Tuesday, May 22 marks the one year anniversary of the devastating tornado that killed 161 people in Joplin, MO and hobbled the city's healthcare delivery infrastructure.
In seconds, an EF5 tornado packing winds in excess of 200 mph destroyed the 367-bed St. John's Mercy Regional Medical Center. It was the most infamous and deadly event in a spate of natural disasters that plagued the Show Me State in 2011. Floods, blizzards, and other ferocious tornadoes across Missouri resulted in fatalities, thousands of injuries, hundreds of millions of dollars in property damages, and severely strained healthcare services.
The Missouri Hospital Association this month issued a report that suggests that hospitals that successfully overcame these disasters in 2011 depended in no small part upon the emergency preparedness plans they've been developing for the last decade.
"This wasn't something that they just learned the day before the event started. This has been a labor of love for the last 10 years," says Jackie Gatz, director of emergency preparedness at MHA.
"We have done a tremendous amount of training and staff competency development around emergency preparedness using hospital preparedness grant funding. We did training on evacuation and incident command and surge management that really improved and assisted all the hospitals as we went through the response."
In Joplin, for example, staff at the devastated Mercy Regional no longer had the systems that they relied upon for routine communications. The tornado hit at about 6 p.m. on a Sunday afternoon, when key administrators were not at the hospital. Land lines and cellular telephone towers were inoperable.
"They had to rely on their instincts and what they had learned in the past. That is a huge takeaway and it really shows the value of training and planning for healthcare workers," Gatz says.
Gatz says there is no way that any hospital can plan for every contingency in an emergency. However, hospitals can focus on the competencies that will be needed regardless of the disaster event. "We look at communications capabilities and their ability to operate different modes of communication, evacuation procedures and patient movement, and medical surge," she says.
"Regardless of the event a lot of those pieces are going to come into play and the consistency is the staff will be involved regardless of the event."
MHA says the disaster at Mercy Regional underscores the need for ongoing emergency response training, and will shape future hospital response strategies. With an emergency plan in place, Mercy Regional staff had safely evacuated patients to interior hallways before the tornado it, and in the minutes after the tornado left the hospital inoperable staff was planning patient evacuations to nearby hospitals.
"If your building is destroyed there is no plan to pull off the shelf. You have to be comfortable with your staff competencies in how to respond," MHA Vice President David Dillon says. "They felt confident they understood how best to respond within the scope of what an incident command should look like and who should be in charge and who is available and what needs were they going to have."
Other key takeaways identified by MHA as lessons learned include a focus on resources and assets, safety and security, staff, volunteers, and utilities. Dillon says the ongoing training that many hospitals were involved in before the disasters creates an emergency response mechanism that is not unlike muscle memory.
"The more you drill it and deeply learn it, the less you will have to think about it when it comes to engaging in that process," he says. "I don't think anyone, if you haven't been to Joplin, could understand the scope of that disaster. But before that disaster I would suspect the folks in Joplin would never have thought they'd need the extent of training or resources they put aside to deal with it."
"How do you prepare for something that is almost incomprehensible? You do it with repetition and realistic training that gives you as close and bad a scenario as you can envision with the hopes that if that comes along you are as prepared as you can be."
It didn't make headlines, but more than 250 U.S. military medical personnel quietly deployed into a stubborn pocket of poverty this month on a relief mission that spent two weeks treating people with little or no access to medical care.
Many of the 12,000 or so people treated by the medical specialists had chronic ailments such as hypertension and diabetes, or neglected health issues such as decaying teeth and vision problems. Access to healthcare has been elusive for the people of the region. Several told their caregivers in camouflage that they hadn't seen a doctor in decades nor ever visited a dentist.
This deployment is a heartwarming story about the generosity and sacrifice of Americans in uniform providing desperately needed medical care for people with few alternatives.
Sadly, the military did not have to leave the United States to provide these badly needed services. The patients all lived around Selma, Hayneville, and Demopolis in Alabama's impoverished Black Belt, which is named for the region's dark, fertile soil.
For a third straight year military medical personnel including physicians, nurses, dentists, optometrists, and even a veterinarian—from the reserve ranks of the Air Force, Army, Navy, and National Guard—came from all over the nation to provide the care that the Department of Defense calls Innovative Readiness Training, or IRT.
"It's a win-win for us and the military," says Chris Masingill, federal co-chair of the Delta Regional Authority, a joint federal-state board that promotes economic development in the eight-state area. "Our part of the world is one of the most economically distressed areas of the country and you can add on top of that our poor health attainment issues and our medically underserved population that we have in the Delta region, Masingill says.
"The military gets to put in place the procedures and plans that it would use during a time of natural disaster or war. This is an opportunity for them to test their supply chain, medical training, staffing levels, logistics, you name it. They run the gauntlet in those two weeks that they are setting up their field medical units in our part of the world."
Masingill says the military has estimated that it provided about $3 million in free medical care during the two-week mission. "The military folks absolutely love this. Instead of going overseas to do their two weeks of annual training they can do it right here at home and the benefit is enormous," he says.
For many of the military medical providers, a trip to the Delta can be illuminating.
"Some of the physicians and particularly the dentists who practice in more affluent areas in their private practices, when they participated in our IRT program their reaction is 'Wow!'" Massingill says.
"You hear about it. You read about it. People tell you about it. But now they've seen the kind of poverty that has an impact on somebody's oral health and it is pretty tremendous. We had one case where every tooth in that individual's mouth was extracted. That is something you don't see every day."
IRT has been operating in the Delta since 2009. The training program was in Mississippi and Arkansas in previous years. Massingill says IRT looks to expand in 2013 and beyond to include multiple missions simultaneously in several Delta states in great part because of the demand for care.
"It affirms in my mind how important it is that we address the issue of affordable accessible quality healthcare in our part of the world, particularly in areas that are economically distressed and medically underserved," he says.
"You can see the sheer numbers of people and the stories that come out when they go through their IRT program and have the opportunity to have their eyes checked or have a cavity filled or see a physician for hypertensions or diabetes, which are big issues in our part of the world."
With a mixture of pride, appreciation, and frustration, Massingill laments that it take a military exercise to bring quality healthcare to the nation's poorest regions.
"We still suffer tremendously from the issue of affordable accessible quality healthcare in rural America and particularly in the Delta region," Massingill says. "If we don't address these issues it impacts our ability to be competitive and maintain strong communities and strong economies."
"You cannot have a healthy workforce without a healthy community," he says. "And there are many people, many Americans in our part of the world that simply cannot afford or have the ability to access quality healthcare."
Three in four healthcare organizations had to find temporary physicians at some point in the last 12 months because they couldn't find permanent physicians, survey data shows.
A survey of more than 100 healthcare organizations conducted by Irving, TX-based Staff Care also found that 41% of healthcare organizations are currently looking for temporary physicians.
"We have seen consistent demand for locums across the industry for five or six years now," says Bonnie Owens, Staff Care's senior vice president of client services. "The demand is still there. If you look at why facilities are using locums there is pretty wide variety, but they are using them mostly until they can find someone in a permanent position."
Some of the blame for the physician shortage has been placed on the nation's medical schools, where enrollments for many years failed to keep pace with overall population growth. This month the Association of American Medical Colleges reported that medical schools are on track to boost enrollment 30% by 2016. However, they may not have residency slots available for all of their new graduates.
"This is the tsunami that's been waiting to happen," Owens says. "Without those residency spots, the number of students isn't impacting the demand like we need it to."
Owens says 20% of the positions that Staff Care was asked to fill in 2011 were for primary care physicians. That was followed by 19% for behavioral care providers; 16% for anesthesia providers; 10% for hospitalists; and 8% for surgeons.
"We are also seeing a fusion of behavioral health and primary care," Owens says. "We are seeing patients come in for a variety of different needs, for instance, diabetes or obesity. Some of that can be caused by depression or onset depression."
The respondents in the survey said they liked the convenience of using locum tenens, mainly for care continuity and preventing revenue loss. However, 86% of the respondents identified the high cost of temporary help as the most significant drawback when hiring locum tenens.
Owens says the costs of any particular locum tenens physician will vary depending upon the specialty, the need, and the geographic areas. "But oftentimes hospitals are able to capture all of the expenses by billing for third-party billers, Medicare, Medicaid, or private pay," she says. "So, the expense would come in sometimes with the travel and hotel costs of putting up a temporary person. But by and large they are able to recuperate through reimbursements the fees they charge for locums."
Owens says the number of locum tenens physicians in the United States has grown in recent years because many physicians find the temporary work satisfying.
"More and more physicians are looking for a different lifestyle that locums provides," she says. "If we look back just five or six years ago there were probably about 26,000 locums. Now we are estimating there are about 38,000. You think about the demands of the practice environment and doctors are trying to find more flexibility for their schedules first of all. Secondarily, they want to avoid the politics that exist in hospitals nowadays. They get to keep their hand in medicine, and not in the business of medicine."
Sometime in late 2013 the doors will open on a $35 million, 230-unit apartment complex in downtown Orlando that will offer its residents a five-minute walking commute to Florida Hospital Orlando.
Florida Hospital won't own the building, which is centerpiece of a new 114-acre Health Village. Instead, the health system sold the land to a local developer who agreed to give Florida Hospital employees a three-month preferred leasing option before the apartments are made available to the general public. When all apartments are rented, hospital employees will be bumped to the top of a waiting list while the hospital contemplates building more apartments.
Jody Barry, administrative director, strategic property development at Florida Hospital, says the project, which breaks ground in July, could serve as a valuable recruiting tool. "We're located in a fairly urban environment. We do have a hard time recruiting nurses and various specialties as well. Our thought was how can we create a competitive advantage in recruiting?" Barry tells HealthLeaders Media.
The availability of safe, convenient, and affordable housing in a major urban area would be a prized asset for any hospital, especially when recruiting from out of state.
"When we are talking to nurses, say in the Midwest, we can say: 'Move to Orlando, work for Florida Hospital and while you are here you can live in an apartment complex that is right near the hospital. You can walk to work, and there is a daycare next door. You can stay in the apartment as long as you want to, or you can move somewhere else once you're settled,'" Barry says.
Florida Hospital's request for proposal in the bidding process specified that 80% of the apartments would be affordable for families earning between $40,000 and $70,000. The remaining 20% of the units would target households with incomes above $70,000. While hospital employees will be given priority in leasing, they won't get cheaper rents and the hospital won't subsidize the cost. "That triggers IRS issues," Barry says.
The idea for an apartment building near the hospital germinated in 2005 in the midst of a housing boom when affordable housing in Orlando was difficult to find.
"When we first started discussing this, the housing market was on fire and the housing costs for Orlando were becoming outrageous," Barry says. "At a hospital you are paid a fair market value based on skill. So, employees had to live far out in the suburbs. This project was a solution to put affordable housing in proximity to alleviate this."
Since then, of course, the housing market in Florida and the rest of the country has cratered. While sky-high housing costs are no longer a concern, Florida is notorious for its boom-and-bust housing cycles. Barry says there is no telling what the city's housing market might look like in a couple of years.
For now, he believes, simple convenience could be the main draw to the new building which will be called The Ivy – Residences at Health Village. Employees who now spend 45 minutes in Orlando's notorious traffic both to and from work each day might find a five-minute walking commute more appealing.
"The economics work out," Barry says. "You can live closer for the same or lower price than you pay in the suburbs, plus you save gas and wear-and-tear on your car, and you get all that time back in your day."
In addition, the residences are a key component of the Orlando campus's Health Village concept, which will include shops, restaurants, a swimming pool, a fitness facility, garage parking, and even electric cars that can be rented by the hour for quick neighborhood jaunts. A SunRail commuter rail station will be built near the hospital for easy access to downtown Orlando.
"We are creating a medical live-work-play community and having multifamily apartments in close proximity to the hospital adds vitality. We want to create a vital community, like a small downtown type atmosphere," Barry says. "Someone could live here without owning a car."
It's not clear when The Ivy will begin writing leases, but Barry says there is already a buzz in the halls of Florida Hospital. "We hold town meetings for our employees and this project is always the most discussed topic," he says.
Tim McKnight, MD, a family physician from Dennison, OH, believes government has a role in healthcare delivery, but not necessarily a big role.
"I think the less government is involved the better off we are," says McKnight, who is not a supporter of the Affordable Care Act.
So when McKnight and three dozen other healthcare providers were invited to meet with cabinet-level members of the White House Rural Council this month, he was skeptical, but he accepted.
"I thought they would be more about promoting their policies and give us very little if any time to express our concerns," McKnight says of the May 1 meeting in Washington, DC, which was hosted by Health and Human Services Secretary Kathleen Sebelius, and Agriculture Secretary Tom Vilsack.
"Two-thirds of the meeting was about them listening to us and I was impressed with that. I felt like they were listening intently. A lot of topics were discussed," he says. "They said they were going to take this back, discuss it, and rehash it, and come together and decide their next step. Let's see what happens."
To be clear, McKnight is not anti-government. He just doesn't believe that all of the problems that plague healthcare delivery in this country can be solved with a government fiat.
In fact, McKnight says he is the product of successful federal healthcare policy. He had no plans to practice in a rural area when he graduated from medical school in 1997 until he tapped federal government debt forgiveness and scholarship programs that situated him in this eastern Ohio town of 2,650 or so souls.
"Traditionally, the problem has been the new docs go to the rural site, you do your time, and you move back to the suburbs or where your ideal practice is. They weren't able to retain them," he says.
Rather than plot an escape, McKnight, his wife, and their three children have made Dennison their home.
"I did thank the council for the scholarship and the loan repayment. I told them I felt like this was a successful placement because in my case, I fell in love with the area and I am committed to [it] and to my patients," he says.
And that commitment to his patients prompted McKnight, a PhD in nutrition, to establish a federally funded 12-week "Fit-For-Life" wellness initiative in Dennison that has improved the health of more than 1,200 people over the last six years through exercise, better nutrition, and knowledge.
McKnight says he was driven to build the program because "I was very dissatisfied with the way we delivered healthcare. In primary care, the way you survive is on volume. You see a lot of patients and that does not allow you to educate them on healthy lifestyles."
He concedes that Fit For Life would not exist without the more than $750,000 in federal grants it has received over the past six years, along with a new $375,000 Rural Health Care Services grant this year to expand the program.
Rather than railing against government, or being overly dependent upon a subsidy, McKnight wants to strike that balance.
"The message I had for Washington was number one, thank you for the support. Number two was that while legislation and policy have a role in delivering healthcare, we have to empower people individually. We have to instill in them hope and give them information and model for them what good health looks like," McKnight says.
The family practitioner told the Rural Council that the nation suffers from a "poverty of hope, belief, and empowerment. I told them we needed to at the local level help empower people and motivate them and show them what they need to do to take control of their health," McKnight says.
"The allopathic approach is failing miserably. It's not healthcare. It's disease management. What is really frightening is if you look at the obesity and diabetes maps, the healthcare crisis we are anticipating in the next five or 10 years is going to be mind boggling. It will break us economically if we don't do something different," he says.
Prevention is the best and most cost-effective weapon against this epidemic, and McKnight says the 1,300 graduates of his Fit For Life program are sending the message that people want to be empowered.
"They are tired being told there is a pill for every problem, but they're not given alternatives," he says. "The primary care docs don't really know better. They're saying 'no, you can't reverse this. This is the way it is going to be.' So people are taking pills. They're suffering through side effects. They are spending a lot of money, but they are still having heart attacks and they're feeling disempowered."
McKnight says improving health outcomes for patients means that primary care physicians have to understand their patients' belief systems, emotional state, and family dynamics at a granular level. That's a task he feels is ill-suited for policy wonks, however well intentioned.
"Washington has the ability to do some things, but this change needs to be at the grass roots where we address the whole person," he says. "It's the message of hope and empowerment that has made this program successful."
There was a time when being "medical director" in some physician practices was an empty title.
"We never had a medical director before and the groups that did, I'm not sure they did a whole lot. They worried about the schedule and helped with interviews," says Jeffrey W. Smith, CEO of Pottstown (PA) Medical Specialists Inc., a 45-physician multispecialty practice. "Now it is important."
The use of electronic medical records to analyze volumes and specific quality measures means that medical directors will become what Smith calls "quality monitors" who use reams of data to identify high- and low-performing colleagues. Those medical directors will be expected to see that those measures are met, and their compensation will be linked to achieving those goals. This breed of medical director will be expected to tell physicians, "Here are your goals. You have to kick tail and make sure we adhere to these guidelines," Smith says.
At Pottstown Medical Specialists, for example, physicians are required to closely monitor patients' hemoglobin A1c as a quality metric. "HA1c's have to be less than seven. They have to have documented blood sugars in their charts. The folks with diabetes have to have a foot and eye exam every year. These are the things that are tied directly to compensation today," Smith says.
On measurable and compensable items such as these, the practice's medical director works with a statistician to review each physician. "Part of the problem before was that the docs would say, 'I've been doing this but I've never recorded it.' It was just a given that it was done," Smith says. "But now with electronic health records, it is easy to see if it has been done. We compare internally doc to doc and do a national comparison, and we determine what an insurance company is looking for as a minimum acceptable level."
It's imperative that analyses and critiques come from a fellow physician—rather than, for example, a practice manager—because peer-to-peer admonishments are harder to brush aside.
"The problem I have is they say, 'Jeff, you are not a doctor,'" Smith notes. "So you need that physician on your side to go into that individual practice to say, 'Doc, you have to be doing this. This is the way the practice is going to be doing this. If you don't agree with it, you need to look for another job.'"
Smith warns that not all physicians are cut out for the work.
"A lot of docs, because they are seeing their compensation fall or static, look at [the] medical director [role] and they think. 'Oh boy, I can do that and make some additional money,'" he says. "But most docs don't have that personality. They are going to want to do this but there is only going to be a select few who are successful."
Most physicians are not confrontational with peers, Smith adds. "You have to have a medical director who is willing to fight the good fight and tell a colleague, 'You might be a good doc but nothing in our electronic record is proving that, so you need to change your ways, and if we can't get there we need to reevaluate your contract.'"
It gets a little more complicated when discussing compensation. A new Medical Group Management Association survey found that annual stipends for the medical director role could range from $25,000 to $44,600 based on scope of responsibilities, time demands, and clinical specialty. In addition, the survey found that nearly half of the medical directors reported working less than six hours a week on directorship activities. Smith says he expects that will change as quality metrics become more sophisticated and play a greater role in determining compensation.
Smith notes that several factors go into determining medical director pay. "In my group, I look at our medical director and I say, 'What would you have made as a primary care doc in our practice?' He works two full days a week in this role. I say that is 'X' amount of money because you would have been in the office otherwise. In addition we say, 'How did you do based on the quality measures?' Then we decide 'Are we going to pay him above that?'"
Existing compensation is a determinant, Smith says. "If we had a vascular surgeon in there doing that job, that rate would it be higher. But if he's making $1 million a year, we probably wouldn't pick him to be the medical director."
Regardless of the details of specific compensation packages, physician practices in this new era of measurable outcomes should understand that they will have to provide more pay for medical directors as their role becomes more complex, time-consuming, confrontational—and valuable.
"There are two things we are trying to do with our medical director: drive down costs and improve the quality of care," Smith says. "The groups that are moving forward as certified medical homes are already compensating medical directors more based on increased hours and increased revenues into the practice. We've already started to see the change."
The healthcare sector created 19,000 jobs in April—accounting for nearly one in six of the 115,000 new jobs in the larger economy for the month, new federal data shows.
April job figures released by the U.S. Bureau of Labor Statistics indicate that healthcare sector job growth is decelerating apace with slowing job growth across the larger economy. Like healthcare, the overall economy recorded strong job growth in January and February that sharply tailed off in March and April.
Elaina Genser, senior vice president of Witt/Kieffer, an Oak Brook, IL–based healthcare executive search firm, says the healthcare sector should continue to see strong job growth relative to the rest of the economy.
"It's a combination of factors and one of them is the fact that healthcare is something that is not easily outsourced. That alone makes it unique," Genser says. "The aging population and the desire to cut costs are creating all kinds of new jobs that focus on bringing care back to the future, back to people in their own homes."
Ambulatory services, which include physicians' offices, accounted for 15,400 new jobs in April, followed by hospitals, which created 4,100 jobs. Nursing homes and residential care facilities lost 500 jobs.
Genser says ambulatory services will continue to be the strongest area of healthcare job growth as providers move to consumer-friendly venues that allow for "one-stop shopping."
"As [hospital leaders] think about what makes sense for the consumer and what makes sense for their own employees, they figure out these ambulatory campuses make a lot more sense," she says. "There's plenty of parking. Your lab is right there. The outpatient imaging is right there. Everything is right there in a cluster, easily accessible to people, as opposed to hospitals that many times have aging facilities that are not necessarily laid out for efficiency."
In the first four months of 2012, healthcare accounted for 14.4% of the 803,000 jobs created in the United States. Even with the slowdown over the last two months, healthcare job growth is outstripping the pace set in 2011. The sector created 116,300 jobs so far this year, compared with the 96,900 jobs created in the first four months of 2011, BLS reports.
Genser says the only thing that could slow job growth in healthcare would be if the U.S. Supreme Court throws out the Patient Protection and Affordable Care Act. "That would slow [job growth] but it won't stop it. It's really the right model, and now that there has been impetus for it, people are excited about it. Improving care in their communities is what they want to do," she says.
BLS data from March and April are preliminary and may be revised considerably in the coming months.
In the larger economy, nonfarm payroll employment rose by 115,000 in April, with most of the new jobs coming in professional services, retail sales, and healthcare. The unemployment rate was little changed at 8.1% . In March the economy created 154,000 jobs, a significant decline after gains averaging 252,000 jobs per month in January and February, BLS reports.
Revised BLS figures show that healthcare created 25,300 jobs in March, 38,200 jobs in February, and 33,800 jobs in January, continuing a strong trend in job growth that saw 296,900 payroll additions in 2011. Healthcare accounted for more than 18% of the 1.6 million new jobs in the overall economy in 2011.
More than 14.2 million people worked in the healthcare sector in April, with more than 4.8 million of those jobs at hospitals and more than 6.2 million jobs in ambulatory services, which includes more than 2.3 million jobs in physicians' offices.
Even with the modest gains, BLS said 12.5 million people were unemployed in April, a slight improvement from March. The number of long-term unemployed, defined as those who have been jobless for 27 weeks or longer, fell slightly to 5.1 million people in April, who represented 41.3% of the unemployed.
The nation's medical schools are on track to boost enrollment 30% by 2016, but they may not have residency slots available for all of their new graduates, the Association of American Medical Colleges reports.
AAMC lobbyist Christiane Mitchell says federal funding for graduate medical education programs is under siege on several fronts, and that graduate education at the nation's medical schools has been targeted for as much as $60 billion in cuts over the next decade.
"We are very worried about a potential bottleneck and that we will see more qualified applicants for residencies than there will be slots," Mitchell says. "We are very concerned that that could happen in the near future. And that will be sped up by the federal cuts in GME support. That is a very real concern."
"If there were a significant cut in residency slots, you would see teaching hospitals reducing the size of their programs and maybe eliminating some training programs. That would be an immediate impact," she told HealthLeaders Media.
The AAMC's annual 2011 Medical School Enrollment Survey found that first-year medical school enrollment is projected to reach 21,376 in 2016-17, a 30% increase above first-year enrollment in 2002-03 and in line with the 30% increase by 2015 that the AAMC called for in 2006.
The 125 medical schools that were accredited as of 2002 will account for 58% of the projected 2002-2016 growth in enrollment, 25% will occur in schools accredited since 2002, and 17% will come from schools that have yet to be accredited, the survey found. While some of these increases happened during the economic downturn of the past few years, 52% of the medical schools responding to the survey expressed concerns about their ability to maintain or increase enrollment due to the economic environment.
"We have to keep in mind that teaching hospitals now without any federal support at all fund 10,000 training positions. The likelihood of seeing those slots disappearing first is very real. And if there are fewer and fewer training opportunities, you might see fewer and fewer talented young people thinking about a career in medicine," Mitchell says.
AAMC has estimated that the United States faces a shortage of more than 90,000 primary care and specialty doctors by 2020 to treat a growing population that includes an aging Baby Boomer generation. In addition, if the Affordable Care Act survives a constitutional challenge, an additional 32 million Americans would be covered by health insurance.
Medical schools generate much of the revenues that keep them open through the clinical practices of their faculties, who often provide care to underserved patients. "Not only do we face cuts, but we still are going to be taking care of those patients because no one else in the community is willing to because there is no money it," Mitchell says.
In addition, medical schools could also see a reduction in research funding, as Congress eyes cuts budget cuts at the National Institutes of Health. And cash-strapped states across the country are cutting Medicaid funding, another source of revenue for medical schools.
"We are educating Congress and the administration. We spend a lot of time pointing out the current shortage and how it will be exacerbated over the next several years because many physicians will be retiring," Mitchell says.
Location! Location! Location! When it comes to Accountable Care Organizations, the federal government is borrowing the adage from realtors that says it’s not so much the house as the neighborhood.
A study in the New England Journal of Medicine suggests that the shared-savings payments that participating providers receive in the Medicare Pioneer and Shared Savings ACO programs might be more dependent upon geography than performance.
"There is a lot of variability in how favorable the payment methodology would be to organizations across the country because spending growth varies so much across different areas," J. Michael McWilliams, MD, a co-author of the study, tells HealthLeaders Media.
"Also we found it is likely these losses or gains would be unrelated to any organizational effort to improve quality of care and lower costs," says McWilliams, a general internist and assistant professor of healthcare policy and medicine at Harvard Medical School.
"It will probably even out over a few years for any given organizations but for half of them it will persist over time and it presents a pretty large gamble to perspective ACOs."
"If you happen to be in an area with high spending growth, your spending target will be well below that," he says. "And even if you do a good job, you might not quite get there. You might lose money or at the very least you might not get the shared savings that reflect your true performance relative to what spending would have been."
The federal government is structuring the payments within these 306 hospital referral regions to address geographic variations now seen in Medicare spending growth.
"There was some discussion in those regulations about using a national growth factor to help compress the geographic variation in Medicare spending," McWilliams says. "So the idea would be in a high-spending growth area using a mean national growth rate to set the spending target would necessarily bring that spending down in the high-spending growth area and vice-versa for a low-spending area. It would bring it up."
Unfortunately, McWilliams says, HRRs can’t draw a correlation between spending growth levels—based on a single year of data or an average across years—and spending growth rates—the percentage change across more than one year.
"There are such things as low-spending level high-spending growth areas, and high-spending level low-spending growth areas. In fact they make up about half of hospital referral regions," he says. "So using a national growth factor would not seem to accomplish the stated rationale in the regulations of compressing geographic variations in spending."
Such a structure makes it difficult for healthcare organizations within specific HRRs to estimate whether the use of a national growth factor to set a spending target would benefit them or not.
"That is because spending growth in one time period does not seem to be correlated at all with spending growth in another time period for a given area," McWilliams says. "For an organization deciding whether or not to participate in these ACOs, it would be unclear to them whether or not it would pay off."
McWilliams and study coauthor Zirui Song suggest instead that the federal government rely more on local growth factors to gauge spending targets. "There would be less of this problem of gains or losses for the organizations that are unrelated to their efforts to lower costs and improve quality," McWilliams says.
McWilliams says the study did not directly examine the affect of the HRRs on rural ACOs, but he identified some vulnerability.
"The variation in spending growth had two components. One was a random component that’s due to changes in healthcare needs of Medicare beneficiaries from year to year," he says. "The other is a more systematic component and the result of market forces that drive spending growth in particular areas. For example, if provider organizations are competing on the basis of attracting the latest and greatest technology to attract patients, spending growth ought to be uniform in the area."
"I would not expect the systematic component to be any more variable in rural versus urban areas," McWilliams says. "But clearly the random component would be because rural areas are more sparsely populated. A prospective ACO in a rural area would probably face a bigger gamble in terms of a one-year loss or gain that is due to the payment methodology than would an ACO in a more densely populated area."
"Again this is all the consequence of using national growth factors to set the spending targets for the ACOs, which is essentially mean spending growth in the nation," he says. "There is going to be a distribution across areas in local spending growth and rural areas will tend to be further out to either end of that distribution than the densely populated areas."
In other words, rural ACOs could be big winners or losers, or break even based largely upon where they are. But they won’t really be able to predict it either way.
"That is one of the concerns of our findings," McWilliams says. "If the current payment methodology is presenting a sizeable gamble to these organizations then some may decide not to participate, which, if the program turns out to be successful, would be a real shame."
Any payment scheme that does not necessarily reflect the work—good, bad, or mediocre—of a particular healthcare organization could put the Medicare ACO experiment in jeopardy.
"If it is determined that some of the losses and gains have happened not because of something the organization did, that would raise a red flag that might limit expansion of the programs," McWilliams says. "Some of the organizations that participate and experience big losses because of this could leave the program and that may cause other organizations to be more reticent to join."
Women and ethnic and racial minorities who, while in medical school, declare their intention to become board-certified general surgeons, are more likely to fall off that career path and into other specialties. And even if they remain in surgery, this group is less likely to complete the surgery board-certification process, a study shows.
Dorothy A. Andriole, MD, coauthor of the study, which appears in the May issue of the Journal of the American College of Surgeons, says she hopes the findings will spur surgical leaders to develop strategies to encourage women and minorities to pursue surgery and achieve board certification.
"If you want to create a workforce of great people and you are only tapping into half the workforce, you are missing a lot of great people," says Andriole, an associate professor in the Department of Surgery at Washington University School of Medicine, in St. Louis. "Physicians from groups that have been historically underrepresented in medicine tend to provide care for those populations."
Andriole told HealthLeaders Media that women represent about half of all medical students, but only about 13% of surgeons. "It is well worth examining why we would be seeing gender, race and ethnicity differences among those people who graduated and wanted to become surgeons," she says.
"There is always going to be some attrition. Having said that, we looked at academic performance and other measures, and even after accounting for those other measures we found women more likely to leave and more likely to be practicing but not as board certified surgeons."
The study examined the records of 3,373 medical school graduates from 1997 to 2002 who at the time of graduation, stated their intention to become board certified in surgery and entered general surgery training.
Andriole and coauthor Donna B. Jeffe tracked these physicians through July 2009 to see if they had achieved their goal. The researchers found that 60% of the graduates in the study achieved American Board of Surgery certification, 10% were certified by another American Board of Medical Specialties-member board, and the remaining 30% weren’t certified by any ABMS member board.
"It is not so much an issue of whether surgery is attracting women, but that the women they do attract are less likely to be retained. The same is true for graduates of non-white race or ethnicity," Andriole says.
Among graduates who remained in the surgery workforce, women, Asian/Pacific Islander graduates, and graduates from racial/ethnic groups historically underrepresented in medicine were more likely to be non-board certified, as were graduates who had initially failed Step l or Step 2 of the U.S. Medical Licensing Examination sequence, the report said.
Jeffe said that physicians who are not board certified often become marginalized. "They may not be able to access the same quality of medical services for their patients as can board-certified physicians," Jeffe said in prepared remarks. "Many practicing physicians from underrepresented groups in medicine provide care for other underrepresented or disadvantaged populations, so this speaks to the disparities in health outcomes for their patients as well."
The study did not speculate on the reasons for the gender gap, but Andriole says it could be linked to "the lengthier training requirements for board certification. That is often more of an issue for young women than young men because they are thinking about starting a family," she says.
Andriole concedes that some of the disparities could be self-correcting as more women and minorities enter medicine. "The graduates we looked at had graduated from 1998-2002," she says. "We are just now seeing women graduate in the current era of work-hour restrictions during graduate medical education and possibly some increased flexibility regarding maternity leave policies during residencies. Those may to some extent help."
"Although the women in our study weren’t as likely to complete the board certification as the men were, there are still a net increase in the numbers of women becoming surgeons, and the numbers of women surgeons who are on faculty," Andriole says. "Slowly the increase number of role models for women may help."
