Nurse practitioners saw an almost 30% growth in total compensation in the past five years, while physician assistants saw a 25% rise in median total compensation over the same period.
Primary care physicians' total compensation rose by more than 10% over the past five years, nearly double that of specialty physicians' over the same period, according to data gleaned by the Medical Group Management Association.
The findings, based on comparative data from over 136,000 providers in over 5,800 organizations, provide more evidence of the nation's worsening primary care physician shortage, said Halee Fischer-Wright, MD, president and CEO of MGMA.
"Many factors contribute to this problem, chief among them being an increasingly aging population that's outpacing the supply of chronic care they require," Fischer-Wright said in comments accompanying the study.
"And with a nearly two-fold rise in median compensation for primary care physicians over their specialist counterparts and increased additional incentives, we can now see the premium organizations are placing on primary care physicians’ skills to combat this shortage," she said.
According to MGMA:
Family medicine physicians saw a 12% rise in total compensation over the past five years, while their median number of work relative value units increased by less than 1%. That's because practices offered more benefits to attract and retain physicians, including higher signing bonuses, continuing medical education stipends, and relocation expense reimbursements.
Nurse practitioners saw the largest increase over this period with almost 30% growth in total compensation. Physician assistants saw the second-largest median rise in total compensation with a 25% increase.
Over the past five years, rises in median compensation varied greatly by state. In two states, median total compensation actually decreased for primary care physicians: Alabama (-9%) and New York (-3%).
Many states saw large increases in median total compensation compared to the national rate, the top five being Wyoming (41%), Maryland (29%), Louisiana (27%), Missouri (24%) and Mississippi (21%).
The District of Columbia is the lowest paying with $205,776 in median total compensation for primary care doctors. Nevada is the highest paying state with $309,431 in median total compensation.
Over the last five years, looking beyond just nurse practitioners, overall non-physician provider compensation has increased 8%. Over the past 10 years, that rate has doubled to 17%.
The difference in compensation between the highest-paid state compared to the lowest ranges between $100,000 and almost $270,000 for physicians depending on specialties, and $65,000 for non-physician providers.
The findings in the MGMA study are consistent with other researching showing impressive compensation gains for primary care doctors.
Physician recruiters Merritt Hawkins last year reported that the average starting salary for family physicians was $231,000, up from $198,000 in 2015, an increase of 17%, while the average starting salary for general internists was $257,000, up from $207,000 two years ago.
The multistate healthcare system has committed upwards of $200 million through its Thriving Communities Fund to tackle housing stability and homelessness in the communities it serves.
Kaiser Permanente is taking the concept of providing care beyond the hospital walls to a new level with its $200 million investment inhousing stability in the communities it serves.
Bechara Choucair, MD, Kaiser Permanente's chief community health officer, spoke with HealthLeaders Media about the initiative.
The following is an edited transcript.
HLM:Where will this $200 million go?
Choucair: We are not sure right now what the investments will be. What we know for sure is that they would be in communities where Kaiser Permanente exists. We have about 12.3 million members in communities where 65 million people live. We operate in eight states and the District of Columbia. As part of our community engagement effort we will identify the right opportunities to invest with a particular focus on housing.
HLM: How will it work? How will you know where to invest?
Choucair: Over the past year we've been engaging with many leaders in this space across the country, people who've been engaging in the development and preservation of affordable housing. There are going to be a wide variety of ways we can invest and leverage our dollars. We will likely be aggregating those dollars with other sources of capital that will be available for specific projects.
It's going to be on a case-by-case basis. That is why, as part of the process, we will be working with community-based organizations and partners that have identified the need and specific projects, and those projects will come through a pipeline to be evaluated and vetted for our Thriving Communities Fund.
There is an advisory committee that includes the senior leadership at Kaiser Permanente that will make the recommendations to invest or not invest in these opportunities.
HLM: So, you will be relying upon outside experts to identify your investment opportunities?
Choucair: Absolutely. The secret sauce is to identify the right partners who do this regularly. There are many community development finance institutions and developers who do this on a day-to-day basis as a core business and they aggregate funds from different sources and we will be working with them to ensure that the right investment opportunities are funded and developed and people have the ability to preserve or build additional affordable housing in our communities.
HLM: What is your return on investment in this?
Choucair: Housing stability is a key factor of what impacts health. We know that what impacts health happens in the communities where people live and the medical system has a lot to offer to advance and maintain health. At the same time, the individual behavior, the social factors, the economic factors, the built environments, all of those impact health. So if we can leverage that fund to invest in opportunities that will allow us to improve on housing stability in communities where we exist, that is the type of social returns that we would like to be able to see.
As we are evaluating each opportunity, we will be looking at financial return on investment but most importantly we will be looking at what type of social return we can see.
Keep in mind that the people who benefit from this don’t have to be Kaiser Permanente members. This is a true community investment in our communities. Part of the social return that you would look at would include things such as hospitalization rates, well-being rate of people participating. Healthcare costs. We will be looking at all of those as part of the social return. Again, it will be on a case by case basis.
HLM: When does this start?
Choucair: For the past year we've been spending a lot of time with community leaders across the country identifying those opportunities. We are in the vetting process now for a couple. I can't tell you exactly when but very soon we will be able to have our first investment announced.
HLM: How far along before you'll know if this investment is having the desired effect, and what metrics will you use to make that determination?
Choucair: It will be, again, on a case-by-case basis. Every investment will have a set of financial and social metrics that we will be tracking and we will be able to evaluate on a regular basis if those investments are paying off from a social perspective the same way as we will be able to track from a financial perspective.
HLM: How far can a hospital go to address social issues "beyond hospital walls?"
Choucair: We don’t do these things by ourselves. We are not going to be running housing developments. We will be partnering with the right people who do this as their core business.
What is important to remember is that as we think about how we meet the needs of our communities, we look at their needs that go above and beyond their healthcare needs. At the end of the day, what impacts your health is the community that you live in. It's how you live. It's where you work and play. If we are going to be truly focusing on optimizing the health and well-being of our members and our communities, we have to think about the conditions for health of equity in the communities where these folks live.
From busting fraudsters, to challenging mergers, acquisition and collusion by hospitals, payers and drug makers, antitrust enforcement remains a top priority for federal regulators.
The Department of Justice will continue to play "an outsized role" in healthcare antitrust enforcement, a federal prosecutor said this week.
In a keynote address at the American Bar Association's Antitrust in Healthcare Conference on Thursday, Deputy Assistant Attorney General Barry Nigro said DOJ will rigorously prosecute Medicare fraudsters and price gouging by drug makers, and continue to cast a skeptical eye toward mergers, potential collusion among health systems and payers.
"Competition in healthcare means being able to afford life-saving surgery, or critical medicines, or an infant's first checkup," Nigro said. "It's important. That's why few, if any, segments of our economy merit higher priority when it comes to antitrust enforcement."
"Because competition benefits consumers in so many ways, antitrust enforcement will continue to play an outsized role in healthcare. Competition keeps healthcare costs down, which broadens access to health care products and services," he said.
Nigro's lengthy speech covered no new ground, but reaffirmed DOJ Antitrust Division's civil and criminal policy and actions against fraud, and anticompetitive practices.
On criminal prosecutions: "Criminal violations are pernicious antitrust offenses. Price fixing and naked market allocation agreements are effectively agreements to steal from consumers (whether in the form of higher prices, lower quality, or fewer choices) and have no procompetitive justification."
On generic drug regulations: "In recent years, there have been large price spikes for certain generic drugs — and the Division’s investigation into this market has revealed that some corporations and executives have sought to enrich themselves at the expense of consumers who rely on these critical medications. It is hard to imagine a more brazen antitrust crime than colluding to take money out of the pockets of seniors and others whose health depends on prescription drugs."
On market allocation and no-poach agreements: "We believe it is important that we use our criminal enforcement authority to police these markets, and to promote competition for all Americans seeking the benefits of a competitive healthcare marketplace."
On exemptions and immunities from the antitrust laws: "Exemptions and immunities should be limited. Often, when an industry is bestowed with an exemption or immunity, competition is displaced, or cabined, by government regulation.
"The Division is skeptical of any claim that government regulation prevents competitors from exercising market power or that consumers do not benefit from the forces of competition to protect their interests."
On defense of the Clayton Act: "Pursuing treble damages under Section 4A has two important benefits. First, it deters cartels and other anticompetitive conduct. Second, it compensates taxpayers for the harms the government suffers due to antitrust violations. We intend to exercise the authority Congress has provided and are actively considering cases in this industry to bring."
On state action doctrine: "When the state action doctrine puts a potentially anticompetitive state regulation (or action pursuant to that regulation) beyond the reach of federal antitrust law, the Division has urged state legislatures to consider the negative effects on competition."
On certificate of need: "Certificate of need laws allow regulators to second guess that business judgment. The new hospital may be profitable at the expense of incumbent competitors, but that is the essence of competition. Incumbent firms thus are the primary beneficiaries of certificate of need laws, and they can take advantage of these laws to thwart or delay entry or expansion by their competitors. Who suffers the consequences? Consumers."
On licensing requirements: "Jointly with the FTC, we have urged state legislatures to carefully consider laws that impose occupational licensing requirements, and insure that any health or safety benefit from such requirements is balanced against the harms to competition such requirements may create."
On professional certification: "By receiving board certification, professionals in these fields can advertise to prospective patients that they have received extra training and thus, potentially, provide higher quality services. But, because certification sometimes becomes a de facto requirement for meaningful participation in a market for healthcare services, certification requirements can at times act as barriers to entry."
The Sacramento-based health system says the issues raised in an anti-competitive suit would impose 'onerous managerial duties' on the court and instead should be handled by state regulators.
Sutter Health has asked a California court to dismiss a suitbrought by the state's attorney general that alleges the health system engaged in systematic anti-competitive practices.
In amotion for dismissal filed this week in the California Superior Court for San Francisco County, attorneys for Sacramento-based Sutter argued that Attorney General Xavier Becerra has made "an unprecedented plea that the court force Sutter to submit to mandatory binding arbitration over its contract terms."
"This is not a suit the Court should consider," the motion stated. "Rather, it should invoke the doctrine of judicial abstention and decline the Attorney General's invitation to assume the role of healthcare policy czar by exercising its powers to dismantle the Sutter system and impose the relief sought in this case."
Instead of the courts, Sutter argued that the "onerous managerial duties" would be better handled by the executive and legislative branches of government which already have the authority and "are better suited to provide long-term oversight over the healthcare contracting issues raised in this case."
"Sutter Health is throwing its weight around in the healthcare market, engaging in illegal, anticompetitive pricing that hurts California families," Becerra said at the filing.
"These tactics are risking Californians' lives by driving up the cost of healthcare for everyone," Becerra said. "Big business should not be able to throttle competition at the expense of patients."
A hearing on Sutter's motion is scheduled for June 11.
Are these organs safe? A new study of transplantation records found no significant change in the recipients' chances of survival when organs came from a drug overdose victim.
The increase in opioid-related deaths has created a grim harvest of vital organs for transplant, a studyshows.
Researchers found a more than 10-fold increase in the proportion of donors who died from drug overdoses between the years 2000 and 2016 in the United States, from 1.2% (59) to 13.7% (1,029).
"We were surprised to learn that almost all of the increased transplant activity in the United States within the last five years is a result of the drug overdose crisis," said lead author Mandeep R. Mehra, MD, medical director of the Heart and Vascular Center at Brigham and Women’s Hospital, in comments accompanying the study.
The central question posed in the study is whether or not organs taken from drug overdose victims are safe for transplants, and the evidence gathered suggests that they are.
The researchers:
Looked at 17 years of transplantation records and found no significant change in the recipients' chance of survival when the organ donation came from victims of drug intoxication.
Compared the survival rate of 2,360 patients one year after receiving a heart or lung transplant from donors who died from drug intoxication compared to recipients of organs from donors who died from other causes, including gunshot wound, asphyxiation, blunt head injury and intracranial hemorrhage or stroke.
Focused on heart and lung data because these organs are the more sensitive to reduced oxygen supply that may occur during a drug overdose.
Focused on survival in the first year, because these concerns would manifest shortly after the transplant.
Clinicians have been conservative when identifying organs from drug intoxication deaths. During an overdose, a person may experience prolonged episodes of low blood pressure that can reduce the supply of oxygen throughout the body.
There are also considerations that include infection risk, such as Hepatitis B and C and HIV, but this risk can be minimized with modern testing, the researchers said.
"I feel hopeful that doctors across the country will read this and feel confident that organs that pass the required tests are safe for transplant," said study senior author Josef Stehlik, MD, medical director of the Heart Transplant Program at University of Utah Health.
Researchers suggest salaried physicians at the publicly funded hospital system are not financially incentivized to overtreat patients with costly and unneeded surgeries or radiation therapy.
The Veterans Affairs health system has made tremendous progress over the past decade in convincing patients to postpone surgery or radiation for non-aggressive prostate cancer, new research shows.
Instead, strong majorities of VA patients are opting for active surveillance of the slow-growing cancer, which relies on regular check-ups, blood tests, and occasional needle samplings of prostate tissue to check for any signs of a tumor getting worse.
The researchers used data from the VA's Central Data Warehouse, in one of the largest studies of its kind, involving a review of the medical records of 125,083 former servicemen, mostly over the age of 55, who were newly diagnosed with low-risk prostate cancer between 2005 and 2015.
Researchers found that:
In 2005, 27% of men under age 65 passed on immediate therapy, and 4% chose active surveillance.
In 2015, 72% passed on immediate therapy, and 39% choosing active surveillance.
"Our study shows that the Veterans Affairs health care system has done a good job over the last decade in adopting 'conservative management' of men diagnosed with early-stage disease, with many men choosing active surveillance as an alternative to immediate therapy," says study senior investigator Stacy Loeb, MD, a urologist.
"This marks a historic reversal, at least at the VA, in the decades-long overtreatment of men with prostate cancers least likely to cause harm, and brings their care more in line with the latest best practice guidelines," Loeb says in comments accompanying the study.
Loeb credits the VA’s success to several factors, and noted that it is part of a national network of publicly funded hospitals, where many physicians are salaried, so there is little financial incentive to overtreat.
"The main conclusion to be drawn from the data is that if so many veterans can quickly adopt this less-risky disease-management strategy, then so too might other American men if they understood the potential benefits of this option," she says.
Editor's note: The headline of this story was updated Friday, May 18, 2018, to clarify that "non-aggressive" describes certain cases of prostate cancer.
Treatment costs for drug-resistant staph infections were about $38,500 compared with more than $40,700 for MSSA-associated pneumonias.
Drug-resistant staph infections continue to be deadlier than those that are not resistant to antibiotics, but treatment costs surprisingly are the same or less, an analysis shows.
"The lower costs for treating drug-resistant infections were a surprise," said study coauthor Trish Perl, MD, chief of Infectious Diseases at UT Southwestern Medical Center. "The findings are contrary to previous predictions and studies that suggested the treatment costs for drug-resistant infections would be greater."
Across four years of data, researchers found:
Treatment costs for drug-resistant staph infections (MRSA, methicillin-resistant Staphylococcus aureus -related pneumonia) were about $38,500 compared with more than $40,700 for pneumonias (MSSA, methicillin-sensitive Staphylococcus aureus –related pneumonias) in 2014.
Treatments costs for non-pneumonia-related hospitalizations related to staph infections were $15,578 for MSSA-related infections compared with $14,792 for MRSA-related infections.
Similar patterns were observed from 2010 to 2013.
Cost differences between MSSA- and MRSA-related pneumonia hospitalizations rose from 26% in 2010 to 31% in 2014.
Reasons for the lower costs may be due to price differences in drugs used to treat the different types of infections or that MSSA infections were more severe or that less-invasive MSSA infections may not be diagnosed or coded correctly, leaving only costlier MSSA infections in the record, researchers said.
Alternatively, this difference may relate to the fact that care providers failed to change from antibiotics used for MRSA to more appropriate antibiotics in a timely fashion, the researchers said.
The federal government has joined the whistleblower lawsuit leveled against the specialty drug maker, as INSYS puts its minimum liability exposure at $150 million.
INSYS Therapeutics, Inc. says it has become "a completely transformed organization" in the face of stinging federal allegations that it bribed clinicians to push its powerful opioid painkiller, and lied to insurers to get reimbursements.
"INSYS continues to have ongoing dialogue with the DOJ regarding this investigation," the Phoenix-based specialty drug maker said in a media release.
"Today, INSYS is a completely transformed organization, with a promising pipeline, a strong commitment to serving patients as well as an organizational culture of high ethical standards."
The statement was issued this week hours after the Department of Justice announced that it would join a whistleblower lawsuit leveled against the drug maker.
The suit, unsealed this week in a federal court in Los Angeles, alleges that INSYS paid kickbacks to physicians and nurse practitioners to get them to prescribe Subsys, a spray form of fentanyl approved by the FDA in 2012 for the treatment of persistent pain in adult cancer patients.
"Many of these kickbacks took the form of speaker program payments for speeches to physicians that were, in fact, shams; jobs for the prescribers’ relatives and friends; and lavish meals and entertainment," DOJ said in a media release.
Federal prosecutors also allege that INSYS pushed physicians to prescribe Subsys for patients who did not have cancer. In addition, INSYS employees allegedly lied to insurers about patients' diagnoses to obtain reimbursement for Subsys prescriptions that had been written for Medicare and TRICARE beneficiaries.
"Insys allegedly bribed doctors who are more concerned with profits than patients," said Christian J. Schrank, Special Agent in Charge for the Office of Inspector General of the U.S. Department of Health and Human Services.
"Encouraging the inappropriate use of this too-often deadly opioid is intolerable enough, but the abuse is compounded when taxpayers are forced to pick up the bill," Schrank said.
The whistleblower suit was filed in 2013 by former INSYS sales rep, Maria Guzman, who detailed what she said were overt and disguised bribes that INSYS made to doctors to increase prescriptions and dosages of Subsys, and lies used to rationalize the off-label benefits for patients.
"Sex, money, luxury items – nothing was out of bounds in INSYS's efforts to persuade doctors to prescribe Subsys without consideration of what was best for patients," Guzman said. "I could not keep silent, knowing how these off-label prescriptions endangered so many."
In its media release, INSYS said it "has learned from the past and remains committed to significant innovation and investment in R&D, which the company believes will result in improving the lives of many patients."
The drug maker, which has lost 85% of its stock value since mid-2015, said it has accrued $150 million, "which represents the company’s current best estimate of the minimum liability exposure which it expects to be paid out over five years in connection with this investigation."
DOJ has been pursuing criminal charges against INSYS founder and majority owner John Kapoor and several former executives and managers, including former CEO Michael Babich and former Vice President of Sales Alec Burlakoff.
Three of the doctors that Guzman's says were top prescribers of Subsys and accepted kickbacks from INSYS – Alabama doctors Xiulu Ruan and John Couch, and Gavin Awerbuch of Michigan – have been convicted of criminal charges and sentenced to prison.
The federal complaint said that Awerbuch wrote 1,283 prescriptions for Medicare patients alone from 2012 until he was arrested in May 2014, costing Medicare nearly $7 million.
While medical schools are reporting solid enrollment and student diversity gains over the past 15 years, the dearth of medical residency slots remains a top concern.
First-year enrollment at U.S. medical schools has increased by 29% since 2002, but school administrators worry that the numbers of medical residency positions available for their graduates aren’t keeping pace.
The Association of American Medical Colleges, in its Results of the 2017 Medical School Enrollment Survey, found that 64% of medical school deans expressed concern about the availability of residency slots in their own state, and 78% expressed concern about the availability nationally.
The survey found that:
Using the baseline of the 2002 first-year enrollment of 16,488 students, a 30% increase corresponds to an increase of 4,946 students. The survey results indicate that the 30% goal will be attained by 2018-2019.
54% of medical schools saw competition for clinical training sites from other healthcare professional programs, an increase from around one-quarter of respondents in 2009.
Nearly all deans (99%) said they had or were planning programs or policies designed to recruit adiverse student body, up from 84% in 2015.
44% of deans reported concerns about their incoming students' ability to find residency positions of their choice after medical school.
A majority of schools are experiencing competitionfor clinical training sites from DO-granting schools and other healthcare professional programs.
46% of deans reported feeling pressure to pay for clinical training slots, though 59% of schools do not pay for clinical training.
Enrollment increases at DO-granting schools continue to accelerate. First-year enrollment at DO-granting schools in 2017–2018 was 8,088, a 163% increase from 3,079 students in 2002–2003.
Combined first-year enrollment at existing MD-granting and DO-granting schools increased by 9,859 students, a 50% increase compared with 2002–2003.
More than $1 billion in Medicare savings projected as CMS and Maryland state officials sign a five-year agreement to expand the state's value-based payment system into non-hospital settings.
The federal government has given the go ahead for a renewal and expansion of the "Maryland Model," which will take Medicare value-based care beyond hospital walls to include long-term and community-based care, and mental health services.
"The new Maryland Model will expand healthcare access and affordability – and ultimately improve quality of life – for Marylanders, especially those with chronic and complex medical conditions,” Maryland Gov. Larry Hogan said in a media release.
With the existing all-payer model up for renewal at the end of 2018, the Centers for Medicare & Medicaid Services required Maryland to build a new model that encompassed all of the healthcare that patients receive, both in the hospital and the community, including long-term care and mental health services.
The five-year contract signed this week by state and federal officials takes effect on January 1, 2019, and is expected to provide an additional $300 million in savings per year by 2023.
The expanded model will:
Invest resources in care that is focused on the patient and enhance primary-care teams to improve individual patient outcomes;
Set a range of quality and care improvement goals and provide incentives for providers to meet them;
Concentrate resources on population health goals to help address opioid use and deaths, diabetes, hypertension, and other chronic conditions;
Encourage and facilitate programs focusing on the needs of Medicare recipients across geographic settings and other key demographics.
The current Maryland All-Payer Model Contract started on January 1, 2014, and was set to expire on December 31, 2018. Maryland officials say the current model has already saved Medicare more than $586 million through 2016, compared to national spending, through reduced readmissions, and lower growth in hospital per capita costs.
