The Making Primary Care Model will be tested in Colorado, Massachusetts, Minnesota, New Jersey, New Mexico, New York, North Carolina, and Washington.
The Centers for Medicare & Medicaid Services (CMS) has announced today a new primary care model that will be tested under the Center for Medicare and Medicaid Innovation in eight states.
Primary care is a fundamental building block of healthcare, including the management of chronic conditions. Access to high-quality primary care is associated with better health outcomes and health equity.
The Making Primary Care (MCP) Model will be tested in Colorado, Massachusetts, Minnesota, New Jersey, New Mexico, New York, North Carolina, and Washington. Primary care organizations in these states will be able to apply for participation in MCP this summer. The model is set to launch July 1, 2024, and it will run through Dec. 31, 2034.
According to CMS, the new primary care model has three goals:
Provide patients with primary care that is integrated, coordinated, person-centered, and accountable.
Establish a pathway for primary care organizations and practices to enter into value-based care payment arrangements. The focus will be on organizations and practices that are small, independent, rural, and safety net.
Improve care quality and health outcomes while reducing program expenditures.
MCP is designed to improve primary care for Medicare and Medicaid beneficiaries, CMS Administrator Chiquita Brooks-LaSure said in a prepared statement. "This model is one more pathway CMS is taking to improve access to care and quality of care, especially to those in rural areas and other underserved populations. This model focuses on improving care management and care coordination, equipping primary care clinicians with tools to form partnerships with health care specialists, and partnering with community-based organizations, which will help the people we serve with better managing their health conditions and reaching their health goals."
The new primary care model features three progressive tracks for primary care organizations and practices, according to the MCP webpage.
Track 1 focuses on building infrastructure. "Participants will begin to develop the foundation for implementing advanced primary care services such as risk-stratifying their population, reviewing data, building out workflows, identifying staff for chronic disease management, and conducting health-related social needs screening and referral. Payment for primary care will remain fee-for-service (FFS), while CMS provides additional financial support to help participants develop care transformation infrastructure and build advanced care delivery capabilities," the webpage says.
Track 2 focuses on implementing advanced primary care. "As participants progress to Track 2, they will build upon the Track 1 requirements by partnering with social service providers and specialists, implementing care management services, and systematically screening for behavioral health conditions. Payment for primary care will shift to a 50/50 blend of prospective, population-based payments and FFS payments. CMS will continue to provide additional financial support at a lower level than Track 1, as participants continue to build advanced care delivery capabilities," the webpage says.
Track 3 focuses on optimizing care and partnerships. "In Track 3, participants will expand upon the requirements of Tracks 1 and 2 by using quality improvement frameworks to optimize and improve workflows, address silos to improve care integration, develop social services and specialty care partnerships, and deepen connections to community resources. Payment for primary care will shift to fully prospective, population-based payment while CMS will continue to provide additional financial support, at a lower level than Track 2," the webpage says.
Mixed reviews of new model
Jack Resneck Jr., MD, president of the American Medical Association (AMA), praised MCP in a prepared statement.
"We're encouraged to see many of the AMA's recommendations featured in this model including a longer model test, a voluntary, progressive model that meets practices where they are and provides on-ramps for them to advance into prospective payment, and meaningful alignment with Medicaid. The longer test period of 10.5 years directly responds to AMA efforts calling for more transparency and stability to foster trust and encourage physician participation. The AMA strongly believes value-based care models are essential to the long-term wellbeing of the Medicare program and its ability to meet the needs of a diverse and aging population," he said.
The National Association of ACOs (NAACOS) criticized MCP in a prepared statement from President and CEO Clif Gaus, ScD. NAACOS supports investment in primary care, and the organization has proposed a new approach to paying for primary care in the Medicare Shared Savings Program, he said. "The approach we've offered would help CMS meet its stated goal of putting all beneficiaries in a relationship with a provider responsible for total cost of care and quality while increasing investment in primary care."
MCP is counter to these goals by excluding practices that participate in an ACO, he said. "While aspects of the new model are positive, practices should not be forced to choose between Making Care Primary and participating in an ACO. Within ACOs, primary care practices are the quarterback of care teams, but they must work with providers across the care continuum to achieve quality outcomes and cost savings. Working with ACOs has proven to be beneficial to primary care practices, and ACOs with practices concurrently participating in primary care models, such as Primary Care First or the Maryland Primary Care Program, are the most successful."
The survey polled clinical healthcare workers, healthcare administrative workers, and healthcare security personnel.
A recent survey found that 40% of healthcare workers had experienced workplace violence in the past two years.
Healthcare organizations carry a heavy workplace violence burden, with about three-quarters of U.S. workplace assaults occurring in healthcare settings, according to the Occupational Safety and Health Administration. Workplace violence is prevalent in emergency departments—78% of emergency physicians have reported being targets of workplace violence in the prior 12 months.
The recent survey, which was conducted by Premier Inc. and the Agency for Healthcare Research and Quality, features data collected from 672 clinical healthcare workers, healthcare administrative workers, and healthcare security personnel. The survey was conducted from Feb. 1 to April 14.
The survey includes several key data points:
Workplace violence is most common among nursing staff, and more than half of incidents involved combative patients as perpetrators
Most workplace violence incidents occurred when healthcare workers were explaining or enforcing an organizational policy, or when healthcare workers provided an update on a patient's condition to a patient or a patient's family members
For female survey respondents, 50% of workplace violence incidents involved emotional or verbal abuse and 50% of incidents involved physical or sexual abuse
For male survey respondents, 62% of workplace violence incidents involved physical abuse and 38% of incidents involved emotional or verbal abuse
Nearly two-thirds of survey respondents who experienced workplace violence identified themselves as bedside nurses
The majority (62%) of workplace violence perpetrators were men, 37% of perpetrators were women, and 1% of perpetrators were non-binary
Two-thirds of survey respondents reported that their workplace violence perpetrator was not noticeably or confirmed to be under the influence of drugs or alcohol
In workplace violence incidents involving combative patients: 62% of survey respondents reported being scratched, bit, and hit; 21% of survey respondents reported that the patient threw objects; 14% of survey respondents reported sexual abuse; and 1% of survey respondents reported being shot by a patient
In workplace violence incidents reported to law enforcements, 45% of survey respondents reported that law enforcement was responsive to physical or sexual violence incidents and 22% of survey respondents reported that law enforcement was responsive to verbal or emotional abuse incidents
Mental illness was cited as the top factor in workplace violence incidents by 27% of survey respondents
Drugs and alcohol were cited at the top factor in workplace violence incidents by 24% of survey respondents
Workplace violence in healthcare settings has several negative consequences, according to the survey report. "Healthcare workers experiencing workplace violence may suffer physical and psychological trauma. These acts of violence can also disrupt patient care when providers fear for their personal safety or are distracted by disruptive patients or family members. Having a strong prevention and mitigation strategy in place is critical in the prevention and reduction of incidents of workplace violence."
The survey report expresses support for the Safety from Violence for Healthcare Employees (SAVE) Act of 2023, which was introduced in the U.S. House of Representatives in April. "This legislation would give healthcare workers the same legal protections against assault and intimidation as aircraft and airport workers. It would also establish a federal grant program at the Department of Justice to augment hospitals' efforts to reduce violence by funding violence prevention training programs, coordination with state and local law enforcement, and physical plant improvements such as metal detectors and panic buttons."
The findings of the survey are significant, Soumi Saha, PharmD, JD, senior vice president of government affairs at Premier, told HealthLeaders.
"It's very concerning as violence in the healthcare setting continues to rise and, according to our survey, more than half of all respondents felt that these incidents had increased during their tenure. What is unique about Premier's survey is that we heard directly from healthcare employees regarding their experiences and the need for change moving forward to address burnout, retention, and recruitment. Furthermore, workplace violence incidents aren't considered a federal crime, which is why Premier continues to support bipartisan legislation like the SAVE Act to provide enhanced legal protections for healthcare workers," she said.
Healthcare workers and their organizations need to take a proactive approach to addressing workplace violence, Saha said. "According to the survey, more than half of the respondents dealt with a combative patient. We believe healthcare workers need to maintain open communication with their peers, teams, and leaders regarding access to workplace violence prevention programs, de-escalation training, and other resources that can help them stay safe while providing a calm and safe place of healing for all patients. The key is that addressing workplace violence requires a proactive approach that creates a safe space for workers to report incidents without fear."
In the wake of the coronavirus pandemic, healthcare organizations must be nimble in identifying needs and be able to pivot to meet those needs.
Now that the crisis phase of the pandemic has passed, health systems and hospitals need to focus on new staffing models and deploying technology, says Allan S. Philp Jr., MD, chief medical officer of Allegheny General Hospital (AGH) in Pittsburgh.
Philp has been CMO of AGH, which is a member of Allegheny Health Network (AHN), since June 2022. He has been chief quality officer of the AHN Surgical Institute since March 2020. His previous experience includes serving as a surgeon for the U.S. military.
HealthLeaders recently talked with Philp about a range of issues, including the primary elements of quality in surgery, how clinicians are involved in organizational administration at AGH, and the differences between military and civilian medicine. The following transcript of that conversation has been edited lightly for brevity and clarity.
HealthLeaders: What are the primary challenges of serving as CMO of Allegheny General Hospital?
Allan S. Philp Jr.: The challenges we have faced are similar to challenges at other hospitals. It has mostly been in regard to resources. Healthcare was a little bit challenging pre-pandemic, and it has become more challenging during the pandemic and post-pandemic largely because of staffing problems and supply chain problems.
One of the ways we have been fortunate is because we have a large network. We have been able to function as a network, which means we can shift resources. For example, we have an internal staffing team, so we can move staffing resources around to meet the needs and do not have to limit access for patients. At the end of the day, it is about getting people the care that they need.
The other piece is figuring out how to prioritize. At my level, that requires strong relationships with my colleagues. We cannot do everything all the time—nobody has the resources to do that, so we must have our priorities in the right order for patients to get care. Being able to work with my colleagues to think outside of the box on solutions to challenges is valuable.
HL: Now that the crisis phase of the coronavirus pandemic has passed, what are the primary clinical care challenges at Allegheny General Hospital?
Philp: The COVID pandemic made us realize that business as usual is no longer a successful model. It is no longer the best practice. We have to be more nimble than we used to be in terms of recognizing what the needs are and pivoting to be able to meet those needs. We need new models for staffing. We need to leverage technology and electronic medical records. Then, we cannot lose track of the fact that medicine is pushing forward every day.
When we look at the best treatment for a condition, if you settle for the best treatment when you trained, that is fine if you trained six months ago. It becomes less fine at three years, and it is not at all fine at 15 years. You must be scrutinizing the whole field all the time. You need to ask, "How can we do a procedure minimally invasively? How can we provide care in a way that has a faster recovery or lower risk?"
We have been fortunate that we have been able to stay on top of medical science during the pandemic and post-pandemic. For example, in the past year we have opened a hybrid operating room, which is like a combination of an interventional radiology suite and a conventional operating room. This allows us to do things like minimally invasive valve repairs and advanced vascular procedures.
Allan S. Philp Jr., MD, chief medical officer of Allegheny General Hospital. Photo courtesy of Allegheny Health Network.
HL: You serve as chief quality officer of the AHN Surgical Institute. What are the main elements of promoting quality in surgical care?
Philp: There are three parts to that. First, you must look critically at your outcomes. That means having meaningful data. There is a tendency for any healthcare provider to say, "We are working very hard. We are taking care of patients. I'm confident our care is fantastic." But if you do not look critically at your outcomes, you will not see opportunities to improve.
Second, once you have looked at your outcomes, you need to bring together the whole team to not only involve them in the solutions but also solicit the solutions from them. When you look at the people who are the boots on the ground, they have fantastic ideas about addressing challenges and figuring out which challenges to address.
The third piece is not living in a bubble. There is great healthcare being provided across the country, and reaching out to colleagues at other facilities is critical. Care should be agnostic of whatever the sign over the door says. We should be able to collectively determine best practices and find innovative ways to address challenges.
HL: How are clinicians involved in organizational administration at Allegheny General Hospital?
Philp: We are a clinician-led organization. There are a lot of places that give lip service to that, and not as many places that actually do it. For example, our president is a practicing hospitalist. I am active in our trauma care. Our chief nursing officer spends an enormous amount of time on the surgical and medical floors to understand what the needs are. So, we are provider driven, which is important because it keeps the patient and their family at the center of everything.
If you look at the way that changes are implemented, it flows through clinical committees. These are not just doctors. For example, our critical care committee that is involved in issues such as providing better respiratory care includes doctors, nurses, and respiratory therapists all working collaboratively—and you have senior people and more junior people so that you have input from all of those levels, and you can mentor the junior staff.
You also need to be realistic and savvy, with good business partners such as financial officers and operating officers. I am a capable trauma surgeon, but if we had to do a business plan for a $200 million addition to the hospital, we would need someone who lives in that world as well. The partnership between our clinical leaders, who are driving what the need is and what we need for our patients, and our operational leaders, who need to translate what we need to do to provide the best care for our community, allows us to draw up plans for providing world-class care.
HL: You have a clinical background in surgery. How has this clinical background helped prepare you to serve in leadership roles such as CMO?
Philp: It is helpful that I have been working in trauma specifically. If you look at the care of a trauma patient, it crosses a bunch of different areas of the hospital and different specialties. For example, we interact with emergency medical services, the emergency department, the blood bank, the operating room, and specialties such as orthopedics and neurosurgery. To be able to do that kind of work, you must have a collaborative approach. When I moved on to do the chief medical officer role, it was like trauma care on a larger scale.
HL: You led critical care teams in Afghanistan and Iraq for the U.S. military. What are the main differences between providing critical care in the military setting versus providing critical care in civilian hospitals?
Philp: The resources can be different. If you are at a military hospital, it is similar to being at a civilian hospital. On the other hand, if you are with a five-member military team and working out of backpacks, you have less resources. So, the resources vary from place to place and time to time in the military.
It has been valuable to have a military medicine background. The transition to the pandemic was easier for me. You are used to working with limited resources in the military, and applying those skills during the pandemic was helpful.
The Institute for Healthcare Improvement and the American Medical Association are co-leading the Rise to Health Coalition.
The recently launched Rise to Health Coalition is designed to move work on health equity from primarily documenting healthcare disparities to addressing healthcare disparities, the president and CEO of the Institute for Healthcare Improvement (IHI) says.
Health equity emerged as a pressing issue in U.S. healthcare during the coronavirus pandemic. In particular, there have been COVID-19 health disparities for many racial and ethnic groups that have been at higher risk of getting sick and experiencing relatively high mortality rates.
The Rise to Health Coalition is a nationwide initiative co-led by IHI and the American Medical Association. The Rise to Health Coalition has three primary goals, IHI President and CEO Kedar Mate, MD, told HealthLeaders.
"We are trying to build the capability for change. We are trying to create real results. And we are trying to change the story of health inequity in the country. Those are the three interlocking goals for the initiative—building the ability for our systems to change across many sub-sectors in healthcare, creating real results for real people, and by virtue of creating the capability for change and real results we are hoping to change the narrative around inequities in healthcare from a story of inaction and inevitability to a story of active change and preventing health inequity in the future," he says.
The Rise to Health Coalition includes a measurement committee, Mate says. "The measures essentially fall into several broad buckets. There are measures of access to care. There are measures of quality and safety. There are measures on the clinical side, which tend to bucket largely in cancer services, cardiovascular disease, and diabetes—for each of them there are efforts to create specific measurements and stratification guidance to help understand where disparities exist. There are also workforce measures around workforce diversity, workforce inclusion and belonging, and workforce turnover and burnout concerns that are prevalent at the moment."
Addressing systemic racism in healthcare is among the top objectives of the Rise to Health Coalition, he says. "Addressing systemic racism is an important question that we have built into the fabric of what we are trying to do. There is a lot of effort in Rise to Health to try to coproduce the goals of the initiative with agencies and community-based organizations that are responsible for trying to end systemic racism. Fundamentally, this focus is on trying to bring a racial justice lens to not just what we do but also how we understand the impact of the coalition."
The Rise to Health Coalition will also address inequities in patient care, Mate says. "Rise to Health builds on several initiatives that IHI and partner organizations have run for many years. We have been focusing on questions of where inequities arise in patient care and how we might go about resolving them. Fundamentally, Rise to Health like its antecedent initiatives builds on quality- and quality improvement-related methods. These efforts were originally designed to reduce variations in healthcare. Now, we are using quality and quality improvement methods to try to reduce inequities in specific care practices where we have found inequities."
Changing the health equity narrative
For many years, the narrative about health equity has reflected the belief that disparities and inequities are not changeable—that they are baked into the healthcare system, Mate says. "The belief is that if we are going to practice medicine, we are going to have some aspect of disparities. But as we start to improve cancer screening rates, or change stroke care outcomes, or improve maternal survival, we must be able to tell that story to demonstrate that these are not just things we document. In fact, we can tell stories about how we can change practices and change the story about inequity in healthcare."
Changing the health equity narrative could be the most significant impact of the Rise to Health Coalition, he says. "Yes, we will improve many different aspects of clinical care. Yes, we will change pharma discovery processes. Yes, we will modify many payment programs. All of these things are already in the works and are being done right now. But the bigger thing that we will hopefully accomplish is we will look back on this time and say, 'Until 2023, we had spent most of our time documenting the disparities in our healthcare system. But in 2023 and 2024, this was the time when the narrative shifted from documenting disparities to doing something about disparities.'"
Changing policy, payment, education, and standards
The Rise to Health Coalition will build on fundamental changes already occurring related to health equity, Mate says.
"I see government moving increasingly toward reducing race-based disparities—I see more effort to understanding where inequities are present in the healthcare system and more action to try to resolve those disparities. I see both public and private payers starting to configure incentive schemes as part of quality contracting to understand where disparities may be present in racial disparities, gender disparities, LGBTQ disparities, location-specific disparities, and income disparities. Payers are starting to pay differently for improvement in specific areas, which is going to be an important aspect of how addressing inequity attains long-term sustainability," he says.
Health equity is becoming a significant element in healthcare education, Mate says. "We have added to medical curricula and nursing curricula to understand implicit bias. We have started to understand where health equity education as well as anti-racism education has a role for us moving forward."
Health equity is also being incorporated in healthcare standards, he says. "The Joint Commission has started to accredit institutions based on equity standards. So, we are starting to see some standard-based change."
Clinics are particularly challenged in finding technical staff such as radiation therapy technologists and physicists.
More than 9 in 10 radiation oncologists report that their practices face clinical staff shortages, according to a new national survey from the American Society for Radiation Oncology (ASTRO).
Workforce shortages are widespread in the healthcare sector. Nursing shortages are being reported across the country, and the physician labor market is reportedly tighter than ever.
The new national survey on radiation oncology staffing shortages is based on data collected from 249 ASTRO members. The survey was conducted from March 24 to April 11. The survey has several key data points:
93% of radiation oncologists reported that their practices are facing shortages of clinical staff, including nurses, therapists, physicists, and dosimetrists
53% of radiational oncologists said the shortages are creating treatment delays for patients and 44% said the shortages are causing increased patient anxiety
On average, practice operating costs are up 23% compared to before the coronavirus pandemic, with 77% of radiation oncologists reporting that professional staffing is driving increased costs
Radiation oncologists reported that staffing shortages are forcing their practices to reduce support services, with 48% of the doctors saying they had reduced patient navigation services
Radiation oncology clinics are experiencing shortages of nurses, medical assistants, and front desk staff like other specialties, but the most acute shortages are in technical staff, says Constantine Mantz, MD, health policy council chair at ASTRO, chief policy officer at GenesisCare, and a practicing radiation oncologist at GenesisCare.
"We are struggling to employ permanent technical staff—particularly radiation therapy technologists, who are critical and irreplaceable to the process of delivering radiation therapy to cancer patients. We are observing an undersupply of graduating and certified technologists to meet the needs of the growing cancer patient populations in our markets. Also, more technologists appear to be taking on locum tenens work to earn more as temporary employees, further exacerbating the problem of finding stable technical staff needed for high-quality care," he says.
The pandemic has exacerbated longstanding shortages of technical staff at radiation oncology clinics, Mantz says. "The training programs have not been producing enough radiation technologists and physicists as the field demands. The coronavirus pandemic prompted retirements, changes in career plans, and other departures from the field. The workforce shortages have become much more acute. We are struggling with workforce in many markets, particularly smaller communities."
Radiation oncology clinics have tried to backfill their staffing needs through locum tenens hires brought on through temporary staffing agencies, he says. "That solution is very costly compared to having a permanent hire to do the work. Temporary staffing also compromises the quality of care because the continuity of care is disrupted when you have to bring in new staff on a temporary basis."
Responding to the shortages
Radiation oncology clinics are trying to boost the pipeline for technical staff, Mantz says. "We are trying to work through the training programs and schools that develop staff for our needs by sponsoring scholarships and providing internships in clinics to offer real-world experience. We are also providing stipends for education and other needs as a way of trying to retain people. The real answer is going to be expanding the training programs, which can be done through the accrediting bodies allowing an expansion of the number of sites that earn accreditation and certification to provide this type of education. At this point, that is the bottleneck."
Staff retention has become a top priority for radiation oncology clinics, he says. "The most effective approach is increasing compensation for the work to discourage our technical staff from looking for locum tenens work, which might pay more on a per week or per month basis. We try to elevate compensation for the staff, so they feel it is worth their while to stay."
However, increasing compensation is a challenge, Mantz says. "The problem with increasing compensation is that we face diminishing reimbursement for our services. Medicare payment has been on a consistent decline over the past 20 years for outpatient specialty care services such as radiation therapy. As margins shrink, it becomes increasingly difficult to compensate existing staff more, and it creates operational challenges that impact the bottomline."
Workforce prospects
About 80% of radiation oncologists surveyed reported that workforce shortages are worse than last year. Severe staffing shortages are likely to continue for the foreseeable future, Mantz says. "With the exception of premier cancer centers in urban centers, the rest of the country is going to face workforce shortages and difficulty meeting the demand for services. For the rest of this year, we will see continued pressure on clinics identifying and hiring much-need technical staff, and that is likely to play out for the next two or three years."
The staffing shortages are going to put pressure on providing services as the country's population ages, he says. "The problem is enhanced by the growing Medicare-aged population, which is the group of people that is most likely to develop cancers that we would treat with radiation therapy. The last Baby Boomer born in 1964 is going to be turning 65 years old in a few years. Between now and then, the population base of cancer patients is expected to grow commensurately with the Medicare population. We are going to encounter struggles over the rest of the decade to provide our clinics with sufficient qualified staff to render services."
Researchers examined four social needs screened at primary care practices: food insecurity, housing insecurity, transportation insecurity, and care coordination needs.
Significant resources would be required to address social needs and financing of interventions is mainly outside federal funding sources, according to a new research article.
Social needs such as housing, food security, and transportation can have a pivotal impact on the physical and mental health of patients. Unmet social needs are linked to health disparities, poor clinical outcomes, and health costs for several medical conditions.
The new research article, which was published by JAMA Internal Medicine, is based on data for patients who visited primary care practices. Four social needs were included in the analysis: food insecurity, housing insecurity, transportation insecurity, and care coordination needs. Primary care practices were divided into four categories: Federally Qualified Health Centers (FQHCs), non-FQHC practices in urban high-poverty areas, non-FQHC practices in rural high-poverty areas, and primary care practices in lower poverty areas.
The study features several key data points:
Among patients with food insecurity, 95.6% of people were eligible for a federal assistance program but only 70.2% were enrolled
Among patients with housing insecurity, 78.0% of people were eligible for a federal assistance program but only 24.0% were enrolled
Among patients with transportation insecurity, only 26.3% were eligible for a federal assistance program
Among patients with care coordination needs, only 5.7% were eligible for a federal assistance program
The cost of conducting evidence-based interventions for food insecurity, housing insecurity, transportation insecurity, and care coordination needs averaged $60 per member per month, with primary care practice screening and referral management accounting for $5 of the cost and federal funding available for $27 of the cost
Among patients who visited an FQHC, 31.9% were estimated to have food insecurity, 1.1% were estimated to have housing insecurity, 3.4% were estimated to have transportation insecurity, and 12.6% were estimated to have care coordination needs
Among patients who visited primary care practices in lower poverty areas, 4.3% were estimated to have food insecurity, 0.2% were estimated to have housing insecurity, 2.2% were estimated to have transportation insecurity, and 9.4% were estimated to have care coordination needs
The percentage of social needs costs paid by federal payers was 61.6% for food insecurity costs, 45.6% for housing insecurity costs, 27.8% for transportation insecurity costs, and 6.4% for care coordination costs
Federal financing is inadequate to cover most of the cost of social needs interventions, the study's co-authors wrote. "Food and housing interventions were limited by low enrollment among eligible people, whereas transportation and care coordination interventions were more limited by narrow eligibility criteria. Screening and referral management in primary care was a small expenditure relative to the cost of interventions to address social needs, and just under half of the costs of interventions were covered by existing federal funding mechanisms. These findings suggest that many resources are necessary to address social needs that fall largely outside of existing federal financing mechanisms."
Interpreting the data
More resources are needed to address social needs, the study's co-authors wrote. "We observed both low enrollment in existing programs, especially for food and housing interventions for which inadequate program capacity may limit participation of eligible people, and narrow eligibility criteria for existing transportation and care coordination interventions that excluded many in need. This suggests that major changes to the way social services are delivered in the U.S. may be needed if we are to respond appropriately to needs identified through healthcare-based screening."
Inadequate funding is a major barrier to addressing social needs, the study's co-authors wrote. "Our findings are consistent with national data on inadequate funding for housing or rental assistance. For example, among eligible households for the Section 8 Housing Choice Voucher Program, the nation's largest source of rental assistance, only 25% receive any rental assistance after an average wait time of approximately 2.5 years. Additionally, our findings suggest the total costs of social needs interventions are far beyond what is typically allocated to programs for addressing health-related social needs, and this is particularly true for practices serving the neediest patients."
Many primary care practices face challenges in addressing unmet social needs, the study's co-authors wrote. "The cost of screening and referral management may be high relative to capitated primary care payments to a practice. The highest needs and highest costs for overall social interventions were among populations attributed to both FQHC and non-FQHC practices in high-poverty areas. While disproportionate funding was available to populations seen at FQHCs, the populations seen at non-FQHC practices in high-poverty areas were found to have larger funding gaps in terms of the intervention costs not borne by existing federal funding mechanisms."
Since Memorial Healthcare System launched a strategic sourcing department, the health system has exceeded the organization's record for savings.
Memorial Healthcare System has added a strategic sourcing department to its supply chain to shift away from transactional contracting, says Saul Kredi, MBA, vice president of supply chain management.
Kredi has been vice president of supply chain management at the Fort Lauderdale, Florida-based health system since May 2016. He was director of purchasing at Memorial from August 2010 to April 2016. His previous experience includes serving as materials manager at Miami Children's Hospital.
HealthLeaders recently talked with Kredi about a range of topics, including Memorial's supply chain philosophy, balancing the benefits and drawbacks of limiting the number of vendors in a supply chain, and the role of physicians in Memorial's supply chain. The following transcript of that conversation has been lightly edited for clarity and brevity.
HealthLeaders: What are the primary challenges of serving as vice president of supply chain management at Memorial?
Saul Kredi: We have a few primary challenges. Coming off COVID, the supply chain team is fatigued. There is instability in the supply chain. We are reconstructing processes after having to operate in a certain way because of COVID. At Memorial, we are also transitioning to a new enterprise resource planning system called Workday.
HL: How are you reconstructing processes?
Kredi: We are taking it to the next level on how we work with our group purchasing organization on better predictive analytics for future backorders. We are working on becoming more proactive instead of reactive. We are realigning with the health system so we can be less reactive and can start planning and doing things organically.
HL: Give an example of a supply chain initiative you have been involved with at Memorial?
Kredi: I have constructed a strategic sourcing department. We had a transactional contracting department, but we needed the skillset of a strategic sourcing department as a best practice. Even though the group is very new—we are about 18 months into this new operation—we exceeded the record for savings at this health system over the past year. This group has generated results early on.
HL: How does the strategic sourcing department work?
Kredi: We have people assigned by service line that are the first point of contact. So, if we want to look at a service, a supply, or some equipment, we are going to start that conversation early on so we can shepherd it through the process. We can make sure that we do our competitive bids, make sure we understand what is needed, have conversations with physicians, and be fully integrated into the planning and execution of the process.
Instead of being a transactional supply chain, we are more strategic now.
HL: You previously served as director of purchasing at Memorial. How did this experience help prepare you to serve as vice president of supply chain management?
Kredi: When I was the director of purchasing, a lot of the processes and the things I put in place helped us to be better prepared. Before the pandemic, we had a supply of personal protective equipment that we managed for many years. I was able to construct the purchasing group and train the purchasing group as a team—we needed to retrain people and hire the right talent to be able to perform the purchasing function at a higher level. In taking over the role of vice president of supply chain, this experience prepared me to continue to develop our supply chain model. I was able to ask questions such as do we have the right talent? Do we need to train? What is our philosophy going to be? The supply chain needs to be aligned and not work in siloes.
When I took over, we had some siloes, and I worked to get the group together. As director of purchasing, I was able to look to the future and see what we needed. So, when I stepped into the vice president role, I already had the assessment done in terms of where we needed to focus.
Saul Kredi, MBA, vice president of supply chain management at Memorial Healthcare System. Photo courtesy of Memorial Healthcare System.
HL: What is your supply chain philosophy at Memorial?
Kredi: We want to make sure that we have the right product, at the right price, at the right time. The right product means we have the right quality product—we are collaborative in how we choose products in this health system using our value analysis team and other venues to make sure we have the right products to care for our patients.
HL: How is it helpful to reduce the number of vendors that you draw upon for your supply chain?
Kredi: No. 1, you get to standardize. You leverage your economies of scale going to one vendor. That is the positive side of reducing the number of vendors.
However, looking at this issue after the experience with COVID, there is value to having redundancy. We need to have options and avoid putting all of our eggs in one basket after all of the supply chain vulnerabilities that we experienced.
We want to standardize where we can and gain the economies of scale where we can. But we need to challenge vendors to have more redundancy, so production is not isolated in one area. If one plant shuts down, we need to be able to secure supply from somewhere else. In addition, vendors need to be more creative and not operate in a just-in-time environment for production.
HL: How has Memorial adopted automation in the health system's supply chain?
Kredi: We are evaluating that now. We are looking at a lot of automation as we transition to Workday as our enterprise resource planning system. We are also looking at more automation in our inventory locations. We are revamping our inventory processes with Workday.
Workday will allow us to manage all of our purchases and contracts. It will allow us to have a supply catalogue, with supplies that are approved for purchase. It will manage ordering and receiving products in the supply chain system. It will manage our inventory. It also manages human resources activities along with finance activities.
HL: How do you engage physicians in the supply chain?
Kredi: Engaging physicians in the supply chain is vital—this is a philosophical pillar for me. We have great relationships with our physicians, but we want to enhance the relationships. We want to be more proactive with physicians when looking at new technologies and products.
Physicians are crucial in negotiating what products we are going to use. Having physicians sitting at the table during negotiations is powerful with the vendors. It is vital to supply chain success to have physicians involved.
Physicians are involved in our value analysis team. We have clinical teams with physicians for new products. We also have ad hoc committees with physicians for certain categories. They give their feedback on how we should proceed, and we are aligned on how we are going to execute initiatives.
In the future, we are going to be more proactive in having physicians look at data and the market. We want to have physicians involved in helping us achieve cost savings and providing better care for our patients.
Researchers compared the performance of doctor of medicine (MD) and doctor of osteopathic medicine (DO) hospitalists in the care of Medicare beneficiaries.
Physicians who are doctors of medicine (MDs) and doctors of osteopathic medicine (DOs) generate similar results on key indicators of quality and cost of care, a new research article says.
Among practicing physicians, about 90% hold MD degrees and about 10% hold DO degrees. Medical education for MDs and DOs is similar, although DOs have a more holistic focus and inclusion of manipulation training in osteopathic schools. MDs and DOs are licensed to practice medicine in all 50 states.
The research article, which was published by Annals of Internal Medicine, features data collected from more than 329,000 Medicare admissions at acute care hospitals from January 2016 to December 2019. Among the Medicare admissions of patients over age 65, 77.0% received care from an MD hospitalist and 23% received care from a DO hospitalist. The inpatients in the study had been admitted to hospitals with urgent or emergency conditions.
The research article features four key findings:
30-day patient mortality was similar for MD and DO hospitalists, with a 9.4% rate for MDs and a 9.5% rate for DOs
30-day readmissions were similar for MD and DO hospitalists, with a 15.7% rate for MDs and a 15.6% rate for DOs
Hospital length of stay (LOS) for MDs and DOs was identical at 4.5 days
Medicare Part B spending for MDs and DOs was nearly identical at $1,004 and $1,003, respectively
"We found that allopathic and osteopathic physicians performed similarly in terms of patient mortality after hospital admission, readmissions, LOS, or health care spending when they cared for elderly patients and worked as the principal physician in a team of health care professionals that often included other allopathic and osteopathic physicians. These findings should be reassuring for policymakers, medical educators, and patients because they suggest that any differences between allopathic and osteopathic medical schools, either in terms of educational approach or students who enroll, are not associated with differences in quality or costs of care, at least in the inpatient setting," the research article's co-authors wrote.
Interpreting the data
There are four potential explanations for why quality and cost of care were found to be similar for MD and DO hospitalists, according to the research article.
MD and DO medical schools are both required to provide standardized medical education based on accreditation systems. MD and DO medical schools have similar accreditation standards such as a four-year curriculum that features science courses and clinical rotations. Standardized tests required for all physicians "may function as a safeguard toward excluding nonqualified medical students from either type of school."
Residency and fellowship training that physicians receive after medical school may help standardize how MDs and DOs practice medicine.
Lack of time, institutional support, and reimbursement are structural barriers that result in most DOs not using osteopathic manipulative treatment. So, there may be only minor differences in how MDs and DOs practice medicine.
This study compared MDs and DOs practicing within the same hospitals. So, hospital efforts to ensure care quality may limit the variation between the ways individual MDs and DOs practice medicine.
To promote population health, healthcare organizations need to serve their population as a whole, a top Sentara Health executive says.
At Sentara Health, population health involves being the trusted partner for individuals and communities on their journey to health and wellness, says Jordan Asher, MD, MS, executive vice president and chief physician executive.
Asher has held his current role since February 2021, when he was promoted from senior vice president to executive vice president. Prior to joining Sentara, he was chief clinical officer of Ascension Care Management, a subsidiary of the Ascension health system.
HealthLeaders spoke recently with Asher about a range of issues, including population health, health equity, and clinical quality. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: What are the primary challenges of serving as executive vice president and chief physician executive of Sentara?
Jordan Asher: When I think about the primary opportunities, it really is how do we continue on our journey as a company to think about how we deliver care and services to more patients and a broader population. Basically, how do we do our job even better and bigger for more people, especially those who need us the most from a health equity perspective. We want to focus on being a community asset.
The challenges are in a couple of different categories. No. 1, are the everyday challenges of dealing with issues as they come up—COVID has been a big example of that challenge. There is also the challenge of dealing with people where they are. We need to think about care from their perspective.
Then there is a strategic challenge of how we can continue to function in the face of situations such as labor shortages. We also need to be prepared for events such as hurricanes and other challenges that are hard to anticipate.
HL: How do you rise to those challenges?
Asher: No. 1, you must be right with yourself. As a leader, you must have a good understanding of who you are, your style, and your true North. No. 2 is how you help others rise to occasions—how do you think about servant leadership in support of those who you are asking to serve other people? Lastly, how do you keep an open mind and think about things differently all the time? For example, when we were going through COVID, I had to say, "How do we think about things 180 degrees differently than we have in the past?"
HL: How is Sentara promoting population health?
Asher: As we think about Sentara and how we are focused on population health, it is within the context of being the trusted partner for our individuals and communities on their journey to health and wellness. We need to think about population health from that perspective. Historically, health systems have focused on how they take care of patients when they are sick, and patients need services. For us, thinking about population health is saying, "How do I think about your health and wellness within the context of your journey both as an individual and as a community?" Then you need to set up structures and processes to promote population health and to be a community asset. We need to focus on the population as a whole.
HL: Give me some examples of those structures and processes that are supporting population health.
Asher: Sentara has multiple populations that it serves. Obviously, for our insurance side with Optima Health and Virginia Premier, there are members we serve from a health insurance perspective. Additionally, we are very active in population health structurally through our clinically integrated network, which is a whole department that is focused on population health as it relates to members that it serves under a clinically integrated network. Then, most importantly, is how we are thinking about the most vulnerable people who need us the most, including from a health equity perspective. We have created structures to focus on that population such as our Community Care structure. As a large organization, we need to bring all of these structures together and bring them to bear on all of the communities that we serve.
Jordan Asher, MD, MS, executive vice president and chief physician executive at Sentara Health. Photo courtesy of Sentara Health.
HL: Give examples of clinical quality initiatives you have been involved with at Sentara.
Asher: For Sentara, delivering high-quality care is the price of entry. We view that as a North Star for us. We have a structure for looking at quality and safety on an ongoing basis both within our individual locations and as an overall system.
For example, we have been focused on hospital-acquired infections—meaning that when patients are in our hospitals how do they not get an infection that is part of being in a hospital? We have design teams. We have teams that focus on hospital-acquired infections. Over the past four or five years, our hospital-acquired infection numbers have dropped precipitously. Those include catheter-associated urinary tract infections, infections after surgeries, and gastrointestinal infections.
Another area that we are focused on is mortality. We are well below the national average on expected mortality when patients come into our hospitals.
More recently, we have been looking at grievances and complaints as a quality indicator. When a patient has a concern or an issue, we take in that information, and we look at that as a quality indicator.
HL: What are the primary elements of promoting patient safety at Sentara?
Asher: We have a just culture of safety and quality, meaning that it is in our core—it is part of who we are to say that we are going to deliver safe care. For example, we open most meetings that we have as an organization with a safety story. These stories show that we follow a highly reliable process to deliver safe care. When you come to us for care, quality and safety and making sure that you are treated with the utmost safety and respect is paramount to us.
We also think about safety for the members of our care teams because your safety as an employee is top of mind for us as well.
HL: How are you approaching high reliability at Sentara?
Asher: We have been on this journey since way before I got here. It is about structure, talent, and process. We have a high-performance design team that is focused on delivering quality and safety. We tie that to setting our goals for key performance indicators. We tie that to everything, from the board down to the front line. We celebrate our successes. We are a learning institution, which is a strong concept for high reliability because we must be continuous learners. We want people to share with us when they think something has not gone correctly. We want to learn from that—we want to do root cause analyses to focus on how to improve.
HL: How is Sentara promoting health equity?
Asher: Health equity is core to our mission of how we improve health every day. We must improve health every day for everybody. Therefore, we must think about communities that have been historically marginalized.
For example, we have a health equity department that is focused on measuring disparities. We also have had incredible support from our community partners—engaging faith-based leadership in marginalized communities. Faith-based leadership is at the grassroots. Healthcare organizations must remember that we are here to serve as a community asset, and the best way to not only learn what is needed but also to create partnerships to deliver care in different ways is by partnering with communities.
HL: You have a clinical background in internal medicine. How has this clinical background helped prepare you for leadership roles such as chief physician executive?
Asher: In internal medicine, we pretty much have to think about everything. Internal medicine has helped me because I must think very broadly as chief physician executive. I must encompass lots of different data points and kinds of information.
Internal medicine has also helped me because internists take care of people over a period of time. So, as an internist, I think more longitudinal than transactional.
The president and CEO of the Healthcare Distribution Alliance says the supply chain is adapting to the "new normal."
"Transformational change" in the healthcare sector is having a significant impact on the healthcare supply chain, says Chester "Chip" Davis, JD, president and CEO of the Healthcare Distribution Alliance (HDA).
As the U.S. healthcare system emerges from the coronavirus pandemic, the healthcare supply chain is recovering from serious disruptions such as shortages of personal protective equipment early in the pandemic. The healthcare supply chain is still coping with challenges, including drug shortages and a changing regulatory environment.
While the healthcare supply chain has been challenged in recent years, it has largely weathered the storm, Davis says. "While not perfect, the healthcare supply chain has been resilient during the pandemic and since the wind down of the pandemic. There are still areas we need to work on collectively with our partners both upstream and downstream. For example, there are growing concerns about the sustainability and viability of the generic drug market—that is a critical area for all stakeholders who rely on generic drugs, which is essentially the entire healthcare ecosystem."
The biggest lesson from the pandemic is the need for active communication and collaboration between all partners in the supply chain, he says. "I started at HDA in the first week of March 2020—right when the pandemic arrived here in the United States. In my first couple of months at HDA, seeing the evolution of the communication cycle, particularly with the federal government, improved when the communication was no longer one-way. When it was the federal government telling us what to do, it was difficult as opposed to a constant feedback loop. We think it is important to maintain two-way communication."
The expiration of the COVID-19 public health emergency is going to have a significant impact on the healthcare supply chain, Davis says. "Obviously, with the expiration of the PHE on May 11, the most important thing is to ensure the sustainable availability and distribution of the treatments for COVID-19 that were developed, including vaccines and therapeutics. During the pandemic, the government played a key centralized role, and by definition with the cessation of the PHE a lot of the medicines are transitioning into the traditional commercial market. The fortunate thing for everyone who relies on the healthcare system is that our members at HDA, who are distributors between the frontline manufacturers and the frontline providers, are in a unique position to ensure that the transition process will be as smooth as possible."
The healthcare supply chain is adjusting to the "new normal," he says. "Things have not gone back completely to what they were pre-pandemic. Healthcare is experiencing an incredible amount of transformational change and it is impacting our members."
Impact of regulatory environment
The second half of 2023 is going to be "very busy" for the healthcare supply chain, Davis says. "We have the final implementation date of DSCSA—the Drug Supply Chain Security Act—which was passed in November 2013. Everyone from manufacturers, to distributors, and to pharmacies must be ready to go as of Nov. 27, and everyone is in various stages of operational preparedness to be in compliance. There is a lot of focus both within the Biden administration and Capitol Hill on the supply chain—what worked during COVID and areas that need improvement. A lot of that will manifest itself through a piece of legislation called PAHPA—the Pandemic and All Hazards Preparedness Act. This must be reauthorized by Congress by Sept. 30."
Implementation of the federal Inflation Reduction Act will have an impact on the healthcare supply chain for years, he says. "That has a profound impact on our partners in the manufacturing community—both brand and generic manufacturers as well as biologics and biosimilars companies. Anything like the Inflation Reduction Act that has a major impact on our partners upstream is ultimately something that the supply chain is going to have to deal with as they realize what the changes to their business models are going to be. We will have to react to that accordingly."
Drug shortages
A challenge related to the healthcare supply chain that has re-emerged after the crisis phase of the pandemic is drug shortages, Davis says. "It is not an easy issue. In terms of the causation, it is not a sole-source problem. There are multiple reasons why there are drug shortages in certain areas of the treatment regimen. It can be related to anything from shortages of raw ingredients and raw materials, to generic or biosimilar companies not having access to the market when they get Food and Drug Administration approval because of formulary designs, to economic challenges in the generics market, where the generics companies are claiming the margins are too low for them to continue manufacturing products."
There are market anomalies that need to be addressed, he says. "At a time when there is sensitivity to high prescription drug costs, there are also instances where prices have gotten so low that manufacturers are having to make hard decisions about what products will remain in their portfolio and what products they are going to stop manufacturing."
The pharmaceutical supply chain has a role to play in easing drug shortages, Davis says. "In the unique position that our members are in, we have a 360-degree lens on the supply chain. We can look upstream to our manufacturing partners. We can try to find out whether they anticipate any manufacturing disruptions. Then we can use the logistics and data expertise that we have to plan accordingly, whether it is accessing secondary manufacturers or alternative manufacturers if we anticipate the primary manufacturer is going to run into challenges."
Jordan Asher, MD, MS, executive vice president and chief physician executive at Sentara Health. Photo courtesy of Sentara Health.