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."
Common areas of medical misinformation are related to childhood vaccinations, natural remedies, and dietary supplements.
Medical misinformation, which was rampant during the coronavirus pandemic, continues to be a significant issue in healthcare, says Frank McGillin, MBA, CEO of The Clinic by Cleveland Clinic,a leading provider of expert second opinions.
Medical misinformation is one of the hallmarks of the pandemic. Medical misinformation was spread about coronavirus vaccines and treatments.
Now that the crisis phase of the pandemic has passed, medical misinformation has returned to areas subject to misinformation before the pandemic, McGillin says.
"What we are seeing is that the misinformation is in areas that were present before the pandemic. Vaccines in general continue to be the subject of misinformation, particularly around childhood vaccines, which is leaving many populations unprotected. There is also misinformation about natural remedies and dietary supplements. People are looking for alternatives. Sometimes, there is a belief that pharmaceuticals are not the best route forward. Unfortunately, there are a lot of people in the natural remedy space who are making unsubstantiated claims. They are tapping into people's fears and desires," he says.
When you look at the typical healthcare consumer who is trying to understand the health journey that they are facing, they are confronted with misinformation, McGillin says. "They are confronted with a lack of quality information. If you look at online health trackers, there is research that has shown that only a third of the responses that consumers have encountered for online symptom trackers have pointed them in the right direction. It gets back to healthcare is complex, and the quality of the questions that are asked help define the quality of the answer."
Online sources of information can lead patients astray, he says. "While Google is a wonderful resource, and our data shows Google is a go-to source for patients, often they do not have the expertise to ask the right questions when confronted with an overwhelming amount of data. It helps to have experts to parse that data."
Misinformation plays a role in misdiagnosis, but part of this problem is just access to quality information, particularly for rare or complex conditions, McGillin says. "In these cases, when you are talking with a physician, you want to access someone who has a lot of experience with your specific condition. That is part of the value of tapping into academic centers such as Cleveland Clinic. We see those kinds of patients regularly."
In addition to clinical consequences, the economic impact of medical misinformation is significant, he says.
"There are more than 10,000 conditions that can be potentially diagnosed and only about 250 symptoms. Some small variability can lead to one conclusion versus another. Our data shows that on average there could be savings for misdiagnosis of about $12,000 per occurrence. Some of that is over-utilization of unnecessary procedures. For example, there are people with back pain who may not be a good candidate for back surgery, but they have been led to believe either through their own research or from a physician that back surgery is appropriate. In reality, physical therapy is the frontline treatment for back pain, and it not only saves money but also spares patients the pain and suffering from recovering from an invasive procedure."
How clinicians can work with misinformed patients
When working with misinformed patients, trust is crucial for clinicians, McGillin says. "You need to establish a level of trust with the patient. Clinicians need to listen to their concerns. If you think about the typical interaction between a physician and a patient, there is not a lot of face time. So, the quality of that face time is important. Is the healthcare provider listening to you? This involves soft skills."
The clinician-patient interaction is pivotal, he says. "It begins with the interplay with the patient and listening to the patient. If a patient comes in and says, 'I printed out this information from the Internet about a condition.' Instead of dismissing the patient out of hand, the clinician needs to understand the patient's concerns. Facts alone are insufficient. People want to be listened to. People want to make sure you are addressing their concerns and their needs. If you do that, then patients will open their eyes to the facts and the scientific research. The worst thing a clinician can do is shut a patient down. They will think their views are not important, and they will not trust the physician."
More than half of medical groups report that workforce shortages are the biggest barrier to productivity growth.
Physician compensation has not kept pace with inflation, according to a Medical Group Management Association reportbased on 2022 data.
The 2023 MGMA Provider Compensation and Production report features data collected from nearly 190,000 clinicians at more than 6,800 healthcare organizations. The report provides insights on the evolving financial circumstances for clinicians.
"Despite physician and advanced practice provider (APP) productivity continuing its post-pandemic recovery, compensation gains are being outstripped by the most severe inflationary growth in decades," the report says.
For example, increases in median total compensation for primary care physicians in 2021 (2.13%) and 2022 (4.41%) were far lower than rates of inflation for 2021 (7%) and 2022 (6.5%), according to the report. "Primary care, surgical specialist, and nonsurgical specialist physician compensation all saw modest gains from 2021 to 2022; however, none of these benchmarks rise to the elevated levels of inflation," the report says.
The report has several key findings:
APPs experience the biggest change in median total compensation from pre-pandemic levels, but growth dipped slightly from 3.98% in 2021 to 3.70% in 2022
More than half (56%) of medical groups reported that staffing is the biggest barrier to productivity growth
A November 2022 MGMA poll found varying performance on productivity at medical groups, with 29% reporting that they had exceeded their productivity goals for the year, 36% reporting that they were on target, and 36% reporting that productivity was below expectations
Physicians with supervisory responsibility over APPs reported earning 7% to 15% more in total compensation than physicians without supervisory responsibilities
Primary care physicians working night shift hours reported earning $70,000 more than colleagues working the day shift and nearly $23,000 more than colleagues working afternoon-to-evening shifts
From 2020 to 2022, there was a "steady shift" to salary-based compensation models for clinicians away from production-based compensation models
MGMA Stat polls found a significant increase in medical groups incorporating quality metrics into their clinician compensation models, with 47% of medical groups linking quality performance metrics to physician compensation in May 2023 and 42% of medical groups linking quality performance metrics to physician compensation in May 2022
According to an October 2022 MGMA Stat poll, only 28% of medical groups reported adding an ancillary service in the previous year, with many organizations citing labor recruitment difficulties as the barrier
An April 2023 MGMA Stat poll reflected a trend toward hiring APPs to offset shortages of physicians and nurses, with 65% of medical groups planning to add new APP roles in 2023
The April 2023 MGMA Stat poll found nearly half (47%) of medical groups had added or created part-time or flexible-schedule physician roles in the past year in response to physician shortages
MGMA recommendations
Jessica Minesinger, an MGMA consultant and founder and CEO of Surgical Compensation & Consulting, made three recommendations for medical groups in the report.
Medical groups need to respond to "rampant" physician burnout, which is decreasing productivity, she said. "Taking a customized, positive, and proactive approach to identifying the causes and finding effective ways to reduce the impact of burnout on your physicians is critical. This includes recognizing the challenges unique to female and male providers. A one-size-fits-all approach won't suffice."
Minesinger identified several components to addressing turnover, disruption to staff, lost revenue and productivity, and recruitment costs, including retention, promotion, staff engagement, and well-being initiatives.
Caring for physicians and other staff members responsible for patient care is critical to financial sustainability, she said. "Establish and invest in leadership roles and departments tasked explicitly with increasing provider recruitment, retention, and well-being. Address the well-documented gender wage gap in medicine and the ongoing challenges female physicians face with openness and transparency. The ultimate goal is to provide the best possible patient care, experience, and outcomes."
The report calls on medical groups to establish retention committees to help ease workforce shortages.
The first step to establishing a retention committee is to create an electronic survey to poll physicians on their feelings about practicing in the medical group, the report says. "The survey should ask physicians: What one or two issues create the highest level of dissatisfaction in practicing with us? What one or two things are responsible for your highest level of satisfaction? What one or two issues would cause you to leave for another opportunity?"
A findings report should be developed from the electronic survey and presented to senior leadership, including CEO, chief operating officer, chief medical officer, chief financial officer, and chief human resources officer. "Discuss all issues, evaluate recommendations, and determine what can be agreed to in this initial meeting. Leave the final report with recommendations for attendees to review on their own, and schedule a second meeting for the following week with expectations that each category will be discussed and addressed," the report says.
Scripps Health has physician operating executives at the health system's five hospitals and about 80 medical directors.
Physician operating executives and medical directors are crucial players in healthcare administration at Scripps Health, says Ghazala Sharieff, MD, MBA, corporate senior vice president of hospital operations and chief medical officer at the San Diego-based health system.
Sharieff has held her current role since January 2020. Her previous experience includes serving as Scripps' chief experience officer and emergency department division director at Rady Children's Hospital.
HealthLeaders recently talked with Sharieff about a range of issues, including addressing healthcare worker burnout at Scripps, her learnings from being a command center leader during the coronavirus pandemic, and the primary elements of a positive patient experience. The following transcript of that conversation has been edited for brevity and clarity.
HealthLeaders: At Scripps, you serve as CMO for inpatient care and Anil Keswani serves as CMO for outpatient care. What are the benefits of splitting the CMO role?
Ghazala Sharieff: Our president and CEO, Chris Van Gorder, is incredible. He always thinks ahead of the curve. He split the role in January 2020, right before COVID hit. So, I was the coincident commander of our COVID response in addition to working on quality, patient experience, and all the regular CMO duties. Splitting the CMO role into two pieces has been crucial. Given what we went through over the past few years, particularly with patient experience and quality, it would have been difficult for me if I was manning everything. We have about 30 clinics and five hospitals—it would have been too much. With 17,000 employees, 3,000 physicians, and 2,000 volunteers, having one person man all of that would have been extremely difficult given the challenges over the past three years.
Dr. Keswani and I work very well together. When we started, we were unsure how we were going to work together—we each had a column and some areas that overlapped like a Venn diagram. Now, it is not like a mine-and-yours situation. The Venn diagram is getting bigger and bigger because we realize there is a spectrum of responsibilities. Most of the things that you do in inpatient care affect ambulatory care because you must have a handoff for patients who have been admitted and discharged, then need care on the ambulatory side.
So, it is working very well, and I highly recommend this structure for other organizations as large as we are.
Ghazala Sharieff, , MD, MBA, corporate senior vice president of hospital operations and chief medical officer at Scripps Health. Photo courtesy of Scripps Health.
HL: What are the main ways you are addressing healthcare worker burnout at Scripps?
Sharieff: During COVID, we launched the RISE program—Resilience in Stressful Events. This is a peer-to-peer responder program, and it has a physician component. Physicians do not like to speak with others about their concerns or crises. When they have another physician to talk to, that is a safe place, and it does not have any stigma attached to it.
We have employee assistance with psychologists. So, if a healthcare worker feels they need more than a peer responder, we have a psychology team that can meet with them.
We also have some simple things such as one-on-one coaching. And we have reminders about mental health such as a webpage for physicians with resources that are available to them.
It is important to have open communication about the burnout that many of us are feeling.
HL: What role do physicians play in healthcare organization administration at Scripps?
Sharieff: We have an amazing infrastructure. One of the first things our CEO asked me to do on the inpatient side when I became chief medical officer was to align my physicians. We have five physician operating executives—one at each of our hospitals. They are dyad partners with chief operating executives because you need physician leadership as well as administrator leadership to run daily operations.
We also have about 80 medical directors across the health system. The medical directors report to the physician operating executives, who report to me. So, we have clear accountability for the metrics that we are trying to improve with this infrastructure. Physicians have a huge role not just in patient experience but also in daily operations. That is our secret sauce.
HL: In general, when you look at the healthcare system, do you think physicians are becoming more involved in healthcare organization administration?
Sharieff: In general, there are a lot more physicians going into administration because they want to make a difference in their organizations. It is also because of the financial climate we are facing, with hospitals struggling with finances. We need physician leadership to help us prioritize. Everybody wants new equipment—there is so much new technology coming out that physicians want to have, but we need them to help us prioritize. What do we need today? Is new technology truly more effective or is it just something you want to try?
You are going to see much more physician involvement in hospital operations as well as on the ambulatory side.
HL: You co-led command center operations for Scripps during the coronavirus pandemic. What were your primary learnings from this experience?
Sharieff: I learned about situational leadership. There was a sense of panic. Among physicians, there was sincere concern not only about their patients but also about themselves and their families. Some of them were not going home because they were afraid they were going to bring the virus home to their families. They were living in hotels. We had to be more directive with our leadership. We would say, "This is the path we are going to take." Eventually, we were able to be more collaborative—bringing in more physicians and staff to help us design our policies. But at first, we had to take control of the situation, which was important. Somebody had to be that voice.
What I have learned is there is a cycle to leadership in a crisis.
We have also learned that we can pivot quickly when we need to. We learned that we could be organized, pivot quickly, and try things that are different. One example is our Sprint Teams—we identify a problem then put a team around it so we can move quickly. With the Sprint Teams, you may not have a solution totally mapped out. Nothing is going to be perfect when you roll it out, but you must start an initiative and pilot it, then you make adjustments as you go.
HL: You previously served as chief experience officer at Scripps. What are the primary elements of a positive patient experience in the inpatient setting?
Sharieff: The key drivers are nursing communication, physician communication, and the environment of the hospital. Patients want to be heard.
We have a unique patient experience effort that we call The One Thing Different campaign. What that means is that I do not want to script anybody. It is horrible when everybody says the same thing because the patients know that somebody has told them to ask questions. Scripting your staff does not work. The One Thing Different campaign started with me thinking about what I can do differently. We ask patients about their greatest concern. It has changed my practice and it has changed the practice of many of our staff as well.
HL: You have a clinical background in emergency medicine. How has your clinical background helped you to serve in leadership roles such as CMO?
Sharieff: For emergency physicians, situational leadership is important. When you have a critical patient come into the emergency department, you must be in charge. One person must be the captain. So, when we have rocky times or there is uncertainty, it is easy for me to slip into that role as CMO.
There is also a lot of camaraderie in the emergency department. After a night shift with the nurses, we would all go out for breakfast. There is that side of leadership as well. You cannot always be directive—you have got to be seen as collaborative.
You must roll up your sleeves as an emergency physician and work with your colleagues. There are leaders who I have seen who do not get in the field with their people, and that does not resonate with me. If my staff is doing something, I like to be there with them. That is the ER doctor in me, and it has affected how I am as a leader.
Emergency physicians need to be transparent with their colleagues and share the "why" behind what they are doing. I tell my staff, "Here is what we are doing for this patient. Here is why I am ordering tests." That naturally translated over to my CMO role. I explain to people what we are doing. It cannot be bossing people around. You must explain the process and why we are going a certain route.