The federal agency's findings, other data, and practical experience suggest that hospitals should brace for a pronounced increase in ED use in 2014 when the ranks of the insured are expected to expand, says a board member of the American College of Emergency Physicians.
Andrew I. Bern, MD, FACEP (Photo Credit: ACEP)
One in five adults visited the emergency room at least once in 2011 and 7% reported two or more visits for the year, the Centers for Disease Control and Prevention reports.
The CDC's 36th annual Health, United States, 2012 report also found that in the decade from 2001 to 2011 both children and adults on Medicaid were more likely than the uninsured and people with private insurance to have at least one emergency room visit in the past year.
Andrew I. Bern, MD, an emergency physician in Florida and a board member with the American College of Emergency Physicians, says much of the CDC report "absolutely validates" what his organization has long been saying.
"The data is debunking the myth that only the uninsured go to the ED," Bern says. "We’ve been saying that for a while but it has not been carried well by the media."
Bern says the CDC data, other reports, and practical experience suggest that hospitals should brace for a pronounced increase in ED use in 2014 when the ranks of the insured are expected to expand by about 30 million people under the Patient Protection and Affordable Care Act.
"If you look at the Massachusetts, which is the basis for the Affordable Care Act, they found their volume of ED visits increased about 9% a year. When Canada instituted similar sorts of coverage their visits went up as well," Bern says. "Wherever this has been attempted to provide universal coverage or near-universal coverage utilization increases unless you provide an infrastructure alternative, such as increasing the primary care physician access."
Bern says it’s becoming apparent that sufficient ED alternatives will not be in place in many parts of the U.S. in 2014 when the ranks of the insured expand.
"You have alternative sites of care being developed but there is not good information on what impact that will have," he says. "Those alternative sites of care include the retail clinics run by nurse practitioners, urgent care centers, and free-standing emergency departments that are popping up in different states. These may ultimately provide different sites of care when people are looking for care urgently but there is no consistent basis. If a patient wants to be sure that they are not going to be turned away the only sure bet they have is the emergency physicians who are under federal law to treat everybody regardless of their ability to pay."
The CDC report also noted that:
In 2009–2010, cold symptoms were the most common reason for emergency room visits by children (27%) and injuries were the most common reason for visits by adults (14%.)
Between 2000 and 2010, 35% of emergency room visits included an x-ray, and the use of CT or MRI scans increased from 5% to 17% of visits.
In 2009–2010, 81% of ED visits were discharged for follow-up care, 16% ended with the patient being admitted to the hospital, 2% ended with the patient leaving without completing the visit, and less than 1% ended in the patient’s death.
In 2009–2010, 59% of ED visits (excluding hospital admissions) included at least one drug prescribed at discharge.
During 2001-2011, the percentage of persons with at least one ED visit in the past year was stable at 20-22%, and the percentage of persons reporting two or more visits was stable at 7-8%.
Bern says the CDC findings are consistent with a RAND Corporation study commissioned by the Emergency Physician Action Fund which shows that emergency physicians are key decision makers for nearly half of all hospital admissions.
RAND found that hospital admissions from the ED increased 17% over seven years, accounting for nearly all the growth in hospital admissions between 2003 and 2009, offset by a 10% drop in admissions from primary care physicians and clinical referrals. Nearly all of the increase was from "non-elective" admissions from the ED—a rate 3.8 times the rate of population growth.
Hospital inpatient care is a key driver of healthcare costs, accounting for 31% of the nation's healthcare expenses. Because of that, the role emergency physicians play in deciding who to admit to the hospital is critical to hospital cost savings, since the average cost of an inpatient stay ($9,200) is roughly 10 times the average cost of a comprehensive emergency visit ($922), RAND said.
"When you look at the overall $2.7 trillion healthcare system and that 31% of that expense is in the hospital and we are integrally involved in 50% of those admissions decisions it points to the value of the emergency physicians in the entire system," he says.
"The things we are proposing in terms of costs savings and integration are important points and our role in the entire healthcare context is one that is very very important to the bulk of that."
A program at the University of Alabama helps students prepare for the rigors of medical school—and careers as primary care physicians.
Mark Christensen, MD, knew he wanted a career in medicine ever since he served as an emergency medical technician with the volunteer fire department while still in high school at his tiny hometown of Toney in northern Alabama.
"I always thought it would be interesting to go the extra step and become a physician," Christensen says. "I enjoyed going into people's houses and taking care of them there and going all the way up to the hospital doors. But I wanted to see that other side of the doors as well and continue that care from inside the hospital throughout their stay."
Now a third-year resident in family practice at the University of Alabama School of Medicine, Christensen plans to return to rural Alabama when he finishes his residency in 2014. In large part, Christensen credits the University of Alabama's Rural Medical Scholars Program with helping him realize his dream of becoming a doctor. Christensen completed the scholars program during his senior year at the University of Alabama at Birmingham and it helped to prepare him for the rigors of medical school.
"They were able to help me because with the rural background and that kind of education I was at a disadvantage compared to some of the students going to bigger schools where they're doing calculus in the 8th grade it seems like," Christensen says. "We just didn't have those resources growing up and I didn't even know what I needed to know. This program definitely helps with that. They saw the potential in me and it turns out, I guess they were right."
Christensen says the tutoring and counseling he received from the program proved to be invaluable. "Coming into college was a rude awakening about how much you needed to study. I had no preparation for that coming in. They really helped you," he says.
"It takes a lot of things to get into med school, MCATs and GPA. A lot of people getting into the program have low MCATs. My MCATS were fine. I probably could have gotten in the regular way, but they help make you a better overall applicant. They understand you have a true desire to do this and they advocate for you to get in."
On Thursday, dozens of recent college graduates and college seniors from across rural Alabama will be interviewed and 24 of them will be selected to become Rural Health Scholars for the coming year. They will spend the time prepping for medical school and shadowing rural providers.
Susan Guin, RN, the associate director the Rural Scholars Program and a nurse practitioner, has been with the program for 17 years. She says interviewers try to find that mix of medical school candidates who can combine solid academics with the relationship-building and communication skills needed to thrive in rural environments.
"The common theme is that they come from a rural area so our selection criteria require that you have spent at least eight years of your life in a rural community. We try to select the student who has the desire to go back for the community and has a sense of family and home and wanting to be involved and immersed in the local community," Guin says.
"We are not necessarily looking for a GPA of 4.0 and an MCAT of 30. That is a great student and a smart person but there are also smart people who may have a 3.3 or 3.4 GPA, but they still do well and can sit down and carry on a conversation. They understand local culture and how to communicate with different people. There is value beyond the typical standardized testing idea."
While the rural scholars are not required to sign any sort of contract, Guin says there is "more of a handshake agreement" that they will commit to rural medicine when they graduate from medical school. The program appears to be working.
"[Within] general regular medical school admissions you are looking at maybe 10% of med students [who] end up going into family medicine/primary care. For us, we've got at least 60%—70% ending up in primary care, which would include family medicine and internal medicine and pediatrics and 90% that are staying in Alabama as practicing physicians. Some are cardiologist and radiologists, but they are still coming through our program and staying in the state. So we are not training physicians and seeing them go to another state. Those numbers alone are way outside the box for the norm."
The Rural Scholars program has proven so successful that it has morphed into a Rural Health Leaders Pipeline with six distinct programs that involve about 150 students of various ages at any given time, and even identifies and recruits 10th graders who've shown an interest in pursuing careers in healthcare.
"We work with them for the nine-month school year, at least having monthly meetings with them. College students, medicals students, and residents interact with the 10th graders to be mentors for students who might be interested in some sort of health profession," Guin says.
A separate program for 25 eleventh graders includes a five-week summer program with courses in chemistry, creating writing, and visits to hospitals and physicians offices. There is also a Rural Minorities Health Scholars program that provides first-year college students with preparatory classes in biology and shadowing healthcare providers.
Although he is committed to practicing in rural Alabama, Christensen says he understands the challenges that come with living in the country.
"It's hard because as we go through medical school we accumulate so much debt. The bill I just got the other day was $187,000. I can defer that because I am in residency for another year, but after that I have to start paying $187,000," he says.
"I don't know what $187,000 is! The most we had in the bank account growing up was $26,000 a year combined. In a rural area, you feel like you want to make up what you are in debt for and then some and so rural areas might not make as much money or you might go into a specialty and they are usually in bigger cities."
"Also as you go through medicine, you decide education is important and you look back at think, 'I was in a rural area and I didn't get a good education and I want my kids to have a better education so I am going to go to a large city where they will get a better education, better cultural opportunities and all that.' So it is hard balancing all of that."
Even with those challenges, Christensen says he's excited about his career path. "The more rural you are, the more skills are in need for all aspects of family medicine, which includes taking care of a kid on the pediatrics floor and then walking over to the ICU to take care of an adult in critical condition and bring them back to life and then you go to your office and treat a family," he says.
"I love that you can practice to your maximum ability. And as long as you are good and passionate about those areas, you will do fine. I put myself against any of those specialists any day."
Gary D. Newsome (Photo credit: Health Management Associates)
In the latest twist for Health Management Associates, the for-profit hospital operator's CEO, Gary D. Newsome, announces he will retire in July. Last week HMA moved to block a takeover bid by filing a shareholders' rights plan.
Just days after launching a shareholders' rights plan to protect Health Management Associates Inc. from a perceived takeover, CEO and President Gary D. Newsome announced Tuesday afternoon that he will retire in July to pursue missionary work in South America.
"I am proud of our accomplishments over the past five years as we've transformed Health Management into a vibrant, innovative company that is well-positioned and on a clear path to great success," Newsome said in prepared remarks.
Newsome has been named by The Church of Jesus Christ of Latter-day Saints to serve as the president of its Uruguay-Montevideo Mission in South America, the HMA release said.
"My family and my faith have always been the most important parts of my life and it is a rare privilege to serve in Uruguay, a place that has remained in my heart since I served my first mission there more than 35 years ago," Newsome said. "I am sincerely grateful for the support I've received from the Health Management Board of Directors, management team, and our associates and physicians."
Newsome's announcement is the latest twist in an eventful week for the Naples, FL-based for-profit hospital chain.
On Friday, just before the long Memorial Day weekend, HMA dropped a filing with the Securities and Exchange Commission stating that its board of directors adopted the shareholders' rights plan to thwart a perceived takeover bid by hedge fund manager Glenview Capital Management, LLC.
Glenview owns 14.56% interest in HMA common stock and in a 13D filing with the SEC on May 6 Glenview said that it "may engage in communications with relevant parties regarding the company and ways to enhance shareholder value, including, but not limited to, the Company's management, members of the board of directors, shareholders or other investors, potential strategic partners, financial advisers and other industry participants."
Pointing to the Glenview filing, HMA in its 8-K filing with the SEC said "the rights agreement is intended to protect the Company and its stockholders from efforts to obtain control of the Company that the Board of Directors determines are not in the best interests of the Company and its stockholders, and to enable all stockholders to realize the long-term value of their investment in the Company."
HMA said that affiliates of Glenview also had filed notice under the Hart-Scott-Rodino Antitrust Improvement Acts on May 22, which "indicates that these affiliates presently intend to acquire, collectively, up to approximately $2.2 billion of the Corporation's outstanding common stock."
HMA's filing, in turn, prompted Glenview on Tuesday to issue a "statement of clarification regarding its holdings" in HMA.
"We feel the 8-K issued by HMA in conjunction with the Board's decision to enact a shareholder rights plan, commonly referred to as a poison pill, may cause confusion regarding our intentions and may lead to undue volatility in the stock price…," the Glenview statement read.
Glenview said its filings with the SEC were intended to comply with provisions of Hart-Scott-Rodino "in order to be in a position to acquire even one additional share of HMA." Further, Glenview said "such an investment size is both beyond our present intention and beyond our present resources available for any single position. Such a filing was required to facilitate even a modest increase in our present holdings. In plain English, we have no present intention or future plan to buy either $2.2 billion of stock or 75% of HMA."
HMA spokeswoman MaryAnn Hodge said Tuesday that Glenview's clarification "will not change (HMA's) shareholders' rights plan. The Board continues to believe that adopting the rights plan at this time is prudent and in the best interest of the company and its stockholders."
Brian Tanquilut, a senior analyst for healthcare services at Jefferies & Company, Inc., says fears that Glenview is mounting a takeover are overblown:
"Glenview is a savvy healthcare investor. It's just a deep value picking strategy and I wouldn't read too much into that," Tanquilut says. "They made a decision to invest in HMA given that HMA is the cheapest hospital stock today. I don't think people thought Glenview was going to try to take over HMA. That's not their M.O. They are a hedge fund, not a private equity shop. They have never been an activist shareholder. People who know Glenview and what they are doing never ever thought it was a takeover strategy, but it was an opportunistic play. It just so happens that because of the size of their investment they had to file and HMA read into it 'Holy cow! They filed for up to $2.2 billion worth of stock and we are a $2.7 billion company.' But for HMA it's the right thing to do on their part, which is to protect their shareholder base."
HMA made no mention of the shareholders rights plan in its announcement of Newsome's retirement, which takes effect July 31.
HMA operates 71 general acute care hospitals in small- to mid-sized markets in 15 states with approximately 11,500 licensed beds, more than 42,000 employees and a medical staff of 10,000 physicians.
Health Management Associates has adopted a shareholders' rights plan to protect the hospital operator and its stockholders from efforts by Glenview Capital Management to obtain control of the company.
Health Management Associates, Inc. has launched a shareholders' rights plan that the investor-owned hospital chain says is needed to block a potential takeover.
In a Securities and Exchange Commission filing Friday Naples-based HMA said the board of directors adopted the rights plan to thwart efforts by Glenview Capital Management LLC to gain control.
"The rights agreement is intended to protect the Company and its stockholders from efforts to obtain control of the Company that the Board of Directors determines are not in the best interests of the Company and its stockholders, and to enable all stockholders to realize the long-term value of their investment in the Company," HMA said in the filing.
Glenview owns 14.56% interest in HMA common stock but filed a 13D filing with the SEC on May 6 suggesting that it would increase its ownership stake and "may engage in communications with relevant parties regarding the company and ways to enhance shareholder value, including, but not limited to, the Company's management, members of the board of directors, shareholders or other investors, potential strategic partners, financial advisers and other industry participants."
HMA noted in its filing on Friday that a Hart-Scott-Rodino Antitrust Improvement Acts was also filed on May 22 by affiliates of Glenview which "indicates that these affiliates presently intend to acquire, collectively, up to approximately $2.2 billion of the Corporation's outstanding common stock."
"In light of Glenview's Schedule 13D filing, as well as its filing under the HSR Act, the Board of Directors determined to implement the Rights Plan," HMA said in its filing. "The Board of Directors believes that the Rights Plan will help promote the fair and equal treatment of all stockholders of the Corporation (not just Glenview) and ensures that the Board of Directors remains in the best position to discharge its fiduciary duties to the Corporation and its stockholders. The Rights Plan adopted by the Board of Directors, which has a short one-year term and a 15% threshold, reflects the Board of Directors' effort to balance these concerns with best corporate governance practices."
HMA operates 71 general acute care hospitals in small- to mid-sized markets in 15 states with approximately 11,500 licensed beds, more than 42,000 employees and a medical staff of 10,000 physicians.
HMA was the subject on an unflattering report on 60 Minutes last December alleging that the company pressured physicians to admit patients regardless of their medical needs in order to boost profits. Producers for 60 Minutes "talked to more than 100 current and former employees." HMA denied the allegations.
A merger between two Michigan healthcare providers has been called off because of stark cultural differences between them, observers say. Those differences include the patient populations they each serve and the organizations' physician compensation models.
Detroit's Henry Ford Health System and Beaumont Health System announced this week that they would let expire a deadline for merger talks that would have created a $6.4 billion integrated system. In the end, observers say, it came down to a clash of cultures that could not be overcome by the advantages gained from a merger of equals.
Seven months after telling a room full of journalists that Beaumont was "the absolute ideal partner for us" Henry Ford CEO Nancy Schlichting sent a note to employees saying the deal was off. "This decision was made because it became apparent that two very different perspectives had emerged for the new organization between Henry Ford and Beaumont," Schlichting wrote.
At Beaumont, CEO and President Gene Michalski said in prepared remarks that "we have benefitted greatly from our merger discussions and have great respect for our colleagues at Henry Ford. However, we found through our discussions that we are not aligned on how to achieve our vision for a model health system due to differences in our structures and business models."
Beyond those public statements, neither side was talking, which left the field free for speculation.
Signs that the deal was faltering surfaced last week when physician leaders at Beaumont reportedly asked the system's board to reconsider the merger.
Marianne Udow-Phillips, director of the University of Michigan's Center for Healthcare Research & Transformation, says she was not surprised that the talks fell apart.
"I was more surprised in the first place when they said they wanted to do it," Udow-Phillips says. "The cultures are so different between these two organizations. Mergers and acquisitions are hard to do generally and in this particular case when you layer on top of it two organizations that have fundamentally different backgrounds and structures, that makes it even harder. I was surprised it was on track for as long as it was."
For starters, Udow-Phillips notes, the two health centers served different patient populations and used different physician compensation models.
"Henry Ford Health System is a very integrated academic health center where the physicians are predominantly salaried. The main campus is in the inner city of Detroit. They serve a population that is predominantly Medicaid and uninsured," Udow-Phillips said.
"In contrast Beaumont Health System," she said, "while it has some staff physicians, the leadership is predominantly led by independent physicians and private practice physicians. Their traditional home is in the wealthy suburbs. Their Medicaid population is very small."
"The physician cultures are quite different. Henry Ford has been an owner of the Health Alliance plan and is very familiar with capitated systems and salaries and structures for physicians and Beaumont is a much more fee-for-service oriented environment.
Allan Baumgarten, an independent health policy analyst and author of the Michigan Health Market Review, acknowledged the vast operational and cultural differences between the two systems, but said he was still surprised that the merger talks flopped.
"I thought these were two organizations that had concluded that they needed to combine forces to be more competitive in what has become a more dynamic and competitive regional market and I thought they had enunciated goals of improving quality and achieving efficiencies and reductions in costs that they thought they could achieve together better than separately," he said.
"Having said that, merging two organizations of that size and with different cultures and structures is obviously very difficult and at a certain point there were enough sticking points that they said they were better off walking away from the table than going any further."
Udow-Phillips believes that the merger talks were initiated last year more as a response to the Patient Protection and Affordable Care Act and other cost-containment and market share pressures brought forward by healthcare reform. Baumgarten says Vanguard Health System Inc.'s $1.2 billion acquisition of Detroit Medical Center in 2010 "stirred things up and was a major driver of Henry Ford and Beaumont to look for a marriage partner literally."
"Since Vanguard acquired the Detroit Medical Center, they have been pumping nearly $1 billion in capital into improving the buildings and the practices and challenging Beaumont on its own turf," he says. "Vanguard has now completed a major clinical center about two miles from the main Beaumont hospital at Royal Oak. Vanguard clearly has a strategy of trying to pick up more patients with better insurance than the inner city patients they have been seeing mostly up to now. They've been doing that by building new facilities and trying to acquire certain specific practices and had some success with that."
Neither Beaumont nor Henry Ford gave any suggestion in their brief statements to the media that they would pursue mergers or other alliances with other providers.
"We haven't seen the first quarter numbers yet, but for the end of the year the Beaumont finances improved significantly so there wasn't the same kind of financial pressure on them as there was when they first started the discussions I am not sure their path is going to be toward a merger," Udow-Phillips says.
"Henry Ford has already in their history done some mergers with other organizations. I am not sure which ones now they would approach. Henry Ford because their patient base is much more heavily based with public programs, they would benefit financially by finding a partner that would balance that out a little bit but I don't know how realistic that is going to be at this stage."
Baumgarten says Beaumont has already rejected advances from Vanguard "and I don't think that is likely to change."
"There are other possibilities," he says. "The University of Michigan Health System at Ann Arbor is about 50 miles from Beaumont and that is a very prestigious academic medical center which has been trying to extend its reach into different parts of the state through some acquisitions but mostly through different kinds of partnerships."
Baumgarten says some sort of alliance between Beaumont and Oakwood Healthcare System might also garner consideration. "Oakwood serves the west side of the Metro area where Beaumont is on the northeast side. There are geographically compatible," he said.
"Or maybe we'll see a partner relationship where Mayo Clinic or Cleveland Clinic is sharing certain lines of expertise of medical management or other administrative expertise with if not Beaumont than one of the other systems in the area."
Baumgarten says Henry Ford's improving balance sheet means the system could keep merger plans on the back burner for a while.
"Henry Ford has remade itself in the last couple of years with some success. Their profitability is much improved over where it was five years ago. It is mostly because of two things: one was the opening of the new West Bloomfield Hospital, which is a prosperous suburb of Detroit; and second was they closed what had been a money-losing (Henry Ford Macomb Hospital-Warren). Their medical group is in good shape. They have their own Health Alliance plan, which about 18 months ago acquired a Medicaid HMO in Detroit, which is strengthening their position. Henry Ford is thinking they're in pretty good shape."
If there is a lesson to be learned from the failure of the merger, Udow-Phillips says that key players in both systems have to be on board. "It is more than just two leaders wanted to come together, and I know the boards wanted to come together. But you saw in the physicians at Beaumont last week came out publicly in opposition to the merger so for any hospital the cautionary tale is to make sure that your physicians are aligned."
"The other message I would take from this is Beaumont and Henry Ford are two very strong institutions with a lot of history and strength in their markets. What you see more in mergers with hospitals is a very weak hospital merging with a strong hospital."
Baumgarten says the breakdown "is just a reminder of how difficult it is to engineer a merger of this scope."
West Virginia pediatric cardiologist Larry Rhodes, MD, speaks passionately about his work at three community outreach clinics. "It is always easy to hide under the guise of 'this is for patient care,' but the best days of the month for me are when I am in my truck driving to one of these clinics."
Larry Rhodes, MD, interim chair of the West Virginia University Department of Pediatrics is a subspecialist who enthusiastically takes his expertise into the field at outreach clinics across the Mountain State.
As director of the WVU Institute for Community and Rural Health, Rhodes has also played a key role in a program that has enabled 400 medical students to complete 2,700 weeks of rural healthcare training in 2012.
For his advocacy of rural health issues and efforts to improve access, Rhodes this month was named the 2013 Rural Health Practitioner of the Year by the National Rural Health Association.
Rhodes spoke this week with HealthLeaders Media about the challenges and rewards of taking his subspecialty skills to the people.
HLM: Talk about your work with outreach clinics.
Rhodes: I do three outreach clinics a month. I'm in Morgantown in the northern part of the state. I go to Parkersburg, which is about two hours away twice a month. And I do a clinic in Beckley, which is about a three-hour drive once a month. Each of our cardiologists do at least one outreach clinic a month. We have almost all areas of the state covered.
There are a couple of reasons why we do it. One is there are a number of children born in these rural communities who have congenital heart disease and we in Morgantown are the only center in the state that does surgery for kids with congenital heart disease. We have two doctors going to Beckley on Friday and we have 40 patients scheduled. We will keep that many patients from having to drive up here for a follow up.
West Virginia is almost all rural. The biggest town in the state in Charleston and it's only got 54,000 people. It's a big deal for some families to drive two or three hours and some of the patients are even five hours away. When I go to Beckley I will see patients that maybe have driven an hour and a half to get to the clinic.
I am primarily a pediatrician, but we do the same thing for adults with subspecialty problems. We have a doctor who does an outreach rheumatology clinic in the coal country in the southern part of the state. We have an ophthalmologist and a neurologist who go there too.
HLM: Why are there so few subspecialists venturing to these outreach clinics?
Rhodes: It's kind of an ivory tower mentality that 'I am here and they will come here.' Frequently when we think about rural healthcare, we think about primary care physicians, who are the cornerstone to the whole thing and who are very important.
But sometimes the patients with acute special healthcare needs are not lost in the shuffle, but we don't think enough about them at times. We just assume they will come back to the tertiary care center for follow up. I have patients who will cancel a clinic visit because they can't find the $50 to put gas in the car.
Or they may find that they can get a ride to an outreach clinic with a neighbor who is willing to drive them a half hour but they are not willing to drive two and a half or three hours and wait for the appointment and drive back.
HLM: Is sending subspecialists into the field a good use of limited resources?
Rhodes: That's true to a degree. You may need to bring the patients into the tertiary care center for the testing and expertise. But the patients I see in these outreach clinics I may be able to see three times before they need to come to Morgantown.
Once every one or two years I may have to bring a patient here, but I can see that patient every six months in their community. I can think of patients I haven't had to bring to Morgantown in five years. I can go and see the patient as a subspecialist. The family medicine guy is good at taking care of the patient in between.
But they get a little uncomfortable if they are watching the kid with the artificial heart valve. They may have the experience of 20 adults with that problem but what do you say to a 12 year old who has an artificial heart value in terms of his physical activities? There are certain things we can take to the community that are not necessarily things that they need to come to the tertiary care hospital for.
HLM: Are you urging other subspecialists to do outreach work?
Rhodes: I think so, very much. I personally prefer going to the communities because I love it. I love going out and seeing the patients in their home communities. I pride myself in knowing where almost every patient of mine is from. If I have not been to where they are from I will drive there sometime to find out.
There are always resources issues. If you only have one neurologist in your practice it is a little harder to say 'go do a clinic once a week somewhere else.' But it is a great public service. It helps the patients. It helps with compliance. It is very rewarding. I am old enough to realize that what I used to think I was doing for the patient I am really doing for myself.
It is always easy to hide under the guise of 'this is for patient care,' but I can tell you the best days of the month for me are when I am in my truck driving to one of these clinics.
HLM: Does clinical outreach make you a better physician?
Rhodes: Yes. It forces you to do things sometimes without all the technology. [Like] when I go to a clinic where I don't have an echo machine or some of the advantages I have here. If I am seeing a patient here and I am a little confused, I can send them for a test. Frequently I can't do that in outreach clinics. I can arrange a test and have it done the next week, but I can't just send them out of the office and tell them to 'go get this test and I will see you.'
We have taken residents and med students with us to the clinics and they love it. It's like practicing medicine the way you were taught to practice—using your physical exam abilities, using simple tests like an EKG or an X-ray. It gives you a rapport with your patients.
HLM: How does the outreach experience help you better understand better patients' perspectives?
Rhodes: Look at a map of West Virginia and you see there are interstates going through the state and you say there can't be anyone who lives more than three hours from here. I have a slide that I use when I talk to medical students about rural health.
I can show you the interstates and I will ask 'how long will that take you to drive?' and a lot of them will say 'it's three hours.' Well it turns out it's five hours, because it takes almost an hour and a half to get to the interstate.
You can't see that on the Google map, but when you drive out to these places and you realize where these people are coming from, you are not angry when they miss an appointment or when they come 25- or 30-minutes late.
I never refuse to see a person who is late and I won't let anyone in my division refuse to see somebody who is late because I have been there. I know where they are coming from. It may not be snowing in Morgantown, but an hour from here they may have a foot of snow.
You get mad because a family doesn't get a prescription filled and then you realize that the closest drug store to them is 45 minutes away and it closed at 8 p.m. and they didn't get back from the hospital until 9 p.m. There are things like that that you don't think of if you don't go out and do this type of stuff. It is that type of stuff that makes you appreciate what they are going through.
HLM: Is clinical outreach a good prescription for doctor burnout?
Rhodes: It is a great cure for burnout. The person who was my boss who is still in our division is 73 years old and he still works and he is the one who started the outreach clinics for pediatric cardiology.
He is not burned out and we will do a clinic together on Friday when I go to Beckley. I have another practitioner in our group who is 71 and another who is 65. They are all cardiologists and none of them are burned out. I have said a number of times; they will drag me out of this building feet first. I will not retire. I will work until I can't walk. And part of it is the passion for doing this.
Doctors in the emergency department are the major decision makers in nearly half of all hospital admissions, giving them a significant role in controlling healthcare costs, research shows.
Jay A. Kaplan, MD, has been an emergency physician for more than 30 years and over the decades he has witnessed firsthand what he says is the evolving role of the emergency department in providing frontline healthcare.
"When I first started practicing we called it the emergency room," Kaplan says. "Then we got called the emergency department. We have morphed again. We are no longer an emergency department. We are an emergency care and acute diagnostic center."
Kaplan, a board member with the American College of Emergency Physicians, points to a Rand Corporation study commissioned by the Emergency Physician Action Fund which shows that emergency physicians are key decision makers for nearly half of all hospital admissions. Because of that, Kaplan says, emergency physicians are playing a critical role in controlling healthcare costs.
RAND found that hospital admissions from the ED increased 17% over seven years, accounting for nearly all the growth in hospital admissions between 2003 and 2009, offset by a 10% drop in admissions from primary care physicians and clinical referrals. Nearly all of the increase was from "non-elective" admissions from the ED—a rate 3.8 times the rate of population growth.
Hospital inpatient care is a key driver of healthcare costs, accounting for 31% of the nation's healthcare expenses. Because of that the role emergency physicians play in deciding who to admit to the hospital is critical to hospital cost savings, since the average cost of an inpatient stay ($9,200) is roughly 10 times the average cost of a comprehensive emergency visit ($922), RAND said.
"Use of hospital emergency departments is growing faster than the use of other parts of the American medical system," Art Kellermann, MD, the study's lead author and a researcher at RAND, said in prepared remarks. "While more can be done to reduce the number of unnecessary visits to emergency rooms, our research suggests emergency rooms can play a key role in limiting growth of preventable hospital admissions."
Kaplan says RAND shows that office-based physicians are directing some patients to the ED who they previously would have admitted themselves. The study also found that EDs perform complex diagnostic workups that cannot be done in primary care physicians' offices, and that EDs supplement primary care providers by handling overflow, after-hours cases and weekend call.
"Patients who come to the ED are coming either because they have been sent there by their private doctor, or they have no other healthcare provider to turn to," Kaplan says. "Even those who have primary care doctors, when they call them for an appointment, they say 'go to the ED.'"
Rather than a focus on keeping people out of the ED, Kaplan says the emphasis should be on providing EDs with the resources they need to successfully adapt to this new trend.
"That includes more widespread adoption of inter-connectability and interoperability of (healthcare information technology)," he says. "If the doctors have the patient in the ED from a skilled nursing facility, if I can access the patient's history and medications and allergies and test results that helps a lot. The more collaboration, the more we can create effective transitions of care."
"Care handoffs are crucial. Rather than seeing the ED as the more expensive place to receive care, they should be viewed as acute diagnostic centers that provide clinically and economically efficient ways to evaluate complex patients with worrisome symptoms."
Two weeks ago the American Hospital Association came out with its own report that showed that EDs are treating growing numbers of sicker Medicare patients who require more complex and expensive treatment regimens. AHA says data show that between 2006 and 2010, the severity of illness of Medicare patients in the emergency department increased, as did the rate of use, a trend that policymakers fear is leading to higher spending with inadequate reimbursements.
The AHA says the federal government's more stringent inpatient admissions guidelines and growing claims denials are also putting more pressure on hospitals to treat Medicare patients in the ED rather than admit them.
The RAND report found that increased admissions were highest among people ages 65 and older.
"If you look at the increase in admissions, what you see is that it has more to do with the aging population," Kaplan says. "Patients are being sent to the ED with their acute illnesses and with their complex illnesses. Admissions to the ED are 50% of all hospital admissions and 70% of all non-elective admissions. One of the things that we do know is that it is the Medicare patients, the sicker patients, who are admitting. When I first started practicing, if you saw an 80-year-old, that was relatively rare. These days probably half the patients I see are 80 or 90 and with more complex illnesses too."
"It's a function of an aging population and it is a function of the workforce shortage, particularly among primary care physicians," Kaplan says.
"And the truth is it also relates to the fact that there are many primary care physicians and other physicians who will not take Medicaid and for that matter will not take Medicare. They only want patients with private insurance."
A survey of hospital CFOs shows primary care physicians generated a combined average of $1,566,165 for their affiliated hospitals in the last year. Other specialties generated a combined annual average of $1,424,917, the lowest average in five years, data shows.
Primary care physicians have emerged as key money makers for their affiliated hospitals and for the first time are generating more revenues on average than their specialist colleagues, a survey data from Merritt Hawkins (PDF) shows.
"For the first time in the survey's history we have primary care overtaking specialties on an average basis," says Travis Singleton, a senior vice president at the Irving, TX-based physician recruiting firm. "I was pleasantly surprised to see the survey show that. We knew it was happening, but we didn't know if the market had shown that yet."
The survey asked hospital chief financial officers to quantify how much revenue physicians in 18 specialties generated for their hospitals in the last 12 months, including net inpatient and outpatient revenue from patient referrals, tests, prescriptions, and procedures performed or ordered in the hospital.
Primary care physicians—family physicians, general internists, and pediatricians—generated a combined average of $1,566,165 for their affiliated hospitals in the last year. The remaining 15 specialties included in the survey generated a combined annual average of $1,424,917, the lowest average in the five years the survey has been conducted, the data showed.
"It's one more example of the changing balance of power from specialist to primary care, whether you see that as market driven or regulated or however you see that happen," Singleton says. "But as government and payers start to favor that gatekeeper—more preventative primary care practice of medicine—we are going to continue to see these primary care providers ascend over specialists, at least on an average basis."
Singleton says the shift is largely due to the migration of primary care physicians away from private practice and toward the employed model.
"We recognize that the majority of this bump is because more of their physicians are employed now so there is greater control," he says. "These health systems have formulated these vast employee networks and it is no secret that an employed physician is going to be much more apt and even directed in some cases to push a lab or a test or a procedure or a referral down the hall and not down the street. They aren't going to send it to an independent imaging group or an independent lab like they used to. In essence that is not really creating new money. That is just pulling that money within the hospital walls."
"As the primary care physician evolves into this quarterback of the medical home model and if they truly do what they are being designed to do, which is to control the entire flux of that patient, in theory they would dictate what tests happen and what procedures are necessary, what specialist are brought in, what preventative care or home health measures are used," Singleton says.
"In theory, if that happens, then that is where you want to invest all of your dollars, because not only are you controlling the outcome, but you are controlling the expense of your specialists."
Even with the newfound emphasis on primary care, key specialties remain top revenue generators for hospitals. Orthopedic surgeons topped the list of specialists examined in the survey. A single, full-time orthopedic surgeon generates an average of $2,683,510 a year. Invasive cardiologists generate $2,169,643, general surgeons $1,860,655, and neurosurgeons $1,684,523, the survey found.
Singleton says he's not sure how long the trend toward higher average revenues will continue for physicians.
"We know the employed physician sees 17% fewer patients than their private counterpart, and it's greater in some specialties. So it wouldn't surprise me if we looked in two or three years from now and the actual revenue per provider was down in some scenarios," he says.
"That doesn't mean the whole pie is smaller. You may have the same amount of revenue but you just may take more primary care providers to generate the same revenue, or you may see some that are leaked towards a nurse practitioner or a physician assistant as they start to grow these networks. But these are all new networks for hospital to control in a lot of cases."
When the survey was last conducted in 2010, family physicians generated an average of $1,692,832 a year on behalf of their affiliated hospitals. In 2013, that number grew to $2,067,567, an increase of 22%. Revenue gene rated by general internal medicine physicians also increased, from $1,678,341 in 2010 to $1,843,137 in 2013, a growth rate of 9%, the survey said.
"If you want to go 10 years out and say the Affordable Care Act is going to do its job then this whole survey should be in theory turned on its ear," Singleton says.
"Revenue numbers per provider shouldn't be anything more than an internal measuring stick to see how your hospital is running because the vast majority of the profits your hospital realizes will be in shared savings through efficient and effective care, theoretically. You could argue that if in 10 years everything works like how we want it to work, high revenue per provider could be seen as a negative because you don't want to see a lot of imaging and tests and other things. I don't know that we will ever get there, but that is the utopia."
"That is why I think this spike per provider may be a short-lived spike. The ramifications you are seeing now are nothing more than people preparing to have a seat at the table."
The second round of federal Health Care Innovation Awards specifically seeks clinical models that will quickly shrink Medicare costs and improve care for populations with special needs as well as population health.
Nearly $1 billion in grant money will be available to healthcare providers that can demonstrate a high likelihood of success in rapidly lowering costs and improving quality for chronic and special needs populations, the Centers for Medicare & Medicaid Services announced this week.
"Over the last three years, we have seen national healthcare cost growth slow significantly and we want to continue that trend by helping to improve the delivery of healthcare by testing new models of paying for quality care, CMS's newly confirmed administrator Marilyn Tavenner said in prepared remarks.
"These awards will help spur private and public sector innovation in this endeavor."
This second round of Health Care Innovation Awards differs from the first round. This time, CMS said it's looking for innovations in four areas:
Rapidly reducing costs for patients with Medicare and Medicaid in outpatient hospital and other settings;
Improving care for populations with specialized needs;
Testing improved financial and clinical models for specific types of providers, including specialists; and
Linking clinical care delivery to preventive and population health.
Colin Roskey, an attorney at Cozen O'Connor Public Strategies in the firm's Health Law Practice Group, says "results" are the focus of the second round of grants.
"Without characterizing the first round of grants, maybe one might call it more generalized and aspirational. The second round is more results-oriented in asking for models that rapidly reduced spending and improve care for populations with special needs," he says. "So already they aren't just saying population health. They are saying population health with an emphasis on patients with special needs."
"This gets more specific when you look at the models they are looking for," says Roskey, a former health policy advice and counsel to the U.S. Senate Finance Committee. "They want approaches that test specific types of providers to transform their clinical and financial models. CMS is moving in Round 2 towards a grant environment that is going to force participants to show scalable provable propositions that can work in an environment where specificity is the rule and generality is the exception."
Roskey says oncology services for special needs populations is expected to be a focus of the grants as well. "For instance, oncologists or the clinical oncology delivery system in the community, or the academic medical center, or elsewhere maybe we take care of patients with specialized needs," he says.
"Not only do they have some type of cancer, they have other co-morbid conditions. While the Innovation Center has taken on accountable care and post-acute care and the notion of bundling payments, they have not yet taken fully on some of the various manifestations of cancer care."
CMS is also expected to target providers who serve populations with significant health needs, Roskey says.
"These might be dual-eligible (Medicare/Medicaid) patients, patients who are chronically ill or reside in long-term care hospitals and/or patients who have other disabilities that prevent them from being fully functional in the work place that this innovation program could facilitate better community-base care services," he says.
"I see some psychology, I see some psychiatry, and I see a larger emphasis on poor people who are dual-eligible being able to access through their delivery system care that might facilitate improvements in their population health."
Last year CMS awarded 107 round one Health Care Innovation Awards out of nearly 3,000 applications to organizations that are currently testing innovative solutions to improve outcomes and reduce costs. Projects are located in urban and rural areas, all 50 states, the District of Columbia and Puerto Rico, CMS said.
Notable projects include:
The Courage Center in Minnesota, which provides a medical home for people with traumatic brain injury and those in wheel chairs. The patients have lower rates of depression and have reduced rates of hospitalization by 71% - from 10.8 days per year to only 3.1 days per year.
Welvie, LLC in Ohio, which is teaming with Anthem Blue Cross Blue Shield in Ohio to enable Medicare beneficiaries to make better informed decisions about surgery and their treatment options. Since September 2012, nearly 3,500 patients have participated, with 48% considering surgery alternatives and 17% choosing less invasive options, resulting in an average savings of $7,000 for each surgery avoided.
The lack of IT staff with expertise represents the top challenge leaders face regarding their IT group.
Where in the IT group are you finding these shortages, what is the effect on the organization, and what can leaders do to address that?
Jack Kolosky
Executive vice president and COO
H. Lee Moffitt Cancer Center and Research Institute
Tampa
Jack Kolosky
On finding the right people: Even with a higher-than-expected unemployment rate, the issue of trying to find really qualified people who understand the program and who are willing to stick with it through all the trials and tribulations and difficulties in implementations is challenging.
A staffing problem across many industries: We thought we might have been unique in healthcare, but we spoke with one of our board members who runs a major corporation and she was saying the same thing about her business. We all agree that information technology and the usage of it—being able to mine the data—is critically important to our businesses. But we really need to have our schools and our infrastructure—be it government or whatever else—step up and help accelerate the idea of recruiting people into this field.
On building partnerships: We are looking at partnerships with some of the major schools, much as we did in nursing and other areas where we had critical shortages, about helping us to recruit and continually train new qualified people.
On the effect of IT staff shortages: To be perfectly frank, I wish we were able to turn out more people who are qualified and can think outside the box and be a little more innovative. We have a great group here. We just don't have enough of them. We obviously get the job done but it seems to take us longer or we can't do some of the innovative things we'd like to do.
Sam J.W. Romeo, MD CEO
Tower Health & Wellness Center
Turlock, Calif.
Sam J.W. Romeo
The evolution of healthcare technology is behind the curve. It will be self correcting for two reasons: There are an increasing number of physicians who are becoming technical themselves and there are technical people who are beginning to learn the physicians' language.
The biggest barrier is we have third-party and other people including Medicare that basically are saying these are the priorities and they distract us away from the patients and toward the payer mechanisms. That is important because if you don't get paid you can't take care of patients. But it seems like we are putting a whole bunch of balls in the air at the same time and we don't have enough technical people to be able to communicate across those bridges to be able to do it with any efficiency.
We are fixing it. I'm an old man. I am a family doctor for 50 years but I have six children, five of whom as physicians are working on this and who are electronically savvy and much of the culture is different. That is a big transformation. They are head over heels involved in creating software that will support documentation of what happens in the examining room so we will have a relational data base so we can do some things that are meaningful in terms of quality and not just meaningful in terms of payment.
Deborah Gaspar
Chief Nursing Officer
Memorial Hospital Sweetwater County
Rock Springs, Wyo.
Deborah Gaspar
We can't recruit skilled health system administrators who understand how the programs interconnect and how they connect to server capacity and how they connect to wireless capacity; how they are upgraded becomes an issue. This needs to be addressed industrywide
Nursing has always had to deal with shortages and we've learned how to train our own and that is what is going to have to happen in healthcare IT.
The IT people are pretty frustrated about it, too, because so many of the IT people don't have leadership abilities. They don't know how to problem solve. And the people they report to in the organizations often don't have competencies doing that problem solving. So I do think there are going to be more clinical people who delve into that role because it's going to be necessary.
We have a couple of RNs who built our clinical system. They are both in their 20s and they are much more competent and capable at that stuff than I am. I can do the clinical background and the clinical standards and the high-level stuff and they do the technical skills-based stuff. We're creating our own solutions. You have to survive so you do what you have to. Give people the abilities because there are people out there who want to do this stuff. You have to be patient and willing to groom them.
Glenn McElroy
Glenn McElroy
Executive Director
Columbia (Mo.) Surgical Associates Inc.
It is pretty easy to find the guy who can handle the complex hardware networks within the office. However, the complex software—and the nuances and constant updates that are associated with each, often unfixing things you fixed last week—gives you constant new challenges, and finding someone who has a handle on both hardware and EMR is very difficult. I am not sure I know anybody who is really happy with their EMR and practice management products as they interrelate.
It is self-correcting somewhat with the younger doctors coming up, but in the short term we aren't going to outgrow it. It is the switchover from the texted base to a data-based EMR that is throwing everybody for a loop. That consternation is going to lessen as more of the old guard who are used to dictating verbal notes either retire or give up and get on a computer and figure out how to make it work. The younger docs coming up are very familiar with messing with computers and can't think of any other way to do it.