Physician leadership development needs to be a top priority for health systems and hospitals as well as physicians who are interested in administrative roles, says this CMO.
Physician leadership development is pivotal for the U.S. healthcare system because many of the top-performing hospitals are physician-led.
Recent research shows there is a gap between physician interest in leadership development and opportunities to gain this experience.
A new report from Jackson Physician Search and the Medical Group Management Association found that 67% of physicians surveyed were interested in leadership development opportunities, but only 18% had been exposed to nonclinical leadership development through their education or experience in clinical practice.
It is essential for health systems and hospitals to offer leadership development opportunities, says Kristin Mascotti, MD, MS-HQSM, CPE, CMO of Penrose Hospital, which is part of CommonSpirit Health's Mountain Region.
"It is vital to provide physicians with leadership development opportunities," Mascotti says. "Some of the best-performing healthcare centers and hospitals in the nation are physician-led."
Leadership development is rarely provided in medical schools, according to Mascotti.
"In medical school, trainees believe themselves to be leaders, but they are so focused on clinical expertise that leadership development is rarely a focus," Mascotti says.
Similarly, early career physicians are focused on clinical expertise, and not on leadership development, Mascotti explains.
"When we look at what leadership roles physicians want to take, they want to either be leading within their department or serving on a committee related to their area of expertise," Mascotti says. "They want to lead in areas in which they are comfortable."
At CommonSpirit, there are formal and informal leadership development opportunities for early career and mid-career physicians who have shown influence in their department or on committees, according to Mascotti.
"We offer them a leadership training program, which can go up to a year," Mascotti says. "They develop expertise in leadership as well as finance, and they work on a project."
There are many committees for physicians to get involved in at the health system through the medical staff structure such as the Medical Executive Committee and Credentials Committee.
"It is a great way for physicians to become a part of committees and lead committees," Mascotti says. "We also have our medical staff involved in our Quality Committee, which is important in oversight of quality in the organization."
Finally, there are usually problems to solve in clinical departments, which can be a proving ground for aspiring physician leaders at CommonSpirit.
"These situations provide informal leadership roles that can evolve into formal leadership roles," Mascotti says. "Physicians can find a problem, solve it, then generate results such as lives saved, improved quality, and financial return on investment."
Beyond leadership development opportunities offered at health systems and hospitals, physicians can take the initiative to build their leadership skills. There are certifications for physicians such as a Certified Physician Executive, which is offered through the American Association for Physician Leadership.
"Physicians can benefit from leadership training programs that are six months to 18 months, depending on how quickly they can participate," Mascotti says. "That can then lead to master's degrees."
Physician leadership skills
When you look at the competencies of a great physician leader, the top two are influence and trust, according to Mascotti.
"To be a physician leader, you must have problem-solving and relationship-building skills in order to have great influence," Mascotti says. "You also need to engender trust. If you have those things, you can drive change in a team environment."
When looking at high-functioning teams, the number one capability of those teams is they have mutual trust and respect, Mascotti explains, which makes trust indispensable.
"Trust encompasses things like integrity, ethics, collaboration, and teamwork," Mascotti says. "If you look at engagement overall, it boils down to trust."
Additionally, Mascotti recommends that physicians who are interested in serving as CMOs seek out formal and informal leadership development opportunities to show that they can make an impact and influence others along strategic priorities.
"Most CMOs will require an advanced degree such as an MBA or MHA," Mascotti says. "I tell people who want to be a CMO to solve a problem and get involved in committees."
Mascotti, who served as CMO of NCH Healthcare System in Florida before joining CommonSpirit, pursued informal and formal leadership development opportunities along her path to becoming a CMO.
"First, I leaned into problems that needed to be solved in my department. From there, I had no dearth of projects to work on. The projects just got larger and larger," Mascotti says. "Then I got my Certified Physician Executive certification and went on to get my masters of science in healthcare quality and safety management degree."
Mascotti also recommends that aspiring CMOs get the Certified Physician Executive certification.
"You get exposed to things that you did not learn in medical school or early in your career," Mascotti says, "such as looking at your own emotional intelligence, finance, quality, and managing performance."
Setting clinical standards boosts patient safety and care quality, says this physician leader.
One of the primary focal points for the inaugural chief physician executive officer at CommonSpirit Health will be reducing variation in clinical care.
Thomas McGinn, MD, MPH, was appointed as senior executive vice president and chief physician executive officer of CommonSpirit in September. He joined the health system in 2021 as executive vice president for physician enterprise, where he oversaw physician and advanced practice provider employment and alignment models with accountability for advancing clinical integration and population health management.
McGinn says he is passionate about reducing clinical care variation to boost patient safety and quality.
"My background is in evidence-based medicine and looking at clinical standards," he says. "We have a national program that sets clinical standards."
According to McGinn, the key to success in setting clinical standards is to have clinicians drive the process.
"It is not a top-down approach," he says. "We put the standards in front of the clinicians, we give them some options, we have multiple group meetings, then the clinicians come to a consensus about the clinical standards."
The process also involves bringing together clinicians and thought leaders from academic and non-academic facilities drawn from across the health system, McGinn explains.
"We have a support system as we pull the working groups together to give them the latest evidence," he says. "There can be three different groups of 20 people each who are multidisciplinary. We summarize their final conclusions."
Once a clinical standard has been set, CommonSpirit promotes widespread adoption, according to McGinn.
"We educate our clinicians about it. We have internal grand rounds. We have podcasts. We have seminars," McGinn says. "We then look at whether there is an opportunity to embed a clinical standard in the electronic medical record. We follow the data on the impact of a clinical standard, and we keep the clinical standard workgroups in place for about a year."
Thomas McGinn, MD, MPH, is senior executive vice president and chief physician executive officer of CommonSpirit Health. Photo courtesy of CommonSpirit Health.
Capitalizing on size and scale
In his new role, the biggest challenge and opportunity for McGinn will be taking advantage of CommonSpirit's size and scale.
CommonSpirit is one of the largest health systems in the country, with more than 2,200 care sites in 24 states, more than 35,000 providers, and 45,000 nurses.
Where some people see a challenge in managing such a large health system, McGinn sees it as an opportunity to leverage size and scale as well as increase efficiencies.
"We are the largest population health, value-based care provider in the United States. We are also one of the largest Medicaid providers," McGinn says. "We have been combining offices and putting them under one national roof to create centralized expertise on data analytics and technology."
The supply chain impact of Hurricane Helene is an example of how CommonSpirit can benefit from its size and scale.
"The recent Baxter IV fluid shortage hit some of our California, Phoenix, and Las Vegas areas," McGinn says, "but we didn't even feel it because we were able shift fluids from the Midwest. So, size and scale have become a real advantages for us."
As another example, CommonSpirit used to have many ways of answering phone calls with different technology, which the health system has moved to consolidate.
"Over the past three years, we have switched to one centralized connection center with four hubs," McGinn says. "We have reduced our costs and increased our efficiency."
McGinn says he has an opportunity to influence care on a grand scale.
"My new job crosses the continuum of care from primary care to specialty care to acute care to intensive care, so I have a lens on all kinds of care," McGinn says. "The opportunity for me is to connect the dots, so patients have a positive experience in the continuum of care."
Dyad partnership
McGinn will be working in a dyad partnership with CommonSpirit's CNO, Kathleen Sanford, RN, DBA, MBA.
Being a dyad partner has two primary elements, McGinn explains.
"One is you are joined at the hip on your decision-making processes," McGinn says. "Each dyad partner knows what the other person is doing and there is no separate decision-making. You run your own workflows, but people see you standing next to each other all the time."
The other aspect of dyad partnerships is the focus on shared platforms. Currently, McGinn and Sanford are prioritizing wellness and career development.
"Kathy and I are going to share a platform for that work," McGinn says. "We are going to have a shared platform that manages talent development, wellness, and educational activities."
Another area of focus for McGinn and Sanford will be patient satisfaction.
"We have a large, centralized service of expertise and a singular way of measuring patient satisfaction across every type of clinical site," McGinn says. "Whenever we see dips in some areas, we can deploy evidence-based patient satisfaction teams."
McGinn cites the example of when CommonSpirit had a market where there was a decrease in patient satisfaction at ambulatory sites.
"We deployed a patient satisfaction team to that market for a week," McGinn says, "and they helped the physicians, nurses, and staff with everything from simple training on eye contact and greeting patients as they walked into clinics to more advanced approaches to patient satisfaction."
Virtual nursing has also been a major initiative to improve patient satisfaction in the inpatient setting, McGinn explains.
"To address nursing shortages at our hospitals, we have been deploying virtual nursing to relieve some of the administrative work that is not patient-facing," McGinn says. "That has enabled the bedside nurses to be more engaging with their patients."
The steps necessary to address health equity gaps include harnessing data and monitoring the impact of interventions.
To address health equity, a health system or hospital needs to have intentionality about identifying gaps in care and closing those gaps, the new CMO of University of Chicago Medical Center says.
Tipu Puri, MD, PhD, was appointed as CMO of University of Chicago Medical Center last month. He joined UChicago Medicine as an internal medicine resident in 1999. Puri has held several physician leadership roles at the academic health system, most recently serving as associate CMO.
To address health equity concerns, a health system or hospital must be inquisitive, according to Puri.
"It starts with asking questions about health equity," Puri says.
The next step is harnessing data, Puri explains.
"You need to have data that you can act on," Puri says. "Our data and analytics team has done a good job of creating an equity lens that we can use when we look at any of our data and break data down along multiple patient demographics, including race, gender, and Zip codes."
Finally, a health system or hospital must decide how to address a health equity gap, according to Puri.
"If we see gaps, we ask, why do those gaps exist and how can we intervene?" Puri says. "Then you need to monitor whether the things you are trying to do to close a gap are working. Are you seeing the gap in care closing? We want our patients—regardless of who they are and where they come from—to have the same outcomes."
According to Puri, University of Chicago Medical Center closed a health equity gap in blood pressure management, with a disparity between Black and non-Black patients. It started with identifying that the medical center was not meeting the targets with the Black population, then leaders asked why the medical center was not meeting its targets.
"To close the blood pressure management gap, we implemented programs such as remote patient monitoring and pharmacy-assisted blood pressure management," Puri says. "Then we monitored the data to see that the difference in patients meeting the targets and outcomes were no longer different between racial and ethnic groups."
Tipu Puri, MD, PhD, was appointed as CMO of University of Chicago Medical Center last month. Photo courtesy of UChicago Medicine.
Biggest challenge
University of Chicago Medical Center serves an urban patient population, and according to Puri, the biggest challenge in serving that population is providing access to care.
"There is a significant need in the community that we serve, and a high burden of chronic disease," Puri says. "Maintaining access to our patients through our ambulatory clinics, emergency department, and specialty care programs is a challenge."
In the inpatient setting, maintaining access to care for patients requires the efficient use of resources, Puri explains.
"That generally focuses on looking at avoidable delays, improving the timeliness of care delivery, improving the planning for patient discharge, and improving medical decision-making," Puri says.
In terms of discharge planning, Puri says the medical center has completely restructured its care coordination team to maximize their coverage of patients, cross-train them, add resources and staff, and lower patient-to-care-coordinator ratios.
"We do care coordination assessments within the first 24 hours after patient admissions," Puri says. "We identify needs that may come up at discharge and identify social determinants of health that we might be able to address."
Mentorship responsibility
As CMO, one of Puri's roles will be to provide mentorship to physician leaders and frontline clinicians, and a big part of mentorship is providing empowerment and support to physician leaders.
"They need to feel empowered to implement solutions," Puri says. "The decision hierarchy and the command chain need to be simplified where they can be simplified. If they have a solution, they should feel empowered to run with it."
A mentor should be able to challenge physician leaders when necessary, Puri explains.
"Sometimes, mentorship involves challenging physician leaders if we are not meeting the targets and the goals we have set for ourselves or if we are not providing adequate access to care," Puri says.
To provide mentorship for frontline clinicians, accessibility is crucial, according to Puri.
"A CMO should be seen," Puri says. "There should be opportunities for hallway conversations. It can be random rounds on the wards. It can be sitting in lounges or being seen in the food service areas."
A mentor must also be approachable, Puri explains.
"If frontline clinicians have an issue they want to talk about, they should feel comfortable coming to you to talk about it," Puri says. "By being accessible and approachable, that is where we are going to get our best information to act on."
Interdisciplinary care team success
The most important factor for success of interdisciplinary care teams is communication, according to Puri.
"As leaders, the best thing we can do is make that communication as easy as possible," Puri says. "It can be as simple and pragmatic as putting offices or workrooms close together. It can be encouraging multidisciplinary rounds to happen at a nursing station, so the nurses can more easily join the session."
Sometimes, CMOs and other physician leaders need to enforce communication among members of interdisciplinary care teams, Puri explains.
"You need to challenge care teams when communication has not been as good as it needs to be," Puri says. "You need to tell an interdisciplinary care team that they need to be better because our patients are counting on it."
In partnership with Columbia University Irving Medical Center, NewYork-Presbyterian is developing an AI tool for the early detection of cardiovascular disease.
NewYork-Presbyterian is involved in a unique effort to develop an artificial intelligence tool for the early detection of cardiovascular disease.
HealthLeaders is conducting its AI in Clinical Care Mastermind program through December. The program brings together nearly a dozen healthcare executives to discuss their AI strategies and offerings.
One of the advantages of NewYork-Presbyterian is that it is affiliated with two medical schools, Columbia University Vagelos College of Physicians and Surgeons as well as Weill Cornell Medicine, says Ashley Beecy, MD, medical director of AI operations at NewYork-Presbyterian.
"There are research teams across the enterprise developing AI models and working on translational research to bring the models to point of care," Beecy says. "They also conduct clinical trials to understand both the factors for the safe use of AI and the efficacy of the models when integrated into the healthcare system."
A team comprised of clinicians and researchers from Columbia University Irving Medical Center is developing an AI tool for the early detection of cardiovascular disease.
"There is a lab at Columbia, CRADLE (Cardiovascular and Radiologic Deep Learning Environment), led by Dr. Pierre Elias, doing incredible work looking at different types of cardiovascular data for early detection of disease," Beecy says. "For example, an AI tool can use electrocardiograms (EKGs) to identify potential markers for structural heart disease that a cardiologist reading an EKG can’t identify with the naked eye. Depending on the score the AI model generates, it will prompt a cardiologist to order an echocardiogram to confirm diagnosis."
Additionally, NewYork-Presbyterian’s Enterprise Heart Failure Program, led by Dr. Nir Uriel, with physicians from its affiliated medical schools, is collaborating with Cornell Tech and the Cornell Ann S. Bowers College of Computing and Information Science to transform cardiovascular health and heart disease prediction and prevention using AI and machine learning.
Ashley Beecy, MD, is medical director of AI operations at NewYork-Presbyterian. Photo courtesy of NewYork-Presbyterian.
Assistive AI tools
In addition to the innovative cardiovascular disease detection AI tool, NewYork-Presbyterian is rolling out several assistive AI tools that are impacting clinical care, according to Beecy. A few examples include:
Ambient scribe: This AI tool has been focused on the outpatient setting. The tool transcribes a conversation between a clinician and a patient, then generates a draft clinical note to document the interaction. "One of the interesting findings so far is that ambient scribe is saving a few minutes for clinicians, but when you survey them, clinicians feel strongly that ambient scribe reduces their documentation time," Beecy says. "This reflects changing documentation from a writing task to an editing task, which reduces the cognitive load."
Risk prediction: NewYork-Presbyterian is using an AI tool that alerts nurses about potential fall risk for inpatients at the health system's Lower Manhattan Hospital. "We are getting feedback from nurses on whether they find the AI tool's alerts useful and whether the alerts are preventing falls," Beecy says. "We want to work closely with nursing teams as stakeholders to ensure that the AI tool's alarms are not interrupting their workflow. We want to make sure it is augmenting their work in a positive way."
Radiology: The health system is using an AI tool to triage radiology images. One example is the use of AI for identification of stroke, including possible intracranial hemorrhage. The goal is to notify care teams for early intervention.
In-basket messaging: This is one of the first AI tools adopted at NewYork-Presbyterian, and it helps clinicians respond to patient questions in their electronic in-boxes. "It is very similar to ambient scribe," Beecy says. "People feel as though it is saving them time since the task moves from writing to editing. The metrics for time savings are variable, and it will be interesting to see whether the in-basket messaging tool reduces clinician burnout over the long term."
For each assistive AI tool, there is still a human in the loop, Beecy assured.
"There is a team member who is responsible for reviewing what AI tools are generating and making sure the information is correct before submitting it," Beecy says.
AI's impact on clinical care teams
For clinical care teams, right now AI is something unique and independent of the way clinicians currently practice medicine, Beecy explains.
"In the long term, we are going to find that AI becomes ubiquitous in the way we practice medicine," Beecy says.
In the short term, the focus of AI tools in clinical care at the health system is on administrative tasks and diagnostic accuracy, according to Beecy.
"This allows us to focus on the human input and the patient interactions for care processes, without radically changing how we work," Beecy says.
Over time, more data will be digitized and transformed into useful data sets that can be harnessed by AI tools, Beecy explains.
"We will generate insights from this data such as wearables and digital pathology," Beecy says. "AI systems will become more of a part of our decision-making process, and we will see more algorithmically guided care."
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Part of being a health system or hospital CMO is working hand-in-hand with the organization's chief financial officer.
CMOs have a role to play in financial stewardship at health systems and hospitals, the new CMO of Christ Hospital Health Networksays.
Marcus Romanello, MD, MBA, started working as vice president for medical affairs and CMO of Christ Hospital Health Network on Oct. 1. He was most recently CMO of Kettering Health Hamilton, a hospital in Hamilton, Ohio.
Christ Hospital Health Network features The Christ Hospital, a 555-bed nonprofit facility in Cincinnati.
Financial stewardship and high-quality clinical care are intertwined, according to Romanello.
"Financial stewardship harkens back to the concept of any healthcare organization that delivers clinical excellence in a compassionate manner will never want for customers," he says. "If you keep your eye on the goal of delivering the best possible clinical outcomes, oftentimes, the financial pieces will quickly fall into place."
CMOs need to help control costs, Romanello explains.
"As CMO, I am frequently working side-by-side with the chief financial officer of the organization looking at ways in which we can elevate our care but do so in a cost-conscious manner," he says.
CMOs can contribute to financial stewardship by having a hand in the acquisition of the products and supplies used in clinical care settings, according to Romanello.
For example, there can be product choices in the operating room environment, where there may be several options available to the surgeon to choose between products that have equivalent outcomes. "The CMO needs to help the surgeon understand there are cost differences, and their selection of a product has an impact on the bottom line," he says.
Implants are another area where a CMO can help a health system or hospital contain costs, Romanello explains.
"With a knee-replacement implant, one particular brand may be two times the cost of another brand," he says. "Oftentimes, those price differences are not well described to the surgeon. So, the CMO can help them become aware."
At healthcare organizations, resources are finite, and CMOs can present valuable information to clinicians that supports financial stewardship, according to Romanello.
"A CMO can promote financial stewardship through bringing cost data to the table, so that it can be considered," he says.
Marcus Romanello, MD, MBA, is vice president for medical affairs and CMO of Christ Hospital Health Network. Photo courtesy of Christ Hospital Health Network.
Service line success
For CMOs, a primary consideration in the success of service lines is working to ensure that there are effective hand-offs of patients between service lines, Romanello explains.
"When we look at the integration of healthcare delivery models, service line architecture often breaks down during hand-offs of patients between service lines," he says. "It is important for the CMO to visualize these hand-offs and make the bedside physician or other members of the care team within a vertical service line aware of hand-offs and make sure they go seamlessly."
Romanello cited the example of a patient with debilitating knee pain.
If the patient is seen in the outpatient setting by a primary care physician, that clinician could refer the patient to the musculoskeletal service line for physical therapy. There may be imaging to diagnose the problem, and, ultimately, the patient could be referred to an orthopedic specialist.
"For each of those hand-offs, there is the risk of incomplete communication. It is important to integrate the service lines, including the primary care service line and the orthopedic service line in this case," he says. "When a hand-off occurs, you want to make sure that information is not lost and the aims of the treatment are not lost."
A CMO plays an essential role in service line success, according to Romanello.
"A CMO should ensure that each service line has clearly identified their metrics for success so service lines can maximize the value of the care delivered to the patient," he says. "Any referring physician or customer seeking out services needs to be confident that they are getting the absolute highest level of quality. That drives the business."
Key metrics for service lines include hospital length of stay, complication rate, mortality rate, and how soon after discharge patients are following up with a physician to ensure everything continues to go well, Romanello says.
Artificial intelligence and clinical care
Artificial intelligence is on the cusp of becoming an essential component of clinical care, Romanello explains.
"AI will never replace a physician, but physicians who use AI will likely replace those who don't use AI," he says. "The volume of data surrounding healthcare has ballooned to the point where it is difficult for any one individual to fully assess data. That is where the AI models can help us better calculate patient risks, better calculate the optimal treatment strategies for patients, and expand our capacity to care for patients."
Romanello has worked on AI initiatives in clinical care before coming to Christ Hospital Health Network.
"For example, I have previously been involved in projects where we have looked at using AI to digest the entirety of a patient's chart to look for all medical problems, both active problems and historical problems, so those problems can be brought to the attention of the treating physician," he says.
Romanello plans to be involved in AI initiatives at The Christ Hospital.
"I am interested in the interface of technology and healthcare," he says. "In the coming years as we integrate AI models into care delivery here at The Christ Hospital, we are going to elevate the level of care we are giving."
With financial support from the Patient-Centered Outcomes Research Institute, AdventHealth is tackling antibiotics use for acute respiratory infections.
AdventHealth is launching an initiative to improve antibiotic stewardship for pediatric patients in the outpatient setting.
Antibiotic stewardship has several benefits, including lowering cost of care, reducing medication side effects, and addressing antimicrobial resistance. For pediatric patients, most antibiotics are prescribed in the outpatient setting.
"What makes what we are doing unique is the focus on ambulatory care," says Jeffrey Kuhlman, MD, MPH, chief quality and safety officer at AdventHealth. "We have launched a program that is focused on patients such as a parent bringing a child in for an acute respiratory tract infection including sinus and throat. In the U.S. healthcare system, there is very little emphasis on antibiotic use in the ambulatory setting for pediatric patients."
Prevea Health's CMO says the proposed 2.8% cut in the 2025 Physician Fee Schedule could force providers to reduce or even cut some services.
A proposed 2.8% cut in Medicare reimbursements for physicians could force healthcare executives to make some painful decisions, the CMO of Prevea Health says.
"Our revenue is tied to payer contracts, which may be signed a couple of years in advance," says Paul Pritchard, MD, senior vice president and CMO of the Green Bay, Wisconsin-based multispecialty medical group. "The Medicare cuts in addition to us not being able to adjust our revenue streams have a dramatic effect.”
“We have been seeing decreases in revenue while our expenses have been climbing," he adds.
The pay cut is contained in the proposed 2025 Physician Fee Schedule, which was released by the Centers for Medicare & Medicaid Services on July 10. It proposes reducing the conversion factor for Medicare reimbursement from $33.29 this year to $32.36 in 2025.
The conversion factor is the number of dollars assigned to a relative value unit (RVU), which is a key element of physician payment by Medicare.
If that pay cut is included in the final rule later this year, it would be the fifth consecutive year that Medicare reimbursements have been cut. According to the American Medical Association, Medicare reimbursements have been cut by 29% since 2021.
According to Pritchard, those cuts have forced Prevea Health, which employs about 500 physicians and advanced practice providers, to make some cuts of their own.
"We have taken some steps such as reduction of staff, which has been primarily non-patient-facing staff such as administrative employees," he says. "We have consolidated certain service lines, particularly specialists. We have not reduced the number of physicians, but we have closed some sites. For example, in Green Bay, orthopedics is now consolidated at one site."
Pritchard said the Medicare reimbursement cuts aren’t happening in a vacuum.
"We experienced a significant reduction in the workforce because of the coronavirus pandemic," he says. "That has created inflationary pressure because healthcare employers are trying to get the same people to work for them. We have seen wages escalate and benefits escalate. Then you couple that with inflationary pressure from supply chain issues."
Potential impact of reimbursement cut
If the reimbursement cut goes into effect, Pritchard said Prevea Health will have to take a hard look at whether to continue providing some services and maintaining some sites of care.
"We will do what any business would do," he says. "We will look at services that are not profitable, which leads to difficult decisions. There are certain things we have done as a physician-run organization because we felt it was right for the community and not because it was profitable."
One such reduction, he says, could come in care management, which Prevea Health established as a service in 2009. While most of the care managers are unfunded positions, the medical group has taken funds out of managed care agreements and risk-based contracts to run the program.
"If we have to consolidate a service line and take it out of our rural areas, so we can have economies of scale, we would reduce access for patients in rural areas," Pritchard says. "But we may have to do this from a business perspective. We may not be able to continue to operate a clinic site in rural Wisconsin that sees 10 patients a day if our revenue continues to get cut."
Broad implications of reimbursement cut
There is widespread unease about private equity getting involved in healthcare and the high volume of healthcare mergers and acquisitions. The continuing Medicare reimbursement cuts are a prime reason for these developments, according to Pritchard.
"As you see your revenue go down, you must start joining larger systems, so that you can get capital, or you have to start reaching out to private equity to get capital," he says.
And the reimbursement cut trend, he added, is unsustainable.
"If you don't know what your capital is going to be because your revenue streams are being cut on a continuing basis, you are going to be reluctant to improve your services," Pritchard says. "The unknown makes it difficult to plan for the future."
"This annual exercise where we must reach out to the federal government to prevent a decrease in reimbursement is déjà vu all over again," he adds. "We have to figure this out because it is not sustainable, and the way it is going, it is only going to get worse."
With financial support from the Patient-Centered Outcomes Research Institute, AdventHealth is tackling antibiotics use for acute respiratory infections.
AdventHealth is launching an initiative to improve antibiotic stewardship for pediatric patients in the outpatient setting.
Antibiotic stewardship has several benefits, including lowering cost of care, reducing medication side effects, and addressing antimicrobial resistance. For pediatric patients, most antibiotics are prescribed in the outpatient setting.
"What makes what we are doing unique is the focus on ambulatory care," says Jeffrey Kuhlman, MD, MPH, chief quality and safety officer at AdventHealth. "We have launched a program that is focused on patients such as a parent bringing a child in for an acute respiratory tract infection including sinus and throat. In the U.S. healthcare system, there is very little emphasis on antibiotic use in the ambulatory setting for pediatric patients."
The initiative is being supported in part by $2.5 million from the Patient-Centered Outcomes Research Institute (PCORI).
The effort is centered on three clinical care settings: Hundreds of AdventHealth doctor's offices such as pediatricians, family medicine doctors, and primary care physicians; AdventHealth's Centra Care urgent care centers, which have more than 60 locations; and 70 emergency departments, which for the purposes of this initiative are considered outpatient locations because most ED pediatric patients are not admitted to a hospital.
"We are working with three sets of providers: Family doctors, pediatricians, and primary care doctors; urgent care doctors, physician assistants, and nurse practitioners; and emergency medicine physicians," Kuhlman says.
A primary element of the initiative is addressing antibiotic use for acute respiratory infections, according to Kuhlman.
"Half of the time for those diagnoses, the illness is viral, which is not appropriate for antibiotics," Kulman says. "Half of the time it is bacterial, and you need to start with a narrow-spectrum antibiotic such as amoxicillin instead of a broad-spectrum antibiotic, which is like using a bazooka to kill a mosquito."
How the initiative works
Provider education is a key component of the initiative. PCORI funding will help AdventHealth to provide more organized and focused education for providers in all three outpatient settings, Kuhlman explains.
"We have online learning for providers through the AdventHealth Learning Network," Kuhlman says. "We have assembled a list of providers in our outpatient settings along with their medical directors. We will engage with the medical directors to encourage the providers to take advantage of our educational offerings."
The initiative is data driven, according to Kuhlman. Providers in all three outpatient settings will have access to dashboards that will have real-time data on the rate of prescribing antibiotics and the rate of prescribing narrow-spectrum versus broad-spectrum antibiotics.
"We have evidence-based literature from PCORI and Children's Hospital of Philadelphia that pediatric patients with an acute respiratory tract infection need antibiotics only half of the time," Kuhlman says. "The other half of the time, the illness is viral and not appropriate for antibiotics. A provider's prescribing patterns for antibiotics should follow that evidence."
Last year, AdventHealth providers gave antibiotics to two-thirds of pediatric patients with acute respiratory infections. With the new initiative, the goal is to decrease that rate to less than half, according to Kuhlman.
Last year, AdventHealth prescribed narrow-spectrum antibiotics for pediatric patients with acute respiratory infections about two-thirds of the time. Now, the goal is to increase that prescription rate to more than 90% of the time, Kulman explains.
"If providers use amoxicillin instead of a powerful antibiotic such as azithromycin, the outcomes are the same and there are fewer side effects," Kuhlman says. "In addition, the cost of care is significantly lower for the antibiotic."
In addition to provider education and data management, the initiative is improving the health system's electronic medical record, Epic. A highly skilled nurse is adjusting the order sets for pediatric patients with acute respiratory infections, according to Kuhlman.
"With these order sets, there are symptoms for acute respiratory tract infections in pediatric patients; the order sets remind clinicians about the differences between a viral infection versus a bacterial infection; and if clinicians go down the bacterial infection pathway, narrow-spectrum antibiotics are placed at the top of the treatment options," Kuhlman says. "We are making it easy for clinicians to do the right thing in the electronic medical record."
Why CMOs should be concerned
Initiatives such as AdventHealth's pediatric antibiotics stewardship program are in the CMO's wheelhouse, according to Kulman.
"CMOs basically have four jobs: professionalism, persuasion, performance, and patient safety," Kuhlman says. "If you think about pediatric antibiotic stewardship, it touches on all four of those areas."
In professionalism, part of integrity in being a clinician is doing the right thing. "Our initiative is helping clinicians to do the right thing," Kuhlman says.
In terms of persuasion, the initiative is designed to persuade clinicians to change their practice of medicine and improve antibiotics stewardship, according to Kuhlman.
For performance, the initiative is striving to improve clinicians' adherence to evidence-based guidelines. "Our initiative is changing the performance of clinicians," Kulman says.
In patient safety, clinicians should not expose pediatric patients with acute respiratory infections to harmful side effects," Kuhlman says. "We need to appropriately decide whether an antibiotic is necessary, then we need to pick the right antibiotic."
Telehealth expanded exponentially during the coronavirus pandemic, and telehealth visits remain high compared to pre-pandemic levels. Having 24/7 telehealth services is relatively rare, but this health system is working to change that.
Hackensack Meridian Health has launched HMH 24/7, a 24/7 virtual care service, in a partnership with K Health.
"K Health, which is providing the app for HMH 24/7, is now a part of our medical group," says Daniel Varga, MD, chief physician executive for Hackensack Meridian Health. "So, HMH 24/7 is the doctors that K Health convenes, and they are part of our employed medical group."
There are different approaches to patient engagement in the inpatient and outpatient settings.
Patient engagement as WellSpan Health includes a personal touch and digital tools, the chief physician executive of the health system says in a HealthLeaders podcast.
Patient engagement is an essential element of generating a positive patient experience. It also is crucial in involving patients in their care, which helps to achieve good clinical outcomes.
As part of the podcast, Anthony Aquilina, DO, executive vice president and chief physician executive at WellSpan, discusses patient engagement in the inpatient and outpatient settings.
Inpatient engagement
In the inpatient setting, patient engagement is pivotal to putting patients at ease, according to Aquilina.
"When you are a hospital patient, it can be one of the most anxiety-producing times of your life," he says. "You are there hoping and praying that the people who have your life in their hands are going to do the right thing for you."
The primary components of patient engagement in the inpatient setting are compassion and respect, and all members of the care team need to treat patients accordingly, Aquilina says.
"An inpatient can see as many as three or more people every hour they are laying in a hospital bed. Almost half of them are nurses, but there are also doctors," he says. "It is important that we focus on everybody who is encountering the patient and make sure they understand the basics about how to make the patient feel comfortable and to make sure the patient feels that the team is working together in their best interest."
A digital tool that the health system is using for patient engagement in the inpatient setting is called MyWellSpan Bedside, which is part of the MyChart experience in the Epic electronic medical record.
"MyWellSpan Bedside is an inpatient version of MyChart," Aquilina says. "It allows patients to engage and to be informed as well as to be empowered in their hospital-based care. They can see things such as upcoming tests, recent results, and other content about their care. It allows them to be digitally engaged."
The health system is also engaging patients through virtual nursing.
"The way this works is there is a nurse sitting in front of a monitor with the ability to view as many as six patients," Aquilina says. "His or her role is to supplement the care delivered by the bedside nurses. This nurse keeps an eye on the patient in the bed and communicates with them."
Virtual nursing allows early identification of potential risks such as falls, and it also improves patient education, transitions of care, and the discharge process, according to Aquilina.
"Virtual nurses can pop into a patient's room through a video feed and engage the patient as well as family members when they are visiting," he says.
Anthony Aquilina, DO, is executive vice president and chief physician executive at WellSpan Health. Photo courtesy of WellSpan Health.
Outpatient engagement
In the outpatient setting, patient engagement is more provider driven, so WellSpan has worked with physicians and advanced practice providers to mximize their patient engagement skills and focus on compassion and respect for all patients, Aquilina says.
The health system understands from the patient's viewpoint that their ambulatory care is not just a patient visit, according to Aquilina.
"It starts when a patient thinks about the need or desire to get care, then continues through the visit and the after care," he says. "We make sure that their instructions after a visit, follow-up after a visit, or tests after a visit are all coordinated."
In the outpatient setting, nurse navigators play an important role in patient engagement at WellSpan for both the pre-visit part of care and the after-visit part, according to Aquilina.
"For the pre-visit part of outpatient care, we started a program for nurse navigation that allows patients who have uncertainty about how to access care to talk with a real human being," he says. "The nurse navigator is trained to understand the patient's personalized needs and get them to the right place. The right place is not always an office visit. Sometimes, it could be a virtual visit. Sometimes, it is urgent care. Occasionally, it is an emergency room visit."
After outpatient visits, nurse navigators focus on patients with acute needs, according to Aquilina.
"For after-visit care, we are using our nurse navigators to make sure our highest risk patients are getting the care they need and the follow-up they need," he says.
Thomas McGinn, MD, MPH, is senior executive vice president and chief physician executive officer of CommonSpirit Health. Photo courtesy of CommonSpirit Health.
Tipu Puri, MD, PhD, was appointed as CMO of University of Chicago Medical Center last month. Photo courtesy of UChicago Medicine.
