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3 key elements in improving hospitalist patient scores


An article in NEJM Catalyst cites the importance of physician-to-physician coaching and medical director engagement in improving hospitalist patient scores. Among the conclusions:

  • “Transparent data sharing is critical to the success of any program.
  • “Physician coaching skills are an essential qualification for the physician lead chosen to interact with physicians.
  • “Engagement of medical directors who can reinforce training and review monthly scores on an ongoing basis is imperative.”


Feds to ask ACOs to take on more risk

From FierceHealthcare:

“A long-awaited proposal from the Trump administration will ask Accountable Care Organizations (ACO) to take on more risk going forward, a move that is likely to drive providers out of the program.

The proposed rule (PDF) issued by the Center for Medicare & Medicaid Services (CMS) on Aug. 9, shrinks the amount of time ACOs can be in an upside only model to two years. Currently, 82 percent of ACOs participating in the Medicare Shared Savings Program (MSSP) are in an upside only model.

Additionally, those in a Track 1 upside only model would only be able eligible to take in 25 percent of any savings. Under the current program, Track 1 ACOs take a 50 percent cut. In an upside model, ACOs get a portion of any savings generated in treating patients but are still paid by CMS if they incur losses.”

To read the full Fierce article, please hit this link.

Tough to track hospital ACO performance indicators

Authors of an article in NEJM Catalyst discuss how hospital-based Accountable Care Organizations (ACOs) are facing big hurdles in tracking performance indicators. They conclude:

“ACOs are a broad-stroke model for changing how health care is delivered. Analysis of {an American Hospital Association} survey results highlights the reasons that a broad tool is challenging: It is difficult to get data at the level of granularity required to resonate with individuals, and primary care physicians have limited control over the wide range of care their patients receive over the course of a year. A more targeted tool, like bundled payments, where one defined episode of care can be studied, measured, and perfected, may be a better answer and could even be used within an ACO to distribute capitated payments.”

To read the article, please hit this link.


Stanford’s chief wellness officer takes on physician burnout


For Kaiser Health News


‘Stanford Medicine hired Dr. Tait Shanafelt as chief wellness officer last year, not so much for the well-being of the patients — but of the physicians.

An oncologist and hematologist by training, Shanafelt, 46, has become a national leader in the movement to end physician “burnout” — the cumulative effect of years of stress that can compromise patient care and cause doctors to leave medicine. After 12 years at the Mayo Clinic, Shanafelt now heads up Stanford’s WellMD Center, dedicated to physician health. He also serves as an associate dean of the Stanford University medical school.

He lives in Portola Valley, Calif., with his wife, a nurse, who works part time, and their four children, ages 4 to 13.

Dr. Tait Shanafelt (Julie Greicius/Stanford School of Medicine)

Shanafelt’s goal is to address the systemic problems in medicine — long hours, a culture of blame, endless record-keeping — and find solutions that go far beyond yoga classes or free ice cream for doctors.

Shanafelt’s research “has raised national awareness of physician burnout,” said Dr. Christine Sinsky, an Iowa physician and vice president of professional satisfaction for the American Medical Association, who has co-authored studies with Shanafelt. “Because of his work, institutional leaders now understand the importance of addressing burnout,” she said. And “improvement is possible.”

It’s a high-stakes effort, one joined by other physicians and researchers nationwide: Roughly 300 to 400 doctors die by suicide each year, and physicians rank among the occupations with the highest risk of death by suicide. A 2017 National Academy of Medicine paper, co-authored by Shanafelt, found that more than half of U.S. physicians experienced “substantial symptoms” of job burnout.

Shanafelt spoke to California Healthline recently about his work. The interview has been edited for length and clarity.

Q: How did you come to be interested in physician burnout and well-being?

It’s a bit of a fluke, to be honest. As an internal medicine resident 20 years ago, I was supervising a team of interns [when my supervisor] asked, “What are you observing?” I said that burnout is affecting the care we give to patients. We did that first study — it was one of the first to show links between burnout and patient-care outcomes. It became an absolute lightning rod. It completely opened a national dialogue on the topic.

Q: How is physician burnout linked to quality of care?

We’ve shown in a number of studies that every one point increase in burnout [as measured by a survey] increases the risk of a medical error in the next three months. Other studies have shown that if a hospitalized patient is being cared for by a doctor who’s burned out, their recovery takes longer. … Burned-out physicians are more likely to [leave their jobs] or work part time, and that’s disruptive to the continuity of care for their patients. Burned-out doctors are twice as likely to have patient complaints from the ombudsman and complaints of unprofessional behavior.

Q: What is it about the physician culture that leads to burnout?

[The notion] that physicians are superhuman and that normal human limitations don’t apply to us. The way we trained physicians to do 36 hours on a shift and somehow, we thought we’d be as good in Hour 36 as we were in Hour 1. We know that’s not true for any profession. We also tend to have a culture of invincibility and … a lack of vulnerability with colleagues.

Q: How have you handled burnout personally?

I have a clear sense of the things that really matter to me, both professionally and personally, and try to make choices that are aligned with that. I have accountability partners — one of whom is my wife — who ask, “Are you living consistent[ly] with the things that matter most?” Being able to recognize within yourself when you need to take a break and step away and have rest and use your vacation in a strategic way, I think about these in far more intentional ways than I did earlier in my career.

Q: What are some changes you’d like to see in medical education to prevent burnout?

We probably need to imbue future physicians with different values about self-calibration and self-care as necessary skills. There needs to be a greater culture around vulnerability and supporting each other in the demands of the work.

We also need to understand the unique challenges and demands of each specialty. A surgeon and a radiologist have different jobs. Emergency physicians, for example, have high rates of burnout but also high rates of work-life satisfaction.

But unless we as a profession have a dialogue about burnout more broadly, all the things we do in training will have a limited impact. The minute new doctors go into practice, they look at behavior of their more senior colleagues and they’re instantly going to adopt that behavior.

Q: How has the consolidation of health care — with fewer independent practice physicians — affected doctor burnout?

It’s a double-edged sword. A larger system has opportunities to think about the way work is distributed to provide more flexibility and to create systems of peer support. … But by the same token, many health care organizations also restrict autonomy, and people have less flexibility than they might have had in a small group practice. … They’re held accountable for productivity expectations and expected to overwork. We need to give people a voice. … We need to help leaders not treat people as cogs or widgets.

KHN’s coverage of these topics is supported by California Health Care Foundation and Blue Shield of California Foundation

Exiting silos to improve public health-health system coordination

An article in NEJM Catalyst looks at how to better coordinate the functions of public health officials and private-sector health systems. The authors write:

“Moving toward a comprehensive community wellness vision requires a fundamental transformation of how healthcare and public health engage with one another. Previously siloed organizations may find they have duplicative efforts that are ripe to be streamlined. For example, we reviewed cases where local health department funding to address certain public health objectives was made dependent on performing a certain service (e.g., reproductive health counseling), even if the local healthcare system was already efficiently and effectively providing that service for the same population. Rather than reject the funding from the state or federal government, local public health was compelled to implement a duplicative service. A structured partnership that arranges consolidation of these repeat programs could free limited resources within a community to be redirected to other health needs.

To read the article, please hit this link.

Physicians are said to grapple with their ‘moral injury’

An essay in STAT suggests that “moral injury,” not “burnout,” is the biggest problem for physicians now.

 The authors write:

“Moral injury is frequently mischaracterized. In combat veterans it is diagnosed as post-traumatic stress; among physicians it’s portrayed as burnout. But without understanding the critical difference between burnout and moral injury, the wounds will never heal and physicians and patients alike will continue to suffer the consequences.

“Burnout is a constellation of symptoms that include exhaustion, cynicism, and decreased productivity. More than half of physicians report at least one of these. But the concept of burnout resonates poorly with physicians: it suggests a failure of resourcefulness and resilience, traits that most physicians have finely honed during decades of intense training and demanding work”.

“The term ‘moral injury’ was first used to describe soldiers’ responses to their actions in war. It represents ‘perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.’ Journalist Diane Silver describes it as ‘a deep soul wound that pierces a person’s identity, sense of morality, and relationship to society.”’

“The moral injury of healthcare is not the offense of killing another human in the context of war. It is being unable to provide high-quality care and healing in the context of healthcare.”

To read the piece, please hit this link.

Population-health approaches seen needed to address high-need GI patients

MedPage Today reports:

“As in other medical conditions, a small fraction of high-need, high-cost patients with gastrointestinal (GI) and liver diseases contribute disproportionately to hospitalization costs, according to a nationwide database analysis published in Clinical Gastroenterology and Hepatology.

“The study found that across five common diseases, patients in the top two deciles of hospital utilization accounted for well over half of hospital costs and those in the top decile accounted for more than a third of costs, and in one case, reached almost 40% of costs.

“‘Population health management strategies directed toward identifying these high-need, high-cost patients and implementing multi-component chronic care models may improve the quality of care and reduce costs of care,’ the study’s senior author, Siddarth B. Singh, M.D., of the University of California at San Diego, told MedPage Today.”

To read the database analysis, please hit this link.

To read the Med Page article, please hit this link.

Trying to measure performance in healthcare


From NEJM Catalyst:

“{W}hat constitutes high performance in healthcare? Three-quarters of  NEJM Insights Council members say there is little consensus around a definition. Yet there is some agreement on the key elements and indicators. A culture of excellence is the top attribute of a high-performing organization, followed by aligned goals among all stakeholders.

“Very few respondents say that individual stars among physicians and staff create high performance. We find this heartening; it is a validation of the industry move toward integrated, team-based care. Plentiful finances also fell low on the list of key attributes. Lack of financial resources need not be a deterrent in becoming a high-performing organization.

“We were surprised, however, by how survey respondents weighted cost considerations in the value equation of high performance. Almost all respondents says high quality and excellent patient safety are extremely important, but low cost falls to the bottom of the list of indicators. These results do not reflect the Triple Aim of healthcare, which values high-quality care, population health, and low cost equally.”

To read the article, please hit this link.

Value of value-based care not yet clear


An article in NEJM Catalyst by three  Catalyst for Payment Reform officials finds sharp growth in valued-based medical payments — “about half of all commercial payments to doctors and hospitals now flow through value-oriented methods. However, none of these efforts have demonstrated conclusively that this increase in value-oriented payments has led to better, more affordable care.”

Take bundled payments. The three write:

“Results on bundled or episode-based payment models have been mixed.  {The Center for Medicare and Medicaid Innovation} Bundled Payments for Care Improvement (BPCI) initiatives have produced variable outcomes. However, other initiatives, such as the episode-based payment programs implemented by the Medicaid agencies in Arkansas and Tennessee, have had success in reducing unnecessary utilization and episode costs, as well as improving the quality of care for certain conditions. The Pennsylvania Employees Benefit Trust Fund, working with the Health Care Incentives Improvement Institute (HCI) in a pilot program for total hip and knee replacements, demonstrated decreases in outpatient costs by $3,524 on average, and UnitedHealthcare’s oncology model led to a reduction of cancer episode costs for five medical groups by a combined $33 million.”

The trio go on:

{THE} “transition from fee-for-service accomplishes nothing unless these reforms are working and balance the significant investments that providers, health plans, and purchasers are making to support these changes — investments such as integrated electronic health records or new staff for care support teams. Even patients may feel frustrated if these changes put barriers between patients and their providers or in any way disrupt the doctor-patient relationship.”

To read the NEJM piece, please hit this link.


Can a community hospital maintain its mission if it’s sold to a for-profit chain?

Mission Health, the largest hospital system in western North Carolina, provided $100 million in free charity care last year. This year, it has partnered with 17 civic organizations to deliver substance-abuse care to low-income people.

Based in bucolic Asheville, the six-hospital system also screens residents for food insecurity; provides free dental care to children in rural areas via the “ToothBus” mobile clinic; helps the homeless find permanent housing, and encourages its 12,000 employees to volunteer at schools, churches and nonprofit groups.

Asheville residents say the hospital is an essential resource.

“Mission Health helped saved my life,” said Susan ReMine, 68, an Asheville resident for 30 years who now lives in nearby Fletcher, N.C. Suffering from kidney failure, she was in Mission Health’s main hospital in Asheville for three weeks last fall. And, from 2006 to 2008, a Mission Health-supported program called Project Access provided her with free care after she lost her job because of illness.

After 130 years as a nonprofit with deep roots in the community, Mission Health announced in March that it was seeking to be bought by HCA Healthcare, the nation’s largest for-profit hospital chain. HCA owns 178 hospitals in 20 states and the United Kingdom.

The pending sale reflects a controversial national trend as hospitals consolidate at an accelerating pace and the cost of health care continues to rise.

“We understand the business reasons [for the deal], but our overwhelming concern is the price of health care,” said Ron Freeman, chief financial officer at Ingles Markets, a supermarket chain headquartered in Asheville with 200 stores in six states. “Will HCA after a few years start to press the hospital to make more profit by raising prices? We don’t know.”

And the local newspaper, the Citizen Times, editorialized in March: “How does it help to join a corporation where nearly $3 billion that could have gone to health care instead was recorded as profit? … We would feel better were Western North Carolina’s leading health-care provider to remain master of its own fate.”

Merger Mania

From 2013 to 2017, nearly 1 in 5 of the nation’s 5,500-plus hospitals were acquired or merged with another hospital, according to Irving Levin Associates, a health care analytics firm in Norwalk, Conn. Industry analysts say for-profit hospital companies are poised to grow more rapidly as they buy up both for-profits and nonprofits — potentially altering the character and role of public health-oriented nonprofits. Nonprofit hospitals are exempt from state and local taxes. In return, they must provide community services and care to poor and uninsured patients —a commitment that is honored to varying degrees nationwide.

Of the nation’s 4,840 non-federal, general hospitals, 2,849 are nonprofit, 1,035 are for-profit and 956 are owned by state or local governments, according to the American Hospital Association.

In 2017, 29 for-profit companies bought 11 not-for-profits and 18 for-profit hospitals, according to an Irving Levin Associates analysis for Kaiser Health News.

Sales can go the other way, too: 53 nonprofit hospital companies bought 18 for-profits as well as 35 nonprofits in 2017.

A recent report by Moody’s Investors Service predicted stable growth for for-profit hospital companies, saying they are well-positioned to demand higher rates from insurers and have less exposure to the lower rates paid by government insurance programs such as Medicare and Medicaid. In contrast, a second Moody’s report downgraded from stable to negative its 2018 forecast for the not-for-profit hospital sector.

“The main motivation of for-profit companies is to grow so they can cut costs, get paid more and maximize profits,” said Suzanne Delbanco, executive director of the Catalyst for Payment Reform, an employer-led health care think tank and advocacy group. “They are not as focused on improving access to care or the community’s overall health.”

‘We Wanted To Thrive’

Ron Paulus, Mission Health’s president and CEO, said he and the hospital’s 19-member board concluded last year that the future of Mission Health was iffy at best without a merger.

HCA declined to make anyone available for an interview but provided this statement: “We are excited about the prospect of a transaction that would allow us to support the caliber of care they [Mission Health hospitals] have been providing.”

Driving Mission Health’s decision, Paulus said, were strained finances and the board’s strong feeling that the hospital needed to invest in new technology, modern data management tools and top clinical talent.

“We wanted to thrive and not just survive,” he said. “I had a healthy dose of skepticism about HCA at first. But I think we made the right decision.”

During the past four years, Paulus said, the company has had to cut costs $50 million to $80 million a year to preserve an “acceptable operating margin.” The forecast for 2019 and 2020, he said, saw the gap between revenue and expenses rising to $150 million a year.

Miriam Schwarz, executive director of the Western Carolina Medical Society, said many area physicians were surprised by the move and “are trying to grapple with the shift.”

“There’s concern about the community benefits, but also job loss,” said Schwarz. “But [doctors] do recognize that the hospital must become more financially secure.”

Weighed against community concerns is the prospect of a large nonprofit foundation created by the deal. Depending on the final price, the foundation could have close to $2 billion in assets.

Creation of such foundations is common when for-profit companies buy nonprofit hospitals or insurance companies. Paulus said the foundation created from Mission Health could generate $50 million or more a year to — among other initiatives — “test new care models such as home-based care … and address the causes of poor health in the community in the first place.”

In addition, HCA will have to pay upward of $10 million in state and local taxes.

Mixed Results

Industry analysts say the hospital merger and consolidation trend nationwide is inevitable given the powerful forces afoot in health care.

That includes pressure to lower prices and costs; improve quality, safety and efficiency; modernize IT systems and equipment; and do more to improve overall health.

But academics and consumer advocates say hospital consolidation yields mixed results. While mergers—especially purchases by for-profit companies—provide much-needed capital and financial stability, competition is stifled, often leading to higher prices.

Martin Gaynor, a professor of economics and health policy at Carnegie Mellon University, and colleagues examined 366 hospital mergers from 2007 to 2011 and found that prices were on average 12 percent higher in areas where one hospital dominated the market versus areas with at least four rivals. Another recent study found that 90 percent of U.S. cities today have a “highly concentrated” hospital market. Asheville is one, with Mission Health being dominant.

“The evidence is overwhelming at this point: Mergers solve some problems for hospitals, but they don’t make health care less expensive or better,” said Gaynor. “In fact, prices usually go up.”

Mission Health CEO Paulus said he believed HCA is committed to restraining price increases and cost growth.

If no obstacles arise, Paulus said, HCA’s purchase of Mission Health would be formalized in August and finalized in November or December, pending state regulatory approval.

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