Clinicians wrestle with what they consider barriers to quality care: insurance preauthorization, trouble making patient referrals, endless clicking on EHRs.

This article was first published on Tuesday, February 4, 2020, in Kaiser Health News.

By Melissa Bailey

Dr. Keith Corl was working in a Las Vegas emergency room when a patient arrived with chest pain. The patient, wearing his street clothes, had a two-minute exam in the triage area with a doctor, who ordered an X-ray and several other tests. But later, in the treatment area, when Corl met the man and lifted his shirt, it was clear the patient had shingles. Corl didn't need any tests to diagnose the viral infection that causes a rash and searing pain.

All those tests? They turned out to be unnecessary and left the patient with over $1,000 in extra charges.

The excessive testing, Corl said, stemmed from a model of emergency care that forces doctors to practice "fast and loose medicine." Patients get a battery of tests before a doctor even has time to hear their story or give them a proper exam.

"We're just shotgunning," Corl said.

The shingles case is one of hundreds of examples that have led to his exasperation and burnout with emergency medicine. What's driving the burnout, he argued, is something deeper — a sense of "moral injury."

Corl, a 42-year-old assistant professor of medicine at Brown University, is among a growing number of physicians, nurses, social workers and other clinicians who are using the phrase "moral injury" to describe their inner struggles at work.

The term comes from war: It was first used to explain why military veterans were not responding to standard treatment for post-traumatic stress disorder. Moral injury, as defined by researchers from veterans hospitals, refers to the emotional, physical and spiritual harm people feel after "perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations."

Drs. Wendy Dean and Simon Talbot, a psychiatrist and a surgeon, were the first to apply the term to health care. Both wrestled with symptoms of burnout themselves. They concluded that "moral injury" better described the root cause of their anguish: They knew how best to care for their patients but were blocked from doing so by systemic barriers related to the business side of health care.

That idea resonates with clinicians across the country: Since they penned an op-ed in Stat in 2018, Dean and Talbot have been flooded with emails, comments, calls and invitations to speak on the topic.

Burnout has long been identified as a major problem facing medicine: 4 in 10 physicians report feelings of burnout, according to a 2019 Medscape report. And the physician suicide rate is more than double that of the general population.

Dean said she and Talbot have given two dozen talks on moral injury. "The response from each place has been consistent and surprising: 'This is the language we've been looking for for the last 20 years.'"

Dean said that response has come from clinicians across disciplines, who wrestle with what they consider barriers to quality care: insurance preauthorization, trouble making patient referrals, endless clicking on electronic health records.

Those barriers can be particularly intense in emergency medicine.

Corl said he has been especially frustrated by a model of emergency medicine called "provider-in-triage." It aims to improve efficiency but, he said, prioritizes speed at the cost of quality care. In this system, a patient who shows up to an ER is seen by a doctor in a triage area for a rapid exam lasting less than two minutes. In theory, a doctor in triage can more quickly identify patients' ailments and get a head start on solving them. The patient is usually wearing street clothes and sitting in a chair.

These brief encounters may be good for business: They reduce the "door to doc" time — how long it takes to see a doctor — that hospitals sometimes boast about on billboards and websites. They enable hospitals to charge a facility fee much earlier, the minute a patient sees a doctor. And they reduce the number of people who leave the ER without "being seen," which is another quality measure.

But "the real priority is speed and money and not our patients' care," Corl said. "That makes it tough for doctors who know they could be doing better for their patients."

Dean said people often frame burnout as a personal failing. Doctors get the message: "If you did more yoga, if you ate more salmon salad, if you went for a longer run, it would help." But, she argued, burnout is a symptom of deeper systemic problems beyond clinicians' control.

Emergency physician Dr. Angela Jarman sees similar challenges in California, including ER overcrowding and bureaucratic hurdles to discharging patients. As a result, she said, she must treat patients in the hallways, with noise, bright lights and a lack of privacy — a recipe for hospital-acquired delirium.

"Hallway medicine is such a [big] part of emergency medicine these days," said Jarman, 35, an assistant professor of emergency medicine at UC-Davis. Patients are "literally stuck in the hallway. Everyone's walking by. I know it must be embarrassing and dehumanizing."

For example, when an older patient breaks an arm and cannot be released to their own care at home, they may stay in the ER for days as they await evaluation from a physical therapist and approval to transfer to rehab or a nursing home, she said. Meanwhile, the patient gets bumped into a bed in the hallway to make room for new patients who keep streaming in the door.

Being responsible for discharging patients who are stuck in the hallway is "so frustrating," Jarman said. "That's not what I'm good at. That's not what I'm trained to do."

Jarman said many emergency physicians she knows work part time to curtail burnout.

"I love emergency medicine, but a lot of what we do these days is not emergency medicine," she said. "I definitely don't think I'll make it 30 years."

Also at UC-Davis, Dr. Nick Sawyer, an assistant professor of emergency medicine, has been working with medical students to analyze systemic problems. Among those they've identified: patients stuck in the ER for up to 1,000 hours while awaiting transfer to a psychiatric facility; patients who are not initially suicidal, but become suicidal while awaiting mental health care; patients who rely on the ER for primary care.

Sawyer, 38, said he has suffered moral injury from treating patients like this one: A Latina had a large kidney stone and a "huge amount of pain" but could not get surgery because the stone was not infected and therefore her case wasn't deemed an "emergency" by her insurance plan.

"The health system is not set up to help patients. It's set up to make money," he said.

The best way to approach this problem, he said, is to help future generations of doctors understand "how decisions made at the systems level impact how we care about patients" — so they can "stand up for what's right."

Whether these experiences amount to moral injury is open for discussion.

Cynda Rushton, a nurse and professor of clinical ethics at Johns Hopkins University, who has studied the related notion of "moral distress" for 25 years, said there isn't a base of research, as there is for moral distress, to measure moral injury among clinicians.

But "what both of these terms signify," Rushton said, "is a sense of suffering that clinicians are experiencing in their roles now, in ways that they haven't in the past."

Dean grew interested in moral injury from personal experience: After a decade of treating patients as a psychiatrist, she stopped because of financial pressures. She said she wanted to treat her patients in longer visits, offering both psychotherapy and medication management, but that became more difficult. Insurers would rather pay her for only a 15-minute session to manage medications and let a lower-paid therapist handle the therapy.

Dean and Talbot created a nonprofit advocacy group called Moral Injury of Healthcare, which promotes public awareness and aims to bring clinicians together to discuss the topic.

Their work is attracting praise from a range of clinicians:

In Cumberland County, Pennsylvania, Mary Franco, who is now 65, retired early from her job as a nurse practitioner after a large corporation bought out the private practice she worked in. She said she saw "a dramatic shift" in the culture there, where "revenue became all-important." The company cut in half the time for each patient's annual exam, she said, down to 20 minutes. She spent much of that time clicking through electronic health records, she said, instead of looking the patient in the face. "I felt I short-shrifted them."

In southern Maine, social worker Jamie Leavitt said moral injury led her to take a mental health break from work last year. She said she loves social work, but "I couldn't offer the care I wanted to because of time restrictions." One of her tasks was to connect patients with mental health services, but because of insurance restrictions and a lack of quality care providers, she said, "often my job was impossible to do."

In Chambersburg, Pennsylvania, Dr. Tate Kauffman left primary care for urgent care because he found himself spending half of each visit doing administrative tasks unrelated to a patient's ailment — and spending nights and weekends slogging through paperwork required by insurers.

"There was a grieving process, leaving primary care," he said. "It's not that I don't like the job. I don't like what the job has become today."

Corl said he was so fed up with the provider-in-triage model of emergency medicine that he moved his ER clinical work to smaller, community hospitals that don't use that method.

He said many people frame burnout as a character weakness, sending doctors messages like, "Gee, Keith, you've just got to try harder and soldier on." But Corl said the term "moral injury" correctly identifies that the problem lies with the system.

"The system is flawed," he said. "It's grinding us. It's grinding good docs and providers out of existence."

Melissa Bailey: mbailey@kff.org, @mmbaily

CMS this week identified 786 hospitals that will receive lower payments for a year under the Hospital-Acquired Conditions Reduction Program.

This article was first published on Friday, January 31, 2020 in Kaiser Health News.

By Jordan Rau

Hundreds of hospitals across the nation, including a number with sterling reputations for cutting-edge care, will be paid less by Medicare after the federal government pronounced that they had higher rates of infections and patient injuries than others.

The Centers for Medicare & Medicaid Services on Wednesday identified 786 hospitals that will receive lower payments for a year under the Hospital-Acquired Conditions Reduction Program, a creation of the Affordable Care Act. The penalties are designed to encourage better care without taking the extreme step of tossing a hospital out of the Medicare and Medicaid programs, which would drive most hospitals out of business.

Now in their sixth year, the punishments, known as HAC penalties, remain awash in criticism from all sides. Hospitals say they are arbitrary and unfair, and some patient advocates believe they are too small to make a difference. Research has shown that while hospital infections are decreasing overall, it is hard to attribute that trend to the penalties.

"There is limited evidence that this is the kind of program that makes things better," said Andrew Ryan, a professor of health care management at the University of Michigan School of Public Health.

Under the law, Medicare is mandated each year to punish the quarter of general care hospitals that have the highest rates of patient safety issues. The government assesses the rates of infections, blood clots, sepsis cases, bedsores, hip fractures and other complications that occur in hospitals and might have been prevented. Hospitals can be punished even if they have improved from past years.

Medicare cuts every payment by 1% for those hospitals over the course of the federal fiscal year, which started in October and runs through the end of September.

Since the program's onset, 1,865 of the nation's 5,276 hospitals have been penalized for at least one year, according to a Kaiser Health News analysis.

Many hospitals escaped penalties because they were automatically excluded from the program, either because they solely served children, veterans or psychiatric patients, or because they have special status as a "critical access hospital" for lack of nearby alternatives for people needing inpatient care.

This year, 145 hospitals received their first penalty, the analysis found. Conversely, 16 that had been penalized every year since the start of the program avoided punishment. Those included Novant Health Presbyterian Medical Center in Charlotte, North Carolina, and Tampa General Hospital in Florida.

Novant Health said in a statement it had lowered infection rates by being more discriminating in using urinary catheters and central lines, standardizing the steps to prevent infections in surgeries, and getting staffers to wash their hands more.

This year, Medicare penalized seven of the 21 hospitals on the U.S. News Best Hospitals Honor Roll, an annual ranking often used as a proxy for identifying the most prestigious facilities.

Those penalized "honor roll" hospitals were UPMC Shadyside in Pittsburgh; Ronald Reagan UCLA Medical Center in Los Angeles; Keck Hospital of USC; Stanford Health Care's main hospital in Northern California; UCSF Medical Center in San Francisco; NewYork-Presbyterian/Weill Cornell Medical Center in Manhattan; and the Mayo Clinic's hospital in Phoenix.

Only UCSF commented to KHN on the penalties, blaming its high HAC rates on its thoroughness in identifying infections and reporting them to the government.

"That commitment will naturally make our rates appear to be higher than some other hospitals," UCSF said in a written statement.

Three other "honor rollees" have avoided punishment in all six years of the penalties: Massachusetts General Hospital, the Mayo Clinic's flagship hospital in Rochester, Minnesota, and Penn Presbyterian Medical Center in Philadelphia.

Johns Hopkins Hospital in Baltimore has also avoided penalties every year, but Medicare excludes all Maryland hospitals from the program because it pays them through a different arrangement than for the rest of the states.

The federal Agency for Healthcare Research and Quality last year estimated there were about 2.5 million hospital-acquired conditions in 2017. Rates have been dropping by about 4.5% a year, the agency calculated, with the biggest decreases since 2014 in infections from Clostridioides difficile, known as C. diff.; bad reactions to medications and postoperative blood clots.

Maryellen Guinan, a senior policy analyst at America's Essential Hospitals, the association of about 300 safety-net hospitals said, "Our folks even before the HAC program was in existence have been doing a lot to put in infection controls."

However, a study Ryan and colleagues published in Health Affairs in November analyzed a clinical surgical data registry used by 73 Michigan hospitals and concluded that hospital complications rates were higher than what the government has estimated. The study agreed rates were dropping but said there was no proof the HAC penalties played a role.

Leah Binder, president of The Leapfrog Group, a patient safety organization, said the complex formula Medicare uses to allot penalties is too confusing and the penalty set by Congress is too small to be effective.

"Americans expect 100% of hospitals to go to the ends of the Earth to prevent needless patient suffering, and singling out some hospitals for a little 1% ding isn't enough," she said.

CMS did not respond to requests for comment for this story.

The Association of American Medical Colleges said 45% of its members were penalized this year — nearly double the rate of other hospitals.

Dr. Atul Grover, the association's executive vice president, said teaching hospitals incurred penalties more often because they often treat some of the sickest people and Medicare's calculations did not sufficiently take into account the especially weakened condition of their patients, which make them more susceptible to infections.

"There are still issues with the methodology, surveillance bias, and the inability to fully risk adjust for our institutions that have patients who are sicker" and are more likely to have multiple medical problems, Grover said in an email.

Jordan Rau: jrau@kff.org, @JordanRau

Gov. Gavin Newsom's Healthy California for All Commission will gather near the Capitol for its inaugural meeting.

This article was first published on Tuesday, January 28, 2020, in Kaiser Health News.

By Rachel Bluth

California Gov. Gavin Newsom was a single-payer candidate.

The Democrat campaigned hard for the creation of one public insurance program for all Californians. And within hours of taking office last year, he called on the federal government to allow California and other states to create single-payer programs.

On Monday, some of the biggest names in California health care policy are convening in Sacramento to fulfill that promise.

Or not.

Those who hope this meeting could lead to the end of private insurance and the creation of a state-based "Medicare for All"-type system should probably temper their expectations.

"The goal of this commission is likely to demonstrate political momentum without making any firm policy commitments," said Thad Kousser, chair of the political science department at the University of California-San Diego.

Newsom's Healthy California for All Commission, which will gather near the Capitol for its inaugural meeting, is made up of 13 people from universities, nonprofit organizations, hospitals and advocacy groups.

The commission will discuss how to get every Californian covered — with an emphasis on single-payer, a system in which health care is paid for by a single public authority.

But the reality is that single-payer is unlikely to materialize anytime soon, given the Trump administration's opposition to the concept and the exorbitant cost of completely overhauling the health care system.

Perhaps most important, members of the commission don't agree on what the commission should accomplish.

Single-payer "is one of the key places to look, but not the only place," said California Health and Human Services Secretary Dr. Mark Ghaly. Newsom's office, which declined to comment on the commission, directed questions to Ghaly, who will chair the panel.

But there will be powerful voices on the commission that are firmly committed to creating a single-payer system for the state.

Stephanie Roberson, the government relations director for the California Nurses Association, won't be on the commission herself, but her union will have a representative on the panel. The union is a loud and insistent advocate for single-payer.

"There is absolutely universal concern across this organization that this commission could be used to slow-walk single-payer," Roberson said. "More often than not, a bill becomes a study or a commission and no one ever hears about it again."

The commission plans to issue two public reports, one in July 2020 and the other in February 2021. The first will detail the current state of health care coverage in California and the second will explain the nuts and bolts of how to get a single-payer system up and running.

For the single-payer advocates on the commission, these questions have already been asked and answered.

A 2017 special legislative committee investigated single-payer in California and issued a report on California's uninsured population that outlined several options for covering them, such as how to implement and pay for single-payer.

Much of that work is now being repeated. The state of California awarded a $2.5 million contract to a group from the University of California to conduct research and analysis for the new commission and draft its reports. These are the same people who wrote the last report for the legislative committee.

But Deborah Kelch, executive director of the nonprofit and nonpartisan Insure the Uninsured Project, said the older findings might not reflect today's reality.

"Those all predate our current coverage landscape, so it's a good time for policymakers and a commission like this one to really take a look at what's true now," she said.

No one thinks single-payer would be cheap or easy to implement, and estimates vary on how much it would cost. A 2017 legislative estimate put the price tag for California at around $400 billion annually. A newer analysis released in mid-January focused instead on savings and concluded that savings from single-payer systems would outweigh the costs.

Whatever the commission decides to do, one huge hurdle to get single-payer up and running in the state remains: President Donald Trump.

Seema Verma, head of the Centers for Medicare & Medicaid Services, said she would reject any state plans to use federal dollars to implement a single-payer system.

But the hostility from the federal government doesn't mean the commission's work is meaningless, said Scott Graves, director of research for the California Budget & Policy Center. Instead, it could give the commission time to get a single-payer plan ready for a different president, he said.

"If we decide as a state that we really want to move towards a single-payer health care financing system, we will have done our homework," Graves said.

Dr. Robert Ross, president and CEO of the California Endowment, a foundation that focuses on expanding health care access among Californians, sees a path forward whether Trump wins or loses in November.

Ross, a member of the commission, said he's willing to look at all options to get the remaining 7.2% of uninsured Californians covered, not just single-payer. For instance, California has expanded Medi-Cal eligibility to people who are in the country illegally, and created state-based subsidies to help people buy private insurance.

"I'm sure there are others on the commission resolutely focused on single-payer," he said. "That's fine. We should have that conversation and that debate within the boundaries of the commission's work."

Jennifer Kent, former director of the state Department of Health Care Services, said it's vital to continue the process of debates, research and public meetings. They will bring in more people to work out the thorny details of what could be a massive overhaul of the health care system, she said.

"Democracy is messy," said Kent, who is now a health care consultant. "The people who say we already know what the answer is — if we knew what the answer is, it would have been done already."

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Rachel Bluth: rbluth@kff.org, @RachelHBluth

The disappointing results from Camden caused some angst among health officials working on the model.

This article was first published on Friday, January 24, 2020 in Kaiser Health News.

By Anna Almendrala and Phil

A highly publicized approach to lowering health costs failed to pass rigorous study this month, but hospitals, insurers and government health programs don't intend to give up on the idea.

The "hotspotting" model was pioneered in Camden, New Jersey, in 2002 and inspired dozens of similar projects around the country, many financed by millions of dollars from the government and private foundations. The model focuses on people who face social barriers such as homelessness or drug addiction and use the hospital multiple times a year, typically for avoidable complications from chronic diseases. The participants work with doctors, social workers and nurses for individual help, seeking to prevent future hospital admission and extra expenses down the road.

A study in the New England Journal of Medicine published this month confirmed that repeat hospitalizations dropped for participants in the Camden program but the result was no better than the results from a group of patients who did not get the intensive care coordination.

A different study, released Wednesday, showed that a similar, multibillion-dollar experiment in California yielded even more discouraging preliminary results: Participants were hospitalized at more than double the rate of patients who were not enrolled in the program.

State and federal policymakers were attracted to the hotspotting model because they saw it as a possible solution for this intractable reality: Just 5% of patients account for half of all health spending.

The disappointing results from Camden caused some angst among health officials working on the model from Oregon to North Carolina — even before the California study was released.

"The study should give everyone who is involved in hotspotting a chance to pause and really reflect on the programs that they are doing," said Dr. Amit Shah, chief medical officer at CareOregon, a large Medicaid managed-care insurer that for a decade has targeted some of these high-cost patients.

But "to stop now would be foolish," said Susan Cooper, chief integration officer for Regional One Health, a Memphis, Tennessee, health system that launched a program in 2018 based on the Camden model. It is geared to patients who have the most emergency room and hospital visits because of unmet social needs such as hunger and housing.

Using nurses and social workers, the hospital pairs up these "super-utilizer" patients with community resources such as housing, transportation and meals as well as connecting them to primary care. From April 2018 through last month nearly 350 people have enrolled in the program and the hospital said it has saved more than $9 million than would have been expected to be spent on them by reducing ER visits and hospital admissions.

A Medicaid experiment similar to the Camden approach may also expand in the most populous state in the nation — at great cost and despite disappointing initial results.

As part of his 2020-21 state budget proposal, California Gov. Gavin Newsom wants to add $582.5 million to Medi-Cal, the state's Medicaid program, to increase intensive, comprehensive care management to high-needs, high-risk patients, including homeless people and those getting out of jail or prison. If approved by the state legislature, the infusion would also fund services designed to decrease reliance on expensive hospital visits and emergency service transportation.

The move would expand the state's $3 billion, five-year Medicaid experiment called "Whole Person Care," which began in 2016 and provides participants with social and medical services, such as substance abuse treatment and recuperative care after hospital stays. In most cases, California is creating services for participants in addition to connecting people to existing programs.

Twenty-five counties, cities, health plans and hospitals currently participate, and nearly 150,000 patients have enrolled.

But a new report by researchers at the UCLA Center for Health Policy Research suggests that California's experiment has resulted in more participant hospitalizations, despite offering comprehensive services.

The study found that, two years into the experiment, there was no significant change in emergency department visits for participants compared with a similar group of patients who were not part of the program. But hospitalizations went up for both groups, with participants getting admitted at more than twice the rate of the control group: 17.47 inpatient admissions per 1,000 enrollees, compared with 7.41 admissions per 1,000 for the control group.

Dana Durham, chief of the policy and medical monitoring branch of the state Department of Health Care Services, said that the data is preliminary and that she expects hospitalizations to drop the longer patients are in the program.

"There hasn't been enough enrollment in the program to make this comparison one that we have confidence in yet," she said.

Clemens Hong, director of the Whole Person Care pilot in Los Angeles, which has served more than 46,000 people and has a five-year budget of more than $1 billion, could not be reached for comment after the results were released Wednesday.

Prior to the release, Hong said it would take time to see positive results because the participant population is "much sicker than most people understand or realize." He also said evaluations of these programs shouldn't focus exclusively on hospitalizations, but should also consider outcomes such as how well they increase employment or reduce time spent living on the street.

"One of the key lessons is that it can't just be medically focused," Hong said about the results of the Camden study.

Camden Coalition officials agree. They say that, although their work was originally designed to help people find safety-net services, they learned that sometimes those resources were not available. The coalition now has expanded its outreach and set up more partnerships, including efforts to start a housing program.

Looking For 'Hot Spots'

The Camden Coalition, which provided services for 194 people last year, was founded by Dr. Jeffrey Brenner, a family doctor, who was looking to improve health care in one of the poorest cities in the country.

Using medical billing data from hospitals in Camden, Brenner located "hot spots" that had larger numbers of high-cost patients — even down to the city block. These patients, he found, repeatedly showed up in emergency rooms and doctors' offices. They often had physical health issues such as diabetes, asthma and other chronic illnesses that were compounded by psychological and social issues such as anxiety and homelessness.

Earlier studies of the initiative primarily measured how patients in the program used services before and then after being enrolled. By coordinating the medical care and social services these patients needed, Brenner and his group were able to cut down the number of rehospitalizations.

The New England Journal of Medicine study, conducted by researchers at the Massachusetts Institute of Technology and published Jan. 9, confirmed that the program over six months reduced readmissions by nearly 40%. But a group of similar patients who did not get the interventions had a similar drop.

This type of randomized-control trial, the gold standard in clinical medicine, is rarely used in health policy studies, partly due to the cost.

Shah of CareOregon said the study results prove there is no single solution that will work in every community for every type of patient.

"There is no one magic bullet," Shah said. "The study confirmed there is a population of super utilizers that will not go away" just through these community efforts alone. He stressed local, state and federal policy changes are needed to fix social and legal challenges that influence patients' health.

Camden Coalition officials said the results were disappointing but noted they have made major changes to the hotspotting efforts since the study trial ended in 2017. This includes efforts to help participants find stable housing and legal services to break down barriers to Medicaid and other benefits.

"We have already made some pivots," said the coalition's CEO, Kathleen Noonan.

She said people should not take away from the study "that focusing on social determinants of health and all those efforts are moot." The study showed some positive benefits, including how participants were more likely to obtain food stamp benefits compared with those in the control group.

"To paraphrase Mark Twain, reports of the death of the hotspotting model are greatly exaggerated," said Rutgers University professor Joel Cantor, director of the Center for State Health Policy, before the California results dropped. Cantor has worked closely with the coalition. "This is a single study, focusing mainly on one of many possible outcomes, in a single location."

Brenner, who won a MacArthur Foundation fellowship — known as a "genius" grant — in 2013, said hotspotting efforts need to keep evolving.

"There are glimmers of things that work, and we need to keep at this. It is a solvable problem," said Brenner.

When he first started the coalition, Brenner said, he hoped just helping people navigate the health system would improve their health and lower costs. But that approach faced shortcomings when services such as addiction treatment and housing assistance were lacking.

"It's not as simple as just navigating and coordinating," he said.

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Anna Almendrala: aalmendrala@kff.org, @annaalmendrala

Phil Galewitz: pgalewitz@kff.org, @philgalewitz