The coronavirus pandemic will continue to ebb and flow, and it comes with related challenges such as workforce shortages, chief clinical officer says.

The coronavirus pandemic and related issues are still a leading concern for healthcare providers, the chief clinical officer of Banner Health says.

Marjorie Bessel, MD, has been with Banner Health for more than a decade. She has  held many physician leadership roles at the health system, including serving as chief medical officer for several hospitals and working as chief medical officer of Banner Health's Arizona Division. Before taking on the chief clinical officer role, she served as vice president and chief medical officer of community delivery.

HealthLeaders recently talked with Bessel on a range of topics, including workforce shortages, potential challenges from the recent coronavirus surge in China, and her predictions for clinical care in 2023. The following transcript of that conversation has been edited for clarity and brevity.

HealthLeaders: What are the primary challenges of serving as chief clinical officer of Banner Health?

Marjorie Bessel: Going into 2023, it would be remiss if I didn't say that the coronavirus pandemic was the No. 1  primary challenge. Not only have we been in the pandemic, but the length of the pandemic has been long, which has led to fatigue in the care teams. There also is fatigue in the communities that we serve. Related to the pandemic are workforce challenges and financial challenges that the pandemic has created.

HL: How are you rising to these challenges?

Bessel: I have been rising to the challenges through several tactics, which is how I approach many things in life. One is reading a lot and sticking to science. I have been focusing on science and what can be done, while also not forgetting about the science of human behavior. There is a whole science around influencing and driving human behavior as well as the science of change management, which are part of my toolkit and help me have the best approaches for implementation and subsequent success.

At Banner Health, we have been talking about high-reliability organizations and the principles that drive that level of performance. One of the principles for an HRO is deference to expertise, which means always using the experts who are available to you to solve problems through a collaborative process.

HL: What kinds of workforce shortages are you experiencing at Banner Health?

Bessel: Workforce challenges are pretty much across the board. They are not only in frontline workers such as nurses and respiratory therapists; there are workforce challenges in many other parts of what it takes to run an integrated delivery network like Banner Health. That includes people who work in technology, people who work in culinary, and people who work in environmental services. Each one of our workforce shortages has a different twist to how you might go about solving them.

Clearly, those individuals who have a lot of training and education tend to require a lot more time to develop short-, mid-, and long-term approaches to how you can address workforce challenges. For individuals such as medical assistants, addressing workforce challenges includes creating a pathway for them to see a longer-term career within the organization, so you focus a lot on retention.

Addressing workforce shortages is a collaborative effort. It is not just the chief nursing officers' role to come up with ways to deal with nurse shortages. It is not just the chief human resources officer who addresses the workforce challenge. We are thinking collectively, with everyone in the organization functioning as one team, which is helping us come up with the right tactics to deal with the complex situation that we are facing.

Marjorie Bessel, MD, chief clinical officer of Banner Health. Photo courtesy of Banner Health.

HL: China is experiencing a coronavirus surge. How could this development impact healthcare providers in the United States?

Bessel: One of the challenges ahead is related to the coronavirus surge in China, which is going to have repercussions for all of us across the world. There is likelihood of emerging coronavirus variants that may or may not be more infectious, may or may not evade vaccine immunity, and may or may not be more lethal. What is happening in China is also likely to create supply chain disruptions.

HL: How can you overcome those supply chain problems?

Bessel: The healthcare industry was not immune to supply chain disruptions before the pandemic. Those disruptions were less lengthy and less numerous. What we have found is if you utilize your structures and your systems to bring the right kind of experts together in a collaborative environment and identify your problems, then ask those experts to work together to come up with possible solutions, you put yourself in the best possible position to be flexible as you approach and experience supply chain disruptions.

A good collaborative approach builds trust up and down your organization as well as resiliency because you have a structure and process to approach difficult problems in a timely fashion.

HL: Do you have any predictions for clinical care in 2023?

Bessel: There are going to be several things we are going to continue to experience. We will have ups and downs with COVID, which will be impacted by what is happening in China. We will continue to experience coronavirus vaccine challenges, which will spur us to focus on preventative measures and building trust between our patients and clinicians, who are the ones having those conversations, to bring science and rational thinking to preventative measures.

I expect we will have stabilization of the female reproductive health challenges that we have been experiencing. Our clinicians will have better ability to have those important conversations with their patients to make decisions about the holistic approach to care, which is what clinicians want to do and what patients are seeking.

HL: You have a clinical background as a hospitalist. How did serving as a hospitalist help prepare you for your role as chief clinical officer at Banner Health?

Bessel: Nothing prepares you for a pandemic like the one we have been experiencing. While I trained in some table-top exercises and I had read about pandemics, we know that the flu pandemic that was at the scale we have experienced with COVID was 100 years ago.

However, being a hospitalist has been helpful for me as a background because a hospitalist has a good overview of the entire care delivery spectrum. A hospitalist also often works in a crisis-management type of environment. You start your day with a list of patients that need to be seen. You may start on one floor expecting to see patients, then you get a page because a patient is not doing well on another floor that you were not expecting to go to yet. You go to that floor, then you get a call that takes you down to the emergency department.

So, your day as a hospitalist must be flexible as you are constantly prioritizing and re-prioritizing the work that needs to be done. The pandemic created similar demands—we needed to manage crises, we needed to respond to the most important item of the day or the hour, and we needed to be able to pivot in a different way than you thought your day was going to go.

Another way being a hospitalist was good preparation for working during the pandemic is a hospitalist works in a team model. While I may have been the physician assigned to work with patients, I worked in a team model with pharmacists, nurses, patients, families, and many other individuals in the hospital. Working in a team model was incredibly important during the pandemic.

Related: The Exec: What It Takes to be an Effective Physician Leader

Monogram Health employs more than 1,000 clinicians and operates in 34 states.

Monogram Health, a polychronic care provider that specializes in home-based treatment of chronic kidney and end-stage renal disease, has raised $375 million in growth funding.

In chronic kidney disease, the kidneys are damaged and have a compromised ability to filter blood, according to the Centers for Disease Control and Prevention (CDC). About 37 million adult Americans have chronic kidney disease, the CDC says. In end-stage renal disease, chronic kidney disease advances to the point of kidney failure, according to Mayo Clinic. In 2019, treating Medicare beneficiaries with end-stage renal disease cost $37.3 billion, the CDC says.

In addition to treating chronic kidney and end-stage renal disease, Monogram Health treats all related conditions, Michael Uchrin, MBA, CEO and co-founder of the company, told HealthLeaders. "To go upstream and effectively treat chronic kidney disease, you have got to stabilize patients' blood pressure. You have got to stabilize their diabetes. You have got to get cardiovascular and pulmonary issues stabilized. We have gotten good at providing care for those other conditions."

The Brentwood, Tennessee-based company, which was founded in 2018, operates in 34 states and employs more than 1,000 clinicians, he says. "Our nationally scaled nephrology practice is akin to a multispecialty practice. We have nephrologists, who are kidney specialists, but we also have endocrinologists, cardiologists, and palliative care specialists. Many of our patients have end-stage comorbidities, and they do better on palliative care rather than dialysis. We also have internists who develop personalized treatment plans for each of our patients and oversee our nurse practitioners. So, each patient has an interdisciplinary care team of clinicians based upon their conditions."

Monogram Health also employs registered nurses, social workers, pharmacists, and care management teams. Utilization management teams focus on hospitalizations and discharge management.

Several organizations contributed to the $375 million growth funding, including CVS Health, Cigna Ventures, Humana, Memorial Hermann Health System, TPG Capital, Frist Cressey Ventures, Heritage Group, Pura Vida Investments, and Norwest Venture Partners.

The growth funding will be used to expand the company and invest in technology, Uchrin says. "Most of the growth funding that the company will utilize will go to continue the widespread deployment of our clinical programs. We will continue to build out our clinical infrastructure and workforce as well as continue to invest in technology. We are big believers in technology to enable our care delivery and deliver more effective care at the right place and right time. We are going to continue to improve our analytics and our artificial intelligence as well as the systems that our clinicians use, including the electronic health record our physicians and nurse practitioners utilize."

Clinical care model

Home care is an essential element of Monogram Health's care model, he says. "We are big believers in providing care in the home, especially for individuals as sick as our patient population. More than 90% of our visits are in the home, with the rest of the visits conducted via telehealth. Whether it is our nurse practitioners or even our care managers such as RNs and social workers, they are all engaging our patients in their communities. First and foremost, our care model enables better access to care. In many underserved communities, we are creating access where other specialists did not have brick and mortar facilities."

Monogram Health treats a range of comorbidities, Uchrin says. "We take a whole person, polychronic view of the treatment plan. We do not silo kidney care from cardiovascular disease or pulmonary disease—we treat the patient. On average, prior to coming to Monogram, one of our patients had seen seven specialists, which exacerbates fractured care. Our patients can just work with Monogram, whether it is kidney, cardiovascular, or any other condition—they know they can trust Monogram."

Providing polychronic care distinguishes Monogram Health from most home health providers, he says. "Rather than focusing on one specific need, we act as an individual's physician to treat all of their needs. Home health may come to the home for a six-week, finite episode of care to treat a wound. We are much more longitudinal. Not only do we treat the patient directly and handle all of their conditions, but we also manage their care across the healthcare delivery continuum. So, if an individual does need home health such as IV antibiotics, we will engage a home health provider and oversee the care to ensure that the treatment works as expected."

Financial model and partners

Monogram Health's financial model is focused on providing value-based care, Uchrin says. "We have a value-based care delivery economic model, where we partner with health plans and other risk-bearing entities such as forward-leaning health systems. We work with health plans to assume full medical-expense risk. We offer access and better affordability. We charge a fee for our services that is based on per-member-per-month fees on populations, and the value we create is better affordability around the total cost of care for the populations we have taken responsibility to treat."

The company works predominantly with Medicare Advantage health plans, but it has other partners as well, he says. "Medicare Advantage payers have leaned into our solution, and we have tremendous relationships with Cigna as well as Humana. We also work with forward-leaning health systems, including AdventHealth and Banner Health. We work with health systems that have value-based care relationships with their payer partners. We partner with those health systems to provide treatment for their chronic kidney and end-stage renal disease patients. We help to improve access to care, boost outcomes, and increase affordability."

Related: Technology Partnership Aims to Improve Kidney Disease Treatment

The number of Black, Hispanic, and female students increased at medical schools for the 2022-2023 academic year.

The number of members of historically underrepresented groups at medical schools increased in the 2022-2023 academic year, according to the Association of American Medical Colleges (AAMC).

Lack of diversity in the healthcare workforce risks undermining trust and patient health, according to the Urban Institute. An Urban Institute report published last year found that only 22.2% of Black adults reported being of the same race as their healthcare providers compared to 73.8% of White adults and only 23.1% of Hispanic/Latinx adults reported racial, ethnic, and language concordance with their usual healthcare provider.

Recently released AAMC data shows student diversity gains at medical schools when comparing the 2020-2021 and 2022-2023 academic years:

• The number of Black or African American matriculants increased by 9%. Black or African American students made up 10% of matriculants in 2022-23, up from 9.5% in 2020-21. First-year Black or African American men increased by 5%.
   
• Matriculants who are Hispanic, Latino, or of Spanish origin increased by 4%. Individuals from this group made up 12% of total matriculants.
   
• Women continued to make gains in 2022-23, making up 57% of applicants, 56% of matriculants, and 54% of total enrollment. This is the fourth year in a row that women made up the majority of these three groups.

Increasing diversity in the physician workforce is a top goal at AAMC and medical schools, David Skorton, MD, AAMC president and CEO, said in a prepared statement. "We know that more diversity in the physician workforce builds trust and enhances the physician-patient relationship, translating into better health outcomes. The AAMC and our member medical schools are committed to increasing the number of both applicants and matriculants from historically underrepresented groups."

Diversity imperative

Diversity in medical school students and the physician workforce is beneficial for the profession and patients, Geoffrey Young, PhD, senior director of transforming the healthcare workforce at AAMC, told HealthLeaders.

"Diversity both in the classroom and the clinical settings is essential for the overall health of our nation. Based on my experience of working at two medical schools, when the classroom and the workplace are more diverse, it promotes a high level of cultural competency with the unique opportunity of peer-to-peer learning. Ideally, students will learn from one another and teach each other to be better doctors because they are engaging with folks who are different from them. These skills ultimately translate into higher performing physicians," he said.

Promoting diversity in the physician workforce has a positive impact on clinical outcomes, Young said. "There are studies that show that health inequities along racial and ethnic lines persist in many aspects of health. These studies also show that increased diversity in the health professions can help close those gaps."

Medical schools should continue to press for diversity gains in their students, he said. "I would not put a limit on diversity in the physician workforce. This country is becoming increasingly diverse; and based on our data, having a more diverse physician workforce is going to improve patient outcomes. What is important is that we have representation both in the process of educating physicians and in creating teams of healthcare professionals. The more diverse they are, the better it will be for patients."

Medical schools have made progress in terms of gender diversity, but that journey is far from over, Young said. "We are pleased that women continue to represent a large percentage of those who apply and matriculate into medical school. But if you look at the physician workforce, it is over 60% men. So, while our medical schools are doing well in accepting and graduating women, when we look at the physician workforce there is clearly more work to be done."

To promote diversity in their students, medical schools are taking several approaches, including a holistic approach to admissions, he said. "They not only look at metrics such as grades and MCAT scores but also look at the experiences and attributes of students. Where did they grow up? Are they from a rural or underserved community? Do they have strong leadership skills? Medical schools are looking purposely at the whole person and not just metrics to increase diversity."

Efforts to boost diversity in the physician workforce must go beyond medical schools, Young said. "Medicine is a microcosm of the larger society. While we are committed to diversifying the workforce, it will not happen until we go further upstream. We need to address inequities in K-12 education. There are also learners who struggle with food security and other social determinants."

The federal agency is creating 200 new residency slots every year over a five-year period.

On Monday, the Centers for Medicare & Medicaid Services (CMS) awarded the first 200 of 1,000 Medicare-funded physician residencies to bolster the physician workforce and add physicians at hospitals serving underserved communities.

The new residencies are designed to improve health equity and access to care. The emphasis of the new residencies is on primary care and behavioral health, with 125 of the residencies for primary care and 20 of the residencies for psychiatry.

The residencies target critical needs, CMS Administrator Chiquita Brooks-LaSure said in a prepared statement. "These graduate medical education residency slot awards will help address access to care challenges and workforce shortages in the highest need areas. The majority of the positions are for primary care and mental health specialists, who are the foundation of our healthcare system. I encourage potential applicants to apply to our next application period, which opens in just a few weeks."

The next application period closes on March 31.

The Fiscal Year 2022 Inpatient Prospective Payment System final rule created 1,000 new Medicare-funded physician residency slots to qualifying hospitals authorized by the Consolidated Appropriations Act of 2021. There will be 200 slots phased in per year over five years.

For the new residencies, CMS prioritized hospitals with training programs in geographic areas with greatest need for additional clinicians, as determined by Health Professional Shortage Areas. The new residencies were awarded to 100 teaching hospitals across 30 states, the District of Columbia, and Puerto Rico. They will be effective July 1, 2023.

The new residencies will enhance the physician workforce and boost health equity, Meena Seshamani, MD, PhD, CMS deputy administrator and director for the Center for Medicare, said in a prepared statement. "Prioritizing these awards to areas that need the most support will bolster the workforce while also arming new providers with a unique understanding of the specific needs of these communities. This is critical in advancing our goals of providing high-quality care to all people."

Related: Emergency Nurses Association Unveils New Residency Program