Findings in 25-state study challenge the notion that the expansion of health insurance coverage under the Affordable Care Act would reduce emergency department visits, but that’s not necessarily bad.
States that expanded Medicaid coverage under the Affordable Care Act saw 2.5 emergency department visits more per 1,000 people after 2014, while the share of ED visits by the uninsured decreased by 5.3%, according to a study this week in Annals of Emergency Medicine.
“Medicaid expansion had a larger impact on the healthcare system in places where more people were expected to gain coverage,” study lead author Sayeh Nikpay, PhD, of Vanderbilt University, said in remarks accompanying the study. “The change in total visits was twice as large in a state like Kentucky, where most childless adults were ineligible for Medicaid at any income level before 2014, as in states like Hawaii, where childless adults were already eligible for Medicaid above the poverty line.”
Nikpay analyzed patient visits in 14 states that expanded Medicaid coverage and 11 that did not and found that the share of visits covered by private insurance remained constant for expansion states and increased by several percentage points for non-expansion states. Gains in insurance coverage in non-expansion states were almost entirely in the form of private coverage, not Medicaid.
Increases in ED visits were largest for injury-related visits. There was also a large change in payer mix for dental visits, because dental ED visits are most prevalent among low-income, non-elderly adults on Medicaid. Out-of-pocket dental costs were reported as one of the more unaffordable types of care among the target population for Medicaid expansion under the ACA.
Ari Friedman, MD, of Boston’s Beth Israel Deaconess Medical Center, wrote an accompanying editorial and said that the increased ED visits in the expansion states “runs contrary to the prediction by many policymakers that by providing greater access to primary care, insurance expansion would break the decades-long trend of increasing ED volume.”
Friedman said there was scant evidence to support that prediction, but plenty of actual experience from states such as Oregon, which demonstrated that decreasing the cost of healthcare by providing for health insurance leads to an increase in care use of all kinds, be it in the ED or the primary care setting.
“More emergency department visits by Medicaid beneficiaries is neither clearly bad nor clearly good,” Friedman said. “Insurance increases access to care, including emergency department care. We need to move beyond the value judgments that have dominated so much study of emergency department utilization towards a more rational basis for how we structure unscheduled visits in the health system. If we want to meet patients' care needs as patients themselves define them, the emergency department has a key role to play in a flexible system."
People with the lowest education level had higher lifetime risks of cardiovascular disease than those with the highest education level, research shows.
Educational attainment is one of the biggest socioeconomic factors contributing to cardiovascular disease, according to a study this week in JAMA Internal Medicine.
Researchers led by Yasuhiko Kubota, MD, of the University of Minnesota, Minneapolis, examined the linkage between educational attainment and CVD risk by estimating lifetime risks of coronary heart disease, heart failure and stroke in a large biracial study. The authors also looked at how income, occupation and parental education were associated with educational attainment and lifetime CVD risk.
The study included 13,948 whites and African-Americans, ages 45-64, who were tracked from 1987 through 2013, who were free of CVD. The subjects lived in Washington County, MD; Forsyth County, NC; Jackson, MS; and the suburbs of Minneapolis, MN. The authors documented 4,512 CVD events and 2,401 non-CVD deaths.
In men, lifetime CVD risks from ages 45-85 ranged 59% for those with a grade school education to 42% for those with a graduate school education. In women, lifetime CVD risks ranged from 51% for those with a grade school education to 28% for those with graduate school degrees, the study found. In general, the more educated the person, the lower the risk of CVD, regardless of other socioeconomic factors including family income, occupation or parental education level.
Kubota’s team caution that lifetime risks of CVD should be interpreted carefully because they could be influenced by other CVD risk factors. “Even with such a proviso, our estimates of lifetime risk can help in elucidating the association between education and CVD risk,” the researchers said.
“More than 1 in 2 individuals with less than a high school education had a CVD event during his or her lifetime. Educational attainment was inversely associated with the lifetime risk of CVD, regardless of other important socioeconomic characteristics. Our findings emphasize the need for further efforts to reduce CVD inequalities related to educational disparities,” the researchers said.
“Both organizations are committed to ensuring our community members receive the healthcare they need, regardless of their ability to pay,” Palmetto Health CEO Charles D. Beaman Jr. said in a media release.
“Our integration to become a new health company continues our commitment to serving our patients. We will create a culture that attracts, retains and develops the highest quality and diversity of team members, and continue to teach the next generation of physicians and other caregivers,” he said.
If the deal clears regulatory review, it would create the largest health system in South Carolina, and one of the 50 largest health systems in the nation, with 13 hospitals and hundreds of physician practices and ambulatory centers. Nearly half of South Carolinians would be within 15 minutes of a facility operated by the merged system, which would be the largest private employer in South Carolina, with more than 28,000 employees and 2,800 physicians, the two systems said.
“Greenville Health System and Palmetto Health are joining together from individual positions of strength,” Greenville Health System CEO Michael C. Riordan said. “We have a long history of successful collaboration, as well as a strong cultural fit and mutual commitment to make South Carolina healthier. Together we will continue to ensure our community members, including those in rural areas, have access to high-quality, locally based care.”
South Carolina has some of the nation’s highest rates of obesity, diabetes, stroke, and cardiovascular and pulmonary disease. The two health systems said the merged company will have the scale, scope and resources to address the health issues of the people it serves. It also will continue to be a not-for-profit, mission-driven organization committed to making healthcare more affordable and accessible.
Because of its scale, the new company will have the potential to invest up to an additional $1 billion over the next five years in programs, technology, facilities and employees. No layoffs are planned.
The merger received the unanimous approval of the boards of directors of both health systems, capping months of discussions and analysis by both organizations. A new board with equal representation from Palmetto and Greenville would oversee the new health company. Riordan and Beaman would be co-CEOs and share leadership responsibilities.
The process now enters a due diligence stage, which is expected to take several months. The merger must also clear state and federal regulatory hurdles. In the meantime, Palmetto Health and Greenville Health System will continue to offer care and services as two separate, independent organizations
Experts say alarming results support findings from earlier studies and underscore the importance of rigorous monitoring of device maintenance schedules to minimize the risk of patient harm.
More than one-in-three heater-cooler units inspected over 18-months tested positive for a bacterium linked to fatal infections in open-heart surgery patients, a new study found.
“Our results showed M. chimera (Mycobacterium chimaera) in 37% of units tested and is consistent with previous findings. The extent of contamination from such a rare organism in multiple units from all over the country was surprising,” said John Rihs, vice president of Laboratory Services at Special Pathogens Laboratory, which conducted the research.
“Some devices remained positive for M. chimera for months, indicating that disinfection can be difficult and routine testing is advisable. Beyond M. chimera, we found other NTM (Nontuberculous mycobacteria) species, Legionella, and fungi, indicating these units are capable of supporting a diverse microbial population,” Rihs said in remarks accompanying the study.
The research, presented at the 44th Annual Conference of the Association for Professionals in Infection Control and Epidemiology, examined 563 water samples from 89 heater-cooler units in use at 23 hospitals in 14 states, the District of Columbia and Canada between July 2015 and December 2016.
Thirty-three units tested positive for M. chimaera, and four units were colonized with Legionella. Rihs said researchers were surprised at how contaminated the units were, with 97 cultures deemed uninterpretable due to high levels of bacterial and fungal contamination. Multiple other strains of mycobacteria were also detected in many of the units.
HCUs control the temperature of a patient's blood and organs during heart bypass surgery. The U.S. Food and Drug Administration and the Centers for Disease Control and Prevention already have issued safety warnings that the widely used LivaNova PLC Stӧckert 3T Heater-Cooler System might be contaminated during manufacturing, putting patients at risk for life-threatening infections. Approximately 60% of heart bypass procedures performed in the United States use the Stӧckert device.
HCUs have water tanks that provide temperature-controlled water during surgery through closed circuits. The water does not come into direct contact with the patient. However, the water can aerosolize and transmit bacteria through the air into the environment and to the patient.
APIC President Linda Greene, RN, said the findings “highlight the importance of monitoring the decontamination and maintenance schedules of these devices to minimize the risk of patient harm.”
“Hospitals must follow the cleaning and disinfection instructions provided in the manufacturer's device labeling, as well as updated communications from the FDA and CDC,” she said.
M. chimaera is often found in soil and water but is rarely associated with infections. However, patients exposed to the bacteria through open-heart surgery can develop symptoms that can often take months to emerge. As a result, diagnosis of these infections can be missed or delayed, sometimes for years, making these infections more difficult to treat.
Hospitals were instructed by the CDC and FDA to notify patients who have had open-heart surgery within the last five years that they were potentially at risk for infection. Patients were notified to seek medical advice if they were showing any symptoms or signs of infection, which can be vague or inconspicuous.
LivaNova Responds
On Friday morning, LivaNova spokeswoman Deanna Wilke responded by email to a request for comment. Wilke wrote that the London-based medical device company has developed a three-part remediation plan to address the issue.
“The remediation plan developed by the company consists primarily of a modification of the 3T Heater-Cooler design to include internal sealing and a vacuum system to existing devices,” Wilke said.
"Another part of this plan we are implementing is a no-charge deep disinfection service for 3T Heater-Cooler users who have reported confirmed M. chimaera mycobacterium contamination,” Wilke said. “The deep disinfection service has been approved by numerous local regulatory authorities and is available in many countries around the world. We anticipate expanding the deep disinfection service globally as regulatory approvals are received.
"Finally, the company will continue its program to loan existing 3T Heater-Cooler users a new 3T Heater-Cooler device at no charge, pending regulatory approval and implementation of the vacuum system and deep disinfection service worldwide,” she said.
Study shows that response times plummeted when a drone carrying an automated external defibrillator was used for simulated out-of-hospital cardiac arrest episodes.
Someday soon, drones toting life-saving medical equipment and supplies may zip across the skies over the United States on missions of mercy.
A new study published this week in JAMA shows that a drone hauling an automated external defibrillator drastically reduced emergency response times by an average of 16 minutes for simulated out-of-hospital cardiac arrest cases.
Out-of-hospital cardiac arrest in the United States has a low survival rate of between 8% -10%, so reducing time to defibrillation is a critical factor for increasing survival. A 12 lbs. drone with a 1.7 lbs. AED attached was used in this study, which was conducted in Sweden.
The drone was activated by a dispatcher and sent to an address provided by a 911 caller so that bystanders could use the device, said study lead author Andreas Claesson, RN, of the Karolinska Institutet in Stockholm.
Claesson said it’s not clear if drones can reduce response times in real-life situations. To get a comparison with traditional emergency medical services response times, a drone was placed at a fire station in a rural setting outside of Stockholm.
The drone, which cost about $20,000, was equipped with a global positioning system, a high-definition camera and integrated with an autopilot software system. It was sent to locations where OHCAs had occurred between 2016-2014 and within a 6.2-mile radius from the fire station.
The drone used in the study has a range of more than nine miles, and is capable of speeds of up to 45 mph, Claesson said.
Eighteen remotely operated flights were performed with a median flight distance of about two miles. The median time from call to dispatch of EMS was three minutes. The median time from dispatch to drone launch was 3 seconds. The median time from dispatch to arrival of the drone was 5:21 minutes versus 22 minutes for EMS.
The drone arrived more quickly than EMS in all cases with a median reduction in response time of 16:39 minutes, the study found.
Claesson and his colleagues acknowledged that the study is limited because the drone flew less than 20 routes of short distances and in good weather. Still, they said the findings warrant further investigation.
“Saving 16 minutes is likely to be clinically important. Nonetheless, further test flights, technological development, and evaluation of integration with dispatch centers and aviation administrators are needed,” the study authors wrote. “The outcomes of OHCA using the drone-delivered AED by bystanders versus resuscitation by EMS should be studied.”
In an email exchange with HealthLeaders Media, Claesson said drones have the potential to provide many other emergency medical services.
“The technology is here,” he said. “The cardiac arrest case is easy to understand and a drone may transport anything. We have shown that in certain areas the timesaving of a drone system as compared to EMS. It’s rather the mindset that needs to change. Manned aircraft needs to adapt to unmanned not just the other way around.”
Claesson conceded that the flight proficiency and licensure for the drone’s operators “requires a lot of training” and that the drone pilots also spent a lot of time before the test preparing flight routes and identifying flight corridors. The use of drones also could be hindered by flight restrictions and local ordinances in some areas, he said.
Audit estimates that 12% of the $6 billion in electronic health record incentive payments made to hospitals, physicians and other “eligible professionals” under the HITECH Act did not comply with federal regulations.
Federal auditors say that $729.4 million in Medicare payments to incentivize rapid adoption of electronic health records did not comply with requirements for attesting meaningful use.
The Department of Health and Human Services’ Office of the Inspector General is urging the Centers for Medicare and Medicaid Services to conduct a thorough review of the incentive program that was created under 2009’s Health Information Technology for Economic and Clinical Health Act (HITECH Act) and attempt to recover improper payments.
CMS began issuing the incentive payments in 2011.
“On the basis of our sample results, we estimated that CMS inappropriately paid $729.4 million (12% of the total) in incentive payments to EPs (eligible professionals) who did not meet meaningful use requirements,” OIG said in its report.
“These errors occurred because sampled EPs did not maintain support for their attestations. Furthermore, CMS conducted minimal documentation reviews, leaving the self-attestations of the EHR program vulnerable to abuse and misuse of Federal funds.”
OIG’s review examined $6 billion in EHR incentive payments that Medicare made to more than 250,000 EPs from May, 2011 through June, 2014.
To establish their estimate, OIG auditors selected 100 EPs at random and reviewed their self-reported support for attestation of meaningful use. Auditors also reviewed payments made to deceased EPs and to EPs who switched between Medicare and Medicaid programs to determine whether Medicare made inappropriate payments during our audit period.
Of the 100 EPs randomly reviewed, 14 EPs with payments totaling $291,222 did not meet the meaningful use requirements because of insufficient attestation support, inappropriate reported meaningful use periods, or insufficiently used certified EHR technology, OIG said.
OIG recommended that CMS:
Recover $291,000 in payments made to the sampled EPs who did not meet meaningful use requirements;
Review EP incentive payments to determine which EPs did not meet meaningful use measures for each applicable program year to attempt recovery of the $729.4 million in estimated inappropriate incentive payments;
Review a random sample of Eps’ documentation supporting their self-attestations to identify inappropriate incentive payments that may have been made after the audit period;
Educate EPs on proper documentation requirements.
The audit also found that CMS also made EHR incentive payments totaling $2.3 million that were not in line with program-year payment requirements when EPs switched between Medicare and Medicaid incentive programs. OIG said these errors occurred because CMS did not have edits in place to ensure that EPs who switched from one program to the other were placed in the correct payment year upon switching.
OIG recommended that CMS recover $2.3 million in overpayments made to EPs after they switched programs, and use edits within the National Level Repository system to ensure that an EP does not receive payments under both EHR incentive programs for the same program year.
CMS concurred or partially concurred with all of the recommendations.
Healthcare spending and inflation continue to outplace inflation as measured by the Consumer Price Index, but that growth is at the slowest pace in three years.
Three key metrics of healthcare sector expansion – employment, spending, and inflation -- have seen their slowest growth in the past three years, according to data collected by the non-profit Altarum Institute.
Charles Roehrig, PhD, director of Ann Arbor, MI-based Altarum’s Center for Sustainable Health Spending, says the leveling off of insurance coverage made possible under the Affordable Care Act, and the ongoing uncertainty over the future of the ACA, may be dampening growth in the healthcare sector.
Healthcare job growth is down by 10,000 per month, prices are slowing across the board, and total spending growth also is down .5% from last year’s rate, which Roehrig says could be a respite for private and public sector purchasers compared to the accelerated health spending in the past three years.
By comparison, annual inflation in the overall economy is approximately 2.2%, as measured by the Consumer Price Index.
Healthcare Job Growth
Healthcare added 24,300 new jobs in May, and job growth through the first five months of 2017 is averaging just under 22,000 jobs per month, versus 32,000 per month in 2015 and 2016, according to data from the Bureau of Labor Statistics.
The 2017 slowdown is occurring in both hospitals and ambulatory care. Hospitals added 5,500 jobs per month in early 2017, compared to 10,000 in 2016. Ambulatory settings (physician offices, clinics, home health) added 14,000 jobs per month in 2017, compared to 20,000 in 2016, BLS data show.
Despite the slowdown, the healthcare sector's share of total employment is at an all-time high of 10.75% because healthcare jobs grew 2.1% year over year, lower than the 2.5% average growth in 2016 but still faster than the pace of non-health job growth, at 1.6%, Altarum said.
The total unemployment rate in the larger economy dropped to 4.3%, the lowest in 16 years. The broadest measure of unemployment, the U-6, dropped to 8.4%, the rate seen prior to the recession, Altarum said, citing BLS statistics.
Healthcare Prices
Healthcare price growth in April continued to slow, rising just 1.6% above April 2016, down from 1.9% in March, and the lowest annual growth rate since June 2016, Altarum said.
Year-over-year hospital price growth rose one-tenth to 1.8% and physician and clinical services price growth rose from .4% to .5% in April. Annual drug price growth in April fell to a 3.1% rate, continuing its fall from the 20+ year high of 7% in November 2016. The small increases in hospital and physician price growth were easily outweighed by declining price growth in six other categories, especially drugs, dental services and medical products, hence the lower HCPI rate.
National Health Spending
National health spending growth also slowed in April to 4.4% year over year, the lowest growth rate in 16 months. For the first four months of 2017, the growth rate is estimated at 4.9%. Spending totaled $3.49 trillion (seasonally adjusted annual rate).
The health spending share of GDP was 18.3% in April, and while representing a downward revision from last month, this remains an all-time high share.
Spending in April 2017, year over year, increased in all major categories. Home health care grew the fastest, at 5.7%. Dental services grew at a 2% rate, the slowest among the major categories, Altarum said.
Compensation for radiology and some other specialties has declined in the past two years, salary data shows. Among the reasons: The competitive market for telemedicine in radiology "has gone bananas."
For the most part, physicians and other high-level clinicians in primary and specialty care are seeing robust compensation increases, according to Merritt Hawkins. Medical doctors in the Midwest, in particular, enjoy among the highest annual average wages.
Nationally, however, physicians in certain specialties are seeing drops in compensation. What's going on?
HealthLeaders Media spoke with Travis Singleton, senior vice president at the Dallas-based physician recruiting firm about the market forces at play. The following is a lightly edited transcript.
HealthLeaders: According to your report, compensation for radiology, dermatology, non-invasive cardiology and anesthesiology has declined in the past two years. What's going on?
Singleton: The most interesting is the radiology front. You have two worlds there: The traditional man-on-site radiologist working in the hospital basement. And then you have a quickly emerging teleradiology, the fastest growing portion of telehealth.
This is the first year that we have seen the telehealth compensation average beat the traditional compensation average. That goes against a lot of logic that we used to use. The thought was that with telerad there are better economies of scale, you would work anywhere, literally in your living room, and that the cost to get that employee would be less than recruiting someone to work in the middle of nowhere.
Over the past two to three years, however, the competitive market in telerad has gone bananas.
We see fewer stand-alone hospitals that want a person on staff for a hundred different reasons; quality, calls, scheduling, you name it. Then, we had a huge boom with independent stand-alone imaging centers and they all needed a staff radiologist.
We are starting to see fewer of those imaging centers and those that are still there are affiliated or acquired or somehow partnered with a hospital or health system. So, you have more of these entities of every different delivery system type moving to telerad.
HealthLeaders: Does this compensation swing suggest that telerad has "arrived?"
Singleton: The traditionalists really fought what telerad could be. "Can they verify the quality? Did you have the results you needed? Is there a comfort level, whether it's a small remote hospital or large entities?" A lot of those fears have gone away.
The requirements to be a teleradiologist have risen dramatically. We staff the largest telerad companies out there and it is difficult to recruit. We are seeing the radiology market move before our eyes, and the compensation mirrors it.
HealthLeaders: Why is dermatology compensation falling?
Singleton: The most overlooked part of dermatology is the grunt work. It's been a demand that's been glossed over by the glamorous cosmetic side of dermatology. When you're a dermatologist, you want to work in the cosmetic environment, doing elective better-paying procedures.
For the past few years that was what the market needed. Now, the rashes, the burn calls, the boils, the lesser, non-glamorous part of dermatology is what our clients are clamoring for.
Most of what we are staffing is a reflection of that market. It doesn't pay as well. It's not as much fun. Typically, the quality of life is worse. It's got a lot of strikes against it. But, if you want to look at the open market, that's what we need in dermatology.
Unfortunately, you've got three or four of the past training classes in dermatology that don't want to do anything but elective or glamorous dermatology and who have not had to do anything else.
That wasn't the case 10 or 15 years ago. You had to do the grunt work to earn the elective-type practice you wanted. Or, you had to have a percentage of your practice that was devoted to that grunt work, or you had to do calls for burn unit. Now we are in this position where there is no money in it.
HealthLeaders: Are CRNAs playing a role in the compensation decline for anesthesiologists?
Singleton: Yup. A lot of the recruiting work we are doing are with mega-groups. We saw this in the hospital-based specialties where you have these huge single-specialty groups. Most of them have moved to a more aggressive form of MD oversight, depending upon state regulations.
Where maybe it was 40% or 50% that were staffed by CRNAs, now it's 70% to 80%, and you don't need the MDs.
HealthLeaders: Non-invasive cardiology compensation has taken a big hit. Why?
Singleton: For all the headlines and rhetoric around value, for all these changes in regulations around stents and heart surgery, there is no purer way to look at how our reimbursements work than cardiology.
We favor procedures and punish diagnostics. It's no-better illustrated than this year when you see the non-invasive, diagnostic cardiology suppressed while the procedural-based has gone up.
That trend has been put on steroids with this do-more-with-less environment, especially with heart centers, which became a bloated machine in the past decade. Then, the feds changed the regulations and the centers had to sell out to hospitals, which are trimming the fat.
Now, they still need an invasive cardiologist, obviously, but they may ask him to do a larger portion of non-invasive, diagnostics than in the past.
It's a lessening of the role for the non-invasive cardiologist. It's nothing so drastic that they will be out of a job in two or three years, but when you look at the real-life competitive recruiting environment, you see it with the compensation.
HealthLeaders: Is there a common thread that explains the drop in compensation for these specialties?
Singleton: I would be remiss if I didn't talk about telehealth emergence, even though it's felt more in some specialties than in others. That continues to be a disrupter in the market and will only become more pervasive and with other specialties as we go on.
But more than that, all of these are a reflection on how we pay doctors. We see dermatologists gravitating to elective because the payer mix is better. You see non-invasive cardiologists make less, and even radiologist.
It's an easier quality of life and I get paid better in telerad and I can work out of my house. All of this is a reflection of our reimbursement system. We can debate healthcare all we want, but until that changes many of these compensation trends aren't likely to change.
HealthLeaders: Do you see these compensation trends reversing anytime soon?
Singleton: It would defy logic to say they will. There is no new money in healthcare. In fact, there is less money in healthcare. We are just moving it around to different parts in the system.
It would require a major regulatory change, and even when you look at the ACA or the pending revisions in Congress, none of them are changing the reimbursement system to that level.
The reality is, until we throw our system on its head and say we are going to reward preventative and diagnostic medicine greater or at least equal to how we reward procedures, I don't see how you are going to see a wildly different market than what we are looking at.
A Merritt Hawkins salary survey suggest that family physicians and other primary care specialists are finally cashing in on more than a decade of high demand.
The law of supply and demand is starting to acknowledge family physicians.
For the 11th straight year, family docs top the list of the most highly recruited physicians in the United States, but they also continue to find themselves on the bottom rung for compensation, according to the Dallas-based search firm Merritt Hawkins.
The average starting salary for family physicians is $231,000, according to the 2017 report, up from $198,000 in 2015, an increase of 17%, while the average starting salary for general internists is $257,000, up from $207,000 two years ago.
"Emerging delivery models that reward quality and population health are driving demand for family doctors," Travis Singleton, senior vice president of Merritt Hawkins, said in remarks accompanying the report.
"Consumer preference for urgent care centers, retail clinics, community health centers, telehealth and other modes of convenient care is another key factor accelerating the recruitment of family doctors."
Jay Fetter, operations manager for the division of medical education at American Academy of Family Physicians, says health systems and hospitals are moving away from fee-for-service to a value-based model.
"They recognize that primary care is a central component of that, so demand has increased," he says. "We hear that a lot from our residency directors and faculty who say 'Gosh, my graduates are getting these enormous offers and heck they're making more than me now!'"
The Review tracks the 3,287 physician and advanced practitioner recruiting assignments that Merritt Hawkins conducted from April 2016 through March 2017. Five of the top six searchers were for primary care clinicians, including:
Family medicine – 607
Psychiatry – 256
Internal medicine – 193
Nurse practitioner – 137
OB/GYN – 109
Hospitalists – 94
Salary Increases and Decreases
The average starting salary for psychiatrists is $263,000, up from $226,000 two years ago, an increase of 16.3%, while the average starting salary for internists is $257,000, up from $207,000 two years ago, an increase of 24%.
Despite the dramatic rise over the past two years, average compensation for primary care physicians remains well below the average compensation for most specialists. Orthopedic surgeons, for example, continue to be the top earners among clinicians, with an average annual salary of $579,000. Invasive cardiology is second on the compensation list, with an annual average of $563,000.
Fetter says it's not surprising that specialists make more money than non-specialists, because they generate more immediate revenue. "Hospitals actually know where the revenue stream is coming from, so they are compensating the physicians who support those revenue streams as they still exist today," he says.
Salaries for some specialties are falling, however. Average compensation for radiology ($436,000), non-invasive cardiology ($428,000), dermatology ($421,000), and anesthesiology ($376,000) declined over the past two years, according to Merritt Hawkins.
Value-Based Incentives
The report also shows that value-based physician incentives are gaining momentum. Of the recruiter's clients offering physicians a production bonus last year, 39% based the bonus in whole or in part on value-based metrics such as patient satisfaction and outcome measures, compared to 32% the previous year and 23% the year before that.
However, the 2017 report indicates that less than 5% of total physician compensation is tied to quality or value-based metrics, suggesting that volume remains the primary method for measuring and rewarding physician productivity.
Merritt Hawkins conducted more searches for psychiatrists in the past year than it has in any previous 12 months in the firm's 30-year history, a finding that coincides with a study in the May, 2016 issue of Health Affairs indicating that for the first time more money is spent treating mental health disorders in the U.S. than any other malady, including heart disease, trauma, and cancer.
A March report from the National Council of Behavioral Health (NCBH) found that a national shortage of psychiatrists is about to spiral out of control, with 77% of U.S. counties reporting a severe psychiatrist shortage.
"Psychiatrists, particularly those willing to work in inpatient settings, are becoming next to impossible to find, and mental health is increasingly handled by other types of clinicians," Singleton said.
More than half (55%) of Merritt Hawkins' recruiting assignments took place in cities of 100,000 or more people last year, the highest percent of searches taking place in large cities since Merritt Hawkins began tracking this number.
Singleton says physician shortages are no longer confined to rural areas, but have spread to large metro centers with a comparatively high ratio of physicians-per-population.
That analysis jibes with a LinkedIn Work Force Report for June, which found that healthcare skills in the areas of clinical data analysis, pharmaceutics, and urgent care are needed in most major cities.
A study finds "massive disparities" and markups that average 340% more than what Medicare pays for a range of emergency medical services. But emergency physicians say the findings are based upon a flawed interpretation of Medicare data and don't tell the whole story.
A sweeping analysis of billing records from more than 12,000 emergency physicians nationwide suggests dramatically inflated and wildly varying charges for services ranging from CT scans to wound suturing.
"There are massive disparities in service costs across emergency rooms and that price gouging is the worst for the most vulnerable populations," says study senior author Martin Makary, MD, MPH, professor of surgery at the Johns Hopkins University School of Medicine, in remarks accompanying the report.
"This study adds to the growing pile of evidence that to address the huge disparities in healthcare, healthcare pricing needs to be fairer and more transparent," he says.
The study, which appeared in the May 30 issue of JAMA Internal Medicine, examined Medicare billing records for 12,337 emergency medicine physicians practicing in nearly 300 hospitals 50 states in 2013 to determine how much emergency departments billed for services compared to the Medicare allowable amount, which is the sum of what Medicare pays, the deductible, and coinsurance that patients pay, and the amount any third party such as the patient pays.
On average, the analysis found that adult patients are charged 340% more than what Medicare pays for a range of services, and that the largest hospitals markups are more likely made to minorities and uninsured patients.
ACEP Cries Foul
The American College of Emergency Physicians disputes the findings on several fronts.
Rebecca Parker, MD, president of ACEP, said that Medicare is not an accurate benchmark for determining "fair market value."
"By defining charges greater than Medicare as "excessive" and a "markup," the authors reveal an inherent bias," Parker said in a media release.
"Medicare does not reflect actual costs and has not kept pace with inflation. Medicare physician payments decreased by nearly 8% in the past 11 years, and Congress further reduced payments to fund other legislation (PAMA and ABLE), as well as continued a 2% reduction under the sequester."
The study found that EDs charged anywhere from one to 12 times ($100-$12,600) more than what Medicare paid for services. On average, emergency physicians had a markup of 340% in excess charges, $4 billion in total versus $898 million in Medicare allowable amounts.
ACEP says "the data do not reflect the reality of uncompensated care and undercompensated care provided by emergency departments, mandated by EMTALA."
"Emergency physicians have the highest rates of non-payment than all other physicians," ACEP says. "For the past 30 years, the Federal EMTALA law has required emergency physicians and hospitals to provide a medical screening to everyone, regardless of ability to pay. No other specialty has this duty. Emergency physicians also are required to charge based on the services provided."
The researchers also looked at billing information for 57,607 internal medicine physicians at 3,669 hospitals in 50 states to determine whether markup differences existed between emergency physicians practicing in a hospital's ED, and internal medicine physicians who see patients at hospitals.
On average, charges were greater when a service was performed by emergency physicians rather than internal medicine physicians, who had an average markup that was two times as high as the Medicare rate.
Parker said that internal medicine is not comparable with emergency medicine because of the significant amounts of uncompensated care and undercompensated care provided by emergency departments, which is mandated by a federal law (EMTALA) that requires hospital emergency departments to care for all patients, regardless of ability to pay.
"Emergency physicians provide more medical care for the poor and uninsured than any other physician," she said. "Comparing internal medicine with emergency care is basically a meaningless comparison. It would have been better to compare internal medicine with the internal medicine sub-specialties and other subspecialists who can pick and choose who they see."
Wild Variations
The study found wide variations in ED billing, even within the same hospital. Wound closure and CT scans had the highest "within-hospital" variations of between one and 27 times the Medicare rate.
In another example, physician interpretation of an electrocardiogram under the median Medicare allowable rate is $16. EDs charged anywhere from $18 to $317, with a median charge of $95. General internal medicine doctors in hospitals charged an average of $62 for the same service.
Overall, EDs that charged patients the most were more likely to be located in for-profit hospitals in the southeastern and Midwestern U.S., and served higher populations of uninsured, African-American and Hispanic patients, the study found.
Parker said emergency physicians charge everyone the same, based on the services provided. Emergency medicine bill collections are lower than any other specialty, with many emergency physicians collecting less than 20% of what they bill.
"Emergency physicians treat every patient equally based on their need, not finances," Parker said. "Most emergency physicians have no idea what insurance coverage a patient has. They uniformly submit identical charges, per CPT code, to all payers, some internists alter their fee schedule to correspond with the expected payment from the involved payers."
Parker said a greater concern is that some health insurance companies are implementing policies not to cover emergency care.
"We have seen this in Missouri and Texas, and it's a violation of the federal law known as the prudent layperson standard," she said. "These kinds of policies mean that patients experiencing emergencies may not go to the ER because of fear of a bill, and could die as a result. People should never delay seeking emergency care out of fear of the costs, and insurance coverage should be based on a patient's symptoms, not final diagnosis."
