Another large health system is betting on clinical integration with independent and employed physicians, and the trend is likely to continue.
WellStar Health System made big news this week with the announcement that it was in merger discussions with Emory Healthcare. WellStar is the largest nonprofit health system in Georgia; merging with Emory Healthcare, which includes the flagship Emory University, would give the system academic support that CEO Reynold Jennings says is needed to help improve and inform physicians on evidence-based guidelines.
"One of the reasons you're going to see a trend of strong community health systems joining with academic medical centers is that they have researchers," says Jennings. "It's a good partnership to give physicians confidence that there are no top-down driven standards."
Another trend that will continue is the development of clinical integration networks. Dignity Health, Baylor Scott & White Health, Memorial Hermann Healthcare System, and now, WellStar Health, are all developing clinically integrated networks as part of their strategy to improve care along the continuum as well as engage and align with physicians.
WellStar Health's clinical integration effort was 14 months in the making, and it will go before the board for final approval next month. Out of 1,200 affiliated and employed physicians, Jennings says WellStar has received a "statement of interest" from 800 to be part of the network, which is called WellStar Clinical Partners.
Engaging Independent and Employed Physicians
Clinical integration networks have the power to fade the bright dividing line between the needs of employed and independent physicians-if the networks are governed right. For example, WellStar Clinical Partners is governed by a 15-member physician board. Ten of the doctors on the board are private; only five are employed by WellStar.
"I've worked with over 30,000 doctors in my career," says Jennings. "Their issue is being connected together, and clinical integration brings information technology and physician leadership structure together to have that connection."
Clinical integration is more than giving a physician practice a new IT platform that aims to connect the dots on patient care, cost, and quality. It can also give them a voice, and a window into how to prepare for major healthcare changes coming down the pike.
Dallas-based Baylor Scott & White Health has developed a robust clinical integration network called the Baylor Scott & White Quality Alliance, and it, like WellStar, includes independent physicians. One such doctor told me that one of the benefits of joining the Quality Alliance was just being able to have a resource available to answer questions about value-based care models.
"Before the Quality Alliance, it was just a big black hole," says Andrew Chung, MD, FACP, who has an independent internal medical practice in Dallas where he sees 30–40 patients per day. "What it (the Quality Alliance) has done is given us more information on how important it is to have a changing healthcare view rather than fee for service."
What hospital and health systems are finding out, sometimes the hard way, is that once-independent-now-employed doctors don't necessarily want to lose all their independence when it comes to patient care and practice. Developing a clinical integration network can give independent doctors the umbrella of support they need to improve cost and patient outcomes.
It's hard to judge these types of networks now because they are so new. But it's becoming clear they are on the rise. In HealthLeaders Media's latest intelligence report, The M&A and Partnership Mega-Trend: Deals for Growth and Survival, improving clinical integration was consistently among the main reasons that organizations entered into new partnerships.
There are other benefits that clinical integration can bring to an organization, says Rob Schreiner, MD, FACP, FCCP, managing director for Huron Healthcare, a healthcare consulting firm. Aside from better clinical outcomes, the potential for savings exist, too because of the efficiencies created by standardizing work among fragmented systems.
Schreiner says he believes there are three basic steps to getting physicians on board with a clinically integrated network:
Create a belief that cost reduction and outcome improvement on a global scale is noble work.
Convince physicians they have they can do this without making their work life worse.
Empower doctors to reorganize themselves to standardize effective care.
Schreiner says many physicians are wary that clinical integration is HMO 2.0. Having lived through that era of patient gatekeeping, he says clinical integration is different.
"The trick is organizing care in such a way that groups of patients experience improvement over time," says Schreiner.
Improving groups of patients' health is the core of population health, which, with major efforts focused on reimbursing for care based on outcomes instead of outputs, may mean clinical integration eventually becomes a new normal instead of another initiative.
"There are a few locations out there who have all or most employed doctors," says Jennings. "That's a small subset of all healthcare systems. Most of us have a changing percentage of employed and private [doctors]. The way the market is settling out, it will be very difficult for most community-based systems to have 100% employment."
Physicians who don't take a leadership stance on vaccine safety give credence to the discredited, unscientific reasons parents use to keep their children unvaccinated and they put the rest of us at risk.
The current multi-state measles outbreak compels physicians to take a tougher stance against parents who won't vaccinate their children.
Anne Schuchat, MD
Assistant Surgeon General,
United States Public Health Service
Director, CDC's National Center
for Immunization and Respiratory Diseases
We are barely a month into 2015, and already there have been more than 80 cases of measles—a serious childhood disease that was declared eradicated in the U.S. just 15 years ago—in 14 states. Most of the cases are linked to an outbreak that began at Disneyland in late 2014.
In a press conference with reporters last week, Anne Schuchat, MD, assistant surgeon general, United States Public Health Service and director of the CDC's National Center for Immunization and Respiratory Diseases said she is worried that this seemingly small number could mushroom into a bigger public health epidemic.
"The very large outbreaks we have seen around the world often started with a small number of cases," Schuchat said. "I have told you before that France went from about 40 cases a year to over 10,000 cases in a year."
A survey from SERMO, a physician-only social network with 300,000 members, reports this week that 92% of doctors they polled attribute the current measles outbreak directly to parents who choose not to vaccinate their children.
The gap in vaccination rates and the reasons these parents use to avoid vaccinating their kids shine a light on the fine line between physician respect to honor a patients' medical decisions and physician responsibility to public health.
"I understand they have concerns," says Linda Girgis, MD, a family practitioner based in South River, NJ, who is also a mother to three teenage boys and leans on her personal experience to relate with parents who worry that vaccines are harmful.
"I tell them I have no qualms about vaccinating my own kids," she says, adding that she continues to counsel and press the importance and safety of vaccine on the parents in her practice who decide to continue and avoid vaccinations. Eventually, she says, those parents stop coming.
Anti-vax Doctor Shopping The reasons parents do not vaccinate their children can range from medical to religious or personal beliefs. Some children have compromised immune systems and can't receive a vaccine. Some physicians don't take the measles outbreak as seriously as the CDC.
But the sharpest point of contention among physicians and a flashpoint of controversy among parents and the public is parents' personal beliefs about vaccinations.
Years after a study that alleged to show that a preservative used in vaccines causes autism was convincingly discredited, the myth it spawned still prevails.
Measles is a serious illness. It's a respiratory virus that can cause blindness, deafness, and even death. "It's not a benign disease," says Girgis.
For a nation that was on edge about the Ebola virus, it is stunning to me that the reaction to measles, a disease that is spread more easily than Ebola, is divided.
"Measles is so contagious that if one person has it, 90% of the people close to the person who aren't immune will also be infected," says Schuchat.
Path of Least Resistance When physicians' persistent requests to vaccinate are rejected by parents, unfortunately, there is another doctor who may not push them as much. That is wrong. Wrong. Wrong.
An inconsistent message about health undermines a physicians' role. When some doctors decide not to toe the line on vaccine safety, it gives credence to the discredited, unproven, unscientific reasons parents use to keep their children unvaccinated against harmful, deadly diseases that put the rest of us at risk.
Girgis is an advisory board member at SERMO, the site that polled its physician members on measles. In addition to blaming the outbreak on unvaccinated children, 79% say children without vaccinations should not be allowed in public schools.
According to the CDC, most states have a vaccination rate among kindergartners above 90%. But there are a handful with vaccinate rates as low as 81%. Colorado, Arkansas, Idaho, Washington, Pennsylvania, Maine, Kansas, and the District of Columbia all have vaccination rates lower than 90%. The majority of time parents are opting out because of philosophical reasons.
As one parent who works with a state social services agency told me, "I have no patience for parents who don't vaccinate." With the majority of parents vaccinating, maybe that lack of patience will spill over to physicians who let parents get off the hook.
"I think it's a big wake-up call for everybody," says Girgis.
For information on how measles presents, potential complications, and current information on the outbreak, visit the CDC.
Administrative burdens and long hours contribute to rising levels of physician burnout, so too do the emotional repercussions of being involved in an adverse event.
Nearly half (46%) of doctors report they felt burnout, up from 40% in 2013, Medscape's Physician Lifestyle Report, shows. Physicians who specialize in critical care emergency medicine, and family medicine reported feeling burnout the most.
Other studies back up Medscape's findings. Physician burnout is on the rise, and the reasons are familiar: administrative burdens, EMRs (and other technology-related office tasks), and too many hours spent at work.
Medscape's study may be new, but for many physicians, the findings aren't news. Robert Wah, MD, president of the AMA, says that one of the biggest concerns physicians have is the complexity of upcoming regulations and the reporting requirements.
"We're in an environment where a lot of those things are on the rise instead of on the decline," he told me.
The news this week that Medicare will transition more of its reimbursement to be based on value rather than volume by 2016 may reverse the level of physician burnout, says Don Crane, president and CEO of CAPG, one of the largest associations of multi-specialty and independent physician groups in 20 states.
"Physicians are burdened with an enormous amount of administrative work," says Crane. "But, now physician leaders are trying to become leaders of an enterprise that will rise or fall based on medical management, not nickels and dimes. Physician leaders' stock will rise and their sense of reward and gratification of the profession will improve."
Burnout Impacts Patient Care
For hospitals and health systems, burnout should be taken seriously because of the effect it can have on patient care.
"The stakes are very high," says Samantha Meltzer-Brody, MD, assistant professor and director of the UNC Perinatal Psychiatry Program in the department of psychiatry. "You're dealing with peoples' lives in high-stress, difficult moments."
Meltzer-Brody developed a program for the University of North Carolina School of Medicine called "Taking Care of Our Own," which aims to de-stigmatize the problem of physician burnout. She says she recognized the need because she was seeing an increasing number of physicians and resident physicians in her practice.
"I was seeing … physicians [who were] just exhausted," says Meltzer-Brody. "That led me to having a sizable number of physicians with burnout, and I started hearing from other doctors, too. I realized it was a big problem."
The program is voluntary, and physicians and residents are either referred to Meltzer-Brody by a supervisor or peer, or they can self-refer. Meltzer-Brody says she can tell the program is catching interest because initially she'd get referrals when she gave a lecture or talk about the program. Now, she has a steady stream of referrals.
In the two years since the program launched, about 200 physicians and resident physicians have sought help for managing stress. "Sometimes, I'll get a call and the person will ask, 'Are you that person?'" she says.
Meltzer-Brody says that physician burnout is not just an apt description for older physicians. She says stress to the point of burnout looks different depending on the age and specialty of the physician.
"Residents, for example, are working horrible hours, and they have fewer resources than faculty. For other physicians, a stressor may be that they are not as facile with an EMR."
Operationalizing Help for Physicians
The program has grown beyond the medical school. UNC Health Care, the nonprofit integrated health system owned by the state, has partnered with Meltzer-Brody to help physicians affected by sentinel events.
Celeste Mayer, RN, PhD, patient safety officer for UNC Health Care, says physicians who are involved in serious adverse patient events are profoundly impacted by the experience and need help coping. "We move on as an organization, but individuals are bearing a huge weight for some time after, she says.
Mayer and Meltzer-Brody started working together last year to come up with a model that provided emotional support for these physicians, often called second victims. They pitched the idea as a pilot project and received one of three grants from UNC School of Medicine last year. Mayer says it's an indication that the organization is taking physicians' need for emotional support seriously.
Meltzer-Brody is equally encouraged because she believes physician wellness needs to be given priority and operationalized across systems. "It's taken me a couple of years to beat the drum loudly," she says. "Now, I am hearing people say, 'this is a problem, what can we do?' "
The adverse patient event program hinges on peer support. Physicians who are involved in an adverse event have the option of being paired with a peer, either within their specialty or outside of it, who is available to talk with them about what happened in a non-judgmental, empathetic way.
Mayer says there is wide support for the program. When she and Meltzer-Brody were preparing to put out a call for volunteers to be supportive peers, the CMO of UNC Health Care sent a message to each department promoting the program.
"Every department nominated at least one person," says Mayer.
Thirty people are now volunteers for the program. They are trained on empathetic listening techniques and to know when a mental health professional needs to intervene.
"It's devastating for well-meaning medical staff," says Meltzer-Brody. "At its worst, it [an adverse event] can cause post-traumatic stress disorder, and it can cause people to leave the profession."
The volunteers are from all halls of medicine: physicians, nurses, pharmacy techs, etc. Once a physician requesting support is matched with a peer, that peer contacts the physician as soon as possible and they meet in person. There is a follow up meeting two weeks later, then another one in two months.
"We have offered it to 32 different people since August, but that doesn't mean we've had 32 adverse events, rather there are 6–12 people who may [have been] affected by an event," says Mayer. "Nine have participated in peer support, 15 did a depression screening survey, and some have declined or not followed up."
Each conversation is confidential, and Mayer says the feedback from the volunteers bears out that this program is needed.
"We're finding a lot of volunteers have personal experience," says Mayer. "They say, 'Thank you for giving me this opportunity; I wish this program could have been there for me."
The pilot program is still in its first year, but Meltzer-Brody hopes this is a training ground for rolling out more programs that support physicians. "One of my goals is de-stigmatizing that burnout only happens to other doctors," she says.
End-of-life care for sick patients is garnering more attention from hospitals and health systems because of its impact on costs. Now leaders need to invest in training physicians to talk to patients about their concerns and wishes.
Angelo Volandes, MD, MPH, is passionate about patients. More specifically, he fervently believes that every physician has a responsibility to give patients information they need to make decisions about the medical interventions they want when they are dying. It's not an easy conversation, and Volandes believes, it's not optional, either.
Hospital and health system leaders are eyeing palliative care programs closely because the ROI is there to support the move toward a more compassionate way of caring for a sick patient. Studies have shown that patients who received palliative care in the hospital in the last week they were alive, had significantly fewer ICU admissions and fewer instances of ventilator use.
In a HealthLeaders Media webcast this week on the strategic use of palliative care, speaker R. Sean Morrison, MD, co-director of the Patty and Jay Baker National Palliative Care Center, as well as director of the National Palliative Care Research Center, and professor of geriatrics and medicine at the Icahn School of Medicine at Mount Sinai, called palliative care "essential" to responding to the aging population.
"Palliative care teams relieve symptoms, distress, and uncertainty; communicate what to expect and match treatment to patient and family goals; and help coordinate care."
6 Questions
As a hospitalist at Massachusetts General Hospital, Volandes sees the need for palliative care in his patients continuously. As an assistant professor of medicine at Harvard Medical School, he shows residents firsthand how to have these difficult conversations. But it is his newest venture, as an author, where Volandes goes straight to the heart of why end of life options are so important for families, and patients.
His recent book, The Conversation, profiles seven critically ill patients, including his father. Through their stories, he drives home the importance of talking to patients about how they want to die. He admits these conversations are hard, but he says physicians need to be asking their patients six questions; and if doctors aren't asking them, patients should take the lead.
What kinds of things are important to you in your life?
If you were not able to do the activities you enjoy, are there any medical treatments that would be too much?
What fears do you have about getting sick or medical care?
Do you have any spiritual, religious, philosophical, or cultural beliefs that guide you when you make medical decisions?
If you had to choose between living longer or having a higher quality of life, which would you pick?
How important is it for you to be at home when you die?
See One, Do one, Teach one
Doctors spend most of their days asking their patients questions, so why is it so difficult for doctors to ask the really hard questions, like the ones above? Volandes says it is because doctors are so focused on solving clinical problems that they forget they are talking to people.
"I teach medical, pre-med students, and residents," says Volandes. "What I try to do is help them understand how critically important it is to have a conversation. They'll see me start the conversation with a family, then I have them go to the next patient and lead the conversation. I have them teach it to one of the younger residents. It's a powerful experience."
Unfortunately, says Volandes, this kind of communication training is not widespread among medical schools. Knowing that doctors weren't getting this kind of training, Volandes says he focused his efforts on empowering patients to speak up and have these conversations with family members and doctors.
To that end, he co-founded Advance Care Planning Decisions, a nonprofit organization aimed at educating patients and their families about the options for end of life care through short, high-quality videos.
Volandes started out developing these videos in his living room with his wife and various family members and friends playing the roles of patient and physician, working through common questions he heard from patients in his practice, and also showing physicians how to ask tough questions (his wife didn't need to act; she is a physician, too). The videos have become such a popular training tool that shooting has moved to a real studio.
In one video, a patient tells Volandes, who is in the real-life role of doctor, that she doesn't want to have a conversation about her end of life care.
"I don't really want to talk about this," she says. "I'm okay now, I'm not sick now."
It raises the question of when to start talking to patients? The answer, Volandes says, is soon and often.
"The best time is when the patient is feeling great, when they have their wits about them, and not critically ill," he says. "This is not a one-time conversation. Doctors should be having these routinely. At a minimum, with anyone over 65, with a critical illness. [Otherwise] it's depriving them of having their wishes honored. We are so compartmentalized that we think we have to pass it off to the oncologist or cardiologist. No, this is a fundamental part of your job."
The focus on empowering patients has turned into a valuable resource for physicians, too. Volandes says 70?100 medical providers are now using the videos to help jumpstart these end of life conversations, including the entire state of Hawaii.
"That's what I didn't expect," he says. "I see physicians, in their documentation, using lines from the video."
The phrase, 'Doing the right thing for our patients,' is uttered more and more around boardrooms and hospital floors. Opening the door to a difficult conversation with patients and their families shows true physician leadership. Doing what is right isn't always easy.
"You're depriving a patient an opportunity to say goodbye, to get their finances in order. I understand these are tough conversations. But trust me; after you have your first, [and] your second, your patients are so appreciative. When we ask patients, they say this is one of the best moments I have had with their doctors."
At issue is whether a private party, in this specific case, Idaho Medicaid providers, can sue a state agency for not paying them a fair rate for the services it provides the state's Medicaid beneficiaries.
All eyes are on the King v. Burwell case that the U.S. Supreme Court will hear in March and which could throw a major monkey wrench into the legal sustainability of health insurance exchanges, the hallmark of the Patient Protection and Affordable Care Act (PPACA).
But another case the justices will hear next week could give Medicaid providers a channel to remedy the lackluster reimbursement rates they receive from states.
At issue is whether a private party, in this specific case, Idaho Medicaid providers, can sue a state agency for not paying them a fair rate for the services it provides the state's Medicaid beneficiaries.
The question arises out of a 2009 lawsuit, brought by five Idaho residential habilitation Medicaid providers. The providers sued Richard Armstrong, director of the Idaho Department Health and Welfare (IDWH), and Leslie Clement, the state's Medicaid director. Armstrong is still the director of IDWH; Clement has since moved onto state healthcare administration in Oregon.
The providers allege Idaho's Medicaid rates were too low. Independent reviews done prior to 2009 showed that the state needed to increase its reimbursement rates, and the department proposed the rate hikes, but state legislators didn't fund recommendations. The independent analysis showed that its recommended increases would have added $4 million to the state budget.
The Medicaid providers won the suit in district court, and in a federal appeals court. The Supreme Court is hearing Idaho's appeal, Armstrong v. Exceptional Child Center, on January 20th.
2 Questions Originally, the state asked SCOTUS to answer two questions:
Do the providers have a right, as a private entity under the Supremacy Clause, to sue the state over its administration of a federal program?
Does Medicaid reimbursement have to be reasonable, relative to provider costs?
The justices agreed to answer only the first question, which could imply that the court is more comfortable considering the limits or protections of the supremacy clause, which was raised in a similar case but never answered, says Anthony Nguyen, an attorney and senior writer and analyst in the health law division at Chicago–based Wolters Kluwer Law & Business firm.
In Douglas v. Independent Living Center of California, a case SCOTUS heard in 2012, the facts were essentially the same: providers rejected the Medicaid reimbursement rates of a state (California) and sued, using the Supremacy Clause as its shield. Back then, the justices sided, in a 5–4 split, with the plaintiffs, but did not address the Supremacy Clause issue because California health officials came up with a reimbursement rate the providers could live with.
"SCOTUS said the issue was moot since they [California] came up with the money," says Nguyen.
But an interesting sidenote to the decision is that Chief Justice John Roberts wrote the dissenting opinion, stating that the Supremacy Clause did not give private parties the right to sue. With the court agreeing to hear Idaho's first question, it could mean the Armstrong v. Exceptional Child Center case is a chance for the Supremacy Clause issue to be settled once and for all.
Nguyen believes the court will again side with the providers complaining about rates. "If they end up closing the door entirely, then states can do whatever they please and providers won't have a recourse," he says.
Converging Forces The suit that could open the floodgates for other Medicaid providers to sue states for better reimbursement rates comes at a time when Medicaid rolls are expanding, but payments to physicians and other providers are not. In fact, after a temporary increase to some providers rates are headed back down.
PPACA Medicaid reimbursement rates went up for primary care services in 2013 and 2014, but now the temporarily inflated rates have expired. Physicians who got used to the higher rates are now reeling from steep cuts. A recent report from the Urban Institute showed that the ratcheting down of Medicaid's reimbursement rates could mean a decrease of nearly 43% in fees that providers who contract with states' Medicaid programs receive.
The cuts are also hurting states. Legislatures around the country are beginning their sessions with gaping budget holes to fill due, in part, to Medicaid growth. At least two states, Hawaii and Maine, are making up the federal reimbursement cut with state funds. Hawaii says it will make up the reimbursement rate gap for six months. Maine hasn't put such a timetable on its commitment to keep rates stable.
As state governments and federal healthcare officials push enrollment in the health insurance exchanges, it raises the question of whether there will be enough physicians to provide services for people who qualify for Medicaid.
Already, in some states, that answer is no. For example, in Texas, there are not many providers who accept Medicaid because the rates do not cover the cost of services. This is the issue that gets at the heart of Armstrong v. Exception Child Center.
In its decision affirming that the Idaho Medicaid providers had a right to sue the state for its subpar rates, the 9th Circuit Court essentially cited language in the Medicaid Act, which states that reimbursement rates have to be "sufficient to enlist enough providers" to take care of beneficiaries.
The opinion goes further, stating, "We have interpreted Section 30(A) to require that reimbursement rates bear a reasonable relationship to provider costs."
But when states do not adhere to this plain and simple language, there is not much the federal government can do, says Nguyen.
"The Centers for Medicare & Medicaid Services could penalize the states, but the way to do that is cut off funds entirely," he says.
Not a likely scenario because its patients who get punished.
States are watching the issue closely; 27 have filed briefs in support of Idaho. Physician and healthcare organizations are watching, too. The American Medical Association, the American Hospital Association, and others filed their own briefs in support of providers.
"Providers have argued that if reimbursement rates don't come up, [they] can't provide services," he says. "If SCOTUS doesn't constrain its decision narrowly, then under the Supremacy Clause, [an affirmation] has broad implications. It would be a pretty important tool... to force states' hands."
Easily accessible technology tools are being used by both doctors and patients, but there's a notable gap between them, and plenty of grumbling—not unlike what's been seen in other industries roiled by massive change.
Mention the phrase "healthcare technology," and many images may come to mind: headache-inducing EHRs, Fitbits, or e-visits. Those are included in the broad scope of technology tools a recent study on consumers' and physicians' assessment of healthcare as well as social media channels, such as Twitter, Facebook, and blogs that offer ways for physicians and patients to communicate.
The problem is the digital divide between the two groups using them.
"Providers are using technology in their clinics and practices," says Grant McLaughlin, vice president of Booz Allen Hamilton, the McLean, Virginia-based consulting firm that co-authored the study with a division of Ipsos Group. "And consumers have a smartphone and are using it, but not necessarily for health."
Some of that may have to do with the FDA approval process for health monitoring devices that give meaningful information to physicians. The results of the survey that Booz Allen and Ipsos commissioned reinforce other, similar studies also showing a gap in understanding how to use technology in a meaningful way that will improve care, quality, and cost of healthcare.
Technology was not the focus of the survey, but the finding that doctors and patients are using technologies separately surprised McLaughlin the most. He estimates the reason is primarily due to privacy concerns, which he believes will dissipate quickly.
"In this study, 82% of consumers rank privacy and security as extremely important, yet, in every other aspect of our lives—the most notable being finance and taking pictures of checks for bank deposits—we are using privacy at the sake of convenience," he says.
To narrow the gap, there are significant hurdles to overcome. For example, virtual visits to physicians via smartphones and tablets are taking hold—telemedicine has been shown to lower costs and increase access—but state licensing requirements and payer coverage differ from state to state.
Common Ground
Physicians and patients have more commonalities than differences when asked about how they view healthcare, but it is remarkable to see that as powerful as technology can be, it is not yet a bigger part of the physician-patient relationship.
The study, which surveyed 1,000 consumers, and 400 primary care physicians, administrators, and specialists, found patients and providers differed in their levels of optimism for the future of healthcare, though they were both generally pessimistic.
Not one group surveyed thought that the reforms of the Patient Protection and Affordable Care Act would lead to improved cost or functioning of the healthcare system.
This is the week where I'd normally preview a list of issues that physicians are facing in 2015.
But after reading this study and its pessimistic results, it occurred to me that the transformation the healthcare industry is going through is similar to what other industries have endured.
The one I am most familiar with (and also recently went through a seismic changes) is media. We used to call it journalism, and you specialized in either print or broadcast, but the plethora of channels pushing information now means we're all digital journalists.
I doubt that physicians and specialists will ever be lumped together like this, but doctors' roles are changing and navigating a path that is both stuck in the past and moving forward is difficult to reconcile.
New and younger physicians are working in a healthcare system that is foreign to older doctors, who question whether the industry is on the right track. For example, Robert Brenner, MD, a gastroenterologist with a 26-year career in private practice, is leaving California for Texas this month to begin working as an employed physician.
"It's not only becoming more restricted as far as access, but patients are going to a setting that is one-size-fits all," he says.
That "one size fits all" mentality is exactly what I thought a few years ago when study after study on media habits showed me that readers are no longer buying newspapers and instead getting their news online. It felt like the news industry was dying. I didn't feel prepared to make the transition to a digital platform, yet I had no choice but to do it, and now here we are—years later with fewer major news sources, but every one of them with an online presence.
Focus on the Stakeholder I wouldn't argue that the system is better, but it has produced unexpected and, I think, some positive effects for readers. I don't want to turn this column into a critical look at media (there's plenty of criticism to make), but what I've come to realize over the last few years is that to survive in an environment that is transforming into something you might not recognize, you have keep the primary stakeholder in mind.
For me, it was news consumers, for doctors, and the healthcare system as a whole, it is patients. Basic stakeholder needs don't change. Consumers still read the news; the basic tenets of reporting are the same.
It raises the question of whether patients aren't like that, too. They still want and value the relationship with their physician (the Booz Allen Hamilton study bears that out), but they also have anxiety about being able to keep that connection because of cost pressures and shifting provider networks.
I am not a physician, and the transformation I lived through is not exactly the same as healthcare's, but I don't think every factor has to be the same to impart a lesson learned, which is that the primary target—patients—of the work you do needs your expertise, but you have to deliver the care where they are, which is, ironically, online.
Keeping your oldest, sickest patients at home not only enhances their dignity, but is a more cost-effective way to care for them. It could even lead to shared savings.
An innovative team-based model of patient care keeps frail and elderly patients at home, reduces costs, builds trust between providers and patients, and reduces emergency department visits.
Fifteen years in, the results are clear.
A study, published in the Journal of the American Geriatrics Society, looks at the middle five years of a program that began in 1999 at MedStar Washington (D.C.) Hospital Center, a 926-bed hospital that is part of the MedStar Health system.
In the late 1990s, K. Eric De Jonge, MD, and George Taler, MD, co-founded what is now known as hospital's House Call program, a hospital-based, team approach that cares for frail and elderly patients in the D.C. area.
"When we started this program, we began a new geriatrics division and talked to the CEO and CMO … and they gave us 2–3 years to break even," says De Jonge. "What became clear is the need. We got 20 new patients per month without marketing and it grew rapidly."
Now, 15 years later, the House Call program cares for approximately 630 patients, says De Jonge. To be eligible for the program, patients must be over 65, have some form of insurance, live within the nine zip codes the MedStar Washington serves, and have trouble getting out of the home.
"These are folks with multiple chronic illnesses and have a high risk of hospitalization and social needs," says De Jonge who also aims to promote not just patient health for this population, but he also wants these patients to be treated with dignity so they can continue to live in their own homes.
Team-based Approach
Two teams take care of MedStar Washington's House Calls' patients. De Jonge says each team includes 10 people, with two people who can float between teams: an LPN and a business manager.
"There are about two and a half teams now," he says. "There are two MDs, two NPs, two social workers, two office coordinators, and including the LPN and business manager, that team is the hub to providing care to about 300 patients."
The first visit with a patient is usually done by one of the doctors and takes about 90 minutes. After that, NPs will keep up with the patients as well as social workers, who De Jonge says provide "tremendous value." Social workers have been fairly easy to find and are typically a good fit, says De Jonge.
Other care team member slots are harder to fill.
"Finding a skilled and dedicated workforce is a major challenge to doing this kind of care," he says. "The financial playing field is not level. Primary care geriatricians, which there are not many anyway, are also not paid a lot, and they have to be willing to leave the comfort of their offices."
There is a nationwide shortage of geriatricians. According to the American Geriatrics Society, there are currently only 7,500 in the U.S. It projects the country will need close to 30,000 geriatricians by 2030, when one in five Americans is eligible for Medicare.
The benefit of creating a team-based approach to care for the frail elderly results in real savings. According the study, led by De Jonge and Toler, patients cared for in their homes had 17% lower Medicare costs.
"The team is the hub of the wheel," says De Jonge. "The wheel includes medication delivery, medical equipment, PT, OT, skilled nursing, transportation, emergency room care, acute hospital care, inpatient rehab, home hospice, inpatient hospice, food, utilities, legal support, [and] adult protective services. It's a comprehensive one-stop stop."
Some hospital leaders I've talked to question taking on the responsibility of providing patients with needs that extend beyond the office walls. Participants in MedStar Washington's House Calls program do not even step into a clinic or doctor's office. However, it's because De Jonge and his team know that social factors play an indirect and direct role in a patient's health, and sloughing off the responsibility of patients' ancillary needs is short-sighted.
Lower Cost
Critical access hospitals and physicians who work in urban areas recognize that connecting patients with social services can often be a critical linchpin. The study shows that despite having similar rates of mortality, the control group was more expensive to take care of than the group of beneficiaries who had home-based care.
De Jonge says a key factor to helping families is giving them one number to call for any issue that arises.
"We work to prevent medical and social crises," says De Jong. "You have to keep it very simple for patients and families when they're dealing with illness."
The House Calls program is staff 365-days a year, 24/7. That kind of accessibility builds trust and loyalty to the health system, says De Jonge.
"It's crucial that the patient and family see you as a team," he says. "When you're making the effort [to see them in the home], there's gratitude and trust that is built up toward MedStar Health."
In addition to reducing health care costs, the study of 722 House Call patients, showed fewer emergency room visits, hospitalizations, skilled nursing facility stays, and specialist visits.
Expanding Home-based Care
MedStar Washington's House Calls program began with two geriatricians recognizing the need in its service area 15 years ago. Today, the program, while still only serving the frail elderly in less than a dozen zip codes, is part of a larger demonstration project that CMS started in 2012.
The Independence at Home (IAH) project includes 17 sites that are offering home-based care services. De Jonge says there six quality metrics that CMS is measuring to determine if sites are hitting the target of reducing costs by at least 8%. He says MedStar Washington is meeting those metrics and will find out in February if the results of the first year will net the hospital any savings.
"If IAH succeeds, we'll be getting shared savings… 80% would go to the provider, MedStar," he says.
That could help cover the costs of operating the hospital-based program, which De Jonge says operates at about a 20% gap every year, but as De Jonge says, "the benefits outweigh the costs."
Lee Aase, the Mayo Clinic's first social media manager, and now director of its Center for Social Media, continues Mayo's excellent reputation by running one of the best social media campaigns in healthcare, and helps its physicians by teaching them about social media and the privacy issues.
In our annual HealthLeaders 20, we profile individuals who are changing healthcare for the better. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. They are making a difference in healthcare. This is the story of Lee Aase.
This profile was published in the December, 2014 issue of HealthLeaders magazine.
"What really drove me into it was the way that these tools make communication free and almost effortless."
If Lee Aase, the Mayo Clinic's first social media manager and now director of its four-year-old Center for Social Media, had his way, this profile would probably only be 140 characters, the maximum length of a tweet. But his pioneering work at the Rochester, Minnesota–based healthcare system deserves a longer description.
The Mayo Clinic is, in many ways, a gold standard that healthcare leaders look to when they want to improve clinical quality, patient experience, and medical outcomes. Patients from around the world also put the nonprofit healthcare system on a pedestal for its team-based approach to helping them get better. In the 24/7 world of social media, too, the Mayo Clinic continues to retain its reputation of doing things well.
With such a strong, recognized brand, Mayo could have passed on jumping into social media. The name is so well-known, so well-respected, that it likely would have survived an absence on Facebook and Twitter. But Mayo chose to participate, largely because Aase saw the potential for social media to continue the system's mission of patient engagement and education.
"We're in our 150th year now, and our founders, Dr. Will and Dr. Charlie [brothers William Mayo, MD, and Charles Mayo, MD] had this tradition where one would stay home and one would travel around to teach and learn," says Aase. "They'd bring back best practices and they would take what they were learning to others, so this really isn't all that different. Instead of traveling by plane and by ship, we travel through cyberspace."
Aase arrived at Mayo in 2000, when only 41.5% of U.S. households had Internet access, which was mostly used to send and receive email. Even then, Mayo had an Internet presence, but Aase describes the website, then known as Mayo Health Oasis, as basic, like most early websites. "Back then, it was a consumer health information website; it wasn't interactive, it was, 'We have knowledge that we can share with other people and people come from around the country, around the world to see us in person, and this is a good way to make that more accessible,' " he says.
Aase says like Mayo, he was also an early adopter of technology, buying an Apple IIe and tinkering with computer programming because of the common problems it could solve. "I remember hanging out in my dorm in my first year in college and having to wait for the one phone that was on the floor to be able to make a collect call home," he says. "What really drove me into it was the way that these tools make communication free and almost effortless."
Effortless is how Aase and his 10-member social media team try to make the learning process for physicians, who may be interested in using social media but are skittish because of privacy rules that guard patient identity. "Part of what we do is make it as easy as possible to get engaged," he says.
A doctor's first foray into the Mayo Clinic's social media space—which includes a major presence on YouTube, Facebook, Twitter, and Pinterest—is doing an interview with a simple flip camera that Aase posts to the Mayo Clinic's YouTube channel. "We're asking them to do the same thing they do a dozen times a day as they talk to patients," says Aase. "One of the concerns physicians have about doing media interviews is being taken out of context, or misquoted, and what they really like about the YouTube videos is that we don't have sound bite limits. They find that comforting, and once they've shared their knowledge, it gives us a resource we can put out on the social channels that could be helpful to patients."
The Mayo Clinic's social media presence looms large. The videos on its YouTube channel have received more than 14 million views; in addition, the health system has more than 900,000 followers on Twitter, approximately 543,000 Facebook likes, and some 13,000 followers on Pinterest.
These impressive numbers are due in some measure to Aase's vision, though he gives credit to the Mayo Clinic's President and CEO John Noseworthy, MD, and Chief Administrative Officer and Vice President Emeritus Shirley Weis for supporting the development of the Mayo Clinic Center for Social Media in 2010.
Like Mayo's commitment to sharing best medical practices with peers, the MCCSM is a resource-rich hub for any hospital, healthcare system, or healthcare leader who wants to participate in social media but is unsure how to do so. Aase has established a membership roster for the MCCSM's social media health network that includes 111 organizations, ranging from large academic medical centers such as Vanderbilt University Medical Center to small, independent hospitals such as the 39-bed Yampa Valley Medical Center in Steamboat Springs, Colorado. Members of this social network get access to real-world case studies, tools, classes, and advice from their peers.
"In one sense, we're air cover," says Aase. "Excuse the military term, but organizations would go to their leadership and say, 'Mayo Clinic has a Facebook page.' They are using us as part of their argument to engage in social media. I think that provides some reassurance."
The responsibility of making sure that the Mayo Clinic brand retains its polish as a healthcare and social media leader in a space where there are so many opportunities to stumble is not lost on Aase.
"Just as our founders had this commitment to outreach, we feel both very fortunate and responsible that we want to do it right," says Aase, in just 125 characters with spaces. :-)
Year-end accolades are making the rounds, but physicians can't afford to be distracted from efforts to repeal the despised sustainable growth rate formula, to fight a large commercial payer, and to fund the education of primary care doctors in rural areas.
As 2014 draws to a close, many of us take time to reflect on the year's events. Media companies are no different. On Wednesday Time magazine unveiled its annual Person of the Year. Time picked the Ebola fighters. I agree with that assessment (after all some of them work right here in my hometown of Dallas), and it's difficult to distinguish one person or one group as doing something notable, especially in healthcare.
That's why we have our HealthLeaders 20, an eclectic group of executives, researchers, nurses, doctors, and others, who are making a difference in the industry.
End-of-year lists are fun and can be thought-provoking, but they should not distract from more pressing issues that threaten physician reimbursements.
SGR Déjà Vu
As House and Senate leaders wrap up their lame-duck session in these last weeks of 2014, I can't help but recall that famous Yogi Berra quote, "It's like déjà vu all over again." That's because nearly exactly one year ago, physicians were asking Congress for a permanent fix to the Medicare Sustainable Growth Rate, just like they are today.
Another temporary "doc fix" was passed instead, averting the 21% cut in Medicare reimbursement. But, here we are, one year later and the American Medical Association as well as other groups, is still lobbying for a permanent solution.
"Before they dismiss this Congress, we want to get it done now," Robert Wah, MD, president of the AMA told me in November during the House of Delegates Interim meeting in Dallas. "We've made so much progress; so much work has been done to create that bipartisan/bicameral bill… we shouldn't lose that momentum and start over again."
One significant barrier that could get in the way of settling on a permanent fix before January is that Congress is not under the same pressure it was in 2013. A year ago, the 21% cut was scheduled to go into effect on January 1, 2014. The current patch doesn't expire until March of 2015.
With a new Republican-controlled Congress coming into power in January, lawmakers can expect to be lobbied hard to finally come up with some sort of solution to this perennial issue.
"It's very hard for physician practices to innovate so long as this uncertainty of a 21% cut is hanging over their hands," says Wah. "No business can make a significant plan when they look at a potential revenue cut in the 20% range."
Groups call on UnitedHealthcare to Back Off Pre-authorizations
In another corner, the College of American Pathologists, along with Florida chapter of the American College of Obstetricians and Gynecologists is fighting with insurer UnitedHealthcare over a policy to not pay for tests that are not pre-authorized or pre-notified.
It is slated to go into effect on January 1.
UHC is requiring doctors that participate in its Florida commercial HMO market to notify the insurer ahead of time when ordering some 80 tests. Two tests require pre-authorization.
Doctors complain the system disrupts their workflow, does not integrate well with commonly used electronic health record systems, and the list of tests do not follow evidenced-based guidelines of some medical societies.
The last issue may have the most legs because there is an increased focus on eliminating tests that are not seen as beneficial to patient care. The ABIM Foundation is aggressively pushing its Choosing Wisely campaign to physicians to make them aware of needless tests that do little more than increase cost of healthcare as well as anxiety for patients and their families.
More than 60 specialty societies, including ACOG, are working with the ABIM Foundation to endorse its stance on eliminating certain tests. UHC says its goal in narrowing its tests is to also improve patient care, quality, and cost.
Despite pressure from multiple physician organizations, UHC is standing by its policy, and if doctors don't comply, they will not get paid.
Idaho Docs to Lobby for Education Funding
States with large rural areas are often designated by the federal government as health professional shortage areas. In Idaho, all 44 counties are designated as HPSAs for mental healthcare, and 40 are primary care HPSAs.
The Idaho Medical Association will be lobbying its state lawmakers in 2015 to improve medical education funding and options to repay loans. The hope is that getting its medical residents to stay and practice will alleviate the shortage in some of the counties.
Idaho has a Rural Physician Incentive Program in place that helps doctors who practice in HPSAs repay medical education loans. The maximum amount a doctor can get for loan repayment is $50,000 over four years. IMA wants to increase the amount of money available and the number of physicians who participate, which is currently 10, according to the Idaho Department of Health and Welfare.
The organization also says that without more funding the state will have to reduce the number of residency slots, which would exacerbate the problem.
A new medical school just authorized by the Washington State University in Spokane could also help ease provider shortages. The University of Washington has the only publically funded medical school in the state and trains doctors from Idaho and other nearby states that also have federally designated HPSAs.
Supporters believe opening a new medical school will mean more medical school graduates who can serve the area. WSU's new medical school will focus on educating primary care physicians.
Recognition of interventional radiologists as more than a subspecialty could increase patients' and physicians' awareness of these pioneers of minimally invasive procedures, especially in treating uterine fibroids.
This article first appeared in the November 2014 issue of HealthLeaders magazine.
Interventional radiologists pioneered the use of minimally invasive surgery, now a widespread technique for numerous procedures ranging from cosmetic to cardiology. But because interventional radiology has historically been a medical subspecialty, patients and fellow physicians often thought of an interventional radiologist as the person who read the x-rays, MRIs, and CT scans. As IRs have developed more clinically significant procedures, particularly in oncology, they have become a more visible and significant clinical addition to care teams. In 2012, the American Board of Medical Specialties (ABMS) elevated the subspecialty to a primary medical specialty.
But in healthcare, change moves at a snail's pace and IRs are still fighting—two years later—to be recognized alongside their fellow physicians.
"It's difficult for patients, even referring physicians, to see us as admitting clinical physicians," says Eric Wang, MD, one of 16 interventional radiologists at Charlotte (North Carolina) Radiology, a large independent practice. Wang just finished up a two-year rotation as chief of vascular and interventional specialists at Charlotte Radiology and for the past four years has been head of the practice's marketing committee, which has become an important component in identifying clinically relevant and profitable IR service lines.
