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."
The one-two punch of massive cuts to Medicaid that are proposed in both the new budget and the House Republicans' revised American Healthcare Act would result in cuts of close to $1 trillion over 10 years, analysis shows.
Cutting Medicaid by more than $860 million over the next decade would be a credit negative for states and not-for-profit hospitals, both of which would be left scrambling for alternative funding to cover the loss, according to a new report from Moody's Investors Service.
Last week the Trump administration unveiled a budget proposal that includes $610 billion in cuts to core Medicaid services, and an additional $250 million in reductions to Medicaid expansion programs created under the Affordable Care Act.
The following day, the Congressional Budget Office released its scoring of the revised American Health Care Act – the Republican plan to repeal and replace the Patient Protection and Affordable Care Act and estimated that it would reduce Medicaid spending by $834 million through 2026.
"The proposals significantly change the longstanding Medicaid financing system and are credit negative for states and not-for-profit hospitals," Moody's said in an issues brief.
For states that don't have the luxury of ignoring budget imbalances, the changes would increase pressure to either kick people off Medicaid, increase the state share of Medicaid funding, or cut payments to hospitals and other providers, Moody's says.
Hospitals, particularly those serving a high mix of Medicaid patients, could expect to see reimbursement cuts and more cases of uncompensated care as Medicaid patients lose the coverage they'd gained under the ACA's expansion.
Medicaid is already a significant budget burden for states, consuming between 7% to 34% of state revenue and averaging 16%.
Under the ACA, bad debt expense at not-for-profit hospitals in states that expanded Medicaid eligibility declined on average by 15% to 20% since 2014, enhancing these hospitals' cash flow. Similarly, the gains in insurance coverage lowered the nationwide uninsured rate to approximately 11%, with uninsured rates even lower in states that expanded their Medicaid rolls, Moody's says.
"Although the budget would give states limited new flexibility to adjust their Medicaid programs, the measure overall reflects a significant cost shift away from federal funding to states," Moody's says. "This cost shift is significant and would force states to make difficult decisions about safety-net spending for hospitals that serve large numbers of indigent patients."
The CBO also estimates that 23 million people who are now insured under the ACA would lose their coverage by 2026 under the AHCA as it was passed by U.S. House Republicans earlier this month. "(That) would be credit negative for not-for-profit hospitals because they would increase their bad debt and uncompensated care costs," Moody's says.
More Bad News for the Poor
Another Trump administration budget proposal forces states to share the costs of SNAP, the Supplemental Nutrition Assistance Program. The federal government now covers all of the benefit costs of the program, while states pay to administer it. The budget proposes to shift 25% of the benefit costs to states, totaling $190 billion by fiscal 2027, Moody's says.
The Trump budget was widely panned immediately after it was unveiled. Bruce Siegel, MD, president/CEO of America's Essential Hospitals, accused President Trump of reneging on his campaign promise to protect Medicaid.
"We remind him now of that promise and ask that he work with us and all stakeholders on policies that modernize and improve federal health programs and ensure no American suffers from lack of access to affordable care," Siegel said in prepared remarks.
"The magnitude of cuts to healthcare programs and agencies in this budget would undermine important work to protect communities of all stripes from existing and emerging health threats, such as opioid addiction, infectious diseases, and chronic conditions," Siegel said.
"The cuts would limit research, putting lifesaving therapies farther out of reach, and drive hospitals and other providers to scale back basic and specialized services."
The revised AHCA, also widely panned by hospital, physician, patient, and payer associations, is also expected to undergo significant revision, if not an outright ground-up rebuild, as the Senate takes it up. In particular, Democrats and Republicans in the Senate have expressed strong opposition to any proposal that significantly cuts access to affordable health insurance.
The difference in mortality rates translates into one additional patient death for every 77 patients treated by physicians 60 and older, compared with those treated by doctors 40 and younger.
Patients treated by older hospitalists are somewhat more likely to die within a month of admission than patients treated by younger physicians, suggests research published this week in the BJM.
Researchers at Harvard note that the difference in mortality rates was modest yet clinically significant—10.8% among patients treated by physicians 40 and younger, compared with 12.1% among those treated by physicians 60 and older.
That translates into one additional patient death for every 77 patients treated by physicians 60 and older, compared with those treated by doctors 40 and younger.
Study lead author Anupam B. Jena, MD, a hospitalist, and associate professor of medicine at Harvard Medical School, spoke with HealthLeaders about the findings. The following is a lightly edited transcript.
HLM: Why did you study physician age and clinical outcomes?
Jena: Two reasons. First, we are broadly interested in understanding how care provided by individual physicians influences patient outcomes, and the particular understanding of how individual physician characteristics such as sex, where the physician trained, and their age relate to patient outcomes and cost of care.
Second, there is ongoing debate about what should be required of physicians in terms of continuing medical education as they age and go further out from residency. There are two competing ideas.
The first is that as physicians age and accumulate experience, their outcomes can improve because they see more and more patients and they have a better idea of how to diagnose and treat disease.
The competing idea is that as physicians go further out from their residency training, they may be less familiar with the latest treatment and diagnoses guidelines. That effect, if it is large enough, could outweigh the former effect and could lead to worse outcomes.
There is active debate about how to ensure that physicians provide high-quality care over the course of their careers and what is needed to ensure that occurs.
HLM: Why did you focus on hospitalists?
Jena: Because we were concerned about the possibility that older doctors might treat sicker patients and as a result their outcomes might be worse, not because of the care that was provided by the doctors, but because of the effect that these patients were sicker and at a higher risk of mortality.
The nice thing about focusing on hospitalists is that patients in this setting don't choose their doctors and doctors don't choose their patients. That allows for a degree of randomization of patients to doctors of varying age, which allows us to better elucidate what is the potential impact of a doctor's age on patient outcomes.
HLM: Could other factors besides age be in play?
Jena: Absolutely. We recognize that care in a hospital and outpatient setting is often team-based. That said, it doesn't explain why it is that the patients whose attending physicians are older would have worse outcomes.
We definitely recognize that the outcomes of a patient relate not only to a physician but to the team members. That could also be an explanation of our findings, aside from the possibility that there may be knowledge or skill differences.
HLM: Why is there no difference in 30-day readmissions?
Jena: It's entirely possible that you would see differences in 30-day readmissions and mortality because in general they are not well correlated.
HLM: You talk about “age effects" versus “cohort effects." Please elaborate.
Jena: “Age effect" means that, as a physician ages and gets further out from residency, is there a depreciation in their skills from time, or is there an inability to keep up with the most up-to-date diagnostic and treatment guidelines?
A “cohort effect" simply means that when you trained influences what your outcomes would be. Doctors who trained in the 1970s versus the 1990s have been trained in a different way, and that influences the kind of care they will provide throughout their careers.
One example might be that older hospitalists in early practice were primary care doctors who saw inpatients occasionally. Whereas, the newer cohort of hospitalists was more ingrained in inpatient care in their residencies and they practiced as hospitalists right out of residency.
That could explain the findings, as opposed to changes in the individual physicians as they get older.
HLM: How would these age or cohort differences manifest themselves at the bedside?
Jena: That is hard to answer. I can speculate that doctors who are in residency training now are more formally educated in team-based care, and that is a larger component of care now than it was 30 years ago. Familiarity with how to work in teams could be an explanation of a cohort-based mechanism for why we see our results.
An age-based mechanism might be that over time newer medications are used to treat certain conditions, but because you are not actively engaged in the literature and reviewing guidelines, you are less likely to use these medications as you get older.
These distinctions are important because if you repeat this study in 10 years you might not find any difference because now all the cohorts are being trained in team-based care.
HLM: Could these findings be applicable to other specialists?
Jena: They could be, but I'd hesitate to go too far.
Internal medicine and hospital care is a cognitively based specialty, where the decisions are almost exclusively about diagnoses and medical treatment of a condition, or referrals to an appropriate proceduralist.
That is very different from surgery, which also has a technical skill-based component. It's possible that the technical skill of a surgeon could improve over time as they do more and more cases, and dexterity and muscle memory evolve. Those features could potentially make these findings different if you look at other procedural fields.
HLM: What should be done with your findings?
Jena: The first thing is replicate it. I would say that about any controversial findings. It needs to be replicated in the same setting and in other settings that are more procedural- or primary care-based.
Once you have a body of evidence that points in a certain direction, then that would imply that we should do two things. One, we should measure outcomes of physicians whenever we are interested in setting policy, in this case whether or not we should be training physicians more as they age.
The second thing is to design policies and evaluate them.
I wouldn't stop there. I would ask what is the effect of that policy on outcomes? Look at when it was implemented. Measure patient outcomes among the physicians who were exposed to that intervention versus a controlled group of physicians who weren't.
Let's make sure that whatever we ask physicians to do, which is very time consuming, results in better outcomes.
HLM: How old are you?
Jena: 38
HLM: Could you be accused of ageism?
Jena: I recognize the implications of the findings, but I would say this is not an attack on older physicians. It is certainly not a fact that we can generalize upon, especially as it may be different outside of hospital medicine.
At the end of the day, what every physician should be concerned with is patient outcomes. That is our business. To the extent that we can use large databases and unique analytical methods to better understand the factors that relate to patient outcomes, we should welcome this kind of analysis.
I'm a low-volume physician as we define it in the study because I only see patients about six weeks out of the year, so I would fall into the category of doctors who could be in trouble. I'm not immune from our analysis.
HLM: Are you concerned that your findings could be distorted in the media?
Jena: That is always a concern. It's a risk/benefit tradeoff. Whenever you write a paper that you hope will get attention and influence how people think about the issue, you run the risk of it being over-exaggerated and scandalized.
I recognize the possibility. But if we are in the business of worrying about quality of care and specialty societies are thinking about how quality of care evolves over a physician's career, then we should look at outcomes. A failure to do that is more of an indictment of the research enterprise than anything else.
Survey data suggests that physicians dislike the GOP's American Health Care Act even more than they disliked the Affordable Care Act.
Two-thirds of physicians do not like the American Health Care Act, the Republican House bill to unwind Obamacare, while only about a quarter support it, a new survey indicates.
The survey of 1,112 physicians by the Dallas-based physician search firm Merritt Hawkins found that 66% of doctors have a negative impression of the AHCA, 26% have a positive impression, and 7% are neutral.
"Physicians have consistently expressed dissatisfaction with government-sponsored healthcare legislation in the past, and the AHCA does not reverse this trend," Mark Smith, president of Merritt Hawkins, said in a media release. "So far, the bill rates a strongly negative diagnosis from physicians."
In a 2016 survey of 17,236 physicians that Merritt Hawkins conducted for The Physicians Foundation, 23% of physicians gave the Affordable Care Act a grade of A or B, 28% gave it an average grade of C, while 48% gave it a D or F.
The AHCA, now being considered by the Senate, gets an even higher negative rating in the new Merritt Hawkins survey. Fifty-eight percent of those surveyed have a strongly negative impression of the bill, 8% have a somewhat negative impression, while 7% are neutral.
At the other end, 27% of physicians favor full repeal and replacement, while only 7% of respondents say keep it as it is, indicating the extent of dissatisfaction with the ACA, the HealthLeaders Media survey showed.
The Merritt Hawkins survey findings are in line with a HealthLeaders Media survey published in January, which showed that healthcare industry leaders support changes to the ACA rather than replacing it. Two-thirds of respondents (66%) said the best option for the healthcare industry regarding the ACA would be to make some changes but otherwise retain it.
Physicians Groups Denounce AHCA
Opposition to the AHCA among practicing physicians is reflected by the nation's major physicians associations, all of which have come out against the repeal and replace proposal.
The Merritt Hawkins survey was sent by email to about 80,000 physicians randomly selected from Merritt Hawkins' database and has an error rate of +/- 2.87% as determined by experts in statistical response at the University of Tennessee.
Male primary care physicians earn 17% percent more than females, while males in specialty care are paid 37% more than females in the same field, an MGMA survey finds.
Age, gender, specialty and productivity are key factors in physician pay, survey data shows.
The Medical Group Management Association's 2017 Physician Compensation and Production Survey, released this week, uses comparative data of more than 120,000 providers across more than 6,600 groups and represents several practice models, including physician-owned, hospital-owned, academic practices, as well as providers from across the nation at small and large practices.
"Our annual survey found that, in aggregate, gender disparity exists for physician compensation," said Halee Fischer-Wright, CEO and president of Englewood, CO-based MGMA. "Knowing what factors contribute to the gender pay gap help us better understand and interpret the cause."
Highlights from the survey include:
Specialty
Specialty area influences the disparity in total compensation with males across all specialty areas earning more than their female counterparts. Males practicing in primary care reported earning 17% higher compensation while males in specialty care reported earning 37% more than females in the same practice area.
Experience
Survey results show that the number of years in a specialty area may play a role in the gap in total compensation.
Males are paid more than 20% more than females in the specialty areas of family medicine and general pediatrics, but have an average of seven years more experience than their female counterparts who participated in the study.
As there are now more females graduating from medical schools than males, females represent a greater percentage of the population of physicians that are early in their career.
Productivity
Productivity increasingly is a significant factor in the development of physician compensation packages. Males in invasive-interventional cardiology are making over 25% more than their female counterparts, but show 42% greater median work relative value units (RVUs), a measure of value used in the Medicare reimbursement formula.
Male general orthopedic surgeons make almost 50% more than their female counterparts with more than 80% greater median work RVUs. The large difference in the data may be due to the number of women in these specialty areas and how much experience they have.
Suzanne Leonard Harrison, MD, president of the American Medical Women's Association, says that experience and specialties alone do not account for the disparity in pay between the sexes.
"There are several studies that have looked closely at this, and even with those factors considered, women physicians are often paid less than men," Harrison wrote in an email exchange with HealthLeaders.
"Women, people of color, and other physicians with minority status are often not given opportunities for advancement, promotion, bonuses, raises and other forms of payment that those in the majority benefit from on a regular basis."
Harrison says the reasons for the lack of opportunities are "multifactorial," and "partly due to a systemic acceptance of this as the norm. In addition, the micro-aggressions contribute to an overall sense of being less valued."
In general, Harrison says, women are paid less than 80% of what men are paid for the same work, and are less often promoted to leadership positions in their practices, hospitals, and academic centers.
Female physicians' career advancement is further hobbled by their responsibilities for running the home and taking care of children and aging parents," Harrison says.
"Many make choices to work fewer hours to accommodate family responsibilities. While that choice is theirs, accommodations are often lacking to account for decreased time at work," she says.
"For example, an academic physician in a tenure-track position may work fewer hours (and is therefore paid less), but the 'clock' on tenure isn't lengthened to reflect the actual work being done and she is might end up putting in extra hours to keep up – but isn't paid for this. If she doesn't meet the requirements for promotion to the next academic rank within the assigned time frame, she might leave the institution rather than try to change the system."
"Another example would be a physician in private practice who works 75% rather than 'full-time' and yet sees the same number of patients and provides excellent care, yet she isn't paid the same because of decreased hours," Harrison says.
"There are endless examples, and women are socialized to be appreciative of what is offered rather than learning essential negotiating skills that would help them change the system."
"I would add that male physicians should also be balancing their professional and personal lives, and we'll know that we've reached pay and work equity when that standard is applied to both men and women," she says.
"I believe the answer to the issue is largely with administration and leadership, and those courageous enough to address pay equity in a transparent way."
Todd Evenson, MBA, chief operating officer at MGMA, also responding by email, says that "compensation drivers include, but are not limited to, specialty, years of experience, region, metropolitan versus rural, collections, and production (wRVUs)."
"By law, physician employment arrangements, require compensation at fair market value. Determination of FMV would include the drivers described above and gender would not be permitted as a factor."
Healthcare remains a vital source for job growth in the overall economy, but hospital job growth has declined by more than half so far this year.
Healthcare job creation remains strong in 2017 but the sector is no longer matching last year's explosive growth, new data from the Bureau of Labor Statistics show.
In the first four months of 2017, healthcare created 77,800 jobs, 10.5% of the 738,000 jobs created by in the U.S. economy for the period. In the first four months of 2016, healthcare created 119,800 jobs, slightly more than 16% of the 741,000 new jobs in the overall economy for the period.
Hospitals have created 19,900 new jobs in the first four months of 2017, a 54% decline when compared with the 44,200 new hospital jobs created in the first four months of 2016.
Nicole Smith, chief economist at Georgetown University Center on Education and the Workforce, says the slowdown in hospital hiring could be linked to churn around the Affordable Care Act.
"The Affordable Care Act in its initiation required a lot more bodies to do the work and take care of the additional 20-plus million new patients on the healthcare rolls," Smith says.
"Even in the recession the healthcare sector continued to add jobs. We're still adding, but maybe we are coming to a situation where we're meeting demand now. We're at an equilibrium."
The recent action by House Republicans to repeal the ACA and replace it with the American Health Care Act could also make hospital administrators skittish about hiring.
"The last time the Congressional Budget Office evaluated the proposal they came up with a loss of 24 million insured Americans. Of course, that has ripple effects and implications for people in that sector and parallel sectors and downstream sectors," Smith says.
"Maybe hospitals are being pre-emptive and not hiring workers at the same pace as in the past in anticipation that this repeal and replace is actually going to go through. We can expect hospital hiring to really slow down until people get a handle on what is going to happen."
Ambulatory Services Leads the Sector
Ambulatory services continue to be the main driver of healthcare jobs, with 52,600 created in the first four months of 2017, including 14,200 jobs in April. However, that number is down about 26% from the 70,400 jobs created over the same four months of 2016.
Nursing home and residential care, the third pillar of healthcare provider job growth, shed 900 jobs in April, but held fairly steady in a year-over-year comparison with the first four months of 2016, with 5,200 new jobs created.
In all of 2016, healthcare created 394,400 new jobs, nearly 33,000 new jobs per month, about 18% of the 2.2 million jobs created in the larger economy. Healthcare employs about 15.8 million people, according to BLS.
