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.
Behavioral health visits account for 87% of Medicare's telemedicine billings. But there is a pronounced uneven distribution of services across states.
Depending upon which baseline you start at, and which state you're looking at, telemedicine use expanded significantly between 2004 and 2014, or not much at all.
While the overall use of telemedicine for mental health diagnosis and treatment in rural America remains very low (1.5%), a new study from Harvard Medical School and the RAND Corp. in the May issue of Health Affairs shows an average 45% jump per year in telemedicine visits among rural patients over the decade, with striking variation across states.
Four states had no such visits in 2014. In nine states, however, there were more than 25 telemedicine visits per 100 patients with serious mental illness.
"In some states it's pretty high. In Nevada, Wyoming, and Iowa we are seeing in the rates of 30-40 visits per 100 people with serious mental illness. Those are really big numbers," says study lead author Ateev Mehrotra, MD.
Mehrotra is associate professor in the Department of Health Care Policy at Harvard Medical School.
The study found that the number of telemedicine behavioral health visits increased from 2,365 in 2004 to 87,120 in 2014. An average of five out of 100 rural beneficiaries with a mental health condition had a telemedicine visit, and the number was even higher—12 out of 100—for patients with serious mental illnesses, such as bipolar disorder or schizophrenia.
The latter group makes up only 3% of rural Medicare beneficiaries, yet it accounted for more than a third of these telemedicine visits. Behavioral health visits account for 87% of Medicare's telemedicine billings.
Mehrotra says the study's findings show that while telemedicine use remains remarkably low, it is also catching on.
"In one sense it interesting that 1.5% usage is starting to have a population-level impact, because 1.5% of the Medicare population, and 3.7% of people with serious mental health issues were getting telemedicine. Those are real numbers now, when most people thought of telemedicine being in the theoretical future," he says.
"In that sense that is the glass-half-full thing, which is people have been talking about telemedicine for a long time. The numbers are small still and yet now we are starting to see in certain communities among certain populations real use. But you could flip it around and say only 1.5%!"
Mehrotra says there is no clear explanation for the state-to-state discrepancy, but he has a few theories.
"There are a lot of conversations about telemedicine parity laws as being critical and we found there was a higher rate of tele-mental health use in states with those parity laws, but the difference was quite small and the growth rate was identical," he says.
"Maybe that is playing a role, but it's a marginal role."
"We did look at regulatory environment," he says. "There are all kinds of rules, in particular, for mental health. For example, you must read a disclaimer every time you have a tele-mental health visit, etc. We found in states with less-strict regulatory environments that are more open to tele-mental health a larger increase in tele-mental health. That probably plays some role."
Mehrotra says he's hearing anecdotally that a big factor may be the idiosyncratic operations of community health centers where the telemedicine remote visits occur. The use of telemedicine may vary depending upon the enthusiasm of clinicians and administrators at a particular site.
"Many of these community health centers are chains, and the person who is the CMO at one of these chains may think tele-mental health is the way to go so she is pushing it at her practices. At another chain, they may think it's a bad way to provide care and they're not pursuing it," he says.
"This is evidence that in certain communities tele-mental health can happen and be a routine part of care, and it spurs the people in other communities to say this is possible and we need to rethink this idea because it is taking off."
Winning systems in 2017 are lauded for shorter emergency department wait times and lengths of stay, higher survival rates, and fewer complications.
Truven Health Analytics has named its 15 Top U.S. health systems for 2017 based on the clinical and administrative evaluations of nearly 3,000 hospitals in 337 health systems across the nation.
"The study recognizes these 15 health systems that have proven it is possible to drive down expense while improving the quality of care," said Jean Chenoweth, senior vice president for performance improvement and the 100 Top Hospitals program at Truven in a media statement this week.
"More importantly, the leaders of these health systems are demonstrating the power of aligning best practices across multiple hospitals to achieve greater levels of efficiency while delivering higher overall standards of care."
The study divides the top health systems into three comparison groups based on total operating expenses. The 2017 winners are:
Large Health Systems (operating expense above $1.75 billion)
Mayo Foundation – Rochester, MN
Mercy – Chesterfield, MO
Scripps Health – San Diego, CA
Spectrum Health – Grand Rapids, MI
St. Luke's Health System – Boise, ID
Medium Health Systems (operating expense $750 million – $1.75 billion)
HealthPartners – Bloomington, MN
Kettering Health Network – Dayton, OH
Mercy Health Southwest Ohio Region – Cincinnati, OH
Mission Health – Asheville, NC
Parkview Health – Fort Wayne, IN
Small Health Systems (operating expense below $750 million)
Asante – Medford, OR
Lakeland Health – St. Joseph, MI
Lovelace Health System – Albuquerque, NM
Maury Regional Healthcare – Columbia, TN
Roper St. Francis Healthcare – Charleston, SC
The study evaluated 337 health systems and 2,924 member hospitals to identify the health systems with the highest overall achievement on a balanced scorecard and focuses on five performance domains: inpatient outcomes, process of care, extended outcomes, efficiency, and patient experience.
The study found that top-ranked hospitals had:
Shorter wait times in emergency departments: Patients at the 15 Top Health System winners had 17.5% shorter wait times in the emergency department.
Higher survival rates: The 15 Top Health System winners had 13.4% fewer in-hospital deaths.
Fewer complications: Patients treated at winning systems had 8.5% fewer complications.
Shorter length of stay: The average patient length of stay at winning health systems was 10.2% shorter.
Data from Nemours Children's Health System suggests that the percentage parents who are willing and eager to use telemedicine services for their children has grown exponentially in the past three years.
The use of pediatric telemedicine may soon be at a tipping point.
A survey this by Nemours Children's Health System shows that while only 15% of the 500 parents who responded to an online query have accessed pediatric telemedicine, 64% plan to use it within the next year for common childhood conditions such as fever and respiratory ailments and for well-child visits.
Overall, the percentage of parents who use telemedicine remains small. When compared with a 2014 survey by Nemours, however, the use of online doctors' visits has grown by 125%, and parents' awareness of telemedicine services has increased 88%.
"That's a very good sign that people are becoming more and more aware of telemedicine being an option," says Carey Officer, administrator of telehealth at Wilmington, DE-based Nemours.
"They're changing that mental model in their head of how they can access care. There's been tremendous growth year over year in the adult population and we've seen tremendous growth when we opened our digital door back in 2015. Every month the visits continue to grow."
Socio-demographic factors are converging in a way that Officer says will accelerate the acceptance of telemedicine. Namely, it's cheaper, faster and more convenient than a trip to a physician's office or an urgent care center.
Nemours charges $49 for a basic 10-minute telemedicine consultation. In addition, technology has improved and simplified the accessibility and navigability of healthcare portals for tech-savvy millennials juggling parenthood and careers.
"We are starting to see the tipping point," Officer says. "Things have been accelerating in the past year or two and I think consumers are going to demand it. These parents are millennials and they like to use digital healthcare. They understand it. They know it. They prefer the convenience. So, how do we meet them where they are?"
Parents are most willing to use telehealth services for cold and flu (58%), pinkeye (51%), rashes (48%), and well-child visits (41%), which accounted for an estimated 171 million in-office visits in 2012 for children under 18, according to the Centers for Disease Control and Prevention.
Parents are less accepting of telemedicine for treating chronic conditions. Those surveyed said they likely would never consider using telehealth services for diabetes (53%), asthma (43%), and ADHD (36%), even though previous research has shown that chronic care can be effectively treated through telemedicine.
"The reason why this hasn't take off more rapidly for chronic conditions is that the 24/7 urgent care model has prevailed and is dominant in the marketplace right now," Officer says. "You have payers and employers who are advertising this to their patients and employees and people haven't been educated, nor has it been deployed to the extent of the 24/7 on-demand urgent care model."
"We are pursuing telemedicine for asthma and diabetes and other critical areas where we think we can intervene to assist in the reduction of readmissions and improve outcomes by meeting patients where they are and alleviating emergency room visits for patients who come in frequently," she says.
Positive Patient Experience
Among parents who have tried an online doctor visit for their child, nearly all of them (97.5%) rated the experience as equal to or better than an in-office visit. Most parents who have already had an online doctor visit for their child cite convenience (81%) as a prime reason for choosing online rather than in-office doctor visits.
"The comments that are coming back from parents who used it for the first time are telling us 'Wow! I had no idea this could be so convenient,'" Officer says. "You can have a doctor on line in five minutes and they can help you solve your problem from the comfort of your own home."
The survey also found that:
Dads surveyed were more likely to have already used telemedicine services for themselves or their children (34%), compared to moms (22%).
A majority of those who have already had an online doctor visit for their child also looked to telemedicine for more immediate care than waiting for an in-office visit (53%) or for an after-hours medical opinion (52%).
Half of the parents said they were comfortable with trying new remote sensing devices on smartphone for sending vitals or other clinical measures to a doctor, and 29% of that group already had had an online doctor visit for their child. This suggests a pattern of "early adopters" for new technologies in pursuing children's healthcare.
Many parents report that work schedules and time pressures create problems for securing in-office appointments. The American Academy of Pediatrics reports that parents spend an average of 30 hours on well-child visits during their child's first five years.
According to Nemours' survey results, parents who have used telemedicine cited convenience, after-hours accessibility, and immediacy as the top three reasons for doing so. Three-out-of-four parents rated the experience as superior to an in-office doctor visit.
Nemours has implemented its CareConnect 24/7 telemedicine throughout its health system with direct-to-consumer care for acute, chronic, and post-surgical appointments, as well as through its partner hospitals, schools, and even cruise ships.
Families can access the Nemours pediatricians through a smartphone, tablet, or computer. When necessary, the physician may order a prescription, using geo-location service on the smartphone or tablet, and send it to the nearest pharmacy.
The biggest speed bumps for the expanded use of telemedicine are beyond the control of providers, Officer says.
"What is hampering the growth at this point is the regulatory and reimbursement environment, from licensing to payer reimbursement," she says.
LinkedIn Salary has released its annual survey of the best paying jobs in the three fastest growing sectors: finance, IT, and healthcare, and the pay is pretty good.
The healthcare sector is one of the fastest growing areas of the economy, and physicians and executives are among the most highly compensated workers in those realms, according to a survey from LinkedIn Salary.
"As evident from our earlier list of jobs with the highest base salary across all industries, a career in healthcare can be one of the most professionally and financially rewarding out there," LinkedIn Salary said in a media release.
"While surgeons and other practitioners rule the roost when it comes to pay, advances in healthcare technology, an aging population and the Affordable Care Act have created a growing need for more healthcare professionals across all sectors of the industry, many of which don't require years of expensive medical training. Roles in business development, marketing and product management all offer alternate routes to a high-earning salary."
According to LinkedIn Salary, the highest paying healthcare jobs and their median income are:
Orthopedic Surgeon - $475,000
Surgeon - $400,000
Cardiologist - $400,000
Radiologist - $373,000
Anesthesiologist - $368,000
Medical Director - $260,000
Pathologist - $258,000
Vice President of Quality - $245,000
Physician - $235,000
Hospitalist - $233,000
Global Marketing Director - $233,000
Vice President Finance - $225,000
Vice President Human Resources - $225,000
Senior Director of Development - $225,000
Psychiatrist - $220,000
The lists were compiled using new LinkedIn Salary data that includes hundreds of roles collected from verified LinkedIn members as of March 27, 2017.
A home-based pre-operative program to improve the physical conditioning of patients will require surgeons to work out "a lot of complex finances and politics between the various parties involved," says a surgeon who champions the idea.
Physicians in the Michigan Surgical Home and Optimizing Program believe that the preoperative training program they've developed for elective surgery patients will someday become a standard of care in hospitals across the country.
So far, however, the adoption process has been slow.
A University of Michigan study shows that elective surgery patients were discharged sooner and were more engaged in their care if they took part in a home-based pre-operative training program to improve their physical condition in the weeks before their surgery.
Michael Englesbe, MD, a Michigan Medicine transplant surgeon who has studied and championed the idea for nearly a decade, spoke with HealthLeaders about his advocacy for "Pre-hab." The following is a lightly edited transcript.
HLM: This program has been in effect for five years, but participation is quite low. Why?
Englesbe: We haven't necessarily proven scientifically that it works. It makes sense. Patients like it, but the primary outcomes we've followed so far have been financial outcomes, which matter to hospitals.
Doctors care more about things such as complications and survival. Most relevantly, it's just hard to change practice.
Strategically we've focused on hospitals but we've learned that the work is done by the surgeons, and surgeons really don't engage with the hospitals where they practice, and vice-versa. There are a lot of complex finances and politics between the various parties involved here that are going to take time to sort themselves out.
HLM: Could anyone in the care continuum take ownership of pre-hab?
Englesbe: Someone has to do the work. Even though it is minimal work, everyone at every hospital and office is already working fulltime so any incremental additional work is a big deal.
It's hard to change physician practices, and that is particularly true among surgeons. I'm a surgeon. I speak their language. So if anyone can convince them it would be someone like me.
It will catch on when the small amount of money it costs to enroll patients and engage them in this program is either mandated, because globally it makes financial sense, or it gets paid for by payers, and we are making progress in that space.
At a macro level, patients training and being optimized for surgery reduces costs profoundly, but that money isn't real to the people who have to do the work. The analogy is you pay your federal taxes but you don't necessarily feel intimately in contact with where that money goes.
That is the way practitioners feel about the cost savings and downstream implications for a lot of these things. That being said, in two years we've gone from one to now 40 practices participating in the program. We are gaining momentum, but it's taking a long time.
HLM: Should the C-suite mandate this?
Englesbe: I think the C-suite has to mandate it, but a lot of physicians don't work for the C suite. Hospitals within the infrastructure they own have to mandate it or at least make it available in the complex flow of care, which takes time.
HLM: Will the shift to population health and value-based care accelerate this process?
Englesbe: Yes. That resonates well with Medicare and other payers.
HLM: Does pre-hab promote patient engagement?
Englesbe: Yes. That's the most powerful message and it resonates with all the groups, the hospitals, payers, and physicians. Patients feel very engaged and empowered to be part of the team with some ownership over their outcomes during a really scary time.
It's a teachable moment for anyone to change lifestyles. It turns a scary time into a time that has more positive energy. That resonates with everyone. It's been the key to our success so far.
HLM: How much of this is pre-hab psychological versus physical?
Englesbe: There is no way to measure it, but I think that most of it is psychological. For the vast majority of patients who have reasonable functional status a lot of it is psychology. It is the remarkable power of positivity and engagement.
You create a care team, the family is on board, patient empowerment, positive energy, positive psychology. For many patients that is probably the secret sauce.
HLM: What about pre-hab for the elective surgery patient who is ill or immobile?
Englesbe: The program isn't for everyone. We are trying to ramp up and engage as many patients as possible. You have to be able to walk to do the program. We are working on more diverse exercise opportunities for patients.
But we are locked in to what we told Medicare we were going to do, which is walking. In our experience, 99% of patients who have elective surgery walk into clinic and can walk. The people who cannot shouldn't do the program.
Now, that's different with the specialties, especially with orthopedic surgery where there are a lot of functional limitations, people have a bad hip or knee, things like that. Those numbers are very different and intentionally our program has been designed around patients having major elective thoracic and abdominal surgery.
HLM: Could you devise some sort of program for less-mobile patients?
Englesbe: Absolutely. At the patient level we do our best to try to enable every patient to do the program. At the University of Michigan, the program is different from the statewide program because our institution devoted more resources and we have more staff to care for the patients and try to enable them to participate.
But it takes time; not a lot, but even 10 minutes, if you're supposed to see a patient every 15 minutes through your day and you add 10 minutes to five interactions, over the course of a day that ruins the day.
Future iterations of the program will be more flexible and empower more patients.
HLM: Could this not be done by hiring more health coaches or physical therapy assistants?
Englesbe: It sounds easy, but a big hospital will do 75,000 operations a year. Then, it becomes a throughput issue. Now you need 15 physical therapy assistants. Don't get me wrong. It makes good financial sense. It just takes time to build the business case.
That is exactly what our Medicare project is doing; building a business case for payers and for hospitals to invest in these programs. Technology can bridge most of the work with patient tracking. There are lots of options there. But, it does takes some incremental staff.
HLM: How could a hospital outside of Michigan take up this initiative?
Englesbe: I'm happy to share everything we've done here. It's a federally funded program. I have no intellectual property nor an equity stake in anything we've done. I'm doing it as an academic, so we'll share anything we've done.
In addition, we use patient-tracking technologies, pedometers, things like that, and there is a litany of private vendors out there who can do that piece of it. More and more hospitals within their own electronic health records have portals where patients can do this.
HLM: How soon before prehab is a universal practice?
Englesbe: Our hope is that if we can prove to Medicare and other payers that this makes sense financially for them, and also it's good for patients, then we have proven the good-for-patients part.
I sincerely think this is going to be standard of care in surgery in about 10 years. It's going to take about a decade for the practice to change to the degree where this is an expectation. Clinical medicine moves very, very slowly. Like… really slowly.
