentage grew to 85%, with only 4.1% getting referred to the ER.
Engaged Patients Part of the success of the triage system is due to engaging patients in their care early and often. At Sprandio's practice, it begins with telling the patient on the first visit that CMOH is always the first point of contact.
"If they think they might have a symptom, whether it's on a potential symptom list or not, they call us," he says. "This is said multiple times by three sets of people: the orientation folks, the nursing staff, and the physicians."
CMOH also orders every test so patients do not have to worry about scheduling or tracking it to completion.
Another key factor to reducing variability was getting physicians to complete their documentation more quickly. The EHR and custom software overlay solved some of barriers to increasing turnaround time, which Sprandio says is now down to a day and a half. That's down considerably from 2006 when he says it was taking 20+ days to get doctors to turnaround their documentation on a patient.
But, Sprandio is quick to say that his organization's model of care is not an easy path to the question of how to transition into a reimbursement model that isn't fee-for-service. He believes strongly in the PCMH standards. While CMOH was the first oncology practice to achieve PCHM Level 3 certification, Sprandio says his practice is now working toward a NCQA certification developed in 2013 for specialty practices, Patient-Centered Specialty Practice Recognition.
Sprandio is also part of a consortium of healthcare leaders examining a national approach to bundling cancer care. He's already participating in an alternative payment method with one insurer, and hopes more insurers decide to offer the same.
"We [CMOH] have what we call an oncology PCMH with Aetna and there's a shared savings component," says Sprandio. "I would maintain that oncology bundling of any kind really requires the foundation or insertion of PCMH standards as a safety net to make sure that patients are advised in the right way."