The screening program is described as a "win, win, win" for consumers, payers, and Walgreens, especially if it improves adherence to medication, says the retailer's CMO.
Retail pharmacy giant Walgreens and the nonprofit Mental Health America this week launched a collaborative mental health answer center to heighten consumer awareness and reduce stigmas associated with mental health.
The platform will connect people to MHA's free Online Screening Program, which uses clinically-based but relatively simple and direct online screenings for conditions including depression, anxiety, bipolar disorder, and post-traumatic stress disorder.
"We have known for a long time that mental health conditions are more prevalent than other common diseases that get a lot of attention and support," says Walgreens CMO , MD.
"For example, one in four or five adults in this country at any given time are suffering from a mental health condition like depression or anxiety or post-traumatic stress disorder and that is more common than diabetes and heart diseases combined."
"As a consumer-based, pharmacy-led healthcare company, we have to step up and offer a range of solutions to our consumers that come into our stores or visit our website every day seeking answers and needing support for mental health."
"It is the right thing to do for us and our partners who are providers as well," Leider says.
Early, timely interventions are often a critical component for diagnosing and improving mental health, and Leider says that Walgreens and MHA have set a goal to complete 3 million online screenings by the end of 2017.
Leider says the program centers around four pillars:
Awareness
Screening
Care facilitation
Therapy support
"Number one, we want to provide increased awareness to our consumers about the prevalence of mental health conditions and the warning signs," he says. "Many people who are depressed, for example, as the most common mental health condition, don't even know they're depressed."
"The second is to increase screenings to provide access to really simple tools that a patient or consumer at Walgreens could do in five minutes to be alerted that they may well have depression," he says.
"The third is once they know they have a problem, to connect them with a trusted source of care and evaluation. The fourth is to use our pharmacy services to support patients once they are put on a medication."
PCPs Lack Time and Resources
Leider says 27,000 pharmacists and 1,100 nurse practitioners in Walgreens' nearly 8,200 stores and clinics nationwide could play "a huge role" in helping patients monitor and stay on their medications.
"We have six million people coming into our stores every day, and another two million coming to our website or our mobile app. The ability of our pharmacists and 8,300 stores to really support patients are incredible value drivers," he says.
"We have the No. 1 healthcare app in America, maybe the world, and the No. 3 retail app. The pure footprint that we have physically and digitally enables us to increase awareness of our consumers, whether they come to the stores or the website."
"On the other end of the spectrum, I am a primary care physician. I can tell you that the busy primary care doctor does not have the time or the resources to be doing these kinds of medication support activities in their office," Leider says.
"Even if they did, when you are describing the medication for the patient and having a dialog about whether they have depression or post-traumatic stress syndrome, at that time the patient isn't totally hearing all the facts you're giving them."
"But the ability of our pharmacists to reinforce this information about side effects and waiting for the medications to take effect is absolutely critical," he says, "and very hard for a primary care doctor's office to achieve in one visit."
The pharmacists and nurse practitioners will not undertake the screenings themselves, but will refer consumers to the website, Leider says, largely out of patient privacy concerns.
"The major support from pharmacists have revolved around the medications that are commonly prescribed, such as antidepressants, [and] antianxiety meds," he says.
A 'Win, Win, Win'
"Their role is to educate patients about the utility and effectiveness and expected side effects, and when to contact the clinicians with side effects or efficacy. It's what we are doing already, but we're just providing our pharmacists and nurse practitioners with some augmented training."
Leider describes the screening program as a "win, win, win" for consumers, payers, and Walgreens, especially if it improves adherence to medication.
"The patient wins because they are much more likely to feel better and get a response to their therapy, be more productive and have a better life," he says.
"It's a win for the payer because a patient suffering from untreated mental health problems spends more money on medical services. They are costlier because they are seeking more solutions from the health system and they aren't managing their comorbid diseases."
"And frankly, to us, patients being adherent to their medication is valuable to Walgreens," he says.
"The patients are filling their prescriptions more regularly and we get economic value out of that, as well as the patient loyalty."
The two health systems said they've signed a letter of intent to explore an exclusive affiliation. No timetable was offered for when the deal would be finalized.
Susquehanna Health, the Williamsport-based four-hospital health system serving Northcentral Pennsylvania, is pursuing an affiliation with regional giant University of Pittsburgh Medical Center.
In a joint press release, the two health systems said they've signed a letter of intent to explore an exclusive affiliation. No timetable was offered for when the deal would be finalized, and neither system suggested what the affiliation will look like when it's agreed upon. Whatever the arrangement, it likely will require state regulatory approval.
"Over the past two years, we've thoroughly explored partnerships and our guiding principle had always been: 'what's best for our patients?"' Susquehanna Health CEO and President Steve Johnson said in an email exchange with HealthLeaders Media. "UPMC emerged as a wonderful cultural fit for our patients, health system, and community. It's the right thing for our patients and for our community."
"This partnership means the continued growth of our organization, more opportunities to bolster our existing services and introduce new specialty services to the region, more effective physician recruitment and retention, a new, competitive insurance option and access to the intellectual capital of one of the pre-eminent academic medical centers in the country," Johnson says.
Susquehanna Health Board Chairwoman Ann Pepperman said UPMC was picked because of its "compatible fit with our faith-based, service-oriented culture and a relationship that enables us to grow services for our community and continue to add family-sustaining jobs. UPMC has a proven track record of investing in and growing services for patients in the Erie, Altoona and Bedford communities. In addition, UPMC supports and maintains the Catholic tradition of its member hospital, UPMC Mercy in Pittsburgh."
UPMC CEO and President Jeffrey A. Romoff said that by "combining our world-renowned healthcare and research programs with our value-driven insurance products, UPMC is able to offer patients and employers clinically integrated programs to better manage the community's health. Together we will enhance and position UPMC Susquehanna Health as the leading provider of world-class care at the lowest possible cost in northcentral Pennsylvania."
Susquehanna Health hospitals include Williamsport Regional Medical Center, Divine Providence Hospital in Williamsport, Muncy Valley Hospital in Muncy, Soldiers & Sailors Memorial Hospital in Wellsboro. The system employs close to 4,000 people in an 11-county service area
UPMC is the dominant health system in western Pennsylvania and the largest nongovernmental employer in Pennsylvania, with more than 60,000 employees, more than 20 hospitals, more than 500 doctors' offices and outpatient sites, a more than 2.9-million-member health insurance division, and international and commercial operations. The system is affiliated with the University of Pittsburgh Schools of the Health Sciences.
The Susquehanna affiliation is the latest in an aggressive line of expansions by UPMC, that includes Pittsburgh's Mercy Hospital in 2008, Children's Hospital in Lawrenceville in 2009, Erie's Hamot Medical Center in 2011, Altoona Regional Health System in 2013, and Jameson Health System in New Castle earlier this year.
VUMC will now be guided by its own board of directors comprised of university and academic medical center leadership, and community business and civic leaders.
Vanderbilt University Medical Center in Nashville has separated itself legally and financially from Vanderbilt University and is now a fully independent, nonprofit hospital.
VUMC President and CEO Jeff Balser, MD, PhD, said in prepared remarks that the new status means that the medical center is "now optimally positioned for the future of health care delivery."
"We have taken care to assure VUMC will remain seamlessly connected to Vanderbilt University in fundamental ways, including a vast array of educational and research programs aimed at training the leaders of the future and driving innovation through discovery science," said Balser, who remains dean for the Vanderbilt University School of Medicine.
The announcement caps a restructuring process that was first announced in late 2014 and included 20 transition teams and involved a multitude of faculty and staff. VUMC will now be guided by its own board of directors comprised of university and academic medical center leadership, and community business and civic leaders.
As an independent hospital, VUMC will have direct capital market access to assure it can compete effectively in the health marketplace. Its flexible governance structure will also support the continued growth of the Vanderbilt Health Affiliated Network, which is the largest provider-organized network of doctors, regional health systems and other health care providers in Tennessee and surrounding states, the hospital said in a media release.
Teaching and research collaboration and connections between the University and the Medical Center remain a strategic priority for both institutions.
The consolidated system that emerges from the deal, with more than 15,000 employees, would provide integrated care services to a broad geographic area in Southeastern New England.
Southcoast Health and Care New England have entered merger talks that, if finalized, would create an eight-hospital, $2 billion not-for-profit health system serving Massachusetts and Rhode Island.
The announcement is the latest development in partnership talks that started in November. In a joint media release, the two health systems said they will develop an affiliation agreement, begin the regulatory approval process in both states, and undertake due diligence reviews.
The consolidated system that emerges from the deal, with more than 15,000 employees, would provide integrated care services to a broad geographic area in Southeastern New England.
Under an agreed-upon framework, Southcoast Health President and CEO Keith Hovan will be president and CEO of the new health system parent company; Care New England CEO Dennis Keefe will be CEO of the Population Health initiative for the unified system; Care New England's board will select the new chair of the system parent Board, and the Southcoast Health board vice chair will be vice chair. Southcoast Health and Care New England will each select 10 people to serve on the new system parent board of trustees.
The Population Health initiative will be a signature program for the new system. Both Care New England and Southcoast Health have established Accountable Care Organizations and have been working to advance innovative approaches to care that improve outcomes, enhance patient experience and reduce cost.
Care New England includes Butler Hospital, Kent Hospital, Memorial Hospital of Rhode Island, Women & Infants Hospital of Rhode Island, the VNA of Care New England, The Providence Center, CNE Wellness Center and Integra, a certified ACO created in collaboration with the Rhode Island Primary Care Physicians Corp.
Southcoast Health includes Charlton Memorial Hospital in Fall River, St. Luke's Hospital in New Bedford; Tobey Hospital in Wareham; and Southcoast Behavioral Health in Dartmouth, a joint venture hospital with Acadia Healthcare.
'Eat your broccoli' isn't a new, sexy message, but healthful eating remains the best way to prevent or contain chronic diseases, and it's something that every hospital in the nation could and should be doing to promote population health.
The best way to a control chronic disease such as diabetes is to prevent it from happening in the first place.
With that in mind there has been a major push over the past decade by hospitals across the nation to promote healthful eating for patients, employees and visitors.
This is not a sexy new topic. "Eat your broccoli" isn't a grabby headline. It is fundamentally important, however, it is blocking and tackling, it is ABCs, it is back to basics, and every other applicable cliché, and it is something that every hospital in the nation could and should be doing in this new era of population health.
That's what they're doing in Kansas, the heartland state with some of the nation's highest rates of obesity.
The Kansas Hospital Association's Hospital Education and Research Foundation says 25 hospitals in the Jayhawk State—many of them in far-flung rural areas—have changed their food and beverage policies. Under a three-year Healthy Kansas Hospitals initiative, gone are the fried foods, potato chips, crème doughnuts and sugary drinks, long the staples of hospital cafeterias. They've been replaced by healthier options, including fresh fruits, smoothies, made-to-order deli wraps, and salad bars with bountiful options beyond iceberg lettuce, ranch dressing and a sprinkling of Bac~Os.
These hospitals are also making prominent the nutritional value and calorie content of the foods they sell in their cafeterias and vending machines and providing their employees with educational materials that promote good nutrition and a healthful diet.
The logic is obvious. If this nation is ever to contain this epidemic of overweight and obesity, then hospitals and their employees—often among the largest employers, and most high-profile citizens in their communities—will have to step up as role models.
James Blackwell is CEO at Clara Barton Hospital & Clinics, a 23-bed critical access hospital in Hoisington, KS, serving more than 25,000 residents of Barton County, and one of the 25 hospitals to adopt the healthful eating initiative. The transition has been relatively easy, he says, but identifying the return on investment for the hospital's 200 employees and the community they serve may take some time.
"ROI is actually something that is not really quantifiable through a short-term effort," Blackwell says. "We want to lead by example so we set these things forth. Our employees engage in it. In time we will be able to see the benefits but that is a long-term effect."
"That's what we're going for when we lead the charge in the community," he says. "You can only swing that kind of perception with a long-term effect, and that is what we are trying to accomplish here."
More Healthful Options
Clara Barton CNO Jane Schepmann says the bigger challenge in adopting the healthful foods model was "a little bit of a change of culture. Folks really like that comfort food, and that might be a little different than, say, New York City."
"We try to offer a healthful entree or two. There is always a soup available. We've got hummus and premade salads in the refrigerator. We have a sandwich cooler with fresh wraps that are off the charts, by the way."
For the night shift workers, Schepmann says the hospital wants vending machine options that include hummus, fruit and vegetables "as opposed to chips and a pop."
Importantly, the shift to healthier foods does not come with a higher price tag. "We did not raise our prices," she says. "Our supplier is very willing to work with us on items. The company that stocks our vending machines is very enthusiastic."
Blackwell adds that "from a dollars and cents standpoint, since we have made this change, our revenue has increased. We call it Clara's Corner Café, but we also have a new dietary manager who has brought some new menu items that have caused a stir. For example, the salad bar used to just offer iceberg lettuce. We now have spinach and romaine to offer more nutritional value.
Clara Barton employees have formed a wellness committee to generate other ideas to promote good health, such as participation in athletic events, walk-a-thons, etc. The hospital is promoting a 5-K race this fall, and sponsoring bike rides. This week, the hospital is sponsoring a smoothie recipe contest among employees. The winners get a gift certificate.
"We're trying to give them some ownership," Schepmann says.
The hospital has formed a mutually beneficial partnership with the local grocery store. "We look at what their sale items are for a given week and we are offering the public a healthful recipe using the items that are on sale."
They're also partnering with the local day care schools to promote healthful eating, working with the children to raise crops in the community gardens, and serving those garden-grown vegetables in the hospital cafeteria. "We invite the children in to partake with us, and work with them on healthier snack options," Schepmann says.
Ultimately, Schepmann hopes the healthful eating initiative at the hospital will spark a change of culture in the larger community.
"We want to promote a healthy culture," Schepmann says, "where folks are taking responsibility for their own health."
"This is telling us that the taxing system may not be working properly if nonprofit hospitals are making a lot of profit and not necessarily putting it back into the community," researcher says.
Seven of the 10 most-profitable hospitals in the United States are nonprofit hospitals, each earning more than $160 million from patient care services, according to a study in Health Affairs.
"We were pretty surprised. I had no idea what hospitals would be the most profitable, and which were not," says study coauthor Gerard Anderson, professor Health Policy and Management at Johns Hopkins Bloomberg School of Public Health. "This is telling us that the taxing system may not be working properly if nonprofit hospitals are making a lot of profit and not necessarily putting it back into the community.
The study analyzed fiscal year 2013 for more than 3,000 acute care hospitals of which 59% were nonprofit, 25% were for-profit, and 16% were public. The study used net income from patient care services to measure profitability and left out profits from non-patient care activities such as investments, charitable contributions, tuition, and parking fees.
"We used Medicare cost reports; essentially the total revenues that they get from patient care and the total expenditure associated with patient care," Anderson says. "It is the only uniformly collected data that I know of on all hospitals in America. If you use general accounting principles, hospitals have a lot more flexibility to include or exclude costs."
By those measures, the most profitable hospital in fiscal 2013 was Gundersen Lutheran Medical Center, a 239-bed hospital in La Crosse, WI, that collected $302.5 million, or $4,241 per patient. In stark contrast, more than half of all hospitals examined in the study lost a median $82 from patient care services.
In general, the study found that hospitals that were part of a health system were more profitable, and Anderson says that likely because they can leverage higher payments from commercial plans, which in turn pass those costs onto their enrollees.
"They are using that to raise prices and accumulate surpluses and some of them are using this surplus to buy more hospitals," he says.
Hospitals with the highest price markups earned the largest profits. Rural hospitals, those with 50 or fewer beds and major teaching hospitals tended to lose more than urban hospitals, larger hospitals and those with minor or no teaching component. The three for-profit hospitals on the Top 10 list are owned by HCA.
"When you go to a specific hospital you are going to that hospital for your care. If that hospital is making a profit, you are not getting all of the services that you are paying for," Anderson says.
In a statement on its website, Gundersen CFO Dara Bartels said the study "does not reflect our costs, as an integrated health system, for the care we provide in a multi-state, largely rural region with a high Medicare patient mix, and does not analyze data on quality of care."
"The portion of the cost report the authors used excludes administrative and shared costs per Medicare rules, with results varying between organizations," Bartels said. "We would rank much differently if these costs were considered. Analyzing Medicare cost reports of a single care center may have been relevant 20 years ago, but using the same methodology now for an integrated health system network isn't constructive."
Bartels said a study by the Dartmouth Atlas showed that Gundersen has the lowest cost of care per Medicare beneficiary in the country.
"We are also a national leader in providing care in the last two years of life by spending less per patient episode of care; shortening patients' length of stay in the hospital; having fewer patient complications and making fewer patient safety errors," Bartels said. "We are dedicated to high-quality, affordable care that balances inpatient and outpatient needs and reinvests earnings into health care programs, services and facilities in the communities we serve."
Anderson says "all of that is taken into account in the analysis."
"If they have a lot of Medicaid then their revenues are going to be less," he says. "It is true that we are not looking at whether or not they provide good quality care. We don't claim to be talking about quality at all. But we have taken into account all the factors that would explain why you are a profitable or non-profitable hospital with respect to patient care."
According to the study, the 10 U.S. hospitals with the highest profit from patient care services are:
Gunderson Lutheran Medical Center, Nonprofit (La Crosse, WI) Profit: $302.5 million
Sutter Medical Center, Nonprofit (Sacramento, CA) Profit: $271.9 million
Stanford Hospital and Clinics, Nonprofit (Palo Alto, CA) Profit: $224.7 million
Norton Hospital, Nonprofit (Louisville, KY) Profit: $211.2 million
Medical City Dallas Hospital, For profit (Dallas, TX) Profit: $210.3 million
Swedish Medical Center, For profit (Englewood, CO) $192.5 million
Hospital of the University of Pennsylvania, Nonprofit (Philadelphia, PA) Profit: $184.5 million
Methodist Hospital, For profit (San Antonio, TX) Profit: $172.4 million
Sacred Heart Medical Center, Riverbend, Nonprofit (Springfield, OR) Profit: $171.2 million
Carle Foundation Hospital, Nonprofit (Urbana, IL) Profit: $163.5 million
Anderson says the communities served by these high-profit hospitals should re-examine their relationships because these communities are footing the bill for higher healthcare costs but they're not collecting taxes on it.
"A lot of the communities where these hospitals are located are having financial difficulties," he says. "The hospitals, which are making money, aren't contributing to the financial reserves of that community. They are obviously employing people, but they are earning substantial profits and not paying any of those profits to the communities."
While the majority of the hospitals were collecting revenues on a fee-for-service model in 2013, Anderson says it's not clear if they can continue to reap handsome profits when the fee structure moves into value-based purchasing.
"That is one of the reasons why we did this study," he says. "We wanted to provide a baseline as to what are the hospitals doing well before value-based purchasing comes on, and then seeing if the same hospitals are able to respond to the new environment. In the old environment, the more you did the more you got paid. In the new environment, the better quality you provide the more you are going to get paid. It is a fundamental shift in payment and the question is will the same hospitals prevail."
Other hospitals on the list also complained that their profits were taken out of context.
Carle Foundation Hospital spokeswoman Jennifer Hendricks-Kaufmann says "the report considers only one year and omits important details like the system's losses, expenses and one-time government payments that occurred in 2013 and that omission makes Carle appear more profitable than the organization actually was."
"It's a significant omission and the authors admit there are factors they could not accurately address. We strive for a 2% to 3% margin, which we reinvest into patient care, including $44 million in charity care at cost to more than 27,000 people in 2013 alone. As a non-profit our community benefits, not shareholders."
Susan Phillips, Penn Medicine's senior vice president for Public Affairs, says the "excess revenue derived from clinical care at HUP is used to subsidize initiatives across the organization, including supporting and improving critical programs like a Level I trauma center and neonatal intensive care units, as well as funding biomedical research activities and education and training efforts in the Perelman School of Medicine."
PeaceHealth spokeswoman Marcy Marshall says the report "does not reflect how we reinvest the dollars back into our community."
"Our mission calls for us to reinvest our revenues back into our communities' health needs," Marshall says. "Each year consistent with the expectations that our community has for us as a nonprofit, these revenues are used to fund critical health and health improvement programs, capital investments and community benefit programs."
For example, in 2013 PeaceHealth investments totaled more than $128.3 million and included a $10 million expansion of the behavioral health services; $22 million for new diagnostic imaging and surgical technology, and $16 million to improve access to primary care and specialty care services.
The American College of Physicians and the Alliance for Academic Internal Medicine have issued a list of reforms that include exploring a performance-based GME payment system.
Primary care advocates, including two physicians groups, are calling for a realignment of funding for Graduate Medical Education that better responds to the nation's urgent and growing need for primary care physicians.
The American College of Physicians and the Alliance for Academic Internal Medicine issued a list of reforms in a joint policy paper published Monday in Annals of Internal Medicine.
ACP President Wayne J. Riley, MD, a clinical professor of medicine at Vanderbilt University, says calls for GME reforms have for years "been floated from various quarters," but with little success.
"The view of the ACP and the Alliance is that those discussions have been disconnected from the real workforce issues we have," Riley says. "The real issues are the number of physicians that we're projecting for the changing demographics of the country and the fact that GME is the ultimate determinative factor in the number of physicians who actually practice."
One of the most glaring problems is the simple lack of residency slots, a number that was capped by Congress at 1996 levels under the Balanced Budget Act. Since then, more than 20 medical schools have opened or expanded class sizes, creating a bottleneck in the physician supply at the residency level.
It's not clear if creating more primary care residency slots would come at the expense of other specialties. Riley says that there needs to be a balanced view of the number of specialists versus primary care physicians, although he concedes that may be more difficult that it sounds.
"There may be a perverse incentive to tilt toward specialty training programs that is not cognizant of the fact that we have a significant mal-distribution of primary care physicians in particular and a projected shortage of physicians in general over the next 25 years at a time when Americans are living longer, but consuming more healthcare," he says.
"The demographics and the utilization of healthcare services continues to increase. Expanded insurance has made healthcare more accessible, and therefore in need of more physicians. We have reached the point where this needs to be brought front-and-center to the policymakers in Washington, DC, and the state capitals."
Lack of Coordination, Coherency
Another problem, Riley says, is the lack of a coordinating body at the federal level to determine workforce needs. Medicare pays about $10 billion each year to fund residency slots, but has little oversight for how that money is directed or spent at individual residency programs.
"The heterogeneity of the residency programs contributes to the confusion and lack of coherency," Riley says. "Bringing rationality into the GME program and the way it is funded will help create some more hegemony around the GME that would better serve the nation and the public well."
Riley says the Affordable Care Act created a workforce commission to determine how many physicians, nurses, and other providers are needed, what specialties are needed, and what regions need them.
Congress has yet to fund it.
"The commission would do that very hard analytic work," he says, "looking at the data and trends and making recommendations to Congress and the executive branch about how best to assign resources. But it has not been funded. That is another part of the conundrum."
Riley says the ACP/Alliance doesn't believe the federal government should have to shoulder all the cost for GME.
"It should be an all-payer situation where providers, insurers, etc., contribute to a common fund for GME because they do benefit by having well-trained physicians," Riley says.
On the other extreme, the ACP has rejected calls to end Medicare funding for GME.
"The reason Medicare got into the business of GME is to drive quality into the healthcare system," Riley says. "Pre-Medicare paying for it, residency trainings were of very low quality. Because Medicare is such a big contributor to GME, the quality has gone up significantly. It has been a key driver to improve training and competency of physicians. It should never be abandoned, but it should be reformed and better linked to the clear workforce demands we have going forward."
Riley says that doesn't mean that Medicare's funding mechanism for GME should not be reformed. Medicare now uses two mechanisms: direct graduate medical education payments (DGME) to hospitals for residents' stipends, faculty salaries, administrative costs, and institutional overhead; and an indirect medical education (IME) adjustment developed to compensate teaching hospitals for the higher costs associated with teaching.
"We are saying, 'homogenize it into one single per-resident fee that follows the resident,'" Riley says. "So, if for a period of your training you are in an urban hospital, but you would prefer to work in a rural hospital, that payment will follow you to a rural training hospital."
"Now, under the rules, that's pretty much precluded at a time when we want to better distribute physicians and encourage young residents toward careers in rural areas. The structure of GME prevents them from getting training experience in different environments."
Even with these reforms, Riley says residency programs will still have to struggle with a perceived bias against primary care specialties that is not-so-subtly reinforced by the huge discrepancies in compensation between primary care physicians and specialists earning two and three times as much.
The ACP/Alliance paper also called for
Exploring a performance-based GME payment system that would need to be achieved without destabilizing the system of physician training;
Pilot projects to evaluate potential changes to GME funding and to promote innovation;
Payments for "well-functioning ambulatory settings" that provide training for internal medicine-pediatrics residents.
"There is a conscious and unconscious bias against pursuing primary care careers because of differential in pay," Riley says. "The other driver is that medical students are coming out $150,000 to $200,000 in debt. That contributes to a perverse incentive that unwittingly entices medical students who may be inclined to choose primary care to something else because of the debt loads and the salary differentials."
Two-thirds of the patients who survived acute respiratory distress syndrome and spent time in the ICU self-reported symptoms of at least one of these psychiatric disorders. The disorders can dog patients months after they’ve left the hospital, research shows.
Intensive care patients who survive life threatening illnesses remain at high risk for persistent bouts of depression, anxiety and post-traumatic stress disorder months after leaving the hospital, especially if they’re young, female, and jobless, according to a recent study from Johns Hopkins University.
The multi-institutional, national study involving more than 40 hospitals, which appears in the May issue of Critical Care Medicine, examined nearly 700 ICU patients. Two-thirds of the patients who survived acute respiratory distress syndrome (ARDS) and spent time in the ICU self-reported symptoms of at least one of these psychiatric disorders, and one-third of those patients with at least one psychiatric symptom said they experienced all three at the same time.
The report shows that these psychiatric disorders can dog patients months after they’ve left the hospital. Based on their self-reporting at six months, 36% of participants showed signs of depression, 42% showed signs of anxiety and 24% showed signs of PTSD. At 12 months, prevalence of these symptoms was nearly the same: 36%, 42%, and 23%, respectively.
Of the patients who experienced symptoms of depression, anxiety, or PTSD at six months, more than one-half, 57% to 66%, still had the same symptoms at 12 months, indicating the persistence of the symptoms.
Of the patients at six months without substantial symptoms of depression, anxiety, or PTSD, less than 15% later developed symptoms by the one-year mark. Most important, the researchers say, the majority of survivors, 63%, with any psychiatric illness experienced two or more symptoms at the same time at both six and 12 months.
A total of 645 survivors underwent a phone-based assessment to collect data for this study at the six-month follow-up, and 606 had a similar follow-up at one year. A total of 613 completed at least one psychiatric measure at six months by using the Hospital Anxiety and Depression Scale and the Impact of Event Scale-Revised (IES-R) surveys. There were 316 female and 297 male participants with an average age of 49, 82% of whom were white. At the one-year follow-up, 576 participants completed at least one psychiatric self-assessment.
The younger age group was 16% and 23% more likely to experience anxiety or PTSD, respectively, than the next older age group. Female patients are at 26%, 43%, and 80% higher risk than male patients for depression, anxiety, and PTSD symptoms, respectively.
Study coauthors Dale Needham, MD, professor of medicine and Joseph Bienvenu, MD, associate professor of Psychiatry and Behavioral Sciences, traded emails with HealthLeaders Media about their findings.
HLM: What is it about the ICU experience that prompts such levels of psychiatric distress?
Authors: There are many different factors hypothesized to be associated with these psychiatric symptoms, including:
Experiencing a life-threatening situation while in a highly vulnerable state without the ability to effectively communicate and access usual coping skills;
Physiological issues such as widespread inflammation; with potential break down of the blood brain barrier
Endogenous and exogenous hormonal effects like cathecholamines and corticosteroids.
HLM: Why does psychiatric distress disproportionately affect women?
Authors: These findings are consistent with psychiatric literature outside of the ICU setting as well. Our study indicates that greater symptoms in women may be due to a higher prevalence of pre-ICU psychiatric symptoms, which is consistent with the psychiatric epidemiology literature that demonstrates women (compared to men) have high prevalence of anxiety and depressive disorders, and low prevalence of substance use disorders. Also there may be differences between men versus women in how psychiatric symptoms manifest and can be detected.
HLM: Can you determine how many of these patients are in psychiatric distress before they enter the ICU?
Authors: Most ICU studies are unable to do this because these symptoms can’t be measured prior to the onset of critical illness given the unexpected onset of critical illness. There are a few unique studies that have followed large cohorts of patients over time with repeated measures of psychiatric symptoms. For patients who were in the ICU, these studies have shown an increase in symptoms after the ICU compared to before ICU.
HLM: Is it the ICU experience that prompts this psychiatric distress?
Authors: These patient outcomes are likely a combination of pre-existing symptoms as well as the ICU experience. However, the ICU experience can’t be separated from the experience of being critically ill. For instance, in addition to the frightening experiences patients have while delirious in the ICU, they are also on the verge of death and unable to interpret what clinicians are doing to keep them alive.
HLM: Why did you focus on ARDS?
Authors: ARDS is an archetypal critical illness. In focusing on ARDS, we reduce some of the heterogeneity in the many different types of patients in the ICU. Moreover, by studying ARDS, we select for patients who are more severely ill and have risk factors for worse outcomes due to issues such as hypoxia and inflammation.
HLM: What should hospitals do to alleviate this psychiatric distress?
Authors: The results of our research are helpful in identifying patients who may be at risk. Identification of early symptoms should prompt further investigation for psychiatric problems. Investigation for psychiatric problems should be broad since patients may have more than one psychiatric condition simultaneously (for example, symptoms of depression and PTSD together). Moreover, the focus should NOT be exclusively on older or sicker patients, or on those with longer length of stay, since ICU severity of illness measures are not associated with worse psychiatric symptoms.
HLM: Should a psychiatric evaluation be a routine part of discharge planning?
Authors: At this stage, it is too early to recommend a specific standardized method for screening all patients for psychiatric symptoms as part of discharge planning. However, if such symptoms are apparent as part of clinical care, that should prompt further investigation.
Providers need to build better links between pediatric hospitals and rural providers, and risk adjustment is warranted for patients coming from a low-income, rural areas, researchers conclude.
One enduring trope of American culture is the healthy country life. Picture the oatmeal ads of gingham-and-overall-clad youngsters, straw hats atop towheads, laughing and skipping through fields of green clover, bathed in golden sunshine, breathing farm-fresh air, far from the toxins of urban life.
Of course, this is a myth for many people living in rural America, adults and children. Studies have shown that nearly one-in-five children in rural America live in poverty. Many of these children, particularly African-American children, are at greater risk of obesity, tobacco exposure, and chronic medical conditions.
Now, a new study in Pediatrics adds to that consensus and documents less-favorable outcomes for rural children at pediatric hospitals when compared with children from non-rural areas.
The study, led by Alon Peltz, MD, MBA, a general pediatrician and Robert Wood Johnson Foundation Clinical Scholar at Yale University, examined more than 670,000 admissions at 41 pediatric hospitals (the majority of which are located in urban settings) in 24 states throughout 2012.
The researchers measured length of stay, hospital cost, and 30-day all-cause readmissions and tracked them against ZIP codes and U.S. Census data to classify children living in urban and rural areas, family income, and Health Profession Shortage Areas.
Here's what they found:
Rural children accounted for more than 81,000 admissions, about 12% of the total admissions under these criteria, and the majority of these rural children lived in ZIP codes with high poverty levels.
On average they lived 68 miles from the pediatric hospital, compared with 12 miles for non-rural children, and in some instances it was not uncommon for children to travel from other states.
The rural children were more likely to live in a low-income ZIP code, (53% vs. 24%), and a HPSA (20% vs. 4%).
Rural children also had a higher prevalence of complex chronic conditions (44% vs 37%); experienced higher inpatient costs (mean: $8,507 vs $7,814); and were at slightly higher odds for a 30-day readmission.
And "despite a higher prevalence of these characteristics, rural children are more often discharged from children's hospitals to low-income and medically underserved areas."
Peltz says he and his colleagues were drawn to the study because of their own clinical experiences trying to coordinate post-discharge care for children from rural areas. "We wanted to assess who comes from rural communities and if they experience a hospitalization any differently than non-rural children," Peltz told me.
"What surprised us the most was even when we accounted for the differences in illness severity, and even when we went through and looked at who had which chronic condition, and could we standardize the level of severity between the kids from rural and non-rural communities, we were still seeing the difference in how long they stayed in the hospital and the readmissions rate."
From a cold, hard, bottom line perspective, these findings are important for hospitals that face penalties for 30-day readmissions.
"One of the first question we asked as a study team was why are we observing differences in readmissions," Peltz says. "Even though they are not marked differences, they are still significant differences. Although we adjusted to try to make the rural and non-rural patients as similar as possible, we are still seeing a difference on the basis of geography. That should give us pause to ask why we are experiencing that disparity and think about how we develop our post-discharge care plans for rural children, especially those with multiple needs."
Peltz says the study findings also suggest that providers need to build better linkages between pediatric hospitals and rural providers, many of whom do tremendous work with limited resources.
"Advocates might use these result to ask how we can better integrate the care in terms of being more creative with telehealth, or e-consultations," Peltz says. "Can we think about policies that promote better financial integration between the entities that enhance the way that we coordinate care?"
The study makes a strong argument that risk adjustment is warranted for patients coming from a low-income, rural areas.
"It's a very complicated issue," Peltz says. "Is it a sign that the needs of a particular community are high, or is it a sign that we need to improve discharge planning? These might be informed by the finding that the readmission rate is high."
Peltz says his next research projects will attempt to provide more detail about how rural communities compare with one another on health metrics and outcomes. "There are differences between rural communities on the basis of geography and size and the next step is to identify differences between large and small rural communities to see if there are predictors of areas of higher need," he says.
Another area for study will examine the differences in how non-rural and rural children use healthcare services at pediatric hospitals. "We want to cast the net a little wider and see if we can look at patterns of care for rural children, both in terms of when they decided to use a children's hospital and when they used a local hospital," Peltz says.
"That can be informative as we think about how to build relationships between hospitals and providers within regions. A collaborative approach to meeting the needs of these families and leveraging the specialty care when it's needed, and supporting local providers is the way to move forward, and we still have a lot to learn about when rural children and rural families seek care in a more distant specialized center and when they stay closer to home."
The study also cries out for the need to improve access to primary care in rural America.
"Anytime we think about this population, particularly rural children with chronic health conditions, the thought is how do we bring more resources to these communities in a thoughtful way that complements the care they're receiving," Peltz says.
"I cannot overstate the importance of the local care providers. This is an opportunity for us to examine post-discharge care and to build relationships between primary care and hospital-based specialty care. We come away from this study thinking about how we can support local healthcare providers and linking children's hospitals within regions is definitely the next step."
The improving economy and the PPACA are not the only reasons why not-for-profit hospitals are doing better than three years ago, says a senior analyst at Moody's Investors Service.
Financial profiles at not-for-profit hospitals have strengthened over the past three years, thanks in large part to the recovering economy and the Patient Protection and Affordable Care Act, Moody's Investors Service says.
"Stronger operating performance is the result of significant gains in the number of people with insurance, growing patient volumes, and sizeable reductions in bad debt expense. The Affordable Care Act increased insurance coverage in states that expanded Medicaid coverage, contributing to lower bad debt expense," Moody's says in its April Healthcare Quarterly newsletter. "The improving economy, related job gains, and stronger patient volumes also contributed to the sector's stronger performance."
Dan Steingart, a senior analyst Moody's, says the improving economy and the ACA are not the only reasons why not-for-profit hospitals are doing better than three years ago.
"I don't want to give the wrong impression that they haven't been working on their own, because they have," he says. "On the expense side hospitals have been working for several years to take a lot of costs out of the system, but there is a lot more work that can and will be done."
"Those hospitals that have installed electronic medical records systems and have them up and running do realize some incremental savings, but that's sort of a small, sexy area," he says. "There are a lot of nuts-and-bolts, blocking-and-tackling around supply costs, along with productivity. Reducing excess layers of middle management has been a popular area."
The productivity improvements include ensuring that providers work at the top of their licenses, and that the administrative bloating that often comes with mergers and acquisitions is addressed.
"Over the past few years there was slower wage growth, and salaries and benefits are the number one line-item for hospitals," Steingart says.
The improved finances come as hospitals contend with medical inflation, especially around pharmaceuticals. "It's been growing rapidly," Steingart says. "That's a big challenge because after labor, supplies, and drug expenses are a big portion of supplies. [Drugs are] the number two expense for hospitals."
The Effects of M&A
Although mergers and acquisitions in the not-for-profit hospital sector have increased over the past few years, Steingart says it's "a notoriously hard thing to measure" how these consolidations have affected hospitals' financial profiles.
"M&A in the not-for-profit sector ranges from large systems acquiring a much smaller community hospital to two larger hospital systems coming together," he says. "I wouldn't say you're seeing savings from M&A, but that is not because it's not necessarily there. It's just much harder to measure because you don't have these big deals that you can point to. You have a lot of drips and drabs in M&A."
"The other side of it, there was a big run up in financial performance in the past two years and that is due to a lot of other factors, the economy, the ACA and the hospitals' own cost-saving initiatives. To attribute that to M&A wouldn't be fair," he says.
The bottom line, Steingart says, is that the improved financial profiles for not-for-profit hospitals means they'll be better positioned to adjust to looming value-based and population health payment models.
Higher Debts Weaken For-Profit Profile
The financial profile for much of the for-profit hospital sector has weakened over the past three years because of higher debt burdens brought on by a spate of acquisitions, Moody's says. However, the debt burden does not affect all for-profits equally, and Moody's says the outlook is expected to improve in the coming year as for-profits look to reduce debt.
"There was definitely a load-up on debt through M&As, in part due to the fact that credit markets were readily available to them," says Dean J. Diaz, a senior vice president with Moody's Corporate Finance Group. "It is nothing that was surprising given the level of M&A activity we've seen of late. It's a period in the cycle and very definitely a consolidation in the sector."
According to Moody's, the for-profit sector's "median debt/EBITDA increased to 5.2x at year end 2015 from 4.7x in 2012, as consolidating companies failed to effectively reduce leverage as much as we had expected. However, we expect that modest deleveraging over the next year will improve the sector's financial flexibility."
The biggest drivers were Tenet Healthcare Corporation's acquisition of Vanguard Health Systems, Inc., in October 2013 and Community Health System's acquisition of Health Management Associates, Inc., in January 2014.
"The rationale for both of these transactions included the desire to increase and leverage scale to combat pressure on reimbursement rates," Moody's says. "Each company's debt/EBITDA increased to close to 6.0x as a result of these transactions. However, we had expected leverage to return to closer to 5.0x through a combination of debt repayment and EBITDA growth resulting from the realization of significant synergies."
That didn't happen. With CHS, leverage remains high owing to weak volumes.
"Many of the initiatives to grow those margins have taken much longer to take hold. While we expect to see improvement at the HMA facilities during 2016, Community's leverage will now remain high into 2017," Moody's says.
Tenet reduced its leverage but then re-levered in 2015 to acquire a majority interest in United Surgical Partners International.
"For-profit operators will continue to invest in outpatient services," Moody's says. "Volume growth at these facilities will outpace inpatient admissions as commercial payers shift patients to lower cost settings. Outpatient services also require much less in capital expenditures to maintain."
